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- Private departure transfer from your downtown Atlanta, North Atlanta, Buckhead, Alpharetta or Marietta hotel to Hartsfield Jackson International Airport (ATL)
- Convenient and efficient door-to-door transfer service in a private, air-conditioned vehicle
- Skip the stress and confusion of taxis and shuttles
- Choose a sedan that seats up to three people or a minivan that seats up to five people
- Service available 24 hours a day, seven days a week
What You Can Expect
When your stay in Atlanta ends, you'll be met at your downtown Atlanta, North Atlanta, Buckhead, Alpharetta or Marietta accommodation by a professional driver and driven in comfort to Atlanta Hartsfield Jackson International Airport (ATL). With this convenient, hassle-free airport transportation , choose either a sedan for up to three passengers or a minivan for up to five passengers.
When making a booking, you will need to advise your flight details, your downtown Atlanta, North Atlanta, Buckhead, Alpharetta or Marietta accommodation details and the size of your party. Your transfer will be confirmed instantaneously and you will be provided with a travel voucher to present to the driver – it's that easy!
Price is per person, based on three passengers per sedan or five per minivan.
Customer Reviews
August 2014
Excellent. Great car and very profession, curtious, easy going driver! I recommend this driver and company to everyone.
March 2013
very nice service and very cooperative driver.
August 2013
The driver arrived on time as promised. He was friendly share information about Atlanta.
We werw quoted one price and had to pay an additional $35.25 to be picked and taken to the airport on July 21, 2013. I had arlready $132.73 before leaving Detroit. I was told that I would not have to add any more fees that night before departed Detroit.
May 2015
OK on this pick up by female driver.
May 2015
Arrived at hotel 20 minutes late.Should rename from Carmel Limousine Service to Excuse Limousine Non Service.
April 2015
This is very poor service that I do not recommend at all. The driver was supposed to pick up at 6:30 AM but called to say he was late. Again he called to say he was running late but meanwhile it was pouring rain and there was terrible traffic getting to the airport from my hotel in Alpharetta. There was no way I could get to my flight on time if I didn't leave right then. I could not wait any longer and got alternate transportation and just made the flight.
May 2014
The driver was nearly an hour late and turned up without shoes on, just socks! Because of him being late we were completely rushed at the airport.
April 2014
To begin we did not get the minivan we paid for. I am handicapped and it is difficult for me to get into a car. The driver was suppose to be at the airport waiting for us at baggage-was not. When I called we were told he was running late to go downstairs to the street and he would pick us up. Thank goodness for an airport wheelchair assistant who was willing to continue to push me and understood where we were to wait. A towncar is NOT a minivan.


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Maria Bauman / André Zachery
Curated by Ishmael Houston-Jones, the DraftWork series hosts informal Saturday afternoon performances that offer choreographers an opportunity to show their work in various stages of development.
October 10, 2015
Saturday at 3:00PM
Free and open to the public! No advance reservations.
Draftwork | St. Marks Church

subset: commoncrawl


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I appreciate the quick service. The rep I dealt with, as I find with all your reps, was very courteous.
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Minority and Diversity Issues
Watch breaking news videos and read news updates about Minority and Diversity Issues on Crain's Chicago Business
Who's Who in Chicago: The 542 names you need to know in business, government and more
Our annual list is the city's most comprehensive directory of decision makers.
Meet the man behind the African Festival of the Arts
P. Saingbey Woodtor is executive producer of the 26-year-old event, which draws more than 200,000 people to Washington Park on Labor Day weekend. He answers our questions.
Illinois enacts ban on gay conversion therapy for young people
Backers of the measure were unsure how Gov. Bruce Rauner, who has kept his stance on several social issues private, would act.
Here's the apology Kristen McQueary should have written
This one is shorter—and sorrier—than the one the Chicago Tribune columnist wrote after the world reacted to her "praying for a real storm" like Hurricane Katrina to hit the Windy City.
Former General Mills chief lawyer joins Dentons
After more than 15 years leading corporate legal departments, Chicago lawyer and diversity advocate Roderick "Rick" Palmore returns to law firm life. "He's a legend," one observer says.
Macy's dumps Trump over racist remarks
The retailer plans to phase out its Trump menswear collection, which has been sold at the chain since 2004, after his remarks about Mexican immigrants caused an uproar.
Chicago's big employers say domestic partners need not wed for benefits
Despite today's Supreme Court ruling, Chicago's largest corporations will let domestic partners keep benefits without marrying.
Chicago brands join the gay-marriage celebration on social media
In the wake of the Supreme Court's 5-4 decision that guarantees a nationwide right to same-sex marriage, social media erupted in celebration. And a number of corporate brands either joined the fray or found their promoted tweets in association with Pride month in the right place at the right time.
How Big Business did—and didn't—affect the gay marriage debate
Business came out strong for gay marriage. But in the end, the Supreme Court ruled as it did not because of practical workplace concerns but because of fundamental principles of liberty.
Same-sex couples have right to marry in all 50 states
The Supreme Court ruling today was 5-4. Read the decision—and the dissents—here.
Turmoil is the only sure thing if Supreme Court rejects gay marriage
A victory on same-sex marriage would be a historic moment for gay rights. Defeat would bring legal pandemonium.
Campus justice: Punished until proven innocent
Northwestern University prof Laura Kipnis stood accused of writing an article that had a "chilling effect" on reporting of sexual misconduct on campus. But who's chilling whom?
Obama loses second bid to overhaul immigration
(Bloomberg) — President Barack Obama's bid to make overhauling immigration policy a second-term victory was dealt a serious blow as federal judges ruled the effort must remain on hold while 26 states sue to overturn it. Obama's executive action, which would allow 5 million undocumented immigrants
We visited the GOP's outreach office in solidly liberal Detroit
After the 2012 election, Republicans made an effort to boost their minority outreach. Here's how their office in the Motor City is doing a year and a half after opening.
Fear of change at core of gay marriage debate
With 7,000 married same-sex couples in Cook County alone, the world has changed however the Supreme Court rules. It's time for everybody to chill out.


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We Have a Pope (2012)
Critic Consensus: No consensus yet.
We Have a Pope Videos & Photos
Movie Info
Nanni Moretti joins forces with the great French actor Michel Piccoli to tell the story of Melville, a cardinal who suddenly finds himself elected as the next Pope. Never the front runner and completely caught off guard, he panics as he's presented to the faithful in St. Peter's Square. To prevent a world wide crisis, the Vatican's spokesman calls in an unlikely psychiatrist who is neither religious or all that committed, played by Moretti, to find out what is wrong with the new Pope. As the world nervously waits outside, inside the therapist tries to find a solution. But Cardinal Melville is adamant: he does not want the job, or at least needs time to think it over. What follows is a marvelous insight into the concept of a human being existing behind the title of God's representative on Earth. -- (C) IFC … More
|Drama, Comedy
|Directed By:
|Nanni Moretti
|Written By:
|Nanni Moretti, Federica Pontremoli, Francesco Piccolo
|In Theaters:
|Apr 6, 2012 Limited
|On DVD:
|Sep 11, 2012
|Box Office:
as Cardinale Melville /...
as Psicoanalista
as Marcin Raijski
as Cardinale Gregori
as Psicoanalista
as Cardinale Bollati
as Cardinale Pescardona
as Cardinale Cevasco
as Cardinal brummer
as Swiss Guard
as Theater Company Memb...
as Child
as Theater Company Memb...
as Theater Company Memb...
as Theater Company Memb...
as Theater Company Memb...
as Master Of Ceremonies
as Chief Of Police
as A Mother
as Shop Assistant
as Hall Porter
as Bartender
as Boy At The Bus
as Priest
as Doctor
as Cardinal
as Cardinal
as Cardinal
as Cardinal
as Cardinal
as Cardinal
as Child
as Theater Company Memb...
as Journalist
as TV Journalist
as Girl At The Bar
as Cardinal
as Cardinal
as Musical Band
News & Interviews for We Have a Pope
Friend Ratings
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Critic Reviews for We Have a Pope
All Critics (76) | Top Critics (28) | Fresh (45) | Rotten (28) | DVD (1)
Always the star of his movies, even when he shouldn't be, the atheist Moretti gets caught up in his own papal bull. But Piccoli's blessed empathy prevails.
This is rich material that Moretti mines for both superficial absurdity and deep pathos. But he refuses to forge an orthodox happy ending, let alone a tinny satire.
We Have a Pope takes its shots at the institution of the Catholic Church, but this is by no means a scathing satire. It's more of a character study, insightful and nuanced, about a man grappling with a profound sense of inadequacy, questioning himself.
"We Have a Pope" is a nuanced, moving and profoundly humane exploration of doubt, faith, weakness and resolve.
Audience Reviews for We Have a Pope
Even with Piccoli in a strong performance, this drama doesn't live up to the promise of its premise. While the first half is efficient and has a good pace, the second part is disjointed, dragging with no direction and going nowhere. Besides, Moretti's character seems completely useless here.
Super Reviewer
What a wonderful film. Shame that it didn't get more recognition in Cannes. Cloaked in humor, this is nonetheless a serious look at a religious leader's internal quest for personal truth. The humility shown is precisely what the Church needs, but... it's merely a film... Michel Piccolli at his very best!
Super Reviewer
As the Papal Conclave wears on, it appears that there is no clear frontrunner which might have something to do with nobody really wanting the promotion. Eventually, the name of Cardinal Melville(Michel Piccoli) takes precedence and wins out. At the worst possible moment right before being introduced to the faithful, he has an anxiety attack. After a time of waiting for him to recover his senses, the cardinals get restless, with the Austrlian contingent wanting to go over the wall to do a little sightseeing. So, while the powers that be read them the rule book, they also bend them a little to bring in a famed psychologist(Nanni Moretti, who also directed and co-wrote).
First off, a disclaimer. "We Have a Pope" really has no problems with the Catholic Church or anybody associated with it. Yes, there is a little white lying and conniving but absolutely no global conspiracies, so hopefully nobody's going to hell.(Still, what the Church would do with the ending and the volleyball tournament is beyond me.) Rather, with amiable good humor, Nanni Moretti shrugs as he wonders what all the fuss is about.(To quote him, he is always harder on himself in his films than others.) More is the shame considering the awful pressure the cardinals are under with such lofty expectations. And don't forget; one should always be vigilant towards those seeking power.
Super Reviewer
We Have a Pope Quotes
|Cardinal Melville:
|I have a parental deficit. But I don't know what it is.
|Female Psychotherapist:
|What do you do?
|Cardinal Melville:
|I'm an actor.
|Cardinal Melville:
|I can't do this.
Discussion Forum
Discuss We Have a Pope on our Movie forum!


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"These are very classic and chic and will look nice on stationery or packages. They are a bit smaller than I expected but the dimensions are given so it was just my perception that was off there. They are nice quality, not too thick, but that's to be expected with the great price."
"I've never seen anything like these fun stickers! I'm using them to put inside the cover of cookbooks I send as gifts and also on food or any other kitchen related gifts. Should have ordered more...and I will!"
"I used this label to put on water bottles at our 11th Annual Wild Game Potluck and people were just tickled pink at the personalization and craftyness. They were peeling them off to save as momentum!"
"Super fun gift and I adapted the writing to say teacher's name and class library book. great little gift/thank you for teachers"
"I put my daughter's teacher's name and room number on these adorable labels to give as a holiday gift. She will be able to put them inside book covers or on anything she might lend out and would like returned. It would also be a great end-of-the-year thank you gift."


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Bridge of Spies
Bridge of Spies is a daring, studied and mannered true story that is at once remarkably genuine and deeply cinematic at the same time.
Bridge of Spies is a daring, studied and mannered true story that is at once remarkably genuine and deeply cinematic at the same time.
As a piece of social satire, Knock Knock winds up being not just toothless but anticlimactic.
"The Ballad of Narayama" is a Japanese film of great beauty and elegant artifice, telling a story of startling cruelty. What a space it opens…
Patrice Leconte's "Monsieur Hire" is a tragedy about loneliness and erotomania, told about two solitary people who have nothing else in common. It involves a…
A NYFF report on Don Cheadle's directorial debut, "Miles Ahead."
A NYFF report on "Carol," "The Assassin" and "Right Now, Wrong Then."
An interview with Joshua Abrams, composer of "Life Itself."
A report about Chaz Ebert's upcoming appearance on OWN's "Where Are They Now?" program.
A FFC review of "The Look of Silence."
A review of "A Girl at My Door".
An essay on David Cronenberg's "The Brood."
The October installment of Bright Wall/Dark Room, which focuses on "The Knick."
Tom Shales served as TV critic of The Washington Post for 25 years, winning the Pulitzer Prize for criticism in 1989. He left the once-proud paper in Ruins. Shales also spent two decades reviewing movies for NPR's Morning Edition and is the coauthor of two bestsellers: "Live from New York," on "Saturday Night Live," and "Those Guys Have All the Fun," on ESPN. No wonder he's tired.
Tom Shales writes about his friendship with Roger.
The World 3-D Film Expo III, running Sept. 6–15 at the Egyptian Theater in Hollywood, may be the last chance to see some great 1950s 3-D films projected the way they were intended to be.
Tom Shales comments on the television news coverage of the George Zimmerman trial. The media avoided the big issues of race and justice in favor of a sensationalistic 'who will win' approach.
Tom Shales looks at "Carson on TCM," a weekly series of shows culling great Carson interviews.
(AP photo)
Jay Leno and I go way back. One of my fondest memories is of Jay chasing me around the parking lot of the Hotel Bel-Air in Los Angeles. I always tell people that I thought of the Bel-Air, which I could still afford in those days (long long ago), as more a sanitarium than a hotel. You know how in L.A. your waiter has probably written a screenplay or two? At the Bel-Air, one of the parking attendants had actually starred in an ABC network series several years earlier! He played a wolf-boy.
Aye, it's the age-old story. Oh the naming of a new pope, sure, but there's another less-age-old story: TV networks covering something that their anchors and reporters call a glorious spectacle and then ruining the spectacle with superfluous graphics littering the screen.
(AP photo)
Listen -- a billion people are throwing up. That's a rough estimate of course, but every year somebody at the Oscars says a billion people on the planet are watching the program; however many watched this year's Oscar show, they may well have felt sickened by it. It was a stomach-churning, jaw-dropping debacle, incompetently hosted and witlessly produced.
(ABC photo)
Roughly five months ago, back in the summer of '12, the spectacularly popular Robin Roberts, co-anchor of ABC's "Good Morning, America," left the show for a sabbatical of indeterminate length. She might be gone for six or eight months, viewers inferred, or for a year. Or, forever.
(AP photo)
Back in ancient days of rampant ignorance and sexist effrontery, a TV commercial for a product now forgotten depicted a happy married couple whose cheer seemed guaranteed by the woman's subservience to the man. At the end of the ad he uttered a phrase that entered, to the dismay of millions, the iconography of the time: "My wife -- I think I'll keep her."
by Tom Shales
Okay, now we know: God DOES "care" about the Super Bowl, as people were wondering during the big build-up to the game -- the one that began around Thanksgiving, 2012. Yes, God cares; He HATES it. And that's why He (or, yes, She) turned off the lights on Super Bowl XLVII in New Orleans Sunday night and left everybody standing there and waiting for the second half to continue. Maybe it was a kind of Old-Testament warning -- ya think?


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A man who says Jerry Sandusky molested him during the 1980s is asking a court to order criminal charges in the matter.
"The man, now 43 years old and living in Massachusetts, was 16 at the time he attended a Sandusky-run football camp on the Penn State campus," AP reports. "His private criminal complaint filed in Centre County alleges two incidences of abuse in which he claims Sandusky subjected him to fondling and oral sex."
Sandusky's lawyer denied the allegations. Read more »


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Items tagged with moon
We don't know what the going rate is for venturing off to infinity and beyond, but if you'd like to boldly go where man has gone a few times before, a company called Excalibur Almaz will take you there... for a price. The commercial aerospace company said it's ready to start selling tourists trips to the moon, tickets of which will reportedly cost around $155 million at the outset. "Suborbital flight experience will serve as an integral preparatory step for the safety, education and enjoyment of our customers traveling on crew expedition missions," said Art Dula, Excalibur Almaz Founder and Chairman.... Read more...
Scientists have theorized that there might be frozen water on the moon for decades—while water vapor quickly boils away on the moon's surface, frozen water was predicted to exist inside permanently shadowed polar craters as far back as the 1960s. Evidence has mounted for the existence of water in the last 10 years, but new findings from NASA confirm the presence of a whole lot of H2O. Using data from a NASA radar that flew aboard India's Chandrayaan-1 spacecraft, scientists have detected ice deposits near the moon's north pole. NASA's Mini-SAR instrument, a lightweight, synthetic aperture radar,... Read more...
NVIDIA CUDA TECHNOLGY USED TO RECOVER HISTORIC APOLLO 11 MAN ON THE MOON VIDEO Lowry Digital Relies on NVIDIA GPUs to Recover Historic Video by Upgrading 1960s Television Footage to 21st Century High-Definition SANTA CLARA, CA - AUGUST 5, 2009 - When NASA's original Apollo 11 moon landing video was accidentally destroyed, it seemed the world had lost a visual record of one of man's greatest achievements. Fortunately, unique digital video restoration technology from Lowry Digital, powered by NVIDIA Tesla GPUs (graphics processing units) with CUDA technology, has enhanced television coverage of the... Read more...
Rolling Rock, a subsidiary of Anheuser-Busch, has come up with an interesting ad campaign: offbeat, though definitely high-powered. Or requiring a lot of power, anyway.It appears to be a teaser to a new advertising campaign for Rolling Rock beer. According to their "Moonvertising," web site: "…we're trying a new, more tasteful advertising campaign this year: Putting our logo on the moon." It goes on to invite readers to "broadcast your own message on the moon as well."Why, of course! There has to be a social media aspect to the campaign in this day and age. The web site is clever, but painfully... Read more...
It sort of makes sense, since Google recently paid NASA $1.3 million just to be able to land their jet at NASA's Moffett Field. Google is funding a $30 million dollar prize for a privately developed moon rover.The Google Lunar X Prize, announced today by the search-engine giant and the X Prize Foundation at the Wired NextFest in Los Angeles, ranks among the richest contests ever offered for technological innovation. It follows up on the $10 million Ansari X Prize for manned spaceflight, which was won nearly three years ago by the SpaceShipOne rocket plane.The new prize calls upon teams to create... Read more...


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Whenever I head to Florida, I make a point of going to Sweet Tomatoes. The salad and soups options are great. I love the breads and pastas and always top the meal with a hot brownie muffin with soft serve.
The quality of the buffet items is comparable in flavor to other buffets. Their schtick is everything is natural, organic, fresh and the have vegan options. This was my first stop at one of these and I didn't know what to do when I walked in. They sort of have people clearing plates, but they don't really have wait staff...
I just love goin to Sweet Tomatoes, on Brandon in Tampa, we camp close by and the first day we go do our shopping then we go sweet tomatoes, I just love the amount of salads and soups they offer, food is always fresh and tasty, we look so forward to goin there, if we stay longer than a week...
Excellent offering of salad, pasta, desserts. Very clean and friendly atmosphere. Good location, easy to get in and out back onto the main road.
Ate there again last night. Good selection of salads, soups and other items. Price was very good because my wife constantly receives coupons via email.
Fresh salad and soups and blueberry muffins bring us back over and over. Finding their email option that sends an email every Thursday for discounts is a bonus. Asian salad and broccoli salad are favorites. Glad there is one close. If our daughter-in-law is in town, she would eat here every day! Soft serve ice cream with toppings is another...
They have a very good selection of salad items as well as bread items , soups, potatoes , pizza & ice cream . A quick , healthy meal near Hy 60 and I-75 .
I usually visit this Sweet Tomatoe's a couple of times a month. Always fresh, always friendly wait staff, always well stocked with a great variety of soups and specialty salads.
Is a great salad buffet and you can enjoy the food.Also there is ice cream,soup,pizza ,soda,lemonade,and garlic bread.Corn bread also and pancakes all fresh .
Sweet Tomatoes is a buffet restaurant with a twist -- the main focus is on salads, though they also offer soups, a potato bar, and a couple of basic pasta options. For dessert, there is an ice cream machine, cookies, and maybe some fruit.
I used to love Sweet Tomatoes, but it had been some time since I'd eaten there...
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Interactive Seating Charts
Unfortunately, we do not currently have
a seating chart for Henderson Pavilion.
Henderson Pavilion200 S Green Valley Pkwy
Henderson, NV 89012
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GLP How many of us are sick today ?????unidentified respiratory illness?????Post if you cant stop coughing!!!!
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I haven't been sick yet this year. I switched my diet this year from eating your average meats at the super market to eating all grass fed beef, natural chicken, drinking local organic whole milk, and avoiding corn syrup in every way possible.
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Nobel Prize for Physics for discovering the mass of neutrinos
WATCH: Fire ants form life rafts out of their own bodies in order to survive historic flooding in South Carolina.
America's cities will collapse into utter chaos the day the EBT cards stop working
Watch: Peruvian Teen Convulses After Playing Ouija Board App (Video)
Huge Container Ship Disappears In Bermuda Triangle
Mysterious Alien Being Discovered In a Secret Chamber Inside the Great Pyramid in Egypt
This Indian River Water Has Reduced For The First Time In History And The Secret Hidden Inside Them?!
This Mind-Blowing Video About The Universe Is The Reason You Won't Sleep Tonight
Steven Seagal: Mass Shootings in the US are "Engineered
Google's FaceNet can detect a face in a 260 million image database with almost 100% accuracy.
It's the end of the world again, for real this time (maybe)
U.S. Senate candidate admits to sacrificing goat, drinking its blood
Montana Law Taking on Federal Militarization of Police Now in Effect
Was Aleister Crowley The Grandfather Of George W. Bush?
"Camping" on Your Own Land is Now Illegal — Gov't Waging War on Off-Grid Living
Media Continues to Call for the Use of Gov't Force to Confiscate Millions of Guns
Hillary's Already Planning to Sign Executive Orders for Gun Control If She's Elected President
Free Speech Watch: Prior Restraint Makes a Comeback as US Courts Seek to Squelch Dissent
Did the UN Really Install a Global Police Force at the Local Level?
Delta Force Planned to Stage a Fake Hijacking After 9/11
This Is The World's Most Amazing Clock, It's Movement Is Completely Mesmerizing
Researchers Just Made Batteries From Mushrooms… And They're Surprisingly Good
ISIS issues a grave warning to America: We have scores of "trained soldiers" positioned in 15 states and we're ready to attack.
Top Scientist Resigns Admitting Global Warming Is A Big Scam
The UN's Disturbing Vision Of The Future Of The Internet
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China on Saturday amended the country's criminal law, tightening corruption sentencing and reclassifying sex with underage prostitutes as rape, state media reported.
The official Xinhua News Agency says the measure approved Saturday could free several thousand prisoners by the end of this year.
The government will publish the findings of the investigation, which it pledged would be timely and accurate, the official Xinhua news agency reported.
Liu said that despite obvious benefits, China and ASEAN countries have lacked proper maritime cooperation, state-run Xinhua news agency reported.
"China will unswervingly support Pakistan's efforts in safeguarding its national security," Xi told Hussain, according to China's official Xinhua news agency.
China's slower growth and economic transition will pose significant risks for the already struggling shipping sector, rating agency Fitch has cautioned.
A low-ranked official has been caught by the China's anti-graft agency for embezzling 821 million yuan ($ 134.2 million) funds.
Due to a problem with a supplier, inflators in the front airbags could rupture when the airbags deploy and broken parts may hurt motorists, the statement said.


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In this article we'll be taking a look at seven of the Dropbox-powered site building platforms available today, and what each one of them has to offer. Demo: http://tutsplusdemo.pancakeapps.com/; Princing: Pancake.io is free of charge. Like other Dropbox-based site management systems you can add content simply by creating Markdown files inside a Dropbox folder, however with Scriptogr.am you also have a fully fledged dashboard from which you can create
[Article Dashboard] footprints "By publishing information packed articles, you'll soon enjoy" "Author Terms of Service" "Publisher Terms of Service" "Disclaimer" "We reserve the right to include advertising on pages with your articles" .. character minimum" "Du hast bereits einen Account? Prima, log dich hier ein!"|"Pligg is an open source content management system that lets you easily create your own social network" [PunBB Forum] footprints "powered by PunBB"
MotoPress Content Editor. MotoPress is a popular premium drag'n'drop content editor for WordPress which is available in Monstroid for free. MotoPress allows you to adjust the size, position and properties of the your website elements "star" ranking systems you can insensibly call your visitors for expressing their opinion. Product rating is a very important factor when it comes to trust, so why not let your customers do a part of your job for you? Cherry Data Manager
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text: Publications Search Results Your query returned 1 citations. Results 1 - 1 Per page: 25 50 100 Sort by: Pub Date (newest) Title Recent Additions Author 1 Clear All Pub. Year Citation 1990 Betson, D.M. . Alternative Estimates of the Cost of Children From the 1980-86 Consumer Expenditure Survey. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Export Options: RIS EndNote XML Results 1 - 1 1


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Happy Go Lucky is a 1943 American comedy film directed by Curtis Bernhardt and written by Walter DeLeon, Melvin Frank, John Jacoby and Norman Panama. The film stars Mary Martin, Dick Powell, Betty Hutton, Eddie Bracken, Rudy Vallée, Mabel Paige and Eric Blore. The film was released on January 4, 1943, by Paramount Pictures.
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Everyone deserves a fair shot at success.
Work With Us
We bring creative thinking, new approaches, and innovative solutions that help drive economic growth throughout our region.
- Business Investments: We understand the needs of business and provide a link between a skilled workforce and industry demand.
- Adult Investments: We coordinate workforce programs that help people improve their skills and advance their careers.
- Youth Investments: We invest in organizations that help young people become college and career ready.
Latest News
Worksystems has been awarded $2.3M by the US Department of Health and Human Services to fund the first year of a... // Read more
This summer, over 750 area youth are engaging in a paid work experience - a first for many of them.
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The Portland Metro area will get an influx of training resources to assist job seekers and incumbent workers at... // Read more
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With a goal of training 10,000 Oregonians for coding jobs that are projected to be available in our region by 2020,... // Read more
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- You will be sorely missed - but we take comfort in knowing that you're not going far! #big-shoes-to-fill https://t.co/rYIXCDqsiB
- Check out our Summer 2015 Newsletter! #pdx http://t.co/WZ0ZBDznBY
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18|20 Cellar Bar Dining and Rooms4
18-20 Lake Road, Keswick, CA12 5BX
Price FromView Rooms
- Very Good
- 58 guest reviews
"Excellent food and very nice people..."
"Loved this small but friendly hotel Peter and Allan couldn't be more helpful they even made my two Dogs welcome. We spent the weekend there..."
"weekend in the Lake District..."
"room a bit small but the shower amazing...."
"Room 4 was excellent, very spacious, clean & a great shower. Well situated on the main street but not noisy at all & we had a great nights s..."
About the hotel
Centrally located in the heart of the popular market town of Keswick, 18|20 Cellar Bar Dining and Rooms offers an ideal base from which to explore the spectacular Northern Lakes. Situated on a quiet street around the corner from the main market square, we present a bar lounge and restaurant decorated in a contemporary style whilst retaining traditional Lakeland character. 18|20 Cellar Bar Dining and Rooms offers four bedrooms comprising two double and two twin family rooms, sleeping up to four people.
All bedrooms are comfortably furnished in a modern style and offer en suite bathroom, TV and tea & coffee making facilities. Please note: 18|20 Cellar Bar Dining and Rooms is a non smoking hotel. Could you add to all of our properties: Well behaved dogs allowed at the charge of £15 per pet for the duration of your stay.
Read MoreLess
Room Availability
Showing Thursday 8 October 2015 to Friday 9 October 2015Change Search
Facilities Show/hide
- Dining
- Restaurant
- In room entertainment
- In room facilities
- Tea/Coffee making facilities in each room
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- Limited Hours Room Service
- Family friendly
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- From 15:00 hours
- Until 10:00 hours
- The price shown is based on the occupancy and dates you have searched for. Prices and availability are subject to change based on the arrival date, number of nights and occupancy searched for. All prices are inclusive of all local taxes.
- Pets are allowed
Customer Reviews
Our reviews are from genuine LateRooms.com customers. We verify that the customer has stayed before leaving a review.
Very Good
90% would recommend it to a friend
Customer service
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Fantastic evening resteraunt with rooms
Excellent food and very nice people
Won't stay here again
No parking we waited bout 30mins for breakfast even thou it wasnt busy.


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October 6, 2015
nick jameson
Gone Too Soon: The Critic
by Jason Hughes, posted Nov 17th 2009 10:12AM
Before The Simpsons begat Futurama, current executive producer of The Simspons Al Jean, along with Mike Reiss, created a short-lived animated series about a film critic who hated almost every film he ever saw.
Starring Jon Lovitz in some brilliant voice work, The Critic ran through two networks in two seasons. Like Futurama and Family Guy, it found some success with reruns on cable -- in this case, Comedy Central -- and a subsequent DVD release. But unlike those series, The Critic remains but a distant memory.
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A relatively cheap way to jump into 3840x2160 territory.
4K resolution and AMD FreeSync unite
GTA V finally launched for the PC yesterday. Given that GTA IV was a resource hog of a port coupled with Rockstar's numerous delays of the PC version, we thought we would run the game through its paces using the beefiest rig we had in the Lab. We opted for Origin PC's new Millenimum Genesis PC, which is equipped with not one or two GeForce Titan Xs, but three of those water-cooled bad boys in SLI.
I'm trying to donate an old computer to my son's Scout troop. I reinstalled Windows, did all of the updates, installed all of the software they will need, and ran it for a couple of days to ensure everything worked. I took it to their next meeting, plugged it in, and only the green power light would turn on. There was no fan activity, no drive activity, just the light turning on. I brought it home and plugged it in and it booted up just fi ne.
After numerous delays, Grand Theft Auto V is finally set to release on Windows-based PCs on April 14, 2015, otherwise known as next Tuesday. It's been a long, excruciating wait -- GTA V first shipped to PlayStation 3 and Xbox 360 consoles on September 17...2013!
While 4K may be all the rage these days, we've yet to see that resolution grace the screens of our gaming laptop panels. The next best thing, however, may be here. Eurocom's M4 gaming notebook made its way into our Lab sporting a super sharp 13.3-inch 3200x1800-resolution display. Dubbed 3K, it has a pixel density of 276 pixels per inch (PPI). This makes it poopoo all over Apple's much-touted MacBook Pro Retina display. What, 227 PPI? Is this 2013 or something?
For the longest time, it seemed as though the monitor market was frozen in time. While CPUs and graphics cards became increasingly advanced and faster with each new generation, monitor makers were content to stick with Full HD 1080p panels of varying sizes for mainstream users, and 30-inch panels checking in at 2560x1600.
Gaming at 4K is still a pipe dream for many people. Too many roadblocks exist, one of them being the need for high-end hardware to push all those pixels around on a screen at a comfortable pace. However, for those who are equipped with sufficient GPU horsepower, you'll be glad to know that companies are paying more attention to 4K monitors.
The pricing for 4K monitors have been dropping to the point that Acer's B2H6HK 28-inch 4K monitor was retailing for $350 last month on Newegg for a short while.
Though the 4K Ultra HD revolution is happening faster than most probably anticipated, the number of 4K monitors actually worth owning are surprisingly low. That's because of early growing pains -- low refresh rates (like 30Hz) without Multi-Stream Transport (MST) support, TN panels, and other undesirables have held the category back.
It's not the version with Nvidia's G-Sync technology baked inside, but Acer's B286HK 28-inch 4K Ultra HD monitor is selling for just $349 on Newegg today. That's a pretty hot price for a 3840x2160 monitor that's capable of 4K video at 60 FPS over DsiplayPort 1.2.
Following up on its funky square-shaped monitor announcement earlier this week, Eizo has introduced a self-calibrating DCI 4K (4096x2160) display for media and entertainment fields like cinema and broadcasting.
Acer today introduced its newest 4K Ultra HD monitor to the U.S. market, the B326HK. It's a 32-inch monitor with an LED backlight and In-Plane Switching (IPS) panel instead of a lower quality TN screen. According to Acer, the B326HK is suitable for a wide range of buyers, from home consumers to commercial customers interested in gaming, watching movies, web design, and more.
We don't typically associate Acer with premium level gear, though the company's new V Nitro Black Edition laptop line may change that perception. First introduced in late September, Acer is now offering a V Nitro Black Edition laptop with a 4K Ultra HD (3840x2160) IPS display, upgraded from the Full HD 1080p panels found on the initial launch models.
Ryse: Son of Rome is a third-person action-adventure game developed by Crytek and published by Microsoft Studios as a launch title for the Xbox One back in November of last year.
For nearly 20 years, Maximum PC is considered by enthusiasts to be the absolute source for the latest hardware reviews, in-depth analysis, and breaking news on the latest PC hardware. Our team of industry experts give you the guidance you need to make the most informed buying decisions and deliver the best guides on how to use and optimize your experience. If you're looking for the definitive reference on PC hardware, you've found it.
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Queen elizabeth News
A new portrait of Queen Elizabeth to go on U.K. coins in 2015
Marcus Hondro
A new portrait of Queen Elizabeth will be adorning U.K. coins next year and there will be a closed competition to win the design of it. An undisclosed number of designers will be invited to submit to the competition.
Angelina Jolie made honorary dame commander by Queen Elizabeth
Markos Papadatos
Oscar-winning actress Angelina Jolie has a major milestone to be proud of. She was made an honorary Dame by Queen Elizabeth.
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Micki Hogan
The internet rumor mill is buzzing with the possibility of Pope Francis resigning to avoid satanic murder evidence becoming public.
Queen Elizabeth slated to visit Game of Thrones set
Nora Meszaros
Belfast - Staying hip with the times, the British monarchy tweeted Wednesday that two members of the Royal Family will be making pit stops at film sets during their next tour.
Angelina Jolie is an honorary dame, thanks to Queen Elizabeth
Samantha Chang
Angelina Jolie has been named an honorary dame by England's Queen Elizabeth for combating sexual violence against women in war zones as the co-founder of the Preventing Sexual Violence Initiative.
Arts features heavily in Queen Elizabeth's birthday honors
Tim Sandle
London - Three times Oscar-winning actor Daniel Day-Lewis has been made a knight in the Queen's Birthday Honors. Several other awards have been given to those famous for acting and writing.
Op-Ed: The archaic stupidity of monarchial reverence
David Delmar
So, a new monarch has been born. Reluctantly, I know this; and only because the tv screens at my gym won't shut up about it.
Singer Adele honored by Queen Elizabeth II for services to music
Markos Papadatos
Adele was recently honored by Queen Elizabeth II. According to an article from the New York Daily News, Adele is one of 1,180 people that was recognized in the Queen's Birthday Honors list as the British monarch celebrated her 87th birthday.
Queen Elizabeth II expected to sign charter supporting gay rights
JohnThomas Didymus
London - Reports say that Queen Elizabeth II is set to sign a new Commonwealth Charter to stamp out discrimination against gays and promote gender equality. UK's Daily Mail reports that signing the charter will be one of the most controversial acts of her reign.
UK: Knife man tasered by police outside Buckingham Palace (Video)
Robert Myles
London - London's Metropolitan Police have confirmed that a man was disabled with a taser outside the Queen's residence, Buckingham Palace, in London. The man is reported to have broken through a cordon and held a knife to his throat.
Chris Hogg to be awarded Queen's Diamond Jubilee Medal
Digital Journal Staff
Toronto - Digital Journal Chief Executive Officer, Chris Hogg, has been named a recipient of the Queen Elizabeth II Diamond Jubilee Medal. A journalist and entrepreneur, Hogg is being recognized for significant achievement and remarkable service to Canada.
Photo Essay: December in Merry Windsor
Tim Sandle
Windsor - There are many special places in England. One of the most interesting is the old town of Windsor, home of the castle and one of Queen Elizabeth's official residences.
Britain's Prince Philip admitted to the Aberdeen Royal Infirmary
Andrew Moran
London - It has just been confirmed that Prince Philip, the Duke of Edinburgh, has been taken to the Aberdeen Royal Infirmary as a "precautionary measure." This is the third time in just eight months he has been admitted to the hospital.
60 poems online to mark the Queen's Jubilee
Tim Sandle
Sixty officially sanctioned poems, each by a different poet, have been uploaded to the Web. The poems were commissioned to mark the Diamond Jubilee of Queen Elizabeth II.
Her majesty, Queen Elizabeth II's underpants up for sale on eBay
JohnThomas Didymus
A pair of Queen Elizabeth II's lacy "royal underwear" are now available for sale on eBay. The estate of Baron Joseph "Sepy" de Bickse Dobronyi wants eBay bidders to celebrate the Queen's Diamond Jubilee by buying an old pair of her "knickers."
Jamaican PM wants Queen removed as head of state
Lynn Curwin
Jamaican Prime Minister Portia Simpson Miller has vowed to take steps toward removing the Queen as head of state and turn the country into a republic.
Queen Elizabeth II set to visit Republic of Ireland amid protests
Leo Reyes
Queen Elizabeth II of England is set to visit Republic of Ireland Tuesday amid protests from republican paramilitary and other splinters groups opposed to the visit of the Queen and Prince Philip.
Prince William's Filipina nanny invited to royal wedding
Leo Reyes
Prince William's nanny Araceli "Lillie" Piccio from Bacolod City, Philippines has received an invitation to attend the Royal Wedding of Prince William and Kate Middleton to be held on April 29 at the Westminster Abbey, United Kingdom.
T-Mobile ad of fake Royal Wedding entrance dance goes viral
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A video ad of actors playing the British Royals and dancing at the William-Kate wedding ceremony has become wildly popular online, accumulating 4.6 million views within four days.
Queen gives her blessing to Oscar-nominated King's Speech
Kev Hedges
Queen Elizabeth II has been shown a private screening of the The King's Speech and has given her approval. Having watched the blockbuster film, nominated for 12 Oscars, Her Majesty is said to have been "moved" by the film.
Rightful heir to throne lineage could change in UK
KJ Mullins
A bill has been introduced into the House of Commons this week that could change how future British kings and queens will be considered.
Royals: Queen Elizabeth's great-daughter named
KJ Mullins
Queen Elizabeth's family is in the news with her great-granddaughter given a name and both Prince William and Zara Phillips having upcoming weddings. Her son Prince Charles was also named the busiest Royal of 2010.
Queen Elizabeth a great-grandmother
KJ Mullins
Queen Elizabeth has become a great grandmother after the birth of a baby girl to grandson Peter Phillips and his wife Autumn on Wednesday.
The Queen talks about the Bible and sport in Christmas message
Lynn Curwin
London - Queen Elizabeth talked of the history of the King James version of the Bible and the role sport and games play in bringing people together during her Christmas message this year.
Monarch's head likely to remain on UK stamps after privatization
Andrew John
The head of the British monarch is likely to remain on postage stamps after Royal Mail is sold off to the private sector, even if it goes to a foreign company.
Could Queen Elizabeth's old panties be worth $9,000?
Igor I. Solar
Miami - Underwear allegedly left behind by Queen Elizabeth in a private plane after a trip to Chile in 1968 is being auctioned in Florida with a starting price of US $9,000.
Queen Elizabeth launching Flickr photo stream Monday
Leo Reyes
Queen Elizabeth of Great Britain is launching her Flickr photo stream Monday showcasing over 600 Royal family picture dating back to 1861.
Queen Elizabeth to become great-grandmother
Michael Bearak
Queen Elizabeth II, the reigning monarch of the United Kingdom, is set to hold another title, great-grandmother, as her eldest grandson, Peter, and his wife are expecting their first child.
Queen Elizabeth stops traffic at Toronto's island airport
KJ Mullins
For ten minutes all traffic was stopped at Bathurst and Queen's Quay in Toronto as Queen Elizabeth left Toronto Island from the airport area. People lined the streets hoping to see Her Royal Highness.
South African Historian Against Royal Pardon For 'Breaker' Morant
Christopher Szabo
Johannesburg - Australia's petition to Queen Elizabeth II for a pardon for soldiers who shot Prisoners Of War (POWs) during the 1899-1902 Second Anglo-Boer War and were subsequently court-martialled and executed, has not gone unnoticed in South Africa.
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Buckingham Palace's west façade
Creative Commons
The Queen Elizabeth II Diamond Jubilee Medal is given to Canadians who have made significant contributions and achievements.
Photo courtesy of the Office of the Governor General of Canada
The Queen's breakfast room at Buckingham Palace
Creative Commons
Queen Elizabeth and Prince Philip, wearing a kilt, attend the Braemar Gathering, traditional Scottish highland games, in Braemar, on September 6, 2014
Andy Buchanan, AFP
The Queen Elizabeth II Diamond Jubilee Medal is given to Canadians who have made significant contributions and achievements.
Photo by Pte Ariane Montambeault
A view of Windsor castle on a crisp December morning.
Tim Sandle
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Contact Innkeeper
Le Manoir dating from late 14th century is an architectural ensemble of exception, a large floral garden with pool and tennis garden, sleeping 6 persons: -1 bedroom for 2 people, double bed, bathroom / wc -1 family suite 2 separate, each with 1 double bed and a washbasin bedrooms - shower room and toilet to share. Each room can accommodate more young children. Large living room with fireplace and French billiards - Garden furniture, barbecue, ping-pong and other games for children. The Manor is located in the Seine valley / Eure between Rouen and Giverny, 1 hour from Paris and the Normandy coast. Many historical sites nearby greenhouse Biotropica Golf, water sports, equestrian club, among other sports activities just minutes away.
Guests: 2
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BedandBreakfast.com gift cards are the perfect gift for anyone who needs a relaxing getaway.
lit 160 - salle de bain attenante
Nightly Rate:
suite familiale de 2 chambres séparées
-1 lit double 140 et 1 lit simple 80
- 1 lit double 160 et 1 lit enfant
Nightly Rate:
Paris, France (CDG-Charles de Gaulle)
Amusement Park,
Antique Shopping,
Art Galleries,
Concert venue,
Gourmet/Fine Dining,
Historical interests,
Movie Theater,
Nature area,
exceptional gardens,
Outlet Stores,
Performing Theater,
Historic Inn, Homestay
BBQ grill, Bath robes, Board games, Copier, DVD Player, Fireplace, Library, Radio, Telephone, Washer/dryer
Hairdryer, TV, Wi-Fi, Wired internet
Bicycle rental, Bicycle riding trails, Billiards, Bird watching, Boating, Fishing, Golfing, Hiking trails, Horseback riding, Kayaking, Shopping, Swimming pool, Tennis courts, Water sports
decoration and decorative painting - theater - kitchen - DIY - Gardening -
Continental More
EUR 85 per night
Simple! BedandBreakfast.com guarantees you're getting the best price on your bed and breakfast stay when you book your room on BedandBreakfast.com. Within 24 hours of your booking, if you find a better price for the same room on the same date(s) at the same B&B, BedandBreakfast.com will refund the difference to you!
The Best Price Guarantee covers any Bed and Breakfast booked online through BedandBreafkast.com. The Bed and Breakfast must be booked using the Book It button on BedandBreakfast.com in order to qualify.
Just call 1-512-322-2710 within 24 hours of booking and give our customer support representative the details on the lower price you found.
The BedandBreakfast.com Best Price Guarantee ensures that when you book and pay for your reservation online through the BedandBreafkast.com website, you are booking your room at the lowest available price. If you find a lower price for the same room on the same dates at the same B&B, and contact us within 24 hour of making your booking, we will refund the difference in price to you. This guarantee does not apply to bookings made over holidays and/or for special events. All requests are subject to verification by BedandBreakfast.com. BedandBreafkast.com will not accept screenshots or other purported evidence of a lower price that cannot be independently confirmed by BedandBreakfast.com personnel. Nor will BedandBreakfast.com verify any requests that it believes, in its sole discretion, is the result of a printing or other error or is made fraudulently or in bad faith.


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By LOUIS IBA
There were strong fears of a total shutdown of Nigeria's airspace, as labour groups in the industry threatened to down tools as from today, over the inability of the management of the Nigerian Airspace Management Agency (NAMA) to implement approved new remuneration packages for workers.
The Air Transport Services Senior Staff Association of Nigeria (ATSSSAN), the National Union of Air Transport Employees (NUATE) and the National Association of Aircraft Pilots and Engineers (NAAPE), on Wednesday, demanded a full implementation of the new remuneration package within 72 hours or it would embark on a warning strike to enforce compliance.
The unions, in a joint statement yesterday, signed by Olayinka Abioye for ATSSSAN, Abdulkareem Motajo, NUATE, and Abah Ocheme for NAAPE, said it would not rescind the decision to embark on the strike as from today, if its terms were not met.
They noted that only the strike could compel the management of NAMA to act fast in implementing the adjusted salary structure for its workers, which it said was signed by the Salaries and Wages Commission in August 13, 2012.
The statement reads in part: "NAMA management has been given 72 hours to meet the demand of the workers. Failure to do so will lead to the shutting down of the Nigerian airspace throughout Friday. We are bent on embarking on the one day strike to press home our demands.
"During the period, no aircraft will be seen flying in the Nigeria airspace as our members will retrieve their services to airlines across the country and if that does not yield the expected result, we will embark on indefinite strike," it said.
However, the Nigerian Airspace Management Agency (NAMA) in a statement, on Wednesday, said it was committed to implement the new condition of service contrary to insinuations from the union leaders on Wednesday in Lagos.
The management attributed the delay in implementing the new salary structure to some critical omissions in the document approved by the National Salaries, Income and Wages Commission, which were of serious concern to the union leaders who implored the NAMA management to alert the commission for necessary correction.
"Having studied the approved salary structure, we observeed that grade levels 01–14 were at variance with what was negotiated, as it fell short of figures of each of the grade levels. " In comparism with the salary structure of FAAN ,the approved salary structure of NAMA fell short to that of FAAN which was approved in 2011.
The differentials therefore undermine the salary parity between FAAN and NAMA.", Amalgamated Union of Public Corporations,civil Service Technical and Recreational Services Employees(AUPTRE),one of the the unions noted in a letter to the management. "As we speak, we are in February 2013 and it is yet to be implemented.
We have written several letters to the management about the implementation and they feel adamant about it, we have just come here to renew the mandate and by the mandate today, if three days after today, management has not done anything to show us that they are ready to implement this conditions of service, we are going to proceed on a day warning strike, the various letters to that effect will be ready as from tomorrow (today) to all our commissions, after that if they are still adamant we have no option than to give adequate notice to commence strike indefinitely until the salary structure is implemented, indefinite strike action."
24 yrs boy started importation with N10,450. Read his story here!
Men, forget Viagra. Use these to increase your manhood size & strength
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Kourtney Kardashian's Son Mason to Be Ringbearer at Kim's Wedding
Mason Disick can't be cranky on Aunt Kim's big day!
Kim Kardashian's adorable nephew is supposed to be the ring bearer for her wedding to Kris Humphries on Saturday, but her sister Kourtney isn't so sure the tot will be able to perform his duties!
PHOTOS: More adorable pics of Mason
Kourtney, 32, told Hollybaby at Wednesday night's launch bash for the Kardashian Kollection in Hollywood that the family is "planning on" Mason being a part of the bridal party.
PHOTOS: The Kardashians strip down for a tropical vacation
"[But] we'll see what happens," she told Us Weekly. "He is 20 months old... We'll see if he behaves!"
PHOTOS: Look back at Khloe and Lamar's wedding
Kourtney also admitted to Hollybaby that she "might be more nervous than Kim" and told her kid sister, 30, "I think I am going to have a heart attack!"
PHOTOS: Kim's white-hot dresses
Khloe, who said "I do" to Lamar Odom in 2008, is more relaxed about her sister's upcoming nuptials. Her advice for Kim? "At some point in your wedding, take your husband in a corner and just be quiet and look and enjoy the whole presence of it," she told Us.
PHOTOS: Kim and Kris' whirlwind romance
The bride-to-be herself is "totally calm" about her wedding, and credited her 26-year-old NBA beau for helping ease her nerves. "We have a really good balancing system of, you know, our personalities," she told Us. "[Kris] lets me chill. He gives me my space when I need to design and approve shoes and clothes and everything, and I kind of do the same for him. We just have a good connection."
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Publications (49)225.34 Total impact
Article: Determinants of Follow-Up Failure in Patients Enrolled in the Vascular Study Group of New England (VSGNE)Journal of Vascular Surgery 06/2015; 61(6):154S-155S. DOI:10.1016/j.jvs.2015.04.294 · 3.02 Impact Factor
Article: SS4. In Patients Stratified by Preoperative Risk, Endovascular Repair of Ruptured Abdominal Aortic Aneurysms Has a Lower In-Hospital Mortality and Morbidity Than Does Open Repair[Show abstract] [Hide abstract]
ABSTRACT: Previous studies have reported that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) has lower postoperative mortality than open repair (OR). However, comparisons involved heterogeneous populations that lacked adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR. In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England RAAA risk score into low-risk (score 0-1), medium-risk (score 2-3), and high-risk (score 4-6) groups. Among 514 patients who underwent EVAR and 651 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (25% vs 33%, P = .001). In risk-stratified patients, EVAR trended toward a lower mortality in the low-risk group (n = 626; EVAR, 10% vs OR, 15%; P = .07), had a significantly lower mortality in the medium-risk group (n = 457; EVAR, 37% vs OR, 48%; P = .02), and no advantage in the high-risk group (n = 82; EVAR, 95% vs OR, 79%; P = .17). Across all risk groups, cardiac complications (EVAR, 29% vs OR, 38%; P = .001), respiratory complications (EVAR, 28% vs OR, 46%; P < .0001), renal insufficiency (EVAR, 24% vs OR, 38%; P < .0001), lower extremity ischemia (EVAR, 2.7% vs OR, 8.1%; P < .0001), and bowel ischemia (EVAR, 3.9% vs OR, 10%; P < .0001) were significantly lower after EVAR than after OR. Across all risk groups, median (interquartile range) intensive care unit length of stay (EVAR, 2 [1-5] days vs OR, 6 [3-13] days; P < .0001) and hospital length of stay (EVAR, 6 [4-12] days vs OR, 13 [8-22] days; P < .0001) were lower after EVAR. This novel risk-stratified comparison using a national clinical database showed that EVAR of RAAA has a lower mortality and morbidity compared with OR in low-risk and medium-risk patients and that EVAR should be used to treat these patients when anatomically feasible. For RAAA patients at the highest preoperative risk, there is no benefit to using EVAR compared with OR. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.Journal of Vascular Surgery 03/2015; 59(6). DOI:10.1016/j.jvs.2015.01.042 · 3.02 Impact Factor
Article: Endovascular Repair of Ruptured Abdominal Aortic Aneurysms Does Not Independently Reduce Long-Term Mortality Compared With Open RepairJournal of Vascular Surgery 02/2015; 61(2):573. DOI:10.1016/j.jvs.2014.11.010 · 3.02 Impact Factor
Article: National Variation in Preoperative Imaging, Duplex Ultrasound Criteria, and Intervention Threshold for Asymptomatic Carotid Artery Stenosis[Show abstract] [Hide abstract]
ABSTRACT: Carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis is among the most common procedures performed in the United States. However, consensus is lacking regarding optimal preoperative imaging, carotid duplex ultrasound criteria, and ultimately, the threshold for surgery. We sought to characterize national variation in preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery for asymptomatic CEA. The Society for Vascular Surgery Vascular Quality Initiative (VQI) database was used to identify all CEA procedures performed for asymptomatic carotid artery stenosis between 2003 and 2014. VQI currently captures 100% of CEA procedures performed at >300 centers by >2000 physicians nationwide. Three analyses were performed to quantify the variation in (1) preoperative imaging, (2) carotid duplex ultrasound criteria, and (3) threshold for surgery. Of 35,695 CEA procedures in 33,488 patients, the study cohort was limited to 19,610 CEA procedures (55%) performed for asymptomatic disease. The preoperative imaging modality used before CEA varied widely, with 57% of patients receiving a single preoperative imaging study (duplex ultrasound imaging, 46%; computed tomography angiography, 7.5%; magnetic resonance angiography, 2.0%; cerebral angiography, 1.3%) and 43% of patients receiving multiple preoperative imaging studies. Of the 16,452 asymptomatic patients (89%) who underwent preoperative duplex ultrasound imaging, there was significant variability between centers in the degree of stenosis (50%-69%, 70%-79%, 80%-99%) designated for a given peak systolic velocity, end diastolic velocity, and internal carotid artery-to-common carotid artery ratio. Although 68% of CEA procedures in asymptomatic patients were performed for an 80% to 99% stenosis, 26% were performed for a 70% to 79% stenosis, and 4.1% were performed for a 50% to 69% stenosis. At the surgeon level, the range in the percentage of CEA procedures performed for a <80% asymptomatic carotid artery stenosis is from 0% to 100%. Similarly, at the center level, institutions range in the percentage of CEA procedures performed for a <80% asymptomatic carotid artery stenosis from 0% to 100%. Despite CEA being an extremely common procedure, there is widespread variation in the three primary determinants-preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery-of whether CEA is performed for asymptomatic carotid stenosis. Standardizing the approach to care for asymptomatic carotid artery stenosis will mitigate the significant downstream effects of this variation on health care costs. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.Journal of Vascular Surgery 02/2015; 61(2):578-579. DOI:10.1016/j.jvs.2014.11.022 · 3.02 Impact Factor
Article: Follow-Up Compliance After Endovascular Abdominal Aortic Aneurysm Repair in Medicare Beneficiaries†[Show abstract] [Hide abstract]
ABSTRACT: Lifelong imaging follow-up is essential to the safe and appropriate management of patients who undergo endovascular abdominal aortic aneurysm repair (EVAR). We sought to evaluate the rate of compliance with imaging follow-up after EVAR and to identify factors associated with being lost to imaging follow-up. We identified a 20% sample of continuously enrolled Medicare beneficiaries who underwent EVAR between 2001 and 2008. Using data through 2010 from Medicare Inpatient, Outpatient, and Carrier files, we identified all abdominal imaging studies that may have been performed for EVAR follow-up. Patients were considered lost to annual imaging follow-up if they did not undergo any abdominal imaging study within their last 2 years of follow-up. Multivariable models were constructed to identify independent factors associated with being lost to annual imaging follow-up. Among 19,962 patients who underwent EVAR, the incidence of loss to annual imaging follow-up at 5 years after EVAR was 50%. Primary factors associated with being lost to annual imaging follow-up were advanced age (age 65-69 years, reference; age 75-79 years: hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.15-1.32; age 80-85 years: HR, 1.45; 95% CI, 1.35-1.55; age >85 years: HR, 2.03; 95% CI, 1.88-2.20) and presentation with an urgent/emergent intact aneurysm (HR, 1.27; 95% CI, 1.20-1.35) or ruptured aneurysm (HR, 1.84; 95% CI, 1.63-2.08). Additional independent factors included several previously diagnosed chronic diseases and South and West regions of the United States. Annual imaging follow-up compliance after EVAR in the United States is significantly below recommended levels. Quality improvement efforts to encourage improved compliance with imaging follow-up, especially in older patients with multiple comorbidities and in those who underwent EVAR urgently or for rupture, are necessary. Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.Journal of Vascular Surgery 11/2014; 60(3). DOI:10.1016/j.jvs.2014.06.006 · 3.02 Impact Factor
Article: VESS27. Lessons Learned from a Single Center's Experience Developing a Complex Endovascular Fenestrated/Branched Aortic Program and Obtaining a Physician-Sponsored FDA Investigational Device Exemption (IDE)Journal of Vascular Surgery 06/2014; 59(6):16S. DOI:10.1016/j.jvs.2014.03.041 · 3.02 Impact Factor
Article: Regarding "The effect of postoperative myocardial ischemia on long-term survival after vascular surgery" ReplyJournal of Vascular Surgery 05/2014; 59(5):1474-1475. DOI:10.1016/j.jvs.2014.01.004 · 3.02 Impact Factor
Article: Management of a Patient With Turner Syndrome Presenting With an Isolated Left Subclavian Artery Aneurysm[Show abstract] [Hide abstract]
ABSTRACT: We describe a case of a 52-year-old female with Turner syndrome found to have an isolated 3.5-cm left subclavian artery aneurysm. Surgical intervention was performed to decrease the risk of compressive symptoms, distal embolization, and rupture. This entailed exclusion of the aneurysm proximally using thoracic stent graft, carotid-subclavian bypass, and ligation of the subclavian artery distal to the aneurysm. One-year follow-up demonstrated exclusion of the aneurysm with a 5-mm reduction in maximum aneurysm sac diameter. This case represents the management of a rare isolated left subclavian artery aneurysm, in the setting of Turner syndrome, treated with a successful endovascular approach.Vascular and Endovascular Surgery 07/2013; 47(5):397-9. DOI:10.1177/1538574413487438 · 0.66 Impact Factor
Article: The Effect of Postoperative Myocardial Ischemia on Long-Term Survival After Vascular Surgery[Show abstract] [Hide abstract]
ABSTRACT: Introduction The impact of a postoperative troponin elevation on long-term survival after vascular surgery is not well-defined. We hypothesize that a postoperative troponin elevation is associated with significantly reduced long-term survival. Methods The Vascular Study Group of New England registry identified all patients who underwent carotid revascularization, open abdominal aortic aneurysm repair (AAA), endovascular AAA repair, or infrainguinal lower extremity bypass (2003-2011). The association of postoperative troponin elevation and myocardial infarction (MI) with 5-year survival was evaluated. Multivariable models identified predictors of survival and of postoperative myocardial ischemia. Results In the entire cohort (n = 16,363), the incidence of postoperative troponin elevation was 1.3% (n = 211) and for MI was 1.6% (n = 264). Incidences differed across procedures (P < .0001) with the highest incidences after open AAA: troponin elevation, 3.9% (n = 74); MI, 5.1% (n = 96). On Kaplan-Meier analysis, any postoperative myocardial ischemia predicted reduced survival over 5 years postoperatively: no ischemia, 73% (standard error [SE], 0.5%); troponin elevation, 54% (SE, 4%); MI, 33% (SE, 4%) (P < .0001). This pattern was observed for each procedure subgroup analysis (P < .0001). Troponin elevation (hazard ratio, 1.45; 95% confidence interval, 1.1-2.0; P = .02) and MI (hazard ratio, 2.9; 95% confidence interval, 2.3-3.8; P < .0001) were independent predictors of reduced survival at 5 years. Conclusions Postoperative troponin elevation and MI predict a 26% or a 55% relatively lower survival in the 5 years following a vascular surgical procedure, respectively, compared with patients who do not experience myocardial ischemia. This highlights the need to better characterize factors leading to postoperative myocardial ischemia. Postoperative troponin elevation, either alone, or in combination with an MI, may be a useful marker for identifying high-risk patients who might benefit from more aggressive optimization in hopes of reducing adverse long-term outcomes.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2013; 58(6):1600–1608. DOI:10.1016/j.jvs.2013.06.062 · 3.02 Impact Factor
Article: The Effect of Postoperative Stroke and Myocardial Infarction on Long-Term Survival After Carotid Revascularization[Show abstract] [Hide abstract]
ABSTRACT: Introduction: The largest randomized controlled trial that compared the efficacy of carotid endarterectomy (CEA) with carotid artery stenting (CAS) showed equivalent outcomes for the composite end point of postoperative stroke, myocardial infarction (MI), or death. However, CAS had a higher risk of postoperative stroke, and CEA had a higher risk of MI. We hypothesize that there is a differential association of postoperative stroke, compared with that of postoperative MI, with reduced long-term survival after carotid revascularization when compared with neither complication. Methods: The Vascular Study Group of New England database was used to identify all CEA and CAS procedures performed between 2003 and 2011. Patients were stratified according to whether they experienced an in-hospital postoperative stroke (minor or major), MI (troponin elevation, electrocardiographic changes, or clinical symptoms), or neither. Primary study end point was survival during the first year and the first 5 years postoperatively. Multivariable Cox proportional hazards models compared the magnitude of association of stroke and MI on survival. Results: Of 8315 patients, 81 (0.97%) experienced postoperative MI, and 63 (0.76%) experienced stroke. During the first year after operation, survival significantly differed among the three groups: neither, 96%; MI, 84%; stroke, 77% (log-rank P < .0001). After adjusting for confounders, survival after postoperative stroke (hazard ratio [HR], 6.6; 95% confidence interval [CI], 3.7-12; P < .0001) was nearly twofold less than that after postoperative MI (HR, 3.6; 95% CI, 2-6.8; P < .0001). During the first 5 years postoperatively, multivariable modeling showed postoperative stroke and postoperative MI remained independent predictors of decreased survival, but the magnitude of association was similar (HR, 2.7; 95% CI, 1.7-4.3 [P < .0001] vs HR, 2.8; 95% CI, 1.8-4.3 [P < .0001]). Conclusions: During the first year after operation, postoperative stroke conferred a twofold lower survival than that after postoperative MI. By 5 years after operation, these survival curves converged, and the survival disadvantage associated with stroke became similar to that of MI. These data suggest that different postoperative complications after carotid revascularization have different implications for patients, with decreased short-term survival in patients experiencing a postoperative stroke. These findings help to inform our interpretation of studies that have used a composite end point in order to evaluate the comparative effectiveness of revascularization strategies.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2013; 56(5). DOI:10.1016/j.jvs.2012.11.118 · 3.02 Impact Factor
Article: A Mycobacterium bovis Mycotic Abdominal Aortic Aneurysm Resulting From Bladder Cancer Treatment, Resection, and Reconstruction With a Cryopreserved Aortic Graft[Show abstract] [Hide abstract]
ABSTRACT: Mycotic abdominal aortic aneurysms (AAAs) are a clinical challenge for vascular surgeons due to their critical location, surrounding inflammation, risk of rupture, and danger of reinfection following treatment. We present a case of Mycobacterium bovis AAA in a 69-year-old male after treatment with intravesicular bacillus Calmette-Guérin (BCG) therapy for bladder carcinoma. The classical approach for mycotic AAA entails extra-anatomic reconstruction followed by resection with oversewing of the proximal and distal aortic stumps. Alternative in-line reconstruction options have also been advocated. This case illustrates a technically straightforward, durable, in-line repair within an infected field utilizing cryopreserved aortic allograft.Vascular and Endovascular Surgery 10/2012; 47(1). DOI:10.1177/1538574412463973 · 0.66 Impact Factor
Article: Reply.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 10/2012; 56(4):1200. DOI:10.1016/j.jvs.2012.06.096 · 3.02 Impact Factor
Article: Colorectal Neoplasia Screening Before Age 50? Current Epidemiologic Trends in the United States: Agency for Healthcare Research and Quality DataDiseases of the Colon & Rectum 09/2012; 55(9):e333. DOI:10.1097/DCR.0b013e3182656225 · 3.75 Impact Factor
Article: Regarding "Outcomes and practice patterns in patients undergoing lower extremity bypass" Reply[Show abstract] [Hide abstract]
ABSTRACT: The appropriate application of endovascular intervention vs bypass for both critical limb ischemia (CLI) and intermittent claudication (IC) remains controversial, and outcomes from large, contemporary series are critical to help inform treatment decisions. Therefore, we sought to define the early and 1-year outcomes of lower extremity bypass (LEB) in a large, multicenter regional cohort, and analyze trends in the use of LEB with or without prior endovascular interventions. The Vascular Study Group of New England database was used to identify all infrainguinal LEB procedures performed between 2003 and 2009. The primary study endpoint was 1-year amputation-free survival (AFS). Secondary endpoints included in-hospital mortality and morbidity, including major adverse cardiac events. Trend analyses were conducted to identify annual trends in the proportion of LEBs performed for an indication of IC, in-hospital outcomes, including mortality and morbidity, and 1-year outcomes, including AFS. Analyses were performed on the entire cohort and then stratified by indication. Between 2003 and 2009, 2907 patients were identified who underwent LEBs (72% for CLI; 28% for IC). The proportion that underwent LEB for IC increased significantly over the study period (from 19% to 31%; P < .0001). There was a significant increase over time in the proportion of LEBs performed after a previous endovascular intervention among both CLIs (from 11% to 24%; P < .0001) and ICs (from 13% to 23%; P = .02). Neither in-hospital mortality nor cardiac event rates changed significantly among either group. There was no significant change in 1-year AFS in patients with IC (97% in 2003 and 98% in 2008; P for trend .63) or in patients with CLI (73% in 2003 and 81% in 2008; P = .10). Over the last 7 years, significant changes in patient selection for LEBs have occurred in New England. The proportion of LEBs performed for ICs as opposed to CLIs has increased. Patients are much more likely to have undergone prior endovascular interventions before undergoing a bypass. In-hospital and 1-year outcomes after LEB for both IC and CLI have remained excellent with no significant changes in AFS.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 06/2012; 55(6):1629-36. DOI:10.1016/j.jvs.2011.12.043 · 3.02 Impact Factor
Article: National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005–2007[Show abstract] [Hide abstract]
ABSTRACT: This study compared, at a national level, trends in utilization, mortality, and stroke after carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA) from 2005 to 2007. The Nationwide Inpatient Sample (NIS) was queried for patient discharges with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CAS and CEA. The primary outcomes were in-hospital mortality, stroke, hospital charges, and discharge disposition. Subgroup analyses were performed to evaluate these outcomes by neurologic presentation using χ(2) and multivariable logistic regression. Of the 404,256 discharges for carotid revascularization, CAS utilization was 66% higher in 2006 than in 2005 (9.3% vs 14%, P = .0004). Crude mortality, stroke, and median charges remained higher for CAS than for CEA; discharge to home was more common after CEA. Results improved from 2005 to 2007. By logistic regression of the total cohort from 2005 to 2006, CAS was independently predictive of mortality (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; P < .0001). Independent predictors of stroke included CAS (OR, 1.43; 95% CI, 1.18-1.73; P < .0001) and symptomatic disease (OR, 2.4; 95% CI, 2.06-2.93;P < .0001). Among subgroups based on neurological presentation, regression showed that CAS significantly increased the odds of stroke in asymptomatic patients (OR, 1.6; 95% CI, 1.2-2.0; P = .0003). Among symptomatic patients, CAS increased the odds of in-hospital death (OR, 3.0; 95% CI, 1.7-5.1, P < .0001) and trended toward significance for stroke (OR, 1.7; 95% CI, 1.0-2.8; P = .0569). Utilization of CAS has increased from the years 2005 to 2007 with some improvements in the outcome. Despite improvements in outcome, resource utilization remains significantly higher for CAS than CEA.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2011; 53(2):307-15. DOI:10.1016/j.jvs.2010.08.080 · 3.02 Impact Factor
- Gastroenterology 01/2011; 140(5). DOI:10.1016/S0016-5085(11)64383-7 · 16.72 Impact Factor
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ABSTRACT: Distinct outcome measures such as in-hospital and 30-day mortality have been used to evaluate pancreatectomy results. We posited that these measures could be compared using national data, providing more precision for evaluating published outcomes after pancreatectomy. Patients undergoing resection for pancreatic cancer were identified from the linked SEER-Medicare databases (1991-2002). Mortality was analyzed and trend tests were utilized to evaluate risk of death within ≤60 days of resection and from 60 days to 2 years post-resection. Univariate analysis assessed patient characteristics such as race, gender, marital status, socioeconomic status, hospital teaching status, and complications. One thousand eight hundred forty-seven resected patients were identified: 7.7% (n = 142) died within the first 30 days, 83.6% of whom died during the same hospitalization. Postoperative in-hospital mortality was 8.1% (n = 150), 79% of which was within 30 days, greater than 90% of which was within 60 days. Risk of death decreased significantly over the first 60 days (P < 0.0001). After 60 days, the risk did not decrease through 2 years (P = 0.8533). Univariate analysis showed no difference between the two groups in terms of race, gender, marital status, and socioeconomic status, but patients dying within 60 days were more likely to have experienced a complication (41.1% vs. 17.0%, P < 0.0001). In-hospital and 30-day mortality after resection for cancer are similar nationally; thus, comparing mortality utilizing these measures is acceptable. After a 60-day post-resection window of increased mortality, mortality risk then continues at a constant rate over 2 years, suggesting that mortality after pancreatectomy is not limited to early ("complication") and late ("cancer") phases. Determining ways to decrease perioperative mortality in the 60-day interval will be critical to improving overall survival.Journal of Gastrointestinal Surgery 11/2010; 14(11):1701-8. DOI:10.1007/s11605-010-1326-4 · 2.80 Impact Factor
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ABSTRACT: Although resection of pancreatic neuroendocrine tumors (PNETs) has a demonstrated survival advantage, further evaluation of the overall morbidity of these procedures is needed. Our objective was to examine a composite outcome of major postoperative complications, including in-hospital mortality. The Nationwide Inpatient Sample (NIS), 1998-2006, was used to identify all patients with a diagnosis of PNET who had undergone pancreatectomy. Candidate predictors consisted of patient and hospital characteristics. Univariate analyses included chi(2) tests. Multivariate analyses were performed with logistic regression to determine which predictors were independently associated with the composite outcome. A total of 463 (2274 nationally weighted) patients were identified. Overall composite postoperative complication rate was 29.6%. The majority of complications involved infections (11.1%), digestive complications (8.8%), or pulmonary compromise (7.3%). In-hospital mortality rate was 1.7%. High Charlson comorbidity score, procedure type of Whipple or total pancreatectomy, and urban hospital location were all associated with significantly increased complication rate. Logistic regression analysis demonstrated: Charlson score of > or =3 versus score of 0 (adjusted odds ratio (OR) 4.1, 95% confidence interval (CI) 2.1-8.3), surgery type of Whipple or total pancreatectomy versus partial pancreatectomy (adjusted OR 2.7, 95% CI 1.8-4.1), and hospital location of urban versus rural (adjusted OR 4.5, 95% CI 3.0-6.9). While in-hospital mortality rates are low for surgical resection of PNETs, there is a considerable overall postoperative complication rate associated with these procedures. Careful patient and surgery selection may be the key to a surgical treatment approach for PNETs that may optimize outcomes.Journal of Surgical Research 09/2010; 163(1):63-8. DOI:10.1016/j.jss.2010.04.017 · 1.94 Impact Factor
Article: A National Propensity-Adjusted Analysis of Adjuvant Radiotherapy in the Treatment of Resected Pancreatic Adenocarcinoma[Show abstract] [Hide abstract]
ABSTRACT: The benefit of adjuvant radiotherapy (RT) for resected pancreatic adenocarcinoma remains controversial after randomized clinical trials. In this national-level US study, a propensity score (conditional probability of receiving RT) was used to adjust for potential confounding in nonrandomized designs from treatment group differences. Patients were identified from the Surveillance, Epidemiology, and End Results (SEER) registry (1988-2005 dataset). Multivariate analyses to determine the effect of RT on overall survival were performed using propensity-adjusted Cox proportional hazards and Kaplan-Meier analyses. In total, 5676 patients with resected pancreatic adenocarcinoma were identified, and 40.8% of those patients had received adjuvant RT. Univariate predictors of survival included age, race, marital status, disease stage, tumor size, tumor extension, tumor grade, lymph node status, year of diagnosis, type of resection, and receipt of RT (all P < .002). In a Cox model, independent predictors of improved survival included white race, married status, earlier stage, smaller tumors, well differentiated tumors, negative lymph node (N0) status, recent diagnosis, and receipt of RT (all P < .05). In a propensity-adjusted proportional hazards regression, the benefit of adjuvant treatment that included RT remained significant after adjusting for the likelihood of receiving RT (hazard ratio, 0.773; 95% confidence interval, 0.714-0.836; P < .0001). Within all 5 propensity strata, Kaplan-Meier survival differed significantly (P < .0001 [lowest and highest probability strata] and P = .0165 [middle stratum with a "pseudorandom" probability of RT]). Adjuvant RT for resected pancreatic adenocarcinoma was associated with a significant survival advantage in a large national database, even after using propensity score methods to adjust for differences between treatment groups. The authors concluded that adjuvant RT should be considered for all appropriate patients who have resected pancreatic adenocarcinoma.Cancer 07/2010; 116(13):3257-66. DOI:10.1002/cncr.25069 · 4.89 Impact Factor
Article: Predictors of Major Complications after Laparoscopic Cholecystectomy: Surgeon, Hospital, or Patient?[Show abstract] [Hide abstract]
ABSTRACT: Regionalization of care has been proposed for complex operations based on hospital/surgeon volume-mortality relationships. Controversy exists about whether more common procedures should be performed at high-volume centers. Using mortality alone to assess routine operations is hampered by relatively low perioperative mortality. We used a large national database to analyze the risk of major in-hospital complications after laparoscopic cholecystectomy (LC). Patients undergoing LC were identified in the Nationwide Inpatient Sample 1998-2006 from states with surgeon/hospital identifiers. Previously validated major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed. Univariate and multivariable analyses were performed and independent risk factors of complications were identified. A total of 1,102,071 weighted patient discharges were identified, with a complication rate of 6.8%. Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates (p < 0.0001). Higher surgeon volume (>or=36/year versus <12/year) and higher hospital volume (>or=225/year versus <or=120/year) were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively; p < 0.0001). Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years; adjusted odds ratio [AOR] = 2.16; 95% CI, 2.01-2.32), male gender (AOR = 1.14; 95% CI, 1.10-1.19), and comorbidities (Charlson Comorbidity Score 2 versus 0; AOR = 2.49; 95% CI, 2.34-2.65) were associated with complications. Neither surgeon nor hospital volume was independently associated with increased risk of complications. Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.Journal of the American College of Surgeons 07/2010; 211(1):73-80. DOI:10.1016/j.jamcollsurg.2010.02.050 · 5.12 Impact Factor
Top Journals
University of Massachusetts Medical School
Worcester, Massachusetts, United States
- Department of Surgery
University of Massachusetts AmherstAmherst Center, Massachusetts, United States
University of WorcesterWorcester, England, United Kingdom