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Creston Residents Get Little Warning Of Twister
A group of women in Creston, Iowa watched Saturday as a tornado ripped off their roof over their heads; another family told KETV they made it to their basement just in time.
Survivors said the whole storm blew through Creston in 30 seconds. Winds flipped cars, uprooted trees and destroyed homes.
I was trying to shut the door, glass was blowing in, then the wind picked it up and it blew right over our heads, Midge Scurlock told KETV Newswatch 7s Amanda Crawford.
Scurlock and her friends were having dinner when the storm hit. They stood together and watched as the roof blew right off the house.
I was holding hands with my friend in the kitchen, we looked up and the roof was just gone, said Cheri Finken. How we didn't blow out, I don't know.
A few houses down, Brad Stehr barely made it to the basement with his family.
We came up, and houses were gone, said Stehr. Its a disaster.
Another womans house in Creston is completely flattened. All that was left Sunday were foundation blocks. The woman told Crawford she didnt have a basement, and the storm blew her into the road and covered her with rubble.
She was actually pretty calm for being through that, described Stehr. It had to be a heck of a ride.
Sunday, neighbors helped each other begin to put their lives back together.
Where do we start? asked Stehr. It's just a mess.
Scurlock and Finken said they are counting their blessings and they will pick up one piece at a time.
It's just stuff, it's just a house, said Finken. We're alive, that's what's most important.
Rescue crews spent much of Sunday going house to house, marking each building when necessary to warn people not to enter.
The hospital in Creston also suffered damage to the roof and windows. The building was under renovation and everyone inside is ok. | <urn:uuid:179901e0-2b05-4746-9d1b-65194eff8f93> | CC-MAIN-2017-30 | http://www.ketv.com/article/creston-residents-get-little-warning-of-twister/7633503 | 2017-07-26T16:55:30Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-30/segments/1500549426234.82/warc/CC-MAIN-20170726162158-20170726182158-00375.warc.gz | en | 0.988097 | 434 |
Taylor Surine, Staff Writer
On Thursday, Sept. 29, the Armstrong Space and Rocketry Club hosted its first Star Party. The Star Party was originally planned to be held on the roof of the Science Center but was moved to the field beside the Science Center parking lot at the last minute. Even with this slight glitch in the evening, the club’s founders and faculty advisors were proud of the great turnout.
Engineering major and club president Karen Furgason was ecstatic about the amount of students that attended.
“For me, the turnout was really surprising. We really want to bring together students who are enthusiastic about space and space exploration and it’s great to see there are many at Armstrong.”
Dr. Clifford Padgett, chemistry professor and co-advisor for the club, showed students the university’s variety of telescopes and stargazing gear. He was excited to share his knowledge of astronomy with many students who share his passion.
Though there was a bit too much light pollution to bring out the Physics Department’s impressive 20-inch telescope, the six-inch and 12-inch proved to be sufficient for the evening.
Many students saw the International Space Station(ISS), the rings of Saturn and the Ring Nebula for the first time. The ISS made a full pass directly overhead the night of the Star Party, which is a rare occasion. The Armstrong Police Department even stopped by later in the evening to do a little stargazing as well.
John Mills brought his own telescope to view the night sky. Mills, a Medical Laboratory Science major at Armstrong, showed some fellow students how to use a manual telescope. He commented on what he and other students saw that night:
“We saw a lot of planets, but I’m not really excited about looking at planets. So, in addition to that, we saw two messier objects, which, in my opinion, are a little more exciting. We saw the Ring Nebula and the Andromeda Galaxy, which are really two of the best objects to see this time of year.”
The beginning of the Star Party was successful but bad weather soon moved in, causing the party to end sooner than planned. Several students were disappointed about this, especially after not being able to stay on the Science Center roof. Fortunately, all attendees were able to get a good look the night’s space wonders.
The Armstrong Space and Rocketry Club is soon planning to becomr an R.S.O. and hosting many more events similar to this one. Meetings are held every other Thursday, the next one being Oct. 13. Location is to be announced. Questions can be directed to armstrongSARC@gmail.com. | <urn:uuid:5a113f95-33bd-4948-abbd-c6822d0e7dba> | CC-MAIN-2017-43 | https://theinkwellonline.com/2016/10/06/star-party-allows-students-to-gaze-at-the-night/ | 2017-10-16T22:15:18Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-43/segments/1508187820466.2/warc/CC-MAIN-20171016214209-20171016234209-00194.warc.gz | en | 0.976134 | 562 |
Our previous visits to the City Planning Commission (here, here, and here) led us to take a strong liking to one caustic and active board member in particular, whom we later discovered to be one Barbara Ernsberger.
Although we admire the intelligence and professionalism of all members, we were especially impressed by Ernberger's willingness to ask uncomfortable questions, demand due diligence, and constructively challenge chairwoman Wrenna Watson.
So it came as no surprise to read that Ernsberer cast the lone "no" vote on UPMC's do-over on the matter of advertsing on the USX Tower.
"I do feel this sign does counteract the historic presence of what used to be the U.S. Steel Building, which was certainly significant in our Pittsburgh history and also to some extent in our national history. So I think that UPMC really ought to consider whether it needs to place a sign on top of the U.S. Steel building," she said. (Mark Belko, P-G)
The skyscraper is, in fact, a uniquely designed architectural landmark, which absolutely merits the attention of the Historic Review Commission, if it is not too late.
Left unstated, however, is that allowing a huge advertisement on the city's tallest building, for a company with a less-then-enlightened sense of corporate responsibility, can be considered plain bad taste.
Why the change of heart? Although it is obvious that UPMC brought its overwhelming resources and influence to bear, the official rationale went like so:
They did so after Pat Ford, Mayor Luke Ravenstahl's director of economic and community development, told them that the decision to reject the sign put the city on "some very shaky legal ground" given that UPMC had met all of the legal requirements in the city zoning code.
What is this nonsense? Can we replace the City Planning Commission with a stack of 3 x 5 notecards? Our civic framers surely recognized that all development propositions are unique, and it takes the educated judgement of an active panel of feeling humans to chart a course for the city that is has its consistency, yet responds to nuance in each case.
It would be worthwhile to go to court to establish that truth now.
The Planning Commission's reluctance to act decisively is also playing out to the detriment of the casino and the science center.
In this case, Ernsberger rightly inquired if the Commission had the power to adjudicate and enforce a settlement to protect the viability of all parties; a course she plainly would have favored. The result was an embarrassed silence from her fellow board members, and later an incredulous outburst from officials with Carnegie Museums.
North Shore casino developer Don Barden offered concessions to the Carnegie Science Center in an 11th-hour bid to get an agreement over issues relating to bus access and lighting.
But the science center's director, Joanna Haas, said last night the moves proposed by Mr. Barden do not solve transportation problems and in fact may make them worse.
Ms. Haas said center officials are moving ahead with their plans to file an appeal to the state Supreme Court over the city's master plan, which was approved last month. (Mark Belko, P-G)
Another board member actually suggested that their primary responsibility was to expedite business, and stay out of the way. The result of this institutional timidity, we all now realize, is legal wrangling that may delay casino revenues even further -- to say nothing of possible damage to an important cultural institution.
The City Planning Commission is charged with the responsibility -- and is in fact invested with the power -- to do much more good for our community than they dare now to attempt. The board could use many more members like Barbara Ernsberger, who have the gumption to actively assert our collective interests. | <urn:uuid:b6ce0b4c-f5c7-4e85-a94d-f2bb2861f19f> | CC-MAIN-2015-06 | http://pghcomet.blogspot.com/2007/06/editorial-planning-board-needs-to-step.html | 2015-01-29T14:20:51Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-06/segments/1422115855094.38/warc/CC-MAIN-20150124161055-00042-ip-10-180-212-252.ec2.internal.warc.gz | en | 0.965209 | 790 |
Jarbidge Canyon in Nevada is a picturesque natural wilderness area. The air quality is some of the best in all of America. It also comes with Native tales of a monster. LINK: The name Jarbidge is said to translate from the Shoshone Indian language to, "monster that lurks in the canyon" or "weird beastly creature." According to legend, Shoshone braves chased the creature into a cave in the present Jarbidge Canyon and blocked its escape with rocks and boulders. Another source says the Shoshone word, "Tsawhawbitts," meaning "man-eating giant" is the root of the name Jarbidge.
LINK: Tsaw-haw-bits lived in a rugged, remote canyon. He was large and very hairy and he ate the native Shoshone and Paiutes who wandered into that country. He had plenty of hiding places in the basalt cliffs, deep ravines, and lava tubes.
The Indians exacted revenge on him, burying him in a cave by piling rocks over the entrance. They never wanted him to escape.
But they also never wanted to wander into that canyon again, and so – legend has it – they never went into the Jarbidge country again.
Not far from the Sawtooth Mountain Range, this area is prime for Bigfoot sightings and encounters. The question becomes, are the cannibalistic giants spoken of by natives and the present-day, hairy, feral people one and the same? | <urn:uuid:23ce024d-0056-45dc-bf2e-160e1b48d6a1> | CC-MAIN-2019-13 | https://www.ghosthuntingtheories.com/2019/01/jarbidge-monster-that-lurks-in-canyon.html | 2019-03-25T19:46:27Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-13/segments/1552912204300.90/warc/CC-MAIN-20190325194225-20190325220225-00306.warc.gz | en | 0.970011 | 309 |
It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results.
In Watching Vesuvius, Cocco paints a rich and detailed portrait of Vesuvius and those living in its shadow. He returns the historic volcano to its place in a broader European culture of science, travel, and appreciation of the natural world.
“Searching into every corner of Italian life and scrutinizing every cliché concerning it, from the charm of the people (an illusion, he maintains) to the consolations of la dolce vita (another one), Mr. Barzini has written an invaluable and astringent guidebook to his country.”—New Yorker. Although nearly fifty years old, this book is still the best introduction to the people of Italy.
Renowned for her sharp literary style, essayist and fiction writer Mary McCarthy offers a unique history of Florence, from its inception to the dominant role it came to play in the world of art, architecture, and Italian culture, that captures the brilliant Florentine spirit and revisits the legendary figures—Dante, Michelangelo, Machiavelli, and others—who exemplify it so iconically. Her most cherished sights and experiences color this timeless, graceful portrait of a city that's as famous as it is alluring. (From the Publisher).
In his monumental Divine Comedy, Dante defined Italian literature, and seven centuries later, it remains intriguing on multiple levels—as poetry, as theology, as a spell-binding story. There are many excellent translations. This recent, highly regarded translation is readily available in print and for the Kindle.
Another classic from a fourteenth-century author, but more easily accessible and engaging than Dante. The book consists of one hundred tales told by ten young men and women over one hundred nights during the plague in Italy. Occasionally bawdy, and always entertaining. Again, there are many translations. This fine Penguin edition is easily obtainable and frequently the translation of choice for Italian literature classes at Penn.
Set in a poor section of occupied Rome during World War II, the film tells the story of a partisan priest and a Communist who aid the resistance. It greatly influenced the film noir movement in American cinema in the late 1940s.
Watch the trailer below.
Film: Roman Holiday
Roman Holiday(1953) – directed by William Wyler and starring Audrey Hepburn and Gregory Peck
Hepburn won the Academy Award for best actress in this classic film, which was selected in 1999 for preservation in the United States National Film Registry by the Library of Congress as being “culturally, historically, or aesthetically significant”.
Watch the trailer below.
Film: La Dolce Vita
La Dolce Vita(1961) – directed by Federico Fellini and starring Marcello Mastroianni, Anita Ekberg, and Anouk Aimée
A film that defined an era. The story of a journalist’s week in Rome and his search for love and happiness. Winner of the 1960 Palme d’or at the Cannes Film Festial. | <urn:uuid:2e834cb9-ba82-46cc-a418-856a52157f60> | CC-MAIN-2022-33 | https://guides.library.upenn.edu/alumnitravelreading/alumnitravelreading_italy | 2022-08-19T13:59:21Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882573699.52/warc/CC-MAIN-20220819131019-20220819161019-00166.warc.gz | en | 0.9418 | 666 |
“A Taste of Canandaigua” Dinner to Benefit Brain Tumor Research
June 16, 2004
"The passage of time has not dimmed our memories of Ron or of his exceptional spirit of giving. We believe that one of the best ways to preserve his memory is to support brain tumor research to work towards a cure that will save others facing this terrible disease."
Community members are invited to “A Taste of Canandaigua,” an event to raise funds for brain tumor research on July 17. The cocktail party, followed by dinner and dessert at more than 30 lakeside homes in Canandaigua, will support the Ronald L. Bittner Gift Fund at the University of Rochester Medical Center.
This is the seventh year an event has been held to support brain tumor research through the Bittner Fund and honor the memory of the man whose name it bears, Ronald L. Bittner. Bittner, who was CEO of Frontier and a prominent figure in the Rochester community, died in 1997 at age 55 from glioblastoma, a type of malignant brain tumor that often spreads quickly and is difficult to remove surgically.
The Ronald L. Bittner Gift Fund was established in 1998 by his family with the goal to find a cure for glioblastoma. Since its establishment, the Bittner family has helped raise over $500,000 for the fund.
“The passage of time has not dimmed our memories of Ron or of his exceptional spirit of giving. We believe that one of the best ways to preserve his memory is to support brain tumor research to work towards a cure that will save others facing this terrible disease,” said Laurie Bittner, wife of the late Ronald Bittner.
With a donation of $125/person or $250/couple, guests will enjoy a cocktail party at the Bittner household, hosted by Laurie Bittner, followed by dinner at one of about 30 lakeside homes. The event will also include a raffle of a piece of fine jewelry from the Gem Lab.
Previously, funds from the Bittner events have helped in faculty recruitment and equipment purchases. This year, the focus will sharpen as organizers hope to raise funds to create a Brain Tumor Research Center at the University of Rochester Medical Center. The new Center would coordinate care for both children and adults with brain tumors, and also advance the search for a cure for primary brain tumors.
A Growing Concern:
Approximately 40,900 new cases of primary brain tumors will be diagnosed in 2004, including both benign and malignant tumors. According to the American Cancer Society, an estimated 18,400 Americans will be diagnosed with malignant brain, spinal cord or other nervous system tumors, and about 12,690 people will die from these tumors in 2004.
The event is sponsored by the Bittner family and the University of Rochester Medical Center’s Neurosurgery department.
For more information on the “Taste of Canandaigua” party and dinner, contact Susan Powell at 275-2834. | <urn:uuid:c2fdc908-2602-4b39-9d7d-8dc76fd4666b> | CC-MAIN-2014-52 | http://www.urmc.rochester.edu/news/story/index.cfm?id=577 | 2014-12-23T04:13:28Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-52/segments/1418802778068.138/warc/CC-MAIN-20141217075258-00065-ip-10-231-17-201.ec2.internal.warc.gz | en | 0.958833 | 640 |
From Wikipedia, the free encyclopedia
|Full name||Associacion Sportif Matelots|
|Nickname(s)||The Shipyard Workers|
|Ground||Stade de la Réunification
|League||MTN Elite two|
Association Sportive Matelots is a Cameroonian football club based in Douala. It is a member of the Fédération Camerounaise de Football. They currently compete in MTN Elite Ligue 2, which is level 2 in the Cameroon football pyramid.
|This article about a Cameroonian football club is a stub. You can help Wikipedia by expanding it.| | <urn:uuid:caf19941-2da5-48ab-a9dc-511b910175f1> | CC-MAIN-2017-17 | https://en.wikipedia.org/wiki/AS_Matelots | 2017-04-24T12:31:57Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-17/segments/1492917119356.19/warc/CC-MAIN-20170423031159-00507-ip-10-145-167-34.ec2.internal.warc.gz | en | 0.783027 | 134 |
Pot shaped like a vintage hand grenade and a lid shaped like a soldier’s helmet. A Mao era vintage piece.
Dimension: 6.25” H x 7.25” W
Notes: Photos are representation of style and size. The actual color, pattern, shape and size may differ slightly from the picture for items that are hand-made, vintage or made with natural materials.
1 in stock | <urn:uuid:d4b265de-a302-4477-b43d-662fac4ac4cb> | CC-MAIN-2020-29 | https://macheflea.com/product/small-military-pot/ | 2020-07-03T13:20:14Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-29/segments/1593655882051.19/warc/CC-MAIN-20200703122347-20200703152347-00518.warc.gz | en | 0.839471 | 87 |
Hardline Shiite opposition leader Hassan Mushaimaa was due to fly home to Bahrain yesterday after Lebanese authorities returned his passport, a friend of his said.
“His passport has been given back to him and he’s bought a ticket. He will land in Bahrain at 3pm [11am GMT],” Abbas al-Amran said.
Mushaimaa, the London-based leader of the Shiite Haq movement, said on his Facebook page on Monday he would try to return to the Gulf Arab country after a week of unprecedented protests by majority Shiite Muslims against the US-backed Sunni monarchy.
He said he wanted to see if the island nation’s leadership was serious about dialogue or not.
However, he was stopped during a stopover in Beirut by Lebanese authorities, who said his name was on an international arrest warrant, and his passport was seized.
On Thursday Bahrain’s foreign minister said Mushaimaa, who was among 25 people charged over an alleged coup plot and who was being tried in absentia, had been pardoned and would return home to join a national dialogue.
Security forces killed seven people and wounded hundreds while trying to disperse protests last week before Bahrain, under pressure from its Western allies, pulled back its army and police and allowed peaceful demonstrations in Pearl Square.
Bahrain’s protesters want a constitutional monarchy instead of the existing system where citizens vote for a mostly toothless parliament and policy remains the preserve of a ruling elite centred on the Sunni al-Khalifa dynasty.
Mushaimaa’s Haq party is more radical than the Shiite Wefaq party, from which it split in 2006 when Wefaq contested a parliamentary election. Haq’s leaders have often been arrested in recent years, only to receive royal pardons.
Meanwhile, the country’s Cabinet has been reshuffled in a further attempt to appease the Shiite opposition sources said yesterday.
The ministers of housing, health and Cabinet affairs were among those sacked, said three government officials who did not wish to be named, adding they had not received official confirmation yet of who was being replaced.
Shiites have long complained of discrimination in government services such as housing and health, and analysts in Bahrain say reshuffling these portfolios is another gesture to the Shiite opposition after the release of political prisoners.
One government source said Labor Minister Majeed al-Alawi, a former opposition activist, could become housing minister.
Minister of State for Foreign Affairs Nazar al-Baharna, one of the highest-ranking Shiite government officials, could be made minister of health, the source added.
The government denies there is any discrimination against Shiites in Bahrain and tens of thousands of government loyalists have also taken to the streets in recent days, saying that reforms launched by the king a decade ago resulted in freedoms and a level of democracy unique in the Gulf.
The sources also said that Sheikh Ahmed bin Attiatullah al-Khalifa, minister for Cabinet affairs, was likely to be replaced.
The Shiite opposition has linked him to an alleged government plan, leaked in 2006, to alter the sectarian balance of Bahrain. The government has denied there was such a plan. | <urn:uuid:a84a88c4-e3b8-49db-952e-9a68991404a1> | CC-MAIN-2014-42 | http://www.taipeitimes.com/News/world/archives/2011/02/27/2003496931 | 2014-10-26T00:45:46Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-42/segments/1414119652530.43/warc/CC-MAIN-20141024030052-00113-ip-10-16-133-185.ec2.internal.warc.gz | en | 0.977144 | 660 |
News Release:El Dorado Engineering, Inc. recently completed installation and startup of its Contained Burn System (CBS) to
dispose of 16 million pounds of M6 propellant and Clean Burning Igniters (CBI) abandoned and left deteriorating on site at Camp Minden, LA.
El Dorado Engineering, Inc. is now
designing and fabricating control panels.
With client satisfaction a priority and a proven track record of
hundreds of successful projects | <urn:uuid:201889ba-3c96-4551-8f73-ed96518c66f2> | CC-MAIN-2019-35 | https://www.eldoradoengineering.com/ | 2019-08-25T02:12:54Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-35/segments/1566027322170.99/warc/CC-MAIN-20190825021120-20190825043120-00460.warc.gz | en | 0.863302 | 97 |
What was your favorite wedding photo?
The beach photos were fantastic, very natural and full of movement!
How did the wedding photographer avoid disrupting the day? Great with candids? Action shots? Portraits?
Elizabeth Morgan photographed my Hawaii wedding in September and she was amazing. Not only did my photographs turn out more beautiful than I could have hoped (full of movement and romance- nothing stiff) but the time I spent with her and my husband on the beach was magical. It was one of the most peaceful and romantic parts of our wedding. She was graciously invisible yet captured every important moment. We loved Elizabeth! | <urn:uuid:0af1f3a7-4409-4738-a56c-98db0840a712> | CC-MAIN-2017-09 | https://www.onewed.com/reviews/us/hi/honolulu-hawaii-us/photographers/elizabeth-morgan-wedding-photography-1035516/ | 2017-02-22T10:58:58Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-09/segments/1487501170940.45/warc/CC-MAIN-20170219104610-00478-ip-10-171-10-108.ec2.internal.warc.gz | en | 0.987527 | 126 |
Your partner in the growth region South East Europe
Consulting and Nearshore - Outsourcing Services
evroenergie L.L.C. based in Pristina, Kosovo as an independent partner offers a wide range of support services that are important to the overall energy industry. We have an excellent Know-How and experience in the implementation of projects based on the guidelines of the energy policy of the European Union.
As an independent partner, we offer processing services through your processes to ensure required by the regulatory conditions. As part of our nearshore outsourcing services we carry out the calculation in power delivery from the use of the supply network, local management, energy data management and communication between actors in the market with latest IT-Software in the energy industry. In the area of back-office, we also offer services such as customer care and complaint management.
In addition, we organize an international conference Energy Market South East Europe with an accompanying exhibition. Energy Market South East Europe provides a platform on which decision-makers in the energy industry and policy challenges in the implementation of the EU requirements, the potential of renewable energies in the Balkans and investment opportunities or to measures taken or planned projects can exchange ideas. The accompanying exhibition of the conference Energy Market South East Europe offers all participants the opportunity to present themselves in a first-class environment, make new contacts and expand your regional and international network. | <urn:uuid:1c713d45-e474-4c52-a598-f2a6b142970d> | CC-MAIN-2019-13 | http://www.evroenergie.com/en/ | 2019-03-24T19:12:41Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-13/segments/1552912203491.1/warc/CC-MAIN-20190324190033-20190324212033-00433.warc.gz | en | 0.93827 | 279 |
I have a really tiny pecker.
Get lost .... get lost NOW ....
Yeah, you heard the girl......
I don't understand what make you think the people on this board would be interested in a replica if all they talk about and want are expensive bags with brand names and quality?? That's such wrong marketing strategy to waste your time here.
I think he/she is hoping someone might be interested or just put it up to piss people off. What a A$$hole
YAY VLAD! Ha ha!!!!! It's probably a replica too!
Hahaha.. oh man, too funny.
"Simple minds simple pleasures." Just another troll trying to push peoples buttons . | <urn:uuid:aa5293f3-0240-43ee-803f-45b0c2dc927e> | CC-MAIN-2017-47 | https://forum.purseblog.com/threads/special-offers-on-all-louis-vuitton-handbags-and-purse.5208/ | 2017-11-21T08:23:06Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-47/segments/1510934806327.92/warc/CC-MAIN-20171121074123-20171121094123-00317.warc.gz | en | 0.955746 | 143 |
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2364 Fountain Gate Dr
Little Elm, TX 75068 | <urn:uuid:4faed63b-4c84-4778-a535-d8f77fdd3048> | CC-MAIN-2018-39 | http://www.datatuples.com/why_data_tuples/cost-advantage/ | 2018-09-19T07:56:38Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-39/segments/1537267155942.15/warc/CC-MAIN-20180919063526-20180919083526-00127.warc.gz | en | 0.890836 | 133 |
Topic: Background music playlist (spotify)
I've been using this playlist for meditation for a while now, sometimes with and sometimes without isochronic tones. currently it has over 5000 tracks (700+ hr) of ambient/atmospheric music for meditation/relaxation.
I don't know if it's possible to export the playlist for another service, but for those who have spotify, here is the link:
https://open.spotify.com/user/0i487kox7 … fs8lj0w6WA
Using maximum crossfade and shuffle is recommended for seamless playback. | <urn:uuid:45e7dde4-d1f6-4618-9ee7-db560c396a68> | CC-MAIN-2019-26 | http://isochronic.io/forum/viewtopic.php?pid=2016 | 2019-06-17T12:16:05Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-26/segments/1560627998473.44/warc/CC-MAIN-20190617103006-20190617125006-00251.warc.gz | en | 0.928434 | 129 |
” All Classes have to be completed within the stipulated period of one month, no remaining classes will be done in the next month”
1. One time Admission Fees will be charged at the time of Admission.
2. Tuition/Course fee is not refundable.
3. Parents/Guardians are requested to take their wards after completion of Classes.
4. Students should not loaf about in the campus after the completion of their respective classes.
5. Students have to attain regular unit tests/Periodic tests conducted by the institute.
6. Parents are requested to attain Parents/Teacher (PTM) after every one month (at the time of deposition of fees).
7. Students have to attain a weekly/monthly tests and their marks will be sent to their parents cell phone.
8. The management reserves the right to modify or alter the structure of any of the courses/fees in order to attain excellence. | <urn:uuid:b91e5d03-dc8b-4e7d-97b5-345392edf395> | CC-MAIN-2023-40 | https://propulsionedughy.com/our-policy/ | 2023-10-01T15:06:05Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-40/segments/1695233510903.85/warc/CC-MAIN-20231001141548-20231001171548-00621.warc.gz | en | 0.931243 | 204 |
By Lorae Vardas, Correspondent
If all goes as planned, 67 choral students from Pierz Healy High School and 11 adult chaperones will be spending a portion of the Christmas holiday break in sunny Florida. The school choir, directed by Diane Hauan, has been invited to perform at Orlando’s Walt Disney World Park where they are scheduled to be part of two 50-minute shows with the Disney Orchestra. The group will perform with a massed choir of 300 singers from around the country in the Dec. 29 Candlelight Processional at Epcot narrated by Amy Grant.
“It’s an honor to be invited back,” Hauan told the School Board at its Oct. 30 meeting. “The trip is similar to one taken by the choir three years ago, except we will be spending two days, instead of three days, on the bus.” Participants in the professionally produced Candlelight show must abide by a strict set of rules and dress code. The choir has to arrive as a group or they will not be allowed on stage. After rehearsal, the students are outfitted with robes, collars and battery-operated candles for the spectacular open-air presentation.
Booked through Leisure Time Travel, the tour will allow ample time for side-trips to Cocoa Beach, Epcot Center, Magic Kingdom, Hollywood Studio, a New Year’s Eve celebration, Animal Kingdom and shopping. The choir will arrive back in Pierz at 7:30 p.m. Jan. 2, 2014. Students will miss only one day of class.
Hauan said choir members currently are in the process of getting their required medical forms and releases filed. To help with the cost of transportation, meals and lodging, the students have done a lot of fundraising in recent months.
Pierz School Board Briefs
In other agenda items at the October 30 meeting, the Pierz School Board:
• Accepted donations from the Pierz Lions for the Art Club’s Empty Bowls project ($250), the cross country team ($250) and for a football coach ($1,500); from the Pierz Area Commercial Club for the National Honor Society ($500) and for the football program ($500); from the Pierz Fire Department for the football program ($500); from Pierz Vet for the FFA program ($265); and from Walmart to the Video Club ($250);
• Hired Kari Mitchell, Lynn Gross and Shelly Erdrich as paraprofessionals at Pioneer Elementary School, and reduced Sheri Kroska’s hours to three days per week. Also accepted was the resignation of Laurie Pry, high school education assistant;
• Approved Tina Otremba as a long-term substitute for Sandy Swaser; Morgan Trang as a long-term substitute for Cameron Anderson and Kelly Gotfredson as a long-term substitute for Lisa Miller. School Nurse Rachel Young was granted a child care leave beginning the first part of December and Lisa Miller for the first part of March 2014;
• Renewed the contract with Melissa Templin to reimburse her for the cost of transporting her student to the border of another district since it is more economical to do so than providing a bus and driver;
• Passed a resolution supporting the district’s application to the Minnesota State High School League Foundation for grants and funding for students participating in extracurricular activities, including athletics and fine arts programs;
• Passed a resolution amending the district’s health reimbursement arrangement to comply with changes in the federal Affordable Care Act. Beginning in 2014, the district can neither offer the current basic plan because it lacks a wellness component, nor put any more funds into the “in lieu of” benefit after Dec. 31. “We have some significant challenges in this area,” said Supt. George Weber about the health care reform. “Another very large issue is how we are going to deal with the law regarding employees who work 30 hours and their salary relative to board contributions.” Pierz is not the only district facing health benefit changes, he said; and
• Adopted a resolution amending the district’s Flexible Benefits Plan to comply with changes in the IRS Code as it pertains to the definition of “spouse.” Language can no longer refer to “person of the opposite sex.”
Because of the Thanksgiving holiday, the next board meeting was rescheduled to Wednesday, Nov. 20, at 6 p.m. in the Healy High Board Room. | <urn:uuid:4ef8021b-5f83-48b0-87b1-b907e408a200> | CC-MAIN-2014-23 | http://mcrecord.com/2013/11/07/pierz-school-officials-give-nod-approval-holiday-choir-trip/ | 2014-07-23T01:17:38Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-23/segments/1405997869884.75/warc/CC-MAIN-20140722025749-00054-ip-10-33-131-23.ec2.internal.warc.gz | en | 0.944399 | 943 |
"Quality End of Life Care in Dementia: How do Family Carers View Quality"
||Friday 26th April 2013|
||12.30pm - 1.30pm (sandwich Lunch)|
Committee Room 2
(Ground floor) Medical School - Royal Free Campus
As a consequence of the ageing population, the number of people with dementia is rising. The number of people in Europe with dementia, for example, is currently about 7.7 million and will double by 2050. In the UK there are around 800,000 people with dementia and this is expected to be over 1 million by 2025. With no known disease modifying treatment for dementia, a growing concern and priority is end of life care.
People with dementia are often cared for by family members. There are currently estimated to be over 670,000 carers of people with dementia in the UK, however this is probably an underestimate. Carers spend more time with the person with dementia than anyone else, they are therefore the people who potentially know the most about the person with dementia. People with dementia at the end of life are often unable to communicate and therefore cannot tell us about their care, however the carers can. Very little is known about end of life care and dementia, and even less is known about carers and their perspective on end of life care.
This PhD is a qualitative study, it aims to explore the features of good quality end of life care for people with dementia from the perspective of family carers. Using in-depth interviews I have interviewed 46 family carers exploring their experiences and views of quality end of life care for dementia.
In this seminar, I will give you an overview of the current understandings of quality of care and an overview of quality end of life care for dementia. I will discuss how I have collected my data, including the challenges of in-depth interviews about such a sensitive topic as death. Finally, I will introduce what I believe to be some of the early themes emerging from the data, including: battles with professionals about stopping or continuing treatment, and neglect of care and compassion.
Page last modified on 19 apr 13 16:58 by Maryanne Ogbogbo | <urn:uuid:e73c9012-7448-4357-9763-19d27e902c43> | CC-MAIN-2015-11 | http://www.ucl.ac.uk/pcph/events/details/upgrade-Apr-13 | 2015-03-04T08:06:35Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-11/segments/1424936463458.93/warc/CC-MAIN-20150226074103-00207-ip-10-28-5-156.ec2.internal.warc.gz | en | 0.955496 | 445 |
Iron Men with Wooden Teeth: 'Turn' Trailer
In light of yesterday’s less than positive news regarding NBC and their nefarious plans for the sweetest of comic books, it only makes sense that the universe give you something to be happy about today. Not because the universe likes you, or has any sense of fairness, but because it knows that making you a little bit happy now and then gives you hope, and it’s so much more delicious to squeeze the hope out of someone than to just stomp one more time on someone who has completely given up. Go ahead and relay that to your therapist, I’m sure that’s sufficiently nihilistic to get you the happy pills for another month.
We showed the first teaser for AMC’s new series Turn back in December, and it was wonderful if far too brief.
But now we are properly in the year the show will debut, and therefore we deserve a full trailer:
Here’s the obligatory plot summary once again:
“Turn” is a spy thriller set during the American Revolutionary War. Based on remarkable new research featured in the book “Washington’s Spies,” by Alexander Rose, it tells the untold story of America’s first spies. “Turn” follows Abe Woodhull (Jamie Bell), a farmer living behind enemy lines in British-occupied Long Island, who bands together with a group of childhood friends to form The Culper Ring, an unlikely team of secret agents who would help turn the tide of the war in favor of the Rebels. Their daring efforts also revolutionized the art of espionage, giving birth to modern tradecraft as we know it today, along with all of the moral complexity that entails.
Need a poem to get excited? We’ve got that too.
Take your Draper, jonesing for a new young sheathe.
And I’ll grant you Walt, baking that blue rock of Lethe.
And sure, Saul’s coming too, plotting from beneath.
But me? I’m waiting for the iron men with wooden teeth.
Pajiba Love Express
Here's some Daveed Diggs for you. On Daveed Diggs' digs, actually. That man does things with clothes that should not make sense, but are absolutely perfect. (Go Fug Yourself)
Woody Allen has "so moved on" from his daughter's accusations and says he never even thinks about it. He equates her words about him to a bad review he won't read and comments on how wacky it is that Mia Farrow is his mother-in-law. He is the worst. (Celebitchy)
Not The Worst but still very gross: Leonardo DiCaprio and his
Here are 5 under-the-radar shows. I had never even heard of the first two. (Uproxx) | <urn:uuid:887b71d8-fb4d-4dc5-9dba-ed56f21f4d91> | CC-MAIN-2016-30 | http://www.pajiba.com/trailers/iron-men-with-wooden-teeth-turn-trailer.php | 2016-07-31T09:35:16Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-30/segments/1469257828314.45/warc/CC-MAIN-20160723071028-00280-ip-10-185-27-174.ec2.internal.warc.gz | en | 0.954647 | 601 |
- Review Price: £197.12
AV receivers aren’t high on the list of things you’d associate with Samsung, but the Korean giant has been turning out a nice line in home cinema amps for quite some time. Its latest range includes this entry-level 5.1-channel model, which is designed to provide a basic introduction to the world of surround sound – a fact reflected by its low price tag.
Aesthetically the HW-C500 is a break from the norm. It’s slimmer than most AV amps and Samsung keeps the front panel free from dials and physical buttons, opting instead for a minimal gloss-black design. It’s possibly one of the best-looking AV receivers we’ve clapped eyes on, but then again what else would you expect from Samsung?
But look closely and the front panel is busier then you might think. A silver strip on the right lets you adjust the volume, while a bank of touch-sensitive controls on the left lets you navigate menus and switch between the various sound modes. They’re so discreet you might not notice them from a distance.
An LED panel in the centre displays key info like the selected input, while a flap at the bottom drops down to reveal a further smattering of buttons, none of which seem important enough to earn pride of place on the front of the unit. We’d rather this space was used to provide a decent array of auxiliary AV inputs for on-the-fly device connection, but disappointingly there are none.
(centre)Version pictured uses binding posts, not spring-clips as on review unit and as stated in review(/centre)
All of the sockets are therefore confined to the rear, and although the selection covers most bases it’s hardly the sort of generous selection Onkyo, Yamaha or Denon would offer at this price. Taking pride of place are four HDMI inputs and one output, and thankfully all of these are specified as v1.4, which will please anyone hoping to bag themselves a 3D Blu-ray deck and TV in the near future.
On the video side, the HDMIs are backed up by two sets of component inputs and one output plus three composite inputs, while audio sockets include four digital audio inputs (three optical, one coaxial), four sets of analogue stereo inputs and 5.1-channel inputs, which will come in useful for Blu-ray decks with built-in HD audio decoding and analogue outputs. In the box, you also get an iPod/iPhone dock that plugs into the terminal on the back.
Also on the back, you’ll find spring-clip speaker terminals in place of more robust binding posts, which is the clearest indication of the Samsung’s budget nature and lack of audiophile ambition. One minor upside to this is that the speaker cables are easier to plug in, which inexperienced (or impatient) users might appreciate.
Internally the HW-C500 features a discrete digital amplifier design, which explains why it feels so much lighter than many other AV receivers. It musters 100W per channel, while the Crystal Amplifier Pro technology includes Multi Variable Feedback to keep unwanted noise at bay, and Intelligence Power boosts power when the volume peaks in order to avoid clipping.
But the rest of the spec sheet is disappointing. It’s unable to decode any of the HD audio formats found on Blu-ray discs, such as Dolby TrueHD, DTS HD Master Audio, DTS HD or Dolby Digital Plus – clearly a way of driving the price down. Thankfully, the HW-C500 can handle multichannel LPCM fed into any of the HDMI inputs, which means you have to tell your Blu-ray player to decode the soundtrack beforehand. The sound quality should be similar, but for people who prefer their AV receiver to do the decoding – or those who simply like seeing the name of the format pop-up on the display panel – this could be a turn-off.
Elsewhere you get the same sound modes found on Samsung’s all-in-one systems – Power Bass boosts low frequencies, Smart Volume keeps sound at a constant level and MP3 Enhancer augments MP3s. There are also 12 DSP modes to further tailor the sound to your taste.
The setup process would have been helped immeasurably by the inclusion of onscreen menus, which are found on several other budget AV receivers, but again that would have meant extra cost. Still, the front panel menu makes things fairly easy to understand, using a logical structure to make up for the lack of onscreen visuals. You can assign inputs and adjust the audio parameters with minimal fuss.
But thanks to the Auto Sound Calibration mode, you don’t have to set the levels manually. Using the supplied microphone and a repeated blast of music (which could send you insane), it measures the acoustic properties of your room and sets the levels automatically. Given the intended audience for this product, this could end up being one of the more significant features.
The remote also helps to keep things nice and simple. The responsiveness and helpful layout of the buttons cause no stumbling blocks and all of the keys are clearly labelled, so you can quickly find functions you don’t use very often.
Onto performance, and although the HW-C500 does a passable job with Blu-ray soundtracks, it simply isn’t in the same league as entry-level models from the likes of Onkyo, Denon or Pioneer. It lacks the control, presence and finesse needed to steal your breath away, a fact exposed by ”Avatar’s” DTS HD Master Audio soundtrack – decoded into PCM by our Blu-ray player first, of course.
Yes, it’s feisty and dynamic, with deep bass and impressive surround channel performance – the HW-C500 conjures up a wide and absorbing soundstage, helped greatly by crisp reproduction of rear effects and smooth steering. But when the action really hots up (during the Battle for Pandora for example) high frequencies begin to strain with the tell-tale signs of harshness, and with the volume approaching maximum there’s an edge to the sound that makes it uncomfortable to listen to for prolonged periods.
We’re painting a negative picture here, and it’s worth reiterating that the HW-C500 is by no means a disaster. For the most part its movie performance is actually quite enjoyable. But when you can pick up a receiver from a dedicated audio brand for around the same price, offering more assured sound quality and lots more features, this Samsung doesn’t really stand a chance.
If you own a Samsung TV and Blu-ray player and want a matching AV receiver, then the HW-C500 might be an appealing option. It’s a highly stylish piece of kit with a decent amount of sockets, plus the supplied iPod dock and support for 3D signals is not to be sniffed at for this sort of money. But that’s where the praise ends – its sound quality isn’t up to the standards of similarly-priced rivals like the Onkyo TX-SR308, which also decodes HD audio signals and throw lots of other features and connections into the mix.
Score in detail | <urn:uuid:c550a575-f37a-4b40-b4e5-ba2f15f355b6> | CC-MAIN-2024-10 | https://www.trustedreviews.com/reviews/samsung-hw-c500 | 2024-03-01T14:32:18Z | s3://commoncrawl/crawl-data/CC-MAIN-2024-10/segments/1707947475311.93/warc/CC-MAIN-20240301125520-20240301155520-00196.warc.gz | en | 0.924361 | 1,520 |
Litehouse Poolsto relocate store
BOARDMAN -- Litehouse Pools, Spas & amp; More is relocating its Boardman store to a new, larger site at 7373 Market St. next to the Southern Park Mall. The 13,000-square-foot retail space will nearly double the store's display area. Andy Shobel and Jeff Browning are owners of the store, which is one of three in the Mahoning and Shenango valleys and one of 26 locations in Ohio, Pennsylvania and Michigan. They plan to complete renovations in time for a move in early October.
From Vindicator staff reports | <urn:uuid:a7ce5a7f-bd2c-4003-b0b2-c780f47ee2b9> | CC-MAIN-2015-11 | http://www.vindy.com/news/2002/aug/08/region/ | 2015-02-28T07:12:36Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-11/segments/1424936461848.26/warc/CC-MAIN-20150226074101-00055-ip-10-28-5-156.ec2.internal.warc.gz | en | 0.884421 | 129 |
Minutes after the Guyana Elections Commission released final preliminary results for Monday’s elections which puts the Opposition Coalition ahead of the ruling party by just over 5000 votes, APNU+AFC Presidential Candidate David Granger has called on his supporters to “let the celebration be sober and short.”
During a visit the Brigadier’s home, he acknowledged the work ahead as the APNU+AFC national unity government seeks to deliver on its promises to fight corruption, crime and poverty.
“We have a lot of work to do so let the celebration be sober and short and get back to work and school and deal,” Granger said.
He said too that he was elated and happy for Guyana. “We worked hard and we are convinced now that the evidence is clear that the majority of the people have spoken.”
These expressions and the release of the results come even as the ruling party continues to challenge the figures with claims of irregularities. But Granger is not being sidetracked by these claims and maintains his confidence in a majority win.
The APNU+AFC is set to secure 33 seats in the National Assembly with a vote count totaling 206,817 over the PPPC’s 201,457 .
“We understand our mission to share our vision,” Granger added as he maintained the six party coalition which he heads was best for Guyana. Granger is very confident that Guyana will not remain the same and children and grandchildren will have a better country as he promised better accountability and transparency.
“I was concerned about the length of time it took to release the results,” Granger added as he called on GECOM of correct its tardiness in this regard. The President elect has promised inclusion to form the best unity government that will continue to seek critical advice from the opposition.
Celebrations have already started at the APNU+AFC Campaign Headquarters, Georgetown as GECOM is yet to declare the final results which should be done by tomorrow. | <urn:uuid:f66dc9a0-554f-4fef-97ee-3364dee7e0f8> | CC-MAIN-2021-49 | https://newssourcegy.com/news/granger-calls-on-supporters-to-let-their-celebration-be-sober-and-short-indicates-lots-of-work-ahed/?shared=email&msg=fail | 2021-11-30T03:41:44Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-49/segments/1637964358903.73/warc/CC-MAIN-20211130015517-20211130045517-00570.warc.gz | en | 0.972906 | 422 |
Agency Information Collection Activities: Documents Required Aboard Private Aircraft
As part of its continuing effort to reduce paperwork and respondent burden, CBP invites the general public and other Federal agencies to comment on an information collection requirement concerning the Documents Required Aboard Private Aircraft. This request for comment is being made pursuant to the Paperwork Reduction Act of 1995 (Pub. L. 104-13; 44 U.S.C. 3507). | <urn:uuid:fcce0c6d-3113-4d4b-8fc4-b36bed3ed963> | CC-MAIN-2023-06 | https://regulations.justia.com/regulations/fedreg/agencies/u-s-customs-and-border-protection/2013/12/23 | 2023-02-01T20:17:37Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764499949.24/warc/CC-MAIN-20230201180036-20230201210036-00493.warc.gz | en | 0.862195 | 87 |
Ages three to five years old are active years for your children. Their inquisitive minds are full of wonders and they begin to enjoy playing outside, where they are exposed to a lot of things. Mild illnesses are part of your child’s growth and development. They develop anti-bodies to some viruses while other illnesses are just normal depending on the environmental conditions of where you live. There is nothing much you can do for your child to avoid them. Colds, for example, can be minimized by being extra cautious during the cold seasons and practicing good hygiene but you can never really stop your child from catching it.
Getting admitted to the hospital can also be very stressful to young kids. It is helpful for parents to know about the infections and ailments most common to children in pre-school. The most useful part is learning how to treat them at home, if possible. Before doing so, it is always best to consult your General Practitioner about your child’s health. Getting a trusted doctor is essential to keeping your family healthy and happy.
Here is a quick guide to some of the most common health issues in young children.
This is the most common illness for everyone, especially kids. Viruses can infect the nose and throat, causing sneezing and runny noses. Your child is likely to catch this at least once a month, but that does not mean that he has a weak immune system. There hundreds of many different viruses out there exposed to your child to which he develops immunity over time.
Colds are best treated at home with lots of fluid and a few days of rest until it goes away.
A sore eye is caused by an infection in the lining of the eyeball called Conjunctivitis. Symptoms include redness, puffiness and stickiness of the eyes. There are 2 types of conjunctivitis—one that is allergic which is not contagious, and the other is bacterial which is transmittable.
It is best to consult your doctor to verify which of type of conjunctivitis you child has and how to treat it.
This is most common in children who experience frequent and watery stool. Diarrhea can be caused by either a viral, bacterial or parasitic infection. It can also be a side effect from taking antibiotics.
Since Diarrhea can last from a few days up to one week, your child will lose so much of his body fluids which can lead to dehydration. It is important to make them drink lots of liquid and continue eating healthy foods to keep them hydrated.
Kids within this age group often experience red and itchy bottoms. It is a normal symptom of having worms caused by dirty hands and clothes. They are easy to prevent by practicing good hygiene; washing hands often and washing clothes & linens properly.
When treating worms, it is advisable to treat your child and the rest of the family at the same time. Visit your local pharmacy for antiparasitic tablets.
Allergies are the initial reaction of the immune system to substances called allergens. Most common allergies come from dust, pollen, insects, food and even medicines. It is best to consult your doctor if your child experiences an allergic reaction for the first time.
If your child is having an allergy attack, use medicines that are only prescribed by his physician.
This condition is common to countries with tropical climates. Given the warm and humid conditions, asthma triggers such as dust and molds thrive in such environment. Studies have also shown that asthma can be caused by hereditary factors.
If your child has instances of short breathing after a strenuous activity, consult your doctor to verify this is asthma and a management plan to cope up with asthma attacks.
It is not wrong to plan ahead for your child’s health as he is growing up. Frequent visits to the doctor while he is young are necessary to make sure that he is monitored properly. Immunizations should be completed during his first two years. At home, practicing good hygiene and healthy eating habits is very important. Keeping the house clean is also essential to the health and well-being of the whole family. | <urn:uuid:02e310b7-9a98-4fda-92c2-39c10397ba1d> | CC-MAIN-2022-49 | http://www.growupfun.com/6-common-health-issues-in-pre-schoolers/ | 2022-11-29T16:02:35Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-49/segments/1669446710698.62/warc/CC-MAIN-20221129132340-20221129162340-00677.warc.gz | en | 0.974114 | 878 |
2015-2016 Regular Session - SB 284
"First Amendment Defense Act of Georgia"
First Reader Summary
A BILL to be entitled an Act to amend Title 50 of the Official Code of Georgia Annotated, relating to state government, so as to prohibit discriminatory action against a person who believes, speaks, or acts in accordance with a sincerely held religious belief or moral conviction that marriage is or should be recognized as the union of one man and one woman or that sexual relations are properly reserved to such marriage; to provide for definitions; to provide for the granting of relief; to provide for construction and application; to provide for waiver of sovereign immunity under certain circumstances; to provide for a short title; to provide for an effective date; to repeal conflicting laws; and for other purposes.
Jan/22/2016 - Senate Read and Referred
Jan/21/2016 - Senate Hopper | <urn:uuid:ff857caf-8011-4015-90fb-010dd1b78346> | CC-MAIN-2019-35 | http://www.legis.ga.gov/Legislation/en-US/display/20152016/SB/284 | 2019-08-19T07:35:48Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-35/segments/1566027314696.33/warc/CC-MAIN-20190819073232-20190819095232-00521.warc.gz | en | 0.924731 | 179 |
PHYS5025 Research Proposal in Experimental Physics
- 6 points
|Semester 1||UWA (Perth)||Face to face|
|Semester 2||UWA (Perth)||Face to face|
- This unit is to provide experimental physics students tools and skills to gain knowledge on the research topics for undertaking the research project. Students will be informed and practise library and database searching, professional scientific writing skills, referencing conventions appropriate to branches of physics and research ethics.
The experimental physics students will be required to take laboratory safety, radiation safety and laser safety courses accordingly, depending on the specific research projects
The students will prepare a literature review of their research topic, and will be exposed to the research environment by starting preliminary experimental investigation and participating the research group meetings.
Students will develop professional scientific writing skills, and are made aware of ethical issues in science, including acceptable scientific practice, standards and behaviour.
- Students are able to (1) assess current knowledge in the field of their research project; learn how to use database; (2) develop written and oral communication skills; (3) acquire special knowledge by taken special courses; and (4) gain experimental skills by working with the research group.
- Indicative assessments in this unit are as follows: (1) proposal; (2) proposal presentation; and (3) supervisor assessment. Further information is available in the unit outline.
Supplementary assessment is not available in this unit.
- Unit Coordinator(s)
- Professor Li Ju
- Unit rules
- enrolment in 53560 Master of Physics (Experimental Physics specialisation)
completion of the core and complementary units for the Physics major
- Contact hours
- Average 1 hour per week (students meet with their project supervisors throughout the semester to define the content of the literature review and research proposal)
- Unit Outline
- Semester 1_2019 [SEM-1_2019]
- The availability of units in Semester 1, 2, etc. was correct at the time of publication but may be subject to change.
- All students are responsible for identifying when they need assistance to improve their academic learning, research, English language and numeracy skills; seeking out the services and resources available to help them; and applying what they learn. Students are encouraged to register for free online support through GETSmart; to help themselves to the extensive range of resources on UWA's STUDYSmarter website; and to participate in WRITESmart and (ma+hs)Smart drop-ins and workshops.
- Books and other material wherever listed may be subject to change. Book lists relating to 'Preliminary reading', 'Recommended reading' and 'Textbooks' are, in most cases, available at the University Co-operative Bookshop (from early January) and appropriate administrative offices for students to consult. Where texts are listed in the unit description above, an asterisk (*) indicates that the book is available in paperback. | <urn:uuid:854abeae-c4a5-4999-bfd5-52b7be10d2cf> | CC-MAIN-2020-05 | https://handbooks.uwa.edu.au/unitdetails?clearc=1&code=PHYS5025 | 2020-01-20T08:55:42Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-05/segments/1579250598217.23/warc/CC-MAIN-20200120081337-20200120105337-00310.warc.gz | en | 0.899966 | 613 |
Knee Osteoarthritis of the knee is a chronic pain condition. It’s a progressive disease that is caused by inflammation and degeneration of the knee joint that worsens over time. If you find that your knees are regularly painful or swollen, are stiff first thing in the morning, or are making crackling noises, a possible cause could be osteoarthritis. According to the Arthritis Foundation, more than 27 million people in the U.S. have osteoarthritis, with the knee being one of the most commonly affected areas. Approximately 14 million people in the United States have symptomatic knee osteoarthritis. While it can occur in young people, the chance of developing osteoarthritis rises significantly after age 45. Women are more likely to have osteoarthritis than men. Approximately 60 percent of women over 55 experiencing osteoarthritis at some point.
What Is Knee Osteoarthritis?
Knee osteoarthritis is the most common form of arthritis in the knee. It is a progressive disease caused by inflammation and degeneration of the knee joint that worsens over time. It affects the entire joint including bones, cartilage, ligaments, muscles, and the synovium in the knee joint.
Recent evidence supports the notion of knee osteoarthritis as a “whole person condition” in which knee deterioration is influenced by a variety of factors, rather than solely based on damaged knee structures (British Journal of Sports Medicine). We now understand that knee osteoarthritis is influenced by each person’s particular context, including life stage, psychological, social, physical and lifestyle factors.
Several factors can increase the risk of developing arthritis, including:
- Age and gender.
- Heredity and bone structure.
- Muscular strength.
- Repetitive stress injuries.
- Activity level / athletics.
- Other illnesses and co-morbidities.
How Does Knee Osteoarthritis Feel?
Individuals who develop knee osteoarthritis may experience a wide range of symptoms and limitations based on the progression of the disease. Because the knee is a weight-bearing joint, your activity level, and the type and duration of your activities usually have a direct impact on your symptoms. Typically these symptoms do not occur suddenly or all at once, but instead develop gradually over time.
Symptoms of knee osteoarthritis may include:
- Worsening of pain during/after activity.
- Pain or stiffness after sitting for a prolonged period of time.
- A feeling of popping, cracking or grinding when moving the knee.
- Swelling and warmth following activity.
- Tenderness to touch along the knee joint.
How is Knee Osteoarthritis Diagnosed?
The diagnosis of knee osteoarthritis is based on two primary factors:
1) Your symptoms combined with a clinical exam
The diagnosis of knee osteoarthritis begins with a physical exam by your physician and/or physical therapist. A normal exam will include questions about your medical history, symptoms, your pain levels, activity levels, and possible family history of osteoarthritis. A physical exam should also be performed including your knee’s movement (range of motion), strength, mobility, and flexibility.
2) Diagnostic Imaging
If knee osteoarthritis is suspected, your physician (physiatrist, orthopedist, or rheumatologist) will order X-rays of your knees to check the bones and cartilage of your knee joint. X-rays are used to confirm the diagnosis of knee osteoarthritis.
It is important to note that just because your x-rays show degenerative changes this does not necessarily mean you are destined to have knee pain. Imaging results are actually poorly related to pain. Findings on imaging, such as meniscal/cartilage tears, arthritic changes, and joint narrowing are common in people without pain, especially as we get older. Vice-versa: just because you have knee pain does not mean you have knee damage.
Other diagnostic tools:
Magnetic Resonance Imaging (MRI) scans may be ordered if more severe joint damage is suspected or to look more closely at the overall status of the joint and surrounding tissues.
Blood tests may also be ordered to rule out other conditions including those similar or related to knee osteoarthritis.
How is it Treated?
Managing chronic pain conditions like knee osteoarthritis is complex. Since there is no cure for osteoarthritis, the primary goals are to relieve the pain, limit its progression, and return function and mobility. All major clinical practice guidelines recommend education, exercise therapy, and weight control as the best first-line treatments to start with. Inappropriate pharmacological treatments, passive treatments, or surgery should not be recommended without adequately trialing education, exercise, and weight control. Understanding your relationship to pain is also important in order to manage your experience.
A typical treatment plan may include a combination of the following:
Your physical therapist will consider the stage and extent of your knee osteoarthritis and prescribe an individualized exercise program to address your needs and maximize the function of your knee.
Specific exercises can help increase range of motion and flexibility, as well as help strengthen the muscles in your leg. Your physical therapist develops an individualized graded exercise program that meets your needs and lifestyle. PT treatment programs may include range-of-motion exercises, muscle strengthening and stretching, manual therapy, bracing, and activity recommendations.
As reported recently in Exercise and Knee Arthritis Pain, exercise has been proven to be the most effective treatment for early and moderate knee osteoarthritis. Strengthening the muscles around the knee makes the joint more stable and actually can decrease your pain. Stretching exercises help keep the knee joint mobile and flexible. Something as simple as walking regularly can help you manage osteoarthritis. And while it used to be believed that rest was beneficial, we now know that rest and avoidance makes the pain worse, and that the joint needs movement, even when painful.
Losing even a small amount of weight, if needed, can significantly decrease knee pain by reducing the stress on the knee joint.
Over-the-counter choices such as acetaminophen, ibuprofen, or naproxen sodium can potentially offer temporary relief.
Managing chronic pain conditions like knee osteoarthritis is challenging. In some situations, when dosed appropriately, medications are an appropriate part of medical treatment. Several types of drugs could be useful in treating knee osteoarthritis. However, with opioid abuse at unprecedented national levels, your doctor will work closely with you to determine the medications and dosages that are safe and effective for you.
Corticosteroids and hyaluronic acid, powerful anti-inflammatory agents, can be injected into the knee to provide short to medium term pain relief and reduce inflammation. Two other injection therapies are Platelet-Rich Plasma (PRP) and stem cells, which are demonstrating promising results in the regenerative medicine realm.
Modalities / Alternative therapies
Ice and heat can be used to help aid in pain management. Some alternative therapies that could be explored include topical creams, acupuncture, or supplements, such as tart cherry extract or turmeric with its anti-inflammatory properties.
Using devices such as a cane, wearing shock-absorbing shoes or inserts, or wearing a brace or knee sleeve can potentially be helpful.
There are many factors to consider when determining the appropriate surgical treatment for you, including the nature of your condition, your age, activity level, and overall health.
Joint replacement surgery is a cost-effective and beneficial treatment for the right person at the right time. When conservative treatments have been exhausted and/or your functional limitations and pain levels have reached a point where they significantly impact your daily life, joint replacement surgery can be a good option as a last resort. A small percentage of people may not get pain relief from joint replacement (up to 20 percent).
The meniscus (the shock absorber of the knee) may be involved in some cases of knee osteoarthritis. In the past, surgery (arthroscopy) to repair or remove parts or all of this cartilage was common. Current research however, has thoroughly shown that this is not as effective as we used to think beyond the short term, and may only lead to a speeding up of the arthritic process in the future.
Should you choose to have surgery, your physician and physical therapist can assist you prior to and following your surgery during your rehab. | <urn:uuid:024d4ccf-e421-4e20-a1d6-886ecaeb6fe9> | CC-MAIN-2021-31 | https://www.pointperformance.com/knee-osteoarthritis-treatments-and-diagnosis/ | 2021-08-05T05:24:23Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-31/segments/1627046155322.12/warc/CC-MAIN-20210805032134-20210805062134-00118.warc.gz | en | 0.928248 | 1,774 |
Light Quest 1.0Free
Light Quest is a 2.5D puzzle platformer that relies on mirror placement. Beams of light are present in each level and the player's task is to split and reflect them to activate sensors (sometimes selectively, according to the needs of the puzzle). There are also mechanical nuts to collect on each level as an additional challenge; levels where all were collected are marked by a golden nut.
The protagonist of the game is a crash-landed robot seeking energy for his spaceship. There are 16 levels, including a tutorial level, that span a rather diverse series of environments, albeit with the the rather uninspiring 3D graphics of yesteryear. Gameplay is adequate; mirror rotation, if not so much placement, can be tweaked with both speed and precision. It's a little awkward using the keyboard to move and the mouse to interact with the environment, but it's not impossible to get used to the setup. It's also sometimes a bit easy to lose track of a mirror or be unable to retrieve it, but at least one can restart the level in such a case.
- Playable, with a couple of decent head-scratchers
- Good level selection interface
- Can almost never see enough of scene to position mirrors properly first time around
- Awkward movement and control system
- Not much in the way of original gameplay | <urn:uuid:3cfa772f-8aae-4c03-b9a7-0cf06b0babb5> | CC-MAIN-2020-34 | https://macdownload.informer.com/light-quest/ | 2020-08-09T06:49:34Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-34/segments/1596439738425.43/warc/CC-MAIN-20200809043422-20200809073422-00131.warc.gz | en | 0.947219 | 282 |
|Publication number||US3595634 A|
|Publication date||27 Jul 1971|
|Filing date||11 Sep 1969|
|Priority date||22 Sep 1965|
|Publication number||US 3595634 A, US 3595634A, US-A-3595634, US3595634 A, US3595634A|
|Original Assignee||Kozo Sato|
|Export Citation||BiBTeX, EndNote, RefMan|
|Referenced by (5), Classifications (8)|
|External Links: USPTO, USPTO Assignment, Espacenet|
United States Patent O fice US. Cl. 51-298 6 Claims ABSTRACT OF THE DISCLOSURE A method for producing a grindstone characterized by molding an epoxy resin binder with a hardening agent, active sulphur and sodium nitrite. The novel grindstone is used to prevent rust and uneven finishing of a treated metal surface. The grindstone replenishes the loss due to hydrolysis of the grinding solution, thereby enabling the grinding solution to maintain its lubricating and anticorrosive properties.
This application is a continuation-in-part of copending application Ser. No. 650,662, filed June 22, 1967 and now abandoned.
BACKGROUND OF THE INVENTION The object of the present invention consists of preparing a grindstone with lubricating anticorrosive properties so as to prevent rust on the treated metal surface by uniformly distributing powerful lubricating anti-corrosive materials in the grindstone to be used for grinding metal. The specific lubricating anticorrosives which are contained in the grindstone gradually dissolve into the grinding solution and act upon the surface of the metal to be ground as the grinding operation proceeds and as the grindstone is abraded. The mixed lubricating anticorrosives are effective throughout the entire use of the grindstone, displaying a distinguished effectiveness in obtaining sufiicient grinding and in preventing rust on the metal products to be treated. The present invention relates to the method for producing such a lubricating and anticorrosive grindstone.
DESCRIPTION OF THE PRIOR ART When metal products are finished in the presence of a water-soluble grinding solution, there has very often occurred the problem of rust on the finished metal surface. This problem frequently arises prior to the anticorrosive treatment of the finished products owing to the deterioration and hydrolytic loss of efficiency of the grinding solution with lapse of time. To avoid such problems, it is necessary that the anticorrosive and lubricating properties of the grinding solution itself should be reinforced and replenished, even when the finished articles are exposed to moisture, which is the cause of rust prior to the anticorrosive treatment. The residual grinding solution should be powerful enough to form its primary anticorrosive function by enveloping the metal surface with a film.
The methods for improving the anticorrosive properties of the grinding solution have so far been limited to the improvement of the primary efiiciency of the grinding solution, for example, to make the pH of the solution higher than 8.5 or to use an ion blocking agent or the like. There has been no method to prevent the loss of etficiency due to hydrolysis of the water soluble grinding solution which is the key source of the above discussed problems. The rate of hydrolysis of anticorrosive and lubricating materials in the grinding solution is referred to as the 3,595,634 Patented July 27, 1971 secondary eificiency of the solution. Since there has been no method to improve this secondary efficiency in preventing rust, loss of grinding properties and the like, a technical bottleneck has remained until broken by the present invention. This has been a great disadvantage to the grinding operation on a mass production system, resulting in a serious hinderance to industrial advancement.
In the grinding operation of metal, lack of precision in grinding and the development of rust are serious problems which call for an immediate solution. Very important in this connection is the fact that the grinding efiiciency is greatly impaired by hydrolysis arising with the lapse of time irrespective of whether a water soluble grinding solution is employed or not. The problem of this loss has not been solved nor has it been fully recognized by those skilled in the art.
Special attention must be paid to the fact that the anticorrosive property of a fresh grinding solution, however excellent it may be, is merely the function of the primary etficiency of the grinding solution. It must be noted that the important problem is how to minimize the loss of efficiency due to hydrolysis and how to retain this efiiciency. With respect to the anticorrosive property of the grinding solution, great emphasis should be placed upon the secondary eiiiciency, that is resistance to decomposition, in view of the fact that all grinding solutions are susceptible to hydrolytic loss in the course of use. Consequently, it is clear that the hydrolytic loss of anticorrosive efliciency is fatal to the precision of the grinding process as well as to the mass production of metal articles.
PARTICULARS OF THE INVENTION The deterioration of the lubricating and anticorrosive efficiency of the water soluble grinding solution has so far been attributed only to (1) the nature of water used for the dilution of the grinding solution, for instance, the effect of hard water containing metals, such as calcium and the like and (2) the problems due to calcium, sulfur, pulverized grindstone and metal waste resulting from the grinding operation. Consequently whenever deterioration of grinding efiiciency arises due to rust or other such problems, the only counter-measure taken by the prior art has been to add fresh grinding solution to compensate for that loss or to replace the entire solution with fresh material.
It has been considered until the present invention, that the deterioration of the lubricating and anticorrosive efliciency of the water soluble grinding solution is due to foreign elements produced in the course of the grinding operation. In reality, the loss of efficiency is chiefly due to hydrolysis and it has never been recognized that there will be no fundamental improvement unless the foregoing disadvantage is avoided.
In the present invention, to remove the aforementioned technical defects, a binder having powerful lubricating and anticorrosive properties is uniformly distributed in the grindstone, said binder slowly dissolving in the grind ing solution in the course of the grinding operation, thereby effectively replenishing the efliciency of the grinding solution as it is deteriorated by hydrolysis. The binder composite will dissolve into the grinding solution throughout the entire period of use of the grindstone and problems arising from the loss of lubricating and anticorrosive properties of the grindstone will be prevented. The invention therefore enables the obtention of an excellent grindstone which can transform the grinding solution into that of an efficient non-degrading type, greatly contributing to the technical development of the metal grinding process.
More specifically, abrasives can be chosen from among materials such as Alundum, Carborundum and the like.
An epoxy resin is employed as the binder. The most significant property of the epoxy resin consists of the fact that this type of resin can be readily changed even at room temperature, from a liquid or thermoplastic state into a solid mass of thermosetting resin characterized by toughness. This phenomenon of changing the plastic or semiplastic mass into a solid mass is called hardening or curing. A suitable epoxy resin to be employed in the present invention is a diepoxide of the epichlorohydrinbisphenol A type such as Epikote 828 (Shell Chemical) (equivalent weight based on epoxide groups 182-194) having epoxide groups at both terminal positions of its molecular chain. It exists in the form of a viscous liquid, its molecular weight being 360 to 560 and its equivalent weight based on epoxide groups being 180 to 260.
For hardening, the addition of a hardening agent (or curing agent) is indispensible. As a hardening agent, a chemical compound which is capable of readily reacting with epoxide groups is employed. Such compounds are primarily amines, secondary amines, dicarbonic acid and its anhydride, and the like. Primary and secondary amines are used most widely. Among suitable amines are diethylentriamine, triethylentetramine and the like.
Although the hardening of the epoxy resin begins with the addition of the hardening agent, the curing time required largely depends on the temperature. When an amine is used as a hardening agent, the hardening may take place even at room temperature, but the curing time can be remarkably shortened by elevating the temperature. The optimal temperature for hardening ranges between normal room temperature and 90 C. Active sulfur (alpha or sublimed sulfur) is mixed with the amine and sodium nitrite to obtain sodium amine nitrite sulfide, which is in turn mixed with the epoxy resin to obtain a molding agent for the preferred abrasive. The amines and sodium nitrite in essence act as anticorrosives while the sulfur acts as a lubricant. In practice, however, these compounds exist in the form of reaction products; the amine nitrite acting as the effective anticorrosive and the amine sulfide as a lubricant.
The molding can be affected either at normal temperature or by heating. When sulfur, sodium nitrite and amine in excess of the equivalent quantity of epoxide, are added, the epoxy resin starts a hardening reaction, and various reactions simultaneously arise from the amine, sulfur and sodium nitrite. For instance, diethylenetri'amine and sulfur react as follows:
Amine and sodium nitrite react as follows:
resulting in production of the amine sulfide and amine nitrite, respectively. Furthermore, sodiumamine nitrite sulfide is obtainable by mixing active amine sulfide, sodium nitrite and amine nitrite sulfide by mixing amine nitrite and sulfur, the products having a powerful anticorrosive and lubricating effect. These products display a far greater anticorrosive property when produced in the presence of epoxy resin, and far greater rust-proof property is obtainable when the anticorrosives, such as amine, sodium nitrite and the like, are compounded with epoxy resin as compared with the case wherein such anticorrosives are simply added to the grindstone as ingredients thereof. Among the suitable epoxy resins is the diepoxide of epichlorohydrin-bisphenol A type, having epoxide groups at both terminal positions of its molecular chain. It exists in the form of viscous liquid, its molecular weight being 360-560 and its equivalent weight (based on epoxide groups) being 180-260.
Preferred ranges of epoxy resin are 30 to 50% by weight of the entire composition; preferred ranges of amine are 120 to 250% of the equivalent amount of epoxide; preferred ranges of sulfur are 0.3 to 1.0% of the entire composition and preferred ranges of sodium nitrite are 3 to 10% of the entire composition. Preferred molding temperatures are room temperature to C. and preferred pressures for molding are 50 to 300 kg./cm.
A grindstone of excellent quality is obtainable by mixing and molding the foregoing materials, the anticorrosives and hardening materials while the epoxy resin hardens, the lubricating and anticorrosive materials being uniformly distributed throughout the grindstone simultaneously. If the metal grinding operation is conducted with such a grindstone, the ingredients gradually dissolve into the grinding solution as the grindstone is abraded, giving the grinding solution enhanced lubricating and anticorrosive properties. Moreover, as the dissolution continuously occurs throughout the period of use of the grindstone, problems arising from the deterioration of the efficiency of the grinding solution can be prevented, displaying the eifect of transforming the grinding solution into an efiicient nondegrading type.
The present invention is useful with grinding solutions which degrade either by hydrolysis or other phenomena. A grinding solution uesful in the present invention is, for example, one containing sodium nitrite, amine and surfactant. Another suitable solution is, for example, one containing amine derivatives. The present invention is most useful with grinding solutions containing anticorrosive lubricants such as amine sodium nitrite, amine nitrite, and amine sulfides, etc.
The term sodium amine nitrite sulfide denotes a mixture composed of an amine sulfide and sodium nitrite which mixture has both anticorrosive and lubricating properties.
All percentages set forth herein are by weight.
The preferred embodiments are disclosed hereunder.
EXAMPLE 1 Abrasives: Parts Alundum 1 60 Corundum 1 40 Lubricating and anticorrosive binders? Fluid epoxy resin (Epikote 828 Shell Chemical equivalent 182-194) 2 Diethylenetriamine 2 15 Sulfur 2 1 Sodium nitrite 2 10 1 Admixture 60 parts.
2 Admixturo 40 parts.
The lubricating anticorrosives are fully incorporated, to 40 parts thereof being added 60 parts of the abrasive, the resultant admixture being fully incorporated and then granulated, the grains thus obtained being heated at 40 to 80 C. and then molded into a grindstone with a pressure of 200 kg./cm.
1 Admixlture 55 parts.
2 Admlxture 45 parts.
The lubricating anticorrosives are fully incorporated, to 55 parts thereof 45 parts of the abrasives being added, the resultant admixture being fully incorporated and then granulated, the grains thus obtained being heated at 70 C. and then molded into a grindstone with a pressure of 200 kg./cm.
METAL SURFACE Rust appearing time, Kind of grindstone Grinding solution min.
Ordinary grindstone Water D0 Water soluble grinding 70 solution. Anticorroslve grindstone Water 2 120 1 Of the invention.
2 Or more.
What is claimed is:
1. A process for producing a grindstone comprising: (a) preparaing a grindstone composition by admixing (l) epoxy resin30 to 50% by weight of said composition,
(2) a hardening agent for said epoxide selected from the group consisting of primary and secondary amines-420 to 250% of the equivalent weight of said epoxide,
(3) sodium nitrite-3 to by weight of said composition,
(4) active sulphur-0.3 to 1% by weight of said composition, (5) abrasive grainsthe balance of said composition;
(b) molding said grindstone composition into a grindstone at temperatures between room temperature and 90 C. under a pressure of to 300 kg./cm.
2. A process according to claim 1, wherein the epoxy resin is a diepoxide of epichlororhydrin-bisphenol A condensate having epoxide groups at both terminal positions of its molecular chain and having a molecular weight of about 360-560 and equivalent Weight based on epoxide groups of about 180 to 260.
3. A process according to claim 1 wherein the amine hardener is diethylenetriamine.
4. A process according to claim 1 wherein the abrasive grains are selected from the group consisting of Alundu-m, Carborundum and mixtures thereof.
5. A process according to claim 4 wherein the alundum and corrundum are employed in admixture in the ratio of to Alundum to 30 to 40% Carborundum.
6. A grindstone produced by the process of claim 1.
References Cited UNITED STATES PATENTS 2,448,985 9/1948 Kuzmick 51-298 2,462,480 2/1949 Eppler 51308 2,779,668 1/ 1957 Daniels 5l-298 3,020,140 2/1962 Bluth 51-308 DONALD J. ARNOLD, Primary Examiner UJS. Cl. X.R.
|Citing Patent||Filing date||Publication date||Applicant||Title|
|US3833346 *||26 Jul 1971||3 Sep 1974||Wirth J||Abrading aid containing paraffin and an inhibitor|
|US4095961 *||5 Nov 1976||20 Jun 1978||Wirth John C J||Method for preserving the grinding characteristics of a grinding tool|
|US4239501 *||7 Mar 1978||16 Dec 1980||Wirth John C||Method for preserving the grinding characteristics of a grinding tool|
|US4765801 *||21 Oct 1987||23 Aug 1988||Tsuneo Masuda||Grindstone-polymer composite for super colloid mill and manufacturing method thereof|
|US5562745 *||10 Feb 1995||8 Oct 1996||Minnesota Mining And Manufacturing Company||Abrasive articles, methods of making abrasive articles, and methods of using abrasive articles|
|U.S. Classification||51/298, 51/295|
|International Classification||B24D3/34, C08K3/00|
|Cooperative Classification||B24D3/344, C08K3/00|
|European Classification||C08K3/00, B24D3/34B2| | <urn:uuid:ff116c29-3014-4213-b56c-d9abb4df9fbb> | CC-MAIN-2016-50 | http://www.google.com.au/patents/US3595634 | 2016-12-08T04:11:59Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-50/segments/1480698542412.97/warc/CC-MAIN-20161202170902-00086-ip-10-31-129-80.ec2.internal.warc.gz | en | 0.904953 | 3,664 |
Japan : policy perspectives one year after the tsunami struck
One year after the devastating tsunami hit the east coast of Japan, UNESCO and the United Nations University (UNU) are organizing a symposium (Tokyo, 16 - 17 February) to examine the lessons learned from the disaster; consider its policy implications, and the importance of preparedness and discuss tsunami warning systems.
The symposium will be opened by the Director-General of UNESCO, Irina Bokova; the Rector of the United Nations University, Konrad Osterwalder; and the Executive Secretary of the Intergovernmental Oceanographic Commission and Assistant UNESCO Director-General, Wendy Watson-Wright. It will bring together leading scientists and policy makers.
These specialists will address a range of questions that have arisen from the tsunami and resulting humanitarian response, including: How can a country prepare for the unexpected? How can education contribute to community preparedness? What are the most effective ways of warning the people concerned? How can the involvement of intergovernmental organizations in setting up warning systems be strengthened?
The 9.0 magnitude earthquake and following tsunami of 11 March 2011, claimed 20,000 lives (65% of the victims were aged 60 or more) and destroyed more than 128,000 homes. It also annihilated infrastructure such as town halls, fire stations, hospitals and schools.
UNESCO’s Intergovernmental Oceanographic Commission established an International Coordination Group for the Tsunami Warning System in the Pacific in 1965, following the major tsunami of 1960 that hit the coasts of Chile, Japan, Hawaii and Philippines, and claimed close to 2,000 lives. The purpose of the Group is to coordinate the ongoing development and enhancement of the Pacific Tsunami Warning Systems and to promote the establishment of national risk assessments, alert and response programmes.
Most tsunamis occur in the Pacific Ocean and connected seas. Over the past three years, three major tsunamis have struck: Samoa in 2009, Chile in 2010, and Japan in 2011.
Media contact: Agnès Bardon, UNESCO Press Service. Tel : +33 (0) 1 45 68 17 64, firstname.lastname@example.org
More on the symposium : www.ioc-cd.org/index.php
<- Back to: Partners & Donors | <urn:uuid:60a2f2fa-6ca7-4d94-9258-5a54aafae0f1> | CC-MAIN-2014-15 | http://www.unesco.org/new/en/unesco/partners-donors/single-view/news/japan_policy_perspectives_one_year_after_the_tsunami_struck/ | 2014-04-21T13:34:15Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-15/segments/1397609539776.45/warc/CC-MAIN-20140416005219-00247-ip-10-147-4-33.ec2.internal.warc.gz | en | 0.88699 | 471 |
We use our normal duvet but bought a smaller pillow to save some space. The mattress is created by an 8 cm tick HR foam mattress and a tin mattress topper.
We bought a 120×200 cm HR foam or cold foam mattress with a thickness of 8 cm. This HR foam is a polyurethane foam with an open cell structure that ensures good ventilation and a high degree of resilience (hence its name: High Resilience).
We sliced this mattress with a sharp kitchen knife into three parts. The food end of the bed is a little bit narrower, but the middle section already follows the wheel arches and becomes 120 cm wide. We ended up with a mattress which was 185 cm long.
Storage of the bed is simple, we use an IKEA bag for the pillows and duvet and strap the mattress to the ceiling of the car. We reclaimed the Velcro straps from our IKEA mattresses we use at home. | <urn:uuid:3f1612c1-a0c1-4c2d-b3d7-287637166650> | CC-MAIN-2022-40 | https://allexclusivecruises.com/going-to-bed/ | 2022-10-04T23:53:47Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-40/segments/1664030337529.69/warc/CC-MAIN-20221004215917-20221005005917-00610.warc.gz | en | 0.934773 | 197 |
"So, because you are lukewarm, neither hot nor cold, I will spit you out of my mouth." Revelation 3:16.
Hi Deanne! THank you so much for you wonderful words, you are part of the community of friends that I am so happy to be in company with.Hugs!Ebeth
Post a Comment | <urn:uuid:3a60681d-13f2-47e2-983f-c43ea0a85ffc> | CC-MAIN-2017-43 | http://notlukewarm.blogspot.com/2008/10/away.html | 2017-10-21T15:36:59Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-43/segments/1508187824820.28/warc/CC-MAIN-20171021152723-20171021172723-00192.warc.gz | en | 0.922377 | 73 |
Takeaway: Holidays are for sitting back and relaxing. “Netflix and Chill” the popular slang amongst weekend lovers had got a new addition “Bong, Netflix and Chill”. The entertainment centre has been curating new shows every month. With the recent developments in the CBD market, weed has become a centre point for numerous new shows. Here is our list of top weed related movies and shows for CBD lovers to watch this holiday season. News, famous and old this blog covers the best of content related to cannabis over the internet.
The holiday season is in full fledge, and many of you must have already had an overdose of social interactions, and believe me when I say this, I feel you. It’s true that the Christmas spirit is in the air, but some of us can handle that only for a day, maybe two. After that, we need our space that has everything we so dearly long for- A couch, some good weed, and Netflix.
If you too are planning on spending the rest of the holidays silently, and are in too much love with cannabis, we have some of the most interesting Netflix weed shows to binge-watch this holiday season. And even if you don’t have a Netflix subscription, we have also listed some off-Netflix weed shows to get you going this holiday season!
Personally, all I want to do during the holidays is to binge-watch the new content, and eat a lot! Because when else would you get time to do that! On that note, let’s start with the list of the weed shows on Netflix:
5 Amazing Netflix Weed Shows
1. That ’70s Show
If you are in a mood to tickle all your funny bones, this is the show for this season! With a stellar cast of Mila Kunis, Ashton Kutcher, Topher Grace, Laura Prepon, Danny Masterson, and Wilmer Valderrama, That ’70s Show is perfect to time travel to your high school days. The backdrop is of the ’70s, but its USP is plain humor.
Now, why did I list it as a Netflix weed series is that it has lots of marijuana in it? Hyde (Masterson) always has marijuana on him, and the lot is seen going crazy in ‘The Circle’ (That’s what they call it) at least once in each episode. Leo is another character who stays high all the time and say some of the most absurd things. Join their circle, and I bet you’ll have a great time binge-watching this show!
From the makers of The Big Bang Theory and Two and a Half Men, could you expect any less funny? Disjointed could be every cannabis activist’s story, only a little too dramatic. It’s a story about Ruth Whitefeather Feldman played by Kathy Bates, a cannabis advocate who runs a cannabis dispensary with her son and a few employees.
Although the reviews are a bit on the low side, I’m sure you would enjoy with your own high. Creatively appealing or not, this Netflix weed show is something I would support anyhow because of its niche which needs a standing right about not.
3. Wild Wild Country
If you are not only a fan of liberalism but also good storytelling, Wild Wild Country is a must-watch. It’s a documentary about Bhagwan Shree Rajneesh who moved his faction from India to Oregon in 1981. His cult changed Oregon, and there was a lot that happened which is articulately shown in the documentary. This is not entirely a Netflix weed series, but it is absolutely fun to watch the beliefs of the sect, like free sex and more.
4. Cooking On High
Netflix doesn’t resist in going with the flow, and Cooking On High is the best example to prove it. Today, marijuana is receiving an understanding nod rather than a cold stare, and with the increase in cannabis culinary experiments, this weed show on Netflix is exactly what people might appreciate.
Cooking on High is a first ever cannabis cooking competitive show. Although the show has not received great reviews from the critics, it could be a great watch if you are high. The people on the show will be high, you’d be with your bong all set to get high, I don’t think anything else would matter.
Snoop Dogg has always been a vocal supporter and user of marijuana, and Reincarnated is his documentary film of taking a new life and music with Rastafari culture in Jamaica. Snoop took a trip to Jamaica to transform himself into a Rastafari, which he did and is now changed to Snoop Lion.
Andy Capper of Vice magazine shot this documentary that has many intimate chats with the singer. As Rastafari of Jamaica indulge themselves in marijuana, Snoop is seen smoking a lot in the documentary. If you are keen on knowing the transformed Snoop Dogg, Reincarnated is the Netflix weed documentary for you this season.
No Netflix But Still Want To Chill? 4 Weed Shows Not On Netflix
A classic Bill Murray film! It is a comedy film which you would enjoy with the company you have (weed). Although the film is not about marijuana, Bill Murray, the vocal advocate of marijuana is the reason why I listed it here.
Nevertheless, the movie does have a classic stoner scene which is considered to be one of the funniest marijuana shots in the industry. Worth a watch!
2. Pineapple Express
Now, this is an authentic stoner comedy film equally loved by both, the critics and the viewers. The film is about two friends, a pot-smoking process server and his drug dealer who accidentally witnesses a murder, and have to flee from the corrupt cop.
It is a marijuana fuelled comedy and delivers everything that’s expected from this genre. It was reviewed as the most entertaining film of that year, and some scenes will leave you in splits. Pineapple express was a Netflix weed movie previously but now, you’d have to watch it on Amazon Prime.
3. Easy Rider
How many of you remember the first time you got high? Well, one can’t remember but only hear stories from friends. Dennis Hooper and Peter Fonda will take you back to your early stoner days with their riding around the country that involves a chilled out attitude. The scene where Jack Nicholson’s character smokes marijuana for the first time is just epic. Here, watch it yourself:
Okay, it’s not a weed show, but it’s that series which is loved by both, the critics and viewers. An extension of Cosmos: A Personal Voyage of Carl Sagan, Spacetime Odyssey is co-created by his widow, Ann Druyan along with Steven Soter, and hosted by the one and only, Neil deGrasse Tyson.
I can’t get enough of this show, and I’m sure you’d too if you love science a little too much with your bongs. This Fox series was on Netflix until the past year but is discontinued as of now. You can watch it on Amazon Prime.
Enjoy your holidays with some amazing strains and Netflix weed content! | <urn:uuid:81c48dec-1cd0-4877-8262-64ff69ad212c> | CC-MAIN-2019-35 | https://marijuanaspan.com/netflix-weed-show/ | 2019-08-23T18:54:45Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-35/segments/1566027318952.90/warc/CC-MAIN-20190823172507-20190823194507-00001.warc.gz | en | 0.967749 | 1,509 |
Ten teens decide to have a party at an abandoned inhumation parlor called Pod House. Hull Crib is on a strip of turf rumored to be unclean and unfit throughout human inhabitance. The house has a ribald history to it including a the Hull being murdered. After the ten kids enter the household they determine to suffer with a s?ance. After an attempt for the s?ance they awaken a demon that lives in the basement. It possesses one of the girls then from her everybody under the sun else becomes controlled and killed past demons that inhabit the land.
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We are excited to present our first ever electrical home renovation give away of up to $3000. Renovate your washroom, kitchen or maybe even wire your whole basement adding that perfect place to relax in your home.
Here’s what you do:
- Like our page.
- Post our website with a friendly comment on your Facebook page.
- Have 3 friends so the same, tagging Hyperion Electrical so we can confirm.
You will be entered to win.
Entry deadline by December 2018. | <urn:uuid:c6337aef-81ed-475d-80cd-0ecca50ed462> | CC-MAIN-2019-35 | http://www.hyperionelectrical.com/blog/ | 2019-08-25T19:13:29Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-35/segments/1566027330786.8/warc/CC-MAIN-20190825173827-20190825195827-00509.warc.gz | en | 0.891252 | 106 |
The radiant sun stretched down its golden fingers and crept beneath my curtain, cascading onto my carpet. As the sun touched my soft, pale forehead I leaned out of bed. It was almost calling me to stand in its' light and absorb its saffron glory. I was reluctant to leave the suns shimmering power when my mum called "Get ready! We're going to the park!"
This got me moving, in a few short seconds I had scrambled downstairs, to wait for my mum. As I stepped out of the glossy black door it was like stepping into a canvas splashed with cobalt, gilt yellow, and vibrant green and lots of other luxurious colours.
When I arrived with my mum I couldn't resist the temptation to just stand and admire the gifts of summer : the indigo flowers dancing in the crisp wind , the emerald green grass slumbering under the fiery sun and the scarlet apples leaping off the trees and plopping onto the earthy ground.
Strangely I heard a rustle in the tree. Then a young girl with blonde hair, a bright yellow dress, golden shoes and a pair of deep yellow eyes appeared " Hello I'm Sunshine." The girl called to me. "Hi I'm Jesse." I called back.
Sunshine and I spent the rest of the day together. The most amazing thing about Sunshine was that wherever she went she spread laughter and light.
A few days passed and Sunshine and I were the best of friends. One day Sunshine had asked to talk to me. She said " I am a sun child I was set upon earth to bring light and joy I have done that now and must go." I watched her as she was blown away into dust by the whistling wind. Never to be seen again... | <urn:uuid:b561348d-0985-4450-9ab5-6993dbef0492> | CC-MAIN-2019-51 | https://www.litrasaurus.com/stories/read/radiant-735397 | 2019-12-12T00:40:17Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-51/segments/1575540534443.68/warc/CC-MAIN-20191212000437-20191212024437-00555.warc.gz | en | 0.975853 | 362 |
Share aiga taxi bg clipart with you friends!
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1979 Mattel Robin Williams Mork & Mindy 9" Mork Doll Boxed Sealed AFA 80 Mint
Mork & Mindy
9 Inch Doll
This is a 9 inch Talking Mork doll with backpack.
The character was played by Robin Williams in the TV show.
The condition is amazing and box is still sealed
with little age & wear.
The boxed doll is graded a AFA 80 , with the grades
of Box80 / Window85 / Window85 . These are high grades
for a boxed item. This is a unique item to be graded and only 1
is graded higher by AFA . This is a great piece.
The pictures show all sides and the grade.
Auction is for 1 item.
The best part is the ........
New: A brand-new, unused, unopened, undamaged item (including handmade items).
|Character Family:||Mork & Mindy||Size:||9"|
|Recommended Age Range:||6+|
|Gender:||Boys & Girls||Packaging:||Original (Opened)|
|Country/Region of Manufacture:||Hong Kong||UPC:||
Does not apply | <urn:uuid:1f920c5d-5e9e-473a-a6c4-c6ce85cc90be> | CC-MAIN-2019-43 | https://beantowncollectibles.com/collections/toys/products/1979-mattel-robin-williams-mork-mindy-9-mork-doll-boxed-sealed-afa-80-mint | 2019-10-24T00:08:43Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-43/segments/1570987836368.96/warc/CC-MAIN-20191023225038-20191024012538-00423.warc.gz | en | 0.732012 | 252 |
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College Hosts Historical Poetics Symposium
Blade Runner 2049 Released in a Dystopia Where Good Movies Fail
As Negotiations Progress, Conn Must Recognize Its Debt to New London
Art of Resistance Met with Reality of Complacence
“The Ability Exhibit” Educates on Allyship
First Year, First Impressions of Social Life
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Cranky blogger Red Ink: Texas has an interesting post today about how Canadians are getting fed up with long waits to see doctors, or get radiation treatment for cancer, in their socialized medicine system. The solution? Privatization.
Quoth he from the New York Times:
The median wait time between a referral by a family doctor and an appointment with a specialist has increased to 8.3 weeks last year from 3.7 weeks in 1993, according to a recent study by The Fraser Institute, a conservative research group. Meanwhile, the median wait between appointment with a specialist and treatment has increased to 9.4 weeks from 5.6 weeks over the same period.
Average wait times between referral by a family doctor and treatment range from 5.5 weeks for oncology to 40 weeks for orthopedic surgery, according to the study.
Last December, provincial health ministers unveiled new targets for cutting wait times, including four weeks for radiation therapy for cancer patients beginning when doctors consider them ready for treatment and 26 weeks for hip replacements.
But few experts think that will stop the trend toward privatization.
Personally, I think the gap between the insured and the uninsured in Houston is a little sickening. But those wait times are a dash of cold water in the face of all who sing the praises of socialized medicine.
Me, I’m even opting out of managed care (for little stuff). Not to brag, but I called my cash-only doc this morning, got her immediately, and received some very sensible advice about a sprained ankle. | <urn:uuid:c16e18b4-4321-413b-b8c9-5c983575544f> | CC-MAIN-2015-11 | http://blog.chron.com/medblog/2006/02/a-four-week-wait-for-cancer-treatment-and-other-horrors/ | 2015-03-04T22:50:15Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-11/segments/1424936463660.11/warc/CC-MAIN-20150226074103-00231-ip-10-28-5-156.ec2.internal.warc.gz | en | 0.966977 | 319 |
Cavities have become a somewhat normal occurrence in pediatric dentistry, but they don’t have to be. Cavities can be avoided with proper hygiene, preventative care, and regular checkups with a Camelback pediatric dentist. With a kids dental office in Camelback like with Dr. Lisa Bienstock, we want to partner with you to provide the proper education and care. This will give your child the best chance at entering adulthood with a healthy smile and teeth. Here are a few tips that can help prevent cavities.
Sealants are growing in popularity among parents and dentists alike. This is because they not only protect your child’s teeth, but they do an excellent job of preventing cavities. Teeth often have many ridges and small spaces for food and bacteria to hide. Foods with high acidity, sugar, and other harmful substances get into these small areas, which can be hard to remove.
Even with kids that brush regularly it’s hard to reach some of these spots. Over time, cavities can form and spread. Sealants put a protective coating on the tooth’s surface, covering these tiny spots, which will prevent food from sitting on the tooth and starting the decay process.
Get Fluoride Treatments
Fluoride is a teeth strengthener. This means that it makes your child’s teeth less susceptible to cavities and tooth decay. Studies have found that when used appropriately through the help of a pediatric dentist in Camelback, fluoride use can significantly reduce the number of cavities that your child develops.
Cut Back on Sugar
Sugar is in nearly everything these days, including in your meals, spices, let alone soft drinks, sports drinks, and most snacks. Sugars are the main reason for tooth decay and cavities. Cutting back on your child’s sugar intake, brushing after a sugary treat, or rinsing with water, are all key to keeping their teeth healthy and strong according to most Camelback pediatric dentists.
Increase Your Child’s Xylitol Intake
Xylitol is found naturally in some berries and fruits and is also widely used as a sugar alternative. It has enormous benefits for children’s tooth health and significantly reduces their development of cavities. Check with your Camelback pediatric orthodontist or dentist to see if Xylitol is suitable for your child.
Brushing your child’s teeth three times a day after meals or snacks is a good rule of thumb. This is because when sticky or chewy foods stick to the surface of the tooth, it causes the protective coating to break down and start to erode and decay the tooth.
Over time this can cause cavities that can be both painful and costly. Brushing with a fluoride toothpaste not only removes the stuck-on food from the tooth, but the fluoride strengthens your child’s tooth. This is a great way to kill two birds with one stone.
Are You Ready to Work with a Premier Camelback Pediatric Dentist?
Dr. Lisa Bienstock is a trusted pediatric dental specialist in Camelback, her combination of compassion and specialized expertise when it comes to your child’s mouth and teeth is unmatched. She not only treats cavities and other dental conditions but is a big part of the education on prevention. She will have a huge impact on making sure your child’s smile turns into a beautiful grown-up grin. | <urn:uuid:60be9460-e7e9-460a-8b6a-18a761636fce> | CC-MAIN-2023-50 | https://www.doctorlisabienstock.com/how-to-prevent-cavities-with-the-help-of-a-pediatric-dentist-in-camelback/ | 2023-12-08T12:52:01Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-50/segments/1700679100745.32/warc/CC-MAIN-20231208112926-20231208142926-00195.warc.gz | en | 0.947496 | 711 |
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President | CEO | <urn:uuid:ff7e36a9-03ee-4022-8de0-531c9852d6dc> | CC-MAIN-2015-27 | http://www.interactive-id.com/ | 2015-06-30T14:26:50Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-27/segments/1435375093974.67/warc/CC-MAIN-20150627031813-00150-ip-10-179-60-89.ec2.internal.warc.gz | en | 0.953564 | 510 |
Author + information
- Published online December 14, 2010.
- Philip Greenland, MD, FACC, FAHA, Chair, Writing Committee Member,
- Joseph S. Alpert, MD, FACC, FAHA, Writing Committee Member,
- George A. Beller, MD, MACC, FAHA, Writing Committee Member,
- Emelia J. Benjamin, MD, ScM, FACC, FAHA, Writing Committee Member⁎,†,
- Matthew J. Budoff, MD, FACC, FAHA, Writing Committee Member‡,§∥,
- Zahi A. Fayad, PhD, FACC, FAHA, Writing Committee Member¶,
- Elyse Foster, MD, FACC, FAHA, Writing Committee Member#,
- Mark A. Hlatky, MD, FACC, FAHA, Writing Committee Member§,⁎⁎,
- John McB. Hodgson, MD, FACC, FAHA, FSCAI, Writing Committee Member‡,§,⁎⁎,††,
- Frederick G. Kushner, MD, FACC, FAHA, Writing Committee Member†,‡‡,
- Michael S. Lauer, MD, FACC, FAHA, Writing Committee Member,
- Leslee J. Shaw, PhD, FACC, FAHA, Writing Committee Member§§,
- Sidney C. Smith Jr, MD, FACC, FAHA, Writing Committee Member∥∥,¶¶,
- Allen J. Taylor, MD, FACC, FAHA, Writing Committee Member##,
- William S. Weintraub, MD, FACC, FAHA, Writing Committee Member and
- Nanette K. Wenger, MD, MACC, FAHA, Writing Committee Member
- ACCF/AHA practice guidelines
- cardiovascular risk assessment
- asymptomatic adults
- cardiovascular screening of asymptomatic adults
- detection of coronary artery disease
- risk factor assessment
- subclinical coronary artery disease
ACCF/AHA Task Force Members
Alice K. Jacobs, MD, FACC, FAHA, Chair, 2009–2011
Sidney C. Smith, Jr, MD, FACC, FAHA, Immediate Past Chair, 2006–2008⁎⁎⁎
Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect
Nancy Albert, PhD, CCNS, CCRN
Christopher E. Buller, MD, FACC⁎⁎⁎
Mark A. Creager, MD, FACC, FAHA
Steven M. Ettinger, MD, FACC
Robert A. Guyton, MD, FACC
Jonathan L. Halperin, MD, FACC, FAHA
Judith S. Hochman, MD, FACC, FAHA
Frederick G. Kushner, MD, FACC, FAHA
Rick Nishimura, MD, FACC, FAHA⁎⁎⁎
E. Magnus Ohman, MD, FACC
Richard L. Page, MD, FACC, FAHA⁎⁎⁎
William G. Stevenson, MD, FACC, FAHA
Lynn G. Tarkington, RN⁎⁎⁎
Clyde W. Yancy, MD, FACC, FAHA
Table of Contents
1.1 Methodology and Evidence Review......e55
1.2 Organization of the Writing Committee......e55
1.3 Document Review and Approval......e55
1.4 Magnitude of the Problem of Cardiovascular Risk in Asymptomatic Adults......e56
1.5 Assessing the Prognostic Value of Risk Factors and Risk Markers......e56
1.6 Usefulness in Motivating Patients or Guiding Therapy......e57
1.7 Economic Evaluation of Novel Risk Markers......e57
2. Approaches to Risk Stratification......e58
2.1 General Approach to Risk Stratification......e58
2.1.1 Recommendation for Global Risk Scoring......e58
126.96.36.199 General Description......e58
2.1.2 Association With Increased Risk and Incremental Risk of Additional Risk Factors......e59
2.2 Family History and Genomics......e60
2.2.1 Recommendation for Family History......e60
188.8.131.52 Association With Increased Cardiovascular Risk and Incremental Risk......e60
184.108.40.206 Usefulness in Motivating Patients or Guiding Therapy......e60
2.2.2 Genotypes: Common Genetic Variants for Coronary Heart Disease......e61
220.127.116.11 Recommendation for Genomic Testing......e61
18.104.22.168 Association With Increased Cardiovascular Risk and Incremental Risk......e61
22.214.171.124 Usefulness in Motivating Patients or Guiding Therapy......e61
2.3 Lipoprotein and Apolipoprotein Assessments......e61
2.3.1 Recommendation for Lipoprotein and Apolipoprotein Assessments......e61
2.3.2 Assessment of Lipoprotein Concentrations, Other Lipoprotein Parameters, and Modified Lipids......e61
2.3.3 Risk Prediction Relationships Beyond Standard Risk Factors......e62
2.3.4 Usefulness in Motivating Patients or Guiding Therapy......e62
2.3.5 Evidence for Improved Net Health Outcomes......e62
2.4 Other Circulating Blood Markers and Associated Conditions......e62
2.4.1 Recommendation for Measurement of Natriuretic Peptides......e62
126.96.36.199 General Description......e63
188.8.131.52 Usefulness in Motivating Patients or Guiding Therapy......e64
2.4.2 Recommendations for Measurement of C-Reactive Protein......e64
184.108.40.206 Association With Increased Cardiovascular Risk and Incremental Risk Prediction......e64
2.4.3 Metabolic: Hemoglobin A1C......e65
220.127.116.11 Recommendation for Measurement of Hemoglobin A1C......e65
18.104.22.168 General Description......e65
22.214.171.124 Association With Cardiovascular Risk in Persons Without Diabetes......e65
2.4.4 Urinary Albumin Excretion......e65
126.96.36.199 Recommendations for Testing for Microalbuminuria......e65
188.8.131.52 General Description......e65
184.108.40.206 Association With Cardiovascular Risk......e66
220.127.116.11 Usefulness in Motivating Patients or Guiding Therapy......e66
2.4.5 Lipoprotein-Associated Phospholipase A2......e66
18.104.22.168 Recommendation for Lipoprotein-Associated Phospholipase A2......e66
22.214.171.124 General Description......e66
126.96.36.199 Association With Cardiovascular Risk......e66
188.8.131.52 Usefulness in Motivating Patients or Guiding Therapy......e66
2.5 Cardiac and Vascular Tests for Risk Assessment in Asymptomatic Adults......e66
2.5.1 Resting Electrocardiogram......e66
184.108.40.206 Recommendations for Resting Electrocardiogram......e66
220.127.116.11 General Description......e67
18.104.22.168 Association With Increased Risk and Incremental Risk......e67
22.214.171.124 Usefulness in Motivating Patients, Guiding Therapy, and Improving Outcomes......e68
2.5.2 Resting Echocardiography for Left Ventricular Structure and Function and Left Ventricular Hypertrophy: Transthoracic Echocardiography......e68
126.96.36.199 Recommendations for Transthoracic Echocardiography......e68
188.8.131.52 Left Ventricular Function......e68
184.108.40.206 Left Ventricular Hypertrophy......e68
220.127.116.11 Usefulness in Motivating Patients or Guiding Therapy......e69
2.5.3 Carotid Intima-Media Thickness on Ultrasound......e69
18.104.22.168 Recommendation for Measurement of Carotid Intima-Media Thickness......e69
22.214.171.124 General Description......e69
126.96.36.199 Independent Relationship Beyond Standard Risk Factors......e70
188.8.131.52 Usefulness in Motivating Patients or Guiding Therapy......e71
184.108.40.206 Evidence for Improved Net Health Outcomes......e71
2.5.4 Brachial/Peripheral Flow-Mediated Dilation......e71
220.127.116.11 Recommendation for Brachial/Peripheral Flow-Mediated Dilation......e71
18.104.22.168 General Description......e71
22.214.171.124 Association With Increased Risk and Incremental Prediction......e71
126.96.36.199 Usefulness in Motivating Patients or Guiding Therapy......e72
188.8.131.52 Changes in Patient Outcomes......e72
2.5.5 Pulse Wave Velocity and Other Arterial Abnormalities: Measures of Arterial Stiffness......e72
184.108.40.206 Recommendation for Specific Measures of Arterial Stiffness......e72
220.127.116.11 Description of Specific Measures of Arterial Stiffness......e72
18.104.22.168 Evidence on the Association With Increased Cardiovascular Risk and Incremental Risk......e73
22.214.171.124 Usefulness in Motivating Patients or Guiding Therapy......e74
2.5.6 Recommendation for Measurement of Ankle-Brachial Index......e74
126.96.36.199 General Description......e74
188.8.131.52 Association With Increased Risk......e74
184.108.40.206 Usefulness in Motivating Patients or Guiding Therapy......e74
2.5.7 Recommendation for Exercise Electrocardiography......e74
220.127.116.11 Association With Increased Risk and Incremental Risk......e74
18.104.22.168 Usefulness in Motivating Patients or Guiding Therapy......e76
2.5.8 Recommendation for Stress Echocardiography......e76
22.214.171.124 General Description......e76
126.96.36.199 Association With Increased Risk......e76
188.8.131.52 Usefulness in Motivating Patients or Guiding Therapy......e77
2.5.9 Myocardial Perfusion Imaging......e77
184.108.40.206 Recommendations for Myocardial Perfusion Imaging......e77
220.127.116.11 Description of Myocardial Perfusion Imaging......e77
18.104.22.168 Evidence of Association With Increased Cardiovascular Risk in Asymptomatic Adults......e77
22.214.171.124 Usefulness in Motivating Patients or Guiding Therapy......e78
126.96.36.199 Changes in Patient Outcomes......e78
2.5.10 Computed Tomography for Coronary Calcium......e78
188.8.131.52 Recommendations for Calcium Scoring Methods......e78
184.108.40.206 Calcium Scoring Methods......e78
220.127.116.11 Data on Independent Relationship to Cardiovascular Events......e79
18.104.22.168 Usefulness in Motivating Patients......e79
22.214.171.124 Use as a Repeat Measure to Monitor Effects of Therapy in Asymptomatic Persons......e79
126.96.36.199 Usefulness of Coronary Calcium Scoring in Guiding Therapy......e80
188.8.131.52 Evidence for Improved Net Health Outcomes......e80
184.108.40.206 Special Considerations......e80
2.5.11 Coronary Computed Tomography Angiography......e80
220.127.116.11 Recommendation for Coronary Computed Tomography Angiography......e80
18.104.22.168 General Description......e80
22.214.171.124 Association With Increased Risk and Incremental Prediction in Asymptomatic Persons......e81
126.96.36.199 Changes in Patient Outcomes......e81
2.5.12 Magnetic Resonance Imaging of Plaque......e81
188.8.131.52 Recommendation for Magnetic Resonance Imaging of Plaque......e81
184.108.40.206 General Description......e81
2.6 Special Circumstances and Other Considerations......e82
2.6.1 Diabetes Mellitus......e82
220.127.116.11 Recommendations for Patients With Diabetes......e82
18.104.22.168 General Description and Background......e82
22.214.171.124 Electrocardiographic Stress Testing for Silent Myocardial Ischemia......e83
126.96.36.199 Noninvasive Stress Imaging for Detection of Ischemia and Risk Stratification......e83
188.8.131.52 Usefulness in Motivating Patients......e83
184.108.40.206 Evidence of Value for Risk Assessment for Coronary Atherosclerosis or Ischemia or Both to Guide Therapy or Change Patient Outcomes......e83
220.127.116.11 Diabetes and Hemoglobin A1C......e83
18.104.22.168 Association With Cardiovascular Risk......e84
22.214.171.124 Usefulness in Motivating Patients, Guiding Therapy, and Improving Outcomes......e84
2.6.2 Special Considerations: Women......e84
126.96.36.199 Recommendations for Special Considerations in Women......e84
188.8.131.52 Detection of Women at High Risk Using Traditional Risk Factors and Scores......e84
184.108.40.206 Comparable Evidence Base for Risk Stratification of Women and Men......e84
2.6.3 Ethnicity and Race......e85
2.6.4 Older Adults......e85
2.6.5 Chronic Kidney Disease......e85
3. Future Research Needs......e85
3.1 Timing and Frequency of Follow-Up for General Risk Assessment......e85
3.2 Other Test Strategies for Which Additional Research Is Needed......e85
3.2.1 Magnetic Resonance Imaging......e85
3.2.2 Genetic Testing and Genomics......e86
3.2.3 Geographic and Environmental or Neighborhood Risks......e86
3.2.4 Role of Risk Assessment Strategies in Modifying Patient Outcomes......e86
3.3 Clinical Implications of Risk Assessment: Concluding Comments......e86
Appendix 1. Author Relationships With Industry and Other Entities......e87
Appendix 2. Reviewer Relationships With Industry and Other Entities......e89
Appendix 3. Abbreviations List......e92
It is essential that the medical profession play a central role in critically evaluating the evidence related to drugs, devices, and procedures for the detection, management, or prevention of disease. Properly applied, rigorous, expert analysis of the available data documenting absolute and relative benefits and risks of these therapies and procedures can improve the effectiveness of care, optimize patient outcomes, and favorably affect the cost of care by focusing resources on the most effective strategies. One important use of such data is the production of clinical practice guidelines that, in turn, can provide a foundation for a variety of other applications, such as performance measures, appropriate use criteria, clinical decision support tools, and quality improvement tools.
The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force) is charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, and the Task Force directs and oversees this effort. Writing committees are charged with assessing the evidence as an independent group of authors to develop, update, or revise recommendations for clinical practice.
Experts in the subject under consideration have been selected from both organizations to examine subject-specific data and write guidelines in partnership with representatives from other medical practitioner and specialty groups. Writing committees are specifically charged to perform a formal literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and clinical outcomes constitute the primary basis for recommendations in these guidelines.
In analyzing the data and developing recommendations and supporting text, the writing committee used evidence-based methodologies developed by the Task Force that are described elsewhere (1). The committee reviewed and ranked evidence supporting current recommendations, with the weight of evidence ranked as Level A if the data were derived from multiple randomized clinical trials or meta-analyses. The committee ranked available evidence as Level B when data were derived from a single randomized trial or nonrandomized studies. Evidence was ranked as Level C when the primary source of the recommendation was consensus opinion, case studies, or standard of care. In the narrative portions of these guidelines, evidence is generally presented in chronological order of development. Studies are identified as observational, retrospective, prospective, or randomized when appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and ranked as Level C. An example is the use of penicillin for pneumococcal pneumonia, where there are no randomized trials and treatment is based on clinical experience. When recommendations at Level C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues where sparse data are available, a survey of current practice among the clinicians on the writing committee was the basis for Level C recommendations and no references are cited. The schema for Classification of Recommendations (COR) and Level of Evidence (LOE) is summarized in Table 1, which also illustrates how the grading system provides an estimate of the size as well as the certainty of the treatment effect. A new addition to the ACCF/AHA methodology is a separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment/strategy with respect to another for COR I and IIa, LOE A or B only, have been added.
The Task Force on Practice Guidelines makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose ALL relevant relationships and those existing 24 months before initiation of the writing effort. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the members voting. Members who were recused from voting are noted on the title page of this document and in Appendix 1. Members must recuse themselves from voting on any recommendation to which their relationship with industry and other entities (RWI) applies. Any writing committee member who develops a new RWI during his or her tenure is required to notify guideline staff in writing. These statements are reviewed by the Task Force on Practice Guidelines and all members during each conference call and meeting of the writing committee and are updated as changes occur. For detailed information about guideline policies and procedures, please refer to the ACCF/AHA methodology and policies manual (1). Authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. In addition, to ensure complete transparency, writing committee members' comprehensive disclosure information—including RWI not pertinent to this document—is available online as a supplement to this document. Disclosure information for the ACCF/AHA Task Force on Practice Guidelines is available online at www.cardiosource.org/ACC/About-ACC/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of the writing committee was supported exclusively by the ACCF and AHA without commercial support. Writing group members volunteered their time for this effort.
The ACCF/AHA practice guidelines address patient populations (and health care providers) residing in North America. As such, drugs that are not currently available in North America are discussed in the text without a specific class of recommendation. For studies performed in large numbers of subjects outside of North America, each writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and the relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.
The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. These practice guidelines represent a consensus of expert opinion after a thorough and systematic review of the available current scientific evidence and are intended to improve patient care. The guidelines attempt to define practices that meet the needs of most patients in most situations. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. Thus, there are circumstances in which deviations from these guidelines may be appropriate. Clinical decision making should consider the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to better inform patient care; these areas will be identified within each respective guideline when appropriate.
Prescribed courses of treatment in accordance with these recommendations are effective only if they are followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles.
The guidelines will be reviewed annually by the Task Force and considered current until they are updated, revised, or withdrawn from distribution. The executive summary and recommendations are published in the Journal of the American College of Cardiology, Circulation, and the Journal of Cardiovascular Computed Tomography.
Alice K. Jacobs, MD, FACC, FAHA Chair, ACCF/AHA Task Force on Practice Guidelines
1.1 Methodology and Evidence Review
The recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted for the period beginning March 2008 through April 2010. Searches were limited to studies, reviews, and other evidence conducted in human subjects and published in English. Key search words included, but were not limited to, African Americans, Asian Americans, albuminuria, asymptomatic, asymptomatic screening and brachial artery reactivity, atherosclerosis imaging, atrial fibrillation, brachial artery testing for atherosclerosis, calibration, cardiac tomography, compliance, carotid intima-media thickness (IMT), coronary calcium, coronary computed tomography angiography (CCTA), C-reactive protein (CRP), detection of subclinical atherosclerosis, discrimination, endothelial function, family history, flow-mediated dilation, genetics, genetic screening, guidelines, Hispanic Americans, hemoglobin A, glycosylated, meta-analysis, Mexican Americans, myocardial perfusion imaging (MPI), noninvasive testing, noninvasive testing and type 2 diabetes, outcomes, patient compliance, peripheral arterial tonometry (PAT), peripheral tonometry and atherosclerosis, lipoprotein-associated phospholipase A2, primary prevention of coronary artery disease (CAD), proteinuria, cardiovascular risk, risk scoring, receiver operating characteristics (ROC) curve, screening for brachial artery reactivity, stress echocardiography, subclinical atherosclerosis, subclinical and Framingham, subclinical and Multi-Ethnic Study of Atherosclerosis (MESA), and type 2 diabetes. Additionally, the writing committee reviewed documents related to the subject matter previously published by the ACCF and AHA, American Diabetes Association (ADA), European Society of Cardiology, and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 7. References selected and published in this document are representative and not all-inclusive.
To provide clinicians with a comprehensive set of data, whenever deemed appropriate or when published in the article, data from the clinical trial will be used to calculate the absolute risk difference and number needed to treat or harm; data related to the relative treatment effects will also be provided, such as odds ratio (OR), relative risk (RR), hazard ratio (HR), or incidence rate ratio (IRR), along with confidence interval (CI) when available.
The focus of this guideline is the initial assessment of the apparently healthy adult for risk of developing cardiovascular events associated with atherosclerotic vascular disease. The goal of this early assessment of cardiovascular risk in an asymptomatic individual is to provide the foundation for targeted preventive efforts based on that individual's predicted risk. It is based on the long-standing concept of targeting the intensity of drug treatment interventions to the severity of the patient's risk (2). This clinical approach serves as a complement to the population approach to prevention of cardiovascular disease (CVD), in which population-wide strategies are used regardless of an individual's risk.
This guideline pertains to initial assessment of cardiovascular risk in the asymptomatic adult. Although there is no clear age cut point for defining the onset of risk for CVD, elevated risk factor levels and subclinical abnormalities can be detected in adolescents as well as young adults. To maximize the benefits of prevention-oriented interventions, especially those involving lifestyle changes, the writing committee advises that these guidelines be applied in asymptomatic persons beginning at age 20. The writing committee recognizes that the decision about a starting point is an arbitrary one.
This document specifically excludes from consideration patients with a diagnosis of CVD or a coronary event, for example, angina or anginal equivalent, myocardial infarction (MI), or revascularization with percutaneous coronary intervention or coronary artery bypass graft surgery. It also excludes testing for patients with known peripheral artery disease (PAD) and cerebral vascular disease. This guideline is not intended to replace other sources of information on cardiovascular risk assessment in specific disease groups or higher-risk groups such as those with known hypertension or diabetes who are receiving treatment.
1.2 Organization of the Writing Committee
The committee was composed of physicians and others expert in the field of cardiology. The committee included representatives from the American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Society of Atherosclerosis Imaging and Prevention (SAIP), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), and Society for Cardiovascular Magnetic Resonance (SCMR).
1.3 Document Review and Approval
This document was reviewed by 2 outside reviewers nominated by the ACCF and 2 outside reviewers nominated by the AHA, as well as 2 reviewers each from ASE, ASNC, SAIP, SCAI, SCCT, and SCMR, and 23 individual content reviewers (including members from the Appropriate Use Criteria Task Force, ACCF Cardiac Catheterization Committee, ACCF Imaging Council, and ACCF Prevention of Cardiovascular Disease Committee). All reviewer RWI information was collected and distributed to the writing committee and is published in this document (Appendix 2).
This document was approved for publication by the governing bodies of the ACCF and AHA and endorsed by ASE, ASNC, SAIP, SCCT, and SCMR.
1.4 Magnitude of the Problem of Cardiovascular Risk in Asymptomatic Adults
Atherosclerotic CVD is the leading cause of death for both men and women in the United States (3). Risk factors for the development of atherosclerotic disease are widespread in the U.S. population. In 2003, approximately 37% of American adults reported having ≥2 risk factors for CVD. Ninety percent of patients with coronary heart disease (CHD) have at least 1 atherosclerotic risk factor (4). Approximately half of all coronary deaths are not preceded by cardiac symptoms or diagnoses (5). One aim of this guideline is to provide an evidence-based approach to risk assessment in an effort to lower this high burden of coronary deaths in asymptomatic adults.
CVD was mentioned on the death certificates of 56% of decedents in 2005. It was listed as the underlying cause of death in 35.3% (864,480) of all deaths (2,448,017) in 2005 or 1 of every 2.8 deaths in the U.S. (6). In every year since 1900 (except 1918), CVD accounted for more deaths than any other major cause of death in the United States (6). It is estimated that if all forms of major CVD were eliminated, life expectancy would rise by almost 7 years (6). Analyses suggest that the decrease in U.S. deaths due to CHD from 1980 to 2000 was partly attributable (approximately 47%) to evidence-based medical therapies, and about 44% of the reduction has been attributed to changes in risk factors in the population (7). The estimated direct and indirect cost of CVD for 2009 is $475.3 billion (6).
CHD has a long asymptomatic latent period, which provides an opportunity for early preventive interventions. Atherosclerosis begins in childhood and progresses into adulthood due to multiple coronary risk factors such as unfavorable levels of blood lipids, blood pressure, body weight and body fat, smoking, diabetes, and genetic predisposition (8–10). The lifetime risk of CHD and its various manifestations has been calculated for the Framingham Heart Study population at different ages. In nearly 8000 persons initially free of clinical evidence of CHD, the lifetime risk of developing clinically manifest CHD (angina pectoris, MI, coronary insufficiency, or death from CHD) at age 40 was 48.6% for men and 31.7% for women (11). At age 70, the lifetime risk of developing CHD was 34.9% for men and 24.2% for women. The lifetime risk for all CVD combined is nearly 2 of every 3 Americans (12). Thus, the problem is immense, but the preventive opportunity is also great.
1.5 Assessing the Prognostic Value of Risk Factors and Risk Markers
Many risk factors have been proposed as predictors of CHD (13,14). New risk factors or markers are frequently identified and evaluated as potential additions to standard risk assessment strategies. The AHA has published a scientific statement on appropriate methods for evaluating the predictive value of new risk factors or risk markers (15). The scientific statement endorsed previously published guidelines for proper reporting of observational studies in epidemiology (16) but also went beyond those guidelines to specifically address criteria for evaluation of established and new risk markers. The current writing committee endorses this scientific statement and incorporated these principles into the assessments for this guideline. The general concepts and requirements for new risk marker validation and evaluation are briefly reviewed to provide a basis for the assessments in this document.
For any new risk marker to be considered useful for risk prediction, it must, at the very least, have an independent statistical association with risk after accounting for established readily available and inexpensive risk markers. This independent statistical association should be based on studies that include large numbers of outcome events. Traditionally, reports of novel risk markers have only gone this far, reporting adjusted HRs with CIs and p values (17). Although this level of basic statistical association is often regarded by researchers as meaningful in prediction of a particular outcome of interest, the AHA scientific statement called for considerably more rigorous assessments that include analysis of the calibration, discrimination, and reclassification of the predictive model. Many of the tests reviewed in this guideline fail to provide these more comprehensive measures of test evaluation, and for this reason, many tests that are statistically associated with clinical outcomes cannot be judged to be useful beyond a standard risk assessment profile. In the absence of this evidence of “additive predictive information,” the writing committee generally concluded that a new risk marker was not ready for routine use in risk assessment.
Calibration and discrimination are 2 separate concepts that do not necessarily track with each other. Calibration refers to the ability to correctly predict the proportion of subjects within any given group who will experience disease events. Among patients predicted to be at higher risk, there will be a higher number of events, whereas among patients identified as being at lower risk, there will be fewer events. For example, if a diagnostic test or a multivariable model splits patients into 3 groups with predicted risks of 5%, 10%, and 15% within each group, calibration would be considered good if in a separate group of cohorts with similar predicted risks, the actual rates of events were close to 5%, 10%, and 15%. Calibration is best presented by displaying observed versus expected event rates across quantiles of predicted risk for models that do and do not include the new risk marker.
Discrimination is a different concept that refers to the probability of a diagnostic test or a risk prediction instrument to distinguish between patients who are at higher compared with lower risk. For example, a clinician sees 2 random patients, 1 of whom is ultimately destined to experience a clinical event. A diagnostic test or risk model discriminates well if it usually correctly predicts which of the 2 subjects is at higher risk for an event. Mathematically this is described by calculating a C index or C statistic, parameters that are analogous to the area under the ROC curve. These statistics define the probability that a randomly selected person from the “affected group” will have a higher test score than a randomly selected person from the “nonaffected group.” A test with no discrimination would have a C statistic of 0.50 and a perfect test would have a C statistic of 1.0. Throughout this document, C statistic information is cited where available.
As an example of a risk marker that improves discrimination, MESA investigators found that the addition of coronary artery calcium (CAC) scores to standard risk factors improved the area under the ROC curve from 0.77 to 0.82 (p<0.001) (18). In contrast, a score based on 9 genes that code for cholesterol levels added no predictive value over established risk factors and family history (19). Similarly, a study comparing the predictive capacity of conventional and newer biomarkers for prediction of cardiovascular events derived a C statistic of 0.760 for coronary events for the conventional risk factor model. Adding a number of newer biomarkers changed the C statistic by only 0.009 (p=0.08) (20). Small changes such as these in the C statistic suggest limited or rather modest improvement in risk discrimination with additional risk markers.
Some investigators have called for evaluating the number of subjects reclassified into other risk categories based on models that include the new risk marker (21). For example, in a model of cardiovascular risk in a large cohort of healthy women, the addition of CRP resulted in reclassification of a large proportion of subjects who were thought to be at intermediate risk based on standard risk markers alone (22). One problem with this approach is that not all reclassification is necessarily clinically useful. If a patient is deemed to be at intermediate risk and is then reclassified as being at high or low risk, the clinician might find that information helpful. It may not be known, however, whether or not these reclassifications are correct for individual subjects. Pencina and colleagues introduced 2 new approaches, namely “net reclassification improvement” and “integrated with classification improvement,” which provide quantitative estimates of correct reclassifications (23). Correct reclassifications are associated with higher predicted risks for cases and lower predicted risks for noncases.
1.6 Usefulness in Motivating Patients or Guiding Therapy
In 1996 the American College of Cardiology Bethesda Conference reviewed the concept of risk stratification, an approach that is now standard for identifying the appropriate degree of therapeutic or preventive interventions (2). Patients deemed to be at low risk for clinical events are unlikely to gain substantial benefits from pharmaceutical interventions and therefore might best be managed with lifestyle modifications. Conversely, patients deemed to be at high risk for events are more likely to benefit from pharmacologic interventions and therefore are appropriate candidates for intensive risk factor modification efforts. Among patients at intermediate risk, further testing may be indicated to refine risks and assess the need for treatment. Although this model is attractive and has been shown to be appropriate in certain situations, there is no definitive evidence that it directly leads to improved patient outcomes. Further research is clearly needed, and it is appropriate to point out that the risk stratification paradigm has not been subjected to rigorous evaluation by randomized trials. Indeed, the impact of various risk assessment modalities on patient outcomes is rarely studied and not well documented in the few studies that have been conducted (24).
1.7 Economic Evaluation of Novel Risk Markers
The progressively rising costs of medical care have increased interest in documenting the economic effects of new tests and therapies. The most basic goal is to estimate the economic consequences of a decision to order a new test. The ultimate goal is to determine whether performing the test provides sufficient value to justify its use.
A complete economic evaluation of the test has to account for all the subsequent costs induced by ordering the test, not just the cost of the test itself. The results of the test should change subsequent clinical management, which might include ordering follow-up tests, starting or stopping drug therapy, or using a device or procedure. The costs of these subsequent clinical management choices must be included in an “intention-to-test” analysis of the economic consequences of the initial decision to use the test. Ideally, the analysis should be extended to account for clinical events that are either averted or caused as a result of the strategy based on performing the test.
An example of the economic consequences of testing will illustrate the importance of these principles. Suppose a patient with diabetes who has no cardiac symptoms undergoes a computed tomography (CT) coronary angiogram, which reveals obstructive CAD but also leads to contrast-induced nephropathy. Further suppose this patient has a follow-up invasive coronary angiogram, undergoes insertion of a coronary stent, and is treated for renal insufficiency. The costs of all these “downstream events” should be included in any economic assessment of the use of CCTA because they all resulted from the initial decision to perform the test. Note that the total costs of a “test strategy” may greatly exceed the cost of the initial test itself.
The cost of any medical intervention has to be placed in the context of the clinical benefits that the intervention provides. In the example of the patient with diabetes, perhaps the aggressive use of coronary revascularization actually extended life expectancy. Cost-effectiveness analysis provides a formal framework with which to compare the clinical effectiveness of an intervention (measured in patient-centered outcomes such as length of life or quality of life) with the cost of that intervention. Cost-effectiveness analysis has been most commonly applied to the evaluation of new medical therapies that directly improve clinical outcomes (e.g., use of bypass surgery to treat CAD). Diagnostic tests do not improve clinical outcomes directly, however, and do so only indirectly by changing clinical management decisions, which in turn may improve clinical outcomes. Thus, determining the cost-effectiveness of a diagnostic test depends on how effectively the information is used and can be evaluated only in the context of available treatments and how effective those treatments are. A test that provides accurate risk information about an untreatable disease is unlikely to be cost-effective simply because clinical outcomes cannot be improved by its use.
In general, testing strategies such as those assessed in this document have not included evaluations of the cost and cost-effectiveness of the tests. Therefore, although this general guidance is offered to the reader as a caveat, the writing committee was generally unable to find evidence to support the cost-effectiveness of any of the tests and testing approaches discussed here. Where exceptions were identified, cost-related information is included. In addition, for the uncommon examples for which clinical outcomes of testing strategies were assessed, the writing committee included that evidence in the assessment of the value of the risk assessment test.
2 Approaches to Risk Stratification
2.1 General Approach to Risk Stratification
2.1.1 Recommendation for Global Risk Scoring
1. Global risk scores (such as the Framingham Risk Score [FRS]) that use multiple traditional cardiovascular risk factors should be obtained for risk assessment in all asymptomatic adults without a clinical history of CHD. These scores are useful for combining individual risk factor measurements into a single quantitative estimate of risk that can be used to target preventive interventions (25). (Level of Evidence: B)
220.127.116.11 General Description
Prospective epidemological studies have established, primarily in studies of people ≥40 years of age, that readily measured and often modifiable risk factors are associated with the development of clinical CHD in asymptomatic individuals. There are robust prognostic data for each of the “classic risk factors,” namely, cigarette smoking, cholesterol levels, blood pressure levels, and diabetes. Data obtained from the Framingham Heart Study and other population-based cohorts have demonstrated that age, sex, cigarette smoking, level of low-density lipoprotein (LDL) cholesterol or total cholesterol, diabetes, and levels of blood pressure can be combined in predictive models to estimate risk of fatal and nonfatal CHD events (26). Beginning in the 1990s, a number of global risk prediction instruments were introduced, based on multivariable models that incorporated risk factor data and clinical events (25–28). These instruments go beyond simple demographics by taking into account modifiable risk markers that are also appropriate evidence-based targets for preventive interventions. Table 2 summarizes a sample of published global risk score instruments.
Global risk assessment instruments, such as the FRS, are considered valuable in medical practice because clinicians and patients may not otherwise accurately assess risk. In some survey studies, clinicians presented with scenarios were found to overestimate the likelihood of a future major clinical cardiovascular event (29). Other studies have suggested that physicians may also underestimate risk (30–32). Failure to use global quantitative risk instruments may result in physicians inappropriately informing patients that they are at high risk and inappropriately promoting therapeutic interventions of modest or questionable benefit or, alternatively, inadequately emphasizing risk when risk is actually present.
Global risk scores, although designed to estimate risk across a continuous range from 0% to 100%, have most commonly been advocated as a method by which patients can be categorized in broad terms as “low risk,” “intermediate risk,” and “high risk.” In general, patients are deemed to be high risk if they are found to have a global risk estimate for hard CHD events of at least 20% over 10 years. The threshold for dividing low risk from intermediate risk is not uniform, with some proposing a lower cutoff value of 6% risk over 10 years, whereas others use a value of 10% over 10 years (27,33,34). This document, unless otherwise noted, uses a lower cutoff value of at least 10% and a higher cutoff of <20% to designate intermediate risk.
The evidence with regard to global risk scores is most appropriate for individuals ≥40 years of age. It is important to note that there are limited data from Framingham and other long-term observational studies on 10-year risk in young adults; consequently, it is difficult to estimate 10-year risk in young adults. This is due to the fact that 10-year risk in young adults is very rarely impressively elevated, even in the face of significant risk factors, and thus there are a limited number of coronary events for calculating risk. As noted earlier in this document, the long-term or lifetime risk may be substantially raised by the presence of risk factors in young adults. Although the earliest age at which these risk scores should be used has not been rigorously established, the application of a particular risk score or test should not detract from adherence to a healthy lifestyle and identification of modifiable risk factors beginning in childhood. Therefore, to direct attention to the lifetime significance of coronary risk factors in younger adults, the writing committee considered measurement of a global risk score possibly worthwhile even in persons as young as age 20.
2.1.2 Association With Increased Risk and Incremental Risk of Additional Risk Factors
A number of global risk instruments have been developed (35). In the United States the best known is the FRS, several variants of which have been published (25–28,34). Some include diabetes as a risk factor (25). The version published with the National Cholesterol Education Program Adult Treatment Panel (ATP III) report did not include diabetes (27), which was considered to be a CHD risk equivalent. Some versions of the FRS have focused on CHD death and nonfatal MI as endpoints, whereas a more recent version focused on more comprehensive total cardiovascular events (27,28,36). A European “SCORE” (Systematic Coronary Risk Evaluation) was developed based on a regression model derived from observations of >200,000 adults (37). This model differs from the Framingham model in a variety of factors, including incorporation of age into a time scale and consideration of geographic variability within European countries as the calibration metric (35).
Many of the multivariable coronary risk assessment functions have been evaluated for predictive capability (38). In a large number of different cohort studies, multivariable risk equations typically yielded ROC areas approximately equal to 0.80, indicating relatively high levels of predictive discrimination. Data from the NHANES (National Health and Nutrition Examination Surveys) prospective cohort study were used to study how well a Framingham-type risk model could predict first-time fatal and nonfatal CVD events (39). Risk factors included in the model to assess risk of CVD were age, systolic blood pressure, smoking status, total cholesterol, reported diabetes status, and current treatment for hypertension. In women the risk model was useful for predicting events, with a C statistic of 0.829. In men the results were similar (C statistic, 0.78). Results such as these are typical for a Framingham-like risk assessment model in most populations, but there has been concern that global risk scores developed in one population may not be applicable to other populations (24). The FRS has been validated in several external populations, but in some cases it has required a “prevalence correction” to recalibrate the scores to reflect lower population prevalence of disease (25). Although global risk scores have often been found to have C statistics indicating that the score is useful for discrimination, the focus on 10-year risk estimates in clinical medicine makes many risk scores less useful for clinical decision making in most younger male patients and most women (40–42).
Some large-scale investigations have suggested that nearly 90% of the population-attributable risk for CAD can be ascribed to traditional biological and psychosocial risk factors (43). However, none of the current risk models, based only on traditional risk factors such as the FRS, are able to discriminate risk to an extent that would eliminate material uncertainty of risk for individual patients being seen by individual clinicians. Even in a global risk model such as the FRS, which predicts risk with an area under the ROC curve of as high as 80% in some studies (38), there is considerable overlap in risk scores between people who are ultimately found to be affected versus those found to be unaffected. Hence, a number of investigators argue for ongoing discovery and investigation of newer risk factors and predictive risk markers to improve the ability of clinicians to discriminate risk among their individual patients (20,44,45).
In summary, a FRS, or a similar type of multivariable predictive score based on traditional cardiovascular risk factors, is highly predictive of cardiovascular events. Given the familiarity of health professionals and the general public with the traditional risk factors and the proven efficacy of interventions for modifiable factors in these models, the writing committee agreed with many previous clinical practice guidelines that a “Framingham-like” risk score should be the basic risk assessment strategy to use for all asymptomatic adult patients (46–53). Additional risk markers should be assessed for their ability to improve on risk assessment beyond prediction from the multivariable global risk score. The writing committee felt that it is reasonable to advocate global risk score measures coincident with guideline-supported measurements of blood pressure or cholesterol beginning at age 20 and then every 5 years thereafter (27). The writing committee also acknowledged that some investigators advocate a shift in the risk assessment focus to ‘lifetime risk” of CHD, but to date, evidence is sparse on how best to incorporate estimates of lifetime risk into clinical management (11). Another approach to the long-term risk estimation problem in younger adults was recently presented by the Framingham Study investigators as the “30-Year Risk of Cardiovascular Disease” (54).
2.2 Family History and Genomics
2.2.1 Recommendation for Family History
1. Family history of atherothrombotic CVD should be obtained for cardiovascular risk assessment in all asymptomatic adults (22,55). (Level of Evidence: B)
18.104.22.168 Association With Increased Cardiovascular Risk and Incremental Risk
A family history of premature (early-onset) atherothrombotic CVD, defined most often as occurring in a first-degree male relative <55 years of age or in a first-degree female relative <65 years of age, has long been considered a risk factor for CVD. Even a positive parental history that is not premature increases the risk of CVD in offspring (56). The importance of family history is not surprising because the risk factors for CVD, including hypertension, dyslipidemia, diabetes, obesity, and smoking behavior, are in part heritable (19,57–62). In addition, lifestyle habits such as diet, exercise, and smoking are in part learned behaviors influenced by family patterns. However, studies examining parents, siblings, twins, and second-degree relatives have demonstrated that the 1.5- to 2.0-fold RR of family history persists even after adjusting for coexistent risk factors (56,63–66). The risk associated with a positive family history for CVD is observed in individuals of White European, African American, Hispanic, and Japanese descent (67–69). The strength of the risk for an individual increases with younger age of onset, increasing numbers of relatives affected, and the relative's genealogical proximity (56,63,66,70). Although the prevalence of a positive family history ranges from 14% to 35% in the general population, almost 75% of those with premature CHD have a positive family history, underscoring opportunities for prevention (71,72).
The reliability of self-reported family history is imperfect (71,73). To address recall bias, investigators from the Framingham Study used validated parental data and reported that although the negative predictive value for reports of premature MI and CHD death was superb (>90%), the positive predictive value for validated events was only fair (28% to 66%) (73). Similarly, the Health Family Tree Study found that the positive predictive value of a positive family history of CHD was 67%, but the negative predictive value was excellent at 96% (70,71). The sensitivity of self-reported family history is ≥70% (71,73). In addition, there has been increasing attention to improving the collection of family history through standardized questionnaires and online resources (74).
Family history modestly improves risk stratification. In the Framingham Heart Study, the inclusion of a positive family history improved ability to predict CVD (the multivariable model C statistic [ROC] increased from 0.82 to 0.83). Family history appeared to aid in reclassifying individuals and was most useful in persons at intermediate risk (third and fourth multivariable predicted risk quintile) of CVD (63,64).
22.214.171.124 Usefulness in Motivating Patients or Guiding Therapy
The ability of family history of CVD to motivate patients is not definitively established. Some studies have reported that persons with a positive family history of CHD were more motivated to modify their risk factors (75). In the CARDIA (Coronary Artery Risk Development in Young Adults) study, however, young adults did not self-initiate or modify their CVD risk factors after a change in family history of heart attack or stroke (76). Intensive interventions targeting those with a positive family history of CHD can improve risk factors; however, the sustainability of such interventions and their influence on CHD events has been more difficult to prove. For instance, a randomized study of black patients with a family history of premature CHD demonstrated that intensive community-based multiple risk factor intervention resulted in significant reductions in global CHD risk (improvements in cholesterol and blood pressure) compared with an enhanced primary care group (77). However, the sustainability of such efforts was disappointing; 5 years after completion, the previously observed improved risk factor profile of the intensive community-based group was no longer apparent and there was no significant difference in events (78).
2.2.2 Genotypes: Common Genetic Variants for Coronary Heart Disease
126.96.36.199 Recommendation for Genomic Testing
Class III: No Benefit
1. Genotype testing for CHD risk assessment in asymptomatic adults is not recommended (79,80). (Level of Evidence: B)
188.8.131.52 Association With Increased Cardiovascular Risk and Incremental Risk
CHD is typically due to the complex interplay between environmental factors and multiple common genetic variants (minor allele frequency >5%) with small or very modest effects (OR typically 1.2 to 1.5, and rarely >2.0) (81). The first widely replicated genetic variant for CHD was discovered by a genomewide association study on chromosome 9p21.3 (82–84). The 1.3- to 2.0-fold increased risk for MI observed with single nucleotide polymorphisms (SNPs) from the 9p21.3 genomic region has been observed in persons of various ethnicities, including European, Asian, and Hispanic descent, but thus far it has not been replicated in African Americans, which may relate to patterns of haplotype diversity in the genomic region (82–87). The mechanisms underlying the 9p21.3 association with CHD remain unclear, although the variants are adjacent to CDKN2A, ARF, and CDKN2B, which are genes thought to regulate senescence and apoptosis (88). Variants tested in the 9p21.3 region (rs10757274, GG versus AA) were associated with a HR for incident CHD of 1.6 for incident CHD in men participating in the NPHS II (Northwick Park Heart Study II) (89). The addition of the genotype to a model based on traditional CVD risk factors did not significantly improve risk discrimination (area under the ROC, 0.62 [95% CI 0.58 to 0.66] to 0.64 [95% CI 0.60 to 0.68]; p=0.14). However, the genotype resulted in better model fit (likelihood ratio, p=0.01) and shifted 13.5% of the men into a more accurate risk category (89).
In the Women's Genome Health Study (n=22,129), an SNP at chromosome 9p21.3 was associated with an increased hazard for incident CVD; however, the SNP did not enhance model discrimination (C index, 0.807 to 0.809) or net reclassification when added to the Reynolds risk score, which includes family history (79). In another study, investigators reported that a genome score including 9 SNPs associated with serum lipid levels was associated with an increased risk of CVD events, but the score did not improve model discrimination (ROC, 0.80 for the model with and without the score). Furthermore, investigators reported that having a parent or sibling with a history of MI conferred a 50% increased risk of incident cardiovascular events (HR 1.52; 95% CI 1.17 to 1.97; p=0.002) in a model including the genotype score (90). Family history may integrate the complexity of interacting genomic and environmental factors shared by family members. Many other SNPs have been reported as risk markers for future CHD events. Given the very small OR and the small incremental risk information of the individual polymorphisms, the writing committee judged that genomic tests for CHD risk currently offer no proven benefit in risk assessment when added to a global basic risk score such as the FRS.
184.108.40.206 Usefulness in Motivating Patients or Guiding Therapy
Studies assessing whether genotype testing enhances motivation and success with adherence to recommended lifestyle and medical therapies demonstrate mixed results (80,91). Smokers given scenarios of genotype testing information report more motivation to quit but lower levels of perceived control and similar success with smoking cessation at 1 year (92,93). In another study, persons who agreed to receive genotype data (GSTM1 SNP) were more likely to abstain from cigarette smoking at 12-month follow-up than those who declined the test, regardless of whether they tested positive or negative for the risk SNP (94).
No data are available as to whether the results of genotype testing alter management or improve outcomes for prevention of CHD (92,95). Despite the uncertainty about the clinical implications of most genotypic markers for CHD, there is widespread direct-to-consumer marketing of these tests (95). A concern is that advertisements and genetic information provided by for-profit genomic testing services may overstate claims and confuse or frighten consumers. In addition, regulation of the companies and provision for genetic counseling is sporadic (95). Thus, the writing committee was aware of no benefit of genotype testing, and given the limited benefit in terms of risk assessment, the writing committee concluded that these types of tests should not be done at this time.
2.3 Lipoprotein and Apolipoprotein Assessments
2.3.1 Recommendation for Lipoprotein and Apolipoprotein Assessments
Class III: No Benefit
1. Measurement of lipid parameters, including lipoproteins, apolipoproteins, particle size, and density, beyond a standard fasting lipid profile is not recommended for cardiovascular risk assessment in asymptomatic adults (96). (Level of Evidence: C)
2.3.2 Assessment of Lipoprotein Concentrations, Other Lipoprotein Parameters, and Modified Lipids
Beyond the standard fasting lipid profile (total cholesterol, high-density lipoprotein (HDL) cholesterol, LDL cholesterol, and triglycerides), additional measurements of lipid parameters or modified lipids have been proposed to extend the risk factor–cardiovascular prediction relationship. Each LDL particle contains 1 molecule of apolipoprotein B (often referred to as ApoB); thus, the concentration of ApoB directly reflects LDL particle numbers. The relationship between apolipoprotein A (often referred to as ApoA) and HDL is less direct. Several techniques directly measure lipid particle numbers or their size distribution. All lipid particles (e.g., LDL or HDL) are present in the circulation in a range of sizes. Oxidative modification of lipid particles occurs and appears to influence their atherogenic potential.
Non-HDL cholesterol, meaning cholesterol transported in LDL and very-low-density lipoprotein, reflects the total concentration of atherogenic particles, is closely related to particle number, and is simply calculated as the difference between total cholesterol and HDL-cholesterol blood concentrations. Particle size is similarly closely related to HDL and triglyceride concentrations. High concentrations of triglycerides lead to triglyceride enrichment of LDL or HDL. Subsequent particle modification by hepatic lipase leads to reduction of particle size and increased density, properties associated with heightened atherogenic potential. Treatment guidelines for the consideration of pharmacotherapy and the therapeutic targets for non-HDL cholesterol are 30 mg/dL higher than the thresholds for LDL cholesterol (27).
2.3.3 Risk Prediction Relationships Beyond Standard Risk Factors
Many so-called “advanced lipid measures” of the type discussed above, particularly apolipoprotein concentrations and particle number, have been shown by some, but not all, studies to be associated with cardiovascular outcomes comparable to standard lipid concentrations (43,97). For example, the EPIC-Norfolk (European Prospective Investigation into Cancer and Nutrition) study among apparently healthy individuals showed a 34% increased odds for future CHD associated with the highest quartile of LDL particle number after controlling for the FRS (97). However, this was similar to non-HDL cholesterol (38% increased odds); thus, no relative benefit of particle number determinations was found. A recent systematic review observed that no study has reported the incremental predictive value of LDL subfractions beyond that of traditional cardiovascular risk factors, nor evaluated their independent test performance (for example, sensitivity and specificity) (96). Although the distribution of advanced lipid measures is different in men and women (and is also related to menopausal status), the outcome relationships are present for both men and women in similar magnitude (98,99).
Two studies have specifically evaluated the predictive performance of ApoB or nuclear magnetic resonance LDL-particle concentration for risk reclassification of asymptomatic individuals compared with standard lipids. In the Framingham Heart Study, little additional risk information was obtained from ApoB or ApoB/A-1 ratio compared with the total/HDL-cholesterol ratio (100). Thus, evidence that these more “advanced” lipid measures improve predictive capacity beyond standard lipid measurements is lacking (101).
The role of lipoprotein(a) [Lp(a)] in risk assessment has received attention as a potential additional risk marker. In the Emerging Risk Factors Collaboration, circulating concentration of Lp(a), a large glycoprotein attached to an LDL-like particle, was assessed for its relationship with risk of major vascular and nonvascular outcomes. Long-term prospective studies that recorded Lp(a) concentration and subsequent major vascular morbidity and/or cause-specific mortality published between January 1970 and March 2009 were identified through electronic and other means (102). Information was available from 126 634 participants in 36 prospective studies and spanned 1.3 million person-years of follow-up. Lp(a) concentration was weakly correlated with several conventional vascular risk factors and highly consistent within individuals over several years. In the 24 cohort studies, the risk ratio for CHD was 1.13 per standard deviation for higher Lp(a) (95% CI 1.09 to 1.18) after adjustment for age, sex, lipid levels, and other conventional risk factors. The corresponding adjusted risk ratios were 1.10 (95% CI 1.02 to 1.18) for ischemic stroke, 1.01 (95% CI 0.98 to 1.05) for the aggregate of nonvascular deaths, 1.00 (95% CI 0.97 to 1.04) for cancer deaths, and 1.00 (95% CI 0.95 to 1.06) for nonvascular deaths other than cancer. This study demonstrated that there are continuous, independent, but modest associations of Lp(a) concentration with risk of CHD and stroke. As with previous individual reports, associations were only modest in degree, and detailed information on incremental risk prediction beyond traditional risk factors is still lacking. There have also been, and continue to be, concerns about measurement and standardization of measurement of Lp(a) in clinical settings (103). The writing committee therefore concluded that measurement of Lp(a) did not merit consideration for cardiovascular risk assessment in the asymptomatic individual.
2.3.4 Usefulness in Motivating Patients or Guiding Therapy
Additional lipid measures, beyond the standard lipid profile, vary in their interassay agreement, laboratory standardization, and established reference ranges and are generally limited by the absence of clear thresholds for initiation of treatment, therapeutic targets, or unique treatments beyond those already recommended by lipid treatment guidelines directed by the standard lipid profile (104).
2.3.5 Evidence for Improved Net Health Outcomes
There is no evidence that the assessment of additional lipid parameters leads to improved net health outcomes, and thus the cost-effectiveness of these measures cannot be assessed.
2.4 Other Circulating Blood Markers and Associated Conditions
2.4.1 Recommendation for Measurement of Natriuretic Peptides
Class III: No Benefit
1. Measurement of natriuretic peptides is not recommended for CHD risk assessment in asymptomatic adults (105). (Level of Evidence: B)
220.127.116.11 General Description
Atrial natriuretic peptide, B-type natriuretic peptide, and their precursors (N-terminal-proatrial natriuretic peptide) are emerging markers of prevalent CVD. Natriuretic peptides are released from the myocardium in response to increased wall stress and have been shown to be helpful in the diagnosis of heart failure among symptomatic patients, as well as having prognostic value in patients with established heart failure. Levels of natriuretic peptides have also been demonstrated to be markers of prognosis in patients with either acute coronary syndromes or stable CAD.
Recent studies have examined whether natriuretic peptides also predict the development of CVD in the asymptomatic, healthy adult population. The evidence from several prospective cohort investigations (Table 3) suggests that higher levels of natriuretic peptides predict the development of incident CVD, including heart failure, stroke, and atrial fibrillation.
There is some evidence that natriuretic peptides are stronger predictors of the development of heart failure than of incident coronary events (106–108), and other studies suggest that their prognostic value is attenuated after adjustment for echocardiographic measures such as left ventricular mass and left ventricular diameter. The mechanism for these associations is as yet undetermined, and it is possible that natriuretic peptides are markers of left ventricular hypertrophy (LVH) or subclinical myocardial damage from hypertension, ischemia, or both.
Most prospective cohort studies (Table 3) report that natriuretic peptides predict prognosis and do so independent of other cardiac risk markers. Although these cohort studies suggest that natriuretic peptide levels convey prognostic information, the value of that information has not yet been rigorously evaluated by use of the C index or measures of risk reclassification (105). Consequently, the value of natriuretic peptide measurement in the assessment of cardiovascular risk among asymptomatic adults free of CAD or heart failure is not definitively known. Because of the absence of such data, the writing committee does not recommend measurement of natriuretic peptides for risk assessment in the asymptomatic adult.
18.104.22.168 Usefulness in Motivating Patients or Guiding Therapy
There have been no studies evaluating whether natriuretic peptides have value in motivating healthy patients, guiding treatment, or improving outcomes (there is some evidence on these points in populations of patients with heart failure but not in asymptomatic adults).
2.4.2 Recommendations for Measurement of C-Reactive Protein
1. In men 50 years of age or older or women 60 years of age or older with LDL cholesterol less than 130 mg/dL; not on lipid-lowering, hormone replacement, or immunosuppressant therapy; without clinical CHD, diabetes, chronic kidney disease, severe inflammatory conditions, or contraindications to statins, measurement of CRP can be useful in the selection of patients for statin therapy (114). (Level of Evidence: B)
1. In asymptomatic intermediate-risk men 50 years of age or younger or women 60 years of age or younger, measurement of CRP may be reasonable for cardiovascular risk assessment (22,115). (Level of Evidence: B)
Class III: No Benefit
1. In asymptomatic high-risk adults, measurement of CRP is not recommended for cardiovascular risk assessment (116). (Level of Evidence: B)
2. In low-risk men younger than 50 years of age or women 60 years of age or younger, measurement of CRP is not recommended for cardiovascular risk assessment (22,115). (Level of Evidence: B)
22.214.171.124 Association With Increased Cardiovascular Risk and Incremental Risk Prediction
Inflammation is considered to be central to the pathogenesis of atherosclerosis, and numerous inflammatory biomarkers have been evaluated as risk factors or risk markers for CVD. The most intensively studied inflammatory biomarker associated with CVD risk is high-sensitivity CRP (hsCRP). CRP is associated with an adjusted increased risk for development of other CVD risk factors, including incident diabetes, incident weight gain, and new-onset hypertension (117–119). Interventions that improve CVD risk factors, such as exercise, weight loss, smoking cessation, statins, and antihypertensive treatments, are associated with lowering of CRP (120–124). CRP concentrations are fairly constant and repeatable over time (125,126). In the JUPITER (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) study participants randomly assigned to placebo, intraclass correlation was 0.54 (95% CI 0.53 to 0.55), which was similar to blood pressure and LDL cholesterol (127). Prior guidelines have recommended measuring CRP twice, particularly in persons with intercurrent illness if elevated when first measured (128).
A meta-analysis of >20 observational studies (both prospective and case-control) demonstrated that CRP levels are associated with incident CHD, with an adjusted odds ratio (comparing persons in the top versus bottom third) of 1.45 (95% CI 1.25 to 1.68) (129). CRP levels have been associated with incident CHD in both men and women and persons of European, Japanese, and American Indian descents (22,130–132). CRP is also associated with other forms of CVD, including incident stroke, PAD, heart failure, atrial fibrillation, sudden death, and all-cause mortality (133–137). Despite consistent evidence that CRP levels above the population median value are associated with increased risk of CHD, it has not been determined whether CRP is causally related to CHD (138–142).
CRP modestly improved risk prediction of CVD endpoints in some studies beyond that accounted for by standard CVD risk factor testing (143). However, after accounting for standard CVD risk factors in many studies, model discrimination (area under the ROC) had no or minimal improvement (144,145). As noted earlier in this guideline, statisticians recently proposed that measures of reclassification should be used to evaluate new biomarkers in addition to metrics of test discrimination, calibration, and other standard approaches to evaluate new markers. Data from the Physicians' Health Study and Framingham Heart Study have shown that CRP measurements improve reclassification of an individual's risk beyond standard risk prediction models (115,145). However, a meta-analysis including data from the NPHS II and the Edinburgh Artery Study concluded that the ability of CRP to reclassify risk correctly was modest and inconsistent (144). As with most new biomarker tests, whether knowledge of CRP levels improves patients' motivation to adhere to CHD lifestyle or pharmacological treatments is unknown.
Recent clinical trial data provided evidence that measurement of CRP in highly preselected patients may have important clinical implications. The JUPITER trial was a randomized, double-blind, placebo-controlled trial of the use of rosuvastatin (20 mg/d) versus placebo in the primary prevention of CVD events in men and women (n=17,802) without diabetes with LDL cholesterol <130 mg/dL and CRP ≥2 mg/L (146,147). After a median follow-up of 1.9 years, rosuvastatin was associated with a significant reduction in the primary endpoint of cardiovascular events. The HR for rosuvastatin versus placebo was 0.56 (95% CI 0.46 to 0.69; p<0.00001), and the event rate was 0.77 versus 1.36 per 100 person-years of follow-up (147). The reduction in endpoints was consistent across prespecified subgroups, including men and women, older and younger persons, whites and non-whites, and persons at higher and lower risk as measured by the FRS (147). Within JUPITER, 17 men and 31 women would need to be treated for 5 years to prevent the endpoint of MI, stroke, revascularization, or death (148). For persons at low risk (FRS ≤10), 37 persons would need to be treated for 5 years to prevent the same previous endpoints (148).
The JUPITER trial leaves a number of questions unanswered about use of CRP levels in cardiovascular risk assessment. Specifically, JUPITER was not a trial of CRP (149), because persons with unknown or low CRP concentrations were not studied. Cost-effectiveness of CRP testing in an asymptomatic population, beyond the specific patient population of JUPITER, has not yet been studied.
2.4.3 Metabolic: Hemoglobin A1C
126.96.36.199 Recommendation for Measurement of Hemoglobin A1C
1. Measurement of hemoglobin A1C (HbA1C) may be reasonable for cardiovascular risk assessment in asymptomatic adults without a diagnosis of diabetes (150–155). (Level of Evidence: B)
188.8.131.52 General Description
HbA1C is a blood test useful for providing an estimate of average glycemic control over several months. The test has been shown to be predictive of new-onset diabetes (156). A systematic review and a recent international expert committee have suggested that HbA1C might be effective to screen for the presence of diabetes (157,158). The ADA has endorsed the use of HbA1C to diagnose diabetes (HbA1C ≥6.5%) and to identify persons at increased risk for diabetes (HbA1C, 5.7% to 6.4%) (158).
184.108.40.206 Association With Cardiovascular Risk in Persons Without Diabetes
In 1 study, in individuals without established diabetes, for every 1 percentage point higher HbA1C concentration, there was an adjusted 40% higher risk of CHD (p=0.002) (150). HbA1C was associated with an increased risk of incident stroke in the Japanese (159). Whether or not HbA1C improves CVD risk discrimination and reclassification is less certain. Some studies have reported that HbA1C does not improve prediction (156) or reclassification (160). However, other studies have observed that in persons without diabetes, higher levels of HbA1C are associated with an increased risk of CVD (161). In a 2010 report using data from the ARIC (Atherosclerosis Risk in Communities) study, it was demonstrated that in persons without diabetes, prediction models including HbA1C levels were associated with improved risk prediction, discrimination, and reclassification compared with prediction models that included standard risk factors and fasting glucose (155). This study is the strongest evidence available concerning the potential value of HbA1C for CVD risk assessment in asymptomatic persons without diabetes. As with most other novel markers of CVD risk, it is unknown whether HbA1C is useful for motivating individuals to adhere to preventive interventions in the absence of diagnosed diabetes.
2.4.4 Urinary Albumin Excretion
220.127.116.11 Recommendations for Testing for Microalbuminuria
1. In asymptomatic adults with hypertension or diabetes, urinalysis to detect microalbuminuria is reasonable for cardiovascular risk assessment (162–164). (Level of Evidence: B)
1. In asymptomatic adults at intermediate risk without hypertension or diabetes, urinalysis to detect microalbuminuria might be reasonable for cardiovascular risk assessment (165). (Level of Evidence: B)
18.104.22.168 General Description
Urinalysis for microalbuminuria is widely available, inexpensive, and associated with cardiovascular events (166). The ADA recommends annual urinalysis for detection of microalbuminuria in persons with diabetes mellitus (167). A recent meta-analysis showed that increased risk of CVD associated with microalbuminuria was present in persons both with and without diabetes (166). However, standardization of the measurement of urine albumin across laboratories is suboptimal (168,169). It is logistically difficult for most patients to perform 24-hour urine collection, but studies have demonstrated that the first morning (“spot urine”) urinary albumin–to-creatinine ratio has a similar ability to predict CVD events (170). On the basis of the urinary albumin–to-creatinine ratio on a morning spot urine sample, microalbuminuria is defined as 30 to 300 mg/g and macroalbuminuria is defined as >300 mg/g (171). Blacks and Mexican Americans have a higher prevalence of albuminuria than their Caucasian counterparts, regardless of diabetes status (172). Longitudinal data from the NHANES, between 1988–1994 and 1999–2004, found that the prevalence of microalbuminuria had increased from about 7.1% to 8.2% (p=0.01) (173).
Excretion of urinary albumin in the microalbuminuria range is considered a candidate for CVD risk biomarker for several reasons. Standard CVD risk factors are associated with microalbuminuria (174,175). Microalbuminuria is associated with incident hypertension, progression to a higher blood pressure category, and incident diabetes (176,177). Microalbuminuria and diabetes each appear to influence the other's progression (178). Furthermore, microalbuminuria has been associated with other novel risk factors for CVD, such as impaired endothelial function and inflammatory markers such as CRP (179–181). Microalbuminuria is considered to be an indicator of vascular dysfunction and early CVD (182).
22.214.171.124 Association With Cardiovascular Risk
A meta-analysis of 26 cohort studies with 169,949 participants reported that after accounting for standard CVD risk factors, there was a dose–response relationship between albuminuria and risk of CHD (166). Compared with individuals without albuminuria, macroalbuminuria was associated with a doubling of risk (RR 2.17; 95% CI 1.87 to 2.52), and microalbuminuria was associated with a nearly 50% greater risk (RR 1.47; 95% CI 1.30 to 1.66) of CHD (166). The increased risk of CVD was present across many different subgroups, including persons with and without hypertension, with and without diabetes, and with and without decreased estimated glomerular filtration rate (165,166,183). The prognostic importance of microalbuminuria also has been observed in older and younger individuals and ethnic minorities, including American Indians, South Asians, and African Carribbeans (166,184–186).
In studies examining the incremental yield of adding urinary albumin excretion in the microalbuminuria range to standard CVD risk factors for CVD risk prediction, the Framingham Heart Study and the Cardiovascular Health Study observed only minor improvements in the C statistic (175,187). However, the Cardiovascular Health Study observed that the urinary albumin–to-creatinine ratio did assist with risk reclassification. Persons at intermediate risk (predicted 5-year Framingham risk of 5% to 10%) with a urinary albumin–to-creatinine ratio ≥30 mg/g had a substantially higher 5-year risk of CHD than those with a ratio of <30 mg/g (20.1% versus 6.3%, respectively) (175).
126.96.36.199 Usefulness in Motivating Patients or Guiding Therapy
The writing committee is unaware of data that suggest that knowledge of albuminuria improves patient motivation or adherence to preventive therapies.
2.4.5 Lipoprotein-Associated Phospholipase A2
188.8.131.52 Recommendation for Lipoprotein-Associated Phospholipase A2
1. Lipoprotein-associated phospholipase A2 (Lp-PLA2) might be reasonable for cardiovascular risk assessment in intermediate-risk asymptomatic adults (188–191). (Level of Evidence: B)
184.108.40.206 General Description
Lp-PLA2, or platelet-activating factor acetylhydrolase, is a proatherogenic enzyme produced by macrophages and lymphocytes (192). Lp-PLA2 hydrolyzes oxidized phospholipids in LDL, leading to the generation of lysophosphatidylcholine, oxidized nonesterified fatty acids, as well as other active phospholipids and inflammatory mediators (192). Reported clinical correlates of increasing Lp-PLA2 mass and activity include advanced age, male sex, smoking, and LDL; Lp-PLA2 activity also was inversely associated with HDL (193). There have been unexplained ethnic differences in Lp-PLA2 concentrations; adjusting for standard CVD risk factors, Lp-PLA2 activity was higher in white and Hispanic participants than in black participants (194).
220.127.116.11 Association With Cardiovascular Risk
In a meta-analysis of 14 studies, Lp-PLA2 was associated with an adjusted OR for CVD of 1.60 (95% CI 1.36 to 1.89) (190). Although there was moderate heterogeneity across studies in the meta-analysis, there was no significant difference between Lp-PLA2 mass and activity for risk prediction (190). A number of studies have reported that the increased CVD risk of Lp-PLA2 remains after adjusting for CRP, in addition to standard CVD risk factors (188,189,191). Several studies have examined whether Lp-PLA2 improves risk discrimination over and above models accounting for standard risk factors. Both the ARIC study and Rancho Bernardo study investigators observed that Lp-PLA2 was associated with a statistically significant increment in the area under the curve (AUC) (p<0.05), although the increments were small (for the ARIC study, 0.774, increased to 0.780 with the addition of Lp-PLA2; for the Rancho Bernardo study, change in ROC was 0.595 to 0.617) (189,195). In a modest-sized study (n=765), Lp-PLA2 was associated with a nonsignificant 9.5% net reclassification (196). These reports indicate that Lp-PLA2 has modest incremental risk prediction information, meaning its use in intermediate-risk patients might be reasonable. There is little information about the predictive capability of Lp-PLA2 in ethnic minorities, because the vast majority of studies reported to date have been conducted in whites of European ancestry (190).
18.104.22.168 Usefulness in Motivating Patients or Guiding Therapy
Presently there is no information about whether Lp-PLA2 concentrations are clinically effective for motivating patients, guiding treatment, or improving outcomes. Randomized studies have demonstrated that lipid-lowering therapies reduce Lp-PLA2, although there may be some variability by medication type (197,198). Drugs under development that specifically inhibit Lp-PLA2 activity have been shown to lower Lp-PLA2 activity and inflammatory markers (199).
2.5 Cardiac and Vascular Tests for Risk Assessment in Asymptomatic Adults
2.5.1 Resting Electrocardiogram
22.214.171.124 Recommendations for Resting Electrocardiogram
1. A resting electrocardiogram (ECG) is reasonable for cardiovascular risk assessment in asymptomatic adults with hypertension or diabetes (200,201). (Level of Evidence: C)
1. A resting ECG may be considered for cardiovascular risk assessment in asymptomatic adults without hypertension or diabetes (202-204). (Level of Evidence: C)
126.96.36.199 General Description
Epidemiological studies have shown that abnormalities on a resting 12-lead ECG are predictive of subsequent mortality and cardiovascular events among asymptomatic adults (200,202,205,206). Specific electrocardiographic findings that have been linked to cardiovascular risk in population-based cohorts and asymptomatic patients with hypertension include LVH (especially when accompanied by repolarization changes), QRS prolongation, ST-segment depression, T-wave inversion, and pathological Q waves (202,207–211). Several studies suggest that subtle electrocardiographic abnormalities detectable only by computer analysis may also be associated with increased risk (212–214).
The 12-lead resting ECG may provide information about other CVD, particularly cardiac arrhythmias, by documenting extra systoles, atrial fibrillation, ventricular pre-excitation, or prolonged QT interval. Many cardiomyopathies display nonspecific electrocardiographic changes. There has been interest in electrocardiographic abnormalities that may be predictive of sudden cardiac death in young, seemingly healthy athletes (215). The usefulness of screening with ECGs for these disorders is beyond the scope of the current document.
188.8.131.52 Association With Increased Risk and Incremental Risk
Table 4 presents a sample of longitudinal studies that report independent predictive value of different resting electrocardiographic measures in asymptomatic populations. A number of classification schemes have been described that may be useful for risk stratification. An example is the Novacode criteria, which divide electrocardiographic abnormalities into major and minor types (216). Major abnormalities include atrial fibrillation or atrial flutter, high-grade atrioventricular (AV) block, AV dissociation, complete bundle-branch block, pathological T waves, isolated ischemic abnormalities, LVH with accompanying repolarization abnormalities, and arrhythmias such as supraventricular tachycardia and ventricular tachycardia. Minor abnormalities include first- and second-degree AV block, borderline prolongation of the QRS interval, prolonged repolarization, isolated minor Q-wave and ST-T abnormalities, LVH by voltage only, left atrial enlargement, frequent atrial or ventricular premature beats, or fascicular blocks. Electrocardiographic findings have also been combined with echocardiography to improve risk stratification in patients with hypertension (201).
Abnormal Q waves on the ECG may indicate clinically unrecognized or “silent” MI. In the Framingham Study, as many as one quarter of nonfatal MIs were found only through ECG changes (217). In a number of population studies, Q waves on the ECG indicate a higher cardiovascular risk (202,211).
Electrocardiographic LVH and associated repolarization abnormalities have been predictive of subsequent cardiovascular risk in numerous prospective epidemiological studies, including the Framingham Study. LVH on a resting ECG may indicate more severe or poorly controlled hypertension, which in turn increases cardiovascular risk (218). In 1 large randomized trial that specifically focused on patients with electrocardiographic LVH, regression of left ventricular mass as assessed by ECGs was a predictor of a lower risk of major cardiovascular events (219).
Few studies have evaluated the ability of the resting ECG to improve discrimination and reclassify risk compared with standard risk assessment. In 14,749 asymptomatic, postmenopausal women enrolled in the Women's Health Initiative, the resting ECG increased the C statistic over the FRS from 0.69 to 0.74 for prediction of CHD events (216). In 18,964 Cleveland Clinic patients without known CVD, the resting ECG similarly increased the C statistic by 0.04 and modestly improved reclassification (relative integrated discrimination improvement, 3%, p<0.001) (212).
184.108.40.206 Usefulness in Motivating Patients, Guiding Therapy, and Improving Outcomes
There have been no randomized trials demonstrating that findings on a resting ECG can be used to motivate better lifestyle behaviors in the asymptomatic adult. One large randomized trial offered suggestive evidence that electrocardiographic assessment of left ventricular mass may be useful for guiding antihypertensive therapy, because regression of electrocardiographic LVH was associated with reduced risk for sudden death (220), atrial fibrillation (219), heart failure (221), major CVD events (200), and diabetes (222). However, no randomized trial has directly addressed this question (223). One policy-based intervention study found that an ECG-based screening program for competitive athletes may have reduced the population risk of sudden cardiac death among young adults (224).
2.5.2 Resting Echocardiography for Left Ventricular Structure and Function and Left Ventricular Hypertrophy: Transthoracic Echocardiography
220.127.116.11 Recommendations for Transthoracic Echocardiography
1. Echocardiography to detect LVH may be considered for cardiovascular risk assessment in asymptomatic adults with hypertension (225,226). (Level of Evidence: B)
Class III: No Benefit
1. Echocardiography is not recommended for cardiovascular risk assessment of CHD in asymptomatic adults without hypertension. (Level of Evidence: C)
18.104.22.168 Left Ventricular Function
Transthoracic echocardiography is a diagnostic modality widely used in cardiology practice. There are no echocardiographic findings with high sensitivity and specificity for the diagnosis of CHD in the absence of ischemia or infarction. Segmental wall motion abnormalities are the most common echocardiographic manifestation of CHD but are only present if there is active or recent (stunning) ischemia or there has been prior infarction. Moreover, segmental wall motion abnormalities do not uniformly represent ischemic territories caused by occlusive CAD, because they may also be present in patients with nonischemic cardiomyopathies. Additional manifestations of CHD include ischemic mitral regurgitation, global reduction in left ventricular systolic function, Doppler findings characteristic of diastolic dysfunction, and right ventricular dysfunction. However, none of these findings has sufficient sensitivity or specificity to be useful for screening or risk assessment in the asymptomatic patient at possible risk for CHD. Given the lack of evidence of risk assessment benefit in the general population, it was the consensus of the writing committee that echocardiography should not be performed for risk assessment in the asymptomatic adult without hypertension.
22.214.171.124 Left Ventricular Hypertrophy
LVH develops in response to varying stimuli and may be physiological in the setting of athletic training and pregnancy or pathological in response to pressure or volume overload, myocardial injury, or underlying genetic mutations. The pathophysiological mechanism for higher cardiovascular mortality in the setting of LVH is not completely understood, although studies have demonstrated decreased flow reserve and greater susceptibility to injury associated with ischemia and infarction (227). The methodology for LVH measurement by echocardiography and the cut points for definition of LVH vary widely among studies. There is also wide variability as to whether LVH is indexed to body surface area, height, or weight (227,228). A recent meta-analysis of 34 studies showed that 19 different criteria were used, leading to differences in the prevalence of LVH (229). The writing committee recommends the use of the methodology and cut points defined by the ASE (230). Separate cut points should be applied to men and women. Further studies may suggest that the definition of pathological LVH should be specific to race as well as sex. A recent study showed that athletic hypertrophy in African/Afro-Caribbeans (blacks) was greater than in whites (231).
LVH has been shown to be predictive of cardiovascular (including stroke) and all-cause mortality, independent of blood pressure, and across all racial groups that have been studied. In the predominantly white population of the Framingham Study, for every 50 g/m2 higher left ventricular mass index, there was a RR of death of 1.73 (95% CI 1.19 to 2.52) independent of blood pressure level (232). In the African-American population enrolled in the ARIC study, LVH conferred an increased risk for CVD events (nonfatal MI, cardiac death, coronary revascularization, and stroke) even after adjusting for other risk factors with a HR of 1.88 in men and 1.92 in women (228). Among American Indians enrolled in the Strong Heart Study (64% female, mean age equal to 58), the prevalence of LVH on echocardiography was 9.5% and conferred a 7-fold increase in cardiovascular mortality and a 4-fold increase in all-cause mortality (201). In this study, echocardiographic evidence of LVH had additive discriminatory power over ECG evidence of LVH. Data from a Hispanic population (226) are similarly suggestive of the association of LVH and cardiovascular mortality. The association of LVH and mortality in many of these studies cannot be attributed only to the risk of developing atherosclerotic CHD, because patients with hypertrophic cardiomyopathy who die suddenly may be misclassified. Recent estimates suggest a 1 in 500 prevalence of hypertrophic cardiomyopathy in the population, which may contribute to the association between LVH and cardiovascular (including stroke) and all-cause mortality.
LVH is considered evidence of target organ damage in hypertension according to JNC 7 (233). The epidemiological association between pathological hypertrophy and CVD has also been studied in hypertensive populations (201,226). For example, in the MAVI (Massa Ventricolare sinistra nell'Ipertensione) study of patients with uncomplicated essential hypertension, there was a 40% higher risk of cardiovascular events for each 39 g/m2 greater left ventricular mass index (225). Left ventricular architecture is also an important variable related to risk, with most studies suggesting that the presence of concentric rather than eccentric hypertrophy in the hypertensive population carries the highest risk.
126.96.36.199 Usefulness in Motivating Patients or Guiding Therapy
Although the finding of increased left ventricular mass on echocardiography could be envisioned to guide selection or intensity of therapy in hypertensive patients, JNC 7 recommendations do not risk stratify patients on the basis of target organ damage (233). Given the adverse prognosis associated with LVH in hypertension, further studies examined the comparative efficacy of specific antihypertensive agents in regressing LVH as well as survival benefits associated with LVH regression, but there was a lack of consistency among the trials. In a meta-analysis of 39 trials of antihypertensive therapy, angiotensin-converting enzyme inhibitors were the most effective agents, leading to a 13.3% reduction in left ventricular mass compared with 9.3% for calcium channel blockers, 6.8% for diuretics, and 5.5% for beta blockers (234). In a comparison of enalapril and long-acting nifedipine in patients with essential hypertension, the PRESERVE (Prospective Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement) trial, a prospective randomized enalapril study evaluating regression of ventricular enlargement, systolic and diastolic pressures as well as left ventricular mass were reduced to a similar degree with both agents (235). The LIFE (Losartan Intervention For Endpoint Reduction in Hypertension) trial echocardiographic substudy demonstrated superior left ventricular mass reduction (21.7 g/m2) in patients treated with losartan compared with patients treated with atenolol (17.7 g/m2) (218). Diuretics demonstrated superiority in treating LVH regression over alternative agents in both the TOMHS (Treatment of Mild Hypertension Study) and Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents, using chlorthalidone and hydrochlorthiazide, respectively (236,237).
LVH regression does not adversely affect cardiac function and may be associated with improvements in diastolic function. Most importantly, patients who demonstrate LVH regression on antihypertensive therapy have a lower rate of cardiovascular events than those who do not, independent of the extent of blood pressure control (238,239).
Despite these observations, there have been no trials that target antihypertensive therapy to regress echocardiographically detected LVH, and thus the results continue to generate hypotheses.
No studies have examined whether a patient's knowledge of echocardiographic results demonstrating LVH will improve adherence to lifestyle modifications or pharmacologic treatment of hypertension.
2.5.3 Carotid Intima-Media Thickness on Ultrasound
188.8.131.52 Recommendation for Measurement of Carotid Intima-Media Thickness
1. Measurement of carotid artery IMT is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (240,241). Published recommendations on required equipment, technical approach, and operator training and experience for performance of the test must be carefully followed to achieve high-quality results (241). (Level of Evidence: B)
184.108.40.206 General Description
Carotid IMT testing is a noninvasive, nonionizing radiation test using ultrasound imaging of the carotid artery wall to define the combined thickness of the intimal and medial arterial wall components. It is most commonly measured in the far wall of the common carotid artery; however, it can also be measured in the near wall and other carotid segments (bulb, internal). With well-trained operators, the test has been shown to be highly accurate with excellent intertest and interobserver reproducibility primarily in research settings and less commonly in practitioner-based settings (242). The available data on risk associated with carotid IMT are drawn almost exclusively from research settings using highly standardized protocols. The use of common carotid IMT as a standard site of measurement has been proposed due to its inherent greater reproducibility and ability to refine the cardiovascular risk prediction. Published recommendations on the required equipment, technical approach, and operator training and experience for performance of the test must be carefully followed to achieve high-quality results (241,243). There is a need for provider competency and lab accreditation standards to ensure quality imaging. An elevated level of carotid IMT is commonly cited as a level that surpasses the population-based 75th percentile value, but this must be identified specific to a particular carotid arterial segment (e.g., common or internal carotid artery) and ultrasound methodology for which tables are available (241).
220.127.116.11 Independent Relationship Beyond Standard Risk Factors
Carotid IMT has been independently associated with future risk for ischemic coronary events and stroke in middle-aged and older individuals (244). The risk of incident CHD events increases in a continuous fashion as carotid IMT increases (RR increases approximately 15% per 0.10-mm increase in carotid IMT); thus, measurement of carotid IMT has been shown in research studies to be a marker of risk for atherosclerotic CVD. Furthermore, the finding of atherosclerotic plaque, operationally defined as a focal increase in thickness >50% of the surrounding IMT, increases the predicted CAD risk at any level of carotid IMT (245). These values were determined after adjustment for traditional CVD risk factors.
The relationship between carotid IMT and incident CHD events was initially noted in the Kuopio Ischemic Heart Disease Risk Factor study, in which risk of future MI in Finnish men increased by 11% for every 0.1-mm increment in carotid IMT (246). For carotid IMT values >1 mm, there was a 2-fold greater risk of acute MI over 3 years. The ARIC study showed that for every 0.19-mm increment in carotid IMT, risk of death or MI increased by 36% in middle-aged patients (45 to 65 years of age) (247). CHD risk was almost 2-fold greater in men with mean carotid IMT >1 mm and even greater in women (RR 5.0). Not all studies, however, have shown differences between men and women in the predictive value of carotid IMT. For example, the Rotterdam study found that the risk of CHD events and carotid IMT was similar among men and women (248).
The association between carotid IMT and incidence of MI and stroke has been noted in older populations and other high-risk populations. In the Cardiovascular Health Study, the RR for MI, adjusted for age, gender, and standard cardiovascular risk factors, was 3.15 (95% CI 2.19 to 4.52) when an average IMT was used for the common carotid and internal carotid arteries and when comparing the highest quintile versus the lowest quintile. These differences held true for patients with and without known CVD (249). Among middle-aged adults with diabetes mellitus in the ARIC study, an IMT ≥1 mm was associated with an increase in the ROC AUC from 0.711 to 0.724 among women and 0.680 to 0.698 in men (250) when this elevated IMT was included in traditional risk factor predictive models. Similarly, in the Cardiovascular Health Study, the incidence of CAD was shown to increase from 2.5% to 5.5% per year among patients with diabetes with subclinical vascular disease (251).
Carotid IMT measurement can lead to improved cardiovascular risk prediction and reclassification. In the ARIC study, 13,145 individuals were followed for approximately 15 years for incident hard coronary events and revascularization. Carotid IMT measurements, which included both IMT and carotid plaque, were incremental to traditional risk factors for prediction of incident cardiovascular events. In particular, among intermediate-risk patients (10% to 20%, 10-year estimated risk group), the addition of carotid IMT and plaque information led to clinical net reclassification improvement of approximately 9.9% (240).
Comparisons of carotid IMT with coronary calcium scoring as methods to modify cardiovascular risk assessment have been made in both middle-aged (MESA) and older individuals (Cardiovascular Health Study). Each study showed that carotid IMT was an independent predictor of cardiovascular outcomes. Coronary calcium was a relatively stronger predictor for coronary outcomes, whereas carotid IMT was a stronger predictor of stroke in MESA (252). In contrast, significant and similar magnitude relationships to cardiovascular outcomes (HRs for fourth quartile versus first quartile for each test, approximately 2.1) were observed in the Cardiovascular Health Study for both tests (253). Given the discrepancy between these available studies, the data are insufficient to conclude whether these tests are clinically equivalent or not. Thus, at this time, test selection in clinical practice is better guided by local and patient factors such as expertise, cost, and patient preference.
Epidemiological studies demonstrate that IMT typically progresses at an average rate of ≤0.03 mm per year, and the rate of progression appears to be related to risk of cardiovascular event (254). Progression can be slowed by cholesterol-lowering drugs (statins and niacin) and other risk factor modifications (e.g., control of blood pressure). However, serial scanning of carotid IMT is challenging in individual patients across brief time horizons due to variability in measurement in relation to the rate of disease progression and is therefore not recommended in clinical settings.
Images of subclinical atherosclerosis are hypothesized to alter patient behavior, but the evidence is insufficient (255).
18.104.22.168 Usefulness in Motivating Patients or Guiding Therapy
The finding of increased carotid IMT should clinically guide selection or intensity of therapy. However, evidence is lacking regarding whether measurement of carotid IMT alters outcome (Table 5). Clinical tools integrating carotid IMT within global risk scoring systems are not available.
22.214.171.124 Evidence for Improved Net Health Outcomes
The incremental value of carotid IMT and cost-effectiveness beyond that available from standard risk assessments to improve overall patient outcomes is not established.
2.5.4 Brachial/Peripheral Flow-Mediated Dilation
126.96.36.199 Recommendation for Brachial/Peripheral Flow-Mediated Dilation
Class III: No Benefit
1. Peripheral arterial flow-mediated dilation (FMD) studies are not recommended for cardiovascular risk assessment in asymptomatic adults (256,257). (Level of Evidence: B)
188.8.131.52 General Description
Peripheral arterial FMD is a noninvasive measure of endothelial function. Augmented flow is produced by a sustained period (typically 4 to 5 min) of forearm compression accompanied by vascular occlusion followed by release. In the setting of healthy endothelium, increased flow stimulates release of nitric oxide, inducing local brachial artery vasodilation. The degree of dilation can be measured using high-resolution ultrasound. The technique requires a highly skilled sonographer, highly standardized measurement conditions (including time of day, temperature, drug administration), and suitable ultrasound machine. Many examiners also use specialized computer software to semiautomatically quantitate the brachial artery diameter. Considerable variability exists for values of FMD determined by different investigators, even in similar patient populations, suggesting technical challenges with the measurement (258). Important technical factors influencing FMD are duration of forearm occlusion and the location of the occluding cuff, but many other factors are also important, as mentioned above. In research settings, brachial artery FMD has been shown to correlate with invasive measures of coronary artery FMD after adenosine triphosphate infusion, suggesting that peripheral FMD may be a suitable substitute for invasive coronary endothelial function testing (257). FMD also correlates with other noninvasive measures of cardiovascular risk, including CRP, carotid IMT, and measures of arterial stiffness.
PAT is a second method of assessing postocclusion vasodilation. This method uses bilateral finger cuffs that sense pulse wave volume. After a 5-minute flow occlusion in 1 arm, the resulting augmentation of pulse volume in the occlusion arm is compared with the control arm, yielding a PAT ratio. The PAT ratio provides information similar to FMD (256,259).
184.108.40.206 Association With Increased Risk and Incremental Prediction
Many studies have documented a relationship between FMD, PAT, and traditional CVD risk factors. FMD and PAT ratios are lower (abnormal) in subjects with greater numbers of risk factors or higher levels of FRS. Diabetes and smoking have the most powerful associations with abnormal FMD. A meta-regression analysis of 211 publications reported on 399 populations where both FMD and traditional risk factors were available (260). By design, many of these populations had existing CVD. The relationship between FMD and risk factors was most clear in the category with the lowest baseline risk. In this group, for each percentage point higher FRS, FMD was lower by 1.42%. In populations with an intermediate or high FRS, FMD was not related to the score. This finding fits with the hypothesis that FMD is an early marker of vascular dysfunction. Once multiple risk factors are present, FMD may become so impaired that additional risk factors do not further impair it.
PAT ratio was measured in the Framingham Third Generation Cohort (n=1,957) (261). In a stepwise multivariable regression model, PAT ratio was inversely related to male sex, body mass index, total/HDL-cholesterol ratio, diabetes, smoking, and lipid-lowering treatment. In this study, hypertension was not related to PAT.
It is unclear whether these measures of peripheral endothelial health provide incremental predictive information when controlling for traditional risk factors. The relationship between FMD and incident cardiovascular events was reported in a population-based cohort of older adults (262). In the Cardiovascular Health Study, 2,792 (2,791 with complete data) adults aged 72 to 98 years underwent FMD measures (262). During 5-year follow-up, 24.1% of these subjects had events. At study entry, 76% of this population (n=2,125) was free of known CVD. In the subset without known CVD at entry, the predictive value of FMD (after adjustment for age, gender, diabetes, blood pressure, cholesterol, and HMG-CoA [3-hydroxy-3-methylglutaryl-coenzyme A] reductase inhibitor use) was directionally similar to the whole population but failed to achieve statistical significance (p=0.08). The addition of brachial FMD to the predictive model containing the classical cardiovascular risk factors increased the AUC by a net change of only 0.001, and the p value for the increase was not significant (area under receiver operating statistic 0.841 versus 0.842). NOMAS (Northern Manhattan Study), a smaller multiethnic, prospective cohort study of 842 subjects free of CVD examined the relationship of FMD to 36-month cardiovascular events (263). Although FMD was associated with the occurrence of future events (HR 1.12 for every 1% decrease in FMD), the association was no longer statistically significant when traditional cardiovascular risk factors were included in a multivariable analysis. In contrast, a study of 2264 asymptomatic postmenopausal women found that FMD was independently related to cardiovascular events (RR 1.12; 95% CI 1.04 to 2.00; p<0.001) when included in a model with traditional risk factors (264). No measures of reclassification were reported in this study.
220.127.116.11 Usefulness in Motivating Patients or Guiding Therapy
There is no evidence that arterial FMD studies are useful for motivating asymptomatic persons to adhere to preventive therapies.
In a study of 400 hypertensive postmenopausal women followed up for an average of 67 months (265), endothelial function was measured as FMD of the brachial artery at baseline and at 6 months after initiation of blood pressure control. After 6 months of treatment, FMD had not changed (≤10% relative to baseline) in 150 (37.5%) of the 400 women, whereas it had significantly improved (>10% relative to baseline) in the remaining 250 women (62.5%). During follow-up, failure to have an improved FMD at 6 months was an independent predictor of nonfatal cardiovascular events requiring hospitalization. This study demonstrates that a significant improvement in endothelial function may be obtained after 6 months of antihypertensive therapy and also appears to identify patients who may have a more favorable prognosis.
Due to the limited data available, the writing committee concluded that it was premature to recommend serial FMD measurements to monitor treatment effects. In addition, due to the technical challenges of standardizing measurement of FMD and the relatively modest evidence of incremental change in risk assessment, measurement for risk assessment was not regarded as appropriate for risk assessment in the asymptomatic adult.
18.104.22.168 Changes in Patient Outcomes
To date, there are no published trials evaluating the impact of specific therapy on clinical outcome in patients identified as having abnormal peripheral endothelial function.
2.5.5 Pulse Wave Velocity and Other Arterial Abnormalities: Measures of Arterial Stiffness
22.214.171.124 Recommendation for Specific Measures of Arterial Stiffness
Class III: No Benefit
1. Measures of arterial stiffness outside of research settings are not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C)
126.96.36.199 Description of Specific Measures of Arterial Stiffness
Arterial stiffness is a consequence of arteriosclerosis, the process of arterial wall thickening, and loss of elasticity that occurs with onset of vascular disease and advancing age. Besides pulse pressure (the numeric difference between the systolic and diastolic blood pressures), multiple other specific measures of arterial stiffness have been described (98,266,267). The most commonly studied measures of arterial stiffness are aortic pulse wave velocity (PWV) and pulse wave analyses such as the aortic augmentation index (266).
Because blood is a noncompressible fluid, transmission of the arterial pressure wave occurs along the arterial wall and is influenced by the biomechanical properties of the arterial wall. When the arteries are stiffened, the pulse wave is propagated at an increased velocity, and increased PWV is therefore correlated with stiffness of the arteries. Factors associated with PWV include advancing age as well as the long-term effects of cardiovascular risk factors on the structure and function of the arterial wall. PWV is generally measured using applanation tonometry but can also be measured by Doppler ultrasound or magnetic resonance imaging (MRI). MRI is more costly and therefore is typically not used for testing in asymptomatic persons.
Pulse wave analysis is based on the concept that the pressure wave is partially reflected back toward the aorta at various points of discontinuity in arterial elasticity. Applanation tonometry is considered a relatively simple and reproducible method of collecting data for pulse wave analysis in research settings. The most commonly reported measure in pulse wave analysis is expressed as a fraction of the central pulse pressure, called the aortic augmentation index. The augmentation index is said to be most useful in patients under the age of 60 years (266). Both pulse wave analysis and PWV are typically determined by commercial devices that perform the analyses based on proprietary analytic algorithms (267).
Although predictive information (see below and Table 6) suggests a potential clinical role for measures of arterial stiffness, there are a number of technical problems that the writing committee believed would restrict the applicability of measures of arterial stiffness predominantly to research settings at this time (266,267). For measures of arterial stiffness to be incorporated into clinical practice, measurement protocols must be well standardized, quality control procedures established, and risk-defining thresholds identified (266). Reproducibility is a problem, as is operator dependence, both of which limit the generalizability of findings derived from research studies. Additional technical concerns include the need to standardize room temperature, time of day of testing, keeping the patient at rest for at least 10 minutes before measurements are recorded, and careful attention to timing of drug and caffeine intake (267). The writing committee felt that the technical concerns make arterial stiffness tests less suitable for addition to the clinical practice of risk assessment in asymptomatic adults due to problems with measurement and data collection.
188.8.131.52 Evidence on the Association With Increased Cardiovascular Risk and Incremental Risk
From the standpoint of predictive studies within general “healthy” populations, measures that have been studied are the PWV, ambulatory arterial stiffness index, and carotid pulse pressure (versus brachial pulse pressure). Predictive results in general populations are summarized for 11 longitudinal studies in Table 6. Although a few of these studies have reported no predictive capability of these measures of arterial stiffness, most studies indicated predictive capability that is additive to standard risk factors, including (in some cases) systolic and diastolic blood pressures as well as ankle-brachial index (ABI). In some studies, but not all, HRs have been higher for stroke risk than for CAD risk. No studies have directly compared these measures of CVD risk with other measures of “subclinical” CVD such as arterial IMT or CAC score. HRs have generally been in the very modest predictive range of 1.1 to 1.3 for various measures of arterial stiffness and CHD outcomes. Information on changes in the C statistic or other measures of incremental risk stratification has generally not been reported.
184.108.40.206 Usefulness in Motivating Patients or Guiding Therapy
No information has been reported on any of these topics in well-conducted studies of populations of healthy adults.
2.5.6 Recommendation for Measurement of Ankle-Brachial Index
1. Measurement of ABI is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (279). (Level of Evidence: B)
220.127.116.11 General Description
The ABI is an office-based test to check for the presence of PAD. It is performed by Doppler measurement of blood pressure in all 4 extremities at the brachial, posterior tibial, and dorsalis pedis arteries. The highest lower-extremity blood pressure is divided by the highest of the upper-extremity blood pressures, with a value of <0.9 indicating the presence of PAD, which is defined as >50% stenosis. When defined in this way, the ABI has both a high sensitivity and specificity for anatomic stenosis. In addition to signifying PAD, an abnormally low ABI has also been shown to be a predictor of cardiovascular events. Intermediate values (0.9 to 1.1) also have a graded association with CVD risk. A high ABI (>1.3), which indicates calcified, noncompressible arteries, is also a marker of arterial disease. The prevalence of PAD as indicated by an abnormal ABI increases with age and is associated with traditional risk factors for CVD (280,281).
18.104.22.168 Association With Increased Risk
Many epidemiological studies have demonstrated that an abnormal ABI in otherwise asymptomatic individuals is associated with cardiovascular events (279,282–293). A recent collaborative study combined data from 16 studies (279) and included a total of 24,955 men and 23,399 women without a history of CHD. Importantly the study included data from a wide representation of the population, including blacks, American Indians, persons of Asian descent, and Hispanics as well as whites (288,293–295). The mean age in the studies ranged from 47 to 78 years, and the FRS-predicted rate of CHD ranged from 11% to 32% in men and from 7% to 15% in women. There were 9,924 deaths (25% due to CHD or stroke) over 480 325 patient-years of follow-up. For an ABI of <0.9 compared with an ABI of 1.11 to 1.4, the HR for cardiovascular mortality and major events was 3.33 for men and 2.71 for women (279). When adjusted for the FRS, the HRs were only moderately lower (2.34 in men and 2.35 in women), demonstrating the additive predictive value of the ABI beyond the FRS (279). An ABI of >1.4 was also associated with higher risk within most of the FRS categories. However, the greatest incremental benefit of ABI for predicting risk in men was in those with a high FRS (>20%), in whom a normal ABI reduced risk to intermediate (279). In women the greatest benefit was in those with a low FRS (<10%), in whom an abnormally low or high ABI would reclassify them as high risk, and in those with an intermediate FRS, who would be reclassified as high risk with a low ABI. Reclassification occurred in 19% of men and 36% of women. Thus, an abnormally low or abnormally high ABI is associated with increased cardiovascular risk in both men and women, and the risk prediction extends beyond that of the FRS alone.
22.214.171.124 Usefulness in Motivating Patients or Guiding Therapy
There are no randomized clinical trials that demonstrate measurement of ABI is effective in motivating asymptomatic patients to comply with measures to reduce cardiovascular risk. There is also no indication that serial measurement of the ABI can be used to monitor treatment or guide treatment approaches.
2.5.7 Recommendation for Exercise Electrocardiography
1. An exercise ECG may be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity (296–298). (Level of Evidence: B)
Patients who are capable of exercising on a bicycle or treadmill with a normal resting 12-lead ECG are connected to a modified-torso 12-lead ECG and asked to exercise at increasing levels of stress until exhaustion or other milestones are met, such as a target heart rate or worrisome clinical findings (e.g., severe chest discomfort). Treadmill testing is more commonly performed in the United States; a variety of protocols are used during which both speed and grade are gradually increased in stages. Ideal exercise times are about 8 to 12 minutes. Although the best known measurement is change in ST-segment deviation during and after exercise, other important prognostic measures are exercise capacity, chronotropic response, heart rate recovery, and exercise-induced arrhythmias (299).
126.96.36.199 Association With Increased Risk and Incremental Risk
Several specific findings on exercise testing are associated with subsequent mortality and cardiovascular events (Table 7) (299). An AHA scientific statement has described in detail exercise test risk predictors in asymptomatic adults (299). Although many clinicians typically think of the exercise test as primarily a measure of ST-segment changes that may reflect ischemia, evidence has demonstrated that the ST segment is a weak marker for prevalent and incident CAD (300,301). In contrast, non-ECG measures have emerged as stronger predictors of risk. Probably the most powerful risk marker obtained during routine exercise testing is exercise capacity; numerous investigators have consistently found that depressed exercise capacity is associated with increased cardiovascular risk (296,298,299,302–305). In a very large primary care population, adding exercise variables to clinical variables increased the C index from 0.75 to 0.83 for prediction of all-cause mortality (306). Among healthy executives, adding exercise variables to clinical variables increased the C index from 0.73 to 0.76 (307).
Markers reflective of autonomic nervous system function can predict major cardiovascular events, total mortality, and sudden cardiac death (297,308–313). Failure of the heart rate to rise appropriately during exercise has been termed chronotropic incompetence and has been linked to adverse outcome whether or not beta blockers are being taken (299,314,315). The fall in heart rate immediately after exercise, also known as heart rate recovery, is thought to reflect parasympathetic tone (316). Decreased heart rate recovery has been associated with death or cardiac events in a number of populations, including those that are entirely or primarily asymptomatic (307,309,310,313,317–319). Frequent ventricular ectopy during recovery, similarly thought to reflect abnormalities of parasympathetic nervous system function, are also independently associated with long-term risk of mortality (309). The adjusted HR is 1.5 (95% CI 1.1 to 1.9; p=0.003) (309).
To synthesize the clinical importance of these measures, a number of exercise test scoring schemes have been developed and validated. Probably the best-known is the Duke Treadmill Score (DTS), which incorporates exercise capacity, ST-segment changes, and exercise-induced angina (313,320,321). The formula for the DTS is exercise time − (4 × angina index) − (5 × maximal ST-segment depression). The DTS has been validated in a number of populations as predictive of risk. Of note however, the only element of the DTS that has been consistently associated with increased risk has been exercise capacity (301,313). In both younger and older adults, ST-segment changes and exercise-induced angina have not consistently appeared as risk predictors (301,313).
The DTS has been criticized for its failure to take into account demographics and simple risk factors. A nomogram based on simple demographics, easily obtained risk factors, and standard exercise test findings was found to better discriminate risk than the DTS (C index, 0.83 versus 0.73; p<0.001); the nomogram was also successfully validated in an external cohort (306).
188.8.131.52 Usefulness in Motivating Patients or Guiding Therapy
No randomized trials have specifically addressed the role of exercise testing in these 3 areas. There is also no direct information on the role of the exercise test to monitor treatment effects in asymptomatic adults.
2.5.8 Recommendation for Stress Echocardiography
Class III: No Benefit
1. Stress echocardiography is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic stress echocardiography is primarily used for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known coronary artery disease or the assessment of patients with known or suspected valvular heart disease.) (Level of Evidence: C)
184.108.40.206 General Description
Stress echocardiography can be performed with dynamic forms of exercise, including treadmill and bicycle, as well as with pharmacologic stress, most often using dobutamine. The manifestations of ischemia on echocardiography include segmental and global left ventricular dysfunction. The use of echocardiography during treadmill testing is indicated for those patients with an abnormal resting ECG, including findings of left bundle-branch block, electronically paced rhythm, and LVH, as well as for patients taking digoxin. The diagnostic performance of the test is highly dependent on the availability of skilled acquisition and interpretation of the images and should be performed according to best practices (322). MPI with echocardiographic contrast agents has not been widely used, and there are no currently approved agents available in the United States, so this technique is not addressed here.
The current guideline focuses on the use of tests and procedures that may be employed for assessment of cardiovascular risk in the asymptomatic adult. In several sections of this document the writing committee has also assessed the evidence for applying conventional diagnostic testing with or without imaging. It is important to realize the vast difference in concepts between use of a diagnostic test, usually in the symptomatic patient, to define a patient's likelihood of obstructive CAD compared with stratification of risk in an asymptomatic patient to serve as a basis for cardiovascular preventive strategies. Stress echocardiography is a test predominantly used in symptomatic patients to assist in the diagnosis of obstructive CAD. There is very little information in the literature on the use of stress echocardiography in asymptomatic individuals for the purposes of cardiovascular risk assessment. Accordingly, the Class III (LOE: C) recommendation for stress echocardiography reflects a lack of population evidence of this test for risk assessment purposes. This contraindication to testing must be placed within the concept of accepted indications for testing asymptomatic patients for diagnosis of CAD, such as for asymptomatic individuals undergoing preoperative risk assessment (323), patients with new-onset atrial fibrillation, or a clinical work-up after episodes of ventricular tachycardia or syncope. In contrast, the current guideline focuses on risk assessment in the asymptomatic adult, which must not be confused with evaluation of the patient without chest pain with ischemic equivalents such as dyspnea, where in some cases, stress testing may be considered appropriate. The focus of these latter evaluations is to assess a patient's ischemic burden and the ensuing likelihood of obstructive CAD. There are clinical practice guidelines and appropriate use criteria that focus on the quality of evidence for assessment of asymptomatic patients or those with ischemic equivalents and clinical indications for the use of stress echocardiography. The current guideline is not applicable in this setting of diagnosis of CAD.
220.127.116.11 Association With Increased Risk
In a cohort of 1,832 asymptomatic adults with no history of CHD (mean age, 51 years; 51% male), the predictive value of exercise echocardiography was examined at a mean of almost 5 years of follow-up (324). The incidence of significant ST-segment depression was 12%, and the incidence of inducible wall motion abnormalities was 8%. The presence of inducible wall motion abnormalities was not an independent predictor of cardiac events in the entire population or those with ≥2 risk factors (324). There are additional clinical studies in patients with type 2 diabetes mellitus. One small series compared screening with combined exercise electrocardiography and dobutamine stress echocardiography to a no-screening strategy in 141 patients with type 2 diabetes. The series found that the screening strategy was associated with reduced cardiac events when those with inducible wall motion abnormalities (21%) underwent revascularization (325).
No information is currently available to assess the role of exercise echocardiography in addition to conventional risk factors for risk assessment in asymptomatic adults. Because of the lack of information on the role of risk assessment in the asymptomatic adult, the writing committee thought that there was no basis to recommend stress echocardiography for routine risk assessment in this type of patient.
18.104.22.168 Usefulness in Motivating Patients or Guiding Therapy
There have been no randomized trials on exercise echocardiography to suggest that it can be used to motivate lifestyle behavior changes in asymptomatic adults. One small pilot trial in patients with type 2 diabetes is cited above (325). No other trials have investigated the use of echocardiography to guide therapy in asymptomatic adults. Thus, there is no clear indication that an exercise echocardiogram can be used to motivate asymptomatic adults or guide their therapy.
2.5.9 Myocardial Perfusion Imaging
22.214.171.124 Recommendations for Myocardial Perfusion Imaging
1. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or asymptomatic adults with a strong family history of CHD or when previous risk assessment testing suggests high risk of CHD, such as a CAC score of 400 or greater. (Level of Evidence: C)
Class III: No Benefit
1. Stress MPI is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults (Exercise or pharmacologic stress MPI is primarily used and studied for its role in advanced cardiac evaluation of symptoms suspected of representing CHD and/or estimation of prognosis in patients with known CAD.) (326). (Level of Evidence: C)
126.96.36.199 Description of Myocardial Perfusion Imaging
Exercise or pharmacologic stress MPI using single-photon emission computed tomography (SPECT) or positron emission tomography (PET) is predominantly considered appropriate for the clinical evaluation of symptoms suggestive of myocardial ischemia or for determination of prognosis in patients with suspected or previously known CAD. As noted in the stress echocardiography section, it is important to recognize the distinction between the use of a diagnostic test to define the likelihood of obstructive CAD in a symptomatic patient and the possible role of a diagnostic test in risk assessment of an asymptomatic individual, for whom the results of testing would be used in decision making about strategies for prevention of CVD. This guideline is not intended to address the evaluation of patients presenting with possible cardiovascular symptoms or signs such as dyspnea, syncope, or arrhythmia, nor does this guideline address the preoperative assessment of a high-risk patient. These patient evaluations are the topics of other guidelines, and the reader is referred to other guidelines when confronted with such symptomatic patients.
Stress myocardial perfusion SPECT and PET involve exposure to ionizing radiation. The effective radiation dose for SPECT and PET considerably exceeds that of a CAC score (median effective dose: 2.3 millisievert [mSv]), and therefore the use of these modalities should be limited to patients in whom clinical benefit exceeds the risk of radiation exposure, for example, higher-risk or older patients. Use of these procedures must be performed with the guiding principle of applying effective doses that are “as low as reasonably achievable” (i.e., ALARA). The estimated effective dose for stress myocardial perfusion SPECT is ∼14.6 mSv, whereas that of Rb82 PET is ∼5 mSv (327). For all patients, dose-reduction strategies should be used whenever possible (e.g., stress-only imaging), and these approaches may reduce SPECT doses to as low as 5 to 8 mSv (328). The clinician is strongly urged to consider radiation exposure when deciding whether the benefit of testing an asymptomatic patient outweighs the potential risks.
188.8.131.52 Evidence of Association With Increased Cardiovascular Risk in Asymptomatic Adults
There are few studies on the role of stress MPI for risk assessment in asymptomatic persons. The writing committee did not identify any studies in population-based (relatively unselected) asymptomatic individuals. Reported studies of stress perfusion imaging in asymptomatic persons have involved selected higher-risk patients who were referred for cardiac risk evaluation. In 1 large series of patients referred to a stress perfusion imaging laboratory (n=3664 asymptomatic patients), those with >7.5% myocardial ischemia had an annual event rate of 3.2%, which was consistent with high risk. High-risk findings were noted in <10% of asymptomatic patients who were referred. Limitations of the study include the absence of clear indications for referral and absence of prior global risk assessment as a basis for advanced risk assessment (329). A second study, from the Mayo Clinic, selected 260 asymptomatic patients from a nuclear cardiology database (67±8 years, 72% male) without known CAD who were at moderate risk for CHD by FRS (330). SPECT MPI images were categorized using the summed stress score. Mean follow-up was nearly 10 years. Abnormal SPECT MPI scans were present in 142 patients (55%). By summed stress score categories, SPECT scans were low risk in 67% of patients, intermediate risk in 20%, and high risk in 13%. Survival was 60% for patients with high-risk scans (95% CI 45% to 80%), 79% with intermediate-risk scans (95% CI 69% to 91%), and 83% with low-risk scans (95% CI 77% to 88%) (p=0.03), including 84% (95% CI 77% to 91%) with normal scans. In asymptomatic intermediate- to higher-risk patients, these available data suggest a possible role for stress perfusion imaging in advanced risk assessment of selected asymptomatic patients.
Risk stratification using MPI has also been studied in asymptomatic patients with diabetes (331–337). In 1 multicenter study of 370 asymptomatic persons with diabetes recruited from departments of diabetology (335), abnormality was defined as a fixed or reversible perfusion defect or a positive stress ECG. These abnormalities (compared with patients with normal study results) were associated with a 2.9-fold (1.3 to 6.4) higher risk for cardiovascular events in patients >60 years of age but not for those <60 years of age. In the DIAD (Detection of Ischemia in Asymptomatic Diabetics) trial, asymptomatic, relatively low-risk patients with diabetes were randomized to screening for “silent” myocardial ischemia using adenosine stress MPI as an initial screening test versus “usual care” (337). The DIAD study found evidence of effective risk stratification, with annual cardiovascular event rates of 0.4% for those with normal- or low-risk scans compared with 2.4% for those with a moderate to large perfusion defect (p=0.001) (337). However, the overall result of the DIAD study was no significant difference in clinical outcomes in the screened group versus the usual care group (see further on this point below).
Stress perfusion imaging tests have been studied in a limited way when used as a secondary test following an initial evaluation with exercise ECG, carotid IMT, or CAC (333,338–343). A summary of the literature from the ASNC synthesized published reports in patients who had these first-level indications of higher risk. Results suggested that as many as 1 in 3 of higher-risk patients with a CAC score of ≥400 had demonstrable ischemia. The prevalence of ischemia can be quite high in patients with diabetes, especially those with a family history of CHD (340,344). In a series of 510 asymptomatic patients with type 2 diabetes recruited from 4 London diabetes clinics, the incidence of myocardial ischemia was 0%, 18.4%, 22.9%, 48.3%, and 71.4% for those with CAC scores of 0 to 10, 11 to 100, 101 to 400, 401 to 1000, and >1000, respectively (p<0.0001).
Three studies have reported the prognosis for patients referred to either initial CAC screening or combined CAC scanning with stress MPI (333,341,343). In 1 series that included a mixed sample of asymptomatic patients and patients with chest pain, high-risk CAC scores did not confer an elevated cardiovascular event risk. In another series of 621 patients who underwent hybrid PET-CT imaging with CAC scoring, one third of whom were asymptomatic, cardiovascular event-free survival was worse for patients with ischemia on PET plus a CAC score ≥1000 (p<0.001). In another study using a patient registry, data on asymptomatic patients with type 2 diabetes were reported (333). The inclusion criteria for the latter prospective registry included patients with diabetes who were ≥50 years of age with either prior carotid IMT ≥1.1 mm, urinary albumin rate ≥30 mg/g creatinine, or 2 of the following: abdominal obesity, HDL cholesterol <40 mg/dL, triglycerides ≥150 mg/dL, or hypertension ≥130/85 mm Hg. One-year event-free survival ranged from 96% to 76% for those with a summed stress score ranging from <4 to ≥14 (p<0.0001). These results suggest that stress perfusion imaging may have a role in the advanced testing of asymptomatic patients who have been evaluated with other modalities and found to be at high risk of silent ischemia. Such patients might include patients with a high-risk CAC score of ≥400 or higher-risk patients with diabetes, including those with a strong family history of CHD.
184.108.40.206 Usefulness in Motivating Patients or Guiding Therapy
There are limited data to demonstrate that stress-induced evidence of silent ischemia in asymptomatic patients will have an impact on patient management. These data are limited to the use of follow-up testing in the DIAD trial. Patients enrolled in the DIAD trial who were randomized to screening with stress MPI had a higher rate of follow-up coronary angiography and revascularization. These data are consistent with single-center studies that have shown that demonstration of high-risk myocardial perfusion scans in asymptomatic patients with diabetes leads to diagnostic cardiac catheterization to identify high-risk anatomy (e.g., 3-vessel CAD or left main CAD) with a view toward revascularization (345,346). One nonrandomized observational study showed that asymptomatic patients with diabetes with high-risk stress MPI scans had a better outcome with revascularization than medical therapy (347).
220.127.116.11 Changes in Patient Outcomes
There is evidence from 1 randomized trial on the utility of stress MPI to screen for CVD in persons with diabetes (337). The DIAD trial randomized 1,123 patients to no screening compared with screening with adenosine stress MPI. The trial results revealed that stress MPI performed as an initial screening test had no impact on 5-year outcomes compared with nonscreening or usual care of asymptomatic patients with diabetes (337). The relative hazard was 0.88 (95% CI 0.44 to 1.88) for those who were screened with stress myocardial perfusion SPECT compared with those who were not screened (p=0.73). Notable limitations to this trial are its small, underpowered sample size, the high crossover rate (n=170/562 nonscreening arm undergoing nonprotocol stress testing), and the high incomplete follow-up rate (n=81/1,123) exceeding the 49 observed cardiovascular events. Importantly, the enrolled patients were low risk with an annual cardiovascular event rate of 0.6% and included patients with a normal resting 12-lead ECG.
2.5.10 Computed Tomography for Coronary Calcium
18.104.22.168 Recommendations for Calcium Scoring Methods (see Section 2.6.1)
1. Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk) (18,348). (Level of Evidence: B)
1. Measurement of CAC may be reasonable for cardiovascular risk assessment in persons at low to intermediate risk (6% to 10% 10-year risk) (348–350). (Level of Evidence: B)
Class III: No Benefit
1. Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for cardiovascular risk assessment (18,348,351). (Level of Evidence: B)
22.214.171.124 Calcium Scoring Methods
Cardiac CT, using either multidetector row CT or electron beam tomography, enables the acquisition of thin slices of the heart and coronary arteries gated to diastole to minimize coronary motion. Both are sensitive noninvasive techniques that can detect and quantify coronary calcium, a marker of atherosclerosis (352,353). The test is typically performed in a prospectively ECG-triggered scanning mode with 2.5- to 3.0-mm thick axial images obtained through the heart. The quantity of calcium within the coronary arteries is typically scored as the area affected on the scan, multiplied by a weighting factor depending on the Hounsfield unit density of the calcium deposits (352). The radiation dose in a prospectively triggered acquisition is low, with a typical effective dose of <1.5 mSv (354). Due to the radiation exposure and general low prevalence of calcification in men <40 years of age and women <50 years of age, patient selection is an important consideration. CT scanning should generally not be done in men <40 years old and women <50 years old due to the very low prevalence of detectable calcium in these age groups.
The widespread use of CCTA has also raised concerns about radiation dose for patients. The National Council on Radiation Protection Report No. 160 stated that radiation exposure to the U.S. population due to medical sources increased >7 times between 1986 and 2006 (355). CT calcium scoring produces the same amount of radiation as 1 to 2 mammograms performed on each breast (356). The radiation dose in a prospectively triggered acquisition is low, with a typical effective dose of 0.9 to 1.1 mSv (354,357), but doses can be higher if retrospective imaging is used (358). All current recommendations suggest prospective triggering be used for CAC scoring. CT personnel must be constantly aware of the risks of radiation and strive to apply the lowest dose to the patient consistent with the clinical study. Because of radiation exposure and the general low prevalence of calcification in men <40 years of age and women <50 years of age, CT scanning should generally not be done in these younger-age patients.
126.96.36.199 Data on Independent Relationship to Cardiovascular Events
The majority of published studies have reported that the total amount of coronary calcium (usually expressed as the Agatston score) provides information about future CAD events over and above the information provided by standard risk factors. Intermediate-risk patients with an elevated CAC score (intermediate FRS and CAC >300) had a 2.8% annual rate of cardiac death or MI (roughly equivalent to a 10-year rate of 28%) that would be considered high risk (352). Pooled data from 6 studies of 27,622 asymptomatic patients were summarized in an ACCF/AHA clinical expert consensus document that examined predictors of the 395 CHD deaths or MIs (359). The 11,815 subjects who had CAC scores of 0 had a low rate of events over the subsequent 3 to 5 years (0.4%, based on 49 events). Compared with a CAC score of 0, a CAC score between 100 and 400 indicated a RR of 4.3 (95% CI 3.5 to 5.2; p<0.0001), a score of 400 to 1000 indicated a RR of 7.2 (95% CI 5.2 to 9.9; p<0.0001), and a score >1000 indicated a RR of 10.8 (95% CI 4.2 to 27.7; p<0.0001). The corresponding pooled rates of 3- to 5-year CHD death or MI rates were 4.6% (for scores from 400 to 1000) and 7.1% (for scores >1000), resulting in a RR ratio of 7.2 (95% CI 5.2 to 9.9; p<0.001) and 10.8 (95% CI 4.2 to 27.7; p<0.0001).
Since the ACCF/AHA expert consensus document was published, other prospective confirmatory studies have been published (18,348,351,353,354). These studies have demonstrated that the relationships between CAC outcomes are similar in men and women and different ethnic groups (353,354). Each of these studies demonstrated that the AUC to predict coronary artery events is significantly higher with CAC than either Framingham or PROCAM (Münster Heart Study) risk stratification alone. In MESA, the C statistic with traditional risk factors was 0.79 for major coronary events in the risk factor prediction model and 0.83 in the risk factor plus CAC model (p=0.006) (18).
188.8.131.52 Usefulness in Motivating Patients
To understand the clinical utility of CAC testing as a risk assessment tool, it is imperative to demonstrate that it alters clinical management (such as the use of preventive medications). In an observational survey study, Kalia et al. showed that self-reported lipid-lowering medication provision increased from 44% over 3 years to >90% in those with baseline calcium scores in the top 75th percentile for age and sex (p<0.001) (360). This finding was independent of underlying cardiovascular risk factors, age, and sex. Other cardiovascular risk behaviors were reported to be beneficially affected, specifically showing that higher baseline CAC was strongly associated with initiation of aspirin therapy, dietary changes, and increased exercise (361).
A randomized controlled study suggested that although a calcium scan did not in itself improve net population healthy behaviors, the post-test recurring interactions with a healthcare provider can be useful to reinforce lifestyle and treatment recommendations that could ensue from calcium testing (362).
184.108.40.206 Use as a Repeat Measure to Monitor Effects of Therapy in Asymptomatic Persons
Coronary calcium progresses at typically 10% to 20% of the baseline value per year, and among persons >45 years of age, approximately 7% per year of those without calcium develop detectable coronary calcium. The value of repeat calcium scanning is governed by the interscan interval, rate of coronary calcium progression, variability in repeated measurements, and independent association to shifts in prognosis and management based on the observed calcium progression rate. Although preliminary data suggest that a calcium scan progression rate of >15% per year is associated with a 17-fold increased risk for incident CHD events (363), there are no data demonstrating that serial CAC testing leads to improved outcomes or changes in therapeutic decision making (354).
220.127.116.11 Usefulness of Coronary Calcium Scoring in Guiding Therapy
Calcium scores >100 to 300 are associated with a high rate of incident CHD events over the ensuing 3 to 5 years, so that persons with calcium scores in this range are a suitable target group for stringent lifestyle recommendations, selection of evidence-based therapeutic agents to reduce cardiovascular risk, and focus on adherence to medical recommendations. In the Prospective Army Coronary Calcium study, among 1640 participants followed up for 6 years, use of statin and aspirin was independently 3.5- and 3-fold greater in those with any coronary calcium over 6 years, suggesting management changes can occur following calcium screening in community-based cohorts (364). Multiple logistic regression analysis, controlling for National Cholesterol Education Program (NCEP) risk variables, showed that CAC was independently associated with a significantly higher likelihood of use of statin, aspirin, or both (OR 6.97; 95% CI 4.81 to 10.10; p<0.001) (364). The OR for aspirin and statin use based on NCEP risk factors alone was dramatically lower (OR 1.52; 95% CI 1.27 to 1.82; p<0.001). Recent data from MESA suggest similar effects of CAC visualization on lipid-lowering and aspirin therapy (365).
18.104.22.168 Evidence for Improved Net Health Outcomes
Evidence is not available to show that risk assessment using CAC scoring improves clinical outcomes by reducing mortality or morbidity from CAD.
22.214.171.124 Special Considerations
126.96.36.199.1 coronary calcium scoring in women
A vast majority of women <75 years of age are classified by FRS to be low risk. In 1 study of 2,447 consecutive asymptomatic women without diabetes (55±10 years), 90% were classified as low risk by FRS (≤9%), 10% as intermediate risk (10% to 20%), and none had a high-risk FRS >20% (366). CAC was observed in 33%, whereas moderate (CAC ≥100), a marker of high risk, was seen in 10% of women. Overall, 20% of women had CAC ≥75th percentile for age and gender, another marker for future CHD events. However, when FRS was used, the majority (84%) of these women with significant subclinical atherosclerosis ≥75th percentile were classified as low risk, whereas only 16% were considered intermediate risk. Thus, FRS frequently classifies women as being low risk, even in the presence of significant CAC. Based on this 1 substudy from MESA, it is possible that CAC scoring may provide incremental value to FRS in identifying which asymptomatic women may benefit from targeted preventive measures (349). A recent report noted net reclassification improvement with CAC in relation to risk factors for all-cause mortality in women <60 years of age (367). In terms of the overall predictive capacity of high calcium scores, several studies have demonstrated that CAC-associated outcomes are similar in men and women (368,369).
For a discussion of the utility of CAC testing in persons with diabetes, see Section 2.6.1.
188.8.131.52.2 Comparison of Coronary Artery Calcium Scoring With Other Risk Assessment Modalities
Several studies have compared multiple techniques for cardiovascular risk stratification (350,369–371). Four studies comparing the predictive abilities of hsCRP with CAC have demonstrated that CAC remains an independent predictor of cardiovascular events in multivariable models, whereas CRP no longer retains a significant association with incident CHD (350,369–371). This has recently been confirmed in MESA as well (18,351). The CAC score was also shown to be a better predictor of subsequent CVD events than carotid IMT. Multivariable analysis revealed HRs for CHD of 1.7 (95% CI 1.1 to 2.7; p=0.07) for carotid IMT and 8.2 (95% CI 4.5 to 15.1; p<0.001) for CAC score (quartile 4 versus quartiles 1 and 2) (252).
2.5.11 Coronary Computed Tomography Angiography
184.108.40.206 Recommendation for Coronary Computed Tomography Angiography
Class III: No Benefit
1. Coronary computed tomography angiography is not recommended for cardiovascular risk assessment in asymptomatic adults (372). (Level of Evidence: C)
220.127.116.11 General Description
CCTA has been widely available since around 2004, when 64-detector scanners were produced by multiple vendors. Two basic scanning protocols may be used; both require ECG monitoring and gating. Helical (or spiral) scanning uses continuous image acquisition while the patient moves slowly through the scanner plane. Axial scanning incorporates a scanning period, followed by a patient movement period, followed by another scanning period (step-and-shoot). Compared with invasive coronary angiography using a cine system, both the temporal and spatial resolution of CCTA are far less (spatial: 200 microns versus 400; temporal: 10 ms versus approximately 80 to 190 ms, depending on the type of scanner). CCTA provides the best quality images when the heart rate is regular and slow (<60 bpm if possible).
CCTA has been compared with invasive coronary angiography for detection of atherosclerosis (typically defined as a 50% diameter stenosis) (373). Sensitivities and specificities from >40 studies are consistently in the range of 85% to 95%, and the most important test feature is the high negative predictive value (>98%) (373). In addition, CCTA can image mild plaque (<50%) in the vessel wall. Plaques may be roughly characterized according to their density (Hounsfield units) as calcified or noncalcified. CCTA requires a CT scanner with at least 64 detector rows and specialized software (approximate cost, $1 million). Concern has been raised that CCTA uses ionizing radiation. CCTA studies using unmodulated, helical scanning deliver 12 to 24 mSv of radiation per examination (373). Methods to reduce the radiation dose, including ECG dose modulation or prospective ECG-triggered axial scanning, have resulted in doses of less than 3 mSv in selected patients (estimated radiation dose associated with CCTA) (374).
18.104.22.168 Association With Increased Risk and Incremental Prediction in Asymptomatic Persons
Very limited information is available on the role of CCTA for risk assessment in asymptomatic persons. In a study from Korea, 1,000 middle-aged patients underwent CCTA as a component of a general health evaluation (372). Patients were either self-referred to this examination or referred by a physician. Patients with chest discomfort or known CAD were excluded from the analysis. Clinical follow-up was obtained at 17±2 months in >97% of patients. Coronary calcium was detected in 18% of patients, and 22% had identifiable atherosclerotic plaque. Significant (>50%) stenoses were found in 5% of patients. CCTA results were compared with the NCEP ATP III risk classification. The majority of patients were classified as low risk (55.7%) by NCEP criteria. Only 10.2% were classified as high risk. The prevalence of significant coronary stenoses in the low-, moderate- and high-risk groups was 2%, 7%, and 16%, respectively. During follow-up, 15 patients had “cardiac events,” although 14 of these were revascularization procedures prompted by the CCTA results. There were no deaths or MIs. Additional diagnostic testing was performed in 14% of patients identified as having coronary atherosclerosis, representing 3.1% of the entire screened population. On the basis of the small number of nonprocedural events in this study, the authors could not compare CCTA results with the NCEP risk assessment data for risk prediction purposes. No other studies have been reported to date on the potential utility of CCTA results for risk assessment in asymptomatic adults with coronary events as the outcome.
22.214.171.124 Changes in Patient Outcomes
There are no published trials evaluating the impact of specific therapy on clinical outcome in patients identified as having noncalcified atheroma by CCTA.
2.5.12 Magnetic Resonance Imaging of Plaque
126.96.36.199 Recommendation for Magnetic Resonance Imaging of Plaque
Class III: No Benefit
1. MRI for detection of vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults. (Level of Evidence: C)
188.8.131.52 General Description
MRI is a noninvasive method of plaque measurement that does not involve ionizing radiation. Studies of the aorta and the femoral and carotid arteries have demonstrated the capability of MRI for detection and quantification of atherosclerosis and suggested its potential for risk assessment and evaluation of the response to treatment in asymptomatic patients. MRI seems to offer the greatest role for plaque characterization as distinct from lesion quantification. Examination of plaque under different contrast weighting (black blood: T1, T2, proton density-weightings, and magnetization prepared rapid gradient echocardiography or bright blood: time of flight) allows characterization of individual plaque components (375,376), including lipid-rich necrotic core (377), fibrous cap status (378), hemorrhage (379,380), and calcification (377,381,382). Although most magnetic resonance plaque imaging studies do not require exogenous contrast administration, gadolinium-based contrast agents can further improve delineation of individual plaque components such as the fibrous cap and lipid-rich necrotic core (383,384).
Several studies have demonstrated that MRI findings are correlated with atherosclerosis risk factors. Aortic MRI scanning in 318 patients participating in the Framingham Heart Study found that after age adjustment, plaque prevalence and burden correlated with FRS for both women and men (385). In another Framingham Heart Study, subclinical aortic atherosclerosis was seen in nearly half of subjects and increased with advancing age. Hypertension was associated with increased aortic plaque burden. In the MESA study, aortic wall thickness measured with MRI increased with age, but males and blacks had the greatest wall thickness (386). In another MESA study, it was found that thickened carotid walls and plasma total cholesterol, but not other established CHD risk factors, were strongly associated with lipid core presence by MRI (387).
A few small prospective studies have been done to investigate characteristics of carotid artery plaque on MRI that are associated with disease progression and future cardiovascular events. One study examined patients with symptomatic and asymptomatic carotid disease to determine whether fibrous cap thinning or rupture as identified on MRI were associated with a history of recent transient ischemic attack or stroke. When compared with patients with a thick fibrous cap, patients with a ruptured cap were 23 times more likely to have had a recent transient ischemic attack or stroke (388). In a separate study of symptomatic carotid disease, patients with lipid cores in carotid plaque by MRI had ipsilateral cerebral infarctions more often than those without lipid cores (68% versus 31%; p=0.03) (389). Another study performed carotid MRI on 53 patients within 7 days of a second cerebrovascular accident. Patients with “vulnerable” carotid lesions, as defined by eccentric shape and heterogeneous signal on MRI, had an 8 times greater risk of a third cerebrovascular accident compared with those without vulnerable lesions (24% versus 3%; p=0.023) (390).
Prospective studies demonstrated that hemorrhage within carotid atherosclerotic plaques was associated with an accelerated increase in subsequent plaque volume over a period of 18 months (391). An increased risk of ipsilateral cerebrovascular events has also been reported over a mean follow-up period of 38.2 months in asymptomatic patients who had 50% to 79% carotid stenosis and the presence of a thin or ruptured fibrous cap, intraplaque hemorrhage, or a larger lipid-rich necrotic core (392). These studies support the hypothesis that the presence of intraplaque hemorrhage is a potent atherogenic stimulus.
At this time there are no published prospective population data to evaluate the role of MRI findings in risk assessment of asymptomatic adults. A number of large-scale studies are ongoing. It is recommended that additional large-scale multicenter trials be conducted to evaluate the possibility of using MRI in the detection of atherosclerosis in asymptomatic patients.
Rapid technological progress is transforming the imaging of atherosclerotic CVD at the molecular level using nanoparticles (393). In addition, a new generation of hybrid technology is now becoming available; this technology combines multiple imaging modalities, including PET in a single platform (e.g., PET/CT and MR/PET), using 1 machine for >1 type of imaging to measure atherosclerotic plaque metabolic activity with anatomical special resolution and contrast (394–396). There is no information available yet on the role of these newer tests for risk assessment in the asymptomatic adult.
2.6 Special Circumstances and Other Considerations
2.6.1 Diabetes Mellitus
184.108.40.206 Recommendations for Patients With Diabetes
1. In asymptomatic adults with diabetes, 40 years of age and older, measurement of CAC is reasonable for cardiovascular risk assessment (344,397–399). (Level of Evidence: B)
1. Measurement of HbA1C may be considered for cardiovascular risk assessment in asymptomatic adults with diabetes (400). (Level of Evidence: B)
2. Stress MPI may be considered for advanced cardiovascular risk assessment in asymptomatic adults with diabetes or when previous risk assessment testing suggests a high risk of CHD, such as a CAC score of 400 or greater. (Level of Evidence: C)
220.127.116.11 General Description and Background
CVD is the major cause of morbidity, mortality, and healthcare costs for patients with diabetes (401). Compared with the general population, patients with diabetes have a 4 times greater incidence of CHD (402) and a 2- to 4-fold higher risk of a cardiovascular event (307). The risk of MI in patients with diabetes without prior documented CHD is similar to the risk of reinfarction in patients without diabetes with known CHD (403). Women with type 2 diabetes are particularly prone to developing cardiovascular complications (the age-adjusted risk ratio of developing clinical CHD among people with diabetes was 2.4 in men and 5.1 in women compared with patients without diabetes) (403).
The prevalence of significant coronary atherosclerosis in a truly representative population of patients with type 2 diabetes has not been ascertained. One estimate is that 20% of patients with diabetes have coronary atherosclerosis (404). However, in an asymptomatic and uncomplicated cohort of patients with type 2 diabetes, 46.3% had evidence of coronary artery calcification reflective of coronary atherosclerosis (344). The prevalence of CAD on multislice CT was 80% in a group of 70 asymptomatic patients with type 2 diabetes (399). The majority of these patients had diffuse involvement of all 3 coronary arteries. In another study by this group, 60% of asymptomatic patients with diabetes had evidence of coronary calcification, of which 18% had calcium scores of >400 (405). Seventy percent had coronary luminal narrowing of 1 or more coronary arteries on multislice CT coronary angiography, patients with diabetes showed more plaques on multislice CT than patients without diabetes (7.1±3.2 versus 4.9±3.2; p=0.01) with more calcified plaques (52% versus 24%) (406). On invasive grayscale intravascular ultrasound, patients with diabetes in this study had a larger plaque burden (48.7%±10.7% versus 40.0%±12.1%; p=0.03). Asymptomatic patients with diabetes have more coronary calcification than patients without diabetes even when controlling for other variables (407–409), and for every increase in CAC on CT scanning, mortality for patients with diabetes is higher than in patients without diabetes (407). However, patients with diabetes with no coronary calcium have a survival rate similar to that of subjects without diabetes and with no identifiable coronary calcium (407). The overall rate of death or MI was 0%, 2.6%, 13.3%, and 17.9% (p<0.0001) in patients with diabetes with a CAC score of ≤100, 100 to 400, 401 to 1000 and >1000, respectively (344). ROC curve analysis showed by AUC that the CAC (AUC: 0.92; 95% CI 0.87 to 0.96) was superior to the UKPDS (United Kingdom Prospective Diabetes Study Risk Score) (AUC, 0.74; 95% CI 0.65 to 0.83) and FRS (AUC, 0.60; 95% CI 0.48 to 0.73; p<0.0001) for predicting cardiac events, with a risk ratio of 10.1 (95% CI 1.68 to 61.12) for patients with a score of 100 to 400 and 58.1 (95% CI 12.28 to >100) for scores >1000 (344).
The CAC score has been found to be predictive beyond conventional risk factors in several studies in patients with diabetes. In the PREDICT (Patients with Renal Impairment and Diabetes Undergoing Computed Tomography) study, 589 patients with type 2 diabetes underwent CAC measurement (398). At a median of 4 years' follow-up, in a predictive model that included CAC score and traditional risk factors, the CAC score was a highly significant independent predictor of CHD events or stroke. The model found that a doubling in calcium score was associated with a 32% increase in risk of events (29% after adjustment). Only the homeostasis model assessment of insulin resistance predicted primary endpoints independent of the CAC score. In another study, after adjusting for CHD risk factors, the CAC score was significantly associated with occurrence of coronary events in patients without diabetes but not in patients with diabetes (410). Another study performed CAC measurement in 716 asymptomatic patients with diabetes and no history of CHD (397). During 8 years of follow-up, 40 patients had MI and 36 additional patients experienced cardiac death. The CAC score was significantly higher in those with events compared with those without events, 5.6% per year for patients with scores of >400 versus 0.7% per year for those with lower scores (397). The area under the ROC curve with CAC in the model was significantly higher (0.77) for prediction of MI than the FRS (0.63).
18.104.22.168 Electrocardiographic Stress Testing for Silent Myocardial Ischemia (See Section 2.5.7)
The value of exercise ECG testing to detect silent ischemia and assess prognosis has been evaluated in a few small studies of asymptomatic patients with diabetes (411–416). ECG stress testing has an approximate 50% sensitivity and 80% specificity (401). The positive predictive value for detecting CAD using coronary angiography as the gold standard ranges between 60% and 94% and was higher in men than women (401,416). Recommendations for exercise stress testing for risk assessment do not appear to be different in patients with diabetes and patients without diabetes.
22.214.171.124 Noninvasive Stress Imaging for Detection of Ischemia and Risk Stratification (See Section 2.5.9)
The prevalence of asymptomatic ischemia as determined by noninvasive imaging in patients with diabetes ranges from 16% to 59% (345,346,417–419) and depends on the pretest clinical risk of CAD in the population. The DIAD study (337) was composed of a group of patients with type 2 diabetes who were at lower risk than those undergoing stress imaging in other studies, with only 6% of the 522 patients manifesting large defects on adenosine MPI. All had a normal resting ECG, whereas in a separate Mayo Clinic cohort, 43% had abnormal Q waves on the ECG and 28% had peripheral vascular disease (346). Approximately 50% of the Mayo Clinic study patients were referred for preoperative testing for risk assessment. In another report from the same group, 58.6% of asymptomatic patients with diabetes had an abnormal scan, and 19.7% had a high-risk scan (345). In another retrospective study, 39% of asymptomatic patients with diabetes had an abnormal stress scan (419). Of those presenting with dyspnea, 51% had an abnormal perfusion study. The annual hard event rate at follow-up (7.7%) was highest in those presenting with dyspnea compared with 3.2% in those presenting with angina. Using contrast dipyridamole echocardiography, approximately 60% of asymptomatic patients with diabetes who were ≤60 years of age had abnormal myocardial perfusion with vasodilator stress.
Asymptomatic patients with diabetes who have high CAC scores have a high prevalence of inducible ischemia on stress imaging (339). In a prospective study, 48% of patients with diabetes with a CAC score of >400 had silent ischemia on SPECT imaging, and in those with a score of >1000, 71.4% had inducible ischemia (344). The majority of the defects were moderate to severe. Patients with diabetes with inducible ischemia have a higher annual death or nonfatal infarction rate compared with patients without diabetes with similar perfusion abnormalities on stress imaging (10% versus 6%) (420). Also, the greater the degree of ischemia, the worse the outcome during follow-up in both asymptomatic and symptomatic patients with diabetes (344,421). The risk ratio for cardiac events was 12.27 (95% CI 3.44 to 43.71; p<0.001) for patients with >5% ischemic burden on stress SPECT (344). These observations should be tempered by the recent report that 16% of patients with no coronary calcium had inducible ischemia by rest-stress rubidium-82 PET imaging (343). The prevalence of diabetes was 28% in that study. These data, in aggregate, suggest that coronary calcium measurement in patients with diabetes may justify different approaches to risk assessment compared with patients without diabetes. The writing committee therefore judged it reasonable to perform coronary calcium measurement for cardiovascular risk assessment in asymptomatic patients with diabetes who were >40 years of age.
126.96.36.199 Usefulness in Motivating Patients
To date there is no evidence that performing coronary calcium imaging by CT scanning is effective in motivating patients to better adhere to lifestyle changes, medical therapy of diabetes, or primary prevention measures to reduce the risk of developing coronary atherosclerosis or future ischemic events.
188.8.131.52 Evidence of Value for Risk Assessment for Coronary Atherosclerosis or Ischemia or Both to Guide Treatment or Change Patient Outcomes
Because of the high risks associated with diabetes, diabetes has been designated as a CHD risk equivalent by the NCEP (27). One study randomized 141 patients with type 2 diabetes without known CAD to receive exercise ECG/dipyridamole stress echocardiographic imaging or a control arm (325). If a test result was abnormal, coronary angiography was performed with subsequent revascularization as indicated by anatomic findings. At a mean follow-up of 53.5 months, 1 major event (MI) and 3 minor events (angina) occurred in the testing arm, and 11 major and 4 minor events occurred in the control arm. Numbers in the study were too small to be considered definitive. In the DIAD study, 561 low-risk asymptomatic patients were randomized to screening with adenosine SPECT perfusion imaging; 562 patients were randomized to no testing (337). All patients had a normal resting ECG and no prior history of CAD. Over a mean follow-up of 4.8 years, the cumulative event rate was 2.9% (0.6% per year), and there was no difference in event rates between the 2 groups. In the tested group, those with moderate or large defects had a higher cardiac event rate than those with a normal scan or small defects (337).
184.108.40.206 Diabetes and Hemoglobin A1C
HbA1C is used to integrate average glycemic control over several months and predict new-onset diabetes (156). A systematic review has suggested that HbA1C might be effective to screen for the presence of diabetes (157). Some experts have noted that screening with HbA1C might be advantageous because it can be performed in nonfasting individuals (422). The ADA now endorses the use of HbA1C to diagnose diabetes and assess for future risk of diabetes in higher-risk patients (158,423).
220.127.116.11 Association With Cardiovascular Risk
Higher HbA1C concentrations have been associated with elevated risk of CVD in asymptomatic persons with diabetes (154). In a meta-analysis by Selvin et al., adjusted RR estimates for glycosylated hemoglobin (total glycosylated hemoglobin, hemoglobin A1, or HbA1C levels) and CVD events (CHD and stroke) were pooled by using random-effects models (154). Three studies involved persons with type 1 diabetes (n=1688), and 10 studies involved persons with type 2 diabetes (n=7435). The pooled RR for CVD was 1.18; this represented a 1% higher glycosylated hemoglobin level (95% CI 1.10 to 1.26) in persons with type 2 diabetes. The results in persons with type 1 diabetes were similar but had a wider CI (pooled RR 1.15 [95% CI 0.92 to 1.43]). Important concerns about the published studies included residual confounding, the possibility of publication bias, the small number of studies, and the heterogeneity of study results. The authors concluded that, pending confirmation from large, ongoing clinical trials, this analysis suggests that chronic hyperglycemia is associated with an increased risk for CVD in persons with diabetes.
18.104.22.168 Usefulness in Motivating Patients, Guiding Therapy, and Improving Outcomes
It is unknown whether knowledge of HbA1C is associated with better cardiovascular clinical outcomes in asymptomatic patients with diabetes. In persons with established diabetes, knowledge of HbA1C concentration was associated with better understanding of diabetes care and glucose control (424). However, such knowledge was unaccompanied by objective evidence of better clinical outcomes (424). It is unknown whether HbA1C is useful for motivating persons without diabetes.
Although the beneficial effects of glycemic control for microvascular complications have been demonstrated by numerous studies, the benefits for macrovascular complications, particularly CVD, remain controversial (425–427). Prevention trials have demonstrated that persons with impaired glucose tolerance have less progression to overt diabetes with lifestyle and pharmacologic interventions but without accompanying reductions in CVD complications (428). A meta-analysis of randomized controlled trials of persons with diabetes reported that improved glycemic control was associated with an improved IRR for macrovascular complications—mainly CVD—for both type 1 (IRR 0.38, 95% CI 0.26 to 0.56) and type 2 (IRR 0.81, 95% CI 0.73 to 0.91) diabetes (429). However, the meta-analysis did not demonstrate a reduction in cardiac events in persons with type 2 diabetes (IRR 0.91, 95% CI 0.80 to 1.03) (429).
Recent large, randomized, controlled studies have also failed to demonstrate that intensive blood glucose control and a lower HbA1C level is accompanied by a reduction in macrovascular events (430–432).
2.6.2 Special Considerations: Women
The rationale for providing a separate section for risk assessment considerations in women was based on reports of underrepresentation of females within the published literature and clinicians who considered women at lower risk when their profiles were comparable to those of men. Moreover, the focus on special considerations in testing women has been put forward as a result of frequent reporting of underutilization of diagnostic and preventive services and undertreatment in women with known disease (433).
22.214.171.124 Recommendations for Special Considerations in Women
126.96.36.199 Detection of Women at High Risk Using Traditional Risk Factors and Scores
Nearly 80% of women >18 years of age have 1 or more traditional CHD risk factors (435). Diabetes and hypertriglyceridemia are associated with increases in CHD mortality in women more so than in men (436,437). In women, traditional and novel risk factors are prevalent and frequently cluster (i.e., metabolic syndrome) (438–440). CHD risk accelerates greatly for women with multiple risk factors, and CHD risk notably increases after menopause.
Global risk scores, such as the FRS, classify the majority of women (>90%) as low risk, with few assigned to high-risk status before the age of 70 years (434,441). Several reports have examined the prevalence of subclinical atherosclerosis in female FRS subsets (349,366). In a recent study of 2447 women without diabetes, 84% with significant coronary artery calcification (≥75th percentile) were classified with a low FRS (366). The lack of sensitivity of FRS estimates in women was presented in several reports, suggesting lower utility of FRS in female patients (366,441). The Reynolds risk score in women improved risk reclassification when compared with the FRS by including hsCRP, HbA1C (if the patient has diabetes), and family history of premature CHD (22). This finding has not been uniformly confirmed in other studies that included women.
188.8.131.52 Comparable Evidence Base for Risk Stratification of Women and Men
Within the past decade, high-quality, gender-specific evidence in CHD risk stratification of women has emerged for novel risk markers (e.g., hsCRP) and cardiovascular imaging modalities (e.g., carotid IMT, CAC). This evidence reveals effective and, importantly, similar risk stratification for women and men as based on relatively large female cohorts or a sizeable representation of females. Detailed discussions and recommendations for each of the tests are provided in Sections 2.4.2 for hsCRP, 2.5.1 for resting ECG, 2.5.3 for carotid IMT, 2.5.6 for ABI, 2.5.7 for exercise ECG, and 2.5.10 for CAC. In the case of hsCRP, carotid IMT, ABI, CAC, resting ECG, and exercise ECG, the recommendations for men apply similarly to women. Limited female-specific evidence is also available for FMD, thus warranting a Class III, LOE B recommendation similar to that for men.
2.6.3 Ethnicity and Race
A variety of disparities exist in different ethnic groups with respect to cardiovascular risk factors, incidence, and outcomes (442). In 2002, age-adjusted death rates for diseases of the heart were 30% higher among African Americans than among whites of both sexes. Disparities were also common with respect to the presence of atherosclerotic risk factors, with Hispanics and black women demonstrating the highest rates of obesity. Blacks also had the highest rates for hypertension, whereas hypercholesterolemia was highest among white and Mexican-American males and white women. Lower educational level and socioeconomic status conferred a greater risk of dying from heart disease in all ethnic groups (443).
Minimal information is available at this time with regard to differing risk assessment strategies in ethnic groups other than whites. The writing committee did not find evidence to suggest that ethnic groups other than whites should undergo selective risk assessment approaches based on ethnicity.
2.6.4 Older Adults
Although increasing age is a risk factor for CVD, with progression of age, the prevalence of traditional risk factors also rises. Conceptually, risk intervention could be anticipated to have greater benefit at an elderly age, due to the increased absolute risk for coronary events; however, age comparisons for risk interventions have not been rigorously tested. Furthermore, the term “elderly” is used to describe a range of age subgroups from 65 to 74, 75 to 84, and ≥85 years in different studies. Elderly patients in the community also vary substantially from those in clinical trials, with greater comorbidity, renal dysfunction, traditional risk factors, etc., and with very limited data available for the oldest of the old.
In the Cardiovascular Health Study, subclinical markers (increased carotid IMT, decreased ABI, ECG, history of MI, echocardiographic left ventricular dysfunction, coronary calcium) predicted CVD events more than traditional risk scores. The DTS does not predict cardiac survival beyond age 75, with a 7-year cardiac survival for those classified as low, intermediate, and high risk being 86%, 85%, and 69%, respectively (444). Elderly patients have a more adverse prognosis than younger patients with the same Duke risk score. Based on information drawn largely from the Cardiovascular Health Study, application of traditional risk factors for risk assessment in the elderly, as well as selected other tests, can be considered an evidence-based approach.
2.6.5 Chronic Kidney Disease
Chronic kidney disease, the permanent loss of kidney function, is considered a coronary risk equivalent in various observational studies. However, data are insufficient to define differences in outcomes in populations with different degrees of renal insufficiency versus normal renal function. Data for lipid lowering with statins in the TNT (Treating to New Targets) study, a population with documented CAD, suggest serial improvement in renal function and clinical outcome, but extrapolation to an asymptomatic healthy population is inappropriate (445). Lipid lowering restricted to the elderly in the PROSPER (Prospective Study of Pravastatin in the Elderly at Risk) study failed to show benefit. Similarly, lipid lowering in a dialysis population failed to show benefit (446). In TNT, patients with diabetes with mild to moderate chronic kidney disease demonstrated marked reduction in cardiovascular events with intensive lipid lowering in contrast to previous observations in patients with diabetes with end-stage renal disease. It is important to note that TNT was not a study of asymptomatic adults (the focus of this guideline) but rather was focused on a CAD population.
3 Future Research Needs
3.1 Timing and Frequency of Follow-Up for General Risk Assessment
There is little information available in the research literature to suggest the optimal timing to initiate risk assessment in adults. There is also limited information to inform decisions about frequency of risk assessment in persons who are determined to be at low or intermediate risk on initial risk assessment. High-risk persons are likely to initiate treatment strategies, and repeat risk assessment is likely to be a standard component of patient follow-up. More research on the optimal timing to begin risk assessment and repeat risk assessment in the asymptomatic patient is warranted.
3.2 Other Test Strategies for Which Additional Research Is Needed
3.2.1 Magnetic Resonance Imaging
Although MRI is an established cardiovascular imaging modality, its use in risk assessment studies to date is very limited. Research questions to be answered should focus on 1) which MRI parameters are the best for predicting major macro- and microvascular disease in the asymptomatic patient, 2) whether such parameters add to existing risk scores, and 3) what is the cost-effectiveness of such imaging according to risk strata.
3.2.2 Genetic Testing and Genomics
At present the plethora of genetic tests available for assessing cardiovascular risk has not reached the point of being able to add to the general risk assessment approach using global risk scoring with traditional risk factors and addition of careful family history. Additional research on the role of genetic testing, with specific attention to the value for incremental risk prediction in asymptomatic people, is needed.
3.2.3 Geographic and Environmental or Neighborhood Risks
Much research indicates that socioeconomic factors play a role in cardiovascular risk. It remains unclear how this information should best be measured and incorporated into individual risk assessment or whether this area of research applies primarily at the population and policy levels. Attention to this area of research for individual risk assessment was deemed to be warranted by the writing committee.
3.2.4 Role of Risk Assessment Strategies in Modifying Patient Outcomes
Although the concept of individual risk assessment as a means of properly targeting intensity of risk treatments is now engrained in the practice of medicine and cardiology, data to support the clinical benefits of alternative testing strategies are very limited. For example, would risk assessments that use images of abnormal vessels be able to motivate patients and achieve better patient outcomes than testing strategies that use only historical information or blood tests? Studies that evaluate the specific testing strategy against a specific patient-centered outcome are needed. In addition, comparative effectiveness of various test strategies is needed to determine costs, benefits, and comparative benefits of competing testing approaches.
3.3 Clinical Implications of Risk Assessment: Concluding Comments
The assessment of risk for development of clinical manifestations of atherosclerotic CVD is designed to aid the clinician in informed decision making about lifestyle and pharmacologic interventions to reduce such risk. Patients are broadly categorized into low-, intermediate-, and high-risk subsets, and level of intensity and type of treatments are based on these differing assessments of risk.
The initial step in risk assessment in individual patients involves the ascertainment of a global risk score (Framingham, Reynolds, etc.) and the elucidation of a family history of atherosclerotic CVD. These Class I recommendations, which are simple and inexpensive, determine subsequent strategies to be undertaken. Persons at low risk do not require further testing for risk assessment, as more intensive interventions are considered unwarranted, and those already documented to be at high risk (established CHD or coronary risk equivalents) are already candidates for intensive preventive interventions, so that added testing will not provide incremental benefit.
For the intermediate-risk patient, this guideline should help the clinician select appropriate test modalities that can further define risk status. Tests classified as Class IIa are those shown to provide benefit that exceeds risk. Selection among these will vary with local availability and expertise, decisions regarding cost, and potential risks such as radiation exposure, etc. Tests classified as Class IIb have less robust evidence for benefit but may prove helpful in selected patients. Tests classified as Class III are not recommended for use in that there is no, or rather limited, evidence of their benefit in incrementally adding to the assessment of risk; therefore, these tests fail to contribute to changes in the clinical approach to therapy. In addition, a number of Class III tests discussed in this guideline require additional efforts to standardize the measurement or make the test more commonly available on a routine clinical basis. Furthermore, some of the Class III tests also pose potential harm (radiation exposure or psychological distress in the absence of a defined treatment strategy) and are therefore to be avoided for cardiovascular risk assessment purposes in the asymptomatic adult. Until additional research is accomplished to justify the addition of Class III tests, the writing committee recommends against their use for cardiovascular risk assessment.
American College of Cardiology Foundation
John C. Lewin, MD, Chief Executive Officer
Charlene May, Senior Director, Science and Clinical Policy
Lisa Bradfield, CAE, Director, Science and Clinical Policy
Sue Keller, BSN, MPH, Senior Specialist, Evidence-Based Medicine
Erin A. Barrett, MPS, Senior Specialist, Science and Clinical Policy
Beth Denton, Specialist, Science and Clinical Policy
American Heart Association
Nancy Brown, Chief Executive Officer
Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations
Appendix 1 Author Relationships With Industry and Other Entities: 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults
|Committee Member||Employment||Consultant||Speaker||Ownership/Partnership/Principal||Personal Research||Institutional, Organizational, or Other Financial Benefit||Expert Witness|
|Philip Greenland, Chair||Northwestern University Feinberg School of Medicine—Professor of Preventive Medicine and Professor of Medicine; Director, Northwestern University Clinical and Translational Sciences Institute||None||None||None||None|
|Joseph S. Alpert||University of Arizona—Professor of Medicine; Head, Department of Medicine||None||None||None||None||None|
|George A. Beller||University of Virginia Health System—Ruth C. Heede Professor of Cardiology||None||None||None|
|Emelia J. Benjamin†||Boston University Schools of Medicine and Public Health—Professor of Medicine and Epidemiology; Framingham Heart Study—Director, Echocardiography/Vascular Laboratory||None||None||None||None||None|
|Matthew J. Budoff‡,§||Los Angeles Biomedical Research Institute—Program Director, Division of Cardiology||None||None||None||None|
|Zahi A. Fayad||Mount Sinai School of Medicine—Professor of Radiology and Medicine (Cardiology)||None||None||None||None|
|Elyse Foster||University of California San Francisco—Professor of Clinical Medicine and Anesthesia; Director, Echocardiography Laboratory||None||None||None||None||None|
|Mark A. Hlatky§∥||Stanford University School of Medicine—Professor of Health Research and Policy; Professor of Medicine (Cardiovascular Medicine)||None||None||None||None|
|John McB. Hodgson‡,§∥||Geisinger Health System—Chairman of Cardiology||None||None|
|Frederick G. Kushner†,¶||Tulane University Medical Center—Clinical Professor of Medicine; Heart Clinic of Louisiana— Medical Director||None||None||None|
|Michael S. Lauer||NHLBI, NIH—Director, Division of Cardiovascular Sciences||None||None||None||None||None||None|
|Leslee J. Shaw||Emory University School of Medicine—Professor of Medicine||None||None||None||None||None|
|Sidney C. Smith, Jr.#||University of North Carolina at Chapel Hill—Professor of Medicine and Director, Center for Cardiovascular Science and Medicine||None||None||None||None||None|
|Allen J. Taylor||Washington Hospital Center, Cardiology Section—Director, Advanced Cardiovascular Imaging, Cardiovascular Research Institute||None||None||None|
|William S. Weintraub||Christiana Care Health System— Section Chief, Cardiology||None||None|
|Nanette K. Wenger||Emory University School of Medicine— Professor of Medicine (Cardiology)||None||None||None||None|
This table represents the relationships of committee members with industry and other entities that were reported by authors to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10,000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted.
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; BCBS, Blue Cross Blue Shield; BSP, Biological Signal Processing; CDC, Centers for Disease Control and Prevention; CME, continuing medical education; DSMB, Data Safety Monitoring Board; FAME, Fractional flow reserve (FFR) vs. Angiography in Multivessel Evaluation; FDA, Food and Drug Administration; LCIC, Leadership Council for Improving Cardiovascular Care; MESA, Multi-Ethnic Study of Atherosclerosis; NHLBI, National Heart, Lung, and Blood Institute; NIA, National Institute on Aging; NIH, National Institutes of Health; SAIP, Society of Atherosclerosis Imaging and Prevention; and SCCT, Society of Cardiovascular Computed Tomography.
↵⁎ Significant relationship;
↵† Recused from voting on Section 2.4.5, Lipoprotein-Associated Phospholipase A2;
↵‡ Recused from voting on Section 2.5.11, Contrast Computed Tomography Angiography;
↵§ Recused from voting on Section 2.6.1, Diabetes Mellitus;
↵∥ Recused from voting on Section 2.5.10, Computed Tomography for Coronary Calcium;
↵¶ Recused from voting on Section 2.3, Lipoprotein and Apolipoprotein Assessments;
↵# Recused from voting on Section 2.4.2, Recommendations for Measurement of C-Reactive Protein.
Appendix 2 Reviewer Relationships With Industry and Other Entities: 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults
|Peer Reviewer||Representation||Consultant||Speaker||Ownership/Partnership/Principal||Personal Research||Institutional, Organizational, or Other Financial Benefit||Expert Witness|
|Frederick G. Kushner⁎||Official Reviewer— ACCF/AHA Task Force on Practice Guidelines||None||None||None||None|
|Marian C. Limacher||Official Reviewer—AHA||None||None||None||None||None|
|Thomas C. Piemonte||Official Reviewer—ACCF Board of Governors||None||None||None||None||None|
|Paul Poirier||Official Reviewer—AHA||None||None||None||None||None|
|Jane E. Schauer||Official Reviewer—ACCF Board of Trustees||None||None||None||• NIH||None||None|
|Daniel S. Berman||Organizational Reviewer—American Society of Nuclear Cardiology||None||None||None||None|
|Roger S. Blumenthal||Organizational Reviewer—Society of Atherosclerosis Imaging and Prevention||None||None||None||None||None||None|
|Robin P. Choudhury||Organizational Reviewer—Society for Cardiovascular Magnetic Resonance||None||None||None||None||None||None|
|David A. Cox||Organizational Reviewer—Society for Cardiovascular Angiography and Interventions||None||None||None||None|
|Daniel Edmundowicz||Organizational Reviewer—Society for Cardiovascular Angiography and Interventions||None||None||None||None||None||None|
|Steven J. Lavine||Organizational Reviewer—American Society of Echocardiography||None||None||None||None||None||None|
|James K. Min||Organizational Reviewer—American Society of Nuclear Cardiology||None||None||None|
|Kofo O. Ogunyankin||Organizational Reviewer—American Society of Echocardiography||None||None||None||None||None||None|
|Donna M. Polk||Organizational Reviewer—American Society of Nuclear Cardiology||None||None||None|
|Timothy A. Sanborn||Organizational Reviewer—Society for Cardiovascular Angiography and Interventions||None||None||None||None||None|
|Gregory S. Thomas||Organizational Reviewer—American Society of Nuclear Cardiology||None||None|
|Szilard Voros||Organizational Reviewer—Society for Cardiovascular Magnetic Resonance||None||None||None||None|
|Karthikeyan Ananthasubramaniam||Content Reviewer—ACCF Imaging Council||None||None||None||None|
|Jeffrey L. Anderson||Content Reviewer—ACCF/AHA Task Force on Practice Guidelines||None||None||None||None||None||None|
|Vera Bittner||Content Reviewer—ACCF Prevention of Cardiovascular Disease Committee||None||None||None||None||None|
|James I. Cleeman||Content Reviewer||None||None||None||None||None||None|
|Mark A. Creager||Content Reviewer— ACCF/AHA Task Force on Practice Guidelines||None||None||None||None|
|Gregg C. Fonarow||Content Reviewer||None||None||None||None|
|David C. Goff, Jr.||Content Reviewer||None||None||• Merck||None||None|
|Thomas A. Haffey||Content Reviewer||None||None|
|Jonathan L. Halperin||Content Reviewer— ACCF/AHA Task Force on Practice Guidelines||None||None||None||None|
|Jerome L. Hines||Content Reviewer— ACCF Imaging Council||None||None||None||None||None||None|
|Judith S. Hochman||Content Reviewer—ACCF/AHA Task Force on Practice Guidelines||None||None||None||None|
|Christopher M. Kramer||Content Reviewer— ACCF Imaging Council||None||None||None||None|
|Donald M. Lloyd-Jones||Content Reviewer||None||None||None||None||None||None|
|Pamela B. Morris||Content Reviewer— ACCF Prevention of Cardiovascular Disease Committee||None||None||None||None||None|
|Srihari S. Naidu||Content Reviewer— ACCF Cardiac Catheterization Committee||None||None||None||None||None||None|
|Vasan S. Ramachandran||Content Reviewer||None||None||None||None||None|
|Rita F. Redberg||Content Reviewer||None||None||None||None||None||None|
|Charanjit S. Rihal||Content Reviewer— ACCF Cardiac Catheterization Committee||None||None||None||None||None||None|
|Vincent L. Sorrell||Content Reviewer— ACCF Prevention of Cardiovascular Disease Committee||None||None||None|
|Laurence S. Sperling||Content Reviewer— ACCF Prevention of Cardiovascular Disease Committee||None||None||None||None||None||None|
|Carl L. Tommaso||Content Reviewer— ACCF Interventional Council||None||None||None||None||None||None|
|Uma S. Valeti||Content Reviewer||None||None||None||None||None|
|Christopher J. White||Content Reviewer— ACCF Interventional Council||None||None||None||None||None|
|Kim A. Williams||Content Reviewer— ACCF Imaging Council||None||None|
This table represents the relevant relationships with industry and other entities that were disclosed at the time of peer review. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10,000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review.
ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; ASNC, American Society of Nuclear Cardiology; CDA, Canadian Diabetes Association; CIHR, Canadian Institutes of Health; FDA, Food and Drug Administration; FRSQ, Fonds de la recherche en santé du Québec; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; JAMA, Journal of the American Medical Association; and TIMI, Thrombolysis In Myocardial Infarction.
↵⁎ Significant relationship.
Appendix 3 Abbreviations List
↵⁎ ACCF/AHA Task Force on Performance Measures Liaison
↵† Recused from voting on Section 2.4.5, Lipoprotein-Associated Phospholipase A2
↵‡ Recused from voting on Section 2.5.11, Coronary Computed Tomography Angiography
↵§ Recused from voting on Section 2.6.1, Diabetes Mellitus
↵∥ SAIP Representative
↵¶ SCMR Representative
↵# ASE Representative
↵⁎⁎ Recused from voting on Section 2.5.10, Computed Tomography for Coronary Calcium
↵†† SCAI Representative
↵‡‡ Recused from voting on Section 2.3, Lipoprotein and Apolipoprotein Assessments
↵§§ ASNC Representative
↵∥∥ ACCF/AHA Task Force on Practice Guidelines Liaison
↵¶¶ Recused from voting on Section 2.4.2, Recommendations for Measurement of C-Reactive Protein
↵## SCCT Representative
↵⁎⁎⁎ Former ACCF/AHA Task Force member during this writing effort.
This document was approved by the American College of Cardiology Foundation Board of Trustees, the American Heart Association Science Advisory and Coordinating Committee, and all cosponsoring organizations in September 2010.
The American College of Cardiology Foundation requests that this document be cited as follows: Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Foster E, Hlatky MA, Hodgson JMcB, Kushner FG, Lauer MS, Shaw LJ, Smith SC, Jr., Taylor AJ, Weintraub WS, Wenger NK. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010;56:e50–103.
This article is copublished in Circulation and the Journal of Cardiovascular Computed Tomography.
Copies: This document is available on the World Wide Web sites of the American College of Cardiology Foundation (www.cardiosource.org) and the American Heart Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail .
Permissions: Modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier's permission department at.
- American College of Cardiology Foundation and the American Heart Association, Inc.
- ↵ACCF/AHA Task Force on Practice Guidelines: Methodologies and Policies from the ACCF/AHA Task Force on Practice Guidelines. http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf http://circ.ahajournals.org/manual/. Accessed August 27, 2010.
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- Aakre K.M.,
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- Lambers Heerspink H.J.,
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- Malik A.R.,
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- Kullo I.J. | <urn:uuid:1c38c3bb-8a45-4123-bd4a-29426ccdbd08> | CC-MAIN-2020-05 | http://www.onlinejacc.org/content/56/25/e50?ijkey=6068f483f448d05285cb65a132d926e5a52f005e&keytype2=tf_ipsecsha | 2020-01-22T18:45:34Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-05/segments/1579250607314.32/warc/CC-MAIN-20200122161553-20200122190553-00109.warc.gz | en | 0.909539 | 45,499 |
Your lipids are ideal. Your doctor is not giving you personalised service (recommending exercise and weightloss when you do the former, maybe excessively, and are not indicated for the latter). Find another doctor that will treat you, not your numbers
Four years Primal with influences from Jaminet & Shanahan and a focus on being anti-inflammatory. Using Primal to treat CVD and prevent stents from blocking free of drugs.
Eat creatures nose-to-tail (animal, fowl, fish, crustacea, molluscs), a large variety of vegetables (raw, cooked and fermented, including safe starches), dairy (cheese & yoghurt), occasional fruit, cocoa, turmeric & red wine | <urn:uuid:776fcba2-6533-42b4-b3c8-8b02fc49ac58> | CC-MAIN-2016-26 | http://www.marksdailyapple.com/forum/thread49711.html | 2016-06-29T20:22:02Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-26/segments/1466783397797.77/warc/CC-MAIN-20160624154957-00022-ip-10-164-35-72.ec2.internal.warc.gz | en | 0.922352 | 147 |
Sense Health allows clinical trial coordinators to create, deliver, and monitor protocol specific patient support plans. These plans are designed to educate, motivate, remind, and check-in with patients throughout the course of a clinical study. Support is delivered to patients through interactive text message conversations that ensure patients feel connected to their trial coordinator, are reminded of key study requirements, and are motivated to continue for the duration of the study (ie. improved retention). These plans allow busy clinical trial coordinators to deliver continuous support to patients without all of the time that typically goes into high touch support. | <urn:uuid:55d874a0-be76-4c9c-88f9-16c960411526> | CC-MAIN-2020-05 | https://devpost.com/software/sense-health--2 | 2020-01-25T00:43:50Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-05/segments/1579250626449.79/warc/CC-MAIN-20200124221147-20200125010147-00230.warc.gz | en | 0.931047 | 116 |
A reputable company in Lekki, Lagos requires the services of suitably qualified candidates for immediate employment in the position below:
Job Title: Admin Manager
Location: Lekki, Lagos
Required Qualifications and Experience
Must have good communication skills
Must be matured with good working relations both internal and external
Must possess relevant certificate and experience in this field.
How to Apply
Interested and qualified candidates must forward their Curriculum Vitae along with a Cover Letter detailing specific job sought with a passport photograph to: firstname.lastname@example.org using the Job Title as the subject of the email.
Note: Only shortlisted candidate will be contacted. | <urn:uuid:5e71d422-4638-4f08-8b88-377ee5673ed2> | CC-MAIN-2021-39 | https://cvclue.com/latest-jobs/admin-manager-at-a-reputable-company-1 | 2021-09-19T11:05:15Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-39/segments/1631780056856.4/warc/CC-MAIN-20210919095911-20210919125911-00325.warc.gz | en | 0.914994 | 138 |
It’s funny how often you hear comments like ‘Who uses these Kindles?’ or “I don’t know anyone who has an e-reader”. So who are these mysterious users of Kindles and electronic readers? Well, here’s a selection:
1) expats like me (I live in Barcelona). With a miserable luggage allowance of 20 kilos on most budget airlines, it gets more and more expensive to haul books overseas. ‘What about Amazon’s free delivery?’ I hear you cry. Well, that’s no good for…
2) people who live in small apartments. I don’t live in a sprawling mansion and so I just haven’t got space on my bookshelves any more. The solution is a Kindle.
3) people with reduced vision (this doesn’t include me). Reading is suddenly easy again as you adjust the display to get larger font. The magnifying glass is clearly also in peril from the e-reader.
4) speakers of other languages. Here in Barcelona, I see many more e-readers than in the UK. This partly a language thing. Catalan has a vibrant publishing scene, but many books are only released in hardback. As English speakers, we’re spoilt in that we know a paperback edition of our favourite books will always be along soon. Many readers of Catalan have to haul a hardback around with them if they want to read a novel on the Metro.
Like many bloggers, I’m an aspiring author. I always dreamed of having a nice paper volume of my work. My ambition was to look at the books on the shelf and turn the pages from time to time, and think ‘I did that’. Now it seems that that will never happen. My destiny is to produce electronic files. But is that so bad?
Every time change comes, people often mourn what has gone before. I once read an article from the early twentieth century where the author ridiculed the idea of giving up the vellum-bound tomes of his library in favour of paperbacks, which he saw as cheap, throwaway products.
Today’s paperbacks are much better quality than those of the 1930s, when generic designs ruled the day. As the new medium evolved, so did the quality of delivery. I suspect that the same will be true of e-books in the future. Few people today would opt for a hardback over a paperback, given a choice.
In any case, no matter what snobbery exists in favour of paper products, it’s clear that other writers are not too bothered about how their stories reach the reader. Recently, Harper Voyager invited submissions from aspiring fantasy and sci-fi authors. The reward was an edited ebook of their novel. In the mere two-week window of opportunity, they received no less than 4,563 submissions: http://harpervoyagerbooks.com/2012/10/17/the-submission-portal-is-now-closed/.
Personally, I’m really enjoying my e-reader and I have noticed that it has already changed my reading habits. For example, I’m re-reading Moby Dick on my Kindle. It’s a novel that I found exhausting on first read, especially when confronted by the mass of pages ahead of me (I am an inveterate page counter). However, on the Kindle I just concentrate on the page in front of me and don’t worry about what is to come. I also find the completion bar at the bottom of the screen strangely comforting. It already tells me that I am 3% of the way through Melville’s tale. 3%, and our narrator Ishmael hasn’t even got into bed with the tattooed harpooner Queequeg yet, let alone encountered Captain Ahab, the manager from Hell.
There’s also the dictionary built in to the reader, which is very handy when a word like ‘quahog’ pops up. Apparently, it’s a type of clam found in New England (useful for Scrabble, if nothing else).
So let’s not fear the e-reader. It will replace the physical book, at least in all but special hardback gift editions. It’s all part of the natural order of things. | <urn:uuid:5c6db376-2f35-45ac-b926-28f4f1e160de> | CC-MAIN-2017-43 | https://alastairsavage.wordpress.com/2012/11/13/dont-fear-the-e-reader/ | 2017-10-22T11:54:35Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-43/segments/1508187825227.80/warc/CC-MAIN-20171022113105-20171022133105-00748.warc.gz | en | 0.950494 | 923 |
OECD Council Recommendation on Principles for Internet Policy Making (Dec. 13, 2011) (full-text).
- Promote and protect the global free flow of information;
- Promote the open, distributed and interconnected nature of the Internet;
- Promote investment and competition in high speed networks and services;
- Promote and enable the cross-border delivery of services;
- Encourage multi-stakeholder co-operation in policy development processes;
- Foster voluntarily developed codes of conduct;
- Develop capacities to bring publicly available, reliable data into the policy-making process;
- Ensure transparency, fair process, and accountability;
- Strengthen consistency and effectiveness in privacy protection at a global level;
- Maximise individual empowerment;
- Promote creativity and innovation;
- Limit Internet intermediary liability;
- Encourage co-operation to promote Internet security;
- Give appropriate priority to enforcement efforts. | <urn:uuid:aa388bbf-80f6-459b-b00c-6687e11f563a> | CC-MAIN-2017-17 | http://itlaw.wikia.com/wiki/OECD_Council_Recommendation_on_Principles_for_Internet_Policy_Making | 2017-04-29T03:43:24Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-17/segments/1492917123270.78/warc/CC-MAIN-20170423031203-00269-ip-10-145-167-34.ec2.internal.warc.gz | en | 0.834652 | 193 |
It turns out that pressing these three acupoints can also lose weight
just so so,reduce weight,Unexpectedly,acupoint,Press this often,3,original
August 03, 2021
Six taboos to soak feet in hot water
March 12, 2020
Does eating sweet potato make you fat? Eating sweet potato often has so many benefits
Women's diet and regimen recipe
The Ministry of public security cracked a huge fraud case of health care products: 38 illegal sales platforms were eliminated and more than 30 million stolen goods were paid
Raptors vs bucks 6-0, the first time in NBA history
Best of the week: bucks forward Adriano Kunbo and warriors guard Kuri
Good morning, "a cold autumn rain" to my most concerned friends! Wish you health and happiness~
Li Yong, a famous CCTV host, died of cancer. Wish the living cherish their health! Health care is urgent!
Slim Beauty fruit and vegetable juice formula, very practical, collect it!
Pepper, pepper, pepper is just seasoning? They are also health experts | <urn:uuid:007a0aee-9e8b-420e-80cb-a0b0ed116228> | CC-MAIN-2022-49 | https://www.minoregimen.com/pc/menuCollect?cname=Knowledge&cid=19&page=14 | 2022-11-29T18:51:54Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-49/segments/1669446710710.91/warc/CC-MAIN-20221129164449-20221129194449-00666.warc.gz | en | 0.924527 | 307 |
Kara DioGuardi may be done with American Idol, but how that came about is still up for debate. Did she quit or has she been fired?
Kara still hasn’t heard about her role on the next season American Idol, but apparently she wants to be done.
“She went to Fox two months ago and told them she didn’t want to do another season,” a source told E! News. “She’s ready to move on. She did two years and thinks that’s enough.”
But for now, Kara is still under contract with Fox if they choose to have her back.
“It’s frustrating because she can’t even take any meetings…everyone wants to know what her schedule will be like, but she doesn’t know,” the source said. “What happens if Fox tells her they still want her for next season?”
As for the judge’s request to done with the show?
“They said they’d get back to her,” the source explained, but that has yet to happen.
Wonder if this is were Kara’s supposed “disappointment” comes with American Idol? | <urn:uuid:a94366ea-2930-47f8-97e3-699661c366a6> | CC-MAIN-2016-50 | http://okmagazine.com/get-scoop/kara-dioguardi-wanted-be-done-american-idol/ | 2016-12-06T20:03:22Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-50/segments/1480698541995.74/warc/CC-MAIN-20161202170901-00419-ip-10-31-129-80.ec2.internal.warc.gz | en | 0.98663 | 265 |
We have enough information. We need inspiration. If you agree with those statements, you will enjoy this week’s Top 10 list. Many of these posts are inspiring and will encourage you to continue the leadership journey. Enjoy!
The following are The Top 10 Leadership Posts I Read The Week Of September 2nd:
- How To Survive The Hard Moments by Jon Acuff
- 5 Reasons Personal Development Is Hard by Dan Black
- Social Media 101 by Trisha Davis
- Why It’s Insane To Pay $132 Million For A Soccer Player – And Why It Isn’t by Anita Elberse of the Harvard Business School
- The 10 Cents Of Tithing by Steven Furtick
- Words Will Fail You by Joseph Lalonde
- Puffer Fish Pastors by Michael Lukaszewski
- Toxic Employees Cost You More Than You Think by Bryan Miles
- The Unfortunate Story Of T-Mac by Bill Simmons
- 4 Inspiring Lessons From Diana Nyad’s Historic Swim by Minda Zetlin of www.Inc.com
Well that is my Top 10. What are some other great posts you read this week?
To subscribe to this site and get my latest FREE eBook 649 Leadership Quotes: Timeless Truths From The 2013 Passion, Exponential, Orange, Chick-Fil-A Leadercast Conferences click here or on the image to the left. | <urn:uuid:77535d16-4103-43b7-a75f-be3b6a55fc24> | CC-MAIN-2017-26 | http://briandoddonleadership.com/2013/09/06/the-top-10-leadership-posts-i-read-the-week-of-september-2nd/ | 2017-06-27T20:55:24Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-26/segments/1498128321553.70/warc/CC-MAIN-20170627203405-20170627223405-00477.warc.gz | en | 0.873518 | 293 |
Prince Edward Island is one step closer to implementing a provincewide EMR solution. Read the news release to learn… https://t.co/rYrlsT9PB4
Welcome to Infoway's connected clinical collaborative. Join the Conversation!
Help us grow the Clinical voice in Digital Health!
For additional Change and Clinical Leadership Resources, please contact email@example.com
Click Manage documents to:
Note: Group members are not currently notified when new documents are added. To notify others, you must post the URL to the new document in the forum. (Notification of document uploads is a feature in development.) | <urn:uuid:189b16a3-72e9-4fa8-8e4f-9dc810b78425> | CC-MAIN-2021-10 | https://infocentral.infoway-inforoute.ca/en/collaboration/communities/clinician-engagement-network | 2021-03-02T23:36:02Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-10/segments/1614178364932.30/warc/CC-MAIN-20210302221633-20210303011633-00252.warc.gz | en | 0.858442 | 137 |
A last minute change of plans landed junior Creative Producing major Panna Warren the opportunity to spend her summer working as a Creative Studios Intern at VICE.
Despite initially having plans to spend her summer in Prague doing an international internship through the Chapman Center for Global Education, the program was cancelled due to travel challenges as a result of the COVID-19 pandemic. With limited time to find new plans for the summer, she began looking for opportunities online, where she came across the opening at VICE on Linkedin.
“It was a scramble to see what happened. They were the only people that got back to me, and they were the only people I interviewed for,” said Warren. “A lot rested on it.”
The initial interview for the Creative Studios role focused mainly on creative based tasks such as script coverage. During the second interview, however, after she expressed interest in budgeting and project management as well, the company realized she could provide additional help with business-oriented tasks and she was offered the position.
“Don’t shy away from the things you’re into,” said Warren. “You never know what the next opportunity can hold, or what you’ll be offered to do.”
Warren enjoyed her experience interning for bosses Katie Peck and Kamalii Kaina, who both work as Vice Presidents of development of VICE’s studio department. Throughout the summer she spent her time creating budgets and assumptions for VICE executives, while also having the opportunity to attend production meetings, help the team meet with casting, and develop research.
Warren’s advice to fellow Dodge students looking for internships would be to take advantage of any opportunity that comes your way.
“I had internships before that were at smaller companies that definitely helped me build knowledge to help me get to a point where VICE even looked at my resume,” said Warren.
“Take the job even if it is not what you were exactly looking for because you never know, you might love it.”
One of Warren’s biggest takeaways from her time at VICE were the skills she gained from working within the development side of the company.
“In Dodge you learn a lot about script development. While you’re in fiction film production, that’s all you know. You don’t hear about reality and nonfiction, which are also a side of the entertainment industry,” said Warren.
“I never knew that in development there was a considerable period where so much was done even before everything is pitched to executives. They don’t touch on that a lot in Dodge, which I think could be worked on,” said Warren.
She also reflected on how her experience this summer will help her further down the line in her career.
“VICE is going to help me with a lot of my goals,” said Warren, who aspires to work on more production based projects in the future, and get further involved in different parts of the industry.
“They’re definitely the type of people that I’m going to stay in contact with,” she said. | <urn:uuid:5a7ce4bc-6231-4c78-87bf-3c8c473e1b2b> | CC-MAIN-2022-49 | https://blogs.chapman.edu/dodge/2021/09/20/a-summer-with-vice/ | 2022-12-05T01:38:24Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-49/segments/1669446711001.28/warc/CC-MAIN-20221205000525-20221205030525-00526.warc.gz | en | 0.983629 | 661 |
The Winchester Multicultural Network stands in solidarity with all those who feel threatened by the Trump administration’s latest round of immigration harassment. While as of Monday, July 15, the wide-sweeping raids announced by the administration have not yet come to fruition, the damages inflicted on civil liberties in this country cannot be easily undone. These actions foment an environment of fear and uncertainty, and none of us can feel truly safe when some among us are threatened. As Mary Bauer, Director of the Southern Poverty Law Center (SPLC), explained, “Immigrants and immigrant communities all over the country are in hiding and people are living in these terrified, terrorized ways, because that is the point of this whole action, whether enforcement actions take place or not.”
In response to this situation, the Multicultural Network’s new Immigrant Justice Committee is advocating for Winchester to become a Safe Community through passage of the “Safe Communities Act.”
This Act aims to maintain MA residents’ trust in their local police force by ensuring that the police are not entangled in immigration matters, and by protecting due process in all interactions with law enforcement. The Act supports an environment where all people living, working, or visiting an MA community can be confident that interactions with town/city agency or officials will not lead to questions about their immigration status.
The key features of the Safe Communities Act are: (click on “+” sign for features details)
The Safe Communities Act now before the Legislature is Senate bill S.1401 (Sen. Jamie Eldridge) and House bill H.3573 (Reps. Ruth Balser and Liz Miranda). There are currently 76 House and 21 Senate co-sponsors. In addition, as of April 20, 2018, 30 cities and towns in Massachusetts have declared themselves to be “welcoming cities” for immigrants.
In service of our goal to be a safe and welcoming community for all, the Winchester Multicultural Network has undertaken the goal of making Winchester a welcoming town. Beginning this fall look for us at town events where we will be soliciting opinions about this important issue from Winchester residents and visitors. | <urn:uuid:ae67f18c-6696-4bb3-ace3-60f94ce6069e> | CC-MAIN-2021-21 | https://www.wmcn.org/wmcns-stance-on-the-current-immigration-crisis/ | 2021-05-14T09:57:03Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-21/segments/1620243990449.41/warc/CC-MAIN-20210514091252-20210514121252-00508.warc.gz | en | 0.944128 | 444 |
On October 2, 2013, the SBA released a new final rule implementing regulations designed to increase small business participation in government contracting with respect to multiple award and consolidated contracts (“Final Rule”). The Final Rule, effective as of December 31, 2013, implements key portions of the Small Business Jobs Act of 2010.
The Final Rule implements quite a few new regulations, however three of the changes stand out as possibly having the largest impact on small businesses: (1) Agencies now have three new options to increase opportunities for small businesses on multiple award contracts; (2) Agencies cannot consolidate contract requirements without documenting the reasoning and impact on small businesses; and (3) Small businesses can now form teams to compete on consolidated contracts without concern for affiliation, as long as all team members are small under the procurement. Each of these new rules is discussed in more detail below:
Small Business Set-Asides on Multiple Award Contracts
Contracting officers have the discretion to set aside for small businesses a portion of the work on multiple award contracts, and these new regulations outline three separate methods of achieving this. A contracting officer is not required to utilize any of these methods, but rather must consider the methods before making an award of a multiple award contract. If the contracting officer decides not to utilize these methods, the rationale for the decision must then be documented. On the other hand, if it is announced that one of these methods will be used, the agency must follow through.
- Partial Set-Asides
Where a procurement can be broken up into smaller, discrete units (such as CLINs), the contracting officer may set aside a portion of the multiple award contract exclusively for small business participation. Certain conditions must be met for a partial set-aside, namely that market research must demonstrate that the “Rule-of-Two” will be met (the agency will receive fair market offers from at least two small businesses for the set-aside portion of the work). In this case, the contracting officer can set-aside a portion of the work for small businesses utilizing any of the SBA small business programs (8(a), SDVOSB, etc.). Orders on the set-aside portion will be competed amongst only small businesses receiving an award for the partial set-aside.Under the current regulations, in order for a small business to be considered for a set-aside portion of a multiple award contract, it must submit an offer on the non-set-aside portion of the contract, as well. The Final Rule eliminates this requirement. Under the new regulations (13 C.F.R. § 125.2(e)), small business offerors will have the option of submitting an offer on only the set-aside portion of the multiple award contract, the non-set-aside portion, or both. If a small business offeror submits a proposal only on the set-aside portion of the work, it will only be able to compete for orders under that set-aside portion of the contract. Conversely, small businesses submitting offers on both the set-aside and non-set-aside portions of the work can compete for orders under either portion of the contract.
- Reserve Awards
In procurements that cannot easily be broken up into smaller units, agencies still have the option of increasing opportunities for small business participation at the order level. Where market research shows that the “Rule-of-Two” will not be met for the entire requirement, but will be met on a certain portion of the requirement, the contracting officer can “reserve” an award for small businesses for that specific portion. The contracting officer can then compete the applicable order(s) exclusively among the small business awardees. This can be done with all small businesses, or limited to a specific group of small businesses (HUBZone, WOSB, etc.).Similarly, where a contracting officer determines that there is only one small business that can perform the entire requirement, but there is no reasonable expectation of receiving fair market offers from more than one small business, a “reserve” award can be made to the single small business. In this case, the contracting officer may then issue orders directly to that one small business awardee for the portion of work it can perform.
- Set-Aside of Orders
Where market research shows that the “Rule-of-Two” will be met for the requirement of an individual order, a contracting officer can then set-aside the order for small business participants. The order set-asides can be utilized for any of the individual small business programs, or among all small businesses.
Consolidation of Contracts
“Consolidation” of contracts occurs when an agency combines the requirements from two or more separate contracts into a single contract or a multiple award contract, where the total costs exceeds $2 million. A “bundled” contract is the consolidation of requirements from multiple contracts into a single contract or multiple award contract that is likely to be unsuitable for small business participation. The Final Rule implements a new regulation (13 CFR § 125.2(d)) which prohibits an agency from consolidating contract requirements unless a senior acquisition official does the following:
- Conducts adequate market research;
- Identifies possible alternate procurement approaches;
- Makes a written determination justifying the consolidation;
- Identifies negative impacts the acquisition strategy will have on small businesses; and
- Ensures that steps will be taken to include small businesses in the procurement.
Because a “bundled” contract is by definition a consolidation of contract requirements, agencies must also follow these new regulations for any bundled procurements. In addition, the Final Rule adds notification and publication requirements for bundled contracts. When an agency contemplates bundling requirements into a single contract or multiple award contract, it must provide notice of the intent to bundle to any small businesses currently performing the requirements. This notice must occur at least 30 days prior to the issuance of the solicitation of bundled requirements. Further, the agency must publish on its website a list of all bundled requirements along with the rationale for each decision to bundle.
Small Business Teaming Arrangements
In order to encourage small businesses to compete with larger businesses on high value contracts, the Final Rule implements regulations which allow for small businesses to team up on a bundled procurement without running afoul of affiliation regulations. A “Small Business Teaming Arrangement” can be either a joint venture comprised of small businesses, or a team comprised of a small business prime contractor and small business subcontractors. This does not really introduce anything new for small businesses, as the SBA does not usually find affiliation simply by virtue of two or more small businesses joining forces for a single procurement, whether as a joint venture or as a prime/sub team. However, the Final Rule does implement a potentially important change to how small business prime/sub teams will be evaluated on bundled procurements.
Generally, when evaluating proposals agencies will only consider the experience and capabilities of a prime contractor, unless the solicitation specifically states that subcontractor experience will also be considered. However, the Final Rule introduces a new provision (13 CFR § 125.3(i)) which requires contracting officers to evaluate offers from teams of small businesses the same as it does all other offers on bundled procurements, with due consideration to the capabilities of all subcontractors. Small businesses forming teams to compete for these bundled contracts will be required to submit their written teaming agreement to the agency along with the proposal.
Small businesses usually find themselves on the outside looking in when it comes to multiple award and consolidated contracts. Typically, the requirements in these contracts are so vast that a small business simply cannot compete with larger companies that have far more capabilities due to their sheer size. However, in a lot of cases, small businesses are more than capable of performing at least some of the requirements on these broad contracts. Given the high dollar value that is typical of these types of contracts, these small portions can be quite significant for a small business. The ultimate impact of these new regulations is unclear at this stage, however the Final Rule does seem to represent a positive step towards an increase in small business participation on high-dollar multiple award and consolidated contracts. | <urn:uuid:b2601b8f-aa33-43ed-9647-f854e4196020> | CC-MAIN-2023-50 | https://www.generalcounsellaw.com/new-sba-regulations-to-aid-in-small-business-participation/ | 2023-12-02T08:48:33Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-50/segments/1700679100381.14/warc/CC-MAIN-20231202073445-20231202103445-00486.warc.gz | en | 0.939994 | 1,689 |
13 Jul Glencarraig Lady League News – additional shows
Points can be gained at the following shows
Tomorrow – Barnadown – 14th July
Coilog – Sat 17th July
Mullingar – 17th July
Barnadown – 17th July
Coilog – Sat 28th July
Barnadown – 28th July
Points gained so far.
If you have a query – please email [email protected]
all points are loaded from SJI tickets from shows. | <urn:uuid:08549553-4f58-4341-8481-f4dd5f9814bd> | CC-MAIN-2022-27 | https://www.leinstershowjumping.com/2018/07/13/glencarraig-lady-league-news-additional-shows/ | 2022-07-01T08:22:15Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-27/segments/1656103922377.50/warc/CC-MAIN-20220701064920-20220701094920-00305.warc.gz | en | 0.942394 | 105 |
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Search - "query"
Hey, Root? How do you test your slow query ticket, again? I didn't bother reading the giant green "Testing notes:" box on the ticket. Yeah, could you explain it while I don't bother to listen and talk over you? Thanks.
Hey Root. I'm the DBA. Could you explain exactly what you're doing in this ticket, because i can't understand it. What are these new columns? Where is the new query? What are you doing? And why? Oh, the ticket? Yeah, I didn't bother to read it. There was too much text filled with things like implementation details, query optimization findings, overall benchmarking results, the purpose of the new columns, and i just couldn't care enough to read any of that. Yeah, I also don't know how to find the query it's running now. Yep, have complete access to the console and DB and query log. Still can't figure it out.
Hey Root. We pulled your urgent fix ticket from the release. You know, the one that SysOps and Data and even execs have been demanding? The one you finished three months ago? Yep, the problem is still taking down production every week or so, but we just can't verify that your fix is good enough. Even though the changes are pretty minimal, you've said it's 8x faster, and provided benchmark findings, we just ... don't know how to get the query it's running out of the code. or how check the query logs to find it. So. we just don't know if it's good enough.
Also, we goofed up when deploying and the testing database is gone, so now we can't test it since there are no records. Nevermind that you provided snippets to remedy exactly scenario in the ticket description you wrote three months ago.
Hey Root: Why did you take so long on this ticket? It has sat for so long now that someone else filed a ticket for it, with investigation findings. You know it's bringing down production, and it's kind of urgent. Maybe you should have prioritized it more, or written up better notes. You really need to communicate better. This is why we can't trust you to get things out.
Fuck the memes.
Fuck the framework battles.
Fuck the language battles.
Fuck the titles.
Anybody who has been in this field long enough knows that it doesn't matter if your linus fucking torvalds, there is no human who has lived or ever will live that simultaneously understands, knows, and remembers how to implement, in multiple languages, the following:
- jest mocks for complex React components (partial mocks, full mocks, no mocks at all!)
- token cancellation for asynchronous Tasks in C#
- fullstack CRUD, REST, and websocket communication (throw in gRPC for bonus points)
- database query optimization, seeding, and design
- nginx routing, https redirection
- build automation with full test coverage and environment consideration
- docker container versioning, restoration, and cleanup
- internationalization on both the front AND backends
- secret storage, security audits
- package management, maintenence, and deprecation reviews
- integrating with dozens of APIs
- fucking how to center a div
and that's a _comically_ incomplete list; barely scratches the surface of the full range of what a dev can encounter in a given day of writing software
have many of us probably done one or even all of these at different times? surely.
but does that mean we are supposed to draw that up at a moment's notice some cookie-cutter solution like a fucking robot and spit out an answer on a fax sheet?
recruiters, if you read this site (perhaps only the good ones do anyway so its wasted oxygen), just know that whoever you hire its literally the luck of the draw of how well they perform during the interview. sure, perhaps some perform better, but you can never know how good someone is until they literally start working at your org, so... have fun with that.
Oh and I almost forgot, again for you recruiters, on top of that list which you probably won't ever understand for the entirety of your lives, you can also add writing documentation, backup scripts, and orchestrating / administrating fucking JIRA or actually any somewhat technical dashboard like a CMS or website, because once again, the devs are the only truly competent ones - and i don't even mean in a technical sense, i mean in a HUMAN sense of GETTING SHIT DONE IN GENERAL.
There's literally 2 types of people in the world: those who sit around drawing flow charts and talking on the phone all day, and those WHO LITERALLY FUCKING BUILD THE WORLD
why don't i just run the whole fucking company at this point? you guys are "celebrating" that you made literally $5 dollars from a single customer and i'm just sitting here coding 12 hours a day like all is fine and well
i'm so ANGRY its always the same no matter where i go, non-technical people have just no clue, even when you implore them how long things take, they just nod and smile and say "we'll do it the MVP way". sure, fine, you can do that like 2 or 3 times, but not for 6 fucking months until you have a stack of "MVPs" that come toppling down like the garbage they are.
How do expect to keep the "momentum" of your customers and sales (I hope you can hear the hatred of each of these market words as I type them) if the entire system is glued together with ducktape because YOU wanted to expedite the feature by doing it the EASY way instead of the RIGHT way. god, just forget it, nobody is going to listen anyway, its like the 5th time a row in my life
we NEED tests!
we NEED to know our code coverage!
we NEED to design our system to handle large amounts of traffic!
we NEED detailed logging!
we NEED to start building an exception database!
BILBO BAGGINS! I'm not trying to hurt you! I'm trying to help you!
Don't really know what this rant was, I'm just raging and all over the place at the universe. I'm going to bed.20
"Hey, Root, someone screwed up and now all of our prod servers are running this useless query constantly. I know I already changed your priorities six times in the past three weeks, but: Go fix it! This is higher priority! We already took some guesses at how and supplied the necessary code changes in the ticket, so this shouldn't take you long. Remember, HIGH PRIORITY!"
1. I have no idea how to reproduce it.
2. They have no idea how to reproduce it.
3. The server log doesn't include queries.
4. The application log doesn't include queries.
5. The tooling intercepts and strips out some log entries the legendary devs considered useless. (Tangent: It also now requires a tool to read the logs because log entries are now long json blobs instead of plain text.)
6. The codebase uses different loggers like everywhere, uses a custom logger by default, and often overwrites that custom logger with the default logger some levels in. gg
7. The fixes shown in the ticket are pretty lame. (I've fixed these already, and added one they missed.)
8. I'm sick and tired and burned out and just can't bring myself to care. I'm only doing this so i don't get fired.
9. Why not have the person who screwed this up fix it? Did they quit? I mean, I wouldn't blame them.
Why must everything this company does be so infuriatingly complicated?11
I’m surrounded by idiots.
I’m continually reminded of that fact, but today I found something that really drives that point home.
Gather ‘round, everybody, it’s story time!
While working on a slow query ticket, I perused the code, finding several causes, and decided to run git blame on the files to see what dummy authored the mental diarrhea currently befouling my screen. As it turns out, the entire feature was written by mister legendary Apple golden boy “Finder’s Keeper” dev himself.
To give you the full scope of this mess, let me start at the frontend and work my way backward.
This function allows the user to better see the rows in the API Calls table, for which there is a also search feature — the very thing I’m tasked with fixing.
It’s worth noting that above the search feature are two inputs for a date range, with some helpful links like “last week” and “last month” … and “All”. It’s also worth noting that this table is for displaying search results of all the API requests and their responses for a given merchant… this table is enormous.
This search field for this table queries the backend on every character the user types. There’s no debouncing, no submit event, etc., so it triggers on every keystroke. The actual request runs through a layer of abstraction to parse out and log the user-entered date range, figure out where the request came from, and to map out some column names or add additional ones. It also does some hard to follow (and amazingly not injectable) orm condition building. It’s a mess of functional ugly.
The important columns in the table this query ultimately searches are not indexed, despite it only looking for “create_order” records — the largest of twenty-some types in the table. It also uses partial text matching (again: on. every. single. keystroke.) across two varchar(255)s that only ever hold <16 chars — and of which users only ever care about one at a time. After all of this, it filters the results based on some uncommented regexes, and worst of all: instead of fetching only one page’s worth of results like you’d expect, it fetches all of them at once and then discards what isn’t included by the paginator. So not only is this a guaranteed full table scan with partial text matching for every query (over millions to hundreds of millions of records), it’s that same full table scan for every single keystroke while the user types, and all but 25 records (user-selectable) get discarded — and then requeried when the user looks at the next page of results.
What the bloody fucking hell? I’d swear this idiot is an intern, but his code does (amazingly) actually work.
No wonder this search field nearly crashed one of the servers when someone actually tried using it.
I told these people that this issue would happen. Did they listen? Nooo
It'll be fine, they say. We likely won't be having that much data returned to the front end, they say.
Day of the install. Web Application attempts to query 68,000 rows of data straight into the web page.
*Surprised Pikachu face* when they are consistently getting crashed browser tabs.
And now everything gets pushed back and we're behind by an entire month because they didn't heed my warnings.
Oh, and now I have to pick up after them, and do some stupid work arounds that will likely be defunct in a month or two. 🙄5
Optimized a query today. Before it timed out after 10 minutes, now it takes 4.3 seconds. Very proud.13
I'm fixing a security exploit, and it's a goddamn mountain of fuckups.
First, some idiot (read: the legendary dev himself) decided to use a gem to do some basic fucking searching instead of writing a simple fucking query.
Second, security ... didn't just drop the ball, they shit on it and flushed it down the toilet. The gem in question allows users to search by FUCKING EVERYTHING on EVERY FUCKING TABLE IN THE DB using really nice tools, actually, that let you do fancy things like traverse all the internal associations to find the users table, then list all users whose password reset hashes begin with "a" then "ab" then "abc" ... Want to steal an account? Hell, want to automate stealing all accounts? Only takes a few hundred requests apiece! Oooh, there's CC data, too, and its encryption keys!
Third, the gem does actually allow whitelisting associations, methods, etc. but ... well, the documentation actually recommends against it for whatever fucking reason, and that whitelisting is about as fine-grained as a club. You wanna restrict it to accessing the "name" column, but it needs to access both the "site" and "user" tables? Cool, users can now access site.name AND user.name... which is PII and totally leads to hefty fines. Thanks!
Fourth. If the gem can't access something thanks to the whitelist, it doesn't catch the exception and give you a useful error message or anything, no way. It just throws NoMethodErrors because fuck you. Good luck figuring out what they mean, especially if you have no idea you're even using the fucking thing.
Fifth. Thanks to the follower mentality prevalent in this hellhole, this shit is now used in a lot of places (and all indirectly!) so there's no searching for uses. Once I banhammer everything... well, loads of shit is going to break, and I won't have a fucking clue where because very few of these brainless sheep write decent test coverage (or even fucking write view tests), so I'll be doing tons of manual fucking testing. Oh, and I only have a week to finish everything, because fucking of course.
So, in summary. The stupid and lazy (and legendary!) dev fucked up. The stupid gem's author fucked up, and kept fucking up. The stupid devs followed the first fuckup's lead and repeated his fuck up, and fucked up on their own some more. It's fuckups all the fucking way down.19
WHY CAN'T YOU JUST BUILD THE BLOODY QUERY WITHOUT DOING FANCY UNNECESSARY SUBQUERY SHIT?!
OR PUT THE LIMIT WHERE IT MAKES SENSE AND DOESN'T CAUSE MYSQL TO TELL YOU TO FUCK OFF?
WHY WHY WHY WHY WHY
THIS ISN'T HARD18
While writing up this quarter's performance review, I re-read last quarter's goals, and found one my boss edited and added a minimum to: "Release more features that customers want and enjoy using, prioritized by product; minimum 4 product feature/bug tickets this quarter."
... they then proceeded to give me, not four+ product tickets, but: three security tickets (two of which are big projects), a frontend ticket that should have been assigned to the designer, and a slow query performance ticket -- on top of my existing security tickets from Q3.
How the fuck was I supposed to meet this requirement if I wasn't given any product tickets? What, finish the monster tickets in a week instead of a month or more each and beg for new product tickets from the product manager who refuses to even talk to me?
Fuck these people, seriously.8
Why does it take a client, who needs the bug fixed immediately, over 24 hours to respond to my query about what the problem is?11
Ah the day before launch of a new app. And right on schedule the businesses is attempting to completely alter their requirements including a COMPLETE OVERHAUL OF THE DATABASE MODEL TO ADDRESS AN ISSUE THAT HAS ALREADY BEEN FIXED. I wish they would share the drugs they are clearly on so I could also live in this dreamland delusion where you can turn something completely on its head right on the finish line and expect everything to go well.
Manager: Hey I think I have a solution to that performance we talked about last week
Dev: I already fixed it, it only takes 1 second instead of 30 now.
Manager: Ok but I’ve also figured out a solution. If we completely change the entire database model that one query could potentially be even faster according to my understanding of how databases operate.
Dev: I fixed it without the need for that, actually it was just a matter of better conc—
Manager: I think we should go with MY solution. Drop everything and restructure the database immediately! Be quick, as you know we launch this application tomorrow! Have an extra coffee today and just crush it out, don’t overthink this either just do it.
Boss: Our app is to memory consuming and heavy weighted. We to do something because we will have hunsdrets of thousands of users.
Dev: Yes, there are a lot of legacy parts which leave plenty of space for optimization. Every query have to be carefully analyzed. Some can be avoided at all.
Boss: We pay externals to do some clustering with our app.5
Dear Microsoft Kusto Query Language (KQL)
Screw you. You suck like more than a sudden depressurization event in an airplane. Creating your own freaking query language is bad, the people who invented SQL based it on a the principles of mathematical relational algebra, which although confusing, and not suited for all use cases is at least consistent.
You were invented by a bunch of oxygen deprived halfwits based on the principles of sadism and incompetence.
The only situation in which I would voluntarily use KQL as my tool of choice is if my purpose was to extract a Dantesque style revenge on someone who had committed grievous harm to myself and my family members. In that case forcing them to work with you day in and day out would still border on cruel and unusual punishment.
Sincerely, A developer who has spent the past 2 hours dealing with your Lovecraftian madness.
P.S. I hope you choke on a raw chicken bone and no one gives you CPR.4
That log4j RCE is some fucking nasty business!!! Its exploits have already been observed multiple times in our company scope.
Time for some unplanned Saturday evening hot-patches :/
P.S. Why the fuck leave such a feature enabled as default??? I mean really, whose brilliant idea was "let's leave the message parser enabled as well as the LDAP query hooks... BY FUCKING DEFAULT!!!"
I mean really, is anyone using that? ANYONE?
And then they laugh at me when I say "stay away from frameworks", "use as little libraries as possible", "avoid foreign code in your codebase",...
you know what.... JOKE'S ON YOU!10
BI dev: Hey, can you help me with my SQL query?
Me: Sure, let me see it.
BI dev: sends screenshot - not even the whole query, literally a screenshot with a segment of text in it. No errors showing either.
Hired a new BI developer. She tested reasonably ok in SQL, and certainly showed good strengths in visualising data, plus had a good attitude in the interview. We hired her. She broke her laptop the first day. We got her another then she complained the camera didn't work but didn't realise the lever in front of the camera was to move the privacy shutter off and on.
Assigned her some work of taking queries that are used in a BI tool that targets the transactional database directly, and re-jigging them for Snowflake which we're using as a data warehouse now, aggregating all our data into one place. Yet, she's struggling to understand why the SQL query she's pasted in doesn't work as-is.
I go over it again; the source schemas and tables are this, but in Snowflake we've named them this. She then bemoans how much work that is to change them all - I say use find and replace. She then struggles with Snowflake syntax errors and asks for a guide on T-SQL to Snowflake. I show her Google and say "this is what I did when I hit these problems - search for 'Snowflake equivalent to T-SQL getdate()' or 'how to get current date in Snowflake' but she still doesn't understand. I ask if she's every had to work between T-SQL and MySQL or MySQL and PostgreSQL or Oracle and so on and she says yes. I say the syntax isn't the same, is it? And she goes oh, now I understand.
She scored reasonably in her SQL test but I'm now concerned there's something fundamental missing in her grasp of SQL. I gave her a detailed demo of the tools, I explained in the interview and on her start about our move to a data warehouse for all our apps, and put her through some training plus gave her time to work through our Confluence pages - not expecting she'll remember everything, but more to ensure she recalls they exist and what the general contents are.
Anyhow, that's my rant.7
[CMS Of Doom™]
Imagine bringing every HTTP Query Param and every god damn fucking POST var into to current code context.
"extract()" is one of the reasons why I have terminal PHPTSD.10
I've been working on a proof of concept for my thesis for a few days and the async query calls drove me nuts for quite a while. I finally managed to deliver all query results asynchronously while still very much relying on a strong architectural design pattern. I am filled with caffeine, joy and a sense of pride and accomplishment.1
EoS1: This is the continuation of my previous rant, "The Ballad of The Six Witchers and The Undocumented Java Tool". Catch the first part here: https://devrant.com/rants/5009817/...
The Undocumented Java Tool, created by Those Who Came Before to fight the great battles of the past, is a swift beast. It reaches systems unknown and impacts many processes, unbeknownst even to said processes' masters. All from within it's lair, a foggy Windows Server swamp of moldy data streams and boggy flows.
One of The Six Witchers, the Wild One, scouted ahead to map the input and output data streams of the Unmapped Data Swamp. Accompanied only by his animal familiars, NetCat and WireShark.
Two others, bold and adventurous, raised their decompiling blades against the Undocumented Java Tool beast itself, to uncover it's data processing secrets.
Another of the witchers, of dark complexion and smooth speak, followed the data upstream to find where the fuck the limited excel sheets that feeds The Beast comes from, since it's handlers only know that "every other day a new one appears on this shared active directory location". WTF do people often have NPC-levels of unawareness about their own fucking jobs?!?!
The other witchers left to tend to the Burn-Rate Bonfire, for The Sprint is dark and full of terrors, and some bigwigs always manage to shoehorn their whims/unrelated stories into a otherwise lean sprint.
At the dawn of the new year, the witchers reconvened. "The Beast breathes a currency conversion API" - said The Wild One - "And it's claws and fangs strike mostly at two independent JIRA clusters, sometimes upserting issues. It uses a company-deprecated API to send emails. We're in deep shit."
"I've found The Source of Fucking Excel Sheets" - said the smooth witcher - "It is The Temple of Cash-Flow, where the priests weave the Tapestry of Transactions. Our Fucking Excel Sheets are but a snapshot of the latest updates on the balance of some billing accounts. I spoke with one of the priestesses, and she told me that The Oracle (DB) would be able to provide us with The Data directly, if we were to learn the way of the ODBC and the Query"
"We stroke at the beast" - said the bold and adventurous witchers, now deserving of the bragging rights to be called The Butchers of Jarfile - "It is actually fewer than twenty classes and modules. Most are API-drivers. And less than 40% of the code is ever even fucking used! We found fucking JIRA API tokens and URIs hard-coded. And it is all synchronous and monolithic - no wonder it takes almost 20 hours to run a single fucking excel sheet".
Together, the witchers figured out that each new billing account were morphed by The Beast into a new JIRA issue, if none was open yet for it. Transactions were used to update the outstanding balance on the issues regarding the billing accounts. The currency conversion API was used too often, and it's purpose was only to give a rough estimate of the total balance in each Jira issue in USD, since each issue could have transactions in several currencies. The Beast would consume the Excel sheet, do some cryptic transformations on it, and for each resulting line access the currency API and upsert a JIRA issue. The secrets of those transformations were still hidden from the witchers. When and why would The Beast send emails, was still a mistery.
As the Witchers Council approached an end and all were armed with knowledge and information, they decided on the next steps.
The Wild Witcher, known in every tavern in the land and by the sea, would create a connector to The Red Port of Redis, where every currency conversion is already updated by other processes and can be quickly retrieved inside the VPC. The Greenhorn Witcher is to follow him and build an offline process to update balances in JIRA issues.
The Butchers of Jarfile were to build The Juggler, an automation that should be able to receive a parquet file with an insertion plan and asynchronously update the JIRA API with scores of concurrent requests.
The Smooth Witcher, proud of his new lead, was to build The Oracle Watch, an order that would guard the Oracle (DB) at the Temple of Cash-Flow and report every qualifying transaction to parquet files in AWS S3. The Data would then be pushed to cross The Event Bridge into The Cluster of Sparks and Storms.
This Witcher Who Writes is to ride the Elephant of Hadoop into The Cluster of Sparks an Storms, to weave the signs of Map and Reduce and with speed and precision transform The Data into The Insertion Plan.
However, how exactly is The Data to be transformed is not yet known.
Will the Witchers be able to build The Data's New Path? Will they figure out the mysterious transformation? Will they discover the Undocumented Java Tool's secrets on notifying customers and aggregating data?
This story is still afoot. Only the future will tell, and I will keep you posted.6
I don't know if I'm being pranked or not, but I work with my boss and he has the strangest way of doing things.
- Only use PHP
- Keep error_reporting off (for development), Site cannot function if they are on.
- 20,000 lines of functions in a single file, 50% of which was unused, mostly repeated code that could have been reduced massively.
- Zero Code Comments
- Inconsistent variable names, function names, file names -- I was literally project searching for months to find things.
- There is nothing close to a normalized SQL Database, column ID names can't even stay consistent.
- Every query is done with a mysqli wrapper to use legacy mysql functions.
- Most used function is to escape stirngs
- Type-hinting is too strict for the code.
- Do not use a package manger composer because he doesn't have it installed.. Though I told him it's easy on any platform and I'll explain it.
- He downloads a few composer packages he likes and drag/drop them into random folder.
- Uses $_GET to set values and pass them around like a message contianer.
- One file is 6000 lines which is a giant if statement with somewhere close to 7 levels deep of recursion.
- Never removes his old code that bloats things.
- Has functions from a decade ago he would like to save to use some day. Just regular, plain old, PHP functions.
- Always wants to build things from scratch, and re-using a lot of his code that is honestly a weird way of doing almost everything.
- Using CodeIntel, Mess Detectors, Error Detectors is not good or useful.
- Would not deploy to production through any tool I setup, though I was told to. Instead he wrote bash scripts that still make me nervous.
- Often tells me to make something modern/great (reinventing a wheel) and then ends up saying, "I think I'd do it this way... Referes to his code 5 years ago".
- Using isset() breaks things.
- Tens of thousands of undefined variables exist because arrays are creates like $this = 5;
- Understanding the naming of functions required me to write several documents.
- I had to use #region tags to find places in the code quicker since a router was about 2000 lines of if else statements.
- I used Todo Bookmark extensions in VSCode to mark and flag everything that's a bug.
- Gets upset if I add anything to .gitignore; I tried to tell him it ignores files we don't want, he is though it deleted them for a while.
- He would rather explain every line of code in a mammoth project that follows no human known patterns, includes files that overwrite global scope variables and wants has me do the documentation.
- Open to ideas but when I bring them up such as - This is what most standards suggest, here's a literal example of exactly what you want but easier - He will passively decide against it and end up working on tedious things not very necessary for project release dates.
- On another project I try to write code but he wants to go over every single nook and cranny and stay on the phone the entire day as I watch his screen and Im trying to code.
I would like us all to do well but I do not consider him a programmer but a script-whippersnapper. I find myself trying to to debate the most basic of things (you shouldnt 777 every file), and I need all kinds of evidence before he will do something about it. We need "security" and all kinds of buzz words but I'm scared to death of this code. After several months its a nice place to work but I am convinced I'm being pranked or my boss has very little idea what he's doing. I've worked in a lot of disasters but nothing like this.
We are building an API, I could use something open source to help with anything from validations, routing, ACL but he ends up reinventing the wheel. I have never worked so slow, hindered and baffled at how I am supposed to build anything - nothing is stable, tested, and rarely logical. I suggested many things but he would rather have small talk and reason his way into using things he made.
I could fhave this project 50% done i a Node API i two weeks, pretty fast in a PHP or Python one, but we for reasons I have no idea would rather go slow and literally "build a framework". Two knuckleheads are going to build a PHP REST framework and compete with tested, tried and true open source tools by tens of millions?
I just wanted to rant because this drives me crazy. I have so much stress my neck and shoulder seems like a nerve is pinched. I don't understand what any of this means. I've never met someone who was wrong about so many things but believed they were right. I just don't know what to say so often on call I just say, 'uhh..'. It's like nothing anyone or any authority says matters, I don't know why he asks anything he's going to do things one way, a hard way, only that he can decipher. He's an owner, he's not worried about job security.13
Hello fellow devRanters, look what I found in our API constants on this fine day!
You get what you pay for, you get what you pay for, you get what you- AAAAAAAAAAAAAAAAAAAARRRGGGGG!!!!!!!!!7
DNS is everywhere.
I hate DNS.
I hate DNS migrations.
I hate having a hundred plus DNS names inside my brain.
I hate resolving issues.
I hate DNSSEC.
I hate CNAMES.
I hate services which cannot be persuaded to stop trying AAAA resolves first.
I hate the fucking stupid braindead idea to use TXT as a configuration store inside DNS... And thus the necessity to blow up DNS query size aka EDNS.
I really really really really really want to burn this whole mfucking shit down...7
Holy crap, I can't take it anymore.
I know that user acceptance testing is supposed to be done by the end user but it's as if they entirely skipped UNIT TESTING and QUALITY ENGINEERING.
Does their API work? Yes. It does.
Are their endpoints working? Sort of... why are query parameters required again?
Is it good overall? No, there are CORNER CASES ALL OVER THE PLACE (are they even still corner cases at this point?). It feels like it was made by amateurs!
Why am I doing quality testing on their services??? holy crap, they should pay ME for doing this1
It’s been so long since I posted but this time it’s juicy again.
I got a coworker, no prio experience but already a year and few months into the job. He’s bad.
Magnitudes of bad!
We’re trying to teach him but to no avail. Everything about him sucks, major ballsack to be exact.
His attitude is to avoid every task, finishes nothing and then starts something new.
„Did you do X like we told you to?“
„No I started on Y, because I thought it [looks better, seems more interesting, thought that X is useless…]“
When you ask him much is done he is always „almost“ finished and needs your help on the „last 5-10%“. Yeah fuck that!
But that guy has a talent, his talent is to always give you technically correct answers which actually are complete bullshit.
„What are you doing at your job?“
„Staring at a screen and typing things.“ dude what?
That guy used the excuse „I can’t do maths“ on everything.
For an exam he had to calculate how long it would take to reach a certain amount if you would get some interest in that every year.
He asked the teacher for the formula. During the exam! And when the teacher didn’t want to give it to him he wrote plainly „can’t do maths“ on the paper and left
His code is of a quality as if he would write his first line in a week and then has the audacity to blame me and the colleagues for not explaining it right.
Ok you might think now we’re teaching him bad, or are too impatient. But honestly if you have to explain how to do a for loop for over about 15 months and get that attitude I think you get the right to be angry. I don’t mind explaining on how things work, even for the hundredth time, but then don’t tell me you understood, go behind my back, complain at a colleague how bad I explained, get explained by him and then do it again until you whored yourself through the whole staff!
It’s like he got the mind swiper from Men in black at home. Every day he hits the reset button.
He had a week of just changing indentation on a html file. Why? Because he wanted to find his style.
Yeah his style
And to produce code like that it takes him atleast 4 hours of trial and error.
And at the same time he goes arround and boasts what a super good programmer he his and that he can do some project work for them.
How we found out? Because he started working in those projects during work time at the office and asked us how to do things.
And he does so like a complete bastard!
Broken sql query? “No that query is perfect as it is, it’s supposed to show no results! But, just in theory, if I wanted to show some results, what would I need to change?”
I’m so mad about it and pissed on a personal level because he goes around blames everyone and the world for his short comings8
Getting real tired of having to reteach the basics of relational databases to the same 2 people. You were brought in as the expert in databases and SQL Server, I shouldn’t have to teach you about effing primary keys, secondary keys, many-to-many relationships, and how to join the damn tables in a basic query. Your 5 years of experience are obviously a waste if all you did was select * from bullshit. This is the 2nd week and 22nd you’ve asked the same damn questions. Get your crap together and study your ass off if you don’t know. Google the error messages if you don’t remember how to solve it before coming to me with the same question a 23rd and 24th time. I’m not going to get any work done if all you do is ninja up behind me with your laptop in tow and just spout off the question that could be done over IM or a quick duckduckgo/google search. Headphones in = do not disturb ya rude mother duckers 🦆.4
I'm a fullstack engineer, this period there is literally nothing to do, we are a 1000+ employees company.
I got so bored I toke over the database of our production server two times in a week, exploiting dumb vulnerabilities I discovered out of boredom, of course I reported everything.
The funny thing is that they just don't care, no one took action or is willing to fix it and they actually insulted me because I set a query in sleep for 8 minutes exploiting one of the vulnerabilities.
I work for a great company that hosts (in this very server) most italian citizens informations C: free to take for everyone c:7
I f&#king hate it here. I am just eyeing to exit as soon as 1 year of my contractual obligation is over. My employer is a good employer. Provides good benefits but I just can't take the bureaucrazy in here. Just yesterday, had to ask another team to deploy objects on our behalf as they are the schema owner. They did it and asked us to review it today. But how? We don't even have manual access to the schema, because we are not the content owner and security! But that's fine, I can always query the catalog views and check the metadata and should be able to conclude the deployment. Right? NOOOO. Because security! Of what? Column names?
Prev rant: https://devrant.com/rants/5145722/...2
This was originally a reply to a rant about the excessive complexity of webdev.
When webdev was simple, it was normal to have the user redownload the whole page everytime you wanted to change something. It was also normal to have the server query the database everytime a new user requested the same page even though nothing could have changed. It was an inefficient sloppy mess that only passed because we had nothing better and because most webpages were built by amateurs.
Today webpages are built like actual programs, with executables downloaded from a static file server and variable data obtained through an API that's preferably stateless by design and has a clever stateful cache. Client side caches are programmable and invalidations can be delivered through any of three widely supported server-client message protocols. It's not to look smart, it's engineering. Although 5G gets a lot of media coverage, most mobile traffic still flows through slow and expensive connections to devices with tiny batteries, and the only reason our ever increasing traffic doesn't break everything is the insanely sophisticated infrastructure we designed to make things as efficient as humanly possible.11
Software runs fine on several in-house instances. First time customers hosting it themselves. Runs fine. Users start using. Server need absurdly high processing power and fucks up. I can not access customers Server to debug. Only hope, get copy of their images to reproduce their setup. And have *** one single fucking hour *** to go into it before having to tell in emergency meeting if we can fix it or they would blew the project.
I didn't expect, but found the cause, a single very badly written query. Written by myself years ago I have to admit.
They also gave me one hour to produce a patch. I did but but lost so many hair.4
I have to add an endpoint to integrate an API and I want to vomit when I think about this major security issue they introduce.
What type of prehistoric dumbass thought GET requests with username and password in the query parameters is a good idea to burden your partner with.4
I am java dev with 5 yoe at a place which has really good engineering talent.
Was assigned a feature request.
Feature request requires me and one more older dev(in age, not in exp at company) to write the code. My piece is really super complex because of the nature of the problem and involves caching, lazy loading and tonne of other optimization. Naturally it makes up 90% of the tasks in the feature request. On the other hand, the older dev simply has to write a select query (infact he only needs to call it since a function is already written).
Older dev takes up all the credit, gives the demo, knows nothing but wrongly answers in meetings with higher ups and was recently awarded employee of qtr.
It looks as if I do the easy work whereas he is the one pulling in all the hard work.
Need advice to justify my work and make others realise it's significance, nuances of area and complexity of it.
Do not expect monetary benefits, just expect credit and recognition for the worth of work I am doing.12
Trying to make use of Google Maps. Search results are always sorted by "most relevant" by default, instead of by distance. Always I switch to distance, next search goes "most relevant" instead, which should be labelled "most irrelevant" instead, as it seems to be an excuse to show a list with promoted businesses not only far away, but often unrelated to my actual query. Wasn't Google supposed to be some sort of search engine experts? or at least the lesser evil of search engines? Oh wait, no, they're actually an advertising company, and it shows. Fuck you, Google. Where am I going to throw my Pixel phone and why did I open your shitty apps in the first place? I should switch MY own defaults back to Open Street Map etc.6
GraphQL fans, please read the whole rant until you jump in the comments.
I get it, when you have multiple data sources (that aren't always proper databases), your stuff is relevant.
But most of the people use GraphQL when they have a single database. In that case, native joins are always faster than GraphQL dataloader N + 1 BS you have. It takes less time and less code to go to the backend and write an endpoint for the frontend with a DB query than write several GraphQL ones on the frontend and then combine the data with imperative JS. It will work faster too.
So why the fuck should I use GraphQL at all?29
Fucking mongo, fucking nested documents in nested documents that need to be filtered. I'm either really fucking dumb, the query is hard or both.8
Me: You decided some records in system A should be obsolete, but the records are tied to active user accounts on the website. Now, I have users emailing and asking why their profile’s last name field says “shell record - do not use.”
Stakeholder: Oh…can’t you stop those profiles from loading? Or redirect the users to the right record in system A? In system A, we set up a relationship between the shell record and the active one.
Me: 😵 Um, no and no. If I stop a user’s profile from on the website, that’s just going to cause more confusion. And the only way to identify those shell record is to look at the last name field, a text field, for that shell record wording. Also, the website uses an API to query data from system A by user id. Whatever record relationship you established isn’t reflected in the vendor’s API. The website can’t get the right record from system A if it doesn’t have the right user id.7
Tip: if you are doing a semi complex or complex query in Django and you have doubts print the SQL statement and analyze it. i.e print(queryset.query)
Just reduced a query to 1 join instead of two by just passing a list of int's instead of a list of objects.
when you work for Jira and get assigned in Jira’s Jira to write code in Jira Query Language to query Jira’s Jira so other Jira users can query their Jira better2
I can now appreciate some design decisions behind react-redux after witnessing some angular OOP clusterfuck.
I am sure there is some clean/correct way to code in angular, but everyone is treating angular as java.
Some angular application (the one I have to work with) is littered with network calls. It's difficult to spot duplicates. People usually resolve promises everywhere. In services, in a top-level component, or in for loops. In react, people use apollo/redux-query or redux-saga to handle network calls. Since these libraries prevent duplicate network calls internally and reassigning apollo network call function or redux action function is always useless, it's easy to spot all network calls in a component tree.
In angular, it's difficult to trace data mutations when data can be updated everywhere. In react, you can easily find UI state updates by tracing state hooks/dispatch/apollo usages.
In angular, it's difficult to trace data pipeline. Since everything is imperative by default, people need to add update functions in data subscriptions. With all the littered mutations. Soon you will lose track of what the fuck is going on.
I hope angular get the agonizing death it deserves and fuck everyone who codes JS OOP clusterfuck UI.11
When I first started down the path to becoming a developer, I was a "business analyst" where I managed our departments reports and ended up migrating all the reports from daily query run in MS Access with Task manager and emailed out to all the managers including the VP of the entire business unit, I created
Views in the database and sent out the same spreadsheet with the view in excel daily since management didn't want "change". Granted this was at a large health care company in the US and didn't want to invest in a real dashboard for their reports. The only thing that was changed in the email and file was the file name with the current date. I left the company a while ago and recently applied for a similar position for the shits and gigs. Interviewed with the It manager and they're still using the same excel macro I wrote 3 years later.2
I hate cloud corps like GCP for pushing down our throats half-baked solutions as Datastore. Why can't i do a simple "NOT IN [list]" query ffs?! Why do you have multiple syntax for doing the same things? Where is your fkin user guide for everything your app can/cannot do? fk u goog2
Fuck sequelize, the bloody query generated by the "ORM" give diferent result on the same DB if you trie it on dBeaver (works fine) vs node (shit results).
order DESC have 0 effect on sequelize, but it appears on the logger as part of the query.
I just want to go to sleep ffs.7
So I inherited this buggy application my company developed to process state rosters for health care. The daily process fails often and I haven’t been able to figure out why. Then I notice one little thing... it’s essentially using SQL injection as a method of updating records from a file that we receive from outside... there’s no checking for validity of the statements or making sure they’re safe to execute. Just a for in loop and calling a sp to execute the query text under elevated permissions.
So there's azure data studio, shiny! nice!
Oh hey, wow, an Oracle extension! Great!! Now I can use one tool for all my database queries!
Below is the list of current limitations:
- Server management and dashboard are not supported
- Packaged objects are not supported
- Table data preview/editing is not supported
- Query execution is not supported
So you're telling me that you can connect and... that's it?
What's the point? Why??
That's like saying: Here's a toaster. But here's the thing's you *can't* do:
- Toast bread
But at least you can look at it. Seriously, what the ****.6
On Friday, I was playing with the ChatGPT integration in DBeaver. I was using the DBeaver sample SQLite database. This database has a couple of tables, among them Album and Artist, where Album has a foreign key into Artist.
So, I asked it:
"give me a query that lists all albums from artists who's name starts with s"
The query I got back was:
SELECT * FROM Album
But then, I noticed that I wrote "who's" instead of 'whose', which would be proper grammatically. So, I changed that, and then I got this query:
SELECT * FROM Album WHERE ArtistId IN (SELECT ArtistId FROM Artist WHERE Name LIKE 'S%');
Hooray, that works! I'm not sure it's the best way to write the query... I might have written:
SELECT * FROM album a, artist r WHERE a.artistid=r.artistid AND r.name LIKE 'S%'
...I'd have to check to see if one performs better than the other, and consider which syntax I find clearer, but that's a separate issue, it's just nice to see a working, reasonable query generated because that's the point, after all.
But I found it interesting that such a minor error would cause it to not work, that's my main point.
Interestingly, it seems to have learned: I just tried the same thing, and I got the right query either way. So that's pretty cool.
It's a pretty neat feature and I can see some legitimate value in it. I'm pretty good writing SQL myself... I've managed to write some truly hideously complex queries over the years... but there are definitely instances I can recall where the query didn't seem obvious at the start, and having an AI that can MAYBE produce something that is AT LEAST a starting point is definitely something I can get onboard with.8
GraphQL question here!
So i recently noticed (few years after everyone?) That graphql seems popular... I decided to try it out, but after playing with it a bit, the conclusion I came to is, that it's a great idea from FE point of view, but for the backend not so much.. a simple sql to return data to ui turns into a bunch of parts, all independant and with even the simplest relationship to some other entity the whole thing becomes very not optimized and when googling about it, all i found were some very awkward libs for work arounds to force everything into 1 optimized query again... But wait, i already have 1 optimized query in my rest api 😆
I don't understand if I'm missing the brilliance of graphql that everyone saw, or is everyone fell for the hype and use a stupid tool and pretend it's cool? 4
Apologies if this has been asked here before, but I wanted an open feedback on a query: Is there such a thing as overdocumenting?
I take pride in being a very articulate developer, being as descriptive as possible in my emails, internal communications, PR review comments, JIRA etc.
A product guy from the company today mentioned: "Though I understand your good intent behind being as descriptive as possible, it is possible that some of the junior engineers might get overwhelmed/ intimidated looking at those comments/ emails and it might stop them reaching out to you with your doubts."
I was not able to wrap my head around this, because I don't understand how a descriptive explanation might overwhelm anyone. It's a skill I picked up going through my career and I personally have always respected peers who documented things properly.
Open to feedback. Thank you in advance.6
I am happy today cause I manage to write a query in which two table have inner join and with third left .. haha...
I mean I was thinking of handling that situation with foreach.. But managed to do it in query by myself :)
Just hoping that query won;t break for different scenarios. But let just be me happy while it last .. I mean my client make some test
Online stores never have an “Exclude X” feature in the filter menus. E.g. I can filter to include all blue clothes but can’t exclude them.
From a query point of view this is not difficult. Would it be a UI nightmare? I don’t think so.3
Q: What do you get when you create a homebrew query language that uses both the stream oriented principles of Unix data pipes and the relational ideas underlying an RDBMS and use incomplete documentation to support it?
A: A frustrated borderline homicidal engineer.3
Working with new guy who is "senior" is such a pain. We had a factory file that is used to populate tables in endpoint tests. The new guy decided to add a static util method called createTestRecord() to a query builder model. Fucking query builder calls in a static method in a query builder class. I send him messages expressing concerns regarding his approach but never got anything back. The guy just ignored me and asked me to review his pr.
I am leaving in 4 months. Release me from my misery. Fuck my life5
*Frustrated user noises* Whyyyy, Grafana, why don't you implement any actual query forgery checks?!
So long as a user has access to the Grafana frontend, they can happily forge the requests going off to the backend, and modify them to return *whatever* data they want from the datasource.
No matter that they're a read-only user. That only stops them from modifying the dashboard definitions on the frontend, but doesn't enforce any sort of immutability on the BE...
If anyone had any tips on how to further secure it, I'm curious...5
So i have been thinking..
SQL is a lang that runs on a specific software on the server, and helps creating data stores(databases and tables) that can be queried & manipulated.
is there a way to run sql like queries on the client side with no interaction from backend at all?
Say i have 5 inter related data models. in a backend world, they will form nice little tables of a db with all their joins and composite keys. from the server, i shall be querying them like "SELECT name from x where y=z & ..."
but what if i could store them like tables in browser memory and run the same query filters via a query language... is this possible?
or am i talking something far fetched here?8
"I claim that the trend which AI/ML continues for lawyers is one that it starts for programmers. Just like how a partner at Cravath likely sketches an outline of how they want to approach a particular case and swarms of largely replaceable lawyers fill in the details, we are perhaps converging to a future where a FAANG L7 can just sketch out architectural details and the programmer equivalent of paralegals will simply query the latest LLM and clean up the output. Note that querying LLMs and making the outputted code conform to specifications is probably a lot easier than writing the code yourself ー and other LLMs can also help you fix up the code and integrate the different modules together!"1
Fucking Quarkus. Fucking Panache. Fucking ORM.
I wanted to do a fucking simple projection. First this piece of fuck, the Panache, won't let me do a Projection because of a fucking bug, that haven't implemented it properly until 2.12 (fuck and you call this v2?). Ok, upgraded, to the latest 2.16, cuz why the fuck, i'm upgrading already. But now the whole fucking quarkus app won't start! Noice! Ok, fuck it, let's go down exactly to 2.12. Quarkus started, perfect. But now, this pice of fuck Hibernate says 'collection was evicted' whenever i tried to read a collection in the setter (Access.PROPERTY), which worked just fucking fine before. But okay, fuck you. I'll write a @PostLoad method, fine, just fuck off.
But that's not the end! Now it says I cannot write `select parent.someColl is not null and parent.collection is empty as canProcess` because "is empty" only supported in where clauses. What fucking wonderful system! Well, fuck you. I'll write a union query. But guess what! JPA standard does not support union queries, nor HQL (Eclipse Link does, btw). Ok, fuck this shit, let's write a native query. But hey, fucking Panache does not support that. There is no fucking place in their fucking docs stating anything about how to use native queries.
So, fuck you quarkus, fuck you panache, fuck you hibernate, fuck you overcomplicated limiting bullshit called full-fledged ORMs. I'm moving to a fucking mybatis and fuck it. It's simple as fuck, does not fucking restrict me in writing whatever shit query I want to write and let's me map the shit just fine.1
Started playing around with react this week. Seams nice and i really love the hooks. But next.js on the other hand seams a lot less developed compared to nuxt.js. For example you cant get just the path or just the query parameters from a url without parsing and splitting the url yourself. Is there any other ssr framework for react i could try (excluding gatsby)?2
Having a senior DBA can save hours if not days of struggle and save your back, if you do not know well enough how to do a more complicated query yet, without fucking up something.
Good guidance and experience is worth so much.
... and no I do not have the rights to drop databases.1
Finally im starting to get hang of how nextjs works. Still no idea how query params work, routing api calls, the proper structure, useEffect vs useState, SSR vs static props, etc but i wrote the messiest spaghetti code youve ever seen, and it works! I built a frankenstein. And its alive. Cleaning this shit up is the least difficult part4
Ok, I have to share this with you all. It makes me snort laugh. And that’s a hard achievement! Check out how many guys have been LEGALLY named Dude and Shorty!
Query with joy!1
Since Google is failing me...
Given a user input (string query) and a list of larger strings (like email bodies or something), what's the best way to search and rank the list of strings against the user input.
So far I have implemented levenshtein distance but it doesn't really seem to do extremely well. (Short strings rank very well against each other, whereas long strings **containing** exact matches will go lower in the list)
Should I be splitting the input and the list by word and then averaging the distances?
The only thing I have tried is removing complete non-matches from the list by not including them if the distance is equal to the length of the largest string17
Hola community!! Everyone going over this, please read this once and honestly answer my query.
I am on a probation at a startup. When i will be full-time, then the startup has promised me to provide CTC of 7,50,000(inr) i.e 10,000$ (usd).
Now I want to switch this startup company. Here are my reasons -
1. Less people, more work. - Well, that's what we call a startup. The tech team consists of 3-4 members only and we ourselves have to do the whole thing from end to end. This consists of designing the architecture, PR reviews, qa testing and coding ofcourse.
2. I see myself that I am capable enough to earn 1.5 times more than the above CTC. Also, all my friends are earning 2x the above ctc.
3. Also, there is no senior in the team except founder himself. This really seems awful as can't learn from anybody.
4. Also, i have plans of higher studying due to which i have to entrance exams. So i need to prepare them too. Switching to an established company can mean more money and less work.
Now, can anyone suggest me whether my reasons to switch are legit or vague??1 | <urn:uuid:3f93202c-2b06-4781-99f2-ea033e48cfbd> | CC-MAIN-2023-14 | https://dfox.devrant.com/search?term=query | 2023-03-20T08:43:22Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-14/segments/1679296943471.24/warc/CC-MAIN-20230320083513-20230320113513-00553.warc.gz | en | 0.953082 | 13,740 |
Tell us about yourself!
Thanks for quick reply, now it's easier to understand but i still didn't understand one thing.What actual processor chip pin numbers do you use for serial io port #1?
Idk if this thread is still alive, but i need a help.According to the last figure where it's show how DEI pins are connected to Arduino mega pins, you connected 34, 33 DEI's pins to 11 and 10 pins of Arduino while they're not digital IOs and you can't control them in order to send data. So, is it right and i'm horribly confused?Secondly, you created a simple protocol over the serial io port #1 (pins 1 and 2) while at the same time you use pin 2 for /OE2 input(DEI's pin 10). Is something wrong with it?Best Wishes,Valikhan)) | <urn:uuid:4e8dea32-682d-432a-9ae5-6223ac5a6262> | CC-MAIN-2018-26 | http://www.instructables.com/member/ValikhanT/ | 2018-06-21T03:24:57Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-26/segments/1529267864019.29/warc/CC-MAIN-20180621020632-20180621040632-00381.warc.gz | en | 0.935914 | 179 |
Inside the Maze of the Mind: The Insanity Plea and the Intricacies of Criminal Defense
June 15, 2023
In the multidimensional world of criminal law, few topics enthrall the public and challenge the legal profession as much as the insanity defense. It is a rare, daring, and complex maneuver, residing at the crossroads of psychology, criminal defense, societal norms, and morality. This defense has become a spotlight, often casting shadows of doubt on the balance of justice, especially in high-profile cases that test our understanding of sanity and its influence on human actions.
A benchmark case in the history of the insanity defense is that of Daniel M'Naghten. In 1843, suffering from paranoid delusions, M'Naghten attempted to assassinate the British Prime Minister. The case gave rise to the M'Naghten rule, stating that defendants may be acquitted on grounds of insanity if they were so impaired at the time of the crime that they did not understand the nature of their actions or realize that they were wrong.
This seemingly straightforward rule has sparked heated debates over the years. It requires the law, primarily a field of tangible proof and fact, to probe into the elusive corridors of the human mind. Moreover, while psychologists and psychiatrists wield the tools to diagnose mental illnesses, making a legal determination of 'insanity' remains an intricate task.
The plea's infrequency (only about 1% of county court cases) is a testament to its complexity and the high stakes involved. One high-profile case where the insanity defense took center stage was that of John Hinckley Jr., who tried to assassinate President Ronald Reagan in 1981. Hinckley's successful use of the insanity defense, based on a diagnosis of narcissistic personality disorder, ignited a public uproar. The case led to the Insanity Defense Reform Act of 1984, which significantly tightened the federal rules for the insanity defense.
The Andrea Yates case is another poignant example of how the law struggles with the sanity-insanity dichotomy. Convicted in 2002 for drowning her five children, Yates' defense claimed she suffered from severe postpartum depression and psychosis. However, it was not until a 2006 retrial, where she was found not guilty by reason of insanity, that the intricate relationship between mental illness and legal culpability was brought to the forefront of public debate.
The insanity defense is not simply a get-out-of-jail-free card. In fact, it often implies an admission of the act, shifting the focus to the defendant's mental state at the time. This defense's success is far from guaranteed. It hinges on compelling psychiatric evidence and an understanding jury. It also subjects the defendant to an unpredictable and often prolonged period of involuntary commitment for treatment, replacing incarceration with hospitalization.
The determination of sanity is a two-tiered process in court: competency to stand trial and culpability during the offense. A person can be found competent to stand trial yet still be acquitted on the grounds of insanity. Conversely, someone can be found temporarily insane at the time of the crime but competent enough to stand trial.
Despite the high-profile cases and the cinematic dramatization, the insanity plea is not a common or easy choice. It is a delicate play of strategy, psychology, law, and luck. Public perception often leans towards skepticism, viewing it as a loophole for the 'guilty'. The legal and mental health community, however, understand its gravity and the complexities involved in its deployment.
States have different standards for the insanity defense, and some, like Idaho, Kansas, Montana, and Utah, have abolished it altogether. This only adds to the maze of legal considerations around this plea. Such diversity in approaches underlines the need for ongoing dialogue and reform in this contentious area of law. The insanity defense continues to pose significant challenges to our justice system and society as it forces us to confront the intersections between law, morality, and mental health. It requires us to question and define the boundaries of culpability, and grapple with how we treat and understand those who transgress societal norms due to disorders of the mind.
The way forward involves a multidisciplinary approach, with legal experts, mental health professionals, lawmakers, and society working together. This collective effort is vital to ensure a balanced view that upholds justice, respects mental health issues, and appreciates the inherent human complexity.
Despite the myriad challenges it presents, the insanity defense also offers an opportunity to examine and improve the ways our justice system interacts with the realm of mental health. It's a call to action for mental health advocacy within the justice system, highlighting the importance of accurate psychiatric evaluation, adequate legal representation, and appropriate sentencing.
For those standing at the crossroads of criminal law and psychology, the insanity defense is not a soft option. It's a labyrinth that echoes with questions about our understanding of the human mind, the essence of criminal responsibility, and the capacity of our justice system to adapt and evolve.
Whether viewed through the lens of legal rigor, societal ethics, or mental health advocacy, the insanity defense stands as a testament to the complexities of the human condition. It's a reminder that our quest for justice must always navigate the shifting landscapes of the human mind. | <urn:uuid:cc7274c3-6c59-4fa8-bff1-c2af43b161d7> | CC-MAIN-2023-40 | https://www.thetownlaw.com/the-town-law-blog/inside-the-maze-of-the-mind-the-insanity-plea-and-the-intricacies-of-criminal-defense/ | 2023-09-22T21:46:25Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-40/segments/1695233506423.70/warc/CC-MAIN-20230922202444-20230922232444-00276.warc.gz | en | 0.947143 | 1,066 |
In this series, Ed takes you from a ‘working generality‘ to a ‘meaning specific‘! We explore the subject and power of purpose, and then very practically take you through the process of building your church, business, ministry or whatever around purpose. Ed helps you in determining who you are, what you do, how you do it, and what it looks like when it’s done. Church government and ways of dealing with organizational crises are also dealt with.
This conference has a complete workbook with it that has also been translated into Spanish.
We would love to have the opportunity to speak at your church or city. Please contact Ed Delph at 623-363-9961 or 623-376-6757. You can also email Ed at NATIONStrategy@cs.com to schedule your conference.
You are welcome to make a flyer out of this sample I have given. In fact, I think people will be motivated to come by the information given here.
Please visit our About Ed page to find a media kit with photos, graphics, and biography to use with marketing efforts. | <urn:uuid:219f8516-1d4a-425a-9e6c-b893194de204> | CC-MAIN-2017-47 | http://nationstrategy.com/nationstrategy-seminars/building-church-around-purpose/ | 2017-11-25T02:13:44Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-47/segments/1510934809229.69/warc/CC-MAIN-20171125013040-20171125033040-00217.warc.gz | en | 0.958655 | 233 |
The bizarre case of Duane Hurley and Daniel Kovarbasich
Danny was not immediately charged with any crimes related to Hurley's death. After release from the pediatric hospital, Danny was allowed to return home for a couple of days to recuperate from the trauma he experienced on January 22. Because of the elevated heart enzymes that he had experienced on the morning of Hurley's death, doctors feared that he might have a heart attack and advised his parents not to upset him or discuss the incident with him when they sent him home. However, before the month was over, Danny was charged with one count of murder, one count of felony murder, one count of felonious assault and one count of felonious assault with a deadly weapon. Accompanied by his attorneys, Danny turned himself in to the authorities and was held at the Lorain County Juvenile Detention Center pending trial. Under Ohio law, the murder charges require that a 16-year-old be tried as an adult. Danny was denied bond.
It should be noted that the count of felonious assault with a deadly weapon was based on the fact that a knife was used in the attack on Hurley, and the felony murder count was based on the fact that Hurley's death occurred during the course of the assault. The prosecution was planning to argue that Danny could have fled Hurley's home at any time by leaving through the front door or through the kitchen door if he had felt threatened by Hurley.
The defense opted for a bench trial held before a judge instead of a jury trial, reasoning that Danny's fate might be better served by waiving a trial by jury. The defense, which would be presented by attorneys Jack Bradley and Michael Stepanik, would ultimately concede that Danny had killed Duane Hurley but would argue that mitigating circumstances made the defendant's crime something less than murder. The defense would place Danny on the witness stand to testify in his own defense in a effort to convince the judge that he was a victim of sexual abuse despite the fact that he had initially told investigators that he had not been inappropriately touched by Hurley. It would all boil down to the point where Lorain County Judge James Burge would try to decide whether Danny Kovarbasich was a victim or a murderer. Burge had 30 years experience on the bench trying both civil and criminal cases, including five death penalty cases in Lorain County.
At the time of his arraignment, many of the students at Danny's school were in a state of stunned disbelief at his arrest and the charges being leveled against him.
"I can't believe he would do something like that," said a female student. "It doesn't seem like anything he would do...he would just like mow...(Hurley's) grass and just walk his dog, wash his car."
Up until the time opening statements would be presented by the defense no one, including prosecutor Michael Kinlin, knew for certain what type of case the defense was going to present. Would they be seeking a conviction on a lesser charge, such as manslaughter or involuntary manslaughter? Or would they put on a case of self-defense by asserting that Danny had killed Hurley to avoid being raped?
Much of Kinlin's efforts in prosecuting Danny would be in trying to prove there was no evidence of provocation by Hurley and that Hurley had been ambushed by Danny and did not have an opportunity to defend himself against the attack. After all, investigators had shown that the bloody footprint found in the kitchen belonged to Danny, a fact which could prompt Kinlin to argue that Danny was in Hurley's kitchen and could have fled through the kitchen door and into the backyard. Instead, authorities had theorized that Danny had grabbed a knife to use in his attack on Hurley who was by that time lying on the hallway floor near the front door. | <urn:uuid:2cea54c6-bdaa-4ee7-9b0c-4c4b7c9a9963> | CC-MAIN-2014-15 | http://www.crimelibrary.com/notorious_murders/young/daniel-kovarbasich/9-charged.html | 2014-04-18T23:21:15Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-15/segments/1397609535535.6/warc/CC-MAIN-20140416005215-00475-ip-10-147-4-33.ec2.internal.warc.gz | en | 0.992152 | 784 |
Court Upholds Denial Of Permit For Cabaret In Wantagh
WANTAGH, N.Y. (CBSNewYork) - The New York State Supreme Court has upheld a town’s denial of a Long Island strip club owner’s quest to open a new cabaret, WCBS 880’s Sophia Hall reported.
WCBS 880’s Sophia Hall On The Story
Billy Dean wanted to open the cabaret in Wantagh, just a stone’s throw from a residential area. Residents were outraged because they did not want the cabaret near their children.
They believed the business would be a strip club. Dean said the business would only have dancers in costumes.
The town of Hempstead denied Dean a permit to open the business, and Dean took the fight to court, but, in the end, the town won.
“This type of a business absolutely does not fit in with and does not conform with our suburban quality of life that we’re always trying to preserve,” Hempstead Town Supervisor Kate Murray told Hall. “They want to preserve the neighborhood. They want to make sure that their families [and] their children grow up in a wholesome atmosphere.”
Dean’s attorney said he was very surprised and disappointed, and will appeal the ruling.
Do you agree with the ruling? Sound off in the comments section below. | <urn:uuid:28cb99fc-6ce2-4415-8ead-140cee05ebd1> | CC-MAIN-2015-06 | http://newyork.cbslocal.com/2012/05/15/court-upholds-denial-of-permit-for-cabaret-in-wantagh/ | 2015-01-29T04:46:57Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-06/segments/1422118973352.69/warc/CC-MAIN-20150124170253-00067-ip-10-180-212-252.ec2.internal.warc.gz | en | 0.962491 | 295 |
INDIANAPOLIS — ESPN analyst Seth Greenberg called the State Farm Champions Classic "a fact-finding mission."
Kentucky's 72-40 smashing of Kansas later Tuesday simply validated a well-established bit of information: Kentucky is good, maybe good on a historic scale.
As if to reassure Coach John Calipari, who questioned the effort in a come-from-behind victory over Buffalo Sunday, the Cats outplayed Kansas from tip-off to final buzzer.
"We have reinforcements," Calipari said of UK's platoons. "It's like tanks coming over the hill."
It was the second-largest margin of victory for Kentucky in the on-again, off-again series between the two winningest college basketball programs. Only a 100-63 UK victory in Louisville in 1975 was larger.
The worst defeat in Bill Self's 12 seasons as Kansas coach (eclipsing a 25-point loss to Texas in 2006) may have surprised, among others, Dick Vitale.
Before the game, Vitale suggested it might be the kind of possession-by-possession adversity Calipari said his team needed.
"You know what's great about this?" he said of the starry doubleheader (Duke beat Michigan State in the opener). "It eliminates the cupcakes."
Kentucky made Kansas look like a cupcake right from the start.
In the State Farm Champions Classic last year, Kentucky opened the game as if it had called Jake from State Farm at 3 o'clock that morning. The sluggish Cats fell behind Michigan State 14-0, a deficit that could not be overcome.
Against Kansas, the Cats came out alert, active and eager to take the initiative. Kentucky blocked three shots before the first television timeout.
Kansas clearly planned to go at Kentucky's strength by driving to the basket. Either that or the Jayhawks were delusional. Kansas made only four of its first 24 shots.
Self tried to stem the tide by calling three timeouts in the first half. Only the third seemed to halt Kentucky's tidal wave of momentum.
The first two Self timeouts came within a 37-second span. He called the first with 10:01 left after Willie Cauley-Stein beat former high school rival Perry Ellis for a layup off an inbounds pass. That put UK ahead 19-9 and highlighted an inconsequential first half for Ellis, the Jayhawks' leader (one-of-six shooting and four points).
The next Self timeout came at the 9:24 mark. It followed UK rebounding its own missed free throw and cashing in with a Cauley-Stein dunk.
After a sloppy Kansas turnover, Aaron Harrison hit a three-pointer to put the Cats ahead 24-9. That was the same UK lead that caused concern in the opener against Grand Canyon last week. No such worries this time.
The blowout stalled after Self's third timeout, this time with 3:01 left and UK holding its largest first-half lead at 35-17.
A three-pointer by Wayne Selden Jr. seemed to steady Kansas. Freshman Kelly Oubre, a McDonald's All-American, finally hit his first two shots. Suddenly, and surprisingly, Kansas got within single digits at 37-28.
After a UK timeout, the Cats went to Dakari Johnson in the post. Fouled on a shot attempt, he made one free throw with 4.3 seconds left to set the halftime score. Johnson led UK with 11 points. Twelve Cats scored.
Apparently not lulled into complacency by the opening 20 minutes, UK opened the second half crisply. Johnson got the half off to a good start with a post-up basket. Then Trey Lyles hit a pullup jumper.
A sequence before the first television timeout of the second half showed how intent Kentucky remained. After Marcus Lee badly missed two free throws (the first barely grazed the rim), he chased down the rebound. The Cats cashed in the bonus possession as Johnson found Lee for a dunk. That put UK ahead 44-28 with 16:51 left.
Later, Andrew Harrison scored on a drive despite being met at the rim by two McDonald's All-Americans: Ellis and Cliff Alexander. The three-point play put UK ahead 53-35 with 12 minutes left. That matched the Cats' largest lead to that point.
Not that anyone would complain, but the rout denied Kentucky a chance to explore what Greenberg said was a key unknown: Finding the clutch performers in the final minutes of a close game.
"If I'm John, who are you giving the ball to?" Greenberg said. "We know Aaron (Harrison) can make that shot. But who are you going to give the ball to at the end of a game? Who is the guy who's going to get us something?
"And I think that's what they have to develop. Who's going to be on the court when you're closing out games? That's going to be John's challenge. That's going to be what he has to do in the next three months."
Greenberg saw the time between semesters as the time to make such determinations. Using the nickname Calipari favors for that time of the season, he said, "I guarantee you at Camp Cal, that's going to be the focal point."
No need for that against Kansas. | <urn:uuid:2065e18a-760a-4cde-9304-8fec6901c7b1> | CC-MAIN-2019-35 | https://www.kentucky.com/sports/college/kentucky-sports/uk-basketball-men/article44524440.html | 2019-08-18T15:14:27Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-35/segments/1566027313936.42/warc/CC-MAIN-20190818145013-20190818171013-00402.warc.gz | en | 0.960271 | 1,118 |
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Holy All Saints Day Meditation
All Saints Day is celebrated on November 1st each year, and is our special time to remember those who have come before us and dedicated their lives for the betterment of others. Serving the needs of others has its own reward of joy in the very moment of action, because the doer feels harmonious.
The reward for acting for the highest good is an option all of us can grab onto at every moment. And if we are not doing so now and wish happiness and harmony for ourselves, now is the time to change our views, attitudes and actions.
Because I have been through the experience I can tell you first hand that instantly your body will relax and mind become calm. This happened to me more that 30 years ago and my life changed for the better from that moment on. It is a personal decision to go for harmony, thereby bringing happiness into your life and acting as a catalyst for others to follow suit.
All Saints Day Meditation
To begin, first arrange your meditation altar if you use one with a nice center or side candles, incense, fresh flowers. Wash and put on fresh clothes. Sit on a cushion on the floor facing your altar, fold your legs in. Alternately, sit up straight in a chair with the soles of your feet firmly planted on the floor. Clasp your hands in your lap or place them palms up or palms down on your thighs.
Close your eyes and begin regular, even breathing for a minute, such as 2 counts to breathe in; 2 counts to breathe out; 2 counts to breathe in and continue the rhythm during the meditation, but let go of counting the numbers.
Breath is a bridge between body and mind and regular even breathing calms the mind and relaxes the body.
Now take a minute to think of an appreciation for someone in your life who has inspired you to be your best. Think on what qualities that person had that struck a chord with you. Those would be traits to emulate.
Take some time to think of a specific saint who has inspired you; reflect on their qualities and how you can incorporate them into your own life.
Finish your meditation by taking a deep breath in and slowly releasing it. Open your eyes and write any new insights in your meditation journal. Stand, stretch and go on with your day with appreciation for the saints who have come before and modeled the highest way to live.
I invite you to join me in a daily group cyber meditation for personal and planetary peace. Click the article here to read about it.
Meditation Lessons for Teens and Adults
More than 70 offerings, from guided meditation techniques to on-the-go stress relief and relationship meditations interspersed with verse, and a section of special occasion prayers. 114 pages. PDF Ebook | EPUB | Paperback | Mac Users | B&N NOOK eBook
Meditation for All Kids
Sitting, walking, dance and group circle meditations, along with positive affirmations, verses and benefits of meditation for kids of all ages and abilities in a 100 page book with illustrations. PDF Ebook | EPUB | Paperback | Mac Users | B&N NOOK eBook
Sign up below or in the right-hand column for our meditation site newsletter. It only requires your email address and is never given out or sold to anyone. If at any time you wish to stop receiving it, each newsletter contains a link to unsubscribe. Each person must sign up themselves. We can't sign up for you. It is an easy way to keep abreast of new articles on the meditation site. Make meditation part of your daily routine and let the Bellaonline meditation articles help you select just what kind of meditation is right for you, whether you are a child, teen, or adult, a beginner, or advanced practitioner.
Article by Susan Helene Kramer
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Content copyright © 2015 by Susan Helene Kramer. All rights reserved.
This content was written by Susan Helene Kramer. If you wish to use this content in any manner, you need written permission. Contact Susan Helene Kramer for details.
Website copyright © 2015 Minerva WebWorks LLC. All rights reserved. | <urn:uuid:101c5d85-ac6c-4f3a-bfd5-471685b9d627> | CC-MAIN-2016-07 | http://www.bellaonline.com/articles/art63083.asp | 2016-02-10T00:48:38Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-07/segments/1454701158481.37/warc/CC-MAIN-20160205193918-00124-ip-10-236-182-209.ec2.internal.warc.gz | en | 0.927713 | 912 |
That said, I don't know if it's in working condition, but from what I can make it's in great shape in it's original box! Any questions contact me and I'll do my best to help, Jesse. The item "Vintage USA NASA Apollo Rocket, Spaceship, Modern Toy TM, Japan, #3847, with Box" is in sale since Thursday, March 21, 2019. This item is in the category "Toys & Hobbies\Robots, Monsters & Space Toys\Space Toys\Pre-1970".The seller is "ogrespringmaker" and is located in McKees Rocks, Pennsylvania. This item can be shipped to United States, Canada, United Kingdom, Denmark, Romania, Slovakia, Bulgaria, Czech republic, Finland, Hungary, Latvia, Lithuania, Malta, Estonia, Australia, Greece, Portugal, Cyprus, Slovenia, Japan, China, Sweden, South Korea, Indonesia, Taiwan, South africa, Thailand, Belgium, France, Hong Kong, Ireland, Netherlands, Poland, Spain, Italy, Germany, Austria, Bahamas, Israel, Mexico, New Zealand, Philippines, Singapore, Switzerland, Norway, Saudi arabia, Ukraine, United arab emirates, Qatar, Kuwait, Bahrain, Croatia, Malaysia, Chile, Colombia, Costa rica, Panama, Trinidad and tobago, Guatemala, Honduras, Jamaica, Macao, Uruguay, Russian federation. | <urn:uuid:94efc067-d73b-4653-8bfb-ab4c098bad21> | CC-MAIN-2019-43 | http://classicspacegames.com/vintage-usa-nasa-apollo-rocket-spaceship-modern-toy-tm-japan-3847-with-box.html | 2019-10-16T11:06:15Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-43/segments/1570986666959.47/warc/CC-MAIN-20191016090425-20191016113925-00415.warc.gz | en | 0.883147 | 287 |
We’ve been shortlisted again for a Vendie!!
Having won last year for ‘Best Product Innovation’, with the single cup dispenser, this year we find ourselves named in another category: Best Ancillary Product.
We’re depending on the Red Bean cup to bring us home the silverware later this month as this is the cup that the voters have chosen to feature in this category, along with an offering from Benders and products and services from Westomatic, The Vending Integrators and Vendmanager.
Our popular Red Bean cup, which underwent a design refresh earlier this year, is currently enjoying a renaissance.
The contemporary line’s universal appeal is reflected in the update, with the cup boasting a more vibrant appearance having embraced busier, eye-catching undertones.
It’s proved to be a hit in the marketplace since it’s relaunch, with sales rising as more customers become aware of the iconic product’s new look.
So, fingers crossed the Red Bean will impress the judges as much as it has impressed our customers…
All will be revealed at the Millennium Gloucester Hotel on the 28th June. Last year’s event was a good one, made even more memorable by our win. Let’s hope the winning streak continues.
Good luck to the contenders across all categories – we’ll see you on the day ! | <urn:uuid:28c78b2a-b441-4c6e-b77b-3a6d3ccde470> | CC-MAIN-2017-43 | http://4acesltd.com/blog-news/on-the-shortlist/ | 2017-10-18T23:58:01Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-43/segments/1508187823168.74/warc/CC-MAIN-20171018233539-20171019013539-00895.warc.gz | en | 0.944157 | 293 |
The baby rubberplant (Peperomia obtusifolia) is a cheerful houseplant with thick, rounded leaves. It’s easy to care for at home, as long as you meet its needs. One of these needs is a soil mix that holds some moisture yet allows excess water to escape. Read on to learn more about how to select the best soil mix for your Peperomia Obtusifolia (Baby Rubberplant).
- The Best Soil Mix for Peperomia Obtusifolia – The Essentials
- Why Soil Choice Matters
- What Are the Primary Components Used in a Potting Mix?
- Common Signs You’re Using the Wrong Soil Mix for Peperomia obtusifolia
- The Importance of Well-Draining Potting Soil for Peperomia obtusifolia
- What Soil pH Levels Are Best for Peperomia obtusifolia?
- The Ultimate Peperomia obtusifolia Plant Potting Mix Home Recipe
- The Best Pre-Mixed Soils for Peperomia obtusifolia
- Soil Mix for Peperomia Obtusifolia FAQs
- Wrapping Up
The Best Soil Mix for Peperomia Obtusifolia – The Essentials
Baby rubberplants prefer a loose, well-draining soil mix with moderate water-holding capacities. The soil should have a pH between 5.5 and 7.0. A mix made from two parts peats moss, one part perlite, and one part compost will work well for baby rubberplants.
Why Soil Choice Matters
While you may think all soil is the same, this isn’t the case. Both naturally-occurring soils and manmade potting soils vary in terms of physical, chemical, and biological composition.
All types of soil provide numerous benefits to plants. However, plants may not experience these benefits if they’re planting in the wrong type of soil.
The right soil:
- Provides a place for plants to anchor.
- Allows for gas exchange.
- Holds moisture for plants to take up.
- Retains nutrients until plants need them.
- Provides a habitat for beneficial microorganisms.
Naturally occurring soil is classified based on its physical composition. Soil is composed of three inorganic particles (sand, silt, and clay) as well as organic matter.
Sandy soils are well-draining, but they don’t hold much water or nutrients.
Loamy soils are composed of relatively equal amounts of sand, silt, and clay. Therefore, they have a good balance of moisture retention and drainage.
Clay soils are composed of small particles that easily pack together. They hold water and nutrients well, but they often drain poorly.
Soils rich in organic matter have a mixture of water holding and drainage. They are also often rich in nutrients.
What Are the Primary Components Used in a Potting Mix?
Most potting mixes aren’t made from soil removed from the outdoors. Instead, they’re composed of various organic and inorganic materials. The following materials are often used in potting mixes.
- Compost is decomposed organic matter. It can add some nutrients to a potting mix, but it mainly increases nutrient-holding and water-holding. It can also add a boost of beneficial microorganisms.
- Sphagnum peat moss is a slightly acidic natural material that is formed when vegetation decomposes under wet and anaerobic conditions. It increases nutrient holding and water holding capacities.
- Coco Coir is made from coconut husk. It is often used as an alternative to peat moss.
- Vermiculite is a type of expanded rock that helps with moisture retention as well as drainage.
- Pine bark fines are small pieces of pine bark that help hold moisture while also increasing drainage.
- Pumice is a type of volcanic rock with many small pockets. It increases drainage and aeration.
- Perlite is an expanded rock that resembles small pieces of styrofoam. It helps increase aeration and drainage.
- Sand is the largest naturally occurring soil particle. It improves aeration and drainage.
- Soil activators contain beneficial microorganisms that help transform nutrients into forms that plants can take up.
- Rocks and Pebbles increase drainage.
Common Signs You’re Using the Wrong Soil Mix for Peperomia obtusifolia
Using the wrong soil can negatively affect your baby rubber plant in multiple ways.
The biggest concern with baby rubber plant soil is that it doesn’t drain well enough. If your soil is too high in clay or organic matter, excess water will have trouble draining. Therefore, your plant’s roots will end up sitting in moist soil.
Over time, this can lead to a fungal condition known as root rot. As plant roots become slimy and rotted, they are unable to properly take up water and nutrients. This can lead to wilted and/or discolored plants.
Another thing to look out for with Peperomia obtusifolia soil is compaction. Compaction is more common if your mix is low in larger particles such as sand, perlite, and pine bark fines.
If soil is compacted, plants will be unable to exchange gasses and transport water and nutrients. This can result in stunted and discolored plants.
If soil contains too much sand and/or perlite, it will not be able to hold much water. Therefore, plants may become wilted.
The Importance of Well-Draining Potting Soil for Peperomia obtusifolia
Thanks to their thick, fleshy leaves, baby rubber plants can retain a good amount of moisture. This means they can withstand a few days of dry soil. However, they can not tolerate consistently moist soil.
If soils don’t drain excess water, plant roots can drown or rot. Both of these will cause issues with water and nutrient uptake.
Well-draining soils will allow excess water to escape. Larger particles such as sand and perlite increase drainage.
You should also make sure to use a pot with drainage holes.
What Soil pH Levels Are Best for Peperomia obtusifolia?
Most types of peperomia plants prefer neutral or slightly acidic soil. Look for a soil mix with a pH between 5.5 and 7.0.
The Ultimate Peperomia obtusifolia Plant Potting Mix Home Recipe
A great baby rubber plant potting mix will hold moisture for a few days but allow excess water to escape. It should also hold nutrients while also allowing for good aeration and gas exchange.
To create a great soil mix for baby rubber plants, thoroughly combine the following:
- two parts peat moss or coco coir
- one part perlite
- one part compost
The peat moss/coco coir will retain water and nutrients while providing air pockets. The perlite will increase drainage and aeration. The compost will provide nutrients and will also increase water and nutrient retention.
Make sure to thoroughly combine the components before adding the mix to a pot.
The Best Pre-Mixed Soils for Peperomia obtusifolia
If you’re looking to buy premixed potting soil rather than making your own, you’re in luck. The following products will work well for baby rubber plants.
(Editors Note: Petal Republic participates in partnership programs with Amazon and other merchants to help connect readers with relevant products and services we may recommend).
Soil Mix for Peperomia Obtusifolia FAQs
How Often Should I Switch Soil for My Peperomia obtusifolia?
You’ll only need to change potting soil when you repot your Peperomia obtusifolia plant. Since these plants like being a bit rootbound, you’ll only need to repot every three to five years.
If you see signs of root rot or soil-borne disease, you should switch your soil immediately.
Can I Use Cactus Soil for Peperomia obtusifolia?
While cactus soil may be okay for baby rubber plants, it isn’t ideal. If you want to use cactus soil, mix one-part soil with one part peat moss or coco coir.
Does Peperomia obtusifolia Like Wet or Dry Soil?
Peperomia obtusifolia doesn’t like wet or dry soils. Rather, they prefer slightly moist soil. A good practice is to water your plants when the top inch of soil is dry.
What are the Primary Considerations for Soil When Repotting Peperomia obtusifolia?
When you repot your baby rubber plant, you’ll want to swap out the old soil for new soil. Make sure to choose a well-draining potting mix and avoid compacting the soil.
Does the Size of the Plant Affect the Soil Mix for Peperomia obtusifolia?
No, the size of your plant does not affect the soil mix. All sizes of plants prefer similar potting soils.
Does the Potting Container Influence the Type of Soil Mix for Peperomia obtusifolia?
A pot’s size and the material do not impact the type of soil you should choose. However, soil in terra cotta pots might dry out quicker than soil in ceramic or plastic pots.
Does Peperomia obtusifolia Need Deep Potting Containers?
No, Peperomia obtusifolia does not require deep containers. Their short roots are happy in medium to shallow pots.
Now that you know about the proper soil mix for the Peperomia obtusifolia plant, you can give your plant a good place to root. Remember to choose a well-draining and well-aerated mix that holds a bit of water.
For more, see our guide to the best plant shops shipping Peperomia obtusifolia plants nationwide throughout the United States.
Briana holds a B.S. in Plant Sciences from Penn State University. She manages a small market garden where she grows vegetables and herbs. She also enjoys growing flowers and houseplants at home. | <urn:uuid:6d8bbdc6-8537-4dc3-b132-577e3b7ba692> | CC-MAIN-2023-23 | https://www.petalrepublic.com/best-soil-mix-for-peperomia-obtusifolia/ | 2023-06-05T00:56:37Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-23/segments/1685224650409.64/warc/CC-MAIN-20230604225057-20230605015057-00324.warc.gz | en | 0.891961 | 2,213 |
More handmade accessories from Los Angeles’ Rogue Territory. Founder Karl Thoennessen cooked these hankerchiefs up just last week, using chambray from Kaihara Mills, denim from Nihon Menpu Mills, and hickory denim from Kaihara Mills respectively. Each has a woven Rogue Territory Loop label. Whip your sweat away in style.
A look at all three handkerchiefs after the jump. | <urn:uuid:9852dc33-31ad-4477-aa9d-b6fb6c0c1fd5> | CC-MAIN-2014-15 | http://www.selectism.com/2011/04/18/rogue-territory-handkerchiefs/ | 2014-04-16T10:24:11Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-15/segments/1397609523265.25/warc/CC-MAIN-20140416005203-00575-ip-10-147-4-33.ec2.internal.warc.gz | en | 0.855866 | 91 |
This gorgeous home is the Albi built Napoli 4 model. Located in Cranston's Riverstone on a quiet street just a few short steps from Dragonfly Park. As you enter you will notice the beautiful wide plank engineered hardwood, secluded den/office, open concept living, kitchen & dining area. The gourmet kitchen boasts full height white cabinets, SS appliances w/ built in oven & microwave, gas countertop stove & hood fan. The nook/dining area looks out onto the backyard w/ access so you can keep an eye on the kids. The living room is perfectly designed w/ centre gas fireplace to keep you warm on winter nights. Walkthrough pantry leading to the mudroom & double attached garage. Upstairs you have 3 bedrooms including the master w/ tray ceiling, spacious walk-in closet w/ custom built ins, stunning 5pce ensuite featuring dual vanities, soaker tub & steam shower. Laundry room, bonus room & 4pce bathroom round out the upper level. Fully developed basement w/ rec room room, living room, 4th bedroom & 4pce bathroom.
Elke Babiuk, 403-998-2735 at CIR Realty, #130, 703 64th Avenue SE, Calgary, Alberta, T2H 2C3 | <urn:uuid:6fdafb75-1f03-44d9-af4d-d41d60bb2769> | CC-MAIN-2019-30 | http://www.sellingcalgary.pro/listing/calgary/cranston/c4256220-19-cranbrook-cr-se?search_id=5b95525e337383e96076fecaa910d9f0 | 2019-07-22T04:01:21Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-30/segments/1563195527474.85/warc/CC-MAIN-20190722030952-20190722052952-00410.warc.gz | en | 0.901873 | 270 |
Complaint Review: Unstoppable Vision LLC
Unstoppable Vision LLC High Class Universe Dog Bank Rip-off Internet
A business' first
line of defense
on the Internet.
If your business is
willing to make a
Click here now..
December 2016, I purchased two dog banks as advertised on Facebook. They were adorable and thought they would make great Christmas gifts for my nieces. $65.97 was taken from my account 12/5/16 to complete the purchase.
I never received the items and now the website and telephone number is no longer accessible. I tried both HighClassUniverse.com and Unstoppable Vision LLC and no luck.
This report was posted on Ripoff Report on 04/30/2017 05:48 AM and is a permanent record located here: https://www.ripoffreport.com/reports/unstoppable-vision-llc/internet/unstoppable-vision-llc-high-class-universe-dog-bank-rip-off-internet-1370462. The posting time indicated is Arizona local time. Arizona does not observe daylight savings so the post time may be Mountain or Pacific depending on the time of year. Ripoff Report has an exclusive license to this report. It may not be copied without the written permission of Ripoff Report. READ: Foreign websites steal our content
If you would like to see more Rip-off Reports on this company/individual, search here: | <urn:uuid:c1d3862e-8e2d-4d7b-9263-6a39c432bbb6> | CC-MAIN-2018-09 | https://www.ripoffreport.com/reports/unstoppable-vision-llc/internet/unstoppable-vision-llc-high-class-universe-dog-bank-rip-off-internet-1370462 | 2018-02-19T08:16:58Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-09/segments/1518891812556.20/warc/CC-MAIN-20180219072328-20180219092328-00344.warc.gz | en | 0.916093 | 305 |
I must confess that I am a collector. I promise that I'm not a "stuff piled to the ceiling, can't walk through the room" kind of collector, but if you look closely, you will see a collection of some kind in just about every room. I tried to do a little research on why some people have a tendency to collect things, but it seem that no one really knows for sure. A couple of articles I saw attribute it to the "hunting and gathering" instinct. I do like to hunt and gather. I probably would have been an awesome cavewoman.
Some of my collections are spread out or partially put away, so I thought I would have little collection reunions and post them once a week until I have run out.
This is sort of an accidental collection. I didn't set out to collect tracing wheels, but whenever I see old sewing boxes, or plastic bags of thread, needles, etc. at yard sales, I grab them and sometimes they contain a tracing wheel. I haven't actually used one since high school, but I've been amazed at how many different syles there are.
Now that I have gotten them out and looked at them, I may have to think of a use for them. Got any ideas? | <urn:uuid:02add534-625d-4d16-a4fe-ea8c97dda601> | CC-MAIN-2017-30 | http://sewthatsit.blogspot.com/2007/05/confessions-of-collector.html | 2017-07-26T00:48:13Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-30/segments/1500549425737.60/warc/CC-MAIN-20170726002333-20170726022333-00372.warc.gz | en | 0.981346 | 258 |
DENIS LABORATORY — CANCER RESEARCH CENTER
B cell malignancy. Mice that constitutively express a BRD2 transgene in their B cell lineage sporadically develop lymphoma several months after birth. These B cell lymphomas are monoclonal in their patterns of immunoglobulin gene rearrangement and show elevated endogenous cyclin A transcription. Transgenic B cells overproliferate in vitro, as established by flow cytometry analysis that measures incorporation of bromodeoxyuridine and DNA content by 7-aminoactinomycin D.
Brd2 functions at least in part through a pathway that targets the gene cyclin A and affects S phase events. A brd2 knockout mouse is currently under development, in which we expect to observe defects in cell cycle progression and proliferative responses to mitogens.
Stem cell reconstitution. To test this idea in the immune system, we have reconstituted mice with hematopoietic stem cells transduced with lentiviral expression vectors for Brd2 overexpression or Brd2 knockdown and compare results to empty vector lentivirus, using expertise that Drs. Darrell Kotton and Alan Fine of the BU Pulmonary Center have generously shared with us.
We have exploited the low Hoescht 33342-staining properties of hematopoietic stem cells, which use an ABC-type transporter to efflux the Hoechst dye, to isolate these stem cells. These cells are termed “side population” cells because in flow cytometry, they are visualized off to the left side of the main population. The “side population” is transitory, not stable, and its appearance and visualization by flow cytometry is a function of the concentration of Hoechst, the time of incubation, the quality of the cells, and other important factors like temperature and pH. The side population cells, either lentivirally transduced or control, can reconstitute mice with high efficiency.
Transcriptional and proteomic profiling of lymphomas. Genome-wide transcriptional profiling of the Brd2-driven murine lymphomas identifies a signature that is most similar to human diffuse large B cell lymphoma, one of the more aggressive forms of non-Hodgkin’s lymphoma (NHL). We collaborate with Dr. Marc Lenburg of the BU Microarray Core and use this approach to identify new biomarkers for human lymphomagenesis, detection of relapse and risk assessment. In functional terms, we have exploited this technology to study resting or proliferating normal B cells and proliferating malignant B cells. We identified two major axes of gene expression: one group of genes significantly differentially expressed between resting and proliferating normal cells (a “proliferation signature”, and another group of genes differentially expressed along an orthogonal axis unrelated to normal proliferation (a “cancer signature”).
We have taken this idea and used state of the art methods in mass spectrometry and proteomics to develop proteomes and phosphoproteomes of lymphomas. We enjoy a close collaboration with Drs. Cathy Costello, Mark McComb and colleagues at the BU Mass Spectrometry Resource to perform these experiments. We derive two dimensional reference maps of B cell proliferative states, and then use MALDI and liquid chromatography-tandem mass spectrometry (LC-MS/MS) of tryptic peptides for online database identification of protein candidates. We are developing new proteomic signatures of lymphoid malignancy and establishing proteomic 2D reference maps for resting, activated and malignant B cells taken from transgenic mouse spleen. Based on these maps, we have been able to conclude that, by analogy with transcriptional profiling, a relatively simple set of protein biomarkers defines proliferating malignant B cells in mice, as distinct from proliferating normal B cells. New instrumentation, including Orbitrap spectrometers, has increased our ability to derive phosphoproteomic information about deregulated signal transduction pathways in B cell lymphomas.
We employ these methods to investigate the malignancy-specific signature of human primary tumor tissue from patients diagnosed with lymphoid malignancy in an ongoing IRB-approved clinical study. This approach greatly simplifies proteomic biomarker discovery for lymphoid malignancy. In the illustration, the total ion chromatogram (TIC) for a tryptic digest of lymphoma proteins is compared to the single ion chromatogram (SIC) at a mass-to-charge ratio of 590.7; this peak in the LC elution profile happens to contain peptides that unambiguously identify histone H4 as part of the Brd2 multiprotein complex.
Pharmaceutical development and experimental therapeutics for lymphoid cancers. We are investigating potential new therapeutic targets and anti-cancer pharmaceutical agents, specifically telomeric DNA-based oligonucleotides (T-oligo), as treatments for lymphoma. T-oligos have had major success as a novel therapeutic approach to NHL in several of our Brd2 mouse model systems, and they cooperate well with the existing therapy for human lymphomas, called CHOP. We have initiated a translational study with T-oligo, under an IRB approved protocol, with patients at Boston Medical Center who are undergoing treatment for NHL.
Check the clickable link below to find this trial:
Brd2 transcriptional control of adipogenesis and inflammation. ‘Leaky’ knockout of Brd2 in mice leads to a hypomorphic phenotype. The mice quite surprisingly develop severe obesity on regular chow, which is an extraordinary enough phenotype for a disrupted MHC II gene, but these mice also manage to avoid whole-body insulin resistance and Type 2 diabetes. This observation has potentially major significance for immunology because a cohort of obese humans who are known to avoid Type 2 diabetes also tend to show a reduced inflammatory profile, but the mechanisms that confer this protection are not well understood. It is well known that alleles in the MHC II locus are linked to Type 1 diabetes, specifically through the mobilization of autoimmune processes. Our new observations also suggest that innate and adaptive immune responses are also important for body energy balance and disposal of blood glucose through the ability of Brd2 to regulate the chromatin status of key target genes for adipogenesis, inflammation and growth. We also suspect that polymorphism of BRD2 and related genes may play an important role in human development. | <urn:uuid:98249ea9-2b6f-4ac4-b7b6-bb9a6487cadd> | CC-MAIN-2014-52 | http://www.bumc.bu.edu/leukemia-lymphoma-laboratory/current-projects/ | 2014-12-21T21:39:21Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-52/segments/1418802772416.132/warc/CC-MAIN-20141217075252-00000-ip-10-231-17-201.ec2.internal.warc.gz | en | 0.902588 | 1,357 |
Boinx Software has updated BoinxTV, a live production software for
video podcasters that turns any recent Mac into a TV studio, to
version 1.4. The upgrade is revved for Mac OS X 10.6 (“Snow Leopard”)
and also includes support for Axis network cameras and streamlines
the production workflow.
Its interface allows a single person to operate BoinxTV during the
recording session, says Boinx CEO Oliver Breidenbach. After the
starting of BoinxTV, the user can choose from the many predefined
templates, or one he previously created, making it easy to produce,
for example, a news show. In education, BoinxTV opens new horizons
for school TV whether students are recording a sport event or setting
up an interview with two cameras, Breidenbach says. In enterprise,
BoinxTV can be used by sales managers who want to address their staff
in a weekly podcast, he adds. And because it runs on a MacBook Pro it
can be used in the field as well as in a studio.
BoinxTV uses various inputs like video cameras, microphones, and
pre?recorded material like movies and sound clips. Those inputs can
be used in any number of “layers” that can be stacked on top of each
other, toggled on and off and dynamically controlled. Multiple layers
— for example a ticker tape, a station logo, lower thirds and others
— can be placed on top of a video source.
Live recording Interactive controls allow one to change aspects of
every layer — for example a movie, a title, the caption of a lower
third — on the fly while the show is being recorded. The movie can
either be encoded directly to a QuickTime movie for later
post?processing (e.g. with Apple Podcast Producer) or be played
fullscreen on a dedicated monitor.
BoinxTV ships with more than 30 layers (video switcher, RSS crawler,
lower third, interview setup, and others), and can be extended by
custom layers designed with Apple’s Quartz Composer software, which
comes free with Mac OS X. Advanced chroma keying makes BoinxTV a
valuable production solution in podcast studios with green screens
and lighting rigs, says Breidenbach.
BoinxTV is available immediately for download
(http://boinx.com/download). In demo mode, BoinxTV can be used for
five days. The single license of BoinxTV is available for US$499 at
the Boinx Kagi Store (boinx.com/kagi). The BoinxTV Sponsored Edition
for US$199 (single license) requires a credit for BoinxTV in every
video created with BoinxTV.
Version 1.4 is a free update for registered users. For education and
volume licensing (multi?seat) of BoinxTV, contact email@example.com .
BoinxTV requires a Power Mac G5 or Intel based Mac with discrete
graphics running Mac OS X 10.5 (“Leopard”). | <urn:uuid:0ccc0ac3-c554-4d5b-a5db-056b9e0b5b73> | CC-MAIN-2019-47 | https://www.mactech.com/2009/09/25/boinxtv-updated-for-snow-leopard/ | 2019-11-22T23:54:21Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-47/segments/1573496672170.93/warc/CC-MAIN-20191122222322-20191123011322-00021.warc.gz | en | 0.845617 | 660 |
You can quickly add a transparent watermark to any image using Photoshop Elements. Transparent watermarks are useful to protect images from being duplicated without permission, to credit an artist, or to include a website or company name without obstructing the image. If the purpose of your watermark is to protect it from being used without permission, especially if your intention is to sell copies of the image, a large transparent watermark can be placed in the middle of the image. If the watermark is too small, or placed on the edge of an image, it could be removed or cropped out by unscrupulous people.
Launch the Photoshop Elements Organizer and select an image from the gallery. Click the “Fix” button and select “Full Photo Edit” from the drop-down menu. The image opens in the Photoshop Essentials Editor.
Select the “Horizontal Type Tool” from the Toolbox. Select a font and font size from the Options bar. For best results in a transparent watermark, select “Bold” from the Font Style menu. Select the “Anti-Aliased” option and select White from the Text Color swatch. If the background color in the Toolbox is already white, you can quickly change the text color to white by pressing “X” on the keyboard.
Drag the Type Tool across the image where you want the watermark to appear. Photoshop Elements automatically creates a new layer for the text. Type the text you want to use as a watermark. "Photo by Your Name" for example. Press “Alt-G” if you want to add a copyright symbol to the text.
Select the “Move Tool” from the Toolbox and drag the text to move its position if desired.
Click the “Blend Mode” menu at the top of the Layers panel. By default this is set to “Normal.” Change it to “Soft Light.” Click the “Opacity” menu and drag the slider to the left to reduce the opacity to about 60 percent.
Click the “Layer” menu, select “Layer Style” and click “Style Settings.” Select “Bevel,” then drag the “Size” slider as desired. The bevel size depends on the size of the text, but in most cases a size below 10 px should work well.
Rotate the text if desired. Click the “Image” menu, select “Transform,” then click “Free Transform.” Move the cursor over a corner of the text box until it changes to a curved double-headed arrow. Drag the cursor to rotate the text. Click the “Green Check Mark” beneath the text box to accept new orientation.
Select “Save As” from the File menu. Type a new name in the text field so you do not over-write the original image.
- Hemera Technologies/AbleStock.com/Getty Images | <urn:uuid:a7867901-c792-488f-9d62-92f88dd4182f> | CC-MAIN-2019-47 | https://smallbusiness.chron.com/tutorial-transparent-watermarks-photoshop-elements-35225.html | 2019-11-15T17:56:31Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-47/segments/1573496668699.77/warc/CC-MAIN-20191115171915-20191115195915-00316.warc.gz | en | 0.838984 | 632 |
- Why TCI?
- Free Lessons
- Professional Development
The benefits that come with volunteering over the summer are far-reaching for teachers everywhere. Not only will they give you fresh perspectives on the world and various communities and cultures, but they can give you new insight into teaching techniques and methods. If you volunteer in a rural or low-income area, you’ll likely be inspired by the thirst for knowledge and the gratitude that is ingrained in the communities. If you volunteer abroad, you’re likely to experience some culture shock in a way that makes you incredibly appreciative of your home and your community and all the advantages you have in life. No matter what type of volunteer opportunity (or opportunities) you embrace this summer, be sure to make the most of your time and of every experience you have.
Check out these different types of summer volunteer opportunities for teachers and make use of the resources to find that perfect summer experience.
Teach English in a Foreign Country
This is probably the top choice for most educators when it comes to volunteer opportunities for teachers. There are countless nations across the world who love having Americans come into their schools and teach their students English. There are also so many organizations that help teachers connect with schools in need that you can simply do a Google search and find some great ways to volunteer in this way. It will help you out if you have any idea of where you want to go before you begin your search, but if you have no clue, just starting looking at some of the countries listed with these organizations and you’re sure to get some ideas. Argentina, Ecuador, Columbia, Costa Rica, China, Laos, Philippines, Uganda, Kenya, and Zambia are just a few of the many, many countries where you could spend your summer teaching. Check out Projects Abroad, IFRE Volunteers, and International Volunteer HQ for teaching abroad opportunities.
Volunteer Locally for Those in Need
Your area is sure to have some local organizations that serve the less fortunate in your community. Habitat for Humanity, Meals on Wheels, local food banks, and the like are all great places to spend some time giving back this summer. Maybe you get involved in an ongoing project, or maybe you just spend a few hours a week organizing shelves or filing papers for a local organization. Find a need in your community and do whatever you can to help improve the lives of others by volunteering in whatever way you can. Look at United Way, Create the Good, and Volunteer Match for local opportunities.
Visit the Lonely
This may seem like a small to-do, but visiting with someone who doesn’t often enjoy visitors can be huge. Find a local nursing home, go to a nearby hospital, or take a trip to your city’s homeless shelter. You may want to read to the elderly or schedule a time to perform with a musical instrument if you’re talented in that way. You might be able to enjoy an event at a nursing home or rehab center where you can connect with residents and just bring a little light to their daily lives. Hospitals are full of people without visitors who may be lonely, scared, and worried. Find out how you can serve those individuals and show them a little love this summer. Maybe you plan a game night at the homeless shelter or organize a charity drive to bring supplies to the homeless. Find people who need to feel loved and do whatever you can to meet their needs.
Go on a Mission Trip
You don’t have to be involved in a local church to go on a mission trip and make a difference. Maybe the “trip” is local and you can serve your own community. Maybe it’s to another city in the U.S. that has a big problem with homelessness or has recently suffered from a natural disaster. Maybe it’s a trip abroad to build an orphanage, dig a well, or teach adults how to read. Find something that lights a fire under you and that makes you passionate in the best ways, and go on a trip to make a difference. While local churches are probably the best place to start when looking for trips like this, many other organizations help fund and organize these trips, so be as specific as you can when searching for a trip, and then sign up and start making a difference.
Help with a Camp
Summer camps create incredible memories for kids, and they can be extremely educational and beneficial for kids of all ages. Maybe you help organize or plan a science camp at your local library, or maybe you help with the crafts at your local community center. Maybe you volunteer at a sports camp at the local high school or maybe you serve as a counselor for a sleepover camp in your community. No matter how big or small your role is, working at a camp is an incredible volunteer opportunity for teachers and it is sure to be fulfilling and significant, both for you and in the lives of those you serve over the summer.
Give Love to Animals
While most teachers are more passionate about working with humans rather than animals, there are the select few among us who are avid animal lovers. For you guys, embrace the animal-loving side of you this summer as you search for volunteer opportunities for teachers. You may want to head down to the local animal shelter and take some dogs on a walk or snuggle up with some of the cats. You might be able to get a volunteer gig at the local zoo or aquarium. If your sights are set on traveling abroad, there are so many places to work with animals while still getting in some fun and adventuresome travel this summer. Work on an elephant conservation project in Sri Lanka, help save sea turtles in Costa Rica, volunteer with monkeys and primates in Thailand or Guatemala, rehabilitate lions in South Africa, or save the whales in Madagascar. | <urn:uuid:62d74932-27db-4542-9768-6479aa609ad6> | CC-MAIN-2023-06 | https://www.teachtci.com/blog/6-types-of-summer-volunteer-opportunities-for-teachers/ | 2023-02-04T12:15:55Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764500126.0/warc/CC-MAIN-20230204110651-20230204140651-00507.warc.gz | en | 0.953241 | 1,189 |
Dresses (similar here) // Wheeler’s Shoes // Effie’s Shoes // Boys’ Shirts // Boys’ Shorts // Bookbag
Well, the kiddos went back to school yesterday! I knew they’d be alright. They’ve honestly been excited for school to start back as soon as they got out for the summer. If that doesn’t say enough about the school they’re attending, I don’t know what does!
Wish I could’ve captured Wheeler’s excitement on Sunday night when she was going to bed. I swear she has the same emotions on Christmas Eve. Looking back, I should have recorded it. For those years on down the line, when she’s not as excited, I’d have proof that she used to love the first day. Her love of school and learning is admirable! I wish I’d been as excited about it as she has, when I was growing up. My hope and prayer for her is that it continues this year too. I know there will be years when she’ll probably have to deal with bullies, thankfully only a little so far, but she has the kindest, sweetest soul and I hate when I see her heart hurting, for any reason at all. She may seem quiet to some, but that’s how her little personality has always been since she was a baby. Quiet and reserved at first, taking it all in, but as soon as she warms up to you, she’ll be talking your ear off in no time. I know there will be a time when she’d rather do activities and have hang-outs with her friends, but for now, she still wants to spend most of her time with us, her family. Love that she still thinks I’m “cool” in her world and wants to spend time with me.
On Effie, she is the most helpful human being. I don’t know where she gets it from, but I don’t care what you’re doing, she’s going to ask you if you need help. Even when she’s enjoying her favorite activity, whatever it is at the time, she’ll drop everything if you need her to help you. I try not to take advantage of her eagerness to help too often, but I will say when I’m in a bind and trying to do too many things at once, I always know who to ask. Love that about her, among so many other things. Friends her age and younger children have always gravitated towards her. She has this sense of comfort there and the undivided attention she gives them, I’m talking even toddlers, warms my heart so much. And she does it so naturally, without hesitation. She’s both perceptive and intuitive, always paying attention to her surroundings. I pray she continues to know her foundation as she gets older and makes the right decisions.
My sweet, happy Logan. Talk about loving school. He practically jumped into the classroom to say hey to all of his friends yesterday. His teacher from last year will tell you that every single day he’d walk into their classroom and greet them with the biggest smile saying, “Good Morning, Mrs. <Teacher>” “Good Morning, Mrs. <Assistant Teacher>! They said it didn’t matter the day or what mood they were in, that that greeting always made their morning. I didn’t even know he did it until maybe two months after school started last year. I hope he keeps it up this year! As a former first grade teacher, I would’ve loved for one of my students to do that too. For as much as Logan loves playing with his friends and will be 7 in September, he’ll still take a small car, dinosaur, LEGO character, you name it, and play by himself for the longest time. His imagination is like no other. He’s very detail-oriented and can create the coolest LEGO ships, buildings, etc. While he always tells everyone he wants to be a Professional LEGO Builder when he grows up, I can definitely see him as an engineer.
He’s also never met a stranger. Since he’s always had to sit near the window because of a weak stomach, it’s been the best thing. I don’t care where we are, even the drive-thru window, he’ll ask to roll his window down too, so he can say hey and talk to them…ask them their name and introduce himself. Then of course the others will want to chime in with their names, ages, favorite colors…I swear they think they’re the modern day Von Trapp Family, but I love it! And yes, The Sound of Music is one of their favorite movies. Needless to say, whatever hurry I may have been in, for “fast” food, quickly reminds me to slow down when I’m with them. Why rush through life, right?
Vaughn. My Baby. Still cannot believe he’s in Kindergarten this year! I still see him with his little diaper, sucking his thumb, holding his lovie that he calls “Puppy Dog.” True story. It was actually Logan’s, has Logan’s name on it and everything, but Logan gave it to Vaughn when he was a baby and Vaughn has never given it up since. Logan’s never asked for it back either which I think is even sweeter. I kept thinking when Logan was finally old enough to recognize his own name, that he’d ask for it back. While Wheeler and Vaughn both have one special “friend” that they’ve always slept with, Effie and Logan have a plethora of “friends” they switch out each night. And at 10, Wheeler STILL sleeps with her stuffed animal friend “Baba.”
I get asked a lot if Vaughn is as sweet in person as he appears in photos. And the answer is yes. He has the calmest demeanor <MOST> of the time, but he can also get wound up and loves to make people laugh. Actually, he loves when you make him laugh too – whether it’s trying to chase him or tickle him. He’s a little jokester at times, and we’ve always said he reminds us of my dad. Not sure if that’s a good thing. Haha. He still lets me snuggle and cuddle him whenever I want, and I hope that never changes. He’ll always be my baby.
If your child is just starting school, you MUST do this for them, if possible! I’ve been doing it since mine were in preschool and haven’t missed a year…yet! At the end of each school year, have your child’s teacher secretly write a note to your child in Oh, The Places You’ll Go or whatever book you find special. Make sure they don’t sign it in front of your children, as this will be your gift to them at graduation! Makes me well up just thinking about the notes my children’s teachers have already written!
On a random note, this just came up in my inbox, but if you’re a fan of Johnnie-O polo shirts for your boys, consider ordering their Mystery Box. They’re cleaning out their inventory and offering boxes where you’ll receive four items from past seasons all for only $99! It could be anything from polos, to pullovers, vests to tees. You never know what you’ll get! If you’re wondering what size to order, I’d suggest going a size up. It’ll give you room in case it shrinks and more time for them to wear it, before they grow out of it.
How cute is this little wrap skirt? For fit, it runs a little big, but you can cinch in the waist to how you like it. Paired it with my go-tee tee that I’ve had for years and goes with everything! And it’s only $19.50 and comes in lots of different colors. How cute are these sandals too? For fit, I’m an 8.5 and wear a 9 in them.
Happy Tuesday, Y’all!
4 thoughts on “Back to School + Getting Sentimental”
I absolutely love the idea of having teachers sign a book! Thank you for the idea!
Ok so that is THE best idea with the book, how sweet! I need to start this with Sully this year here in London. -Erin, Attention to Darling Blog
Yes! Start it there! Will be so cool!
Comments are closed. | <urn:uuid:76a789dc-d1dd-44a9-b104-61c377b9d2a4> | CC-MAIN-2023-23 | https://sweetsouthernprep.com/back-to-school-getting-sentimental/ | 2023-06-03T04:20:08Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-23/segments/1685224649105.40/warc/CC-MAIN-20230603032950-20230603062950-00368.warc.gz | en | 0.976586 | 1,887 |
“The eye sees the world, sees what inadequacies keep the world from being a painting, sees what keeps a painting from being itself, sees- on the palette- the colours awaited by the painting that answers to all these inadequacies just as it sees the paintings of others as other answers to other inadequacies.”- Maurice Merleau-Ponty
Art in any form – painting, writing, music – CREATION in any form is the most honest act of self expression. To create is to be naked; to evoke raw, unabridged emotion. To create is to cultivate and nourish human connection. To create is to trust.
In a paint-by-numbers world, where the lines are already drawn in black, to create is to allow splashes of hope, of emotion, of LIFE to reclaim the canvas.
This blog is my outlet. It is my response to arbitrary boundaries and preconceived reality. It is my perception of life and love and pain and magic. It is my answer to all of the world’s inadequacies. It is my typewriter and my ivory keys. It is my palette.
The world might spin in shades of grey, but in my mind I escape into colour. | <urn:uuid:c5eb0336-9677-46ce-9ced-65e327a479ef> | CC-MAIN-2018-09 | https://colourunabridged.wordpress.com/about/ | 2018-02-20T03:43:40Z | s3://commoncrawl/crawl-data/CC-MAIN-2018-09/segments/1518891812873.22/warc/CC-MAIN-20180220030745-20180220050745-00548.warc.gz | en | 0.945916 | 254 |
Streets takes care of a range of specialist services, including forensic accounting and litigation support.
Our specialist services include:
- Enhanced client service
- Forensic accounting and litigation support
- Independent financial advice
- International accountancy and taxation
- Private clients
- Registered office
- Remuneration Planning
If you are interested in any of these services or have a related query please contact us using the form below. | <urn:uuid:6e51c27e-c41d-4543-8bb6-aadffb0d98d0> | CC-MAIN-2021-43 | https://www.streetsweb.co.uk/accounting-services/specialist-services/ | 2021-10-24T22:58:23Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-43/segments/1634323587606.8/warc/CC-MAIN-20211024204628-20211024234628-00264.warc.gz | en | 0.926606 | 85 |
Axl Hates Slash
Axl Rose, lead singer of Gun n Roses really is an idiot! Axl Rose has just issued his most insane lawsuit yet, suing “Guitar Hero” makers Activision for $20 million for featuring Guns N’ Roses’ “Welcome to the Jungle” in “Guitar Hero III: Legends of Rock.”
Axl initially signed off on “Jungle” being used in the game, but on one condition: Do NOT put any music by Slash’s band Velvet Revolver in the game. Well, not only did “Guitar Hero III” offer a bunch of Velvet Revolver songs, they made Slash the game’s spokesperson, featured him on the games cover and made him a playable avatar. Now Axl is upset and here comes a $20 million lawsuit. Question this is three years AFTER the game has come out and been on the shelf. Do you think Axl went Christmas shopping, walked into the local electronics store and saw Guitar Hero with Slash on the cover and got perturbed?? Yep thats what I think!! | <urn:uuid:43e540a2-ac77-4c2c-b69e-96f6e4ba4d19> | CC-MAIN-2015-11 | http://q103albany.com/axl-hates-slash/ | 2015-03-05T20:15:10Z | s3://commoncrawl/crawl-data/CC-MAIN-2015-11/segments/1424936464840.47/warc/CC-MAIN-20150226074104-00239-ip-10-28-5-156.ec2.internal.warc.gz | en | 0.972378 | 234 |
So, today I’m beginning a new series called Friday Favourites (in short Friday Faves). Rather than let so many inspiration photos sit in-waiting on my many pin-boards, I’m going to share them here with you each Friday.
- I love the combination of blue, orange and gold for a room, but when I saw this photo I instantly wanted it for my wardrobe!
- Sugar Paper Los Angeles makes me found of pretty stationary. With Valentines Day coming up, I revisited their site and viola… pink, gold & stripes – fabulous!
- Some how this week I landed on Modern Luxury Magazine and this dining room grabbed my attention. It’s not my taste but there’s something organic about it that had me stop and stare.
- I’ve been completely smitten by Manifesto. A limited edition t-shirt line owned and developed my Meg Biram. The concept behind it, brilliant. Making it happen, inspiring.
- I love Rue Magazine, so I needless to say I was thrilled to hear about their new blog site this week: Rue Daily. Have you checked it out yet? | <urn:uuid:836af39b-79d5-4cfd-b2f6-0731145f2753> | CC-MAIN-2016-22 | http://www.desiretodecorate.com/2013/02/friday-favourites.html | 2016-05-27T12:12:46Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-22/segments/1464049276759.73/warc/CC-MAIN-20160524002116-00126-ip-10-185-217-139.ec2.internal.warc.gz | en | 0.943424 | 244 |
CBNNews.com - TEL AVIV, Israel - The Tel Aviv Municipality and the Israel Taxi Drivers Association are approving plans that will make taxi driving more environmentally friendly, which they claim will benefit both taxi drivers and Tel Aviv residents. The plan involves converting 5,000 taxis in the Tel Aviv Municipality to hybrid vehicles within the next few years.
Hybrid vehicles emit fewer pollutants because of a combination gasoline-electric motor. Of the two hybrid models available in Israel, the Honda Civic and the Toyota Prius, the Prius is the only one currently used by taxi drivers.
The plans stem from recent government legislation on transportation that allows local leaders to create and implement pollution-reduction strategies for transportation. The current plan will allow for perks, including lower toll rates and new parking spaces for drivers who opt for hybrids.
Moshe Belsenheim, Tel Aviv Municipality's environmental authority, recently said that the drivers will need no persuasion to switch.
"They had already checked and come to the conclusion that the switch to hybrids is in their own best interests, both economically and environmentally," Belsenheim said.
The only ones not mentioned are the customers, who may be paying for these upgrades. The switch will be relatively easy and inexpensive for taxi drivers because they don't pay sales tax on vehicles, allowing them significant discounts.
The only foreseeable problem with the plan is the current low sales tax on hybrids. If all drivers switched to hybrid models at once, the hybrid market could crash. The proposed solution is for the government to create 'green taxes' that will also charge according to a vehicle's estimated pollutants.
Source: YNet News | <urn:uuid:932ac35a-fc84-46c0-bcbc-c8693fcb8fda> | CC-MAIN-2014-10 | http://www.cbn.com/cbnnews/insideisrael/2008/May/Driving-Green-for-Tel-Aviv-/ | 2014-03-10T14:48:37Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-10/segments/1394010845496/warc/CC-MAIN-20140305091405-00052-ip-10-183-142-35.ec2.internal.warc.gz | en | 0.943934 | 336 |
Whitney Houston: Watch her earliest TV appearances [Video]
Whitney Houston, who was found dead at age 48 on Saturday in a hotel room at the Beverly Hilton Hotel, was known the world over for her singing career and a handful of notable film performances, including the 1992 film "The Bodyguard."
Houston made her TV debut, however, on April 29, 1983, on "The Merv Griffin Show." The 19-year-old singer had just signed a recording deal with Clive Davis and Arista Records and performed the song "Home" from the "Wizard of Oz" musical "The Wiz."
After her performance, Davis and Griffin both embraced her.
But that performance did not launch Houston into superstardom immediately.
Though her starring role in the "The Bodyguard" was touted as her acting debut, the future pop superstar actually made her acting debut in a 1984 episode of the Nell Carter sitcom "Gimme a Break!"
Just two months before her first hit single, "Hold Me," recorded with Teddy Pendergrass, was released, she appeared as Rita, the friend of the sitcom family's airheaded oldest daughter, Katie (Kari Michaelsen) in the episode "Katie's College."
The plot of the episode revolved around Katie's decision not to go to college and to open a boutique with her friend Rita. Ultimately, Katie didn't attend college and opened her boutique, but Houston's role was limited to this one episode, which aired March 15, 1984. On May 25, her duet single with Pendergrass would be released and become a top 5 hit on the U.S. R&B chart.
The following year, her debut album, "Whitney Houston," was released and her singing career took off and left supprting roles on sitcoms behind. (She did, however, make an appearance as herself on a 1985 episode of "Silver Spoons.")
-- Patrick Kevin Day
Photo: Whitney Houston performing at the 2011 pre-Grammy gala at the Beverly Hilton. Credit: Mark Ralston / AFP / Getty Images | <urn:uuid:d7fec5ee-015d-4fb2-b6ac-8e7e65ccc092> | CC-MAIN-2019-22 | https://latimesblogs.latimes.com/showtracker/2012/02/whitney-houston-dead-her-earliest-tv-appearances-video.html | 2019-05-27T12:42:18Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-22/segments/1558232262369.94/warc/CC-MAIN-20190527105804-20190527131804-00254.warc.gz | en | 0.982999 | 433 |
THIS WEEK’S FEATURED ITEMS – search all
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Virtual/Face Time in-store appointments with an expert salesperson.
In-store consultation for essential needs by appointment.
Contactless curbside pickup!
Our Expert Install team is available to help with your DIY project
Read a letter from our President, Scott Erlbaum | <urn:uuid:fc93f0ae-0cdf-43c2-b56d-061e24e686d1> | CC-MAIN-2021-39 | https://floorsusa.com/ | 2021-09-21T22:21:28Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-39/segments/1631780057274.97/warc/CC-MAIN-20210921221605-20210922011605-00160.warc.gz | en | 0.875664 | 80 |
I don’t know why we didn’t think of this recipe. Mark Bittman gets the credit. Although, you could really serve almost anything over toast, top it with a poached egg, and have a winning recipe on your hands.
This is a delicious, easy weeknight dinner for shrimp lovers. Our food friend Megan turned us on to this Mark Bittman recipe, and threw in a Bittman recipe book so we could make it ourselves. Love that Megan (and Mark). | <urn:uuid:342cfeba-95fc-4020-bd71-1be506abcc6b> | CC-MAIN-2017-43 | https://seattlefoodshed.wordpress.com/tag/toast/ | 2017-10-19T00:06:50Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-43/segments/1508187823168.74/warc/CC-MAIN-20171018233539-20171019013539-00276.warc.gz | en | 0.963264 | 105 |
Our business will be changing its name and ownership, therefore TOTAL BETTY gift cards must be used by 12/9/23. Thank you for understanding! FREE shipping on orders over $75 // Curbside and order pick-up available.
clothing. accessories. gifts. local goods.
V-neck speckled knit sweater.
Model is wearing size 1XL.Material: 43% Recycled Polyester / 37% Polyester / 20% Acrylic.Care: Hand wash cold. | <urn:uuid:3468d2f7-b731-4dee-93ca-64150088895e> | CC-MAIN-2023-50 | https://www.totalbettyco.com/products/untitled-aug30_14-49 | 2023-11-29T18:21:13Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-50/segments/1700679100135.11/warc/CC-MAIN-20231129173017-20231129203017-00408.warc.gz | en | 0.846225 | 104 |
Concierge Waikiki is the preferred service provider of the Diamond Head Beach Hotel, DHBH Suites and Waikiki Grand Suites. Our goal is to provide both a superior customer experience and ensure our clients have access to every service they need while visiting the island.
Our friendly staff will do their best ensure your stay is as relaxing as possible for you, whether we are out shopping to stock your fridge, assisting in your restaurant selection or booking your transportation needs including Black Car Services with professional local drivers.
Our number one request is “Where is the best Luau?” and we have several great recommendations for you both in Waikiki and surrounding areas, just ask and we’ll ensure to match you with the right one for your party, we strongly advise you to book a luau early during your stay to confirm availability, after all, it really is the best way to truly experience Hawaii’s Aloha culture and of course our superb traditional island dishes.
Whether here as an individual for business or traveling with your entire family for a wedding. Please use our Contact Page to let us know how we may best serve you. Our charges may be billed direct to your room or we can bill your pre-authorized credit card for all supplemental services. | <urn:uuid:1fb3e1e3-b25c-4381-9da3-372a5baf0fb3> | CC-MAIN-2019-47 | https://conciergewaikiki.com/ | 2019-11-13T14:27:32Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-47/segments/1573496667262.54/warc/CC-MAIN-20191113140725-20191113164725-00260.warc.gz | en | 0.949892 | 263 |
In 2017 new developments, new leaders and new threats promise to tug the reins of global health organizations and send us off in unexpected directions. In fact, we’re already feeling the road change beneath us.
This year, IntraHealth International’s annual list of global health issues to watch is filled with abundant uncertainty, and cautious hope for progress. These aren’t the only issues on our minds, of course – global migration, the refugee crisis and climate change happening now, for example, will likely affect global health for decades or even centuries to come.
Here are some of the big developments we’ll be watching and responding to in 2017:
7. Superbug: Drug-resistant bacteria are here
Last summer, a Nevada woman went to the hospital with a bacterial infection. She’d picked it up during a visit to India, where she had broken her thigh and was in and out of care. In Nevada, the hospital gave her antibiotics – it didn’t stop the infection. The doctors tried another kind of antibiotics. That didn’t work either.
In the end, researchers found that the bacteria attacking the woman couldn’t be stopped by any of the 26 antibiotics available today. The U.S. Centers for Disease Control and Prevention refers to the woman’s infection as carbapenem-resistant Enterobacteriaceae – another name for it is a superbug.
The threat of bacteria that are immune to our entire arsenal of medicines has been looming for years, and it is now a reality – superbugs kill some 700,000 people per year. At the U.N. General Assembly last September, world leaders agreed on some steps to stop superbugs from spreading. In 2017, they’ll have a chance to put their commitments into action.
6. Dangerous complacency around HIV.
If progress and fatigue had a baby, its name would be complacency.
Great strides in HIV treatment and management over the past decade, along with successes in reducing the stigma against people who live with the virus, have had some troubling side effects. In some areas, such as northern Namibia (where HIV rates among women in particular reach almost 31 percent), many have come to think of HIV as a normal part of life, a manageable issue like any other chronic condition. The results can include a loss of caution and more new infections.
“The truth is we have every tool we need to prevent the spread of HIV,” Charlize Theron said at the 2016 International AIDS Conference last July. “Every tool we need. Condoms. PrEP. PEP. ART. Awareness. Education. And yet 2.1 million people, 150,000 of them children, were infected with HIV last year.”
While UNAIDS and other major organizations have vowed to end the AIDS epidemic by 2030, we’re now at a crucial point from which it will be all too easy to backslide, including in the United States. We hope to see progress, urgency and continued global investments in 2017 as countries work toward their HIV-related targets and build the health workforces they need to achieve them. But some fear we may see stagnation instead.
5. Reproductive health care on the precipice
Abortions and teen birth rates in the U.S. are now at the lowest rates ever recorded. Two big reasons, according to the Pew Research Center: education and highly effective methods of contraception. According to the Copenhagen Consensus, making access to sexual and reproductive health services universal is one of the best, most cost-effective ways to achieve the global Sustainable Development Goals. By investing $25 per year, the consensus reports, we could see returns of up to $150 for every dollar invested.
But between 2000 and 2014, while most of the world was reducing its maternal mortality rates, pregnancy-related deaths in the U.S. went up. In Texas, for instance, where politicians have slashed funding for reproductive health care clinics, the number of maternal deaths doubled between 2010 and 2014.
Reproductive health and rights – both domestically and globally – could come under further attack in 2017 as new lawmakers arrive in Washington, D.C., and new international aid agendas are set.
4. Zika settles in
It’s been almost a year since the World Health Organization declared a state of emergency around the Zika virus. Less than 10 months later, the same organization startled public health experts by declaring the emergency over – not because Zika is no longer a threat, WHO officials said, but because the virus isn’t going away.
We know now that Zika will be an ongoing menace much like malaria and yellow fever, and that health workers will be fighting it for the foreseeable future. Two big differences that could affect U.S. action on Zika, though: the virus is a tangible threat to U.S. citizens, and there is no vaccine – yet.
3. A race for new vaccines and the struggle to uphold the ones we have
This year will see scientists hard at work on the vaccines for Zika and Ebola viruses. Already in 2017 a group of prominent donors announced that it had raised almost $500 million to develop and stockpile vaccines for new and known viral threats.
But in the U.S., some of the older vaccines we rely upon are facing challenges, too.
A researcher in Texas said the state is on the verge of a massive outbreak of measles. Seven cases cropped up in Los Angeles County last month. In Washington state, a mumps outbreak is making its way through public schools. Both measles and mumps are easily prevented with vaccines.
2. Strikes, shortages and other labor woes in the health workforce
Staff in most of Haiti’s 19 public hospitals have been on strike since Dec. 12. Jamaica is in the midst of a health care crisis as specialized nurses leave the country en masse for jobs in North America and Europe. And in Kenya, a massive strike among doctors demanding better working conditions has left millions of people without access to health care.
The global shortage of health workers is getting worse. And in many countries, it’s leaving doctors, nurses, midwives and others to burn out in bad working conditions – or leave their countries altogether – while their communities suffer under lower-quality care.
Organizations are working to change this, but it will take time, investment, and a new generation of aid.
1. The uncertain future of global health and international aid
This year the World Health Organization will elect a new director-general, who’ll be charged with moving past the WHO’s widely criticized reaction to West Africa’s Ebola outbreak two years ago and guiding a global organization that’s low on budget and high on bureaucracy. But of course, the new WHO appointment is not the only one that will shape global health this year.
No one knows yet how the incoming administration will carry on the United States’ traditional commitments to global health aid. We contribute more than any other country (though it adds up to less than 1 percent of our overall national budget), part out of do-goodery and part out of enlightened self-interest.
The U.S. government and public have long valued our investments in the future of global health, cooperation and prosperity. But changes in leadership and the rise in nationalism around the world could hurt global aid to those in need.
What other global health issues are you tracking this year? | <urn:uuid:153194fa-2636-49a2-b5af-05407e988b12> | CC-MAIN-2017-39 | http://www.humanosphere.org/global-health/2017/01/7-global-health-issues-to-watch-in-2017/ | 2017-09-21T03:16:49Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-39/segments/1505818687606.9/warc/CC-MAIN-20170921025857-20170921045857-00219.warc.gz | en | 0.949458 | 1,536 |
Anthony Mundine will continue his stance against the Australian national anthem when he fights Danny Green in Adelaide on Friday.
The indigenous boxer told the Daily Telegraph he will not stand when Advance Australia Fair is played at Adelaide Oval, leaving organisers scrambling to avoid a controversy.
"It's a racist anthem and doesn't represent our people," Mundine said. "It's disrespectful to our people. And this is close to my heart."
Mundine also said indigenous singer Jessica Mauboy had only been selected to sing the anthem "because she is black".
Stellar Magazine editor-in-chief Sarrah Le Marquand slammed the former world titlist for calling Mauboy's talent into question.
"That is highly insulting to her," Marquand told Today. "She has proven her worth over 10 years in the spotlight. She does a beautiful spot. I think she is in a very difficult position now."
Mundine made it clear in the interview he was responding to a question from a journalist and not seeking to be controversial, but his comments have been criticised as a stunt to generate interest in the fight.
"First and foremost I want to focus on the fight," Mundine said. "I'm not trying to divide people or be controversial but you've asked the question and I'm answering it honestly to tell people where I stand. We're not young and free.
"My people are still being oppressed. Nothing's changed ... the anthem isn't right. It's not for all of Australia. I just can't stand up for something I don't believe in."
Speaking on Sunrise, social commentator Prue MacSween said Mundine's argument didn't stack up. "Anthony always does a PR stunt for his fights," MacSween said. "He has a lot of form in that way ...
"He says that they are not free and that there is no opportunity for aboriginal people. We throw billions of dollars at the aboriginal industry. If the money is not filtering through, I think you need to take the argument up with the indigenous administrations that are not funnelling that money through.
"When you compare (Mundine) with the graciousness and dignity of Roger Federer, and his performance last night, you think, 'Anthony, you have so much to learn'. A lot of people will hope that Anthony cannot stand after the fight."
Politician Pauline Hanson was similarly dismissive. "Who cares what Anthony Mundine is saying?" Hanson told Sunrise.
"That is his opinion, but the fact is, we have teachers in schools who are telling kids, children, you don't have to stand for the national anthem. They're saying if you find it offensive, don't stand and leave the classroom.
"We are saying this in our classrooms. Why should we worry about what Anthony Mundine is saying? I am more concerned about what the kids are being taught in our classrooms."
Mundine's stance is not new. He called for all players participating in last year's AFL and NRL grand finals to boycott the anthem and was reportedly spotted sitting during the pre-match ceremony at a National Basketball League game in December.
Indigenous Sydney Swans star Lance Franklin described Mundine's stance as "stupid" last year while Green accused the former NRL star of copying African-American NFL player Colin Kaepernick, who infamously knelt during the US anthem at games this season.
"Personally, I think it's pretty stupid really. It's the Australian national anthem, it's a part of our sport, our history," Franklin said.
"This dingaling sees some blokes pull a stunt and he copies," Green wrote on Facebook. "Once again he doesn't come up with anything original." | <urn:uuid:f19d7a6e-c884-477d-96a2-d06be3ba05d6> | CC-MAIN-2017-34 | http://www.nzherald.co.nz/sport/news/article.cfm?c_id=4&objectid=11791378 | 2017-08-21T12:48:55Z | s3://commoncrawl/crawl-data/CC-MAIN-2017-34/segments/1502886108268.39/warc/CC-MAIN-20170821114342-20170821134342-00087.warc.gz | en | 0.98235 | 767 |
Global value-added pro AV distributor Stampede has been acquired by the technology division of DCC plc, a £14.3 billion revenue, London Stock Exchange listed (LSE) international sales, marketing, and support services group that employs 11,000 people in four divisions operating in 17 countries.
“The acquisition of Stampede adds an exciting new brand to our portfolio that complements our Exertis brand in Europe," said Tim Griffin, managing director, DCC Technology. "The combination of Stampede’s expertise in value added distribution and our resources is going to unleash a new wave of opportunity for our partners in pro AV around the world. By establishing a presence in North America, we will be strategically positioned to leverage all of the new opportunities we expect to develop as a result of this acquisition.”
Stampede president and CEO Kevin Kelly called the acquisition a paradigm shift that ushers in an exciting new era for a global pro AV industry. “Overnight, Stampede has become one of the world’s largest pro AV distributors, able to operate at a level certain to create exciting new business opportunities for our partners," he said. "Supported by the resources and long-term commitment of DCC, we are now able to scale across all pro AV product categories in all vertical markets globally in a way that we simply could not do on our own. For our manufacturer partners this means greater reach and scale. For our resellers, this means more products and new product categories than ever before.”
Kelly called the acquisition the right move at the right time. “Everything we have accomplished as a company over the last 20 years is due to the amazing talent and ingenuity of our employees who created a world class company that has been limited in its growth potential only by its balance sheet," he said. "With this acquisition, we no longer have the same financial constraints limiting what we can do as a value added distributor.”
Kelly said that the acquisition does not change the way Stampede conducts business around the world. In fact, it will accelerate the company’s global business development efforts. “Our employees, resellers and vendor partners will see an exciting evolution in how we go to market and the level of investment we can now make to grow our business.”
With the completion of the acquisition, Stampede founder and CEO Mark Wilkins has decided to retire, after nearly 40 years of service to the pro AV industry. “I am incredibly proud of everything we have accomplished as Stampeders over these last 20 years,” Wilkins said. “Now, with the backing and support of DCC, I can retire knowing that the company’s future is in very good hands.” | <urn:uuid:51fc9df3-d0f1-4970-b544-a107dfcf6c45> | CC-MAIN-2023-06 | https://www.avnetwork.com/news/stampede-acquired-by-dcc-plc | 2023-02-02T23:52:14Z | s3://commoncrawl/crawl-data/CC-MAIN-2023-06/segments/1674764500041.2/warc/CC-MAIN-20230202232251-20230203022251-00479.warc.gz | en | 0.960239 | 570 |
AutoTweet is going to be distributed by Prieco
For reasons that are strictly private I can no longer develop and support AutoTweet. The good news is, that our partner Prieco will continue the work and take over AutoTweet and all other 1st-movers.com extensions. - Thx to Anibal!
Starting from July 23th, 2012, AutoTweet and the family of extensions are going to be distributed and supported by Prieco on www.extly.com. Also all subscriptions are transfered and still valid.
We will migrate the files and database on July 22th and we need a maintenance window to do it. So the site will be offline for some hours on July 22.
After the migration, 1st-movers.com is in some kind of "readonly mode". This means you can login and you can read articles and other content on the site, but you can't post, subscribe or downlaod something. On the new site (www.extly.com) you will find the support forum, download area and you can manage your subscriptions. You can login to the new site with your 1st-movers.com account data.
Finally, I would like to thank all of you, have supported AutoTweet in recent years! I'm sure you and AutoTweet are in good hands with Prieco. | <urn:uuid:bdc4ae0d-b659-4527-ab87-0ff013f36fd7> | CC-MAIN-2022-27 | https://www.extly.com/blog/22-latest-news/265-a-message-from-ulli.html | 2022-06-27T11:26:16Z | s3://commoncrawl/crawl-data/CC-MAIN-2022-27/segments/1656103331729.20/warc/CC-MAIN-20220627103810-20220627133810-00411.warc.gz | en | 0.927893 | 296 |
For you iPhone, iPad, and Android users, you are able to chat with your facebook friends using “Facebook Messenger / Facebook Chat Application for Mobile” officially from Facebook. You can have this application for free on iTunes App Store and Android Market.
With this Facebook Messenger, you can chat with your facebook friends wasily using your cell phone everywhere you are. And for facebook geeks, I think this application is a must-have, either it’s on iPhone, iPad, or your Android Devices.
Facebook Messenger Top Features :
- Send messages instantly to other friends who have Messenger
- Chat with friends who are on Facebook
- Get free push notifications for incoming messages
- Reach friends via text message if they don’t have Messenger yet
- Create group conversations for making plans on the go
- Add more friends to group conversations at any time
- Attach photos and location to messages
- Control alert settings for each conversation
Download Facebook Messenger for iDevice
Download Facebook Messenger for Android
facebook messenger jar, facebook chat jar, Facebook Jar | <urn:uuid:1e514e59-9cab-4c2d-b09e-d5afd6033b65> | CC-MAIN-2020-05 | http://blogspc.com/facebook-messenger-for-iphone-and-android-mobiles/1934 | 2020-01-19T04:01:56Z | s3://commoncrawl/crawl-data/CC-MAIN-2020-05/segments/1579250594209.12/warc/CC-MAIN-20200119035851-20200119063851-00103.warc.gz | en | 0.796675 | 219 |
Cognitive behavioural therapy (CBT) is a talking therapy that can assist you handle your problems by altering the method you behave and believe.
It’s most frequently used to treat anxiety and anxiety, but can be useful for other mental and physical illness.
How CBT works.
CBT is based on the concept that your thoughts, sensations, physical feelings and actions are adjoined, which unfavorable ideas and sensations can trap you in a vicious cycle.
CBT intends to help you handle frustrating issues in a more favorable method by breaking them down into smaller parts.
You’re demonstrated how to change these negative patterns to enhance the method you feel.
Unlike some other talking treatments, CBT deals with your existing problems, instead of concentrating on issues from your past.
It tries to find useful ways to improve your mindset on a daily basis.
Utilizes for CBT.
CBT has been revealed to be a reliable way of dealing with a variety of various psychological health conditions.
In addition to anxiety or anxiety disorders, CBT can also help people with:.
- bipolar disorder.
- borderline personality disorder.
- consuming conditions– such as anorexia and bulimia.
- obsessive compulsive condition (OCD).
- panic attack.
- post-traumatic stress disorder (PTSD).
- sleep problems– such as sleeping disorders.
- problems connected to alcohol abuse.
CBT is also often used to treat individuals with long-term health conditions, such as:.
- irritable bowel syndrome (IBS).
- fatigue syndrome (CFS).
CBT can not treat the physical symptoms of these conditions, it can assist people cope better with their signs.
What happens during CBT sessions.
If CBT is advised, you’ll normally have a session with a therapist once a week or when every 2 weeks.
The course of treatment normally lasts for in between 5 and 20 sessions, with each session lasting 30 to 60 minutes.
Throughout the sessions, you’ll deal with your therapist to break down your issues into their different parts, such as your ideas, physical feelings and actions.
You and your therapist will evaluate these locations to exercise if they’re impractical or unhelpful, and to determine the impact they have on each other and on you.
Your therapist will then be able to assist you exercise how to change unhelpful thoughts and behaviours.
After exercising what you can alter, your therapist will ask you to practice these changes in your daily life and you’ll discuss how you got on during the next session.
The ultimate objective of therapy is to teach you to use the abilities you have actually learnt during treatment to your every day life.
This must assist you handle your problems and stop them having a negative influence on your life, even after your course of treatment surfaces.
Advantages and disadvantages of CBT.
Cognitive behavioural therapy (CBT) can be as effective as medicine in dealing with some psychological illness, but it may not be effective or appropriate for everybody.
A few of the advantages of CBT consist of:.
- it may be useful in cases where medication alone has not worked.
- it can be completed in a relatively short amount of time compared with other talking treatments.
- the extremely structured nature of CBT implies it can be provided in various formats, consisting of in groups, self-help books and apps (you can discover psychological health apps and tools in the NHS apps library).
- it teaches you useful and useful techniques that can be used in everyday life, even after the treatment has ended up.
A few of the disadvantages of CBT to think about consist of:.
- you require to commit yourself to the process to get the most from it– a therapist can help and encourage you, however they need your co-operation.
- attending regular CBT sessions and carrying out any extra work in between sessions can use up a lot of your time.
- it might not be suitable for people with more complex psychological health requirements or discovering troubles, as it needs structured sessions.
- it involves confronting your anxieties and feelings– you might experience preliminary durations where you’re nervous or emotionally uncomfortable.
- it focuses on the individual’s capacity to change themselves (their behaviours, sensations and thoughts)– this does not attend to any broader issues in systems or households that typically have a significant effect on somebody’s health and health and wellbeing.
Some critics also argue that due to the fact that CBT only focuses and resolves current issues on particular problems, it does not resolve the possible underlying reasons for mental health conditions, such as an unhappy childhood.
How to discover a CBT therapist.
You can get psychological treatments, including CBT, on the NHS.
You can refer yourself straight to an NHS mental therapies service (IAPT) without a referral from a GP.
Find an NHS mental therapies service (IAPT).
Or your GP can refer you if you choose.
If you can afford it, you can select to pay for your therapy independently. The expense of private therapy sessions varies, however it’s typically ₤ 40 to ₤ 100 per session.
The British Association for Behavioural & Cognitive Psychotherapies (BABCP) keeps a register of all recognized therapists in the UK and The British Psychological Society (BPS) has a directory site of chartered psychologists, some of whom specialise in CBT.
- Cognitive Behavioral Therapy
- Online therapy
- CBT for OCD
- Cognitive Behavioral Therapy children
- Therapy depression
- Marriage counselling
- Contact us | <urn:uuid:47a30289-4eb1-4808-8c5d-81efd09cb0f7> | CC-MAIN-2021-49 | https://direct-therapy.org.uk/what-are-the-standard-principles-of-cognitive-therapy/ | 2021-12-08T22:48:51Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-49/segments/1637964363598.57/warc/CC-MAIN-20211208205849-20211208235849-00193.warc.gz | en | 0.931075 | 1,207 |
Aphrodite:: The goddess of love, beauty, and sexuality. Born when Cronus cut off Uranus' genitals and threw them into the sea, and from the foam arose Aphrodite. Because of her beauty other gods feared that jealousy would interrupt the peace among them and lead to war, and so Zeus married her to Hephaestus, who was not viewed as a threat. Her unhappiness in marriage caused her to frequently seek out the companionship of her lover Ares.
You will cause quite a stir when you wear this amazing pendant...
Four retaining rings wired together using 28ga silver plated wire. At the bottom an assortment of vintage clock gears with a beautiful black clock hand dangling in front of the whole pendant and extending below it and an 8mm emerald Swarovski marguerite lochrose in front of it all... at the bottom of the hand dangles a single 11mm emerald swarovski crystal teardrop. On the bottom of each side retaining ring a single 4mm fern green sew on Swarovski crystal in front of a tiny little watch hand that compliment the center hand nicely . The clock hands add a delicate touch to this piece... All of the hands are wired in such that allows them to sway freely with your every movement.
Pendant Dimensions: 1 1/2 inches tall x 2 inches wide
18inch gunmetal rolo chain with a 3 inch extender chain
Purchase this necklace here: [link]
See the matching earrings here: [link] | <urn:uuid:aa5b6d31-cc44-42da-98c4-680d8e0cece8> | CC-MAIN-2014-49 | http://youniquelychic.deviantart.com/art/Aphrodite-v6-SOLD-341238393 | 2014-11-27T15:49:53Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-49/segments/1416931008899.16/warc/CC-MAIN-20141125155648-00011-ip-10-235-23-156.ec2.internal.warc.gz | en | 0.876842 | 314 |
Pressing issues regarding water supplies and sustainability have motivated AIChE to develop the AIChE Water Initiative. The ultimate goal of the Water Initiative is to determine the role and approaches for AIChE to lead chemical engineers to become recognized thought-leaders on the subject of water quality, security, and sustainability. The group has an advisory board which is co-chaired by David Klanecky of Dow and Wendy Young of GE Water & Process Technologies.The water challenges to be explored by the AIChE Water Initiative in a series of workshops, conferences, webinars, and new website content include:
- Access to water, which includes issues of potable scarcity, freshwater for croplands, and industrial water access.
- Water purification and sanitation with a specific focus on bacteria disease (e. coli), heavy metals, agricultural chemicals run off, and pharmaceuticals and metabolites.
- Water energy nexus and the relationship between the energy footprint of water and the water footprint of energy.
“Beyond access,” she explained, “there is, of course, a special role for chemical engineers in dealing with purification and sanitation issues, especially combating bacterial diseases, pollution by heavy metals and agricultural run-off, and the growing awareness of the impact of pharmaceuticals in wastewater.”AIChE hosted a water workshop in November at its 2010 Annual Meeting in Salt Lake City, Utah. This workshop served as the launching point for this exciting new initiative. AIChE also hosted a water workshop at the Second International Congress on Sustainability Science and Engineering (ICOSSE) taking place at the University of Arizona in January 2011. Additional activities are being planned around AIChE’s Spring Meeting in Chicago from March 13-17, 2011, and at its Annual Meeting in Minneapolis in mid-October. For information about the new AIChE Water Initiative please visit water.aiche.org. | <urn:uuid:5a254d83-5edf-4e27-b8fc-d20fb42178c2> | CC-MAIN-2013-48 | http://chenected.aiche.org/sustainability/aiche-announces-new-water-initiative/ | 2013-12-09T13:33:56Z | s3://commoncrawl/crawl-data/CC-MAIN-2013-48/segments/1386163976781/warc/CC-MAIN-20131204133256-00037-ip-10-33-133-15.ec2.internal.warc.gz | en | 0.947311 | 391 |
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Have Fun and don't trash talk its only a game
my 1st killtrocity.......mostly luck but was fun to get
Dont be afraid to take the shootDont be afraid to step it upPlay to win,hit em hard hit em good...LOVE YA BUNGIE!
haha Very cool,best ive got is extermenation on 5 bridgeaders XDKeep up the work kid
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© 2014 Bungie, Inc. All rights reserved. | <urn:uuid:0dc0fa73-692e-4126-8e09-8fb27686ef5d> | CC-MAIN-2014-23 | http://halo.bungie.net/online/Halo3UserContentDetails.aspx?h3fileid=55044538 | 2014-07-29T19:13:07Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-23/segments/1406510267824.47/warc/CC-MAIN-20140728011747-00408-ip-10-146-231-18.ec2.internal.warc.gz | en | 0.874383 | 219 |
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$155,0003 br, 2 ba, 1-½ ba3151 Hazel Park DrHouston, TX 77082
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Connect with Buyer Agents in your area to get your questions answered. | <urn:uuid:1a9f3f36-685b-47fe-b3f7-28a9423a4ab5> | CC-MAIN-2014-15 | http://www.homes.com/for-sale/houston-tx/acres-home/?FEATURE=WATER&MAXSQFT=4999&MINSQFT=2000 | 2014-04-20T14:45:59Z | s3://commoncrawl/crawl-data/CC-MAIN-2014-15/segments/1397609538787.31/warc/CC-MAIN-20140416005218-00397-ip-10-147-4-33.ec2.internal.warc.gz | en | 0.856972 | 208 |
Rated 5 out of 5 by 3
Rated 5 out of 5 by MrGarcia Great quality
Item quality is great! Just what we were looking for. Real sturdy and heavy duty. Not flimsy or anything like that. And the design is is pretty nice. Ended up buying 3 and would buy these again.
May 10, 2016
Rated 5 out of 5 by Car03 Sleek and elegant
These rods look like a million bucks and are so affordable! I paired these with my custom made curtains and they look fabulous!
September 17, 2015
Rated 5 out of 5 by amesyp Best Curtain Rod I have purchased
I found these at my local Kirkland's store right after I had already purchased some from somewhere else. I really liked the looks of these so I purchased them as well. After getting them all home and comparing to my other ones, I took the other ones back and purchased more of these from Kirkland's to use on additional windows in my home. I love them. They install very easily and look great!
September 16, 2015 | <urn:uuid:db16af13-42da-4791-929c-c067c72edf1b> | CC-MAIN-2016-30 | http://www.kirklands.com/product/Rugs-Windows/Curtain-Rods-Hardware/Black-Studded-Curtain-Rod-66-in/pc/2288/c/2677/175774.uts | 2016-07-29T23:45:36Z | s3://commoncrawl/crawl-data/CC-MAIN-2016-30/segments/1469257832399.72/warc/CC-MAIN-20160723071032-00311-ip-10-185-27-174.ec2.internal.warc.gz | en | 0.983708 | 220 |
Celebrating 10 years of the St Albans Food and Drink Festival!
- Credit: Archant
Herts Ad food writer Becky Alexander looks ahead to the 10th St Albans Food and Drink Festival...
The biggest food event on the St Albans calendar is back, and is now in its 10th year!
Once again, St Peter’s Street will be closed to traffic on Sunday October 1 from 12noon–6om for the Street Feastival; the Dylans double-decker Champagne bus will be there, along with the Tabure pop-up restaurant and more than 100 food, drink and produce stalls.
There is so much going on that I am going to focus on the new events that have caught my eye. For a complete listing, pick up a free brochure from around the city centre.
Poppycock Bar, run by the Mokoko team will be on the Village Green near the Town Hall (remember the pineapples from the summer festival?), along with Farr Brewery.
You may also want to watch:
The Cookery Theatre is focusing on our local chefs and authors this year; the line-up includes Theo Michaels, who presents regularly on This Morning and is the author of Mug Meals and Ren Behan, who has recently published a book on modern Polish food, Wild Honey & Rye.
will be there with my co-author Michelle Lake, talking about Packed, our book about healthy, nutritious packed lunches for adults. It was published earlier this year and has been featured in delicious, Great British Food, The Guardian, Coast, Prima, SheerLuxe and Top Sante among others. The timings of each demonstration will be on the blackboard alongside the kitchen; there is no charge to attend any demos – just turn up and grab a seat.
- 1 Why is there a 50mph speed limit on small section of A414?
- 2 Which Herts communities have seen the biggest rises and falls in COVID-19?
- 3 How many people in St Albans were fined for breaking COVID rules?
- 4 Rapid community COVID-19 testing launches in Hertfordshire
- 5 Police swoop on organised gangs as part of major operation
- 6 Number of COVID patients in Herts hospitals falls slightly
- 7 Hitchin and Harpenden MP responds to questions over new £2,500 a month part-time role
- 8 Remembering one-of-a-kind local legend Lee Bozier
- 9 Charity for older people has busiest year ever during pandemic
- 10 Oaklands College principal leaving after 10 years
Oaklands College will be hosting a pop-up farm again, and there will be meat preparation and butchery demos from the Master Butchers from the Hospitality and Catering section.
There will be live music and entertainment for all; young children will love the Teddy Bear’s picnic; just bring a bear and choose lunch from one of the many stalls, and all sorted!
As well as the main Feastival day, the St Albans Food and Drink Festival runs several fringe events, from September 27 until October 7. New for this year is the Gin and Jazz night on George Street on Friday October 6, where the street will be closed and you can listen to live music, shop and enjoy drinks from Dylan’s, Suckerpunch and ThirtyNine10. It runs from 7.30-10pm.
Also new for this year is ‘Sustainable Saturday’ on October 7, where the focus shifts to what we are doing locally to make our community more eco-friendly. There will be a Sustainable Food Zone at the Charter Market and you can find out about the community gardens in Harpenden and St Albans. The Courtyard Café is the place for information and discussion about what is happening locally, or you can book for a Vegan Afternoon Tea at The Green Kitchen on Hatfield Road.
There are some really great pop-up events to book: the pasta workshop by Chappell & Caldwell will be great, or try Coffee, Canapés and Conversation at Charlie’s on London Road. Author Ren Behan is also hosting two events; a pop-up Supper at the Street Café on Catherine Street, and a vodka tasting at Dylans. Book as soon as possible as these will all sell out.
Despite having lived in St Albans for 17 years I have never visited the Organ Museum; I do like the sound of the The Vintage Afternoon Tea to be held there, so that might be my excuse!
To pause for thought in all this, St Albans Cathedral will be hosting a more traditional harvest celebration on October 1; it’s also a chance to find out more about how we can help others around the world and donate to our local foodbanks. St Nicholas Church in Harpenden is hosting harvest festival on the same day too, with food tastings, a quiz and lunches. There really is something for everyone this year – see you there! | <urn:uuid:67b26ca5-2bf3-4cec-8712-8c9cadc3ee11> | CC-MAIN-2021-04 | https://www.hertsad.co.uk/lifestyle/celebrating-10-years-of-the-st-albans-food-and-drink-5104544 | 2021-01-23T17:03:17Z | s3://commoncrawl/crawl-data/CC-MAIN-2021-04/segments/1610703538226.66/warc/CC-MAIN-20210123160717-20210123190717-00274.warc.gz | en | 0.952695 | 1,042 |
Silver City Blues Festival
May 24-26, 2019
Comfortable scenic lodging nestled along Bear Creek or secluded, private Bear Creek Canyon Retreat in Gila NM is just 32 miles away from Silver City Blues Festival when you stay at the Double E Ranch and New Mexico Cabin Rentals! Double E Ranch and New Mexico Cabin Rentals welcome Bikers! Please keep in mind once you leave the blacktop on Hwy 211, it's a 4 mile well maintained county dirt road (Hooker Loop) which dead-ends at Double E Ranch and cabin lodging. Call Double E Ranch office with any questions or concerns (575-534-2047). Take in the sights and smooth sounds of the 2019 Silver City Blues Festival Friday - Sunday, May 24-26 in historic Downtown Silver City, New Mexico. Presented by the Mimbres Regional Arts Council, this year's musical line-up is diverse and promises to be the best, yet!
Bikers are always special welcomed guests at the Silver City Blues Festivals. That tradition will continue in 2019. There will be designated bike parking sponsored by Lawley Toyota, on 12th and Pope Streets, adjacent to Beer & Spirits Pavilion, sponsored by Little Toad Creek Distillery and Brewery. | <urn:uuid:b26c5ab0-c975-4bcd-8657-b36e5d76df3f> | CC-MAIN-2019-47 | https://www.newmexicocabinrentals.com/blues-festival-silver-city | 2019-11-19T01:06:45Z | s3://commoncrawl/crawl-data/CC-MAIN-2019-47/segments/1573496669868.3/warc/CC-MAIN-20191118232526-20191119020526-00530.warc.gz | en | 0.910514 | 254 |
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