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Treatment of Chronic Thromboembolic Pulmonary Hypertension: The Role of Medical Therapy and Balloon Pulmonary Angioplasty
Fernandes TM, Poch DS, Auger R. Treatment of Chronic Thromboembolic Pulmonary Hypertension: The Role of Medical Therapy and Balloon Pulmonary Angioplasty. Methodist DeBakey Cardiovasc J. 2016;12(4):205-212.doi: https://doi.org/10.14797/mdcj-12-4-205
Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable disease when treated with pulmonary thromboendarterectomy (PTE). However, even at experienced surgical centers, nearly one-third of patients with CTEPH will be deemed inoperable for reasons including distal disease, comorbidities, or out-of-proportion pulmonary hypertension. It is in these patients with inoperable CTEPH that pulmonary hypertension (PH)-targeted medical therapy and balloon pulmonary angioplasty have potential therapeutic value.
Previous unblinded cohort trials have assessed PH-targeted medical therapy in various subpopulations of CTEPH patients using epoprostenol, treprostinil, sildenafil, bosentan, and iloprost, each demonstrating measurable pulmonary hemodynamic effects. However, riociguat, a soluble guanylate cyclase stimulator, is the first FDA-approved therapy for inoperable CTEPH to demonstrate both an improvement in functional capabilities (6-minute walk time) as well as significant gains in secondary pulmonary hemodynamic end points in a large placebo-controlled trial.
Balloon pulmonary angioplasty is an interventional procedure using telescoping catheters placed in the pulmonary arteries, through which wires and balloons are used to mechanically disrupt chronic clot material and relieve pulmonary vascular obstruction. Contemporary case series from multiple centers worldwide have demonstrated pulmonary hemodynamic improvement with this approach.
As a result of these advances, patients with inoperable CTEPH who had few options as recently as 5 years ago now have alternatives with emerging evidence of therapeutic efficacy.Keywords
pulmonary hypertension , chronic thromboemboli , pulmonary hypertension targeted medical therapy , balloon pulmonary angioplasty
Since the 1980s, pulmonary thromboendarterectomy (PTE) has been recognized as an effective treatment for selected patients with chronic thromboembolic pulmonary hypertension (CTEPH). When the surgery was performed at an experienced center, there was a decline in perioperative mortality rates, and long-term pulmonary hemodynamic and functional status benefits were realized; as a result, the procedure was regarded as a potential cure for this form of pulmonary hypertension.1–3 However, it has also become evident that there are identifiable CTEPH patients for whom PTE surgery is not an option—notably, those with technically inoperable chronic thromboembolic disease and those whose comorbidities preclude a reasonable expectation that surgery will have short- or long-term benefits. This observation was underscored in the results of the International Prospective CTEPH registry, where 36.6% of enrolled patients were deemed inoperable. The most common reasons included surgical inaccessibility of disease (47.8%), comorbidities (13.4%), and an "imbalance" between the degree of pulmonary vascular resistance (PVR) and the amount of accessible chronic thromboembolic disease (10.1%).4 Additional patient groups that present unique problems include those with symptomatic, residual pulmonary hypertension (PH) following PTE surgery as well as CTEPH patients with operable disease awaiting surgery with severe pulmonary hypertension and right heart dysfunction. It is in these patients that a role for PH-targeted medications and possibly balloon pulmonary angioplasty exists. In published recommendations from both the 2013 World Symposium of Pulmonary Hypertension in Nice5 and the 2016 ERS/ESC Pulmonary Hypertension Guidelines,6 these therapies should be considered for CTEPH patients when a surgical option has been excluded.
|Pulmonary Hypertension Targeted Medical Therapy
Inoperable Chronic Thromboembolic Pulmonary Hypertension
Several clinical trials have examined the efficacy of PH-targeted medical therapy in CTEPH patients with inoperable disease and in those with residual PH following endarterectomy surgery. Early investigations involved cohort, case-controlled trials that were typically small in size. A summary of seminal trials and cohort studies of PH-targeted medical therapy is presented in Table 1.
Intravenous epoprostenol and subcutaneous treprostinil have both been evaluated in retrospective cohort studies. Cabrol and colleagues retrospectively analyzed 27 patients with inoperable CTEPH who were treated with epoprostenol. After 3 months of therapy, there was a decrease in mean pulmonary artery (PA) pressure (mPAP) (56 + 9 mm Hg to 51 + 8 mm Hg), total pulmonary resistance (29.3 + 7.0 U/m2 to 23.0 + 5.0 U/m2), and an increase in the 6-minute walk test (6MWT) of 66 m. NYHA functional status improved by one class in 11 of 23 patients.7 In a single-center uncontrolled observational study, 28 patients with severe inoperable CTEPH were treated with subcutaneous treprostinil. Right heart catheterization was repeated in 19 patients after 19 + 6.3 months of treatment. Treprostinil therapy was associated not only with a significant reduction in PVR but also an improvement in the 6MWT (59 m), World Health Organization (WHO) functional class, brain natriuretic peptide (BNP) levels, and cardiac output. The 5-year survival rate was 53% compared with 16% in untreated historical controls.8 Early work in this patient group with inhaled iloprost, another prostacyclin analogue, demonstrated some efficacy, although less so than in idiopathic pulmonary arterial hypertension (PAH).9 Although the long-term benefit of inhaled iloprost in patients with inoperable CTEPH was not examined by Krug and colleagues, an acute pulmonary hemodynamic benefit was observed. With the administration of 5 ug of inhaled iloprost to 20 CTEPH patients (12 with distal chronic thromboembolic lesions), these investigators were able to show a decline in PVR from 1057 + 404.3 to 821.3 + 294.3 dynes·sec·cm-5 and a reduction in mean PA pressure from 50.55 + 8.43 to 45.75 + 8.09 mm Hg. This was accompanied by an increase in cardiac output from 3.66 + 1.05 to 4.05 + 0.91 L/min. Of note, 16 of the 20 patients were already receiving one or more PAH-specific medical therapies at the time.10
Other early studies examining the efficacy of other classes of PH-targeted medical therapy for patient with inoperable CTEPH were similarly limited. Sildenafil, a phosphodiesterase-5 inhibitor, was evaluated in a small, single-center, randomized placebo-controlled trial.11 In a 12-week pilot study, Suntharalingam and colleagues enrolled 19 patients with inoperable CTEPH to assess the benefit of sildenafil (9 patients receiving drug) in this group. Though there was no significant difference detected in the 6MWT (the primary end point), there was an improvement in WHO functional class and an average 197 dynes·sec·cm-5 difference in PVR between treatment groups. Control subjects were then transitioned to open-label sildenafil use and reassessed at 12 months. Significant improvement in 6-minute walk distance (6MWD), activity and symptom scores (CAMPHOR), cardiac index, PVR, and N-terminal (NT)-proBNP values (1000 to 811 pg/mL) were noted.11 In a larger patient group, Reichenberger and colleagues conducted an open-label study of sildenafil (50 mg 3×/d) in 104 patients with inoperable CTEPH. After 3 months of therapy, there was a modest decrease in pulmonary vascular resistance (863 + 38 dynes·sec·cm-5 to 759 + 62 dynes·sec·cm-5), with an increase in 6MWT from 310 + 11 m to 361 + 15 m; this distance further improved to 366 + 18 m after 12 months of sildenafil.12
An endothelin receptor antagonist (bosentan) was evaluated in the first randomized controlled trial in patients with inoperable CTEPH. In the Bosentan Effects in Inoperable Forms of Chronic Thromboembolic Pulmonary Hypertension (BENEFiT) trial, 157 patients (116 of whom were deemed inoperable) were randomized to either bosentan or placebo.13 There were two coprimary end points investigated: improvement in 6MWT and percent change from baseline in PVR. After 16 weeks of treatment, bosentan did not improve 6MWT (+ 2.2 m; 95% CI -22.5 to +26.8 m) but did reduce PVR 24% from baseline. A meta-analysis of the effects of bosentan on the 6MWT that included the BENEFiT study as well as eight uncontrolled cohort studies using bosentan demonstrated a significant weighted mean improvement of 35.9 m in the 6MWT.14 A new endothelin receptor antagonist, macitentan, is currently being evaluated in inoperable CTEPH in the ongoing MERIT-1 trial.15
Riociguat, a soluble guanylate cyclase stimulator and the first agent in this pharmaceutical class, was the first PH-targeted medical therapy to achieve a statistically significant improvement in 6MWD in a large, randomized, controlled trial. This resulted in FDA approval for use in CTEPH patients with inoperable disease and in those with residual PH following endarterectomy surgery. In the Chronic Thromboembolic Pulmonary Hypertension Soluble Guanylate Cyclase-Stimulator Trial 1 (CHEST-1) study, 261 patients with CTEPH (189 of whom were deemed inoperable) were randomized to 16 weeks of either riociguat (starting at 1 mg and titrated to 2.5 mg or the maximum tolerated dose) or placebo.16 In the riociguat-treated group, there was a placebo-adjusted mean change of 46 m (P < .001). Additionally, there were positive hemodynamic benefits in the treated group, with a mean reduction in PVR of 246 dynes·sec·cm-5 as well as a reduction in NT-proBNP with a placebo-adjusted least square mean difference of -444 pg/mL. Long-term follow-up of patients treated with riociguat was reported in 237 patients who continued on in the open-label CHEST-2 trial. At 2 years of riociguat use, overall survival was 93% (95% CI: 89%–96%) and clinical worsening-free survival was 82% (95% CI: 84%–92%) without additional safety concerns. After 12 weeks of open-label use of riociguat, the patients previously receiving placebo in CHEST-1 achieved a similar improvement in 6MWD to those in the extended riociguat treatment arm.17
The CHEST-2 mortality results can be contrasted with those of Scholzel et al. in an observational study of patients with inoperable CTEPH treated with PDE-5 inhibitors, endothelin receptor antagonists, prostacyclin analogs, or a combination of these.18 In this study, 32 patients were followed over a mean time period of 3.4 years. Even with advancement of non-riociguat medical therapies, the 1- and 3-year rates of freedom from clinical worsening (a composite that included death, need for IV prostacyclin, worsening functional class, or 15% drop in 6MWT) were 74% and 60%, respectively. Mortality during this time period was 34% (11 of 32 patients).18 Whether a mortality benefit will be seen in clinical practice with riociguat has not been determined.
Interpretation of survival benefit with PH-targeted therapy is difficult given the potential confounders affecting both survival and access to medical therapy. Therefore, clinical follow-up of patients with inoperable CTEPH should further focus on functional improvement as evidenced by 6MWD. Additionally, unlike numerous investigations in WHO group I PAH patients, there are no data on the use of combined multiple classes of PH-targeted medical therapy in inoperable CTEPH patients.
Right Heart Dysfunction and Residual Pulmonary Hypertension after Thromboendarterectomy Surgery
Following PTE, right ventricular dysfunction and residual pulmonary hypertension can be a significant cause of morbidity and mortality in the immediate postoperative period. A retrospective analysis from a single center revealed that in a group of 500 CTEPH patients undergoing PTE between 2006 and 2010, a postoperative mortality of 10.3% was observed in those patients with a postoperative PVR > 500 dynes·sec·cm-5; this compared to a 0.9% mortality rate in patients with a PVR below this level.1 Theoretically, initiation of PH-targeted medical therapies in these patients immediately after surgery may worsen hypoxemia due to nonspecific loss of hypoxemic vasoconstriction. Therefore, short-acting agents such as inhaled vasodilators and iloprost have been studied in this setting. In a small, single-center study, patients with residual PH at ICU admission following PTE who were treated with inhaled iloprost had significantly lower PVR for 60 minutes following treatment compared to placebo.19 Alternatively, inhaled nitric oxide (NO) may be considered in patients with postoperative right ventricular failure since inhaled NO has been demonstrated to lower PVR and helps improve oxygenation after PTE.20,21
After the immediate perioperative period, however, the presence of residual PH carries potential adverse consequences. Depending on definitions, up to 35% of patients undergoing PTE surgery will have residual PH.22–24 Freed et al. found that patients with a postoperative mean pulmonary arterial pressure over 30 mm Hg remained limited in exercise capacity and were more symptomatic compared to those with a mean pulmonary arterial pressure less than 30 mm Hg.23 Furthermore, an mPAP > 38 mm Hg and a PVR > 425 dynes·sec·cm-5 measured 3 to 6 months after PTE correlated with long-term mortality due to CTEPH.24
Patients with residual PH were included in both the BENEFiT and CHEST-1 studies. In the BENEFiT trial, bosentan-treated patients with residual PH actually saw an 11.9-m loss in the 6MWT compared to placebo-treated patients despite a 34% reduction in PVR compared to baseline.13 In CHEST-1, those with residual PH treated with riociguat experienced a 27-m improvement in the 6MWT compared to a 1.8-m improvement in the placebo-treated patients; they also experienced improvements in secondary end points including reduction in PVR (-154 ± 127 dyn.sec.cm-5 with riociguat compared to -11 ± 205 dyn.sec.cm-5 with placebo) and improvement in functional class (38% with riociguat vs 16% with placebo).16 For this reason, riociguat is considered a first-line oral therapy for patients with residual PH after PTE.
"Bridging Therapy" Prior to Pulmonary Thromboendarterectomy
A subgroup of CTEPH patients in whom PH-targeted medical therapy is increasingly used includes operable patients awaiting surgery. Whereas this approach might seem logical for hemodynamically unstable patients, the indication for "bridging therapy" in the majority of operable CTEPH patients remains controversial. Previous reports have suggested that a preoperative PVR > 1000 dynes·sec·cm-5 carries with it higher postoperative mortality and morbidity risks.1,25,26 The presumption, therefore, has been that if PH and right heart function can be positively affected in these high-risk patients, an improvement in postoperative outcomes might be realized. Nagaya and colleagues, one of the first groups to investigate this hypothesis, administered intravenous prostacyclin at a mean dose of 6 + 1 ng/kg/min for a duration of 46 + 12 days prior to PTE surgery in 12 patients with operable CTEPH, each with a PVR > 1200 dynes·sec·cm-5. This resulted in a significant preoperative reduction in PVR (1,510 + 53 to 1,088 + 58 dynes·sec·cm-5) and a decline in plasma BNP levels. While one patient in the treatment group died during the first 30 postoperative days, no one died in the group of 21 patients with a preoperative PVR < 1200 dynes·sec·cm-5. Pulmonary hemodynamic outcome in both patient groups was comparable.27
In another study, Reesink and colleagues conducted a 16-week, randomized, single-blind study using bosentan as a bridge to PTE surgery in 25 patients with operable CTEPH. Out of the 25 enrolled patients, 13 received bosentan. The mean differences in change from baseline between those receiving bosentan and those not receiving the drug were as follows: total pulmonary resistance decrease of 299 dynes/cm5 (P = .004), 6MWD increase of 33 m (P = .014), mean pulmonary artery pressure decrease of 11 mm Hg (P = .005), and increase in cardiac index 0.3 L/min/m2 (P = .08). Though postoperative mean PA pressure and total pulmonary resistance were lower in the bosentan group, this did not achieve statistical significance. Three patients died postoperatively in the no-bosentan group compared to no deaths in the bosentan-treated patients. Otherwise, for those who survived surgery, the short-term postoperative clinical course (ICU days, ventilator days, occurrence of lung injury) between groups was comparable.28
In a more recent study, Surie and colleagues conducted a pilot study of 15 patients with operable CTEPH to assess the effect of the preoperative use of bosentan, with a focus on right ventricular (RV) function.29 Eight of these 15 patients were randomly assigned to receive bosentan in addition to "best standard of care" for 16 weeks, with pre- and post-treatment evaluation of right heart function and remodeling using cardiac magnetic resonance imaging. Discernible improvement in RV stroke volume index (6 vs 1 mL/m-2, P = .037), RV ejection fraction (8% vs 4%, P = .028), RV mass (-3 vs 2 g/m-2, P = .001), RV isovolumic relaxation time (-0.03 vs 0.01 msec, 0.041), and LV ejection fraction (8% vs -2%, P = .037) were noted. This was accompanied by a change in mPAP (-11 vs 5 mm Hg in the non-bosentan group, P = .011) and an increase in 6MWD (20 vs -4 m in the non-bosentan group).29 Though the above studies may have demonstrated some pulmonary hemodynamic benefits with the use of selected PH-targeted therapies in patients with operable disease, the effects on postsurgical outcomes remain unproven.
Uncertainties regarding the use of PH-targeted medical therapy in this group are further fueled by two recent reports. In a retrospective analysis of patients referred for PTE surgery between 2005 and 2007, Jensen and colleagues revealed that the use of PAH-specific medical therapy in patients with surgical CTEPH increased from 19.9% of patients in 2005 to 31.9% in 2006 and to 37% in 2007. They also observed that this practice was associated with a significant delay in time to referral without having a discernible benefit on measured postoperative outcomes.30 The report of the long-term outcomes from the International Prospective CTEPH Registry reinforced these observations. Although patients receiving bridging therapy were more likely to have a more compromised hemodynamic profile preoperatively—with higher right atrial pressure, higher PVR, and lower cardiac index—the postoperative PVR was similar between groups; furthermore, postoperative complications (including the presence of postoperative PH and the incidence of reperfusion lung injury) were not significantly different whether or not PH-targeted medical therapy was prescribed before the endarterectomy. However, multivariate analysis in operated patients disclosed that bridging therapy with PH-targeted medications increased the risk of death. Possible explanations included a delay in surgical referral resulting from the use of medical therapies, a more difficult operation due to the effect of medications on the thrombus being endarterectomized, and a greater use of medications in the more hemodynamically compromised patients, or it may just be a marker of more extensive disease preoperatively.31
|Balloon Pulmonary Angioplasty
Balloon pulmonary angioplasty (BPA), sometimes referred to as percutaneous transluminal pulmonary angioplasty, is a percutaneous approach for the treatment of CTEPH. It relies on the use of telescoping catheters placed in a central vein, through which wires and balloons are guided to mechanically disrupt chronic clot material and relieve pulmonary vascular obstruction. Despite first being described in 1988,32 it is only in recent years that BPA has emerged as a viable treatment option for CTEPH. In 2001, a case series described 18 patients who underwent BPA with unacceptably high (61%) complication rates.33 As a result, BPA was not a widely accepted approach in the treatment of CTEPH until 2012, when several publications from medical centers in Japan and Norway demonstrated the safety and efficacy of a refined approach.34–37 Since then, interest in BPA has rapidly expanded with an accompanying proliferation in the number of BPA-related publications. BPA now carries a class IIb recommendation for the treatment of inoperable CTEPH in the most recent European guidelines and may be considered in patients who are technically inoperable or carry an unfavorable risk:benefit ratio for PTE surgery (Figure 1).
While there is considerable variation in the technical approach and patient selection among BPA centers, particularly as it relates to determination of operability, there are some common guiding principles of the procedure. First, to achieve hemodynamic and clinical end points, BPA requires more than one interventional session. During each BPA session, attempts are made to maximize the number of segments treated while minimizing the risks of BPA-associated lung injury. The improvement in mPAP does not occur immediately following BPA.35,38 Completely occluded vessels and pouch defects without angiographically visible runoff are less suited for BPA and are associated with higher complication and lower success rates. Patients with higher mPAP (> 35 mm Hg) prior to BPA and more severe PH may be at higher risk of BPA-associated lung injury.33,35 Finally, the use of intravascular imaging techniques and measurement of pressure gradients are useful tools to maximize efficacy, efficiency, and safety of BPA.39
Although histological examination of vessels after BPA is limited, two patterns have been described in post-mortem examination. The first demonstrated enlargement of the pulmonary arterial lumen by incision and compression of the thrombi without dissection of the vessel wall. In the second, the media of the PA was dissected by angioplasty and the organized thrombi were forced to one side, leaving a larger pseudo-lumen with formation of a new intimal layer.40
Despite differences in patient selection, differences in background use of PH-targeted therapies, and variations in the technical approach to BPA, all of the published series since 2012 have demonstrated substantial improvements in hemodynamics, functional class, and markers of heart failure such as BNP or NT-proBNP (Table 2).41 Many of the large BPA series have included patients who may have been surgical candidates had they been evaluated at an experienced PTE center. This observation does not necessarily detract from reported BPA results but rather highlights the ongoing subjectivity in determining which intervention might be best for any given patient. The mPAP across the series improved from a range of 40 to 47 mm Hg pre-BPA to a range of 24 to 34 mm Hg following BPA. The majority of patients also achieved NYHA/WHO functional class II status following this intervention. Some of the series also report decreased requirements for supplemental oxygen with BPA.
Perhaps more importantly, safety of BPA has improved dramatically from the first series reported in 2001. The rates of severe BPA-associated lung injury that required major interventions such as noninvasive ventilation and mechanical ventilation declined from 16.7% in the initial series by Feinstein et al. in 2001 to 6% in the large series by Matsubara et al. in 2012. In subsequent reports, the rate of severe BPA-associated lung injury has declined even further, in the range of 0% to 3.5%, while the incidence of mild BPA-associated lung injury has declined to less than 40%.42–45
The improved safety of BPA owes to a steep technical learning curve incorporating improved operator skill, the use of intravascular imaging modalities such as intravascular ultrasound and optical coherence tomography,46,47 the use of intravascular pressure gradient measurements,42,48 the characterization of specific lesion types,49 and the adaptation of interventional technique to the severity of PH. However, BPA requires significant quantities of iodinated contrast and radiation exposure under fluoroscopy. While there are currently no reports of complications related to either of these exposures, the length of each BPA session is often limited to the maximum safe levels of radiation and contrast.
Future Directions
With the rapid evolution of BPA, clinical practice is outpacing what is represented in the published literature. To date, no single technical approach has become dominant; instead, multiple high-volume centers are refining the technique in parallel.
The use of PH-targeted medical therapy is common in patients who undergo BPA. In some reports, this approach has been initiated to "stabilize" patients or lower mPAP prior to BPA. The benefit of this approach on outcomes is unknown, but an obvious detrimental effect has not been observed. How PH-targeted medical therapies compare to BPA for the treatment of inoperable CTEPH is also unknown and currently under investigation. In the small series by Sugimura, patients with inoperable CTEPH were treated aggressively with medical therapy prior to BPA, which resulted in improved cardiac output/index, PVR, and functional status but little change in mPAP.36 The patients then underwent BPA and had significant further reductions in mPAP and PVR and further improvement in WHO functional class and 6MWT. This suggests that BPA combined with medical therapy may have an advantage over medical therapy alone, although larger prospective studies are necessary to substantiate this finding.
The use of BPA in conjunction with PTE surgery is another approach currently being explored. A recent publication describes a combined approach in three patients with high PVR, each with operable CTEPH in one lung and inoperable disease in the other lung. The patients underwent PTE on the operable lung and BPA on the inoperable lung during the rewarming phase of surgery.50 Ultimately, the number of patients with clot distribution likely to benefit from this approach is small, and as already demonstrated in a previously published series,42 BPA may emerge as a reliable tool for the treatment of residual PH after PTE. As the collective BPA experience grows, there will assuredly be an interest in comparing BPA directly to PTE in select patient populations.
As has been the case for PTE surgery, proper patient selection for management with PH-targeted medical therapies or BPA is paramount in achieving favorable outcomes. Although these treatment options are currently indicated only for patients who are deemed inoperable, the diagnostician should appreciate that operability assessment is subjective and depends largely on the level of surgical experience at any given center.4 Though progress achieved in this area has been remarkable over the past several years, refinements of the treatment algorithm for CTEPH will likely evolve as operable CTEPH is better defined, and the optimal application of medical therapies and BPA will achieve greater clarity once appropriate clinical trials become available.
|Key Points
Even at experienced surgical centers, nearly one-third of patients with CTEPH will be deemed inoperable for reasons including distal disease, comorbidities, or out-of-proportion pulmonary hypertension (PH). It is in these patients with inoperable CTEPH that PH-targeted medical therapy and balloon pulmonary angioplasty have potential therapeutic value.
Though many PAH-targeted medications (including sildenafil, bosentan, iloprost, and epoprostenol) have demonstrated hemodynamic improvement in inoperable CTEPH, riociguat is the only FDA-approved therapy for both inoperable CTEPH and residual PH after surgery based on the demonstrated improvements in both 6MWD and pulmonary hemodynamics in a placebo-controlled trial.
Balloon pulmonary angioplasty is an interventional procedure using telescoping catheters placed in the pulmonary arteries, through which wires and balloons are used to mechanically disrupt chronic clot material and relieve pulmonary vascular obstruction. Contemporary case series from multiple centers worldwide have demonstrated pulmonary hemodynamic improvement with this approach.
Dr. Fernandes conducts research funded by Actelion Pharmaceuticals and is on the speaker's bureau for Bayer Pharmaceuticals US, Inc.; Dr. Auger is a formal advisor to and conducts research on behalf of Bayer Corporation. Dr. Poch conducts research funded by Actelion Pharmaceuticals and is on the speaker's bureau for Bayer Pharmaceuticals US, Inc.References
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|Delcroix M, Lang I, Pepke-Zaba J, et al. Long-term outcome of patients with chronic thromboembolic pulmonary hypertension. Results from an International Prospective Registry. Circulation. 2016 Mar 1; 133( 9): 859– 71. [Crossref]
|Voorburg JA, Cats VM, Buis B, Bruschke AV. Balloon angioplasty in the treatment of pulmonary hypertension caused by pulmonary embolism. Chest. 1988 Dec; 94( 6): 1249– 53. [Crossref]
|Feinstein JA, Goldhaber SZ, Lock JE, et al. Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Circulation. 2001 Jan 2; 103( 1): 10– 3. [Crossref]
|Mizoguchi H, Ogawa A, Munemasa M, et. al. Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2012 Dec; 5( 6): 748– 55. [Crossref]
|Kataoka M, Inami T, Hayashida K, et al. Percutaneous transluminal pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2012 Dec; 5( 6): 756– 62. [Crossref]
|Sugimura K, Fukumoto Y, Satoh K, et al. Percutaneous transluminal pulmonary angioplasty markedly improves pulmonary hemodynamics and long-term prognosis in patients with chronic thromboembolic pulmonary hypertension. Circ J. 2012; 76( 2): 485– 8. [Crossref]
|Andreassen AK, Ragnarsson A, Gude E, et al. Balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension. Heart. 2013 Oct; 99( 19): 1415– 20. [Crossref]
|Hosokawa K, Abe K, Oi K, Mukai Y, Hirooka Y, Sunagawa K. Negative acute hemodynamic response to balloon pulmonary angioplasty does not predicate the long-term outcome in patients with chronic thromboembolic pulmonary hypertension. Int J Cardiol. 2015 Jun 1; 188: 81– 3. [Crossref]
|Ogawa A, Matsubara H. Balloon pulmonary angioplasty: A treatment option for inoperable patients with chronic thromboembolic pulmonary hypertension. Front Cardiovasc Med. 2015 Feb 17; 2: 4. [Crossref]
|Kitani M, Ogawa A, Sarashina T, Yamadori I, Matsubara H. Histological changes of pulmonary arteries treated by balloon pulmonary angioplasty in a patient with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2014 Dec; 7( 6): 857– 9. [Crossref]
|Kimura M, Kohno T, Kawakami T, et al. Balloon pulmonary angioplasty attenuates ongoing myocardial damage in patients with chronic thromboembolic pulmonary hypertension. Int J Cardiol. 2016 Mar 15; 207: 387– 9. [Crossref]
|Roik M, Wretowski D, Labyk A, et al. Refined balloon pulmonary angioplasty driven by combined assessment of intra-arterial anatomy and physiology–Multimodal approach to treated lesions in patients with non-operable distal chronic thromboembolic pulmonary hypertension–Technique, safety and efficacy of 50 consecutive angioplasties. Int J Cardiol. 2016 Jan 15; 203: 228– 35.
|Shimura N, Kataoka M, Inami T, et al. Additional percutaneous transluminal pulmonary angioplasty for residual or recurrent pulmonary hypertension after pulmonary endarterectomy. Int J Cardiol. 2015 Mar 15; 183: 138– 42. [Crossref]
|Taniguchi Y, Miyagawa K, Nakayama K, et al. Balloon pulmonary angioplasty: An additional treatment option to improve the prognosis of patients with chronic thromboembolic pulmonary hypertension. EuroIntervention. 2014 Aug; 10( 4): 518– 25. [Crossref]
|Inami T, Kataoka M, Shimura N, et al. Pulmonary edema predictive scoring index (PEPSI), a new index to predict risk of reperfusion pulmonary edema and improvement of hemodynamics in percutaneous transluminal pulmonary angioplasty. JACC Cardiovasc Interv. 2013 Jul; 6( 7): 725– 36. [Crossref]
|Ikeda N, Kubota S, Okazaki T, et al. Comparison of intravascular optical frequency domain imaging versus intravascular ultrasound during balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. Catheter Cardiovasc Interv. 2016 Jun; 87( 7): E268– 74. [Crossref]
|Jorge E, Baptista R, Calisto J, et al. Optical coherence tomography of the pulmonary arteries: A systematic review. J Cardiol. 2016 Jan; 67( 1): 6– 14. [Crossref]
|Inami T, Kataoka M, Shimura N, et al. Pressure-wire-guided percutaneous transluminal pulmonary angioplasty: A breakthrough in catheter-interventional therapy for chronic thromboembolic pulmonary hypertension. JACC Cardiovasc Interv. 2014 Nov; 7( 11): 1297– 1306. [Crossref]
|Inohara T, Kawakami T, Kataoka M, et al. Lesion morphological classification by OCT to predict therapeutic efficacy after balloon pulmonary angioplasty in CTEPH. Int J Cardiol. 2015 Oct 15; 197: 23– 5. [Crossref]
|Wiedenroth CB, Liebetrau C, Breithecker A, et al. Combined pulmonary endarterectomy and balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant. 2016 May; 35( 5): 591– 6. [Crossref]


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Opinion Analysis: United States v. Garner, No. 12-0282/AR
United States v. Garner, No. 12-0282/AR, 71 M.J. 430 (C.A.A.F. Jan. 8, 2013) (CAAFlog case page) (link to slip op.), involves an unusual question about the procedure members use to determine a sentence in a court-martial. The Appellant was ultimately sentenced to confinement for life (with the possibility of parole), but only after the members first returned with a sentencing worksheet that included a term of years and language excluding parole. The judge called the sentence ambiguous and gave the members additional instructions, but did not instruct them on the procedures for reconsideration of a sentence, and CAAF granted review to determine if this resulted in instructional error. Writing for a majority of the court (with Senior Judge Effron and Judge Stucky concurring), Judge Erdmann tests for plain-error and finds that the military judge did err by failing to instruct the members on the procedures for reconsideration after they returned the final sentence of life, but also that the error was not plain and obvious and that it did not prejudice the Appellant.
At the outset, Judge Erdmann's opinion provides an image of the actual worksheet language at issue, clarifying what the members did (previously described as "35 years no parole"):
Slip op. at 5. Judge Erdmann agrees with the Government "that the confinement portion of the sentence worksheet was clearly ambiguous." Slip op. at 10. Accordingly,
"[t]he military judge did not err in returning the members to their deliberations to clarify the ambiguity. However, when the members returned from their deliberations with a revised sentence worksheet that did not merely clarify the ambiguity but rather reflected a "new" sentence that included confinement for life, it was obvious that the panel had "reconsidered" the initial sentence and had adopted a sentence that was not reflected on the initial sentence worksheet. Regardless of which of the two initial sentences the members intended, the second sentence either increased or decreased that sentence, and therefore reconsideration occurred.
At that point the military judge erred by not sua sponte providing the members with appropriately tailored instructions for reconsideration and returning them to deliberations to ensure compliance with R.C.M. 1009(e).
Slip op. at 10-11. Judge Erdmann then (somewhat charitably, in my opinion) finds that "considering the circumstances under which this
issue arose and the inconsistencies between this court's precedent and R.C.M. 1009, we are not convinced that the error was plain or obvious." Slip op. at 11. A footnote explains that CAAF's caselaw, and the language of the Manual for Courts-Martial prior to the 1995 revision, blur the difference between "reconsideration" of a sentence (in order to increase or decrease the severity) and "clarification" of an unlawful or ambiguous sentence. Presumably, the court will be less generous in the future. Judge Erdmann also gently notes in a footnote that the Manual could benefit from further clarification: "[C]onfusion in the application of R.C.M. 1009 as evinced by the issue presented in this case and potentially in other similar circumstances, we consider this an area warranting clarification by the President in the MCM." Slip. op at 9 n.5. With the court's comment about additional transparency in the sentencing process in United States v. Altier, this is now two cases in a row where CAAF has called for Presidential attention to a procedural matter.
Judge Erdmann also discusses the lack of prejudice, noting that the mathematical realities of the sentencing rules (requiring a majority to reconsider, and three-fourths to return a sentence of life) make a vote for reconsideration before the vote for a sentence of life in this case a mere formality, and "under the unique circumstances of this case [the Appellant] was not prejudiced."
In a separate concurring opinion, Judge Stucky explains that he would not find any error. Because the sentencing worksheet (pictured above) indicates that the members first returned a sentence of both "35 years" and "life without eligibility for parole," Judge Stucky notes that any instructions on reconsideration would have to be tailored for reconsideration with an eye towards increasing the sentence (requiring a majority vote) or with an eye towards decreasing the sentence (requiring just more than one-fourth of the members, in this case). But a sentence of "life" is more than "35 years" and less than "life without eligibility for parole," so instructing on reconsideration "makes no sense." Op. at 3.
Senior Judge Effron also writes separately, mainly adding that "In view of the lack of clarity in the current state of the law, I would not reach the issue of prejudice."
Case Links:
• ACCA opinion
• Appellant's brief
• Appellee's (Government) brief
• Blog post: Argument preview
• Oral argument audio
• CAAF opinion
• Blog post: Opinion analysis

subset: commoncrawl


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With a full-time staff including administration, air medical communication specialists, nurses, respiratory therapists, Emergency Medical Technicians, mechanics and pilots, Angel One has a highly diversified group of dedicated personnel. All Angel One staff are required to attend mandatory Safety Day training annually which includes flight physiology, survival, post-accident/incident training, helicopter safety, ambulance safety and other safety hot topics.
We have a 24-hour dedicated communications center with NAACS trained air medical communication specialists to take all incoming requests for transport or consults. Our communications center handles more than 7,000 phone calls per month which include more than 180 patient transports and 150 patient consults from physicians just requesting advice in management of a critical pediatric, neonatal or burn patient.
Our staff tracks all vehicles transporting Angel One staff including helicopter, fixed-wing and ground units. We obtain latitude, longitude and ground speed on the air vehicles and mile marker or GPS location of our ground units. Our communication staff not only handles phone calls, but radio traffic as well.
Along with basic transport training, our medical staff is trained in Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support, Neonatal Resuscitation Program, Transport Nurse Advanced Trauma Course and other specified pediatric and neonatal training.
Our Registered Nurses and Respiratory Therapists have experience in both Pediatric Intensive Care (PICU) and Neonatal Intensive Care (NICU), as well as specific training for transport. Our average transport medical team member has been on the Angel One staff 10 years or more.
Each of our medical staff are required to maintain their skills quarterly. These skills include: umbilical line placement, interosseous needle placement, intubation/rapid sequence induction (RSI), needle decompression, angiocatheter placement, high frequency ventilation, nitric oxide administration, IV placement, IV pump, cardiac/hemodynamic monitoring, defibrillation/cardioversion, cardiac pacing, fracture stabilization/splinting, cervical spine stabilization, care of the burn patient and High Risk Obstetrics.
With the development of pediatric medical simulation at the Simulation Center, Angel One has utilized this resource to further sharpen our skills not only with medical procedures, but also those of overall patient management and interaction with referring hospital staff and patient family.
Our Emergency Medical Technicians are all Arkansas licensed EMTs or higher and maintain licensure according to the Arkansas Department of Health, Section of EMS and Trauma Systems. Each EMT has transport-specific training, including completion of an Emergency Vehicle Operations Course (EVOC). They provide safe transport for our patients and crews, as well as providing assistance within the scope of their practice, as EMTs, on ground and air transport, as necessary.
Our commercially-licensed, instrument-rated pilots are required to have attained a minimum of 2,000 helicopter flight hours. On average the Angel One pilots have thousands of hours of total flight time and decades of experience. Each of our pilots are required to attend annual training at Flight Safety for extensive, hands on simulated emergency and instrument flight training as well as on site, monthly training with semi-annual check rides. Pilots complete a minimum of 60 hours of annual classroom and computerized academic training and testing.
Angel One has a helicopter maintenance staff of 6 FAA licensed mechanics who are dedicated to the daily required maintenance of our helicopters. The Angel One Aviation maintenance staff complete 8 major inspections per year, depending on flight hours. Each of our mechanics have many years of experience and attend a minimum of 60 hours of continuing education annually to include, but not limited to: Flight Safety's Master Technician training, factory engine school, human factors and quality control.


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I have been real busy and also trying to work on an issue that new members are not getting their activation email, we have 100's of new members waiting to get this email to activate their account. I am working on this and will get it fixed sorry for the problems everyone, it will all be ok.
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Tuesday, December 13, 2011
A Friendly Dog Christmas
22 comments:
That looks like the trees in Fortnums and Mason just now.ReplyDelete
I liked your wish list - I'm old and jaded and tired of travel now! I need to find myself a new passion, hmm but what?
it seem that you had fun! love bowling. have a Cupcake sweet day!ReplyDelete
Thank you for your blog comment and the tip with the other christmas tree alternative. Sounds very interesting.ReplyDelete
I see you had much fun on the party. Here in Germany we call that bowling "Kegeln". But we have bowling alleys, too. Very good you didn't kill someone with that balls. :)
Have a nice day.
- Diana TeodoroDecember 13, 2011 at 3:11 PM
Is the girl in the picture your daughter? God, she looks so much like you!ReplyDelete
I've never heard of a dog club...What exactly is that?
Yes! That's my little mini-me hehehe. A dog club is where local dog owners can go to learn how to train and socialize their dogs so that they're more well behaved. Sometimes, a dog goes all crazy around other dogs barking and other inappropriate behavior. If you take them to a club, a trainer can help teach the owner techniques to reduce or stop that behavior completely. The same with all kinds of bad dog behaviors. Sort of like parenting classes for parents with problem kids but with dogs instead hehehe. Plus, it can just be a fun social event for some of the pet owners.ReplyDelete
- chillairandperfumeDecember 13, 2011 at 8:53 PM
I'm glad someone else asked what a dog club is; I didn't know either. Looks/sounds like you had a great time!ReplyDelete
oh my heavens. i think i just died a little bit. a dog nativity is something that has been missing from my life but no longer! those barks! those outfits! suffice it to say you just made my night with this awesome video. i played it pretty loud, and pablo got a little confused, but all is well:) adorable!ReplyDelete
- Blindingbrightlights.blogspotDecember 14, 2011 at 2:50 AM
This is really cute :) love the rings!ReplyDelete
awwww. the dog nativity is cute!!ReplyDelete
Awe, I loved that YouTube video. I couldn't stop laughing and saying, "how cute!"ReplyDelete
I love bowling, but I'm not good at it...at all. LOL I am curious. I never knew bowling was different in the UK. So wait, there is no holes? So, do you roll it with both hands?
The kids did use both hands. Full on granny pose with a squat and roll hehehe. The balls were just about too large for my hand as well. Typically you just cup it. It's so scary to me because you have to launch it into a roll down the lane just cupped in your hand and it feels like you could lose control soooo easily. I'm not the most hand eye coordinated person either so that could've gone disastrously lol.ReplyDelete
I was also just informed by my husband that there is regular bowling here as well. Somehow that makes me feel so much more relieved. It's not like I'm an avid bowler or anything so it makes no sense as to how that gives me relief but it does lol.ReplyDelete
- Diana TeodoroDecember 14, 2011 at 11:59 AM
Oh my God, I so need to go to a dog club! Mt dog needs intensive training! She's picked up on the entire family's difficult personality!ReplyDelete
I think it's so cool when daughters look like moms! She's a lovely looking girl!
Thank you! There are a lot of different approaches to dog training. The Friendly Dog Club is clicker training based. They're also a non-profit organization. If you're looking for a club, I hope you can find one that fits and helps conquer the doggy issues. It can definitely help.ReplyDelete
I'm glad you liked it! The dogs and their owners certainly had fun making it. The little one that was "baby Jesus" cracked me up. I have no idea what he was thinking but it was hilarious.ReplyDelete
Thank you! It was a really fun night.ReplyDelete
Thank you! I know they worked very hard on it. I'll be showing them everyone's comments too because I know they'll appreciate them greatly.ReplyDelete
We did! This particular dog club holds the world's record for having the largest # of dogs line dancing at one time. How great is that?! lol.ReplyDelete
You know, the title of your blog caught my imagination from the word go. I grew up in the deep southern states of America where bourbon was somewhat of a historical staple. One of my most favorite types of jewelry for the moment is pearls. I have my grandmother's and collect them avidly. Your blog title is the epitome of the area of where I grew up and conjures romantic images of warm lazy afternoons where gentlemen still wear white suits and the ladies wear frilly sheer dresses. I hope you find your new passion soon!ReplyDelete
Luckily, my husband assures me that there bowling alleys that I'm more used to here in England. I feel better knowing that if I have to do more bowling in the future, I might get to do it with balls that actually have holes to hold onto and therefore have less chances of going to jail for accidental manslaughter. Thanks for visiting my site. If I find the DIY with the paper tree again, I'll share the URL with you.ReplyDelete
This is definitely woke up Coco from a deep slumber. She loved looking at the other pups. I just couldn't stop laughing. It was ridiculously cute.ReplyDelete
THAT IS AWESOME, love love love this!! My doggie and me would have fit right in!!! Cute ring too! You're adorable!ReplyDelete


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The configuration was surprisingly easy once I worked out how!
- 4 GB memory - (I have 8GB in mine)
- At least 20 GB free disk space
- OS: I am running Mac OS X 10.8.2
- VMware Player: - Buy VMWare Fusion. I have version 5.0.2 (900491)
- ** Make sure to order the professional version, as only this version has the new
- ** Network Editor feature
- 7-Zip: To extract (or uncompress) the Aster Express package.
You get to the Network Editor from Preferences. Create a new network adapter vmnet2 as shown in the screen shot below:
Then make sure that for both the Queen and Worker VMWare images you assign vmnet2 as your network adapter as illustrated in the screenshot below:
That is really the only changes you need to make. Follow the rest of the instructions as outlined in the Getting Started with Aster Express 5.0 to get your Aster nCluster up and running.
If you have 8GB of memory you might decide to allocate 2GB of memory to each VM instead of the 1GB which is the default. Again you can set this in the settings for each VMWare image. I also run the utility Memory Clean (available for free from the App Store). You would be amazed how much a memory hog FireFox and Safari can be. I normally shutdown most other running programs when I am working with Aster Express to give me the best user experience.
You will also find mac versions of act and ncluster_loader in /home/beehive/clients_all/mac. I just copy them to my host. In fact, Once I start up the VMWare images, I do most everything natively from the Mac.
In future posts I plan to cover the following topics:
- How to scale your Aster Express nCluster and make it more reliable
- Demo: From Raw Web log to Business Insight
- Demo: Finding the sentiment in Twitter messages
If there are topics you would like me to cover in the future, then just let me know.


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In a large bowl, cover lima beans with water, cover with a towel and soak overnight.
In a large pot, add oxtails, onions, scallions, garlic, thyme, red pepper, paprika, bay leaf, hot sauce, and gravy master and marinate at least 4 hours or overnight in the refrigerator, stirring occasionally.
Add enough water to just cover the oxtails and bring the mixture to a boil. Lower to a simmer, cover and cook for two hours. Every 30 minutes for two hours add 500ml of water or broth, alternating, as necessary, to keep oxtails covered with liquid.
At 2 hours, add the beans, tomato paste, and two more cups of beef stock and water, if needed. Bring to a boil then simmer uncovered for two hours, skimming fat off top and stirring occasionally. In the last half hour of cooking time, season with two tablespoons of salt.
Serve with rice.
For the rice: Rinse rice three times to remove starch. Put rice in a medium saucepan. Fill saucepan with enough water to cover the rice by 1.5cm or measure by placing your thumb tip on the rice and filling the pot with water until the water reaches the middle of your thumbnail. Bring rice to a simmer, cover and cook until tender and liquid is evaporated, about 15 minutes. Remove from heat and let rice stand another five minutes, covered.


text:
iEcoApparel necesitaba un nuevo diseño de camiseta y lanzó un concurso de diseño en 99designs.
Un ganador ha sido elegido entre 33 diseños de 5 diseñadores freelance.
iEco apparel
We are a company aimed at leading by example and having fun with graphics and sayings on t-shirts.
Our passion is the environment but we are tired of how the "eco" message is being conveyed on poster, cards, signs, and t-shirts these days. We want to have more fun with all things eco.
We believe leading by example is the strongest most powerful way to convey your message. We are creating all shirts from certified organic cotton and for every shirt sold there will be one tree planted. Beyond this design we want to create hundreds or thousands, if we're lucky enough, of designs and spread the word.
People buying the shirts will most likely be moms, aunts or grandmothers. So ages of buyers will be 24-64 years young.
People that are eco conscious are probably more likely to purchase.
Majority of the population wearing this product are children 0-12ish years old.
Design must be unisex.
The idea of the this shirt is "iEco Change" and play off of the saying "I equal Change", basic little things we all can do to make a difference to our environment.
We want a toddler that takes coins (money) puts it into piggy banks, see files "DSC_0001 through DSC_0005".
I'd like for the theme to be consistent throughout the shirt
Please place "i", then the logo, and then the word "change" after the logo graphic so it reads "i eco (equal sign logo) change" somewhere where it makes sense...you tell me.
-The lower case "i" and "change" must be in same font type as in the logo.
-Looking for a toddler with a stuffed koala, somewhere in the design, with a similar style to "picture 1" or http://www.squidoo.com/watercolor-lessons-funny
-Must show on light and dark shirts
-Minimalism is encouraged so we don't use much ink
-Front of shirt design only


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There are no reviews yet.
Pancakes with maple syrup & butter.
There are no reviews yet.
Our range of dishes consists of freshly cooked meal options that are prepared from our experienced chefs especially for you! Please note that all orders must be placed at least 24 hours in advance. Additionally, you have the option to arrange and pre-order your everyday meal plan upon your arrival. Due to high demand and in order to maintain the high quality of our services all dinner orders need to be placed on the previous day no later than 17:00


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This guest post is by Heather Eigler of HomeToHeather.com
Yes, you do have a niche. You've likely read it a thousand times on blogs about blogging. Two of the number one pieces of advice are 'choose your niche wisely' and 'write what you know.'
So what if you aren't wise and don't know anything? What could you write about that qualifies as a niche? And what does having a niche do for you anyway?
Having a niche has its benefits
Your niche gives you focus. It gives you identity and purpose. A blog with no niche is like a magazine with no cover model. The model on the cover of a magazine tells readers instinctively what they are likely to find on the interior pages. A fashion model indicates articles about celebrities and shopping can be found inside. An athlete tells us we can likely learn how to improve our golf swing.
The same goes for blogs. A niche is our version of a cover model. We include it in our headers, our buttons, our posts and our SEO. Readers who land on our page will instinctively know what the blog is about—if we've done our jobs well.
There are blogs about food and blogs about cameras. Blogs about travel and blogs about sports. But what if you just write about your everyday life? What if there is no core subject matter and your blog is a grab bag of this and that.
What can you do then?
You have a pre-made, bona fide, built in niche
Yes, you do! It's your location. Everyone lives somewhere. And there are other people who live where you do who might be searching for information on local events or restaurant reviews. And there are many people who don't live where you do who might be interested in visiting someday … but how would they know if they can't come across anything on the web that tells them what a great place it is?
When I rebranded my site, HomeToHeather.com, to be more of a personal blog, I knew that I was going to have issue expanding my readership because of my content—it's a mom blog. Only so many people are going to want to read about my kids
and they certainly aren't going to surf in from search engines to do so. Yes, I write about other things, too—like blogging and products.
I've had a small bit of success with traffic from StumbleUpon but not enough to keep the site growing. Since I live in a fairly large, dynamic city I decided that incorporating a local slant could be my niche. So I started incorporating a few posts here and there about Calgary. I added my city to my title tags and banner. Then I sat back and watched my stats to see if anyone arrived via search.
And they did.
What topics can you take local on your blog? How about:
- events
- restaurants
- parks
- wildlife
- sports
- local celebrities
- local schools, clubs, and associations
- tourist info.
If they're talking about it, they're Googling it
What's going on right now that people are talking about? Read through your paper and write a post on the opposite view on a major topic. What are people talking about at work? Write about it.
I get a smattering of Google traffic every day for phrases such as Calgary Daycare, Calgary Blog or Calgary mom blog. I've attended a few events as a "local blogger" and have had one or two advertising inquiries from local
businesses. The new local focus is working and I'm excited about what's next for me.
While HomeToHeather is still a small blog—very small, I am slowly working my way towards establishing a local readership, with local content. It's a great way to round out the rest of my more random posts about blogging, motherhood and creativity. So try it yourself and take advantage of your built in niche—you never know where it will take you.
Have you done any local posts on your blog? Could this technique work for you? Share your thoughts in the comments.
Heather lives, parents and blogs in Calgary, Alberta, Canada. Grab her rss feed for more posts on local blogging.


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Islam in Diversity
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Bismillah irrahman irrahim
Assalamu alaikum
I got a pm saying i dint show enough patience with the first topic and started the second topic already when some people want to contribute to first. Well if some1 wants to discuss the first topic, you are more than welcome to discuss it and inshaAllah i will wait for replies. Actually i was quite, well how should i put it, The topic of taqwa is very huge subhanAllah and this discussion never quenched my thirst you could say. So I will be looking forward to more detailed replies.
Say: (O Muhammad) If you love Allah, then follow me, Allah will love you and forgive you your faults, and Allah is Forgiving, MercifuL
Senior Member
Joined: 29 March 2006
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Points: 1283
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Assalaamu alaikum:
In my simple view, Taqwa and patience could also be discussed in a similar light.
Taqwa, the importance of making the correct intention. Didn't I read in a thread somewhere in this forum in the past about the brother that made wudu at home, and while attempting to go to the masjid for prayer, fell and soiled his clothing? He then went home, changed to clean clothing, repeated his wudu and was again dirtied by a passing car on the way to the masjid again.Being the ever patient brother, he again started over up to three times. He was cited for his extreme patience and his faithfullness to the teachings of the prophet. What patience this brother must have had! His intentions to follow procedure correctly is an example! It reminds me of certain ayats that were discussed in some of our kutjahs in the past few months:
3:15 Say: Shall I give you glad tidings of things Far better than those? For the righteous are Gardens in nearness to their Lord, with rivers flowing beneath; therein is their eternal home; with companions pure (and holy); and the good pleasure of Allah. For in Allah's sight are (all) His servants,
3:16 (Namely), those who say: "Our Lord! we have indeed believed: forgive us, then, our sins, and save us from the agony of the Fire;"-
3:17 Those who show patience, Firmness and self-control; who are true (in word and deed); who worship devoutly; who spend (in the way of Allah.; and who pray for forgiveness in the early hours of the morning.
Oh, how beautiful are many of the words of the Qu'ran. That all may come to knowledge of the true path in life!
Wa salaama.
"Every good deed is charity whether you come to your brother's assistance or just greet him with a smile.
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Joined: 18 March 2006
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Points: 1334
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Actually when I thought about this...taqwa and sabr go hand in hand... so alhamdulillah sis fatima, you mentioned both one after the other.
Since taqwa means being conscious of Allah, we do things always keeping in mind that Allah is watching, we refrain from haram stuff thinking that we may displease Allah, we do good things to please Allah. So think of it, if we go by Allah's likes and dislikes, insha allah we will not go wrong, save our errors made in ignorance. (Maryah mentioned the verse regarding this).
Some verses from the Quran on taqwa:
"Alif. Lam. Mim. This is the book wherein there is no doubt; a guidance unto those who ward off (evil): who believe in the unseen, and establish worship, and spend of that we have bestowed upon them: and who believe in that which is revealed unto thee (Muhammad) and that which was revealed before thee, and are certain of the Hereafter." (2 : 1-4)
"Friends on the Day will be foes one to another, save those who kept their duty (to Allah)." (43 : 67)
"It is not righteousness that you turn your faces to the East and the West; but righteous is he who believes in Allah and the last Day and the angels and the Scriptures and the Prophets; and gives his wealth for the love of Him, to kinsfolk and to the orphans and the needy and the wayfarer and those who ask, and to set slaves free; and observes proper worship and pays the poor-due. And those who keep their treaty when they make one, and the patient in tribulation and adversity and time of stress. Such are they who are sincere. Such are the God-fearing." (2 : 177)
"And vie one with another for forgiveness from your Lord, and for a paradise as wide as are the heavens and the earth prepared for those who ward off (evil); those who spend (of that which Allah has given them) in ease and in adversity, those who control their wrath and are forgiving toward mankind; Allah loves the good; and those who, when they do an evil thing or wrong themselves, remember Allah and implore forgiveness for their sins - who forgives sins save Allah only? And will not knowingly repeat (the wrong) they did." (3 : 133-135)
The prophet sallallahu alayhi wa sallam said "taqwa is here, taqwa is here, taqwa is here." he said this while pointing towards his heart. (please someone give reference to this hadith)
Allah loves the muttaqee (person with taqwa). Can all of you give your pointers on how to increase our taqwa?
Jazakallahkhair, wassalaam.
Allah is Sufficient as a Walee (Protector) and Allah is Sufficient as a Naseer (Helper).
(Surah An-Nisa, Chapter #4, Verse #45)
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A Man once prayed "God give me patience.....but hurry!" Ok..jokes apart...
Prophet Yaqoob [alayhissalaam] said "Fa Sabrun Jameelun" meaning "patience is good/most fitting." ( Yusuf, Chapter #12, Verse #18)
Yaqoob ,Ayyoob [alaykumassalaam ] and Muhammad [sallallahu alayhi wasallam] are such good examples of patience. Anyone wants to share their stories?
Patience ie. "sabr" comes from a root meaning to detain, refrain and stop. patience means to stop ourselves from despairing and panicking, to stop our tongues from complaining, and to stop our hands from striking our faces and tearing our clothes at times of grief and stress.
Allah says:
And seek help in patience and As-Salat (the prayer) and truly it is extremely heavy and hard except for Al-Khashioon (i.e. the true believers in Allah - those who obey Allah with full submission, fear much from His Punishment, and believe in His Promise (Paradise, etc.) and in His Warnings (Hell, etc.)).
Except those who show patience and do righteous good deeds, those: theirs will be forgiveness and a great reward (Paradise).
"Salamun Alaikum (peace be upon you) for that you persevered in patience! Excellent indeed is the final home!"
Prophet sallallahu alayhi wasallam said:
"(Remember) Whoever abstains from asking others, Allah will make him contented, and whoever tries to make himself self-sufficient, Allah will make him self-sufficient. And whoever remains patient, Allah will make him patient. Nobody can be given a blessing better and greater than patience." (Book #24, Hadith #548)
Narrated Anas: The Prophet said, "The real patience is at the first stroke of a calamity." (Book #23, Hadith #389)
Some scholars have explained patience very well:"Patience means to adhere to the rules of the Qur'an and Sunnah".
"Patience means to keep close to Allah and to accept calmly the trials He sends, without complaining or feeling sad."
We need patience to do ibaadah and follow Allah's commands. We need patience to stay away from haram actions.
Making shikwah (complaint) to Allah does not go against patience. Many Prophets made dua to Allah asking for His help to overcome difficulties. Ayyub (Job), when he cried to his Lord, "Truly distress has seized me..."" (Al-Anbiya 21:83) "I only complain of my distraction and anguish to Allah." (Yusuf 12:86)
Complaining to people, either directly, through our words, or indirectly, through the way we look and behave. This is contradictory to patience.
Indeed patience is a great virtue, may Allah bless us with a lot of patience.
Edited by amah
Allah is Sufficient as a Walee (Protector) and Allah is Sufficient as a Naseer (Helper).
(Surah An-Nisa, Chapter #4, Verse #45)
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Salaamu Alaykum Dear Sister Fatima,
Jazzak Allah Khayr for sending a pm to me about this topic heading. It sounds like a lovely idea. Would this be just for Muslims then? Or for people considering Islaam possibly? Or also for those with a deep, respect and understanding for the Islaamic principles headlined who may have benefitted from their implementation?
The helpful quoted dictionary definition of Taqwa is similar but not quite the same as that which I have come to understand that it means. Which is when you love someone so much that you fear to displease them, that is like Taqwa. I fear to displease Allah, the Most Wise and All-Loving because I love his majesty and glory and every aspect that we can understand as humans.
Intention is more than the thought of something passing through our heads. "It might be good if someone fed that poor hungry guy that we pass on the freeway ramp each day" is only a wisp of a thought. But "I will put a dollar or a granola bar and juice box in my car so that when I pass him here again, I will be able to feed him" is a serious intention blessed by Allah, even though you may never see this man again, the intention of your heart, which only the All-Knowing really knows, is blessed by the Provider.
To opine which is more important the act or the intention may be irrelevant unless a person just has to keep an accounting of his/her good and evild deeds. But according to the hadith, the intention is blessed, while the act is more blessed (maybe it says 10 times.) So I'm obviously not a literalist, but the important thing in this hadith to me is that an evil intention is not written down as a sin, while a good one is rewarded. The point I see is that we should try to have good intentions and drive out evil ones from our minds.
And then intending to have Taqwa isn't at all the same as actually having it, so that may not fit at all into the above scenario.
Al-Hamdulillah (From a Married Muslimah) La Howla Wa La Quwata Illa BiLLah - There is no Effort or Power except with Allah's Will.
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Jazakillahu khairan sis. Amah, I benefited a lot from your explanation of Sabr. Here goes the story of Ayyub alayhi salam:
The Prophet Ayyub (peace be upon him) was one of the descendants of the Prophet Ibrahim (peace be upon him) and a nephew of Prophet Ya'qub (peace be upon him). He was sent to reform the people who lived in the desert situated in the north eastern corner of Palestine.
When Ayyub (Job) was chosen to be the Prophet, he started to teach the people about God and His religion. He advised the people to do good and shun evil. As usual with all the Prophets very few people believed in him in the beginning but gradually the number of his followers began to increase.
The Prophet Ayyub was Well Off:
The Prophet Ayyub Displays Patience:
After a few years Prophet Ayyub (peace be upon him) suffered from skin disease. His parts of body were covered with loathsome sores. He had many ugly looking ulcers on his face and hands. The sores were full of worms. It is narrated that he picked up those worms which fell from his abscess and praised Allah for creating them. Above all, his false friends attributed his calamities to his sins. They ridiculed and looked down upon him. All the persons deserted him with the exception of his faithful wife, Rahima. She also grew tired of him in the long run and prayed for his death. She cursed her husband for retaining integrity in Allah. When Prophet Ayyub (peace be upon him) was in an extremely pathetic condition he prayed:
"Truly adversity has afflicted me and You are Most Merciful of all who show mercy." (21: 83)
Allah accepted his prayer. The Holy Qur'an affirms:
"Then We heard his prayer and removed that adversity from which he suffered, and We gave him his household and the like thereof along with them, a mercy from Our store and remembrance for the worshippers." (21: 84)
The Prophet Ayyub Recovers and Prospers:
The Prophet Ayyub (peace be upon him) was one of the celebrated Prophets. His example illustrates: that those who remain patient under the stress � of all circumstances, art never deprived of high rewards. The Holy Qur'an affirms:
"And surely we try you with something of fear and hunger, and loss of wealth and crops, but give glad-tidings to the steadfast, who when a misfortune befalls them, say lo! we are Allah's (possession of Allah) and to Him shall we surely return. � Such are they on whom are blessings from their Lord, and mercy. Such are the rightly-guided." (2: 155-157)
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Bismillah irrahman irrahim
Assalamu alaikum
MashaAllah good to see this topic prospering. I think whatever topic we are going to pick up is going to be linked with taqwa. Because thats what being mindful of Allah subhanahu wa ta'ala is that whenever a had of Allah subhanahu wa ta'ala come you refrain.
Sister herjihad picked a very good point, 'And then intending to have Taqwa isn't at all the same as actually having it'. But would that not be a start? Because if the person is sincere in his intention Allah subhanahu wa ta'ala is going to create means for him.
And JazakAllah khair for the story sister abeer, i think it is a light for everyone. So what about the blameworthy patience then?
Say: (O Muhammad) If you love Allah, then follow me, Allah will love you and forgive you your faults, and Allah is Forgiving, MercifuL
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Masha-allah good discussion and agar ijazath ho tho , i will add up here few notes regarding patience
-an essential element in fulfilling our ubudiyyah to Allah (swt)
- Rasulullah (saws) said: Sabr is a source of light
- In the Quran it says: [And practice sabr, for you are under Our gaze] One of the early ulamah used to carry a parchment with this ayah on it in his pocket, and he looked at it constantly.
- Sabr is human; animals know nothing more than their basic needs and instincts, all they can do is react; humans have been endowed with reason which balances instinct. We go from wanting food as baby, play as a child, zinnah in adolescence, until we reach puberty and are endowed with some reason.. but reason is not enough, it is not alone sufficient as guidance, the 'aql (intellect) needs 'naql (revealation) "Descartes said I think therefore I am, Ghazali before him said I will therefore I am, I say: I perform sabr, therefore I am human" This deen is the completeness of our maturity and our humanity.
So what is sabr?
The steadfastness of the religious call over the call to passion- if the deen overcomes the nafs, this is sabr
Sabr is an UPHILL BATTLE- when we're going downhill we're losing energy, when we're going uphill we're gaining potential energy. In sabr, we are gaining "spiritual potential energy".
There are 2 kinds of sabr (or two ways we can perform sabr):
1) when something we desire happens to us, something we like, we exhibit sabr in controlling our selves, not going into excess, not transgressing the bounds set down for us by Allah(swt)
Abdur Rahmad ibn Auf said: We were tried by hard times and we showed sabr, but when we were tried in ease and excess, we failed.
Hadeeth: I do not fear for you poverty; I fear for you plentifulness of dunyaa, and it will destroy you as it had destroyed nations before you.
Quran: O you who believe, do not let your families and your wealth draw you away from the dhikr of Allah; and whosoever does that is indeed the loser.
2) Sabr in what we dislike. In 3 areas of life:
a.) sabru ala ta'aat: in obeying Allah (swt). sabr against our nafs who dislikes it, whether in spirituality or mundane, sabr before, during and after the act of obedience.
b.) sabru anil ma'asee: to show sabr against disobedience to Allah (swt). We are attracted to do injustice to others thinking we are doing justice to ourselves. We live in an environment that is dangerously attractive, we need to have patience, constancy, steadfastness = sabr.
c.) sabr andil ma'asid: to show sabr in times of calamity, adveristy, pain, whether physical or emotional. Everything that is in the capacity of an individual to change, he should- but have sabr in what you cannot. Not reciprocating harm is sabr.
Hadeeth: whenever a museebah (hardship) befalls you (and you show sabr) Allah (swt) atones for you some of your sins
Hadeeth: Allah (swt) atones some of our sins not only by physical endurance but by emotional ones as well
Sa'ad ibn Abi Waqqas (ra) asked the Prophet (saws) "Ya Rasulullah, who amongst people are the most tried (subject to hardships)?" Rasulullah (saws) said: The Anbiyyah (messengers of Allah) and after them the Salihoon (righteous) and then in accordance to your eman, taqwaah etc, there will be more hardships, not less. Every mu'min will be tried by difficulties in accordance (proportion) to their deen. If in this person's deen is solidity (their deen is deeply rooted) the balaa' will increase, to purify, cleanse, strenghten, elevate the person. And if in the deen in this person there is riqaa (weakness, thinness), then that persons balaa will be weakened, until the person walks on the earth cleansed of sins until they meet Allah.
Prophet Muhammad (peace be upon him) said: �All the descendants of Adam are sinners, and the best of sinners are those who repent."
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About our Academics
BridgePrep Academy's curriculum is rigorous, challenging and focuses on creating global leaders who have an enthusiasm and passion for learning. To accomplish this, our faculty engages in practices that promote and encourage exploration, inquiry and discovery. Students are active learners and teachers guide their learning. Together with the student, the teacher sets learning goals based on data, classroom and teacher observations. Parents receive information in the form of emails, newsletters, teacher website and our online grading system (Engrade).
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BridgePrep Academy develops an environment in which students become lifelong readers. Our reading series is called Wonders. Wonders is a comprehensive language arts program that introduces, reinforces and enriches reading comprehension skills and strategies. Teachers use a wide variety of assessments to enhance the student's ability to learn. Within this curriculum, students gain valuable knowledge about spelling, grammar, vocabulary and handwriting skills. The writing process is highlighted, and students are encouraged to write creatively by expanding their ideas with supporting details.
Go Math creates a spiraling curriculum that builds on the concrete and moves to the more abstract. BridegPrep believes that children understand mathematics best when it is related to real world experiences. Go Math also has an online component called Gizmos, which engages students to practice and reinforce math skills. Our faculty places an emphasis on basic fact mastery and knowledge of number sense. Students experience fun methods of learning whole numbers and place value, decimals and fractions, measurement, geometry, data analysis and quantitative reasoning.
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Our social studies curriculum is designed to connect students to community, state, nation and world. Teachers discuss current events, such as economy, environment and government and students develop a global perspective through an open forum. By immersing students in real world events, students discover links to the past, have a better understanding of the present and develop skills to be worldwide citizens of the future. BridgePrep utilizes videos, internet websites and blogs as opportunities to connect with other classes around the world and to enrich the learning experience.
Every student has the opportunity to use technology in a safe and proficient manner. Teachers have access to the computer lab, where students can research and work on specific programs to strengthen their skills such as Achieve 3000 and Gizmos. It is BridgePrep's philosophy that technology is an important tool that students need to become successful in the working world.
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Muy Bien is a Spanish program for non-native and native speakers in grades K-5. In the lower grades, the language comes alive through music, puppets, big books, posters, picture cards, theater, felt board, a trivia game, a bingo game, and interactive CD Rom. In the higher elementary and secondary grades, Spanish vocabulary and grammatical concepts continue to be developed to achieve a higher level of conversation, reading, and writing skills. All students receive daily Spanish. It is BridgePrep's philosophy that students who practice speaking, reading and writing Spanish will become more fluent as they progress through the program. Our proficiency-based Spanish program enables students to master all aspects of foreign language, from listening and speaking to reading and writing. By providing more than just exposure to a second language, the Spanish faculty inspires students to engage and understand the cultures and traditions of the Spanish-speaking world. Through this exploration of language, students are able to communicate meaningfully and effectively in a globalized world.
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Lanner Electronics has announced the new LEC-7020, an Intel Atom-based industrial computer with 3G, GPS and Wi-Fi capabilities. The small form factor (SFF) computer has a VGA, COM, DIO, four USB ports, and an optional LVDS output, and also boasts a new simplified design allowing quick component installation, the company highlighted.
With an on-board SIM card socket and mini PCI Express 3G/GPS mini-card module, the LEC-7020 can send GPS signals and communicate via a 3G modem, in addition to connections via the two built-in Gigabit Ethernet and optional Wi-Fi module, Lanner said.
To drive digital content the LEC-7020 has an integrated Intel GMA 950 graphics engine and features a VGA port and optional LVDS port. The addition of an LVDS port allows for a direct computer to panel connection and reduces deployment costs for system integrators, Lanner noted.
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As a boy growing up in San Jose in the 1930s, Ray Scoffone roamed local creeks and open spaces, hunting birds and hiking up hillsides.
"They called it 'Valley of Heart's Delight' for good reason," he said. "In the late spring every year you could walk into the foothills and the whole valley was in blossom. Then we lost the orchards and the canneries. There was tremendous change and a lot of sprawl."
In a deal set to be announced Monday, Scoffone, now 85, and his wife, Virginia, are doing their part to preserve some of the area's natural heritage.
The Scoffones have completed a deal to sell a 357-acre property they own to the Peninsula Open Space Trust, a nonprofit land conservation group based in Palo Alto. The property, a rolling expanse of chaparral that is home to deer, bobcats, red-tail hawks and other animals, sits adjacent to Uvas Reservoir, between Morgan Hill and Gilroy. The transaction will double the amount of protected land around the reservoir for wildlife and public recreation for years to come.
"I very much like the idea of leaving some of the space open for the next generations," said Scoffone, a retired Lockheed engineer. "We shouldn't leave a mess for them."
The land will be managed by the Santa Clara County Parks and Recreation Department, which oversees an adjacent 340 acres at Uvas Reservoir County Park.
Santa Clara County's board of supervisors is expected to consider in about a year contributing $287,000 toward the purchase price and adding the land to the county park. After that, it could be open for hiking and other uses.
The deal preserves the land in its natural state, blocking future development of the kind of trophy homes that have sprung up in the past three decades along some ridges and hillsides south of San Jose.
"The placement of a large luxury estate at the top of the property would have destroyed habitat values, and the views from the lake and the lake's shore," said Walter Moore, president of the Peninsula Open Space Trust.
The land also is the latest in a series of purchases and deals by county agencies and environmental groups that have preserved more than 30,000 acres between Highway 101 south of San Jose and Lexington Reservoir near Los Gatos over the past generation. Although not as well-known as preserved lands along the coast or the Peninsula, the emerging necklace of parks and open space preserves — including land around Calero Reservoir and Mount Umunhum — is part of an effort to provide deer, mountain lions and other wildlife a corridor from the Santa Cruz Mountains to the Diablo Range.
"If we don't prevent them from being bottle-necked, they will have a hard time surviving," Moore said.
Uvas Reservoir was built in 1957. It is the fifth largest of the 10 reservoirs owned by the Santa Clara Valley Water District.
The rustic area, which sits five miles west of San Martin in the foothills of the Santa Cruz Mountains, was owned by Martin Murphy, an early pioneer of Morgan Hill and Gilroy in the 1800s. Around 1900, a woman named Minnie Kell, or "Ma Kell", ran a campground in the Uvas Creek Valley, with a dance floor, baseball diamond and swimming hole.
After the land involved in Monday's deal changed hands several times, a developer, Roy Havens, attempted to build more than 200 homes on the 357 acres in the early 1960s. But he was thwarted when PG&E used eminent domain to put a transmission line through part of the property, and Scoffone acquired it in 1966.
At first, Scoffone — a World War II Navy veteran who graduated from San Jose State in 1951 — thought he'd develop the land. But his time was consumed working at Lockheed, and county development laws tightened over the years. He took his six children there on hikes when they were growing up, and eventually decided not to develop it.
Under Monday's deal, the Peninsula Open Space Trust paid the Scoffones, who live in Willow Glen, $1.075 million for the property. The trust put up $287,000, the Santa Clara County Open Space Authority contributed $268,750, the state Coastal Conservancy put in $250,000 of state parks bond money, and the Gordon and Betty Moore Foundation funded $268,750.
"It's a beautiful place," Scoffone said. "I'm happy it's been preserved."
Paul Rogers covers environmental issues and resources. Contact him at 408-920-5045. Follow him at Twitter.com/PaulRogersSJMN.


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Mike Tomlin named to NFL competition committee
Tomlin replaces former Arizona coach Ken Whisenhunt
Pittsburgh Steelers coach Mike Tomlin has been named to the NFL's competition committee.
Commissioner Roger Goodell named Tomlin to the committee on Tuesday.
Tomlin will replace former Arizona Cardinals coach Ken Whisenhunt. Tomlin had worked on the Coaches Subcommittee of the Competition Committee since 2009.
The 41-year-old Tomlin is 68-36 in six seasons with the Steelers and led them to victory in the 2009 Super Bowl.
Goodell said Tomlin has "strong, perceptive views about the game and is effective in expressing them."
Tomlin said he is "excited" about the appointment and is looking forward to contributing.
The nine-man committee, which includes Atlanta Falcons president Rich McKay and Cincinnati Bengals coach Marvin Lewis, recommends rules and policy changes to the NFL.


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Mothers and children march to protest against the proposed commercialization of the genetically modified rice variety called golden rice by Syngenta in Quezon City. Greenpeace supports the creative demonstration of more than a hundred members of Green Moms, a nationwide coalition of mothers advocating for organic foods and breastfeeding practices, to protest their strong opposition to a genetically modified rice variety called Golden Rice (GR) on World Environment Day.
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