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Explore what is changing the lives of tens of thousands of people in more than 170 countries around the world.
Meet the creators of Access Consciousness & read about how it became a worldwide movement.
Explore what the 3 key tools of Access are and how you can use them to start creating the change you desire.
Receive tips of what you can choose to get started. You know what will work for you!
There are many videos about Access Consciousness that you can explore! Watch a few that we recommend starting with, in no particular order.
Hear from people all over the world about how they are different after Access Consciousness.
Read news articles, watch videos, listen to radioshows – you can find Access in many media channels!
Explore some of the most frequently asked questions about Access.
There are thousands of Access Consciousness events and classes offered weekly around the world. You can search for a class by topic, facilitator, language or location in our class calendar.
Gary Douglas travels extensively facilitating advanced Access Consciousness classes as well as a range of evening and several day workshops on specific topics from Choice and Possibilities, to Money, Benevolent Capitalism, Relationships and more.
Dr. Dain Heer offers classes on a wide array of topics through out the world and is best known for his transformation process The Energetic Synthesis of Being as well as the Being You, Changing the World events.
Simone Milasas travels extensively facilitating advanced Access Consciousness classes as well as a range of evening and several day workshops on specific topics from Choice and Possibilities, Relationship Done Different, Business Done Different, Getting Out of Debt Joyfully and more.
Brendon Watt travels extensively facilitating beginning advanced Access Consciousness classes as well as a range of evening and several day workshops on specific topics from The Foundation, Choice and Possibilities, Relationship Done Different, and more.
The Access Bars are the very core and foundation of Access Consciousness. It can be the starting point of a great adventure and it can be something you add to your life that will assist you in creating a greater ease with everything.
Dr. Dain Heer offers classes on a wide array of topics through out the world and is best known for his transformation process The Energetic Synthesis of Being (ESB).
Dr. Dain Heer offers classes on a wide array of topics through out the world and is well known for his Being You, Changing the World events, based on his bestselling Being You, Changing the World book.
The Speciality Programs are branches of Access Consciousness where you can dive deeper into particular topics with specialized facilitators. Each program offer introductory classes, advanced classes and certification facilitator training.
Access Consciousness offers classes on an infinite array of topics. There are many types of variety classes available.
Access Consciousness have many ways of engaging with the tools worldwide via expos, meet ups, radio shows, tele summits, google hangouts and more.
Each Access Facilitator is facilitated by the creators of Access Consciousness, Gary Douglas and Dr. Dain Heer. There are several license types for Access Consciousness Core Classes as well as Specialty Programs and Special Topic Classes.
Are you looking for more change? Use our search function to find a facilitator near you.
Access Consciousness has over 8,000 facilitators and practitioners in more than 170 countries. Find all their specific certifications and licenses here.
Find an article on almost any topic you could think of! Where would you like your adventure to begin?
Explore the leadership and capitalism that is about building longer-term and sustainable businesses, that have a positive impact on society and the planet.
A curation of content from all over the world with input from Dr. Dain Heer. To empower, inspire, invite and awaken you!
We created a special log in help page to assist you!
The Being You classes are designed to take you from having a life run on autopilot into becoming fully alive and totally present as the infinite being you truly be.
It will open you up to an expanded awareness of a life without judgment and empower you to know that you know.
These series of classes are facilitated by Dr. Dain Heer, author of the popular Being You, Changing the World and they're available live and online all over the world.
The Being You, Changing the World Les évènements de 3.5 jours sont à peu près entrer dans les possibilités étonnantes de vous et le cadeau que vous êtes ici pour être dans le monde. S'appuyant sur le livre de Dr. Dain Heer intitulé «Être vous, changez le monde», le Dr Heer utilise les outils de Access Consciousness en combinaison avec le processus d'énergie transformationnel unique qu'il a développé, appelé The Energetic Synthesis of Being.
Rejoins le Dr Dain Heer pour un voyage d'être toi d'une soirée où la partie fun de la réalité commence et où tu peux changer ce que tu pensais être impossible à changer. Dr Dain partagera des outils simples et puissants pour déverrouiller les énergies subconscientes et latentes qui te limitent.
Que faire si le voyage pour être l'être infini que vous êtes vraiment, est-ce que c'est la plus grande aventure que vous allez jamais? Si vous aviez les étapes à suivre, est-ce que vous feriez le voyage? Dans le cadre de Access Awareness, le Dr Dain Heer a créé une série unique de cours sur les éléments d'être conçus pour vous permettre de savoir que vous êtes le créateur de votre vie et de votre vie.
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Headache Q&A: Test Yourself
You probably know someone who suffers from headaches — most of us do. But how well do you understand this common pain condition? Advertising Policy Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy Test your knowledge of … Read More

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Social Media Management – The number one way to organically grow your business. Let our expert team handle all your social media needs.
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We also manage review websites like Yelp, Google+, and Foursquare on behalf of our clients. The concept is still the same. We create great content, engage your target audience, and grow your followers to increase awareness and website traffic.


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Our free clinic provides primary care for minor, non-life threatening illnesses and injuries.
Everything we do is aimed to provide
Offering friendship with both God and his people.
Offering the highest possible medical care.
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Our Services include:
• General Physical Exams
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*We may be able to provide referrals to specialists if we are unable to diagnose or treat a patient's problem.
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See if you qualify for our services, fill out the form below and we'll be in contact with you soon.


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Who we are
Our website address is: https://dvaclinic.ca.
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When disclosing personal health information, you need to take reasonable steps to ensure that no information is inadvertently disclosed to unintended recipients. You also need to take reasonable steps to ensure that the information is as accurate, complete and current as is necessary for the purposes of the disclosure or clearly set out the limitations, if any, on the accuracy, completeness or currency of the information.
You may disclose personal health information without an individual's consent in certain circumstances. However, simply because a disclosure is permitted does not mean it is mandatory, unless it is necessary to carry out a statutory or legal duty.
Here are some examples of permitted disclosures of personal health information without consent:
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Earrings // Accesorize
Heeled boots // Hidden Fashion
Hi guys, welcome back to my blog.
I know this is isn't really colourful, but I am wearing this ruffled floral shift dress that I got from Primark and my favourite heeled boots from Hidden. I am not really a dress kind of girl, in fact, I really feel uncomfortable when I wear them and I just don't feel like myself. Dresses are very feminine but I am nowhere near that lol. I don't own many dresses, I can legit count all of my dresses on one hand lol. But anyways, it was so hot In Brussels that day and so I decided to put on this dress and I even wore big dangly earrings (also not like myself lol) to complete the outfit.
Thank you for reading & I will see you in my next post, bye!


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Call : 212.988.4441
Limousine Service
The global center of culture, finance and fashion, New York City is the ideal location to host an event. The multitudes of venues available in New York can accommodate any event's necessities. Farrell Limousine Service has the experience and knowledge necessary to assist with the planning and management of all transportation requirements during the course of your event. Depending on your specific needs, one of our experienced transportation coordinators will customize a specific itinerary that ensures all transportation runs smoothly. Our professional chauffeurs will provide impeccable service to your clients throughout the event. Farrell Limousine Service will focus on all possible needs of the clients and go behind the role of transitional limousine service in fulfilling them.


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May 27, 2015 - Red Tide is Turning Against Tribal Disenrollment by Gabriel S. Galanda
This spring there has been a surge of tribal public opinion against the practice of tribal disenrollment. The tide of tribal public opinion is dramatically turning on that non-indigenous mode of Indian self-termination, and those tribes and tribal leaders who extinguish their kin.
Most recently, Marty Two Bulls drew and pubished this political cartoon:
While Two Bulls had done so before, in 2013 (see "Self-Termination" here), his latest cartoon was inspired by Professor David Wilkins latest commentary, "The Sovereignty of Everything, The Power of Nothing." Prof. Wilkins—the most longstanding anti-disenrollment advocate—writes:
Tribal politicians and jurists who work to disenroll legitimate Native citizens justify their perverted behavior by wrapping themselves in the cloak of sovereign power, often described as sovereign immunity, and then declare that this protects them from their own people. . . .
But . . . "sovereignty as a right to do as one pleases is part of the concept, but not sovereignty as anarchy, not sovereignty as resistance to cooperation. And not sovereignty as immunity." This term, he noted, was wrongly used to excuse "immunity from law, immunity from scrutiny, immunity from justice." Sovereignty does not mean that leaders are above the people.
In 2015, Two Bulls and Wilkins have been joined by a host of other disenrollment critics and commentators:
The National Native American Bar Association "denounce[d] any divestment or restriction of the American indigenous right of tribal citizenship, without equal protection at law or due process of law or an effective remedy for the violation of such rights" and declared it "immoral and unethical for any lawyer to" aid and abet such human rights abuses;
Two state bar association Indian law chapters, in Washington and Arizona, are featuring discussions about how to afford legal remedies to disenrollees, at their annual meetings in Seattle and Phoenix, respectively;
Grassroots Lakota social activists Last Real Indians also denounced disenrollment, bluntly proclaiming: "Real Indians don't disenroll";
Indian legal historian and critical-race theorist Professor Rob Williams tackled the subject on Native American Calling, saying simply:
NextGen Native helped push disenrollment further "into the spotlight" through a podcast about "Forcing Hard Conversations" regarding the "wholly non-indigenous" practice; in short "there may be differing views on these subjects, but if Indian Country does not have these discussions, others will, and others will also make decisions for us."
This month, Ryan Dreveskracht said our piece by publishing an Arizona Law Review article, "Curing the Tribal Enrollment Epidemic: In Search of a Remedy," which Prof. Williams describes as "the most important, and most thoroughly researched and argued treatment of the tribal disenrollment available in literature . . . a must read for all of Indian country."
Meanwhile: Hollywood, through Native actors, is increasingly portraying Indian Country through the negative light of disenrollment—most recently in the show The Red Road, starring Jason Mamoa. Leading tribal—and tribally owned—media outlets like Indianz.com, Pechanga.net, Native News Online, and Indian Country Today Media Network, increasingly allow free speech to reign over the once-taboo subject. Indian law blogs Turtle Talk and Law360 have gotten in on the act too. And with every like, share and tweet, social media Natives are saying "enough is enough."
There is no doubt that the red tide is turning against disenrollment. It is only a matter of time before a tidal wave of tribal public opinion washes over the colonial practice—and hopefully washes it away.
Gabriel S. Galanda is the managing partner of Galanda Broadman, PLLC, in Seattle. Gabe is an enrolled citizen of the Round Valley Indian Tribes.


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Sen. Mark Udall's support for the Paycheck Fairness Act produced plenty of dueling charges today, with Republicans accusing the Democratic senator of hypocrisy when it comes to paying women staffers and Democrats asking why Congressman Cory Gardner won't support the measure.
The back-and-forth in Colorado echoed a national effort, with Republicans today calling out President Obama and other Democrats, questioning how much they pay the woman on their staffs.
Udall, a Democrat, and Gardner, a Republican, are likely to face off in November.
Gardner's supporters noted his female staffers earn more per dollar than Udall's female staffers and that Gardner's vote against the paycheck act was in response to a "parliamentary technique" that has been used by the minority in the House.
Udall told supporters in an e-mail that in Colorado "a working woman makes 78 cents for every dollar a male makes." He said it's time women earn equal pay for equal work, which is why he supports the bill Majority Leader Harry Reid is bringing up this week for a vote.
"Congressman Gardner, my Republican opponent, voted to block the Paycheck Fairness Act last year — choosing Washington partisanship over fairness and opportunity for Colorado families," Udall wrote.


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Today's tutorial for a Blue Whale and a Sperm Whale comes from Drygoods Design, a beautiful fabric and goods shop in Seattle's Ballard neighborhood and online everywhere at www.drygoodsdesignonline.com. Drygoods Design curates fabric and goods, offers classes in their Seattle shop. They also have a blog which is where we first saw their recent, super-fun window display featuring these whales! (Scroll down to the bottom of this post for a quick peek!) Take a look at Drygoods Design (where they have both excellent inventory and shipping prices), and have fun with today's whales. We can't wait to see what you do with the tutorial!
Thank you to Sew Mama Sew for having us here today! Today we're sharing two fun projects for stuffed whales. Located in the Scandinavian fishing village of Seattle, we just had to capture the spirit of the sea for our most recent window display.
Here you'll find the instructions for making a stuffed blue whale and a stuffed sperm whale. These are general inspirations and not a true replica of each anatomical detail but with touches like zippers and selvedge edges, they take nature to a fun and whimsical level. The whales can be fun projects for and with kids.
Here's a snapshot of what you'll need for both whales:
These patterns both have a 3/8" seam allowance included and are for your optional use. Whales have a general shape and you can feel free to embellish where you wish. We decided to go bigger here for our window but you can adapt the size as you see fit.
Blue Whale
(Finished dimensions end up being about seven inches by 27" long.)
What you'll need…
- 1/2 yard fabric (We chose woven grays and blues to reflect a maritime aesthetic.)
- Thread
- Two zippers (We chose metal for the fun contrast of gold teeth.)
- Scrap of striped fabric
- One skein Perle cotton/embroidery floss
- Five to eight ounces of fiber fill or similar (not pictured)
- Printed PDF Blue Whale pattern template
- Paper scissors
- Fabric scissors
- Rotary cutter
- Ruler
- Hand sewing needle/embroidery needle
- Fabric marker(s) (At least one is erasable.)
- Point turner (not pictured)
Using the included PDF, print out and attach by tape the template for the blue whale. In addition to the body of the whale (two pieces), you'll want to also cut four flipper pieces and two pieces of striped fabric, cut to the length of your zipper.
Cut out two whale bodies from your fabric (be sure that you make note of right sides of the fabric and how you will attach the zipper). Cut out two pieces of striped fabric, one inch wide by the length of your zipper. Cut out four flipper pieces.
Measuring down between 3 to 3 1/2 inches from the top of the whale, line up your zipper per the template and have the end of the zipper tape line up with the edge of what would be the "nose" of the whale. (You'll want to do this so that any metal parts are clear of your seam allowance.) Once you know where you want it to go, use fabric adhesive to attach the striped fabric to the zipper and then the striped fabric to the whale body.
Once temporarily adhered, stitch along all edge of the zipper (no need to use a zipper foot here) on all sides, and backstitch at the beginning and end. In order to miss the zipper teeth and not have your presser foot out of balance, use your needle position to easily maneuver around.
Facing the two whale bodies towards each other as mirrors, line up the next zipper and striped fabric and repeat these steps.
Now that both zippers are installed, use a ruler or a hem gauge to measure out past the end of the zipper (dumb end) approximately six inches plus some more. Working from a quarter inch from the bottom, make a small dot with a removable marker and then go up and over 1/4″ to 3/8″ until you have about 11 to 12 dots. These will be your starting points for the lines that create the underbelly of the whale.
Stitching the Lines:
Variegated thread created a unique stitch quality. If you don't use cotton, you may want to do a couple of the lines twice so that they're more pronounced. Starting at the first dot at the bottom, backstitch and then sew in a questionable straight line, following the contour of the whale body outline. Backstitch once you reach a quarter inch of the zipper. Continue until you've started from each dot. The picture shows what about 11 lines look like (you'll more than likely lose the first one after you stitch the whale together).
Repeat on the other whale body piece. Trim threads.
You're now ready to make the whale. Line up the two pieces, making sure to align the zippers as close as possible. Pin and mark an opening about 6″ – 8″ long, just 1″ to 2″ towards the center from the tail (this will make it easier to turn the tail). Backstitch and start from the mark on the right using a 3/8" seam allowance. To make the tail turning easier, make the seam allowance skinnier at the narrow portion of the tail. Once you reach the other mark, backstitch and cut threads.
Cut the corners of the tail (without cutting into the stitches) and clip the curved portions of the seam allowance and then turn. Take care when turning the tail and use a point turner/chopstick to push out the points. Once it's turned right sides out, be sure to press and shape the opening well. Strong creases will make a hidden closure much easier.
Time to stuff! Start with the tail; it will be a little hard so start with small increments of fill and then fill the rest. Given the length, you'll want to make sure there's enough fill in the tail and small part of the body so that it doesn't flop. Once you're happy with the shape, you can sew the opening closed. We love a hidden stitch here so a ladder or fell stitch is ideal.
The Flippers:
Now sew, right sides together, two of your flipper pieces with about a quarter-inch seam allowance leaving the top 3/8" open without stitches so you can easily press the raw edges in. Turning them will be a little tough so gentle here. Press raw edges inside of the flipper, right sides together. You can now attach this to the body of the whale, much like you closed it. Repeat for other side.
Making the Eye:
With your embroidery needle and either Perle cotton or embroidery floss, stitch about a 3/8" stitch, repeating over and over until it's at least four or five stitches visible, looking like a small oval. Tie off and knot.
You're done! Unzip the teeth of the zipper if you wish to show off its grill! We hung these in our window but they also be great bed decorations too.
Sperm Whale
(Finished dimension are approximately six inches tall by 20" long.)
What you'll need…
- 1/3 or 1/4 yard neutral fabric (We chose woven grays and blues to reflect a maritime aesthetic.)
- At least 25" of selvedge but ribbon or other trim work too (Here we used a different fabric for the selvedge.)
- Scrap contrasting fabric
- Thread
- Embroidery floss or Perle cotton
- 1/2 pound of fiber fill or similar (not pictured)
For the Blow Hole (optional):
- Hot glue gun
- Two pipe cleaners
- Scrap sheer or metallic fabric
- Heat n' Bond Lite or similar
- Printed PDF Sperm Whale pattern template
- Tape
- Paper scissors
- Fabric scissors
- Rotary cutter and ruler
- Chalk marker
- Embroidery needle
- Hand sewing needle
- Fabric adhesive
Make the Mouth of the Sperm Whale:
If you're taking the selvedge edge off a fabric (we used this since it looked most like teeth), trim it down now and you'll want approximately 25" of selvedge or ribbon. Lining up in a "V" to start from the top and bottom of the dip in the mouth (should be about 6.5" for the top piece and 6" for the bottom); cut your selvedge edges. Lay the contrasting fabric underneath the two and trace around the selvedge edges to know where to cut your contrasting fabric. Cut your contrasting fabric and then use fabric adhesive or a glue stick to first secure the contrasting fabric and then each of the selvedge edges with adhesive too. This will make topstitching easier.
Line up the other whale body (right side up) to face the prepared body so you can easily match up the other side.
Topstitch around the selvedge edges, lining up to the outer edge and then stitching back up closer to the selvedge edge. You can use needle position to get closer without running over the fray of the edge (or the teeth). Increasing your stitch length by a few measures will make a nice topstitch and decorative touch. Repeat on the other piece.
Make the Whale:
Once your whale mouth has been made, you can now put right sides together, pinning along the edges. Mark an opening about 5″ – 6″ long, close to where the tail starts; if you're making the blow hole, mark an opening directly above the end of the mouth about a 1/2″ long. It will make inserting your "spray" much easier and reinforce the hole. Starting at the mark on the right, backstitch and sew a 3/8" seam until you reach the first blow hole mark. Backstitch and lift both your needle and presser foot, moving your fabric so that you put the needle and the presser foot down above the second blow hole mark. Backstitch and continue with the 3/8" seam until you reach the last chalk mark.
Clip your curves, the tail joints and the points of the tail. Turn right side out and smooth out using a point turner. Press the opening well so you can sew shut easier later.
The Blow Hole:
Cut your pipe cleaners to be about four inches long, which will make four to six. Take your sheer or white fabric and follow the fuse instructions to adhere the fabric to the fuse. Peel off the backing once it's fused and then center the pipe cleaner on one half of the fabric and then fold the remaining half over the top of the pipe cleaner. With a pressing cloth fuse the fabric to the pipe cleaner. Trim and repeat to the other three.
Bend the pipe cleaners and arrange into what looks like a spout of water and gently insert into the blow hole. Either sew or adhere with hot glue. Be careful not to use too much if using glue.
Stuff the whale with careful attention to the tail.
Now the Flippers and the Eyes:
Use the same process with the flippers and the eyes as the blue whale.
Time to sew shut! Same as the blue whale, make sure the tail is properly stuffed so it doesn't flop before you sew it all the way closed. Use a ladder or fell stitch to create as close to an invisible closure as possible or don't worry about it and do whatever stitch you enjoy most!
Now you're done!
This is what our window looked like with some friendly narwhals along for the ride.
All fabrics were sourced from our store and site: www.drygoodsdesignonline.com. You can also find us on our Drygoods Design Online blog, and follow us on Instagram, Facebook and Twitter for more fun inspirations.
Fabrics used: Andover Chambray in Navy, Pickering International Lightweight Organic Duck in Grey, Essex Linen in Steel, Pickering International Organic Hemp Stripe, Pickering International Organic Reversible Double Gauze Dots in Blue, all available at www.drygoodsdesignonline.com.


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Asthalin® Inhaler is manufactured by Cipla and is used to treat and relieve symptoms of bronchospasm, which is narrowing of the small airways of the lungs or bronchioles that happens in reversible obstructive diseases like asthma, chronic bronchitis, and emphysema. The inhaler is used to relieve breathing difficulties caused by bronchospasm with symptoms including, wheezing, shortness of breath, chest tightness. It can also be used to prevent exercise-induced bronchospasm, which is a form of asthma that is only triggered by exercise, and also allergy induced asthma to known allergens like pollen or cats. The medicine is a 'reliever' inhaler because it is has a rapid onset (within 5 minutes) but is a short-acting medicine, hence it cannot be used to treat the asthma disease. Asthalin® Inhaler contains Salbutamol as the active ingredient. Salbutamol is a bronchodilator belonging to the class of short-acting, selective beta2-adrenergic receptor agonists. It has a direct action on the sympathetic supply to the smooth muscles of the airways. It also acts on the beta2-adrenergic receptors in the airway. Both its activity causes relaxation of the smooth muscles which relieves bronchospasm.
- asthma;
- emphysema.
MOA (mechanism of action):
Salbutamol, a beta2-agonist, and bronchodilator that acts directly on the small airways of the lungs (bronchioles). Contraction of the bands of smooth muscle that surrounds the small bronchiole tubes causes narrowing of the airways in response to an asthma trigger. Salbutamol in Asthalin® Inhaler binds to beta2-receptors on the smooth muscle causing the muscle to relax and the airways to widen (bronchodilation). This reduces bronchospasm (contraction or the airways) and allows the airways to open making it easier to breathe and removing symptoms of asthma, such as chest tightness, wheezing, cough and, shortness of breath. Salbutamol is a rapid-acting bronchodilator but has a short duration of action, lasting 4-6 hours and is used as a reliever medication for severe asthma, delivered into the lungs as an aerosol with each actuation (puff).
Asthalin® Inhaler should be used on an empty stomach.
For the relief of acute episodes of bronchospasm:
- 1 or 2 puffs as necessary;
-maximum dose is up to 8 puffs in 24 hours.
Children (6 - 12 years):
- 1 puff as necessary;
- maximum dose is up to 4 puffs in 24 hours.
To prevent allergen- or exercise-induced bronchospasm:
- two inhalations 15 minutes prior to exercise or exposure to an allergen;
- maximum dose is 2 puffs up to 4 times a day.
Children (6 - 12 years):
- one inhalation 15 minutes prior to exercise or exposure to an allergen;.
- maximum dose is 1 puff up to 4 times a day.
How to use Asthalin® Inhaler:
1. Insert the mouthpiece in the mouth.
2. Seal your lips around it.
3. Depress to release medicine.
4. Inhale deeply.
5. Do not exhale into the inhaler.
6. Rinse your mouth after use.
7. If you use more than one inhalation at a time, wait at least 1 minute before using the second inhalation and shake the inhaler again.
Missing a dose
If you miss a dose you should take it as soon as you remember. If it is the time for the next dose you should continue your regular dosing schedule. Do not exceed the doctor's recommended dose.
If an overdose occurs and you are feeling unwell, you should seek emergency medical attention or contact your healthcare provider immediately.
Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F) and away from excess moisture and heat. Throw away any unused medicine after the expiration date. Keep out of the reach of children. Keep it capped.


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It's nice to see AMD taking the initiative in releasing some upgraded "stock" coolers with their CPUs. Those in the enthusiast community likely have a shelf full of "stock" coolers from both AMD and Intel that due to their lackluster performance have never been used. Starting in February, AMD announced the Wraith cooler, which came bundled with the AMD FX 8370 and the AMD A10-7890K. They have now expanded the Wraith CPU cooler availability to the AMD FX 8350 and the AMD FX 6350. Read More
Posts Tagged: fx-8350
AMD's Piledriver FX-8350 Gaming Comparison
When we looked at the Piledriver CPU, we ran it with our standard CPU review HD 6970. However, our CPU review game and 3D benchmark suite is a bit long in the tooth. In an effort to keep our readers more well-informed, we went back to the drawing board to run our much more modern gaming suite (which we use in all GPU reviews) on a more modern, powerful GPU – the ASUS HD 7970 DirectCU II TOP. Read More
AMD FX-8350 - Piledriver - CPU Review
Today AMD is releasing their new FX processors. They are an evolutionary step from AMD's oft-maligned Bulldozer processors released just over a year ago. How large of a step forward is Piledriver? We're here to show you! Read More
Rumor: AMD FX-8350 -Piledriver- to Launch in Q3
According to the website Hexus.net, AMD is preparing Piledriver CPUs sometime in August. This is welcome news for AMD fans who have pretty much dispaired since Bulldozer debuted last year. It wasn't a bad CPU per se', but compared with Ivy Bridge, it's just not competitive. Read More


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If you're craving for some burgers this could be one of a few places here in Luxembourg where you can eat a good one. Appereantly this homemade burger style is a thing now. Everywhere you go they serve "the" homemade burger. 🍔
If it's not at Hitch, it is at Edelwyss, Franz, Coppers, Max and Moritz or Bei den Bouwen just to name a few restaurants here in Luxembourg. A friend of mine said that they serve one of the best veggie burgers at JFK. The name for this burger restaurant came up because it's situated on the John F. Kennedy street. Bummer!
The service was quiet fine and the staff was very friendly. We ordered two burgers one veggie and one cheese burger. I took the garlic mayo and if you really want to kiss your boo afterwards this mayo is not a good idea. #buffy'snewestweapon. I love garlic and this mayonnaise was one of the best things that happened to me in 2016! Single 4 eva! Mayo is life…No, not really, it's actually pizza, or tacos…
After our dinner we ordered some coffee and as a little gift (probably because I made so many pictures during that whole evening) we recieved some yummy treats to take with our coffee. Such a nice thing to do, and the chocolates were okay.
It's a shame that there are so many burger diners here in Luxembourg because the JFK's has a great potential. It's rusty and totally lumber-ish…
I would say if you're really a burger fan, I mean, GO FOR IT! Or if you're at the theatre and after the movies you want to go out to have a bite, this could also a great place for you because it's near the Utopolis.
I wouldn't go if I weren't in the surrounding area because it's not situated in a practical place. Even if I had a great burger and everything was just fine this place would not be one of my first choices.
Don't forget to love yourself and always stay fresh 💕 💝


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In the early days of computers, companies used a fee-for-shared-service model for technology. It was common to pay a company like IBM rent for use of its mainframe machines. As computers became smaller and less expensive, businesses began to purchase their own equipment and the computer rental model went the way of the dinosaur. Interestingly, we're now seeing a return to that old model, but instead of computers, businesses are renting web and cloud infrastructure services for apps and storage.
This is great news for small- and medium-size companies, as building the data centers to run those services is exorbitantly expensive. By only purchasing the infrastructure cloud services that they need from large companies like Microsoft, Google and Amazon, they eliminate the risk of that huge financial investment.
Even better, we've seen recent price wars among those service providers. Some of them slashed their prices by as much as 85 percent this spring in an effort to attract and retain customers.
I sit on the board of several companies that are dependent on web services and have seen this decision to rent play out several times. A good example is Carbonite, which is launching its computer backup services across Europe and recently joined the ranks of Amazon customers for web services. The decision for Carbonite was simple: If it were to build its own data center, not only would it cost excessive funds, it would have to maintain it and then (all too soon) upgrade it. It would be akin to building its own telephone or cable company instead of simply renting what it needs from a provider like Verizon or Comcast.
While the computer rental model disappeared long ago, this rental model for infrastructure cloud and web services is here to stay. The costs for companies to build their own platform aren't going down, and it's unlikely that the rental prices are going to skyrocket any time soon. Instead, the service providers will continue to fight it out for the lion's share of customers, as volume is the key to remaining a leader in this market.
Then, providers will start to offer additional services. Similar to cell phone companies, the basic plans may remain more or less the same, but those added services are where they'll start to see real profits.
So what's a company to do in this new environment? Sit back, watch this battle of the behemoths, and enjoy the lower rental prices for as long as they can.
Charles Kane is a senior lecturer in Finance at MIT Sloan School of Management and sits on the boards of numerous publically-traded technology companies as well as several social entrepreneurial ventures. He is the former president of One Laptop per Child and coauthor of the book Learning to Change the World: The Social Impact of One Laptop Per Child


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People can experience an altered state of consciousness by staring into someone else's eyes for 10 minutes. more...
November 17 , 1973 : US President Richard Nixon insisted he was not a crook. more...
Learn something new every day
More Info... by email
Sweet and sour wings is a culinary dish in which chicken wings are paired with a sauce that has both a sugary and tangy quality. People prepare this dish in a variety of different ways. It can be served as either an appetizer or main dish.
Originating from Asian cuisine, sweet and sour wings combine two contrasting tastes in a unique and tantalizing manner. Typically, chefs either coat the wings in a specialized mixture while cooking or cook the wings separately to later be dipped into a sweet and tangy sauce. The wings themselves can be left whole or separated at the joint so that each wing actually creates two pieces. Whether the wings are separated or not, most cooks prefer to remove the pointy tips.
The key to sweet and sour wings is the sauce, which must contain a tasteful balance of both sweet and tart flavors. For the most part, chefs uniformly create the sour taste with vinegar, preferring white or cider vinegars over red or balsamic. On the other hand, cooks can use a host of different ingredients to create the sweet flavor in the sauce. For instance, some people simply use either white or brown sugar, while others prefer the fruity taste of grape jelly or apricot preserves. Still others opt for the natural taste of honey or molasses.
Some recipes for sweet and sour wings require that the sauce be added directly. Usually, people deep-fry, pan fry, or bake the wings before coating them with the sauce. Oftentimes, chefs cook the wings again after the sauce is added so that the flavor has a chance to set and adhere to the chicken. Occasionally, chefs will batter dip the chicken before frying so that the sauce, once applied, can soak into the batter, giving the wings a more intense flavor.
Certain recipes for sweet and sour wings don't use the sauce during cooking at all. Instead, people prepare the mixture for dipping the wings after they are cooked. For this style of recipe, the chicken is typically coated with a selection of spices or tasty batter to give them a little more stand-alone flavor before they are dunked into the sauce.
Many times, chefs add different twists to their sweet and sour wings to make them even more distinctive. For instance, when cooking the wings with the sauce, some chefs throw in chopped scallions, sesame seeds, or crushed peanuts. In addition, to give the dish a more Asian flare, many cooks include spices such as ginger and soy sauce. Additionally, some cooks add a bit of cayenne pepper or hot sauce to give the wings an extra spicy kick.
This dish is versatile enough to be served as either an appetizer or a main course. If being used as an entree, a side of rice or sautéed vegetables will generally complement the plate very nicely. Regardless of how the sweet and sour wings are presented, plenty of napkins should usually be included.
One of our editors will review your suggestion and make changes if warranted. Note that depending on the number of suggestions we receive, this can take anywhere from a few hours to a few days. Thank you for helping to improve wiseGEEK!


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|Latin name
|Hologymnosus annulatus - (Lacepède, 1801)
|Common name
|Ring wrasse
|Labridae - Hologymnosus
|East Indian Ocean, West Indian Ocean, Australia, Japan, The Red Sea, Indonesia, East Pacific, Central/West Pacific
|Max length
|40.0 cm (15.7")
As aquarium fish
Jumps out of open aquaria
This species is known to jump out of open aquaria.
Threat towards crustaceans
This species poses a threat towards shrimps and crabs etc., which are relatively small.
Can be a threat to small fish
This spicies might be a threat to smaller fishes.
Demand a very large aquarium when fully grown
This species needs a very large aquarium when fully grown.
Exactly how big the aquarium should be is hard to say, but the size of this species is such, that it cannot normally be kept in a home aquarium.
Grows fast
This species grows very quickly if fed well.
Threat to snails
This species likes eating snails whenever possible.
Rearranges rocks etc.
This species like to move rocks and sometimes corals in the search for food.
Sensitive during transportation
This species is very sensitive during transportation and acclimatizing into the aquarium.
Deep sandy substrate
This species needs a minimum of 2 inch (5 cm) of sand in the aquarium bottom, so it can dig itself down when afraid or needing to sleep.
Requires plenty of space for swimming.
This species revels in swimming and requires an aquarium with ample space.
This species can change gender from female to male.
When a male is needed, a female changes sex and takes on the role.
Genus description (Hologymnosus)
Hologymnosus species are very active and relatively large, they therefore need a lot of space. Has one space enough, these fish are well suited to aquarium life.
They cannot crush prey like many other Wrasses, but eat a range of invertebrates and fish, as long as they can be swallowed whole. Occasionally they can be observed smashing up their prey on rocks, into smaller pieces.
They dig themselves into the sand when feeling threatened or needing to sleep. When they are transported without sand in the container, they can sustain injury around the mouth. When selecting fish in the shop, this must be checked for.
Family description (Labridae)
Wrasses are nearly always seen in reef aquaria, since many of the species are both attractive and useful in battling a range of unwanted invertebrates like i.e. flatworms, pyramide snails.
These fish live of everything from zooplankton to large crustaceans, sea urchins and the like.
The needs and behaviour of Wrasses vary greatly, so it is vital to familiarize oneself with the specific species before buying one.
|Aquarium trade
|Indo-Pacific: Red Sea and South Africa (Ref. 11228) to the Society and Pitcairn islands, north to southern Japan, south to southeastern Australia and Rapa Island.
|English common names
|Narrow-banded rainbowfish, Ring wrasse, Ringed slender wrasse, Ringed wrasse, Ringwrasse
|French common names
|Tamarin, Labre annelé, Colombine annelée
References and further reading
Bob Fenner. Genera Hemigymnus and Hologymnosus Wrasses - Wet Web Media - (English)
Scott W. Michael. 2009. Wrasses and Parrotfishes (Reef Fishes Series Book 5) - TFH Publications / Microcosm Ltd. - (English)
Froese, R. and D. Pauly. Editors. 2014. FishBase. World Wide Web electronic publication. www.fishbase.org, version (08/2014).
|hermaphroditic, eats shrimp, eats crab, eats fish, eats snails


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Link through this for 5% Discount
Animal Health
American Veterinary Medical Association
The American Veterinary Medical Association (AVMA) is proud to offer this website to assist you and your veterinarian in working together for the benefit of your pet.
Pet Poison Helpline
Pet Poison Helpline is a 24-hour service available to pet owners wno have questions or would like assistance with treating a potentially poisoned pet.
Payment Options
Care Credit
Care Credit offers convenient monthly payment plans and can be used repeatedly for your entire family without requiring reapplication.
Pet Nutrition
Hills Pet Nutrition
The Pinecrest Veterinary Clinic recommends Hills Science Diet pet food for all stages of your pet's life. Click here for more information.
Natural Pet Supply
Natural Pet Supply is a locally owned business offering "superpremium" foods, supplies, and supplements for dogs and cats.
Microchip Providers
Pet Dental Care
AVDC: Information for Owners
This website is provided by the American Veterinary Dental College and is a useful resource for frequently asked questions regarding pet dental care.
How to Brush your Dog's Teeth
This is a YouTube video demonstrating this important tool.
Client Education
YouTube Video about Flea Education
If you want to understand flea control, please click on this link.
Subcutaneous Fluid Administration
This is a YouTube video concerning subcutaneous fluid administration in a cat.
Injection Administration
This video helps explain how to give your pet injections.


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Politics & Government
Now, the details: Banks to get nearly unlimited federal funds
WASHINGTON — Taking the wraps off its much anticipated bank-rescue plan, the Obama administration on Wednesday announced that it will provide a virtually unlimited solvency guarantee to the nation's 19 largest banks.
Shortly after Treasury unveiled details of its plan, President Barack Obama appeared before TV cameras with congressional leaders to launch what he hopes will be a quick move to replace what he called a 20th century financial regulatory system.
"This financial crisis was not inevitable," Obama said, noting that his goal wasn't to inhibit the free market but to regulate it better to prevent a repeat of the global meltdown now occurring.
Treasury Secretary Timothy Geithner unveiled the administration's bank-rescue plan on Feb. 10, and financial markets tanked as investors fretted over a lack of detail.
Markets got those details Wednesday and the Dow Jones Industrial Average initially recovered from a loss of 200 points in mid-afternoon trading. However, that rally faded, and the Dow closed the day down 80.05 points to 7270.89. Other market indexes were off by similar margins.
While investors appeared to cheer the confidence-boosting design of the Capital Assistance Program, it may prove less popular with taxpayers because it amounts to a blank check to ensure that the top banks — those with assets over $100 billion — remain solvent.
The plan works like this: Through the end of April, federal regulators will pore over the books of the 19 largest banks — such as Citigroup, Bank of America, Wells Fargo and others. They'll be looking at conventional measures such as the composition of a bank's cash on hand, and at unconventional ones, such as how financial firms are valuing complex and opaque investments that are often shorthanded as toxic assets.
The idea behind the so-called stress tests is to gauge if the banks have enough capital to cope with a more severe downturn than even today's — one in which the economy contracts by 3.3 percent and the unemployment rate tops 10 percent. That's far from the worst-case scenarios that some of the gloomier forecasters predict.
"Supervisors will work with institutions to estimate the range of possible future losses and the resources to absorb such losses over a two-year period," said a joint statement from four federal bank regulators — the Federal Reserve, Federal Deposit Insurance Corp., Office of the Comptroller of the Currency and the Office of Thrift Supervision.
At the end of the exercise, if it's determined that banks lack enough capital to weather such a storm, they'll be given six months to raise more capital from private investors or to ask for a capital buffer from the government.
"The more specificity, the less uncertainty, the more it does provide banks an opportunity to raise private capital . . . is frankly the right way to go. It clearly is a time frame that I think is reasonable," said Stuart Hoffman, chief economist for PNC Financial Services, one of the 19 firms that will be put through the stress test.
If a bank is unable to raise private capital and needs to get capital from the federal government, it would do it in exchange for "convertible mandatory preferred shares." They could be converted into common stock on an as-needed basis, which would inject new capital into the bank. The government would become a shareholder in the company through its ownership of common stock.
Banks don't have to complete the stress test to apply for this capital buffer. Citigroup is expected to get a fresh injection of capital through this program in coming days. In exchange, the government is expected to take a stake as high as 40 percent.
The administration's plan has two goals. One is to ensure that banks have adequate capital cushions to withstand any downturn. The other goal is to restore investor confidence by showing that these big financial firms have access to as much money as they need, because the government is willing to invest as needed.
How much will it cost? No one is saying.
There's no price tag on the CAP, at least until the stress tests are over in April. If most of the 19 banks were determined to need additional capital, the Obama administration would have to seek much more Wall Street bailout money from Congress.
"The fact is there is no explicit cap on the assistance that can be provided under this program," said one senior government official on the condition of anonymity to speak freely.
Whether the plan will work depends in part on whether other components of the administration's rescue effort prove effective. Those include the public works spending envisioned in the $787 billion stimulus plan and an effort coming next week from the Federal Reserve to serve as the buyer of last resort for pools of securities backed by loans for new cars, students, small businesses and credit-card debt.
Few analysts are willing to guess whether Obama's plan ultimately will work.
"I don't know what its going to take to calm the markets at this point, because everyone is just so paranoid that it's hard to know," said David Wyss, chief economist for the rating firm Standard & Poor's in New York.
To ask a question about this story or any economic question, go to McClatchy's economy Q&A
Congress set to ease travel restrictions to Cuba
GOP hates earmarks — except the ones its members sponsor
Bernanke: This isn't nationalization (experts aren't so sure)


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Nationwide Health Properties, Inc. (NHP) incorporated in October 1985, is a publicly traded real estate investment fund (REIT) that invests in senior housing facilities, long-term care facilities and medical office buildings throughout the United States. NHP generally acquires real estate and then leases the assets under long-term triple-net leases to senior housing and long-term care operators and various types of leases to multiple tenants in the case of medical office buildings. As an REIT specializing in healthcare real estate, NHP provides a focused investment strategy with a diversified portfolio. NHP employs a conservative, long-term approach to real estate investments with an experienced professional management team having extensive operating, real estate and finance backgrounds.
Contact Information
Street: 610 Newport Center Drive, Suite 1150
City: Newport Beach
State: CA
Zip Code: 92660
Phone Number: 949-718-4400
Fax Number: 949-759-6876
Email: firstname.lastname@example.com


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Dolls !! Here are some referral links and coupons codes you can use when making some purchases. Just click the highlighted words and it will directly link you to each website.
Ebates – Earn 10$ when you sign up, make sure you add the email email@example.com to add your referral.
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Clarria Cosmetics – Referral link click here
For 10% Off your purchase used the code : clarria10 at checkout..
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Muddy Body – for 10% off your entire purchase use the code (KRISV10) at checkout !


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Media Information
The following information is provided to assist members of the media covering Lake Dallas ISD. If the information you are looking for is not here, or you need additional information, please contact the Lake Dallas ISD Director of Public Information at 940-497-1525.
Visiting Lake Dallas ISD Schools
Members of the media wishing to visit a Lake Dallas ISD campus should first contact the Lake Dallas ISD Director of Public Information at 940-497-1525 prior to arriving on campus. Students are only to be interviewed by the media with prior consent from a parent or legal guardian, and with a member of the Lake Dallas ISD communications department present.
Media Contacts
Media inquiries should be directed to the Lake Dallas ISD communications office at 940-497-1525. Members of the media may also e-mail directly: Melaynee Broadstreet, Director of Public Information


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Swiss back tighter asylum rules
Swiss voters have overwhelmingly backed a controversial move to tighten asylum restrictions amid a spike in the number of refugees in the country.
Almost 80% of voters approved changes made to the asylum law last September, final results of a referendum said.
Under the new rules military desertion is no longer a reason for granting asylum, and people cannot now apply through Swiss foreign embassies.
About 48,000 people are in the process of seeking asylum in Switzerland.
The BBC's Imogen Foulkes, in Geneva, says Switzerland has a long tradition of generosity towards asylum seekers - its proportion of refugees per head of population is twice the European average.
But the number of asylum seekers is rising sharply and is at its highest in a decade.
That, coupled with sharp rises in immigration overall, has led to public concern that too many people are coming to Switzerland, our correspondent says.
'Economic reasons'
Human rights groups and left wing parties gathered enough signatures to force Sunday's referendum, in a bid to get the government measures withdrawn, warning that they could lead to discrimination.
Speaking after the result, the groups described the outcome as "a disaster for asylum seekers and refugees" that left "no winners".
One of the most controversial changes was the removal of military desertion as a valid reason for asylum.
Desertion is the key reason cited by Eritreans -the largest group of applicants last year - whose country imposes unlimited military service on all able-bodied men and women.
The result also removes the provision - unique in Europe - that enabled asylum seekers to claim asylum in Swiss embassies around the world.
Celine Amandruz of Switzerland's largest party, the populist Swiss People's Party (SVP), however welcomed result, telling AFP news agency that that nine out of 10 people who sought refuge in the wealthy country did so "for economic reasons".
"There is clearly a need to change this system," she said.
Switzerland counts one asylum seeker for every 332 inhabitants. The European average is one asylum seeker for every 625 inhabitants.


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Headquartered in Nottingham, Addo produces more than 287 million packs of chilled savoury pastry products every year. The business manufactures a range of own brand and branded products including sausage rolls, hot pies, slices, pork pies, scotch egg products and quiches, which it supplies to the UK's leading names in food retail including all the major supermarkets.
Alongside its market-leading ranges of premium pastry products such as Tottle pork pies, Walls savoury pastry and Pork Farms pork pies, the business launched its 'Too Good to Be' range of gluten-free sweet and savoury pastry products last year - the first of its kind.


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Choose your strategy, Steer the plane to missiles or escape and make them destroy themselves with your driving skill. That's so cool if you can let the missiles approach but do not touch any part of your fighter and your fighter will have an invincible shield in seconds at once. Join the game Go Plane Online and have a good time.
Click and hold or tap and slide to navigate the jet fighter.


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More Practitioners
About Ezgi
for booking a class: https://yogawithez.simplybook.it/v2/
Vinyasa Yoga for All - Wedn. evening 5.45-7pm
£9 per class
£48 - 6 class pass
£75 - 10 class pass
My yoga journey has started in 2010. Yoga has always been an inspiration to live healthy and think positive for me.
I qualified as a British Wheel of Yoga (BWY) teacher which always encourages us to teach with a strong emphasis of breathing and relaxation throughout the sessions.
Yoga is one of the greatest ways of taking quality "me time" from everyday life. So why not give a chance to yoga and start your own journey?
"Our body is the bow and the asanas are the arrows to hit the target- the soul." BKS Iyengar
Ezgi's Treatments
Yoga Private Tuition
Ezgi's Events
Mindful Vinyasa Yoga Wed 6th Nov to Wed 27th Nov 2019
Breathing and Meditation Class - FREE - Tue 3rd Dec 2019
Mindful Vinyasa Yoga Wed 4th Dec to Wed 11th Dec 2019
YOGA BASICS Course for Beginners and Improvers Sat 11th Jan 2020
YOGA BASICS Course for Beginners and Improvers Sat 18th Jan 2020
YOGA BASICS Course for Beginners and Improvers Sat 25th Jan 2020
Ezgi's Cancellation Policy
Ezgi Acar
Energetic Yoga Flows
Contact Ezgi


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The Bachelor's Degree programme in Applied Mathematics at the University of Verona includes two main concentrations, or curricula: the first focused on financial and economic issues, and the second on computational modelling. Both curricula are aimed at providing students with a solid modelling and numerical-algorithmic background.
At the end of their programme of study, graduates who wish to continue their academic career, will have the opportunity to choose between the Master's Degree programme in Mathematics, offered by the Department of Computer Science, and the Master's Degree programme in Banking and Finance ("Quantitative Finance" curriculum), offered by the Department of Economics.
A wide range of internship opportunities are also available, either within the research teams of the University of Verona or at external facilities. Graduates in Applied Mathematics can find employment in banking and financial institutions, insurance companies and research departments of Italian and foreign companies.
Academic supervisor: Prof. Giuseppe Mazzuoccolo
For further information, please contact the Department's Secretariat
© 2002 - 2019
Verona University
Via dell'Artigliere 8, 37129 Verona | P. I.V.A. 01541040232 | C. FISCALE 93009870234


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We'll be doing wall-to-wall coverage of the off-the-wall climate talks in Paris this week, but I can hardly do better in setting this up than to recall some of the testimony I presented to the House Foreign Affairs Committee back in 2011. Here are a couple of excerpts:
I will begin with my contentious conclusion, which is that the international diplomacy of climate change is the most implausible and unpromising initiative since the disarmament talks of the 1930s, and for many of the same reasons; that the Kyoto Protocol and its progeny are the climate diplomacy equivalent of the Kellogg-Briand Pact of 1928 that promised to end war (a treaty that is still on the books, by the way), and finally, that future historians are going to look back on this whole period as the climate policy equivalent of wage and price controls to fight inflation in the 1970s. . .
One of the problems of the sheer sprawling nature of climate change science and policy is that it became something of an all-purpose issue on which advocates could attach their pet ideas and concerns. The idea of climate adjustment assistance has revived at the UN an old idea from the 1970s—what was called then the "New International Economic Order." The premise of the New International Economic Order, as explained at the time by West Germany's Chancellor Willy Brandt, was that there needed to be "a large scale transfer of resources to developing countries." This was back in the hey-day of post-colonial Western guilt, and it came to an abrupt end in the 1980s when President Reagan forcefully repudiated it at a UN summit in, coincidentally, Cancun.
But climate assistance has revived the old idea of requiring wealthy nations to indemnify poor nations. The German newspaper Neue Zurcher Zeitung observed shortly before the Cancun summit last year: "The next world climate summit in Cancun is actually an economy summit during which the distribution of the world's resources will be negotiated." What prompted this conclusion was a candid admission from a UN official closely involved with the climate negotiations, German economist Ottmar Edenhoffer: "But one must say clearly that we redistribute de facto the world's wealth by climate policy. Obviously, the owners of coal and oil will not be enthusiastic about this. One has to free oneself from the illusion that international climate policy is environmental policy. This has almost nothing to do with environmental policy anymore."
I expect we'll hear a lot of this kind of talk coming out of Paris, because these folks just can't help themselves when they want to help themselves to your money.


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The enormous volume, velocity and variety of data flooding the enterprise, along with the push for analytics and business intelligence, is creating a massive challenge that is overwhelming traditional storage approaches. As the demand for capacity continues to escalate, companies must be able to effectively and dynamically manage the storage supply, but also the demand for storage resources. The key is to optimize the infrastructure through standardization and virtualization, and replace manual tasks with policy-based automation.
Latest insightful articles delivered straight to your inbox weekly


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You can pronounce GIF however you like! The creator of GIF argues for a JIF-like pronunciation but for us, we prefer to be straight up hard Gs.
Plus, Jive the jift of jif just doesn't have quite the same ring to it.
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text:
Evaluating Catheter-Based Mitral Valve TherapiesLessons Learned and Future Directions
Author + information
- Published online December 29, 2015.
Author Information
- Anelechi C. Anyanwu, MD and
- David H. Adams, MD∗ (david.adams{at}mountsinai.org)
- ↵∗Reprint requests and correspondence:
Dr. David H. Adams, Department of Cardiovascular Surgery, Mount Sinai Medical Center, 1190 Fifth Avenue, New York, New York 10029.
- clinical trials
- mitral valve repair
- transcatheter mitral valve repair
- transcatheter mitral valve replacement
In this issue of the Journal, the EVEREST II (Endovascular Valve Edge-to-Edge REpair Study II) investigators have reported the 5-year results of their randomized trial comparing percutaneous edge-to-edge mitral valve repair, using the MitraClip device (Abbott, Menlo Park, California), with mitral valve surgery (1). The primary outcomes of the trial have been previously published (2). We congratulate the investigators for concluding an important pivotal study in the emerging field of transcatheter mitral valve therapy and for providing key information on percutaneous edge-to-edge mitral repair. We have already learned 4 principal lessons from the EVEREST II trial: 1) the clip procedure is safe; 2) the clip may be applied to both degenerative and functional subtypes (although with less efficacy in reducing mitral valve regurgitation compared with surgery); 3) patients may safely undergo surgical reintervention if the clip fails; and 4) improvements in symptoms occur after successful clip treatment. The U.S. Food and Drug Administration (FDA) has now approved the device for use in the United States for patients with significant symptomatic degenerative mitral regurgitation (MR) who are too high risk for surgery. The role of clip therapy in functional MR has not been established and is the subject of an ongoing U.S. trial (3), but the device is widely used in Europe for this indication (4).
The current report provides new data on the midterm performance of the clip in the EVEREST II study. Device failure and need for surgical intervention were uncommon after the first year post-clip implant, and importantly, midterm mitral stenosis occurred in <1% of implants. Clip repairs did have a higher midterm incidence of reoperation and recurrence of moderate or severe regurgitation compared with surgery; however, patient survival was the same (1).
The EVEREST II trial was pioneering and, despite concerns regarding the trial design and conduct (5), the experience and observations from this study provide future investigators with a framework on which to conduct trials of transcatheter mitral valve therapy (Table 1). We have previously discussed the unique features that will set apart trials of transcatheter mitral valve replacement (TMVR) from those of transcatheter aortic valve replacement (6). The EVEREST II study demonstrates that trials of percutaneous mitral valve repair pose even greater challenges. Several lessons gleaned from the EVEREST II study can help form the framework for future trials of transcatheter mitral valve therapy.
Study Populations
A major limitation of EVEREST II was the inclusion of both degenerative MR (for which the role of surgery is certain) and functional MR (where the role of surgery and transcatheter intervention remain uncertain). This greatly limited interpretation and applicability of the results. The trial was unable to draw conclusions regarding the role of the clip in either functional or degenerative etiology, because neither was specifically studied. Even within the degenerative group, there is a spectrum of pathology and lesions that have different implications for valve repairability (7). Although there is an obvious attraction to study all-comers, doing so risks the same predicament of EVEREST II, as it can be impossible to draw reliable conclusions about relevant clinical subsets. To demonstrate effectiveness of a percutaneous mitral therapy, study of a well-defined etiology (such as degenerative) and lesion subset (such as P2 prolapse due to chordal rupture) will likely yield results that are more definitive.
Inclusion Criteria
To allow generalizability of results, inclusion criteria should closely mirror current practice and agreed indications for intervention. In EVEREST II, the inclusion criteria included asymptomatic or symptomatic patients with moderate to severe (3+) regurgitation (8), whereas current and previous guidelines recommend mitral valve surgery for only patients with severe (4+) regurgitation (9–11). Only 24% of patients in EVEREST II had severe MR, as defined by their core laboratory assessment (2). The majority (71%) had moderate to severe regurgitation—some of these patients, particularly those without symptoms, may not meet agreed criteria for intervention in current practice. Indeed, although indication for surgery was a pre-requisite for trial entry, about one-third (13 of 41) of patients who had a failed attempt at device placement did not undergo subsequent surgical operation during the initial study period (5), raising the question as to how strong an indication for surgery had existed in those patients in the first place. It therefore becomes difficult to extrapolate the EVEREST II results, as there is the possibility that the clip was used on less-severe stages of disease. Of note, 5% of patients in the study had mild or moderate MR, and should not have met criteria for study inclusion; this highlights the importance of core laboratory adjudication of echocardiographic images before recruitment of patients into trials.
Quality of Centers
Although the paper did not provide a breakdown of volume and outcomes among trial centers (1), this was a likely variable. The mean number of clip procedures per center was 5 and the mean number of surgical procedures was 2.5. Most probably there was considerable variation with relatively few high enrollers and others as low enrollers. Procedural outcomes may be linked to experience with the new technology and with previous experience, such that low enrollers may remain in early stages of the learning curve for an entire study. Additionally, a high enroller with suboptimal techniques and outcomes could negatively influence measured effectiveness of a new device. Although it is desirable to include many centers to allow quick enrollment in a trial, a more restricted number of participating centers with balanced recruitment volume and procedural quality will likely give a more robust assessment of effectiveness of a novel device, albeit at the expense of a longer recruitment period. It may be argued that including more centers presents a pragmatic real-world experience, but it should be remembered that the role of trials of new devices is not to determine how they perform in the real world, but to determine whether they are safe and effective when used in a proscribed and ideal manner.
To test the effectiveness of percutaneous versus surgical repair, trialists should choose surgical centers on the basis of expertise in mitral valve repair, rather than expertise in mitral valve surgery (which includes also valve replacement), as the skills for replacement and repair are not interchangeable. The EVEREST II investigators do not report whether specific surgical expertise or volume in mitral valve repair was a prerequisite for the 37 participating centers (2,8). Public information from the FDA in their executive summary of EVEREST II, however, indicated that a high proportion of patients with adverse events in the surgical arm were operated on by surgeons who performed <15 mitral valve repairs per year (5). Utilizing low-volume mitral valve repair surgeons to perform trial procedures may not allow measurement of the true effectiveness and safety of surgery. Of note, the surgical arm of the EVEREST II trial had a 14% valve replacement rate, and the only significant predictor for valve replacement in the surgical cohort was the presence of bileaflet prolapse, which was present in 47% of the replaced valves (12). In experienced repair centers, bileaflet prolapse should not be a strong predictor for replacement, as high-volume mitral repair surgeons routinely repair such valves at a rate exceeding 95% (13–16). In addition, bleeding, which was the main complication in the primary safety composite outcome (2), was weighted toward low-volume centers (5). All these suggest that center volume and experience could have confounded the results of EVEREST II. For future trials, surgical center selection should be on the basis of the ability to deliver guideline-recommended therapy for the mitral disease being studied at a rate pre-specified by investigators. At a minimum, the researchers should disclose the full dataset, including enrollment volumes and key variations per site.
Patient Compliance
Maintaining consent in trials of percutaneous devices versus surgery can be difficult, as the EVEREST II trial demonstrates. Compared with 3% in the clip arm, 16% of those randomized to surgery withdrew from the study after randomization (2). Although these patients were included in an intention-to-treat analysis (2), in reality they cannot be seen as a reflection of the effectiveness of a procedure (but rather the effectiveness of a strategy). From the device perspective, what is most important is the effectiveness of the procedure in patients who actually received the procedure, or in whom it was attempted. In effectiveness or safety trials comparing percutaneous valve therapy to surgery, the results of all analyses (intention to treat, as treated, per protocol, and so on) should be presented to fully evaluate the trial.
Late follow-up also was an issue in EVEREST II. The 12-month completeness of follow-up was 94%, whereas at 5 years it was 87% in the clip group and 70% in the surgical group (1). The higher late follow-up rates in the clip group could be indicative of bias in perception by patients or bias in follow-up by recruiting centers. Such biased follow-up could have bearing on study outcomes (better follow-up could translate into superior medical management and surveillance, for example). Trial design should take into account these considerations. Preferably, the source of patients for entry should be patients who have already accepted surgical treatment (and are then introduced to a concept of a trial of a less-invasive approach), as opposed to patients with a disease who are primarily seeking the least invasive therapy. Randomization after anesthetic induction is one strategy that can circumvent withdrawals after randomization.
Inclusion of Young and Low-Risk Patients
Early technical failures are inevitable with any percutaneous (or surgical) repair. As failures will generally necessitate surgical intervention, the frequency of failures and the outcomes of patients with failed techniques or devices is particularly relevant. In EVEREST II, 21% of patients who were randomized to a clip subsequently underwent surgical operation within the first year because of residual regurgitation (12). Of these patients, 46% had the valve replaced, and 54% were repaired (12). The overall valve replacement rate in the first year for patients who received the clip was 10%. Therefore, a young asymptomatic patient with mitral valve prolapse undergoing clip placement could have up to a 10% probability of ending up with a valve replacement. In contrast, the same patient having surgery in a reference center should expect a valve replacement rate below 1% (13).
The key factor driving replacements (as opposed to repair) after failed percutaneous clip repair appears to have been leaflet injury by the clip (5,12). Therefore, the possibility of permanent injury to the valve should be considered when selecting patients for trials of repair devices. If devices have an effect on the valve that is irreversible, or only partially reversible, then testing should be avoided in young and asymptomatic patients (as surgical valve replacement is particularly undesirable and negatively impacts life-expectancy). Such devices should preferably be tested on patients at high surgical risk, patients in whom valve replacement would not be an unreasonable option (such as rheumatic or functional etiology), or patients in whom the consequences of valve replacement may be less pronounced (such as older patients). All TMVR devices, by definition, would also fall into the category of devices with an irreversible effect on the valve. Devices under development for investigation and use on low-risk patients should not permanently damage the valve in a way that could compromise subsequent surgical repair.
The essence of mitral valve intervention is resolution of MR. All patient benefits stem directly from this effect. In primary MR, "the disease" is MR (11), and its elimination should be the primary effectiveness endpoint. However, its elimination in secondary MR, although necessary, is not sufficient to evaluate the clinical utility of surgical or transcatheter mitral valve intervention. Primary effectiveness endpoints in secondary MR should be chosen to demonstrate clinical improvement.
The EVEREST II investigators used a composite primary endpoint of death, freedom from surgery for mitral valve dysfunction, and freedom from grade 3+ or 4+ MR (73% in the surgery group vs. 55% in clip group) (2). This primary endpoint was controversial and was challenged by the FDA, which believed freedom from 2+ (moderate) or greater regurgitation was a more appropriate measure (5). Indeed, a post-hoc analysis of EVEREST II data with freedom from more than 2+ (rather than 3+) regurgitation as the main driver of the composite endpoint in a modified intention-to-treat population found that only 31% of clip patients would have met the more stringent primary endpoint, compared with 77% of surgical patients (5). Future trials should provide similar sensitivity analyses to test key assumptions around primary endpoints, so readers can attain a complete picture of the data.
It is also problematic to have death as part of an effectiveness endpoint for mitral repair devices, as mitral valve repair is not typically performed to enhance short-term survival. In a strict sense, death should be part of a safety endpoint, as should other major adverse major clinical events. Composite safety endpoints should generally include death, major adverse cardiac and cerebrovascular events, major infective complications, major vascular complications, major organ dysfunction, major bleeding episodes, and other events specific to the procedures or mitral disease being studied.
The inclusion of 2 units (U) or more blood transfusion as part of the primary safety composite endpoint in EVEREST II heavily skewed the safety outcomes in favor of the clip (15% adverse events with clip vs. 48% with surgery). If blood transfusion (which was present in 45% of those who had surgery) is excluded, the adverse event rates were 5% for the clip and 10% for surgery (2). A major driver for blood use in the surgical arm was the addition of concurrent procedures (such as coronary bypass, maze, or other valve surgery) in almost one-half the surgical patients—considering that no clip patients received concomitant procedures, this adds another unmeasurable source of bias to the study (5). Ideally, the 2 arms of a percutaneous versus surgery trial should differ only in the mode of delivery of valve therapy, and not also in concomitant application of other procedures. Where bleeding is used as part of a safety endpoint, investigators should consider the approach proposed by the Mitral Valve Academic Research Consortium (MVARC) (17), which requires the presence of overt bleeding and also considers drop in hemoglobin and clinical sequelae of bleeding, rather than transfusion alone, to classify bleeding as an adverse event. MVARC defines criteria for minor, major, extensive, life-threatening, and fatal bleeding events, and on the basis of MVARC classification, 2 U of blood transfusion (used in the EVEREST II as part of the safety endpoint) would constitute a minor bleeding event, 3 U transfusion would be major, and 4 U transfusion (or a hemoglobin drop of 4 g/l in 24 h) would be extensive bleeding. Bleeding into critical organ space (such as causing cardiac tamponade or cerebral effects) would be life-threatening, regardless of whether blood was transfused. The bleeding endpoint chosen should be relevant for the procedure being studied—for surgical procedures where minor blood loss is obligatory, minor bleeding should not constitute a safety endpoint (but extensive bleeding should), whereas for a trial of 2 percutaneous approaches, even a minor bleed may be deemed relevant.
Finally, investigators should resist the temptation to evaluate device effectiveness on the basis of 1-year follow-up alone. We have learned more about the clip therapy from this 5-year report that would not have been known if the study closed after the 12-month primary report. Other investigators should follow the model of EVEREST II and maintain follow-up for at least 5 years after study closure, as this midterm information is critical for durability evaluation.
Inclusion Criteria
The EVEREST II investigators specified the key study inclusion criterion as patients who are candidates for mitral valve repair or replacement. The clip, however, is a mitral valve repair device and should be an alternative to surgical repair and not surgical replacement. Thus, the results are confounded because: 1) allowing valve replacement candidates resulted in a lower frequency of surgical repair both directly (by allowing surgeons a priori to decide pre-operatively that a patient would have a replacement) and indirectly (by permitting surgeons to convert intraoperatively to replacement without impact on study endpoints); and 2) percutaneous repair will likely be less efficacious in those patients whom a surgeon has decided a priori would have a valve replacement (if undergoing surgery). In surgical arms of repair device trials, a surgical valve replacement should be seen as a failure to meet an effectiveness endpoint in the same way that a valve replacement after a failed percutaneous device is deemed a therapeutic failure. In EVEREST II, the 14% in the surgical arm who received valve replacement should have been deemed surgical failures to make a fair comparison with percutaneous repair. Future trials of percutaneous or surgical repair devices should pre-specify surgical repairability as an inclusion criteria, and any valve replacement (surgical or percutaneous) should be seen as a failure.
We applaud the EVEREST II investigators for pioneering a new field of investigation and therapy in mitral valve regurgitation. The lessons we have learned from this trial will allow us to better conduct and understand trials on newer percutaneous repair devices, which will likely emerge over the next decade.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Adams is the National Co-Principal Investigator of the Medtronic CoreValve US Pivotal Trial; and the Icahn School of Medicine and Mount Sinai receive royalties related to intellectual property for valve repair devices from Edwards Lifesciences and Medtronic. Dr. Anyanwu has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2015 American College of Cardiology Foundation
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- ↵ClinicalTrials.gov. Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial. Available at: https://clinicaltrials.gov/ct2/show/NCT01626079. Accessed November 4, 2015.
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- ↵U.S. Food and Drug Administration. FDA executive summary: Abbott Vascular MitraClip clip delivery system. Available at: http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/CirculatorySystemDevicesPanel/UCM343842.pdf. Accessed November 4, 2015.
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text:
Rejoice, Rejoice Believers!
Good morning class, it is "Gaudete" Sunday. The word "Gaudeo" in Latin means "Rejoice". No doubt you noticed that we lit the Rose Candle on the Advent Wreath today. That's becuase we blend the white color of joy and expectation with the penetential purple color of preparation. This Rose Candle is the candle of "Gaudete Sunday". We celebrate the cardinal feast of the Third Sunday in Advent because of the nearness of the Holy Child of Bethlehem.
By the way, Rose vestments were permitted to be worn this day in the church year; one of only two Sundays in the Church year when the color Rose is used. The other Sunday is "Laetare" Sunday. The word "Laetare" means as in the introit psalm for that Sunday"O be Joyful O Jerusalem". We celebrate that cardinal feast on the Fourth Sunday in Lent again because of the nearness of Christ's death and resurrection in Holy Week and Easter.
The scripture calls on us to "Rejoice" this day. The prophet Zephaniah calls out to "Rejoice with all your heart O Daughter of Jerusalem." He goes on to say "The Lord is in your midst."
In Philippians we read "Rejoice in the Lord always" and "The Lord is near".
John the Baptist recognized the innate sinful nature of the human condition; he greets those following him with the words; "You brood of vipers!" He seems to have gotten up on the wrong side of bed that day except that he knew that those who had two coats were not predisposed to share with those who had none. He also knew that tax collectors tended to exploit their position in life by taking advantage of their power and taking in more than the just amount owed from the tax payer. Sound familiar? Likewise extorion from soldiers was not unusual, and on it went and when asked what was necessary for them all to repent, John merely said, do the right thing; share what you have with others, collect only what is owed to you, and be done with extortion and be content with your wages. He concluded the passage with the Gospel proclamation, and a joyful one it was, that the one to come after him would baptize us not just with water but with the Holy Spirit and with Fire. Rejoice then in the proclamation of the Gospel. Listen to it and proclaim it in your lives!
These are the words of the Introit Psalm of Gaudete Sunday in ancient times. "Rejoice in the Lord always" and "The Lord is near".
You meay notice that this joy comes to us at a dark time of year. Its not the shortness of the days that produces this darkness alone, but there are some dreadful events near and far away that reflect a dark dimension of the human spirit. The shootings in San Bernadino and Colorado among them. Good heavens there's even the business of a runaway train on the T. And much more darkness beside of allsorts.
It is in the midst of this very darkness that we light this beautiful Rose candle and pray the Collect of the Day "Stir up your power, O Lord, and with great power come among us, and because we are sorely hindered by our sins, let your bountiful grace and mercy speedily help and deliver us".
Sorely hindered by so many sins indeed. So much violence, so much hatred. So little love. Or so it seems. Particularly so when we spend too much time glued in to the media and fix our gaze on the chronicle of the sins of humankind, its violence and its hatred.
Gaudete Sunday stands in stark contrast to all this sin. "Stir up Your Power". Yes, "because we are sorely hindered by our sins". "Stir up your power and come among us." This is precisely the promise of Gaudete Sunday. We have the promise of the nearness of God. In just a few short days we will celebrate the Birth of the Holy Child in the Manger.
If we were to read our history books, we would notice that this is by no means the darkest of times. And if we read our Sacred History we may remember how heroicly our ancestors in faith faced the darkness with amazing transformational courage.
Take Dame Julian of Norwich for instance. Not a household name perhaps but familiar to all who study the history of Christian Spirituality in any depth. Dame Julian was born on November 8, 1342 and died in 1416AD. She was an anchoress. which is to say, she separated herself from secular society, not as a hermit, but as one set aside in a small cell at the church in Norwich, England. She devoted herself to prayer and Eucharistic life and made herself available to folks who would seek her out for spiritual guidance and counsel, through a small window in her enclosure.
She was sought out by many because the times in which she lived were not just dark times but catatrostophic. The Black Death and the Peasant Revolts were the scourge of contemporary life for her and her beloved people. Contemporary theology was legalistic and judgmental. But Julian saw God as loving and compassionate and seeking the salvation of all. She was accused of believing in universal salvation. She believed that behind the reality of hell there was the greater mystery of God's love. She saw the universe resting in God's hands as it were a hazel nut, beloved of God, and that each soul within was the beloved of God.
She is believed to be the first woman to have written a book in the English language. "Revelations of Divine Love" is a masterpiece of midaeval mysticism and I commend it to you for reading.
There is an expression she used with quiet confidence to all who came to her, in whatever state of anxiety, fear, depression, guilt or despair. She very quietly assured all who came to her; "All shall be well and all manner of thing shall be well".
Nowadays we might say; "Keep calm and carry on."
But it is the same message. Our times may seem like dark times but when compared to the times in which Dame Julian lived and so many others, we certainly can rise to the occasion.
Particularly so in our spirituality. We are called to Rejoice. More than that we are called to recognize the nearness of Jesus within our hearts and in the hearts of those around us.
And so; "Stir up your power O God and come among us, and because we are sorely hindered by our sins come speedily with your Grace and Power."
In the Name of the Holy, Blessed and Undivided Trinity. Amen
Fr Paul


text:
Sherlock Holmes: The Man Who Disappeared
Directed by: Richard M. Grey
Screenplay by: Sir Arthur Conan Doyle
Cast: John Longden
Campbell Singer
Hector Ross
Walter Gotell
Release Date: 1951
IMDB Storyline:
A Sherlock Holmes story in which the detective investigates the disappearance of a missing husband who is traced to an opium-den in Wapping, where the proprietor denies knowledge of him. Holmes finds him upstairs in a pool of blood, is attacked and fights his way out. After various enquiries he solves the mystery. Originally the pilot for a proposed television series, this film ended up as a B-movie short.