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Closeouts. With an amphibious, supportive design, The North Face's Hypershock shoes are made to perform from trail to creek-wading adventure. Specially placed HydroTrak® rubber pods improve grip from slick, wet surface to dry, dusty trail.
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Is Yes Education incorrect or missing key business information? Update your Hotfrog listing today.
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Hotfrog INDIA provides information regarding Yes Education in Mumbai Maharashtra. Yes Education is located at B - 301, Pranav Commercial Plaza, Above Shiv Sena Shakha MGRoad Mulund W, Mumbai Maharashtra 400 080 and provides Engineering services. Contact them on +91 22 6770 4856 or by visiting them on their website http://www.yeseducation.in.
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11, Apple Heritage, 54-C Andheri-Kurla Road Mumbai Maharashtra 400093
Workshop, No 5 & 8 Devji Keshavji Industrial Estate, Off Waman Tukaram Patil Marg Opp Dukes Factory Mumbai Maharashtra 400 071
19, Odhavram Krupa, S. N. Road, Opp. Shanti Ind. Est., Mulund (W), Mumbai Maharashtra 400080
10, Ratna Sagar, 2nd Floor, Gaushala X Lane Daftary Road Mumbai Maharashtra 400 097
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subset: commoncrawl


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My all time favorite movie I would have to say is A Walk to Remember. That movie really hits home. I also like comedy, drama, and action movies. I am a huge scardy cat and cant handle scary movies. Ill admit if I have someone to cuddle with then I can manage the scary movies.
As Far as music is concerned, I grew up listening to The Beach Boys, The Eagles, Led Zepplin, Journey, Bruce Springsten, and a whole bunch of other stuff. I like rap to dance to, I like country, I like rock, and R&B. Just a little bit of everything and i am okay.
As far as food is concerned, I love sushi, pizza, mexican, pasta, and my all time favorite is vietnemese. I love me some good Horchata.
You are willing to admit when you are wrong and you aren't going to just disappear!


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About cws6196
I provide a weather email service for people in MD. I am a storm chaser & Skywarn spotter. For daily weather tidbits follow me on Twitter: @wxmanMD.
By: cws6196 , 3:26 PM GMT on June 24, 2012
Talking about the tropics when our current temps are dropping doesn't seem to make sense, but it is hurricane season. Fortunately/unfortunately, "Chris" was a bust, so on to other storms. Let me reiterate my policy on posting about the tropics: I only post about those storms which I feel have the potential to impact MD. I don't talk about all the storms, hence why you didn't hear me talk about "Chris" even though I wanted to. ... But, if any of you are travelling to a hurricane prone area let me know and I will give you a forecast.
Ok, on to the latest tropical issue, Debby. I only bring her up due to a slight; very slight, chance she will impact MD. I know the official path from the NHC has her headed toward TX and LA, but I am respectfully disagreeing with that track. Actually, in their latest update, the NHC has moved the track further to the east, more in line with what I am thinking. I see Debby either crossing FL and running along the Atlantic, or entering land between LA and AL with a possible inland track to MD. This latter path would bring us much needed rain! Given climatology in the area, I see Debby intensifying to hurricane status, being picked up by the trough in the area, and crossing FL. The probable track at that point would be out to sea, but with a slight chance for her to ride up the east coast toward MD.
Bottom line: Watch to see if the NHC continues to move Debby's track further to the east, then watch for either landfall around LA/AL, or for her to cross FL into the Atlantic. I will be keeping an eye on this, but again, it is a "slight" chance for her to impact MD. "IF" she does impact MD it would be around next weekend or so.
Follow me daily on Twitter (@wxmanmd or www.twitter.com/wxmanmd) and I will keep my Weather Phone updated as needed (443-470-9804).
The views of the author are his/her own and do not necessarily represent the position of The Weather Company or its parent, IBM.
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Talkeetna, AK
|393 ft
|Dew Point:
|Wind Gust:
|0.0 mph
Updated: 8:07 PM AKST on February 20, 2017


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hotelF1 Nimes est Marguerittes
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Day 72 - Avignon of Popes and Palaces
After getting use to the sound of hoot owls in the night we slept in until 8:00am this morning. We awoke to a low cloud level and cool temperatures but the promise of a sunny day lay ahead. After a pot of coffee (loved that after a month of espressos) and a light breakfast, we took a walk through the village of Noves.
Noves is is a very small village with only a few hundred inhabitants. At one time there were ramparts around the town but only a few remain along with a few ...
Day 71 - Provence Provincial
... a hundred years old. Check out the photos on the website of our cottage as we have no photos today. This location would be great for a family gathering, albeit a bit far to go.
http://www.moulindelaroque.com/la-roque -villa-maison-du-meunier-en.htm
After settling our things in the cottage, we headed to a nearby village for an exciting afternoon of ....laundry. Yes, since ...
Sur la Pont D'Avignon ....
... back in 19BC, and certainly deserves being a Unesco site. After touring the Pont Du Gard all morning it was off to the car for a quick trip to Nimes - the end point of the Roman Aqueduct. We had a great lunch and toured many Roman structures and walked and walked and walked...in 36 degree heat! We literally baked our shoes.... Once back at Arles it was off to a great dinner at Le Criquet - to date probably our best meal. Situated in an old house with exposed walls and ...
Days 6 & 7 - Arles, La Camargue & Mediterranean
... biggest beach either of us had seen. Not the longest, we had both seems many long beaches. This was DEEP. From our first step on the sand the closest point to water was nearly a kilometre away. We walked across the sand and eventually set down our packs on a big piece of drift wood on the bank. We changed into our swim suits and dove in! The water in the Mediterranean is salty! Christina had swum there before, but this was a first for Justin. We jumped into huge oncoming waves ...
Last day in France
... times. Just as with other Roman architecture, it would have been covered with colorful marble and would have had lots of columns and statues. Whenever there was a new Caesar, the body of the statue would stay and a new head would replace the old one. Other than for a couple of hundred years, this theater has been used continuously. For a time, houses were built inside and along the walls. Now it is used for performances, and the acoustics are ...


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Attention teens: Join us on the first Saturday of the month at 4pm at the beautiful Ortega Branch!
For our meeting in May we will be reading The Manny by Sarah L. Thomson.
Questions? For more information or assistance reserving a copy of the book, please contact Tony at firstname.lastname@example.com.
Upcoming Events
- Next Chapter Book Club
- Friday, February 24, 2017, 3:00 pmMain Library, Learning Studio
- The Boris Rozenfeld Russian Bibliophiles Book Club
- Saturday, February 25, 2017, 2:00 pmMain Library, Latino/Hispanic Rms A & B
- Excelsior Branch Book Club: Underground Railroad
- Tuesday, February 28, 2017, 7:00 pmExcelsior, Excelsior Meeting Room
Upcoming Classes
- Great Books Discussion Group
- Tuesday, March 14, 2017, 6:15 pmRichmond, Richmond Meeting Room
- Great Books Discussion Group
- Wednesday, March 22, 2017, 6:30 pmWest Portal, West Portal Children's Area
*Funded by Friends of the San Francisco Public Library.


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While role models are always good, women in Australia are finding that cutting their own trail in the business world can be a strategic and successful path to attaining gender equality. Businesswomen say mentoring is a key factor in the effort and a successful approach.
Full Story:Sunshine Coast Daily Online (Australia)


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A room — more than the window itself — is really the frame for the window covering. The room's dimensions, colors, exposure to natural lighting, and its use, all impact the type of covering that works best in the space.
Need is what most people think of first when they consider a window fashion. Does it provide privacy? Will it retain cool air during the warmer months? What degree of light control does it offer?
Your vision, your ideas — create a look that defines your personal style with the help of Artistic Windows. Whether you're looking to add custom window treatments or to update your entire room, we have everything you need.
Custom window coverings: Blinds. Artistic Windows offers a...Read More
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The finishing touch: Hardware. Drapery hardware is the...Read More


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There are countless milestones young people encounter as they transition through high school. However, none of them may leave more lasting memories than prom.
For many Brunswick County girls, the costs associated with getting a prom dress and all its related accessories can be so high, it can completely eliminate the dream of a teenager's rite of passage.
I could feel the cold coming in through the windows before I got of bed. Reluctantly, I wiggled out from under the covers and put my feet on the floor. As soon as they hit the floor, I jumped back onto the bed.
"It's too cold. We should at least have some snow if it's got to be this cold," I thought.
As soon as I uttered the words, I began thinking of all the lucky people in the western part of the state who probably had a little of the powdery stuff I wanted so badly. Why couldn't I be the one with a snowdrift at my back door?
It was hard to believe he was dying.
He was just a boy.
While others his age were thinking of first kisses and video games, Adam was talking to me about his relationship with God, how tired he was and how he looked forward to his chance to move on.
He was courageous and optimistic, but he was going to die. Somehow, he had come to terms with that.
To the editor: I've never given much thought to the political race for Brunswick County clerk of the superior court. It has always been a recordkeeping position in any county I've lived until I understood the Brunswick County clerk of superior court presides over minor cases and settles legal questions between parties.
To the editor: My wife Kathleen is in South Florida with the Red Cross. Some of her duties have placed her in direct contact with planeloads of children who have been traveling for 12-14 hours.
Most of the children are frightened and confused and most need clean diapers and underwear. The bureaucrats who meet their planes and process them take hours to complete the paperwork to allow them on to their next stop.
To the editor: As you may already know, there has been a 29.8 percent increase in your homeowners insurance as of May 1, 2009.
Wayne Goodwin, N.C. insurance commissioner, has approved this percentage. It is the largest increase in the entire state of North Carolina.
I contacted the commissioner's office to verify this increase. If this issue is of concern to you, I ask you forward this information to anyone who lives in Brunswick County. You may contact Wayne Goodwin at (800) 662-7777 or its Web site at www.NCDOI.com.
To the editor: Every time there is a natural or manmade tragedy, someone comes out and says it is the result of God's wrath for specific sins.
What does God say in His Word? In Luke 13:4, Jesus was asked: "On those 18 on whom the tower in Siloam fell and killed them, do you think that they were worse sinners than all the other men who dwelt in Jerusalem?" God said: "I tell you no, but unless you repent, you will all likewise perish."
To the editor: Another view of healthcare reform:
•Increase supply of healthcare providers by expanding enrollment in all medical professions using federal money and clout in schools and associations;
•Influence professional specialties and geography by incentives to medical students paying for education;
•Increase roles of highly educated pharmacists and nurses in providing non-critical health services;
•Allow U.S. pharmaceutical firms to bargain collectively with single-payer countries—no subsidies for U.S. technology;
Copyright © 2017
The Brunswick Beacon is your source for local news, sports, events and information in Brunswick County, North Carolina and surrounding areas.


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I think I'm experiencing the same thing Daniel F is reporting, I have experienced this twice when logging into an expired session with the login logs in view. This is what appears in the System Logs of IPS: "The log entry was triggered by a guest" Error: Call to a member function inGroup() on array (0) #0 /var/www/html/hvportal/init.php(442) : eval()'d code(26): IPS\loginlogs_hook_logs->log('GUEST', Array) #1 /var/www/html/hvportal/applications/core/modules/admin/system/login.php(52): IPS\loginlogs_hook_logs->authenticate() #2 /var/www/html/hvportal/system/Dispatcher/Controller.php(96): IPS\core\modules\admin\system\_login->manage() #3 /var/www/html/hvportal/system/Dispatcher/Dispatcher.php(129): IPS\Dispatcher\_Controller->execute() #4 /var/www/html/hvportal/admin/index.php(13): IPS\_Dispatcher->run() #5 {main} Backtrace: #0 /var/www/html/hvportal/init.php(506): IPS\_Log::log('Error: Call to ...', 'uncaught_except...') #1 [internal function]: IPS\IPS::exceptionHandler(Object(Error)) #2 {main}
I did the upgrade from IP.Board 3.4.9 to 188.8.131.52 last night and can confirm that the old version v1.1 can be left as is through the upgrade. I did not deactivate or remove v1.1. Once the IPS4 was completed sorting itself out I installed v2 of the Login Logs by simply uploading the tar file and it took care of converting the data and removing it's old v1.1 remnant bits. This was nice to carry over the old data because I have login trends that are good to use for helping folks and backing up known issues or patterns of not remembering some types of credentials. I could have easily just removed the v1.1 instance prior to the upgrade but would have lost that history.
jlow99 changed their profile photo
Hello, I'd like to confirm what to do to keep the logs when upgrading from IP.Board 3.4 to IPS 4. I seems like I can just leave the Login Logs 1.1 installed on the IP.Board 3.4 instance and then after upgrading to IPS 4 I just simply install the new version of Login Logs 2.x? Is it really that easy? I don't have to remove the incompatible old version after or anything? My experience in the past with test upgrades from IP.Board 3.4 to 4.x is that it disables the v1.1 Log In Logs application. What I did was just remove the Login Logs application prior to upgrading to IPS V4. I can't recall but maybe there is a preserve data question but I can't remember prior to removing the app. Anyhow, I'm just hoping to see if the old app can be left during the upgrade of IPS to V4 and to simply install this v2.x of the Login Logs.
jlow99 commented on IPS News's article in IPS NewsWhen these patches come out I just create a copy (tar) file of my admin directory, just in case, and then extract the patch and then test. This patch works fine with 3.4.7 as I've just tested, but is intended for any 3.4.x as with other patches IPS have produced in the past.
jlow99 replied to spiderman168's topic in Pre-Sales QuestionsHi bfarber Can you post a link please to this guide?
jlow99 posted a topic in Product FeedbackI'd really like an optional setting to enable a "follow this topic" link to appear on email notifications of new topics. I'm not sure if the emailWrapper is the right place for it and should do some testing. I thought I'd ask regardless. It's great that the system can be set to send notifications of all new topics, but I need to take it a step further for really easy following capacity right within that notification. Does anyone know how to accomplish this? I was thinking of the the html emailwrapper in the manage system templates area. Would this be a feature request or something already accounted for in version 4? I guess the new topic link would have to be creativly caught as a variable for use in the email wrapper, I just don't know how it could be done automatically or if it's possible. Much Obliged, ~j
Thanks Lindy, Kirito, AncientMariner!! AncientMariner's suggestion worked but I'm curious about what is more appropriate... open_basedir = /var/www/html:/usr/bin upload_tmp_dir = /tmp or open_basedir = /tmp:/var/www/html:/usr/bin Also, please confirm the /usr/bin definition there, I use ImageMagick as well for mediawiki but I'm not sure if /usr/bin leaves a vulnerability. I'll try it out in the next few days. One more thing, I hear about root kits installing themselves in /tmp so I'm also wondering about defining something other than /tmp, or are we stuck with that. I'm assuming we're stuck with /tmp and probably need something like selinux to protect the OS. I've gone way too far here. Thanks though for your help!
This might be just me, but I've tested out setting open_basedir = /var/www/html (happens to be my web root default) with some negative side effects. The ability to upload files with ip.downloads or upload avatars seems to not work. Everything else seems to function which is good. Commenting open_basedir out again from my /etc/php.ini allows things to be uploaded again. Is this expected? The use of ip.downloads is pretty important to me and it would be nice if there is a work around for security sake. Note that I'm running on a physical host and have full control over the OS and files. I've tested this out with the latest and greatest version of IP.Board and IP.Downloads.


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Is Philippine Coast Guard incorrect or missing key business information? Update your Hotfrog listing today.
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Hotfrog Philippines provides information regarding Philippine Coast Guard in Cebu City Cebu. Philippine Coast Guard is located at Cebu City Cebu 6000 and provides resources services. Contact them on (032) 345 0166 or by visiting them on their website http://www.coastguard.gov.ph.
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The Accountant & the Clown (2008)
- Studio: Perception Pictures
- Release: October 10, 2008
- Director: Josh Tanner
- Writer: Josh Tanner
- Cast: Ben Campbell, Nicholas D. Kervin
Video archive for the film The Accountant & the Clown, which has a domestic theatrical release in the year of 2008. There is currently one video available for the film, of which zero are trailers, as listed below. Happy viewing!
Featured Movie John Wick: Chapter 2


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Tickets go on sale Jan. 27 for the Sept. shows.
Multiple Grammy Award-winner brings 5 decades of hits to Toledo.
The shows often include medley of Motown hits.
4 concerts comprise inaugural season.
Keith Saunders, ballet master with the Dance Theatre of Harlem, instructs at Valentine.
Band creates dreaminess pegged to sense of purpose.
The Andersons Family Series: Valentine Theatre, 400 N. Superior St.; 242-2787 / 246-8000; Toledo Symphony Orchestra, Score! Sound of Sports; Sun., 3:30. Stranahan Theater: 4645 Heatherdowns Blvd.; 381-8851 / etix.com; Dionne
Except where indicated, all area codes are 419. DANCE Ballroom, Big Band, Polka, Country, Latin, and Salsa Diehn American Legion: Post 468, 5580 Centennial Rd., Sylvania; 601-1057; today: line dance lesson (beginner) 6:30; line dancing with
A.J's Doolittles: 8525 Secor Rd., Lambertville; 734-856-3838; Temperance Tonic: Fri. Bar 145: 5305 Monroe St.; 593-0073; Sugar Pax: Fri.; Cherry On Top: Sat. Bier Stube: 5333 Monroe St.; 841-7999; BOFFO: Fri. The Blarney: 601
It's Only a Play: Toledo Repertoire Theatre, 10th St. Stage, 16 10th St.; today, Fri., Sat., 8, Sun., 2:30. Tickets, $8 to $20, from 419-243-9277 or toledorep.org. The Croswell Miscast: Cabaret-style performance, all-area high school


text: US Open Gallery: Down To... Nine? The WTA stars have been shining on and off the court over the last few days as the US Open field has been cut from 16 to nine - it would have been eight if Flushing had stayed completely dry... Published September 03, 2013 12:00 The last few days have seen the round of 16 take place, with Carla Suárez Navarro making the cut. Sloane Stephens did not, falling in straight sets in her fourth round match against Serena Williams. Williams still hasn't dropped a set the whole tournament - she hasn't even been pushed beyond 6-4. Sister, fellow former US Open champion, doubles partner and more - Venus Williams cheered her on. Sunday night also saw the biggest upset of the tournament, as Ekaterina Makarova took out the No.3. Agnieszka Radwanska was looking to complete her Grand Slam quarterfinal set, but not this time. Meanwhile on Arthur Ashe Stadium, Jelena Jankovic was struggling with on-song No.5 seed Li Na. Li won seven straight games from 5-3 in the first set to cruise past a bewildered Jankovic, 63 60. Roberta Vinci snuck her win in on Monday morning before the rain fell on Flushing Meadows... After that Flavia Pennetta became the next to win on Labor Day, pulling off quite the shocker. Simona Halep had been the form player coming into the tournament, but Pennetta got her in straights. And Daniela Hantuchova also got to the quarters. Victoria Azarenka and Ana Ivanovic were postponed. The stars kept coming out to the Open over the last few days, including famous voice Estelle. And Kelsey Grammer - of Cheers and Frasier fame - was also in attendance over the weekend. Billie Jean King and Martina Navratilova met some young WTA stars at their Power Hour group session. Topics: 2013, tournaments, news, photos or videos, carla suarez navarro, angelique kerber, alison riske, daniela hantuchova, jelena jankovic, na li, ekaterina makarova, billie jean king, martina navratilova, agnieszka radwanska, sloane stephens, serena williams, venus williams, flavia pennetta, simona halep, us open [+] More Share this page! Print Email Related photos WTA Stars Take A Taste Of Taiwanese Culture January 30, 2017 Before the start of the Taiwan Open - which kicks off right on Lunar New Year - Lucie Safarova, Jelena Jankovic, Elina Svitolina and more WTA players got a chance to celebrate at the Welcome Party! Serena Wins Historic 23rd Major Title At The Australian Open January 28, 2017 Check out all the best photos from the Australian Open final between Venus Williams and Serena Williams, where Serena took home a record-breaking 23rd Grand Slam title. Australian Open: And Then There Were Two January 26, 2017 Venus and Serena Williams are in the final of the Australian Open, the first all-Williams Grand Slam final since 2009. So how did we get here? Take a look back at the best photos of the fortnight! To The Top 3


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A Frenchwoman's Journal of the War Unabridged [CD-Audio/MP3 Edition]
By (author) Agnes Humbert Barbara Mellor
Narrator Joyce Bean
Format: CD-Audio
Normal Price: $66.59
Your Price: $59.93 AUD, inc. GST
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Resistance by Agnes Humbert
Book DescriptionAgnes Humbert was an art historian in Paris during the German occupation in 1940. Though she might well have weathered the oppressive regime, Humbert was stirred to action by the atrocities she witnessed. In an act of astonishing bravery, she joined forces with several colleagues to form an organized resistance-very likely the first such group to fight back against the occupation. (In fact, their newsletter, Resistance, gave the French Resistance its name.) In the throes of their struggle for freedom, the members of Humbert's group were betrayed to the Gestapo; Humbert herself was imprisoned. In immediate, electrifying detail, Humbert describes her time in prison; her deportation to Germany, where for more than two years she endured a string of brutal labor camps; and the horror of discovering that seven of her friends were executed by a firing squad. But through the direst of conditions and ill health in the labor camps, Humbert retains hope for herself, for her friends, and for humanity. Originally published in France in 1946, the book was soon forgotten and is now translated into English for the first time. Resistance is more than a firsthand account of wartime France; it is the work of a brave, witty, and forceful woman, a true believer who refused to go quietly.
Buy Resistance book by Agnes Humbert from Australia's Online Bookstore, Boomerang Books.
Book DetailsISBN: 9781400108336
(137mm x 163mm x 27mm)
Imprint: Tantor Media, Inc
Publisher: Tantor Media, Inc
Publish Date: 2-Sep-2008
Country of Publication: United States
Other Editions...
Books By Author Agnes Humbert
Resistance, Paperback (July 2009)» View all books by Agnes Humbert
'Agnes Humbert bears devastating witness to her time An insider's account of the germination of the French Resistance' William Boyd
» Have you read this book? We'd like to know what you think about it - write a review about Resistance book by Agnes Humbert and you'll earn 50c in Boomerang Bucks loyalty dollars (you must be a member - it's free to sign up!)
Author Biography - Agnes Humbert
Agnes Humbert was a distinguished art historian and a member of the Musee de l'Homme group in the French Resistance. Barbara Mellor is a translator specializing in the fine and decorative arts, art history, architectural history, fashion, design, and all things French. Joyce Bean is an accomplished audiobook narrator and director. In addition to being an "AudioFile" Earphones Award winner, she has been nominated multiple times for a prestigious Audie Award, including for "Good-bye and Amen" by Beth Gutcheon.
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Tag Archives: Sexual Abuse
40,000 Christians Persecuted By Muslims In Germany
40,000 Christians Persecuted By Muslims In Germany No adult is persecuted or abused unless they allow themselves to be. Fight back, it's THAT simple. Pick up a rock, a stick, a limb, a ball bat, an ax, a shovel, a … Continue reading
Posted in America 1st Tagged Child Abuse, Mental Abuse, Physical Abuse, Religious Persecution, Sexual Abuse, Spousal Abuse 6 Comments
Priest accused of U.S. abuse works in India
Priest accused of U.S. abuse works in India NEW DELHI – A Catholic priest charged with sexually assaulting a 14-year-old girl in Minnesota is working in his home diocese in India and has no plans to return to the U.S. … Continue reading
Anglican leader: Irish church lost all credibility
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Labour's real guarantee: WorkfarePosted: January 9th, 2013 | Author: editor | Filed under: Info on schemes, Welfare to work industry | 9 Comments »
Last week saw the Labour Party announce its own form of workfare: the Job Guarantee. Labour, who introduced workfare and welfare reform into the UK whilst in government, now guarantees a number of things: It guarantees that yet again politicians will give billions of taxpayers' money to subsidise big private businesses – probably the likes of failing and government contract reliant A4E, and workfare-users ASDA – helping them to drive up their profit margins. It guarantees to further undermine real job vacancies as companies replace job roles with subsidised compulsory short-term placements.
Labour, like the coalition government, also now guarantee to undermine the idea of a living wage, which just two months ago Ed Milliband appeared to champion. After all if a company can get staff forced to work for it, both provided by and subsidised by the state at minimum wage, why pay the living wage? Indeed, earlier announcements about the scheme suggest that it will include 10 hours unpaid, so will also be far below minimum wage. In addition, Labour's 'guarantee' will only last for six months. With a revolving door workforce on tap, why would an employer create permanent jobs? As this campaign has revealed, workfare replaces paid employment, and undermines the wages of people already in work, who have seen their overtime and hours reduced: Debenhams is the latest to use workfare to staff its shops during the busy festive season.
With each placement lasting only six months, Labour guarantees to use its scheme to massage the unemployment figures, not giving those who finish their placements anything to go on to, but effectively resetting the clock on their long term unemployment. If you refuse to take part, then Labour guarantees harsh sanctions.
When Labour talk of training, they do not guarantee real skills training to get a job, or qualifications to gain employment in demand where there is a skills shortage. Past form suggests that what Labour guarantee as training, is shorthand for guaranteeing people sit in rooms and write up a CV at A4E or Deloitte-owned Ingeus for the hundredth time. After all it was Labour who guaranteed A4E's first contract and Emma Harrison millions.
Some in Labour realise exactly what workfare means and are privately aghast at this policy initiative. While Labour join in promoting the idea that everyone who is unemployed is a scrounging benefits cheat, the fact is that spending on JSA is just 3% of the DWP's budget. The majority of the social security budget is spent on pensions, and paying in-work benefits to those in work on low wages, wages made lower all the time by workfare. Yet ignoring such facts, this year one MP has promised that Labour will launch a 'Workers not Shirkers' campaign, guaranteeing to boost government spin which demonises those who are unemployed. Labour guarantees workfare. We guarantee to fight it.


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Town Square
San Ramon Valley students earn National Merit Scholarships
Original post made on Aug 27, 2014
Read the full story here Web Link posted Tuesday, August 26, 2014, 5:31 PM
Comments (2)
a resident of San Ramon
on Aug 27, 2014 at 6:39 pm
The Scholarships indicates much deep preparation which these scholarship winners received in their respective high school of San Ramon District.
a resident of another community
on Aug 29, 2014 at 3:04 pm
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The state water board missed the mark
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Community Status Updates
PHPF is back! And hopefully better with a new owner.May 02 2016 06:40 PM
Stefany93We shall drink to that!
May 22 2016 05:04 AM
Did you ever notice the most common and frequent things need to do in coding never have a well made function?Oct 06 2015 08:22 AM
Tip of the day: HTTP referer - The word referer is mispelled in most coding and should have been referrer. Although some spell it correctly such as any using DOM.Sep 23 2015 04:08 PM
When kids talk in class, here is how they handle the punishment. for($i=1;$i<=1000;$i++){ echo "I will not talk in class. <br />"; }Sep 21 2015 06:09 AM
The best thing about a Boolean is even if you are wrong, you are only off by a bit.Sep 21 2015 06:02 AM
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Although right ventricular (RV) failure is the main cause of death in patients with pulmonary arterial hypertension (PAH), there is insufficient data about the effects of PAH treatment on RV geometry and function mainly because the RV assessment has been hampered by its complex crescentic shape, large infundibulum, and its trabecular nature. Echocardiography is a widely available imaging technique particularly suitable for follow-up studies, because of its non-invasive nature, low cost, and lack of ionizing radiation or radioactive agent. Real-time three-dimensional echocardiography (RT3DE) has been shown to be accurate in assessing RV and left ventricular (LV) volumes, stroke volumes, and ejection fractions in comparison with cardiac magnetic resonance imaging. In this review, we describe RV structural and functional changes which occur in patients with PAH and strengths and weaknesses of current non-invasive imaging techniques to assess them. Finally, we describe an ongoing multicentre, prospective observational study involving seven centres expert in treating patients with PAH from four different countries. Investigators will use conventional and advanced echo parameters from RT3DE and speckle-tracking echocardiography to assess the extent of LV and RV remodelling before symptom onset and during pharmacological treatment in patients with PAH. Seventy patients who will survive for at least 1 year will be recruited. All the participating institutions will perform comprehensive standard 2D and Doppler as well as RT3DE examinations with a pre-defined imaging protocol. Measurements will be performed at the core echocardiography laboratory by experienced observers who will be unaware of each patient's treatment assignment and whether the examination was a baseline or a follow-up study. Enrolment duration is expected to be 1 year.
Pulmonary arterial hypertension (PAH) is a progressive and seriously debilitating disease characterized by pathological lesions of the pulmonary arteries progressing from early medial hypertrophy to end-stage plexiform fibrosis and leading to an increase in pulmonary artery pressure that may exceed systemic levels. Although pulmonary pressure rise is the distinctive characteristic of this disease, the level of pulmonary artery pressure itself has only modest prognostic significance in patients with PAH. It is rather the ability of the right ventricle (RV) to cope with the progressive increase in pulmonary arterial pressure that mainly determines both the patients' functional capacity and survival. 1–4 However, in patients with PAH, RV dysfunction has not received the same scientific interest as the mechanisms of PAH.
Thus, the aims of our paper are: (i) to review the alterations of cardiac morphology and function associated with PAH; (ii) to outline the strengths and weaknesses of currently available non-invasive imaging technologies (mainly echocardiography) in assessing RV size and function; and (iii) to present a study protocol aimed at assessing the extent of RV remodelling that occurs in asymptomatic patients with PAH and in those treated with current disease-targeted therapies.
Right ventricle in pulmonary hypertension
The geometry of the normal RV is complex. It consists of an inflow (sinus) and an outflow (conus) portions separated by the crista supraventricularis. It is crescent shaped in cross-section, formed by the concave RV free wall opposite to the convex interventricular septum. Functionally, the RV pumps the same stroke volume as the left ventricle (LV), but using 25% of the stroke work because of the low resistance of the pulmonary vasculature. Therefore, the RV wall is thinner and more compliant than the LV wall. Normal RV contraction acts in a sequential manner, as a peristaltic wave directed from inflow to infundibulum. Spatially, RV wall deformation consists of three components (inward, longitudinal, and circumferential traction due to LV contraction), of which longitudinal shortening is the major contributor to the overall RV performance. 5 Right ventricular free wall and interventricular septum contribute equally to RV performance. Right ventricle is closely connected to the LV: they share a wall (interventricular septum); the RV free wall is attached to the anterior and posterior interventricular septum; and they have mutually encircling epicardial fibres and share the same intrapericardial space.
Significant morphological and functional adaptative changes of the RV develop in patients affected by PAH. 6
The first adaptation that occurs is myocardial hypertrophy, 7 followed by progressive contractile impairment. Possible mechanisms involved in the progression of RV myocardial contractile dysfunction include: ischaemia, 8 changes in gene expression of the sarcomere proteins, 9 and activation of myocardial renin–angiotensin system. 10 However, afterload mismatch remains the main determinant of RV dysfunction in patients with PAH.
Right ventricle dilatation occurs in order to compensate a reduced fractional shortening by an increase in preload, so that stroke volume is maintained. As contractile dysfunction progresses, RV failure occurs and it is characterized by high RV filling pressures, diastolic dysfunction, 11 and reduced cardiac output. The decrease in cardiac output is also due to the functional tricuspid regurgitation caused by tricuspid annular dilatation and impaired leaflet coaptation. Augmented RV volume is the result of chamber remodelling, owing to the increase in cardiac myocyte length as a consequence of newly synthesized sarcomeres assembled in series. With hypertrophy and dilatation, the RV progressively becomes more spherical, its cross-sectional area enlarges, and the interventricular septum flattens, causing also LV diastolic dysfunction. 12
Diastolic dysfunction is the most frequent type of LV impairment in patients with PAH. Usually, patients with PAH show a delayed relaxation pattern of LV filling and a small end-diastolic LV volume. 12 The reduced LV end-diastolic volume contributes to the decrease in stroke volume. 13 Although reduction of LV ejection fraction may occur in patients with PAH, it is a rather uncommon finding.
The exact mechanisms leading to the development of RV failure in patients with PAH are still unclear. Several mechanisms have been hypothesized: RV myocardial ischaemia, microvascular endothelial cell dysfunction, and myocyte apoptosis. In severe end-stage PAH, the RV changes its shape from the normal conformation to a more spherical one, 14 , 15 and RV wall stress increases because RV wall thickness does not increase proportionally. 16
Imaging the right ventricle and assessing its geometry and function
A variety of two-dimensional echocardiographic (2DE) measurements and Doppler parameters have been described for the assessment of RV dimensions and function, although none so far has demonstrated superiority over cardiac catheterization or cardiac magnetic resonance (CMR). Major challenges for RV assessment by conventional 2DE derive from (i) complex asymmetric geometry; (ii) heavily trabeculated inner contour with poor endocardial definition; (iii) separate inflow and outflow which may be adequately visualized only from separate views; (iv) load-dependency and lower accuracy of most conventional echo parameters in comparison with invasive measures. 17
Probably the best non-invasive correlates of RV function are ejection fraction (EF) and RV volumes, but these parameters are rather difficult to accurately obtain by conventional echocardiographic methods. Cardiac magnetic resonance is currently the most reliable non-invasive tool for this purpose, mostly due to its unique spatial resolution and 3D imaging capacity. Cardiac magnetic resonance is, however, inapplicable in certain patients (e.g. with claustrophobia or implanted metallic devices). In addition, its wide use is precluded by cost, long scan and analysis time, limited availability, and dedicated expertise. Moreover, CMR has limited ability to assess load-independent parameters (such as myocardial contractility) in patients with long-standing pressure overloaded RV. 18
Unfortunately, echocardiographic assessment of RV in clinical practice is rather elusive and mostly qualitative. A multiparameter approach to compensate for each other flaws is time-consuming and not clinically feasible.
Recent recommendations from the 4th World Symposium on PAH from Dana Point, California 19 underline that a PAH-targeted therapy guided by RV function correlates may be superior to the traditional strategies outlined by previous guidelines. 20 Therefore, there is a compelling need for non-invasive assessment of accurate, simple, and reproducible parameters of RV geometry and function: (i) to outline the subtle changes in early disease stages or the response to treatment in order to guide specific therapy; (ii) to compare measurements between patients or serially within a given patient; and (iii) to improve communication between clinicians.
The following paragraphs briefly review the various echocardiographic parameters proposed for RV geometry and function assessment, for an increased awareness of their pitfalls and of the obvious need for newer techniques to complement standard approaches.
Right ventricular linear dimensions
Right ventricle free wall thickness and dimensions can be easily measured from parasternal, apical four-chamber, or subcostal view. Cut-off values of RV diameters 21 may identify RV dilation independently or relatively to LV size. However, relative comparison to LV size may be misleading when LV dilation coexists. Right ventricular diameters are inherently 1D estimates and cannot describe by themselves the complex shape of RV. Although M-mode measurements are time-saving, widely applicable, and practical, even for less experienced operators, they are highly dependent on image quality, insonation angle, and load. Diameter measurement inconsistency is even higher when performed regardless of the respiratory phase. In addition, significant variability related to probe or patient position during examination renders them unreliable to identify mild RV abnormalities. For instance, simply rolling patient from supine to left lateral position increases measured RV diameter up to 40%. 22 Of note, progressive RV dilation is also accompanied by changes in heart position and by rotation in the thorax, which impact on the interpretation of serial measurements.
Right ventricular areas and right ventricular fractional area change
In patients with a dilated RV, the four-chamber view often displays a foreshortened cavity, since it often fails defining anatomical landmarks for the RV and may not intersect the RV crescent at its maximal dimension. Right ventricular area measurements are grossly affected by inherent manual tracing pitfalls, particularly in PAH patients with hypertrophied, heavily trabeculated RV. Although significantly correlated with angiographically measured RV volumes, 23 there is a significant overlap of the four-chamber view diameters and areas between normal and volume overloaded RV. 22 Right ventricular fractional area change (RVFAC) is calculated from the RV end-diastolic and end-systolic areas measured from four-chamber view as: RVFAC = 100 × (RV end-diastolic area − RV end-systolic area)/RV end-diastolic area. The RVFAC is a rather simple method of assessing RV function that has been shown to correlate well with CMR data. 21 When compared with other 2DE measures of RV systolic function [including tricuspid annular plane systolic excursion (TAPSE) and transversal fractional shortening], FAC was best correlated with CMR-determined EF. 24 Suboptimal RV endocardial definition, especially at the anterior RV wall, limits the accuracy and reproducibility of RVFAC. 25 , 26
Right ventricular ejection fraction and right ventricular volumes by two-dimensional echocardiography
In clinical practice, probably the most intuitive parameters of RV size and contractile function are RV volumes and RVEF, same as for LV quantitation. Right ventricular ejection fraction is widely used as a noninvasive measure of RV performance, despite its well-known load dependency. Several methods are used to assess RV volumes and EF, including 2DE and real-time three-dimensional echocardiography (RT3DE), radionuclide angiography, and CMR. Selection of the best method and interpretation of its results hamper the adequate use of these indices. 27 Depending on the type of modality used to assess the RV, EF can vary from 40 to 76%. Currently, magnetic resonance imaging (MRI) is the gold standard for calculating RV volumes and EF. Cardiac MRI has shown that normal RVEF is 61 ± 7%, ranging from 47 to 76%. 17
Several methods have been used to calculate RV volumes, such as the Simpson's method and the area–length method assuming the RV to be an ellipsoid or a pyramid. Four-chamber RV area and maximal short-axis diameter offered the best estimation of RV volumes with 2DE. 21 Volumes derived from calculations based on 2D measurements (diameters and areas) are based on geometric assumptions which are inaccurate in describing the complex RV shape. This explains the variable correlation of different RV models with angiographic or radionuclide studies. Difficulties in obtaining two standardized orthogonal RV views and failure to include the RV infundibulum (which may account for up to 25% of RV volume) are additional causes for 2DE limitations. 22 Image quality and operator experience may further impact on the results.
Tricuspid annular plane systolic excursion
This is a simple M-Mode measure from the apical four-chamber view of the longitudinal excursion of the lateral tricuspid annulus towards the RV apex, with demonstrated prognostic value in PAH. 26 Tricuspid annular plane systolic excursion is used as a correlate of RV systolic function, since longitudinal displacement of RV base accounts for the greater proportion of total RV volume change 28 in comparison with radial shortening in normal ventricles. A reasonable correlation between TAPSE and RVEF assessed by radionuclide angiography was found. 29
However, TAPSE ignores the outlet portion and the septal contribution to RV ejection, 30 which may become important to maintain overall RV function, 25 especially when the longitudinal component decreases. In fact, TAPSE in patients after mitral valve repair surgery was discrepantly reduced in contrast with unchanged RVEF measured by RT3DE, demonstrating its reduced accuracy to estimate true RV performance after cardiac surgery. 31 Although simple, widely available, and feasible also in patients with poorly visualized RV endocardial borders, TAPSE is 1D and angle-dependent. Regional RV myocardial abnormalities are also neglected when using TAPSE as a single measure. Since it is measured with external reference point, it also takes into account the overall heart motion and not only the longitudinal excursion of RV base. 22 Moreover, its load dependency needs to be considered in case of significant tricuspid regurgitation, when RV base active excursion may inaccurately reflect overall RV contractile function. Not only RV but also LV systolic performance may influence TAPSE value due to ventricular interdependence. 32
Eccentricity index
Eccentricity index (EI) described by Ryan et al.33 is a relatively easy-to-use measure of septal shift towards LV in overloaded RV. Eccentricity index is calculated on routine 2D short-axis view of LV and may discriminate between RV volume overload and pressure overload states. A high EI is an important echocardiographic predictor of mortality in PAH. 34 Improvement in EI is seen with PAH-targeted treatment. 13 However, there is the problem of different level measurements impacting on the results. Again, slightly off-axis images can result in artefactually flattened septum, giving rise to wrong EI. Other possible problem is identifying end-diastole and end-systole, which could also affect the measurements for EI. 33
Myocardial performance (Tei) index
Myocardial performance index (MPI) is calculated from time intervals obtained from Doppler recordings of tricuspid and pulmonary flow. It incorporates both measures of systolic and diastolic function, so it represents an estimate of global RV performance independent of geometric assumptions. The normal value of this index for the RV is 0.28 ± 0.04 and increases with increasing RV dysfunction. 17 A significant advantage is that MPI is relatively independent of RV loading conditions and heart rate. Moreover, its prognostic value was ascertained in PAH patients 35 and its accuracy was also demonstrated in congenital heart disease, 36 myocardial infarction, 37 and chronic respiratory diseases. 38 The calculation of this index based on short intervals requires very good quality Doppler tracings with special care for optimal visualization of isovolumic event timing. Shortcomings derive from its calculation based on different cardiac cycle measurements and being adversely affected by rhythm and conduction disturbances. In addition, the Tei index may suffer a 'pseudonormalization' effect due to a shortened isovolumic relaxation time when increased right atrial pressure coexists. 30 Yet, colour-tissue Doppler enables the time measurements to be obtained from the same cardiac cycle in a more practical and time-saving manner.
Since newer echocardiographic technologies have been made available, novel indices of RV dimensions and function have been proposed and tested.
Tissue Doppler myocardial velocities
Right ventricular free wall sampling allows quantitative assessment of both RV systolic and diastolic function. Myocardial systolic velocity ( S ) by pulsed tissue Doppler imaging (TDI) is a relatively simple and accurate non-invasive correlate of RV systolic function, although several cut-off values have been described to predict RV systolic dysfunction in various studies (<9.5–11.5 cm/s). 39–42 It is important to mention that peak S-wave value with pulsed TDI and with colour-TDI cannot be used interchangeably, since the former measures peak myocardial velocities, whereas the latter measures mean myocardial velocities, which are ∼20% lower. 5 Tissue Doppler imaging velocities may also be affected by overall cardiac motion and by tethering of the adjacent segments. Poor spatial resolution due to active systolic motion of RV base is problematic for the RV.
Isovolumic myocardial acceleration is a new TDI-derived parameter, less affected by preload or afterload. It is calculated by dividing the maximal isovolumic myocardial velocity by the time-to-peak velocity. 43 It was the most reliable contractility index among various velocity parameters in an experimental study. 44 Further validation of this new index is warranted for clinical use. 17
Right ventricular deformation imaging
Tissue Doppler imaging has been extensively studied and validated for its ability to quantify myocardial deformation. Myocardial strain represents the percentage of myocardial fibre shortening and hence this could be used as a 'true' segmental systolic performance, being less dependent on preload. Strain and strain-rate abnormalities of RV are seen in pulmonary hypertension, as well as in amyloidosis, congenital heart diseases, and arrhythmogenic RV dysplasia. Doppler-derived strain and strain-rate may identify subtle changes in response to vasodilator treatment 45 and may outline early signs of RV involvement in the PAH course. Drawbacks of the TDI method are angle-dependency, 1D estimation, and low signal-to-noise ratio. It requires a high frame rate, for which separate wall imaging is usually accomplished with pulsed TDI. In contrast, colour TDI may facilitate simultaneous segmental recordings for comparative analysis of event timings.
Speckle-tracking echocardiography (STE) is a relatively new, non-invasive method for the assessment of myocardial deformation from grey-scale 2DE images. The unique speckle pattern in each region represents a 'fingerprint' which can be tracked frame-by-frame throughout the cardiac cycle and consequently derive myocardial deformation in 2D. Therefore, this technique has a great promise in assessing regional and global RV deformation in different directions, i.e. longitudinal, radial, and circumferential, in terms of both amplitude and timing ( Figure 1 ). However, STE has been criticized for its lower temporal resolution and dependence on optimal image quality. Recently, this new method demonstrated its value to outline changes in RV systolic function, as assessed by 2D strain and strain-rate, in proportion to the severity of pulmonary pressure rise in PAH patients. 46 Also, it proved to be sensitive enough to detect early alterations of RV function in patients with systemic sclerosis and normal pulmonary pressures. 47
Real-time three-dimensional echocardiography
Complex anatomy is ideally displayed using 3D reconstruction techniques. Therefore, the assessment of RV volume and function for clinical use may represent the most justified application of RT3DE, as the awareness of 2DE drawbacks in this regard and the advancements in ultrasound technology are fastly growing.
Accurate volume analysis independent of RV size and shape, without foreshortened views and geometric assumptions ensure the superiority of RT3DE for RV quantitation over the conventional echocardiographic methods. Good correlation between RT3DE and CMR for calculating RV volumes and EF was reported. 48 Compared with CMR data, RV volumes calculated from 3D echocardiography showed significantly better agreement and lower intra- and interobserver variability than 2D echocardiography. 49 Real-time three-dimensional echocardiography enables unique views to outline and better understand particular causes of pulmonary hypertension, such as septal defects or complex congenital pathology. 50 Real-time three-dimensional echocardiography quantitation of RV end-diastolic volume was recently demonstrated to be feasible and superior to 2DE-derived value in the subset of PAH patients. 51 The capability to complement RV assessment with geometric data on tricuspid valve tenting in tricuspid regurgitation secondary to pulmonary hypertension confirms the unique value of RT3DE to comprehensively address PAH patients. 52
Wide-angle full-volume acquisitions to accommodate enlarged RVs are presently feasible with good image quality in a time-saving manner. The apical approach is generally used to acquire full-volumetric data sets from four to seven ECG-triggered subvolumes. However, a key advantage of RT3DE is the ability to acquire full-volume RV data sets from any traditional parasternal, apical, or subcostal view to fit each patient's best imaging window. Then, post-processing analysis with electronic cropping, slicing, rotating, and translating tools allows the identification of pre-defined RV views to start quantitative analysis workflow. Current semi-automated softwares for offline analysis of RV based on RT3DE data sets use border-detection algorithms to obtain a dynamic surface-rendered RV cast which enables the evaluation of RV geometry and contraction from any perspective ( Figure 2 ). Qualitative assessment is complemented by time–volume curve display and a panel of quantitative data derived from actual volumetric measurements and not simple calculations. Digitally archived 3D data sets may also be post-processed retrospectively for comparison during serial follow-up.
Yet, no imaging technique is ideal and RT3DE makes no exception. Patient's inability to cooperate for breathhold, arrhythmias, the larger footprint and size of matrix-array transducer, dependence on optimal acoustic quality, and need for specific training are among the most incriminated drawbacks of this method. To date, limited data are available regarding normal reference values for RV volumes and EF using RT3DE 49 and further extensive studies are required in this area.
Study protocol
Currently, several disease-targeted therapies are available such as endothelin receptor antagonists (ERA), phosphodiesterase-5 inhibitors, and prostacyclins that improve exercise capacity and cardiopulmonary haemodynamics, as shown in several large-scale clinical trials. 53 Two studies have shown that compared with placebo, short-term treatment with bosentan 13 or prostacyclin 54 prevented further enlargement of RV area. However, there is a lack of available data on the effect of long-term treatment of PAH on RV function and geometry. 1 , 55
Real-time three-dimensional echocardiography has been shown to be accurate in assessing RV and LV volumes, stroke volumes, and EFs in comparison with CMR imaging. 48
Study objectives
The study has five main objectives:
to investigate the effect of treatment on RV and LV remodelling and function using RT3DE (treated arm);
to assess the effect of treatment on RV and LV myocardial function using STE to measure maximal longitudinal 2D strain (treated arm);
to correlate results obtained from RT3DE and STE with changes in New York Heart Association (NYHA) functional class, 6 min walk test (6MWT), quality of life (QoL), and cardiac biomarkers in PAH patients (both treated and non-treated arms);
to compare results obtained from RT3DE and STE with conventional 2DE and Doppler indices of RV and LV function (both treated and non-treated arms);
to assess the relationship between RV geometry and function with patient's clinical status irrespective of being in the disease-targeted group (treated arm) or in the conventional treatment group (non-treated arm).
Study design
This is a multicentre, prospective observational study involving seven centres: three Italian (Udine, Trieste, and Padua), two British (Bath and London), one Belgian (Liege), and one Romanian (Bucharest). All these centres are expert in treating patients with PAH. According to the current recommendations, PAH will be defined as a mean pulmonary artery pressure >25 mmHg at rest in the setting of a normal pulmonary arterial wedge pressure ≤15 mm Hg. 19 , 56 Two distinct groups of patients will be evaluated: Group 1 (treated arm), those in whom active therapy is required (ERA, phosphodiesterase-5 inhibitors, prostacyclins or, if acute vasoreactivity has been demonstrated, calcium channel blockers); and Group 2 (non-treated arm), patients with confirmed PAH at cardiac catheterization, but, for any reason (low functional class, contraindications, or patient refusal to assume targeted therapies), will receive only supportive therapy (i.e. patients on any or in combination with oxygen/diuretics/digoxin/anticoagulants). Treatment will be prescribed according to clinical criteria by the clinician taking care of the patient. 3
Seventy patients in the treated arm (∼10 per centre) who will survive for at least 1 year will be recruited. This sample volume will give a 90% power of showing a ≥15% increase in the RV MPI (an echocardiographic parameter which is independently correlated with survival in patients with PAH 35 ). The study inclusion and exclusion criteria are summarized in Table 1 .
|All the following criteria need to be fulfilled for study inclusion:
|Idiopathic PAH, associated with collagen vascular disease or due to chronic thrombo-embolic disease not suitable for thromboendarterectomy
|A resting mean pulmonary artery pressure >25 mmHg at rest on right heart catheterization
|Sinus rhythm
|Age >18 years
|Adequate acoustic window for speckle-tracking analysis and possibility to acquire 3D data sets for both right and left ventricular volume assessment
|Any of the following criteria excludes the patient from the study:
|Patients on active treatment for PAH or PAH secondary to congenital heart disease
|Patients who are severely disabled and will not be able to complete the study
|Significant lung disease as shown by FVC < 70% predicted or FEV1/FVC < 50%
|HIV, portopulmonary hypertension, haemolytic anaemia associated PAH, anorexigen associated PAH
|WHO Group 2 PAH as evidenced by pulmonary wedge pressure >15 mmHg or elevated LV end-diastolic pressure
|WHO Group 5 PAH
|Life expectancy <1 year due to severe PAH or any other forms of terminal disease
|Pregnant women
|Refusal to give informed consent
|All the following criteria need to be fulfilled for study inclusion:
|Idiopathic PAH, associated with collagen vascular disease or due to chronic thrombo-embolic disease not suitable for thromboendarterectomy
|A resting mean pulmonary artery pressure >25 mmHg at rest on right heart catheterization
|Sinus rhythm
|Age >18 years
|Adequate acoustic window for speckle-tracking analysis and possibility to acquire 3D data sets for both right and left ventricular volume assessment
|Any of the following criteria excludes the patient from the study:
|Patients on active treatment for PAH or PAH secondary to congenital heart disease
|Patients who are severely disabled and will not be able to complete the study
|Significant lung disease as shown by FVC < 70% predicted or FEV1/FVC < 50%
|HIV, portopulmonary hypertension, haemolytic anaemia associated PAH, anorexigen associated PAH
|WHO Group 2 PAH as evidenced by pulmonary wedge pressure >15 mmHg or elevated LV end-diastolic pressure
|WHO Group 5 PAH
|Life expectancy <1 year due to severe PAH or any other forms of terminal disease
|Pregnant women
|Refusal to give informed consent
Study protocol
Patients with PAH confirmed by cardiac catheterization, who agree to be enrolled, will undergo the following evaluation before starting therapy: All clinical and echocardiographic examinations will be repeated at 3, 6, and 12 months on patients recruited to the treated arm for PAH. Patients in the non-treated arm for PAH will undergo the same evaluation at 6 and 12 months ( Figure 3 ).
clinical evaluation including clinical examination, NYHA functional class assessment, Borg dyspnoea score, 57 Euro QoL questionnaire, and a 6MWT; 58
resting electrocardiogram;
blood sampling for N-terminal pro-brain natriuretic peptide and troponin;
a representative 2DE, Doppler, and RT3DE study.
Two-dimensional and Doppler echocardiography
A comprehensive transthoracic 2D and Doppler echocardiography will be performed using second-harmonic imaging from parasternal and apical windows, with the patient in the left lateral position. Loops from three cardiac cycles will be acquired during breathhold. Particular attention will be paid to avoid foreshortening of apical views. Apical views of the LV and RV will be recorded with the sampling frequency of 60–80 Hz and sector width adjusted accordingly for subsequent analysis using STE (frame rate 60–80/s). Loops and tracings will be digitally stored for offline analysis.
Tissue velocity imaging
Pulsed tissue velocity imaging (TVI) will be performed using spectral pulsed-Doppler signal filters, adjusting the Nyquist limit to15–20 cm/s and using the minimal optimal gain. In the apical four-chamber view, a 5 mm pulsed Doppler sample volume will be placed at the level of the lateral mitral annulus and lateral tricuspid annulus. The apical view will be chosen to obtain a quantitative assessment of the regional wall motion almost simultaneously to the Doppler inflow and outflow and to minimize the insonation angle between the Doppler beam and the longitudinal wall motion. Pulsed TVI is characterized by a myocardial systolic wave ( Sm ) and two diastolic waves—early ( Em ) and atrial ( Am ). The myocardial peak velocity Sm (cm/s) and the time from Q-wave to Sm onset (ms) will be measured as systolic indices. Em and Am peak velocities (cm/s) and the Em / Am and E / Em ratios will be determined as diastolic measurements. 59
Real-time three-dimensional echocardiography
Harmonic RT3DE will be performed from the apical window immediately following 2DE and Doppler imaging, using a matrix-array transducer to obtain two pyramidal data sets with standard sector field and line density in the full-volume acquisition mode: one containing the entire LV cavity and a second one containing the RV cavity. In the full-volume acquisition mode, four wedges will be obtained over four consecutive cardiac cycles during a breathhold with electrocardiographic gating. Data sets will be digitally stored for offline analysis.
The ECG, respiratory rate, and blood pressure will be recorded throughout the imaging process for quantitative evaluation of echocardiographic data.
Echocardiographic image analysis
Recordings will be analysed at the core echocardiography laboratory by experienced observers who will be unaware of each patient's treatment assignment and whether the examination was at baseline or during follow-up. Two-dimensional echocardiography and Doppler measurements will be made on three representative beats and the results will be averaged. All heart chamber dimension measurements will be indexed to body surface area calculated using the DuBois method.
Echocardiographic variables
The following echocardiographic variables will be measured:
left ventricular end-diastolic and end-systolic volumes; 21
right ventricular fractional area change; 21
tricuspid annular plane systolic excursion; 60
eccentricity index will be calculated by the method of Ryan et al. ; 33
maximal diameter and inspiratory collapse of the inferior vena cava during respiration will be measured from subcostal images to obtain an estimated right atrial pressure; 61
pericardial effusion size will be determined from parasternal long- and short-axis views. Effusions will be graded and assigned a score as follows: absent (score = 0), trace (score = 1; separation of pericardial layers in both systole and diastole), small (score = 2; diastolic separation <1 cm), moderate (score = 3; diastolic separation of 1–2 cm), or large (score = 4; diastolic separation >2 cm); 54
linear RV dimensions will be taken as per previously published guidelines. 21
Doppler parameters
The following Doppler parameters will be measured:
right ventricular (pulmonary artery) acceleration time; 62
right ventricular ejection time will be measured from the RV outflow pulsed-wave Doppler signal as the interval from the onset of forward flow to pulmonic valve closure;
Doppler LV and RV indices, as global measures of LV and RV function, respectively, will be calculated as described by Tei et al.63
peak tricuspid regurgitant jet velocity; 64
cardiac output will be calculated from pulsed-wave Doppler recordings of the LV outflow tract velocity profile;
left ventricular filling will be assessed from pulsed-wave Doppler mitral inflow signals. Quantification will include measurements of mitral E- and A-wave peak velocities, and the E-wave deceleration time.
Two-dimensional speckle-tracking image analysis
Speckle-tracking analysis will be carried out using a commercially available echo analysis software (EchoPAC, BT08, GE Healthcare, Horten, Norway) equipped with Automatic Function Imaging analysis package. The software allows automated identification of natural acoustic markers within the myocardium 65 , 66 and subsequent tracking of their movements during the cardiac cycle. After manual marking of subendocardium, the endocardial and epicardial LV and RV borders will be automatically tracked and delineated. After manual adjustment (if necessary) or approval of the computer-generated myocardial wall delineation, the automated speckle-tracking analysis will be performed in the apical views, in which the LV myocardium will be automatically divided into six regions of interest (ROI) and the RV into three ROI ( Figure 1 ). For each ROI thus identified, maximal longitudinal strain during cardiac cycle will be obtained.
Real-time three-dimensional echocardiographic right ventricular analysis
Real-time three-dimensional echocardiography RV analysis will be undertaken with a commercially available offline system (4D RV-Function 1.1, TomTec Imaging Systems GmbH, Unterschleissheim, Germany). Each RV volume data set will be imported into the application and manipulated by rotating, angulating, and slicing in any of the three displayed orthogonal planes, which will simultaneously reset views in the other two planes. A central reference point will be selected by moving through any plane. Secondary rotation is also possible. In this way, the clearest possible views will be obtained to start the full-volume analysis. All images will be viewed in sagittal (to outline the tricuspid valve in the best possible view), four-chamber (to outline the apex), and coronal (to outline the RV outflow tract) views, in the best possible view containing a full-volume set ( Figure 2 ). Contrast, zoom, shading, and colour will be used to improve delineation of the endocardium. The end-diastolic and end-systolic frames are chosen in all views by visual inspection of cine loops. The endocardial border of the RV has to be drawn in end-diastole and at end-systole in every plane (sagittal, coronal, and four-chamber views); dependent on the quality of the data set, 5 up to 12 points will be sufficient for subsequent automatic contour detection. Three-dimensional images will be generated with the possibility for manual correction in every frame of the cardiac cycle ( Figure 4 ). The interventricular septum will be excluded from RV volume assessment. Trabeculations will be included in the endocardial rim, but the apical component of the RV moderator band will be excluded from the cavity.
Real-time three-dimensional echocardiographic left ventricular analysis
Left ventricular volumes and EF will be measured with dedicated offline computers and software (4D LV analysis 2.6, TomTec Imaging Systems GmbH). The data set will be aligned in two orthogonal planes along the long axis of the single ventricle with clear depiction of the atrio-ventricular valve ( Figure 4 ). Brightness and contrast will be adjusted to optimize signal-to-noise ratio. End-diastole will be chosen as the largest chamber size and/or the frame before mitral valve closure. End-systole will be chosen as the smallest chamber size and/or the frame before mitral valve opening. Using still and motion frames, the endocardial and epicardial borders will be identified and manually traced in sequential cross-sectional planes.
Statistical methods
The null hypothesis of the study is that in patients enrolled in the treated arm, there will be no change in echocardiographic and Doppler parameters of RV geometry and function from the baseline. Right ventricular Doppler MPI has been considered the primary parameter because of favourable changes shown in a previous pharmacological trial in patients with PAH 13 and its correlation with survival in these patients. 35 As a consequence, the sample size of the study was based on these changes. The changes from baseline to treatment values of each echocardiographic and Doppler parameter will be calculated for individual patients in whom technically adequate studies will be available at baseline, 3, 6 months, and 1 year. Statistical analysis will be based on the intention-to-treat population (full analysis set). Continuous data will be expressed as mean ± SD. Baseline data will be compared by means of the χ2 test for categorical variables and unpaired t -test for continuous variables. Analysis of variance with the Tukey post hoc test will be used to analyse repeated measures. Multiple stepwise regression analyses will be performed to identify among the echocardiographic and Doppler parameters the predictors of the increase in the 6 min walking distance or of the QoL score improvement. Statistically significant variables in univariate analysis will be entered in the multivariate models. A value of P < 0.05 will be considered statistically significant. Statistical analyses will be performed using SPSS 13.0 (Chicago, IL, USA) for Windows.
The present study has been designed to provide additional information that may help in understanding the pathophysiology of PAH and PAH-targeted treatment effects on RV geometry and function. Compared with current literature, this study presents many innovative aspects, summarized as follows:
relatively long follow-up (up to 1 year);
use of RT3DE to assess changes in size and function of RV and LV;
assessment of RV geometry and function in PAH patients in NYHA class I and II;
assessment of RV myocardial function in PAH patients and its changes with and without therapy using 2D STE;
explore the relationship between changes in RV and LV function during therapy, if any, with changes in patient functional class.
Conflict of interest: none declared.
D.M. was supported by a scientific grant from University Hospital S Maria della Misericordia. The work has been supported by an unrestricted grant from Actelion Pharmaceuticals Italia, s.r.l.


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Despite the dire predictions that it would be impossible to pull off a successful party for outgoing state Sen. Frank Padavan on such short notice during the holiday season, with all of its many demands on everyone's time, money and participation in traditional events, we did it. In fact, it exceeded our expectations. Everyone was thrilled to be part of the Padavan tribute.
Aside from the wonderful folks who purchased tickets and came out on a cold, wintery evening, I would like to give a big thank you to our elected officials who took the time to thank Frank for his 38 years of service, which was one-half of his lifetime.
Thanks to Mayor Michael Bloomberg, who made the trip to Leonard's. Thank all you guests for not personally attacking the mayor and not complaining about the inadequate snow removal. As it turned out, it really wasn't the mayor's fault. The city Sanitation Department apparently was suffering from the equivalent of the "blue flu." Thank you Senate Majority Leader Dean Skelos; Sen. Martin Golden; Sen. Owen Johnson; City Councilmen Dan Halloran, Peter Koo and Eric Ulrich; Michael Long, the state Conservative Party chairman; Tom Long, the Queens Conservative Party chairman; Judith Stupp, the Republican commissioner of the Queens Board of Election; and the Haggerty brothers, John and Bart, of the Queens GOP.
Of course, a large thank you to Queens DA Richard Brown as well as our original Queen of Queens, Claire Shulman, one of my favorite ladies. While everyone there was important in their own way, the above mentioned were the most highly profiled names.
The entertainment was stupendous. It started off with the NYPD Emerald Society Pipe Band, who marched all the dignitaries through the lobby and into the "Da Vinci Room." The color guard was provided by Boy Scout Troop No. 1, the oldest troop in America, represented by Eric Moore and Andrew Gitkin, who led the Pledge of Allegiance. "The Star-Spangled Banner" was sung by Margret Able, the wife of former Councilman Mike Able. Alexandria Dunne sang "Unforgettable" to Frank and Liz Berney was gracious enough to bring her violin and play for everyone's entertainment.
The senator decided to get into the act and sang "I Did it My Way." No one can deny that! The music was provided by DJ Jim Darmos, who played the music at a level comfortable for all to dance to but soft enough for everyone to have conversations.
The decorations were gorgeous. Ron Keil of Keil Bros. outdid himself. Everyone raved about the magnificent poinsettias and the mind-boggling total amount of them. The guests were told they could take them home at the end of the evening, which they did. Devon O'Conner of Dabby's Party Space was responsible for the nice balloon centerpieces on each table. There wasn't one of those left either. Leonard's decorated Frank's cake beautifully and it was delicious. Each table had a huge tray of cookies which were impossible to eat after all the food. Leonard's provided bright red boxes for anyone wishing to take the cookies home. Needless to say, there wasn't a crumb left.
Of course, we can't forget the media. They turned out in impressive numbers and included TV, daily and weekly newspapers and a slew of photographers. There were bloggers there, too. In short, we had good coverage. Thank all you media guys for providing coverage.
Being the political junkie that I am, even though the event was promoted as non-partisan and non-political, there were many side deals going on, but what would you expect when you get a room full of politicians and political-types?
The most surprising part of the evening was, even though they were invited, that no one from the Queens GOP hierarchy showed up, nor did they have the good manners to send a thank-you letter to the senator for all his good work. It would have been nice to have had a letter to be read during the party. The letter could also have included their regrets with some sort of excuse for their absence.
I know I am not one of their favorite people, as I have a horrible habit of writing and telling how it is. This party was not about them nor was it about me. It was about the senator.
You surely make the Haggerty brothers look better all the time. In fact, better than any highly priced spin doctor could do. Remember: Good manners are never out of style.
I look forward to your voice mails at 718-767-6484, faxes at 718-746-0066 and e-mails at firstname.lastname@example.com.
©2011 Community News Group
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Arizona Cardinals
Calais Campbell wants to return Sunday
Arizona Cardinals defensive end Calais Campbell sat out Sunday's loss to the Falcons with a calf injury but says he doesn't plan on watching from the sidelines this weekend when they host the Rams.
"Oh yeah, I'm feeling good about it and I'm looking forward to getting back on the field and helping my team win games," he said Monday. "It was tough watching, don't want to do that again."
Campbell, who has 37 tackles and 3.5 sacks on the season, was injured before the bye week and says he hurt his calf while running. He felt a pop and said it's just one of those things that happens during football.
"I mean it's just little things, different kind of movements and stuff," he said. "I'm pretty sure I'll be back this week unless I have a setback."
That's something Campbell does not expect to be an issue, adding that he sat out Sunday in part just to be safe.
"It's something that's not that serious. You know it can nag so you just want to be careful and be smart with it," said Campbell. "The team looked real good out there without me so I was excited to see David Carter go in there and play well."
The defense did look good against the Falcons, forcing five interceptions and one fumble, but chances are they would still like to get Campbell back this week against the St. Louis Rams to try and help stop this six-game losing streak.
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[PHOTO] RE: 2002 SDB intro | Sat, 8 Dec 2001 10:34:50" />
Three siblings from the same cross. None of this cross are rebloomers.
92-245-2 (Rusty Dusty X Pal Sam)X Klingon Princess (Chubby Cheeks X Bantam)
KP has throwen many "Ringed" Plicata seedlings. 95-85-1 is a good example of the ringed plicata
Chuck Chapman, Guelph, Ontario, Canada. Zone 4/5
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A/N: Okay, Alex is perfection. Just saying <3 So here are the long awaited (sort of) Character pictures.
Isabel Lucas as Nina:
francisco lachowski as Alex (ASDFGHJKL:)
Nina Nesbitt as Sophie:
so I tried to make them all the same size....FAIL! But let me know what you guys think? And sorry the ones of Isabel (Nina) arn't that good, pictures of her with blondish brownish hair were hard to find !
XoXo Taylor
P.S Francisco is mine, go find some one else to have babies with.
© Copyright 2017 MysteriousStars. All rights reserved.
Status: Finished
Genre: Romance
They're all awesome! :D Alex is crazy looking! >.< Love it!
Wow, good taste, I like them!
Nina and Sophie are adorable. you found the perfect characters :D
... I might have to steal your babies......
They are like god and godesses!
Awesome,you have a great taste!
lol Alex is heavenly
Book / Romance
Book / Romance
Book / Romance
Paste the link to picture in the entry below:
Paste the link to Youtube video in the following entry:
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Siam Place Airport - Bangkok
- Free WiFi
Main amenities
- 78 guestrooms
- Restaurant
- Rooftop terrace
- Breakfast available
- Massage/treatment rooms
- Airport shuttle
- 24-hour front desk
- Air conditioning
- Daily housekeeping
- Garden
- Car rentals on site
- Front desk safe
For families
- Refrigerator
- Private bathroom
- Free toiletries
- Garden
- Yard
- Daily housekeeping
What's around
- The Paseo Mall (0.8 mi / 1.2 km)
- Seacon Square (6.5 mi / 10.4 km)
- Paradise Park (6.9 mi / 11.1 km)
- Bangkok Chain Hospital Public Company Limited (7.6 mi / 12.3 km)
- Batcat Museum & Toys Thailand (8 mi / 12.8 km)
Siam Place Airport - Bangkokfrom Rs1,281
- Superior Room
- Standard Room
- Deluxe Room
- Deluxe Greetings Season Package
More great choices
At a glance
Key facts
Hotel size
- This hotel has 78 rooms
- Check-in time noon-2 PM
- Check-out time is noon
- Express check-in
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- One child (12 years old and younger) stays free when occupying the parent or guardian's room, using existing bedding
- No cribs (infant beds)
- Pets not allowed
- Free WiFi and wired Internet access in public areas
- Free WiFi and wired Internet access in rooms
- Airport shuttle (available 24 hours) *
- Area shuttle within 5 km *
Other information
- Resort fee included
Nearby Three Star Bangkok hotels
In the hotel
- Buffet breakfast (surcharge)
- Restaurant
- Snack bar/deli
- Room service (during limited hours)
- Spa treatment room(s)
- 24-hour front desk
- Tours/ticket assistance
- Limo or Town Car service available
- Free newspapers in lobby
- Luggage storage
- Multilingual staff
- Porter/bellhop
- Elevator/lift
- Safe-deposit box at front desk
- Designated smoking areas
- Rooftop terrace
- Garden
- Accessible bathroom
- In-room accessibility
In the room
- Air conditioning
- Minibar
- Premium bedding
- Sleep Number by Select Comfort mattress
- In-room massage available
- Yard
- Balcony
- Private bathroom
- Shower only
- Bidet
- Free toiletries
- Hair dryer (on request)
- Flat-screen TV
- Satellite TV channels
- Free newspaper
- Free WiFi
- Refrigerator
- Free bottled water
- Daily housekeeping
- In-room safe
Top Bangkok hotels
Recently reviewed hotels in Bangkok
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"GREAT PLACE TO STAY.. DOUBLE VALUE FOR MONEY"Jan 14, 2017
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"Value for money"Jan 11, 2017
- Silom City HotelFrom
"awesome hotel. was better than expected. couldn't expect anything more."Jan 10, 2017
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"Excellent location, good service and nice room except for view from the window. It is closed from sides and views windows of other buildings."Jan 9, 2017
Nearby hotels
Recommended hotels
Special features
DiningAt Siam - This restaurant serves breakfast, lunch, and dinner.
Siam Place Airport - Bangkok's small print
Also known as
- Siam Airport
- Siam Place
- Siam Place Airport
- Siam Place Hotel
- Siam Place Hotel Airport
For transfers, guests must contact the property before arrival at the number on the booking confirmation.
Reservations are required for massage services and can be made by contacting the property before arrival at the number on the booking confirmation.
Mandatory fees
The charges below are included in the total price displayed:
- Resort fee
Optional extras
Onsite credit card charges are subject to an extra charge
Buffet breakfast is offered for an extra charge of THB 150 for adults and THB 120 for children (approximately)
Airport shuttle service is offered for an extra charge of THB 200 per room (one way)
Area shuttle service is offered for an extra charge
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Recent reviews
Good 3.3 /5 from 62 reviews
We stayed two nights here and have no complaints. The hotel was very attentive, greated our cab on arrival and secured us a cab without hesitation when it was time to go. Staff was always helpful and willing to make sure our stay was perfect.
Worst place in our 17days travel Bangkok-Vietnam. Photos do not correspond to reallity. Not recommend.
Stayed here just for one night to catch early from BKK. You get what you pay for: it's acceptable for one night but I wouldn't recommend staying here any longer. Room was spacious, OK bathroom, but very uncomfortable bed and tons of mosquitos in the room. There is a restaurant in the hotel but didn't seem to be functional! You can still get food there.. I would suggest going to local places just 2 minutes away to get food though. Free Internet. Shuttle to BKK 24 hours, cost 150 baht. Hotel is barely OK, but again, it was about $15 per night so can't expect too much.
ok to the airport
Dont bother if you need to stay longer than a night or 12hrs. Rooms are old and very depressing, mosquitoes are common, no furniture on balcony as advertised. Restaurant closes at 12pm and not much local choice. Shuttle service quick and on time. Staff okayish but not overly happy in their job choice.
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text: Pinch to zoom Single Poppy Earrings by Good Intentions £9.95$17.07€11.92$12.74 132 customer reviews(132) Favourite Favourite View your favourites quantity personalise & pay by Good Intentions Location: Powys, GB read seller's profile see seller's complete range more items from this seller Poppy Trio Stud Earrings by Good Intentions £14.95$25.65€17.91$19.15 Poppy Trio Lapel Pin by Good Intentions £10.95$18.79€13.12$14.03 Double Poppy Brooch by Good Intentions £15.95$27.37€19.11$20.43 Poppy Lapel Pin by Good Intentions £10.95$18.79€13.12$14.03 Classic Poppy Brooch by Good Intentions £12.95$22.22€15.52$16.59 Large Poppy Brooch by Good Intentions £18.95$32.52€22.71$24.28 view all you may also like PRODUCT DETAILS CUSTOMER REVIEWS DELIVERY RETURNS Made in Britain ask seller a question save for later Pretty hand painted small Poppy stud earring This small red poppy stud earring is suitable for every day wear or for special occasions with it's vibrant red brightening many outfits. Part of our collection of Poppy jewellery the earrings make a perfect choice for any Remembrance occasion. hand crafted and hand painted in our rural Welsh studios made from: The earrings are made in a resin mixture and hand painted. The metal components are silver plated. The earrings may be gently hand washed in warm soapy water without scrubbing dimensions: The earrings are 7 mms across product code: 103614 132 customer reviews see more customer reviews read about our product rating system ratings guide trusted independent customer feedbackforum excellent bad good poor This product is dispatched to you by Good Intentions. You have 28 days, from receipt of cancellable goods, to notify the seller if you wish to cancel your order or exchange an item. Please note: goods that are personalised, bespoke or made-to-order to your specific requirements, perishable products and personal items sold with a hygiene seal (cosmetics, underwear) in instances where the seal is broken are non-refundable, unless faulty. Read more about our returns policy.Should you choose to return or exchange your order you will need to deliver the item(s) to the UK, where this seller is based. Good Intentions's return policy Please see notonthehighstreet.com's returns policy.