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Kira is shocked since she spent that period of time hiding from the Cardassians in caves during a harsh winter, so she remembers it quite well. At Odo's advice, she contacts her last surviving "cellmate", a Bajoran named Yeln. Much to Kira's surprise, Yeln recognizes her, claiming he thought she was dead after she was dragged away from her cell. Faced with records and witnesses disagreeing with her memories, she decides to go Bajor to get to the bottom of this, with Sisko's blessing. Unknownst to Kira, she is being followed by a mysterious woman.
Some time later, Sisko and Dax are contacted by Alenis who claims that Kira never arrived to meet her and apparently vanished shortly after leaving the spaceport on Bajor. An unconscious Kira is seen awakened by the woman from earlier. Kira looks at a mirror and to her horror she sees she is now a Cardassian!
Accompanying the woman is a Cardassian named Entek who explains she is "home" in Cardassia. Kira naturally believes this to be some sort of set up and vows to tell them nothing but Entek insists he is trying to help her. Entek claims she is not Kira Nerys but rather an undercover operative of the Obsidian Order named Iliana Ghemor, and he is her former trainer. Ten years ago, Iliana volunteered to infiltrate the Bajoran Resistance so the Order kidnapped the real Kira Nerys, surgically altered Iliana to look like her, implanted Kira's memories onto her and sent her back to the Resistance. The room she is held in is not a prison but her father's house. Entek gives Kira a data rod containing a personal statement from Illiana as further proof but Kira refuses to watch it.
Entek "introduces" Kira to Legate Tekeny Ghemor, "her" father. Kira treats him with hostility since her father died fighting the Cardassians. Entek explains to Ghemor that "Iliana's" memories haven't surfaced yet and Ghemor claims that until they do, she is a guest in his home. Ghemor treats Kira warmly, replicating her Bajoran food and assuring her that as a member of Central Command, he can have the Obsidian Order surveillance devices disabled. He apologizes for not having convinced her from going on the mission but she was so determined to serve Cardassia. Kira still believes none of this.
Back on Deep Space 9, Garak reports to Sisko and the crew that a "friend" of his informed him that Kira is being held by the Obsidian Order. Sisko decides to mount a rescue mission, which Garak claims is utterly impossible. Sisko then press gangs Garak into coming along by pointing out that the Bajoran government wants Garak off the station (which would leave him with nowhere safe to go), but Sisko doesn't plan to do that ... yet. Garak begrudgingly accepts.
A couple of days later, Kira still doesn't "remember" anything, despite receiving injections that would supposedly restore her original memories. Entek starts getting more aggressive and attempts to pump Kira for information on Deep Space 9. Kira remains evasive prompting Entek to show further evidence of his claims: he brings out the cryogenically preserved corpse of Kira Nerys (which Kira naturally dismisses as a fake) as well as telling her about a memory of accidentally shooting a mother hara cat which she had never told anyone about, claiming it's a memory he implanted himself. Entek warns Kira that the Order is losing patience with her.
Kira attempts to escape by disabling the window's force field but Ghemor enters claiming that she set off a silent alarm. He also points out that even if she does escape, there's no way she can leave the planet without the Order finding her. Ghemor vows that no one will hurt her and begs Kira to watch the recording Entek gave her. Kira does so and is shocked to see that Iliana looks and sounds exactly like her.
Meanwhile; Sisko, Dax, Odo and Garak are deep into Cardassian space on the Defiant disguised as a Kobheerian freighter. They nearly get their cover blown by a Cardassian Gul demanding them to be stopped and searched but Garak orders him to leave and erase his logs with a complex military code he heard while hemming some trousers.
Entek once again interrogates Kira, who at this point is almost broken and unsure of what to believe. Ghemor orders this to stop and Entek replies that their next interrogation will be at Order headquarters. Ghemor tells Kira that he will help her escape since even if she no longer remembers him, he still loves her.
Ghemor later gives Kira her "mother's" bracelet and introduces her to Ari, who will help her escape the planet. Kira asks how this is possible and they explain that they have friends who think as they do that the Central Command and the Obsidian Order have too much power, which they aim to change. Kira realizes that Ari and Ghemor are part of the Cardassian dissident movement. Ari urges Kira to come along but she cannot believe this is a coincidence...and it hits her: Ghemor is the real target of this charade. The Order exploited Kira's resemblance to Iliana to set up this whole thing in order to expose Ghemor's ties to the dissidents. Kira's suspicions are confirmed when Entek shows up with two armed guards, shoots Ari and gloats that he has exposed a traitor and is about to destroy the dissident movement. Luckily Odo, Garak and Sisko show up in the nick of time and disarm the guards. Entek recognizes Garak and taunts him that until now the Order was willing to let him live his exile in peace but no longer. Entek then tries to draw a hidden weapon but Garak kills him.
Back on Deep Space 9, Kira is Bajoran again and tells Ghemor that Bashir confirmed that all the alterations were surgical and that she is indeed Bajoran. Yeln has gone missing, meaning he was likely a Cardassian agent. Kira asks why go to all the trouble of kidnapping her instead of getting the real Iliana and Ghemor points out that then her memories would return and thus Ghemor wouldn't needed to save her and expose himself. Ghemor still believes Iliana is alive and hopes to find her. The Mathenite government has given Ghemor sanctuary but before he leaves, he gives Kira some "fatherly advice": never trust Garak. He also tells her to keep the bracelet since until Iliana is found, Kira is now the closest thing he has to family. Kira sends him off saying that despite anything she has previously said, that he is an honorable man and his daughter must have loved him very much.
- Amnesiac Dissonance: What Ghemor thinks is going on with Kira.
- Big Damn Heroes: Sisko, Odo, and Garak show up to rescue Kira.
- Blackmail: How Sisko gets Garak to cooperate.
- Blunt "Yes":Garak: Commander, this is extortion!Sisko: Hmm... (considers for a moment) Yes, it is.
- Bond One-Liner: After Garak vaporizes Entek:"A pity...I rather liked him."
- Call-Back: Garak mentions his "brief excursion to Bajor" with Bashir as his only trip from the station in a long time.
- Chekhov's Gun: Early on, Garak mentions (in his typical oblique way) that he'd likely be assassinated if he tried to leave DS9. This winds up getting used as leverage to pull him into Kira's rescue.
- Contrived Coincidence / Identical Stranger: Amazingly, Kira looks exactly like a Bajoran version of Iliana would, and even has the same voice. Without this inexplicable resemblance, Entek wouldn't have been able to make Ghemor believe she is his daughter.
- Crazy-Prepared: Entek had a corpse of Kira made in an attempt to convince her. She dismisses it as a fake.
- Double Reverse Quadruple Agent: Lampshaded by Kira with regards to Garak during the rescue.Kira: Don't worry, he's on our side — I think.
- Explain, Explain... Oh, Crap!: Kira realizing that the Obsidian Order is using her to arrest Ghemor.
- Funny Background Event: Odo rolling his eyes behind Garak and Sisko when Garak claims that the authority he just wielded as a member of the State Sec was "something he overheard while hemming someone's trousers."
- Holographic Disguise: Sisko uses one to disguise himself as a Kobheerian.
- Implausible Deniability: When the Defiant is about to be boarded and have its cover blown by a Cardassian ship, Garak drops the holographic overlay they've been using to address the captain:Garak: Gul Benil.Gul Benil: You're not Kobheerians!Garak: Very observant of you. Now turn your ships around.Gul Benil: Excuse me?!Garak: This is an alpha red priority mission, clearance verification 9218-black. By authority of the Central Command, you are ordered to turn your ships around, erase all records of this encounter from your logs, and talk of it to no one! Is that clear?[Gul Benil taps on his computer console]Computer: clearance code verified.Gul Benil: My apologies. I had no idea.Garak: You were doing your duty. End transmission.Sisko: Mr. Garak, I'm impressed.
- Rage Against the Reflection: Kira smashes a mirror once the whole facade drives her to a Despair Event Horizon.
- Screw This, I'm Outta Here!: Mentioned as Garak makes it clear to Sisko that if things go badly, he'll cut them loose and let them hang rather than risk his own life.Sisko: Mr. Garak, I believe that's the first completely honest thing you've ever said to me.
- Tomato in the Mirror: A Downplayed Trope example with Kira as she's told she's just a Cardassian in disguise with false memories.
- Was It All a Lie?: It was... but Kira was sure convinced for a while.
- Originally, Bashir was supposed to have been unable to determine if Kira was actually Cardassian or not, leaving the ending for her MUCH more ambiguous. The ending was rewritten before the episode filmed to make her definitely Bajoran.
- Wham Shot: Cardassian Kira!


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Living in the Birmingham, Alabama, means dealing with mild winters and incredibly hot summers year after year. During the cooler winter months, rain and cold temperatures often result in us cranking up our thermostats to keep our homes comfortable. However, when the season shifts to summer, you'll … [Read more...]
Add Personality to Your Home with Wallpaper
Your home is your own personal space where you can showcase your personality and unique style. What you include in your home from the furniture you choose to the accents and decoration you put on your walls can say a lot about you. However, with the popularity of big box stores, finding ways to show … [Read more...]
Create a Classic Look that Stays in Style
As we embrace new technology, we also fall into an endless cycle. While we all enjoy innovation and technological improvements, we can't ignore the fact that we constantly invest in items that we know will be obsolete or outdated in a few years. Each cell phone we purchase will probably be replaced … [Read more...]
Showcase Your Style with Specialty Paint
When you're decorating your new home or redecorating your current space, you have a great opportunity to show your personality. This starts with the basic selection of paint for each room in your home, or for some, for each specific wall. While you might be anxious to get started with your home … [Read more...]
Finding the Highest Quality Paint for Homes
If you've experienced student housing or rentals with frequent new tenants, you are probably familiar with the attributes of low-quality paint. For example, if you touch these walls with damp hands, you might come away with paint. For some, the chalky quality of layers of this type of paint might … [Read more...]
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However, records from the Richmond County Board of Elections show about 22 percent of the county's 30,419 registered voters took advantage of the early voting period that ended Saturday.
Elections Director Connie Kelly said there were 6,700 early voters in this mid-term election, more than in either of the past two elections.
Kelly said she considered that a "heavy turnout," especially for those from Ellerbe and Hamlet, since the only polling location for early voting was the Cooperative Extension office in Rockingham.
Below is a list of polling places around Richmond County, with two being new locations:
Rockingham No. 1
City of Rockingham Parks & Recreation (Browder Park), 1311 Rockingham Road
Rockingham No. 2
Leath Memorial Library (Calvin Little Room), 412 E. Franklin Street
Rockingham No. 3
Northside Fire Department, 209 Bear Branch Road
Wolf Pit No. 1
East Rockingham Senior Center, 135 Safie 6th St.
Wolf Pit No. 2
Community Church Recreation Building, 193 Mill Road
Wolf Pit No. 3
Cordova School, 194 Church St.
Wolf Pit No. 4
Ellerbe Grove Baptist Church, 162 Ellerbe Grove Church Road
Marks Creek No. 1
First United Methodist Church Fellowship Hall, 300 Charlotte Street, Hamlet
Marks Creek No. 2
First Presbyterian Church Fellowship Hall, 200 Rice Street, Hamlet
Beaver Dam No. 1
Fletcher's Chapel United Methodist Church Fellowship Hall, 108 McCoy Drive, Hoffman
Beaver Dam No. 2
Mt. Zion United Church of Christ Fellowship Hall, 986 Ledbetter Road
Mineral Springs No. 1
Ellerbe Town Hall, 108 W. Page St.
Mineral Springs No. 2
Norman Community Center, 107 East Moore Street
Steeles No. 1
Mangum Community Building, 5838 Grassy Island Road
Steeles No. 2
Concord United Methodist Church Fellowship Hall, 316 Concord Church Road
Black Jack No. 1
Mount Pleasant Community Building, 876 Grassy Island Road
The polls will be open from 6:30 a.m. until 7:30 p.m. and unofficial results will be announced after all precincts have reported.


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When Microsoft announced its $26 billion purchase of the business-networking company LinkedIn this past week, the deal touched off speculation that Twitter would be the next big social media outlet to be taken over. Growth of the 140-character microblogging platform has been slow. Its stock has suffered. But if there's no hope for Twitter as a stand-alone company in a tech world increasingly dominated by a Big Five — Apple, Google, Microsoft, Amazon, and Facebook — the prospects for all sorts of other businesses look even scarier.
By lots of measures, Twitter has much going for it. It has 320 million active users, who provide content for nothing. It has a dedicated following in influential niches: news junkies, sports fans, tech buffs, politicians. Indeed, a certain Republican presidential candidate has built his campaign around it.
Compared with Facebook users, people on Twitter skew younger, wealthier, more urban, more ethnically diverse. Despite some high-profile executive shifts and other business goofs by the company, your favorite band, your college econ professor, and the restaurant across the street all want you to follow them on Twitter.
Yet as Facebook and Google soak up an ever larger share of digital ad dollars, Twitter's recent efforts to keep up are "all sad, and too late," as one influential investor put it.
Here's a warning for every other enterprise: A service can be innovative, highly useful, something 320 million people can't do without — and still not be able to compete against members of the Big Five. That's a problem for Twitter, obviously. But when a handful of firms become so dominant that nobody else survives, it's also a problem for the economy as a whole.
The promise of capitalism is that anyone with a great idea can overturn an entire industry. But other factors work against new entrants. In a winner-take-all economy, the greatest rewards flow to those who are already successful. Last year, according to an analysis by USA Today, just 28 companies earned half of all the income generated by all the American companies in the S&P 500; Apple alone accounted for 6.7 percent of that total.
In the tech world in particular, life is getting tougher, because of network effects and economies of scale, for anybody who's not the Big Five. Apple, Google, Microsoft, Amazon, and Facebook compete with each other across a startling range of businesses: operating systems, instant messaging, cloud computing, advertising, voice-controlled personal assistance, driverless cars, thermostats, home delivery. The question is how much room they're leaving for everyone else. Traditional businesses like retail stores and news organizations are feeling the squeeze, but so are prominent Internet brands such as Twitter and Yelp.
The challenge isn't just that the tech giants can amass more data and apply more engineering muscle than everyone else. Yeah, we all love our iPhones, but Apple didn't gain the world's largest market capitalization just through the genius of Steve Jobs. It's also been the practitioner of dark arts like "Double Irish with a Dutch Sandwich," a highly complex accounting loophole (now closed) in which US firms could limit their taxes by channeling revenues through Ireland, the Netherlands, and the Caribbean.
Because of the piles of cash that they amass by whichever methods, the tech giants can outspend and outlast anyone.
LinkedIn CEO Jeff Weiner all but said that this week. In a letter to employees, Weiner noted LinkedIn's disadvantage relative to the Big Five and the pressure his company faces "to compromise on long-term investment." The underlying message was: If you can't beat 'em, let yourself be assimilated into 'em.
Large, dominant firms often slip up, as Microsoft has with past acquisitions. Yet even in the tech world, companies can dine off old advantages for years. Among the only firms with the scale and deep pockets to compete with the Fab Five are the broadband providers Verizon and Comcast, whose current success is grounded in ancient, government-enforced telephone and cable monopolies.
The longer the current oligopoly holds, the more attention it deserves from Congress and federal antitrust regulators.
Government efforts to promote competition in the tech world have yielded mixed results. In the 1990s, the Justice Department went after Microsoft for using its Windows monopoly to elbow out competing Internet browsers. Praised by consumer advocates at the time, the suit looked far less prescient as mobile devices began to supplant desktop computers a few years later. But consider a far bolder effort — the government's breakup of AT&T in the 1980s. The move was controversial at the time, and mystifying to many consumers. But the innovation that flourished in telecommunications might never have happened had the Bell System kept its grip on that one vital industry.
Today's environment is far different: A handful of companies fight each other fiercely in an ever-expanding number of business categories but squeeze out or buy up everyone else. It's not even clear regulators have the legal tools to address this new type of competitive gigantism that forecloses other competition.
Maybe some brash, insurgent company will acquire Twitter and use it to shake up the status quo. But probably not. One possible buyer is Comcast. Most of the speculation, though, revolves around Google.
Dante Ramos can be reached at email@example.com. Follow him on Facebook: facebook.com/danteramos or on Twitter: @danteramos.


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WALPOLE, MA -- United Electronic Industries (UEI) is pleased to announce the release of the DNA- and DNR-AI-217 high speed, high resolution analog input boards. The boards provide 16 fully differential channels of 24-bit, analog inputs with seven software programmable input ranges from ±10 to ±0.156 V full scale. The A/D per channel configuration eliminates the noise and offset errors associated with multiplexed inputs and, at the same time, allows all 16 channels to be sampled simultaneously. Both boards offer 30 Ksps sampling rates per channel and 480 Ksps aggregate for an entire board. The new board is pin-for-pin compatible with UEI's popular DNx-AI-207 series and provides an easy upgrade to a higher speed, higher accuracy solution.
The DNA version of the board is designed for mounting in any of UEI's popular 6-slot PowerDNA UEIPAC, UEISIM, and UEIModbus "Cubes". The DNR version is designed for use with the 6- or 12-slot rack-mounted HalfRACK and RACKtangle chassis.
Software for the boards includes support for all popular operating systems including Windows, Linux, QNX, VxWorks and more. Windows/Vista software for the DNA/DNR-AI-217 is provided in the UEIDAQ Framework. The Framework provides a comprehensive, easy to use API that supports all popular programming languages and DAQ applications, including LabVIEW, MATLAB/Simulink, DASYLab or any application supporting ActiveX, OPC or Modbus TCP control.
"The availability of new low cost, high speed, high resolution A/D converters has made it possible for UEI to offer the DNx-AI-217 simultaneous sampling analog input boards", says UEI President Shaun Miller, "Release of these high performance boards allows our popular platforms to address many new control applications in a wide range of industries."
|Delivery from Stock (starting 4/19/10)
|Delivery from Stock (starting 4/19/10)
About the "Cube"
UEI's powerful "Cube" architecture is a compact (4 x 4 x 4 in. or 4 x 4 x 5.8 in.) Ethernet-based I/O platform. It may be deployed in five configurations: 1) Ethernet I/O slaved to a host PC, 2) Stand alone Data Logger/Recorder, 3) Linux-based Programmable Automation Controller (UEIPAC), or 4) Simulink / RTW target (UEISIM), 5) Modbus TCP based I/O slave (UEI Modbus). Each Cube consists of a core module (with processor and network interface) and three or six open I/O slots. Users select the deployment option and I/O boards that meet their system requirements. With over 30 I/O boards available, there's sure to be a configuration to meet any application requirement. A six-slot Cube provides up to: 150 analog inputs (up to 24 ICP channels), 192 analog outputs, 288 digital I/O, 48 counter or quadrature channels, 72 ARINC-429 channels and/or 24 Serial or CAN-bus ports.
About the RACKtangle
The RACKtangle I/O chassis offers a similar capability as the cube, but in a more conventional, 3U rack form factor with easily accessed front-loading I/O boards. In addition, it offers 12 I/O slots and supports up to 300 A/D (including up to 48 ICP channels), 394 D/A, 576 DIO, 144 ARINC-429 or 96 CAN or Serial I/O ports. The Gigabit interface also provides two independent ports, one used for primary system control and the second used for real-time diagnostics. The HalfRACK chassis is the same except with 6-slots.
About UEI
Founded in 1990, UEI is a leader in the PC/Ethernet data acquisition and control, Data Logger/Recorder and Programmable Automation Controller (PAC) markets. UEI's I/O "Cube" and RACKtangle I/O chassis are compact, rugged platforms, ideal for DAQ, Logging, and control applications in a wide range of applications and industries including automotive, aerospace/aviation, unmanned vehicles, appliance test, simulator control, in-vehicle test, wind and solar power system control, semiconductor manufacturing, medical equipment, and more. UEI offers both COTS and custom products to OEMs, end-users, and systems integrators worldwide. With analog, digital, counter, CAN-bus, Serial I/O, ARINC-429 I/O and more, UEI will have the interface you need. UEI supports all popular Windows, Vista, Linux and Real-time operating systems, programming languages and application packages, including LabVIEW, MATLAB and DASYLab.


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Nominees should dress in business casual attire and send a video to firstname.lastname@example.com with a brief speech (2-3 minutes) about why they want to be on the board and how they can contribute to the Accounting Society. This video needs to be submitted by Tuesday, April 21st before midnight.
Elections for the Fall 2020 Executive Board will be held on Thursday, April 23rd, 2020 . Accounting society members will be sent a survey where they can vote for their preferred candidate. The candidate with the majority of the votes will be elected for the board.
Elected Board members will be announced on Tuesday, April 28th.


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The Tunisian Top Bar Stitch is a variation of the Tunisian Simple Stitch and is also known as the Top Loop stitch or the Top / Upper Horizontal Bar stitch. The latter indicates exactly how this stitch is worked, pulling the loops up from the top or upper horizontal bar. The fabric it creates is less dense than that of the Tunisian Simple Stitch and the V-bars create a more off-center, diagonal staggering line giving it a differently textured and more flexible fabric.
Using the The Tunisian Top Bar stitch also gives considerably less curl than the Tunisian Simple Stitch. It is also excellent to use during increasing to create a more invisible increase than stitches like the Tunisian Full Stitch.
Ttb Tes
Return or Close Stitch
2 variations on working the first and last stitch on the forward pass:
Amount of Stitches for Stitch Pattern
Any amount of stitches
Ttb – Tunisian Top Bar Stitch
|sc – single crochet (US)
ch – chain
lp(s) – loop(s)
rep – repeat
slst(s) – slip stitch(es)
|Tes – Tunisian Extended Stitch
Tss-wise – Tunisian Simple Stitch Wise (watch this video on hook placements)
v-bar(s) – vertical bar(s)
YO – yarn over
For the purpose of creating a Tunisian Sampler Blanket that you will find HERE, let's work a square as follows:
Ch 35, (work the following pattern for 34 rows incl the foundation row or until square)
|1. Foundation Row: Find a tutorial on the Foundation Row HERE.
|2. Row 1: (Forward Pass) Skip the 1st v-bar and skip the 1st top horizontal bar (the 1st top bar is allocated to the 1st vertical bar),
|3. *insert the hook from front to back under the next horizontal bar,
|4. yarn over and pull up a loop;
|5. Rep from * across to last stitch (last top horizontal bar),
|6. work last st as for Tss (This is the ch-1 of the previous row. Insert hook behind both the front v-bar and the back bar of the chain).
|7. (Return Pass) ch1, close as for Tss [*YO and pull through 2 loops (one ch will be formed while one loop from the hook will be dropped); rep from * across until ONE loop remains].
|8. Rep rows 1 for pattern.
|9. Ending off: sk 1st v- bar, sl st in 2nd horizontal bar and each horizontal bar across, sl st into last st Tss-wise.
Variation on working 1st & last stitch
Steps 2: ch 1, continue with Step 2,
|Continue from Step 3 up to Step 6:
Work same as for Step 6, then ch 1
Continue return pass as for Steps 7-8
Watch the full video on the Tunisian Top Bar Stitch with lots of tips and trix.
The Tunisian Scalene Shawl is worked in a combination of Tunisian Top Bar stitch and Tunisian Extended Stitch.
Great for the beginner crocheter.
Find the pattern in my Ravelry Store, or just click on this link: Tunisian Scalene Shawl


text:
The Annual Legal Inclusiveness & Diversity Summit is a full-day annual conference which features national experts discussing cutting-edge diversity and inclusiveness topics. The Summit features two plenary speakers, three tracks comprised of 12 concurrent sessions, and a reception located at Embassy Suites Denver Tech Center North.
With workplace environments experiencing ever-changing dynamics around societal changes, political movements, and biases related to racial, gender and generational, it is more important than ever to have the skills and tools necessary to drive strategies for advancing diversity, equity and inclusion.
Notice: Their will be photography and video recording happening at event
More details:
Career Fair/Informational Interview
Practice Pitch


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Even better one of heradded by Siddhartha for Phasarani on 15.12.2019 in 18:57
Hi.I have had many people try to scam me, so I am very much guarded and will not provide any kind of monetary favors or suggestions of any sort and will discontinue the communication ..if you are.added by Cerulescent for Phasarani on 16.12.2019 in 16:50
I still hope you take it, roll with it and have some fun along the way.added by Hortative for Phasarani on 14.12.2019 in 14:05
Those are not minor inconsistencies, at least if you're really thinking of building a future and a family with her. 1.added by Subversion for Phasarani on 09.12.2019 in 10:28
It doesn't even sound like a joke. yes emotional cheating..... I don't believe for a minute that he said that as a joke. the fact that hes in constant contact with her coupled with that comment I'd think.. If he flips out, then you know its a long road with this guy as your future with him... is a future with him and her. A "joke" is the standard comeback when you've been caught at something to get off the hook. I wouldn't be able to deal with it and would tell him how it feels. Personally...added by Misdirected for Phasarani on 07.12.2019 in 08:37
until someone else points it out to us. We are often unaware of it... Some people call it a *vibe* they get from someone. Same thing.added by Recti for Phasarani on 11.12.2019 in 05:57
You don't want to be the guy in the middle of all that 'undoing'.added by Gospodar for Phasarani on 15.12.2019 in 03:05
You just want more and more, instead of less. It's like you doing something that really gives you an adrenaline rush or that's really exciting, are you like ready to go right away?added by Patsy for Phasarani on 08.12.2019 in 23:17
hell yes to that stomschadded by Tricord for Phasarani on 09.12.2019 in 00:13
She's just awesomeadded by Borgia for Phasarani on 09.12.2019 in 13:21
apple wristband cockeye bathroom mirror selfpic leaning cutoffs pockets headtilt restroom dark red cami


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Over 60 tonnes of problematic food products seized in NW China
Problematic food products are destroyed in Xining, Qinghai province. [Photo/Chinanews.com]
XINING -- Northwest China's Qinghai province has seized 64.73 tonnes of problematic food products during a food safety campaign, according to the provincial administration for market regulation.
The products are worth 957,000 yuan (about $137,000), including fake, expired and other problematic products.
Since mid-September, the administration launched the joint food safety campaign targeting food safety on campus, the quality of agricultural products and other problems, together with several other departments.
"We launched the campaign to ring the alarm for criminals and show our determination to safeguard the rights and interests of consumers," said Ma Guowei, director of the food safety coordination department of the administration.
It will step up efforts to reinforce food safety supervision and establish a series of long-term mechanisms for food safety on campus and in other fields, according to the administration.


text:
28 July 2006
Germany's Finance Ministry is speeding up the legislative process for the German REIT.
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Isaac Mamaysky is a Partner who provides insightful, strategic business advice to management teams and in-house attorneys across a variety of industries. His clients range from multinational corporations and large educational institutions to national nonprofits and privately-held companies. Mr. Mamaysky advises clients in matters related to employment law, regulatory compliance, education law, high stakes negotiations, dispute resolution, and litigation. Mr. Mamaysky is also well-versed in crisis management and crisis communication, and he supports leadership teams when they face complex, unexpected challenges.
Mr. Mamaysky has overseen numerous internal investigations, written and assessed employment agreements, managed sensitive employee separations, assisted with international hiring and visa needs, drafted and reviewed employee handbooks, ensured compliance with state and federal regulations, composed corporate bylaws, advised governing boards, overseen litigations, led a variety of negotiations, and advised on mandatory reporting obligations. He also regularly conducts corporate trainings on preventing sexual harassment, managing institutional risk, and related topics.
In addition to his legal background, Mr. Mamaysky has nearly a decade of business experience running a large tax-exempt corporation. With a deep understanding of management, organizational leadership, financial modeling, and strategic planning, Mr. Mamaysky approaches his clients' legal matters with a business mindset. For this reason, Mr. Mamaysky especially enjoys serving as outside general counsel to management teams, bringing together his business background and legal insights to help them achieve their organizational goals.
Representative Experience
- Oversaw numerous internal investigations regarding employment issues, such as harassment and discrimination allegations, drafted investigation reports, and supported management teams in implementing appropriate resolutions.
- Drafted and reviewed employment agreements, employee handbooks, and various internal employment policies, and advised management teams on compliance with federal and state employment laws.
- Designed and implemented anti-harassment policies and related corporate trainings, analyzed and ensured compliance with mandatory reporting obligations, and supported management teams in resolving related challenges.
- Advised on many aspects of international staffing, including the obligations of international visa sponsors, the application process to become a sponsor, using international volunteers, and related matters.
- Advised management teams regarding compliance with various state regulations and developed strategic approaches to relationships with regulatory bodies to achieve desired outcomes.
- Reviewed and drafted various corporate governance documents, including incorporation documents, by-laws, conflict of interest policies, and 501(c)(3) applications.
- Reviewed and drafted university policies to ensure compliance with industry best practices and state regulations.
- Experienced in a variety of litigation matters, including multi-district, multi-party commercial litigations, smaller state court matters, and assisting clients in overseeing third party insurance-provided litigation counsel in covered matters.
Publications and Speeches
Recent Publications
- (Book) Letter to a One L Friend: A Little Guide to Seeing the Big Picture and Succeeding in Law School, Carolina Academic Press (2019)
- Featured in Making the One L Path (a Little) Easier, Joel Brown, Bostonia (2019)
- Employer Takeaways from EEOC Virus Screening Guidance, Law 360, Expert Analysis (2020)
- Temporary Payroll Cuts in a Downturn: Furlough and Other Strategies, Potomac Law Group Client Alert (2020)
- Quoted in Some Employers Forgo FMLA Certifications During COVID-19 Pandemic, Society for Human Resource Management (2020)
- FFCRA and Paid Leave: State and Federal Law, with Alan Cooper, AM Skier Newsletter (2020)
- Coronavirus Paid Leave: The Intersection of New York and Federal Laws, Westchester County Bar Association (2020)
- Summary of S8091: New York's Paid Leave Law in Response to COVID-19, Westchester County Bar Association (2020)
- Quoted in 10 Tips for Protecting Workers During the Coronavirus Pandemic, Society for Human Resource Management (2020)
- Quoted in Weathering Coronavirus: Furloughs, Layoffs, or Pay Cuts? Society for Human Resource Management (2020)
- Key Policies for Minors on University Campuses, with Catherine Guttman-McCabe, University Business Magazine (2020)
- Are We Obligated to Give Refunds? The Impossibility Doctrine and Business Considerations, Regpack Blog (2020)
- Ask the EEOC: Key Takeaways for Employers from the March 27th Webinar, Westchester County Bar Association (2020)
- Rehiring Furloughed and Laid Off Workers Post-Pandemic, with Wendy Fischman, Law 360, Expert Analysis (2020)
- Quoted in What to Do When Scared Workers Don't Report to Work Due to COVID-19, Society for Human Resource Management (2020)
- Quoted in Recalling Furloughed Staff: Two Common Legal Risks, Gartner, Legal and Compliance Research Team (2020)
- Supreme Court Decides Whether to Protect Transgender Staff, Camp Business Magazine (forthcoming)
- COPPA Goes to Camp, with Alan Cooper, AM Skier Newsletter (2019)
- The FTC Has Its Sights on COPPA, and Edtech Providers Should Take Notice, EdSurge (2019)
Representative Lectures and Presentations
- City University of New York, Adjunct Lecturer: Multiple semesters teaching an undergraduate philosophy course on critical thinking and logical reasoning.
- University of Rhode Island Honors Program, Humanities Symposium: Invited to speak to students and faculty regarding the value of a humanities degree to business careers.
- University of Connecticut, Guest Speaker: Invited to speak to aspiring law students regarding all aspects of legal practice, the law school experience, and related topics.
- Business Incubator Program: Invited to speak to recently-accepted members of a multimillion dollar business incubator about managing organizational growth from the start-up phase through organizational maturity.
- FJC Leaders Assembly: Selected to speak regarding essential legal considerations to reduce organizational exposure.
- ACA Tristate Conference: Selected to lead a roundtable discussion regarding key legal trends impacting management teams, with a particular focus on employment law, the law surrounding minors on campus, and related matters.
- ACA New England Conference: Selected to speak in three sessions covering employment law, risk mitigation, online privacy, and related matters.
- Nonprofit Montgomery: Delivered a presentation called (un)Employment Law in the COVID-19 Era with Wendy Fischman
- Potomac Law Group, Client Webinar: Delivered a presentation called What Executive Leadership and HR Professionals Need to Know with Catherine Guttman-McCabe, Mark Papadopoulos, and Wendy Fischman
- Co-Presenter, Rehiring from Layoffs and Furloughs, Who to Bring Back and How? Critical Return-to-Work Issues Including Health Screenings and Waivers of Liability, Federal Bar Association and MyLawCLE, with Wendy Fischman, May 13, 2020
Memberships and Affiliations
- Society for Human Resource Management, National and New York City Chapter
- Employment Law Committee, Westchester County Bar Association.
- Higher Education Protection Network (organization works to safeguard minors on university campuses).
News, Events & Insights
- 07.24.2020
- 05.19.2020
- 05.14.2020
- 05.05.2020
- 04.28.2020
- 04.21.2020
- 04.10.2020
- 04.06.2020
- 04.03.2020
- 03.31.2020
- 03.31.2020
- 03.24.2020
- 03.19.2020
- 05.10.2019
Boston University School of Law, J.D., 2008
- cum laude
- Paul J. Liacos Distinguished Scholar
- Edward F. Hennessey Scholar
- Member of the International Law Journal
University of Rhode Island, Honors Program, B.A. in Philosophy, 2005
- summa cum laude
- Recipient of the Reslow-Bannon Award for Embodying the Spirit of the Honors Program
Previous Experience
- Bingham McCutchen LLP (now Morgan, Lewis & Bockius LLP)
Areas of Practice
- Connecticut
- New York
- U.S. District Court for the Southern District of New York


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The new Toy Story film looks like it will be as good as the other 2. The film is being promoted quite a lot at the moment and should appeal to both adults and children.
Toy Story Costumes are always popular but at Props n Frocks, we are anticipating an increase in demand for costumes for the main characters, Woody, Buzz Lightyear, Jessie & Mr. Potato Head.
I have heard some people say that they thought it was a bit sinister in places for young children, and grown men were seen to be wiping away a tear (no, apparantly that is not true, they all had something in their eye!), so it will be interesting to see how it does at the cinema.
If yo have been to see the film, please letusknow what you thought of it.


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Classification of indications for CABG surgery.
The definite feature of coronary artery disease is the focal narrowing in the vascular endothelium, and this leads to the decrease in the flow of blood to the myocardium. Atherosclerotic plaque is the main lesion. These patients can present with chest pain (angina or myocardial infarction) and need further workup noninvasively and invasively for the management. The main reasons for myocardial revascularization can be: (1) relief from symptoms of myocardial ischemia; (2) reduce the risks of future mortality; (3) to treat or prevent morbidities such as myocardial infarction, arrhythmias, or heart failure. Coronary artery bypass grafting (CABG) is the surgical technique of cardiac revascularization. In 1910, Dr. Alexis Carrel described a series of canine experiments in which he devised means to treat CAD by creating a "complementary circulation" for the diseased native coronary arteries. No clinical translation occurred at the time, but he was awarded the Nobel Prize in Medicine. Experimental refinements of coronary arterial revascularization, including the use of internal thoracic artery (ITA) grafts, were later reported by Murray and colleagues, Demikhov, and Goetz and colleagues in the 1950s and early 1960s. Dr. Rene Favaloro performed his first coronary bypass operation in May 1967 with an interposed saphenous vein graft (SVG) and shortly thereafter used aortocoronary bypasses sutured proximally to the ascending aorta. The stenosed segment is bypassed using an arterial or venous graft. Left internal thoracic artery is the most commonly used artery, and long saphenous vein is the most commonly used vein for the coronary artery grafting to reestablish the blood flow to the compromised myocardium. This can be performed with or without the help of cardiopulmonary bypass machine and also with or without arresting the heart. These techniques are called as on-pump beating or on-pump arrested and off-pump beating coronary artery bypass grafting surgery. Distal and proximal anastomoses are usually performed in an end-to-side manner, but in the case of doing sequential grafting, side-to-side anastomosis is also performed proximal to the end-to-side anastomosis. In this chapter we are going to discuss the coronary artery bypass grafting tips and tricks in details.
- coronary artery bypass grafting
- off-pump CABG
- on-pump CABG
- radial
- sequential grafting
1. Introduction
Coronary artery disease is a major cause of mortality and morbidity not only in the developed countries but also in developing countries. Over the last decade, mortality with this disease has decreased, but still it accounts for approximately one-third of all the deaths in people over the age of 35 years. The American Heart Association reported that nearly 16.5 million people (20 years or more age) had coronary artery disease in 2017, with male predominance of 55% [1].
Coronary artery disease is the narrowing or occlusion of the vessel lumen due to arterial wall thickening caused by subintimal deposition of atheroma and loss of elasticity of the arterial wall. Atherosclerosis involves the proximal portions of the coronary arteries, specifically at the branching sites. In the beginning it only affects the flow reserve of the coronary artery, but as it advances, it affects the blood flow even at rest and leads to myocardial ischemia or infarction depending on the severity of the disease. This can be divided as supply ischemia (myocardial infarction and unstable angina) and demand ischemia (stable angina as during exercise, fever, emotional stress, etc.) [2]. The subendocardium is most vulnerable to myocardial ischemia due to the limited collateral blood flow. Therefore myocardial necrosis progresses from the subendocardium to the epicardium with continuing ischemia.
A 75% cross-sectional area loss (50% diameter) is considered an important but moderate stenosis, while a 90% cross-sectional area loss (67% diameter) is considered severe stenosis (Figure 1) [3].
There are three methods of treating coronary artery disease—medical management, percutaneous intervention, and coronary artery bypass graft surgery [4, 5].
2. Medical management of coronary artery disease
Aspirin—it should be used daily in the case of stable angina. Daily use of aspirin in stable angina decreases myocardial infarction and sudden death. Its role is very important in unstable angina and myocardial infarction. Aspirin should also be continued after PCI or CABG.
Platelet inhibitors—it inhibits the binding of the ADP to platelet P2Y12 receptors and consequently inhibits activation of GPIIb/IIIa complex. Therefore it inhibits platelet aggregation. Clopidogrel is recommended if patient is intolerable to aspirin or there are adverse or side effects of aspirin such as GI bleeding or allergic reaction [6]. Both aspirin and clopidogrel are recommended for at least 1 year after PCI and CABG. Aspirin and clopidogrel combination is not recommended for stable angina as it is not superior to aspirin alone and increases the risk of bleeding [7].
Beta blockers—these medicines decrease the myocardial oxygen demand and improve exercise capacity. These are effective for stable angina, and dose should be adjusted to keep heart rate about 60/min at rest and less than 100/min with exercise.
Calcium channel blocker—as beta blockers, these agents are also effective to treat stable angina. They act mainly by causing vasodilatation and reducing peripheral vascular resistance. The dihydropyridines (nifedipine, amlodipine, etc.) do not affect the SA or AV node conduction. Their mechanism of action is by dilating the coronary arteries and reducing the peripheral residence, thereby leading to the decrease in myocardial oxygen demand. On the other hand, non-dihydropyridines (verapamil, diltiazem, etc.) also affect the SA and AV nodes and decrease the oxygen demand.
Nitrates—these are the coronary vasodilator agents. In the lower doses, they are venodilator and reduce the preload, while in higher doses they are also arterial dilators and thereby decrease the afterload too.
Ranolazine—this is the selective inhibitor of the late influx of sodium, thus decreasing the myocardial contractility. It is usually used in combination with beta blockers to treat angina.
Statins—these are hypolipidemic drugs that inhibit the HMG-CoA reductase enzyme and decrease atherosclerotic effect.
ACE inhibitors—they inhibit the angiotensin-converting enzyme. These are the class I recommendation for patients with chronic coronary artery disease with low LVEF (˂40%) or diabetic and a class II recommendation for patients without these mentioned features [8].
3. Percutaneous coronary intervention (PCI)
Although the term percutaneous coronary intervention refers to any therapeutic coronary artery intervention, it has become synonymous with the percutaneous coronary stent implantation. In the earlier days, bare metal stents were used, but over the last decades, drug-eluting stents are the most commonly used stents for PCI. PCI is performed in patients with stable coronary artery disease and also in settings of acute coronary syndrome.
3.1 Indications for PCI
Moderate to severe stable angina with evidence of reversible ischemia.
High-risk unstable angina or ST elevation myocardial infarction (STEMI).
Acute STEMI.
Rescue PCI after failed thrombolysis.
Cardiogenic shock after myocardial infarction (MI).
Revascularization after successful resuscitation.
3.2 Absolute contraindication
Lack of vascular access.
Active untreatable severe bleeding.
3.3 Relative contraindications
Bleeding disorder.
Severe renal insufficiency unless patient is on hemodialysis or has severe electrolyte abnormality.
Poor compliance with medicines.
Terminal illness (advanced or metastatic malignancy).
Short life expectancy.
Difficult coronary anatomy.
Failed previous PCI or not amenable to PCI.
Severe cognitive dysfunction or advanced physical limitation.
Other indication for open heart surgery.
3.4 In view of the following conditions, patients should not go for PCI
Small area of myocardium is at risk.
No objective evidence of ischemia with either noninvasive or invasive testing (e.g., fractional flow reserve).
Less likelihood of technical success.
Left main coronary artery (LM) or multivessel coronary artery disease with a high SYNTAX score (better for CABG).
Insignificant stenosis (˂50% stenosis).
End-stage cirrhosis with portal hypertension resulting in encephalopathy or visceral bleeding.
4. Coronary artery bypass grafting (CABG)
Coronary artery bypass grafting is a coronary revascularization by surgery. Dr Rene Favaloro performed his first coronary bypass operation in May 1967 with an interposed saphenous vein graft (SVG) and shortly thereafter used aortocoronary bypasses sutured proximally to the ascending aorta. In the words of Dr Denton Cooley, "Although he [Favaloro] was always hesitant to carry the moniker of 'father' of coronary artery bypass surgery, he is the surgeon we should credit with introducing coronary bypass surgery into the clinical arena" [9]. It has been shown to be highly effective in the relief of severe angina and under some circumstances has the capability for considerably prolonging useful life. The stenosed segment of the coronary artery is bypassed using an arterial or venous conduit, and by this it reestablishes the blood flow to the distal ischemic myocardial area. Many studies have shown that surgical revascularization is superior to medical and percutaneous interventional management for multivessel CAD. Full workup should be done before taking patient for surgery.
4.1 The anatomical factors which favor the CABG are as follows
Significant LM disease.
Significant proximal left anterior descending (LAD) disease.
Lesions not amenable to PCI.
Diabetes mellitus.
Depressed left ventricular (LV) ejection fraction.
Indications for CABG can be classified as per Table 1.
4.2 Indications for CABG
High-grade LM stenosis.
Significant stenosis (>75%) of proximal LAD with double- or triple-vessel disease.
Symptomatic double- or triple-vessel disease.
Disabling angina despite maximal medical therapy.
Poor LV functions.
Post MI angina.
Post NSTEMI with ongoing ischemia that is unresponsive to medical therapy or PCI.
STEMI with inadequate response to all nonsurgical management.
Emergency CABG.
Failed PCI.
4.3 Contraindications
4.3.1 Absolute contraindication
There is no absolute contraindication.
4.3.2 Relative contraindications
Asymptomatic patient with low risk of MI or death.
Advanced age.
Co-morbidities (COPD, pulmonary hypertension, etc.)
4.4 Factors increasing mortality after CABG
Preoperative renal insufficiency.
Peripheral vascular disease.
Recent MI.
Recent brain stroke.
Emergency surgery.
Cardiogenic shock.
5. Types of grafts
5.1 Arterial grafts
Internal thoracic artery (internal mammary artery)
Radial artery
Right gastroepiploic artery
Inferior epigastric artery
Ulnar artery
Splenic artery
5.2 Venous grafts
Greater saphenous vein
Short saphenous vein
Cephalic vein
5.3 Arterial grafts
5.3.1 Left internal mammary artery (LIMA)/left internal thoracic artery (LITA)
Drs. Vineberg and Miller were the first to recognize the properties of internal mammary artery (IMA) and used it for myocardial revascularization in 1945 [10]. They found that it is usually spared from atherosclerosis and reasoned that its branches could form collaterals with myocardial arterioles. They injected contrast medium in postmortem specimens demonstrating connections between the implant and the coronary arteries, but few surgeons took their work seriously [11].
LIMA originates from subclavian artery just above and behind the sternal end of the clavicle (Figure 2). The artery descends vertically 1 cm lateral to the sternal border, behind the first six costal cartilages. Figure 3 shows the LIMA position regarding pectoralis muscle, sternum, and pleura with endothoracic fascia. LIMA is widely used these days, especially for the anastomosis with LAD. After dividing the sternum, retractor is placed to lift the left sterna edge. The operating table can be elevated and rotated to expose LIMA properly and harvest it. LIMA can be harvested as pedicle graft (along with internal thoracic veins, fat, muscles, and pleura) or skeletonized vessel. Skeletonized LIMA is supposed to preserve the venous drainage of the sternum, and it is often preferred when there is suspicion of sternal healing and wound infection. All small branches of LIMA are clipped. The proximal end of the LIMA kept attached to the subclavian artery, and then after giving heparin, the distal end is ligated and divided. In the same way as LIMA is harvested, RIMA can also be harvested if it is needed for grafting.
5.3.2 Radial artery
The second most commonly used artery is the radial artery (RA). It is usually harvested from nondominant hand (Figure 4). The RA arises from the bifurcation of the brachial artery in the cubital fossa and terminates by forming the deep palmar arch in the hand. The main concern using RA is blood supply to the wrist and hand. Before using the radial artery, we should assess the patency and collateral blood circulation from the ulnar artery. It can be assessed clinically by Allen's and modified Allen's tests. This can also be assessed by preoperative arterial ultrasound. The radial artery can be harvested by open conventional method or endoscopically. The radial artery should be flushed and kept in a solution prepared with Ringer lactate (500 ml), sodium nitroprusside (50 mg), and heparinized blood (30 ml).
5.3.3 Right gastroepiploic artery
It is very rarely used as an arterial graft when other conduits are not available. To harvest this artery, the midline incision over the sternum is extended to the upper abdomen, and the abdominal cavity is opened. There are two gastroepiploic arteries (Figure 5): left and right. Both arteries participate in the stomach vascularization and are collateral blood circulation with other blood vessels of the stomach. Harvesting right gastroepiploic artery as conduit does not compromise stomach blood supply. Branches of this artery to the stomach and omentum are ligated and divided. This artery is positioned either anteriorly or posteriorly to the duodenum and stomach, depending on the tension on graft. A circular opening is made in the diaphragm, medial to the inferior vena cava, and the gastroepiploic artery is passed through this opening to anastomose it with RCA or PDA coronary arteries. The anatomy of gastroepiploic arteries is presented in Figure 6.
5.3.4 Inferior epigastric artery
The inferior epigastric artery (Figure 6) arises from the medial aspect of the external iliac artery and gives branches to the spermatic cord, pubis, abdominal muscles, and skin. Its harvesting requires additional either low midline, or paramedian, or oblique inguinal approach. The anterior sheath of the rectus muscle is divided, and then the muscle is pushed medially. The artery is harvested along with the accompanying veins as a pedicle graft and kept in the solution as mentioned for radial artery preservation.
When the length of this artery is not sufficient for an independent graft, it is used as a composite graft with the LIMA as extension graft.
5.3.5 Ulnar artery
Occasionally, when surgeons do not have other choice, they use the ulnar artery as arterial conduit.
5.3.6 Splenic artery
When there is lack of other conduit, the splenic artery can be used for grafting. The same as harvesting gastroepiploic artery, midline sternal incision can be extended over the abdomen, and the abdomen is opened. Then lesser peritoneal sac is opened. The splenic artery (Figure 7) runs along the superior margin of the pancreas. Branches to the pancreas are ligated and divided. Then the splenic artery is ligated and divided at the splenic hilum and passed through an opening made in the diaphragm medial to the inferior vena cava.
5.4 Venous grafts
5.4.1 Greater saphenous vein
The greater saphenous vein (Figure 8) is the most commonly used conduit for CABG. The greater saphenous vein (GSV) of the lower extremity is the best choice of this type of graft based on:
There are two independent types of low extremity vein system, and removal of superficial one (GSV) does not jeopardize the venous flow from the leg.
Position, diameter, and length of the GSV are in constant pattern which simplifies its harvest.
Usually a single long segment is harvested. About 12–15 cm segment may be needed for diagonal branch, about 20–24 cm length for OM branches, and 18–22 cm length for RCA and PDA coronary arteries. Poor quality and veins with varicosities should be avoided. Branches can either be ligated or clipped. These should be ligated or clipped; just flush with GSV to avoid the narrowing or diverticulum. Creation of skin flaps should also be avoided.
GSV is harvested in two different ways:
Directly by single full incision or through multiple incisions (Figure 9)
Endoscopic vein harvest
5.4.2 Short saphenous vein
In rare cases when not enough conduits are available, some surgeons have to use short saphenous vein (Figure 8). It can be harvested by positioning the patient in prone or supine position.
5.4.3 Cephalic vein
Even though we have not used the vein as alternative graft, this can be used in the case other grafts need it. The cephalic vein can be harvested from the wrist up to the shoulder. The walls of the vein are thinner than the saphenous veins, and long-term patency is also lesser than saphenous veins [12].
6. Types of CABG
Traditional on-pump CABG.
Off-pump CABG.
Minimally invasive direct.
Totally endoscopic CABG.
6.1 On-pump CABG technique
A median sternotomy is done (Figure 10).
The same time arterial or venous conduit is harvested.
LIMA is harvested.
Full-dose heparin is given.
LIMA is divided distally and a bulldog clamp is placed on the artery.
Distal segment of LIMA on the chest wall is ligated or clipped.
The pericardium is opened and pericardial stay sutures placed.
Purse string sutures are placed on the ascending aorta and right atrial appendage for cannulation.
A purse string suture is placed on the ascending aorta for cardioplegia cannulation.
Aortic and right atrial cannulae are inserted.
Epiaortic ultrasound can be used to find the site devoid of calcification or atherosclerotic plaques, for cannulation [13].
Aorta is cross clamped and antegrade cardioplegia given.
Cold saline or ice slush can be used for topical cooling.
The heart is retracted out of the pericardial cavity, toward the head of the patient.
Usually first distal graft is done to RCA or PDA (Figure 11).
Graft is distended with blood cardioplegic solution, graft lie is checked, and appropriate length is divided.
The heart is then retracted to the right and then OM is selected for grafting.
Distal anastomosis is done to selected OM vessel.
Graft is distended with solution and appropriate length divided.
The same technique is used for diagonal anastomosis.
Then focus is changed to LIMA-LAD anastomosis.
LIMA is cut to appropriate length.
LIMA-LAD anastomosis is created with Polypropylene 7-0 or 8-0 sutures (Figure 12).
Rewarming is started while doing anastomosis.
A pericardial window is made to pass LIMA without tension.
Phrenic nerve should not be injured.
Aortic cross clamp is removed.
Partially occluding clamp is applied on the ascending aorta (Figure 13).
Two to three openings are made in the aorta using aortic punch.
Proximal anastomosis is done between the aorta and grafts with Prolene 6-0 sutures.
Partially occluding clamp is removed.
De-airing of the grafts is done.
Proximal anastomosis can also be done on the arrested heart with single aortic cross clamp [14],
If the heart is in sinus rhythm, then start weaning off CPB.
Graft flow could be checked with flow meter device.
Protamine is given to reverse the effect of heparin.
Decannulation is done and bleeding secured.
Temporary pacing wire is placed on RV.
One mediastinal and one left pleural drains are inserted.
Sternum is closed with wires.
The skin and subcutaneous tissue are closed in layers with vicryl sutures.
6.2 Off-pump CABG (OPCABG) technique
6.2.1 Patient selection
18.104.22.168 Beginner beating heart surgeon
They should avoid patients with unfavorable characteristics:
Cardiomegaly-making exposure of lateral and inferior walls difficult
Small (<1.5 mm diameter), intramyocardial, and diffusely diseased vessels
Hemodynamically unstable patients
Critical left main disease
Recent acute MI
220.127.116.11 Experienced beating heart surgeons
Majority of the cases can be performed without complication after getting a good experience in off-pump CABG, but it is better to avoid if multiple unfavorable factors are present in the same patient (cardiomegaly with EF <25% and small vessels).
OPCAB is particularly beneficial for:
6.3 Contraindications
6.3.1 Absolute contraindications
Preoperative hemodynamic instability
Deep myocardial LAD
Moderate to severe mitral regurgitation
6.3.2 Relative contraindications
Pulmonary hypertension
Diffuse coronary artery disease
Dense myocardial adhesions during reoperative surgery
Enlarged ascending aorta
LM disease with a non-reconstructable RCA system
6.4 Operative steps
Preserve normothermia by keeping the operating room warm.
CPB machine and perfusionist should be available in OR.
No need to prime the CPB machine.
Off-pump setup (octopus, starfish, CO2 blower, intracoronary shunts) should also be available (Figure 14).
Maintaining the systolic BP is important during positioning of the heart for grafting.
Inotropic supports and IV fluid is usually required.
Midline sternotomy.
LIMA and other conduits are harvested.
Heparin is given (1–1.5 mg/Kg) to keep ACT of about 300 s.
ACT should be checked every 20 min and added as required.
Coronary arteries should be grafted in the order of increasing cardiac displacement (anterior wall vessels, then inferior wall, and finally lateral wall vessels).
Most of the surgeons usually do distal anastomoses first, but proximal anastomoses can be done before distal anastomoses.
Performing proximal aortic anastomoses last allows precise estimation of graft length, whereas performing them first allows immediate myocardial reperfusion once each distal anastomosis is completed.
Positioning the heart is very important and needs mechanical stabilizers as octopus and starfish.
Anterior wall vessel anastomosis—anterior wall vessels (LAD, diagonal, ramus) need to be brought near midline for better visualization and anastomosis. Deep pericardial retraction sutures of silk, vicryl, or ethibond (1-0) should be taken fast near the left superior pulmonary vein in order to prevent hemodynamic instability.
Inferior wall vessel anastomosis—for distal right coronary artery and posterior descending artery, the table is in steep Trendelenburg position. Manipulation of the deep pericardial retraction sutures is done to better expose the grafting vessel. For grafting the right coronary artery, the table is made flat, and retraction sutures are relaxed with the heart failing to the left side. Maneuvering the heart for RCA and PDA grafting can cause bradycardia and hypotension, so anesthetists should be more vigilant and need to give fluid and inotropes to keep hemodynamic stability during grafting.
Lateral wall vessel anastomosis—for obtuse marginals, posterolateral branches of the right coronary artery, the OR table is placed in steep Trendelenburg position, raised and rotated toward the right [17]. This will allow gravity to displace the heart to the right and apex anteriorly. The right pleura is opened, and the right pericardial incision is extended toward the inferior vena cava, so that the heart can be displaced toward the right side without hemodynamic compromise. Some extra deep pericardial retraction sutures may need to be taken between the inferior vena cava and pulmonary vein. The first suture is anchored just above the left superior pulmonary vein, the second below the left inferior pulmonary vein, the third one called "the intermediate" is located between the inferior pulmonary vein and the inferior vena cava, and the fourth one close to the inferior vena cava. These stitches are quite comparable to the "Lima Stitches" introduced in North America in 1997 by Tom Salerno [18].
Do not compromise the exposure, and if it is not possible, then convert to conventional on-pump CABG.
A silastic tape or vascular sling is passed around the selected coronary artery proximal to the site chosen for anastomosis.
Intracoronary shunts are inserted in coronary arteriotomy.
A CO2 blower is used to disperse the blood to create the anastomosis.
Blower is used selectively when needed and at a rate not >5 L/min to prevent endothelial damage.
A temporary pacing wire can be placed for anastomosis to RCA to combat the bradycardia.
Anastomosis is performed in a routine manner with Polypropylene 7-0 or 8-0 sutures for LIMA grafting or venous grafting.
The intima of both the graft and the recipient vessels must be visualized each time the needle is placed through the anastomosis.
Bilateral IMA grafting (typically to the left heart) has been shown to improve survival and intervention-free survival and should be performed whenever contraindications do not exist.
After completion of anastomoses, heparin could be reversed with protamine.
Protamine is given (0.75–1.0 mg/kg) to incompletely reverse the heparin, leaving each patient with an ACT less than 150 s at the conclusion of the case.
The avoidance of CPB should not come at the price of any compromise in anastomotic precision.
6.5 Hemodynamic instability and conversion to cardiopulmonary bypass
In some of the situations, CABG should be performed on CPB. These are as follows:
Ischemic arrhythmias unresponsive to heparin and antiarrhythmic medications.
Cardiogenic shock due to acute infarction or severe global ischemia.
Physical conditions that limit rightward displacement of the heart (deep pectus excavatum, previous left pneumonectomy)
Although avoidance of CPB is generally a worthwhile goal, it does not supersede the goals of hemodynamic stability and complete, precise revascularization.
6.6 Causes of hemodynamic instability
Imperfect technique in cardiac displacement (compressing the right atrium or right ventricle or kinking of the right ventricular outflow tract during rightward displacement of the heart).
Application of compression with the coronary stabilizer—achieve and maintain tissue capture with a minimum of downward pressure on the heart. This will optimize both coronary stabilization and hemodynamic stability.
Less commonly, regional myocardial ischemia is a cause of hemodynamic instability.
The risk of myocardial ischemia during off-pump CABG can be reduced by keeping the following points in consideration:
The most stenotic vessel is always revascularized first because this vessel is normally well collateralized.
The proximal anastomosis of the graft is performed just after the distal anastomosis of the same graft is completed before proceeding to the next distal anastomosis.
Intracoronary shunts are used to prevent ischemia.
The ascending aorta is side clamp only once during the procedure to minimize the aortic trauma.
The systemic pressure is always reduced around 90–100 mmHg before and during the entire side clamping of the ascending aorta.
The anterior and the inferior territories are always grafted before the posterior territory.
6.7 Sequential bypass grafting
The sequential bypass graft is an effective multiple-bypass technique when graft availability is limited [19] and has been reported to allow improved rates of patency in bypass procedures on narrow coronary arteries [20, 21]. Compared with regular end-to-side anastomosis, however, side-to-side anastomosis is a relatively complex procedure.
Methods of side-to-side anastomosis include the following:
A diamond configuration, in which the graft axis lies perpendicular to the axis of the target coronary vessel (crossed side-to-side anastomosis) (Figure 15)
A parallel configuration in which the graft and target coronary axes are aligned (parallel side-to-side anastomosis) (Figure 16)
Continuous or interrupted sutures can be used.
The side-to-side anastomoses used in SB are technically difficult compared with regular end-to-side anastomoses.
Interrupted crossed side-to-side anastomosis greatly simplifies this procedure.
In an experimental study with animals, Shioi [22] compared various techniques for performing anastomoses, reporting that crossed side-to-side anastomosis enabled a larger opening than did parallel side-to-side anastomosis and that interrupted sutures enabled a larger anastomotic opening than did a continuous suture.
6.8 Complications
Early death—in general, after isolated CABG, approximately 98% of patients survive at least 1 month, and 97, 92, 81, and 66% survive 1, 5, 10, and 15 years or more, respectively. In an analysis of seven large datasets representing more than 172,000 patients, Jones and colleagues identified seven variables most predictive of early mortality [23]:
Older age
Female gender
Previous CABG
Urgency of operation
Severe LV dysfunction
Left main disease
Increased extent of coronary artery disease
Adverse neurological outcomes—a multicenter study by Roach and colleagues of 2108 patients undergoing CABG with CPB documented adverse cerebral outcomes in 129 patients (6.1%) [24]. Type 1 deficits (major focal deficits, stupor, and coma) occurred in 3.1%, and type 2 deficits (deterioration in intellectual function or memory) in 3.0% of the patients. Predictors of type 1 deficits included the presence of proximal aortic arteriosclerosis, history of prior neurologic disease, intra-aortic balloon pump, diabetes, hypertension, unstable angina, and older age.
Mediastinitis—deep sternal wound infection occurs in 1–4% of patients after CABG with CPB and is associated with increased mortality [25]. Obesity is a risk factor for mediastinitis [26]. Other factors associated with an increased prevalence of deep wound infection include diabetes, previous CABG, the use of both IMAs, and duration of operation [26, 27]. Randomized trials have shown that off-pump CABG is not associated with a lower prevalence of sternal wound infection [25, 28].
Renal dysfunction—in a multicenter study of renal dysfunction after CABG with CPB in 2222 patients, "dysfunction" was defined as a postoperative serum creatinine level of 2.0 mg dL−1 or greater, or an increase of 0.7 mg dL−1 or more from preoperative level [29]. Renal dysfunction occurred in 171 (7.7%) patients, and 30 (1.4%) required dialysis. Early mortality was 0.9% among patients who did not develop renal dysfunction, 19% in those with renal dysfunction who did not require dialysis, and 63% among those who required dialysis. Preoperative risk factors for renal dysfunction included advanced age, moderate to severe cardiac failure, previous CABG, diabetes, and preexisting renal disease [29]. In two randomized trials, prevalence of postoperative renal failure was similar in on-pump and off-pump groups [28, 30].
Myocardial infarction—perioperative MI, usually defined by the appearance of new Q waves in the ECG or non-Q wave MI can also occur which are detected by elevation of serum myocardial biomarkers, is most often related to inappropriate myocardial management, technical problems, or incomplete revascularization. Prevalence of MI is approximately 2.5–5% [31]. Perioperative infarction, when quantitatively more than trivial, is a risk factor for later death [32]. Including perioperative cases, MI is relatively uncommon after CABG, with 94% of patients in the Katholieke Universiteit, Leuven, Belgium (KU Leuven) experience free of infarction for at least 5 years and 73% for at least 15 years [33].
7. Results
Unsatisfactory quality of life—even though unsatisfactory quality of life after CABG is one of the most important unfavorable outcome events, quantifying it is very difficult because it depends on the following three factors:
Freedom from angina or heart failure;
Freedom from the need for medication, rehospitalization, and reintervention.
Preservation of exercise capacity.
Most of the patients have a satisfactory quality of life early after CABG, but this gradually begins to decline after about 5 years [34].
Neurobehavioral outcomes—damaging effects of CPB machine are usually blamed for neurobehavioral disturbances and decline in cognitive function in some patients. These are mild most of the times and might not be apparent unless patients are tested specifically for them. As many as 75% of patients may exhibit these subtle defects when tested 8 days after CABG, but by 3–6 months postoperatively, proportion drops to only about 10–30% [35]. Gross defects most likely result from embolization of arteriosclerotic debris from the ascending aorta or from air and intracardiac thrombus rather than from damaging effects of CPB [36]. Prevalence is about 0.5% in relatively young patients but rises to about 5% in patients older than age 70 and about 8% in those older than 75 [37]. Randomized trials comparing on- and off-pump procedures showed similar prevalence of adverse neurologic outcomes [28].
Functional capacity—maximal exercise capacity of patients is improved by CABG. The degree of exercise capacity depends on preoperative LV function, graft patency, and completeness of revascularization. Maximal exercise capacity generally is improved more by CABG than by medical treatment, at least for 3–10 years [38].
Left ventricular function—resting regional perfusion defects are improved after CABG in at least 65% of patients [39]. Left ventricular wall segments that are hypokinetic, akinetic, or even dyskinetic at rest preoperatively often have improved systolic function after CABG [40]. This is associated with increased regional myocardial perfusion. Improvement in segmental wall motion 12 months after CABG has been observed even in areas of scarring from previous MI [41]. This finding supports the concept that viable muscle cells, which may be hibernating, are scattered through hypokinetic and, at times, even akinetic and dyskinetic segments and that wall motion in such segments can be improved by CABG [42]. When segmental wall contraction does not occur after CABG, incomplete revascularization is the cause in some patients. LV diastolic function, more specifically LV "relaxation," is also improved by successful CABG, and improvement may be immediate [43].
Exercise—the decrease in EF with exercise that is a characteristic of ischemic heart disease is absent 2 weeks after operation in most patients. This favorable response to stress can be brought about only by CABG or PCI and does not result from collateral circulation alone, even when extensive [44]. When global and segmental function during exercise is not improved early (3 months) after operation, one or more bypass grafts are usually occluded or stenosed.
Patency of grafts: internal mammary artery—the highest patency rates for coronary bypass grafts are associated with the use of the left internal mammary (thoracic) artery to bypass the left anterior descending coronary artery. These patency rates are approximately 95% at 10 years after operation, and closure of the mammary artery after that time is uncommon. This favorable performance of the internal mammary artery when anastomosed to the left anterior descending coronary artery is probably due to its particular wall structure and function and the potentially large runoff through the left anterior descending artery system. Internal mammary artery grafts to other vessels appear to have lower patency rates late postoperatively than do those to the left anterior descending artery, and these may be no greater than those of vein grafts [45]. IMA as a free graft from the aorta to LAD provides patency almost as high as with an in situ graft.
Other arterial grafts—early (<13 months) patency of radial artery grafts exceeds 90% and does not differ from ITA patency [46]. A native coronary stenosis of less than 70% is associated with lower patency of a radial artery graft than if the stenosis is 70% or greater. Tatoulis and colleagues [47], in a study of long-term patency of 1108 radial artery grafts, reported patency of 89% at a mean follow-up interval of 48 months. Of 318 grafts in place for more than 5 years, 294 (92%) were patent. Of 107 in place for more than 7 years, 99 (92%) were patent. Patency was highest for grafts placed to the LAD (96%) and lowest for grafts to the RCA (83%).
In a study by Suma and colleagues [48] of gastroepiploic artery grafts in 685 patients who underwent postoperative angiographic evaluation, patency was 94% within 1 year in all 685 patients, 88% between 1 and 5 years in 102 patients and 83% between 5 and 10 years in 102 patients. Time-related patency at 1 month, 1 year, 5 years, and 10 years was 96, 91, 80, and 62%, respectively. The principal causes of late occlusion were anastomotic stenoses and anastomoses to less critically stenosed coronary arteries.
For the inferior epigastric artery, Gurne and colleagues [49] performed postoperative angiography in 122 patients early (11 ± 5 days) and in 72 patients late (11 ± 6 months) after operation. Early patency was 98%, and late patency was 93%. Of 14 grafts that were occluded or threadlike at the late study, 8 were anastomosed to arteries with a stenosis of 60% or less.
Saphenous vein grafts—diffuse intimal hyperplasia is a universal finding in vein grafts that have been in place for more than 1 month [50]. Thickness of the intimal hyperplasia seems to be inversely related to flow in the graft, and the process appears to result in a matching of vein lumen size to that of the coronary arteries supplied by the graft. About 10% of vein grafts get closed within the first few postoperative weeks. By 10 years after insertion, half of vein grafts still patent have undergone at least some arteriosclerotic changes [51]. About 20% of vein grafts have proximal suture line stenosis within 1 year; about one fourth of these are found to be occluded 5 years later. Almost 50% of patients have some narrowing of the distal anastomosis within 1 year, but most have not progressed by 5 years after CABG. The 10-year patency rate of vein grafts appears to be highly variable, and in some reports [52] only 50–60% overall are still patent. Arm veins have a still lower prevalence of patency [53] as do synthetic conduits. The patency rates are lower when the anastomosis is to small coronary arteries and to arteries supplying areas with considerable scar. Thrombosis, another process that can reduce graft patency, may develop early postoperatively. Endothelial cell loss and exposure of the basement membrane and collagen to blood tend to appear early after inserting the vein graft, predisposing it to early accumulation of platelets, fibrin, and thrombus on its luminal surface.


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Happy Easter! Today, as we continue our look into the 12 men that were Jesus' desciples, we look at John. As we look at the men who were Jesus' closest friends in the context of his death and Resurrection, it is especially interesting to see what it meant for them, and what it means for us today!


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Healing – a workshop for anyone facing infertility/involuntary childlessness
7th - 8th March 2015,
Sat and Sun 10.00am - 5.00pm
This workshop is for anyone who has experienced infertility, failed fertility treatment, miscarriage, ectopic pregnancy, premature menopause, secondary infertility, stillbirth, neonatal death, or unwanted childlessness – whatever the cause, including lack of a partner.
The groups aim to continue and develop the innovative work in this field of the therapist, Meredith Wheeler. The intention is to allow participants to explore their emotions, and to open up the possibility of moving on in their life.
Some may need to acknowledge feelings of grief and loss and this can help women to feel lighter and calmer.
Sharing feelings and experiences can alter the perspective of participants on their own story. This process can provide clarity for those difficult decisions on what the next step might be.
Links may be forged during this process that could form the basis of valuable supportive networks offering a route out of isolation.
The longer term benefits may take various forms:
Some people may come to terms with childlessness and decide to stop further treatment.
Some people may decide to undertake further treatment, but in a new spirit.
Some people may reconsider the possibility of adoption.
Although the focus of the workshops will be on shared experiences and emotions, there will also be an openness to finding 'ways in' to people's feelings by creating art or using meditation techniques. The emphasis will be on expression rather than ability - no prior experience is necessary. Care will be taken to create a safe, compassionate and healing atmosphere.
Fees for London weekend workshop: £190 or £175 early bird if booked at least three weeks in advance.
Limited spaces available.
Some bursaries for unwaged or low-income individuals. Financial issues should never be the factor preventing anyone from taking part.
Women, men and couples are welcome. Partners are particularly encouraged to attend.
All sexual orientations welcome.
Organiser:Gill Tunstall Phone: 07825 581 148 firstname.lastname@example.com
Location:The Bonnington Centre
11 Vauxhall Grove
Do call me on tel. 07825 581 148 to ask any questions and you can register your interest by using the contact form.
Quotes from previous attendees
"I feel so much better after last weekend. My brain has got room to deal with life again and I can talk with other people about their problems without feeling like my head's going to explode! I feel more like the old me again - such a lovely feeling."
"It was so good to meet other women in the same situation as me, to talk and empathise, as I've felt so isolated and different from friends and family. I think hearing someone else's story also helps put your own into perspective. Also, when you tell your story and people accept you and don't judge you, it helps you stop judging yourself."
"I am me again! I know I can now focus on the future. For the first time in over 2 years I have had a very enjoyable weekend - without feeling like I have my burden of "infertility" clouding my mood. Finally been able to relax - all part of letting go I guess!"
"Just thank you so much to Gill…a wonderful experience and with wonderful women!"
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