text:
'Regional Rail' Seen as Viable Alternative to I-35 Congestion
While high speed rail and attempts to build new highways to improve mobility between San Antonio and Austin remain stuck in neutral, officials of the Lone Star Rail District say what is known as 'regional rail' is on track to pull out of the station, 1200 WOAI news reports.
Attorney Tullos Wells, who is vice chair of the Lone Star Rail District, says his organization has raised $100 million, and is negotiating for as much as $2 billion in private funding to build a standard speed passenger rail line between Texas A&M San Antonio in south Bexar County to north Austin.
Wells says unlike high speed rail, which could take 25 years to materialize because it would rely on brand new tracks, the regional rail system would use the existing Union Pacific tracks.
He points out that the UP is already in the process of moving its freight rail operations out of cities like San Marcos and New Braunfels, due to cargo, noise, and scheduling restrictions imposed by the communities. He says passenger rail would use those tracks, and the freight traffic would be moved to a new system of rail and regional logistics centers which are planned for east of the existing line.
Wells says the proposed rail line would have up to sixteen stops for passengers to get on board and get off.
"What's been interesting is the number of communities that are competing to have a station placed in their locale," he said.
Wells says the plan right now is to be able to travel from downtown San Antonio to downtown Austin in 75 minutes, guaranteed.
He says as I-35 gets more and more congested, the 'guaranteed' part is what will begin to matter to commuters.
"People who drive up and down that corridor every week like I do, quickly learn that, maybe you will be able to drive it in an hour and ten minutes," he said. "But then, maybe it will take you three hours because there's an accident."
Environmental studies are getting underway and should be completed in 2014. Wells says the passenger rail has a much shorter timeline than either significant improvements to I-35 or any of the high speed rail proposals which are in the works. He says trains running along the tracks in five to seven years.
Planned are up to 32 trains a day, including midday and evening service, seven days a week in each direction for students, commuters, and other regional travelers.
There would also be local service, enabling, for example, individuals to get on the train on San Antonio's north side and get off at a station convenient to Texas State University in San Marcos.
So how much would a ticket on what would be called the LSTAR train cost?
"We can't give you a hard and fast price, but I can tell you it would cost a lot less than the cost of gasoline for going up and down the corridor."


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Box score and play-by-play (pdf)
Recap courtesy of The Badger Herald: Badgers bruise No. 12 Illini in 74-51 blowout win
Notes: Wisconsin earns its first 3-0 start in Big Ten play since the 2008-09 season, marking the fifth time UW has accomplished the feat in the Bo Ryan era ... The Badgers began the game on a 14-0 run, holding Illinois scoreless for periods of 6:47 and 4:57 during the first half ... UW has now won 11 of the last 15 meetings vs. Illinois, including four straight ... Senior Jared Berggren recorded his first career double-double, tallying 15 points and 12 rebounds, while adding a pair of blocks ... Sophomore Traveon Jackson scored a career-high 14 points on 5-of-8 (.625) shooting from the field, including a 2-for-2 (1.000) effort from beyond the arc ... Freshman Sam Dekker added 13 points, while senior Ryan Evans tallied 10 points to round out the double-figure scoring for the Badgers.
Join the Badger conversation on Facebook! Go to our Facebook page and "like" us!
For more Badger sports news, notes and discussion, especially on game day, follow Badger Nation on Twitter @TheBadgerNation

subset: commoncrawl


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Gasoline prices rose for the seventh week straight, hitting an average $3.744 a gallon for self-serve regular in the government's weekly survey just released. That's up 2.3 cents since last Monday.
In the daily survey by AAA and Opis, the national average price slipped Monday from $3.70 to 3.717 a gallon.
California, the nation's largest gas market, remains the place with the highest prices, the Energy Information Administration reports. A gallon averages $4.129, up about 3.3 cents from $4.096 last week. The Golden State is still reeling from a fire at a major Bay Area refinery that could take months to repair. New England has the second-highest average gas prices at $3.808 a gallon, up from $3.773 a gallon last week.
The cheapest gas is now in the Rocky Mountain states, where it averages $3.535 a gallon, up 3.5 cents. It's now slightly cheaper than the Gulf Coast, where gas prices average about a penny more a gallon.
Chris Woodyard is an auto writer for USA TODAY who covers all aspects of motoring. He revels in the exhaust note of a Maserati and the sharp creases of a Cadillac CTS. Chris strives to live a Porsche life on a Scion budget. More about Chris


text:
|Ingo Molnar <mingo@xxxxxxx>
|Re: [PLEASE-TESTME] Zerocopy networking patch, 2.4.0-1
|"Stephen C. Tweedie" <sct@xxxxxxxxxx>
|Tue, 9 Jan 2001 18:10:43 +0000
|"Stephen C. Tweedie" <sct@xxxxxxxxxx>, Christoph Hellwig <hch@xxxxxxxxxx>, "David S. Miller" <davem@xxxxxxxxxx>, riel@xxxxxxxxxxxxxxxx, netdev@xxxxxxxxxxx, linux-kernel@xxxxxxxxxxxxxxx
|<Pine.LNX.4.30.0101091641180.4491-100000@e2>; from firstname.lastname@example.com on Tue, Jan 09, 2001 at 05:16:40PM +0100
|<email@example.com> <Pine.LNX.4.30.0101091641180.4491-100000@e2>
Hi, On Tue, Jan 09, 2001 at 05:16:40PM +0100, Ingo Molnar wrote: > On Tue, 9 Jan 2001, Stephen C. Tweedie wrote: > > i'm talking about kiovecs not kiobufs (because those are equivalent to a > fragmented packet - every packet fragment can be anywhere). Initializing a > kiovec involves touching a dozen cachelines. Keeping structures compressed > is very important. > > i dont know. I dont think it's necesserily bad for a subsystem to have its > own 'native structure' how it manages data. For the transmit case, unless the sender needs seriously fragmented data, the kiovec is just a kiobuf*. > i do believe that you are wrong here. We did have a multi-page API between > sendfile and the TCP layer initially, and it made *absolutely no > performance difference*. That may be fine for tcp, but tcp explicitly maintains the state of the caller and can stream things sequentially to a specific file descriptor. The block device layer, on the other hand, has to accept requests _in any order_ and still reorder them to the optimal elevator order. The merging in ll_rw_block is _far_ more expensive than adding a request to the end of a list. It's not helped by the fact that each such request has a buffer_head and a struct request associated with it, so deconstructing the large IO into buffer_heads results in huge amounts of data being allocated and deleted. We could streamline this greatly if the block device layer kept per-caller context in the way that tcp does, but the block device API just doesn't work that way. > > We have already shown that the IO-plugging API sucks, I'm afraid. > > it might not be important to others, but we do hold one particular > SPECweb99 world record: on 2-way, 2 GB RAM, testing a load with a full > fileset of ~9 GB. It generates insane block-IO load, and we do beat other > OSs that have multipage support, including SGI. (and no, it's not due to > kernel-space acceleration alone this time - it's mostly due to very good > block-IO performance.) We use Jens Axobe's IO-batching fixes that > dramatically improve the block scheduler's performance under high load. Perhaps, but we have proven and significant reductions in CPU utilisation from eliminating the per-buffer_head API to the block layer. Next time M$ gets close to our specweb records, maybe this is the next place to look for those extra few % points! > > Gig Ethernet, [...] > > we handle gigabit ethernet with 1.5K zero-copy packets just fine. One > thing people forget is IRQ throttling: when switching from 1500 byte > packets to 9000 byte packets then the amount of interrupts drops by a > factor of 6. Now if the tunings of a driver are not changed accordingly, > 1500 byte MTU can show dramatically lower performance than 9000 byte MTU. > But if tuned properly, i see little difference between 1500 byte and 9000 > byte MTU. (when using a good protocol such as TCP.) Maybe you see good throughput numbers, but I still bet the CPU utilisation could be bettered significantly with jumbograms. That's one of the problems with benchmarks: our CPU may be fast enough that we can keep the IO subsystems streaming, and the benchmark will not show up any OS bottlenecks, but we may still be consuming far too much CPU time internally. That's certainly the case with the block IO measurements made on XFS: sure, ext2 can keep a fast disk loaded to pretty much 100%, but at the cost of far more system CPU time than XFS+pagebuf+kiobuf-IO takes on the same disk. > > The presence of terrible performance in the old ll_rw_block code is > > NOT a good excuse for perpetuating that model. > > i'd like to measure this performance problem (because i'd like to > double-check it) - what measurement method was used? "time" will show it. A 13MB/sec raw IO dd using 64K blocks uses something between 5% and 15% of CPU time on the various systems I've tested on (up to 30% on an old 486 with a 1540, but that's hardly representative. :) The kernel profile clearly shows the buffer management as the biggest cost, with the SCSI code walking those buffer heads a close second. On my main scsi server test box, I get raw 32K reads taking about 7% system time on the cpu, with make_request and __get_request_wait being the biggest hogs. --Stephen
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text:
"Side Effects" Drops New Trailer: Watch Here!
Offering a break from the winter blahs, "Side Effects" has unveiled a new teaser trailer ahead of its February 8th release date.
And with a cast that includes Jude Law, Channing Tatum, Catherine Zeta-Jones, and Rooney Mara, expectations are high for the provocative thriller.
Per the synopsis, "Side Effects follows Emily and Martin, a successful New York couple whose world unravels when a new anxiety drug prescribed by Emily's psychiatrist creates all kinds of trouble.
And given both Mara and Law's propensity for strange and beautiful performances, this Steven Soderbergh project is on top of the must-see list.


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Heart attack and acute coronary syndromeAcute coronary syndrome; Myocardial infarction
An in-depth report on the causes, diagnosis, treatment, and prevention of heart attack.
Heart Attack Symptoms
Common signs and symptom of heart attack include:
- Chest pain or discomfort (angina), which can feel like pressure, squeezing, fullness, or pain in the center of the chest. With heart attack, the pain usually lasts for more than a few minutes, but it may increase and decrease in intensity.
- Discomfort in the upper body including the arms, neck, back, jaw, or stomach
- Shortness of breath, which can occur with or without chest pain
- Nausea and vomiting
- Breaking out in cold sweat
- Lightheadedness or fainting
- Women (and some men) may have atypical symptoms such as abdominal distress, nausea, and fatigue without chest pain.
Immediate Treatment of a Heart Attack
The American Heart Association and the American College of Cardiology recommend:
- If you think you are having a heart attack, call 911 right away and wait for an ambulance. Do not attempt to drive yourself to the hospital. After you call 911, chew an adult-size (325 mg) non-coated aspirin. Be sure to tell the paramedics so an additional aspirin dose is not given.
- Angioplasty, also called percutaneous coronary intervention (PCI), is a procedure that should be performed within 90 minutes of arriving at the hospital. Patients suffering a heart attack should be transported by emergency services to hospitals equipped to perform PCI.
- Fibronolytic ("clot-busting") therapy should be given if a center that performs PCI is not available. The patient should then be transferred to a PCI facility without delay.
Secondary Prevention of Heart Attack
Secondary prevention measures are essential to help prevent another heart attack. Do not leave the hospital without discussing these secondary prevention steps with your doctor:
- High blood pressure and cholesterol control. (Nearly all patients who have had a heart attack should be discharged from the hospital with a prescription for a statin drug, an ACE inhibitor, and a beta blocker).
- Low-dose (81 mg) aspirin, which most patients will need to take on an ongoing basis. Patients who cannot take aspirin may benefit from the anti-platelet drug clopidogrel (Plavix, generic). Prasugrel (Effient) and ticagrelor (Brilinta) are new antiplatelet drugs that may be used as an alternative to clopidogrel for select patients with acute coronary syndrome. Patients who have had angioplasty/PCI along with drug-eluting stent placement will need to take one of these antiplatelets along with aspirin for at least a year following surgery.
- Cardiac rehabilitation and regular exercise program
- Weight management
- Smoking cessation and avoidance of second-hand tobacco smoke
- An annual "flu" shot
The heart is the human body's hardest working organ. Throughout life it continuously pumps blood enriched with oxygen and vital nutrients through a network of arteries to all tissues of the body. To perform this strenuous task, the heart muscle itself needs a plentiful supply of oxygen-rich blood, provided through a network of coronary arteries. These arteries carry oxygen-rich blood to the heart's muscular walls (the myocardium).
A heart attack (myocardial infarction) occurs when blood flow to the heart muscle is blocked, and tissue death occurs from loss of oxygen, severely damaging a portion of the heart.
Coronary Artery Disease. Coronary artery disease causes nearly all heart attacks. Coronary artery disease is the end result of a complex process called atherosclerosis (commonly called "hardening of the arteries"). This causes blockage of arteries (ischemia) and prevents oxygen-rich blood from reaching the heart.
Heart Attack
Heart attack (myocardial infarction) is among the most serious outcome of atherosclerosis. A heart attack can result in several ways from atherosclerosis:
- Type 1 heart attack occurs when the plaque develops fissures or tears. Blood platelets stick to the tears to seal off the plaque, and a blood clot (thrombus) forms. A heart attack can then occur if the blood clot completely blocks blood flow to the heart.
- Type 2 heart attack, which is less common, develops from a problem with oxygen supply and demand. A heart attack can occur if the heart's oxygen demand increases to exceed the narrowed artery's ability to deliver oxygen-rich blood.
Angina, the primary symptom of coronary artery disease, is typically experienced as chest pain. There are two kinds of angina:
- Stable Angina. This is predictable chest pain that can usually be managed with lifestyle changes and medications, such as low-dose aspirin and nitrates.
- Unstable Angina. This situation is much more serious than stable angina, and is often an intermediate stage between stable angina and a heart attack. Unstable angina is part of a condition called acute coronary syndrome.
Acute Coronary Syndrome
Acute coronary syndrome (ACS) is a severe and sudden heart condition that, although needing aggressive treatment, has not developed into a full blown heart attack. Acute coronary syndrome includes:
- Unstable Angina. Unstable angina is potentially serious and chest pain is persistent, but blood tests do not show markers for heart attack.
- NSTEMI (Non ST-segment Elevation Myocardial Infarction). This condition, also called non Q-wave myocardial infarction, is diagnosed when blood tests and ECGsindicate a heart attack that does not involve the full thickness of the heart muscle. The injury in the arteries is less severe than with a full-blown heart attack.
Patients diagnosed with acute coronary syndrome (ACS) may be at risk for a major heart attack. Doctors use a patient's medical history, various tests, and the presence of certain factors to help predict which ACS patients are most at risk for developing a more serious condition. The severity of chest pain itself does not necessarily indicate the actual damage in the heart.
Risk Factors
The risk factors for heart attack are the same as those for coronary artery disease (heart disease). They include:
The risks for coronary artery disease increase with age. About 85% of people who die from heart disease are over the age of 65. For men, the average age of a first heart attack is 66 years.
Men have a greater risk for coronary artery disease and are more likely to have heart attacks earlier in life than women. Women's risk for heart disease increases after menopause, and they are more likely to have angina than men.
Genetic Factors and Family History
Certain genetic factors increase the likelihood of developing important risk factors, such as diabetes, elevated cholesterol and high blood pressure.
Race and Ethnicity
African-Americans have the highest risk of heart disease in part due to their high rates of severe high blood pressure as well as diabetes and obesity.
Medical Conditions
Obesity and Metabolic Syndrome. Excess body fat, especially around the waist, can increase the risk for heart disease. Obesity also increases the risk for other conditions (such as high blood pressure and diabetes) that are associated with heart disease. Obesity is particularly hazardous when it is part of the metabolic syndrome, a pre-diabetic condition that is significantly associated with heart disease. This syndrome is diagnosed when three of the following are present:
- Abdominal obesity
- Low HDL cholesterol
- High triglyceride levels
- High blood pressure
- Insulin resistance (diabetes or pre-diabetes)
There are many ways to control your weight.
Unhealthy Cholesterol Levels. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol responsible for many heart problems. Triglycerides are another type of lipid (fat molecule) that can be bad for the heart. High-density lipoprotein (HDL) cholesterol is the "good" cholesterol that helps protect against heart disease. Doctors test for a "total cholesterol" profile that includes measurements for LDL, HDL, and triglycerides. The ratio of these lipids can affect heart disease risk.
High Blood Pressure.High blood pressure (hypertension) is associated with coronary artery disease and heart attack.For an adult, anormal blood pressure reading is below 120/80 mm Hg. High blood pressure is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Blood pressure readings in the prehypertension category (120 - 139 systolic or 80 - 89 diastolic) indicate an increased risk for developing hypertension.
Diabetes. Diabetes, especially for people whose blood sugar levels are not well controlled, significantly increases the risk of developing heart disease. In fact, heart disease and stroke are the leading causes of death in people with diabetes. People with diabetes, both type 1 and type 2,are also at risk for high blood pressure and unhealthy cholesterol levels, blood clotting problems, kidney disease, and impaired nerve function, all of which can damage the heart.
Lifestyle Factors
Physical Inactivity. Exercise has a number of effects that benefit the heart and circulation, including improving cholesterol levels and blood pressure and maintaining weight control. People who are sedentary are almost twice as likely to suffer heart attacks as are people who exercise regularly.
Smoking.Smoking is the most important risk factor for heart disease. Smoking can cause elevated blood pressure, worsen lipids, and make platelets very sticky, raising the risk of clots. Although heavy cigarette smokers are at greatest risk, people who smoke as few as three cigarettes a day are at higher risk for blood vessel abnormalities that endanger the heart. Regular exposure to passive smoke also increases the risk of heart disease in nonsmokers.
Alcohol. Moderate alcohol consumption (one or two glasses a day) can help boost HDL "good" cholesterol levels. Alcohol may also prevent blood clots and inflammation. By contrast, heavy drinking harms the heart. In fact, heart disease is the leading cause of death in alcoholics.
Diet.Diet plays an important role in protecting the heart, especially by reducing dietary sources of trans fats, saturated fats, and cholesterol and restricting salt intake that contributes to high blood pressure.
NSAIDs and COX-2 Inhibitors
All nonsteroidal anti-inflammatory drugs (NSAIDs) -- with the exception of aspirin -- carry heart risks. NSAIDs and COX-2 inhibitors may increase the risk for death in patients who have experienced a heart attack. The risk is greatest at higher dosages but some research suggests that even low doses of NSAIDs taken for short periods of time are not safe after a heart attack.
NSAIDs include nonprescription drugs like ibuprofen (Advil, Motrin, generic) and prescription drugs like diclofenac (Cataflam, Voltaren, generic). Celecoxib (Celebrex) is currently the only COX-2 inhibitor that is available in the U.S. It has been linked to cardiovascular risks, such as heart attack and stroke. Patients who have had heart attacks should talk to their doctors before taking any of these drugs.
The American Heart Association recommends that patients who have, or who are at risk for, heart disease first try non-drug methods of pain relief (such as physical therapy, exercise, weight loss to reduce stress on joints, and heat or cold therapy). If these methods don't work, patients should take the lowesteffective and safedose of acetaminophen (Tylenol, generic) or aspirin before using an NSAID. The COX-2 inhibitor celecoxib (Celebrex) should bea last resort.
Heart attacks may be rapidly fatal, evolve into a chronic disabling condition, or lead to full recovery. The long-term prognosis for both length and quality of life after a heart attack depends on its severity, the amount of damage sustained by the heart muscle, and the preventive measures taken afterward.
Patients who have had a heart attack have a higher risk of a second heart attack. Although no tests can absolutely predict whether another heart attack will occur, patients can avoid having another heart attack by healthy lifestyle changes and adherence to medical treatments.
Heart attack also increases the risk for other heart problems, including heart failure, abnormal heart rhythms, heart valve damage, and stroke.
Higher Risk Individuals. A heart attack is always more serious in certain people, including:
- Elderly
- People with a history of heart disease or multiple risk factors for heart disease
- People with heart failure
- People with diabetes
- People on long-term dialysis
Women are more likely to die from a heart attack than men. The gender difference isgreatest foryounger patients.
Factors Occurring at the Time of a Heart Attack that Increase Severity. The presence of other conditions during a heart attack can contribute to a poorer outlook:
- Arrhythmias (disturbed heart rhythms). A dangerous arrhythmia called ventricular fibrillation is a major cause of early death from heart attack. Arrhythmias are more likely to occur within the first 4 hours of a heart attack, and they are associated with a high mortality rate. Patients who are successfully treated, however, have the same long-term prognosis as those who do not have such arrhythmias.
- Cardiogenic shock. This very dangerous condition is associated with very low blood pressure, reduced urine levels, and cellular abnormalities. Shock occurs in about 7% of heart attacks.
- Heart block, also called atrioventricular (AV) block, is a condition in which the electric conduction of nerve impulses to muscles in the heart is slowed or interrupted. Although heart block is dangerous, it can be treated effectively with a pacemaker, and it rarely causes any long-term complications in patients who survive it.
- Heart failure. The damaged heart muscle is unable to pump all the blood that the tissues need. Patients experience fatigue, shortness of breath, and fluid build-up.
Heart Attack Symptoms
Heart attack symptoms can vary. They may come on suddenly and severely or may progress slowly, beginning with mild pain. Although chest pain is the classic symptom associated with heart attack, a third of patients do not experience this symptom.
Symptoms can vary between men and women. Women are less likely than men to have chest pain, but they are more likely to experience shortness of breath, nausea or vomiting, or jaw and back pain.
Common signs and symptom of heart attack include:
- Chest pain. Chest pain or discomfort (angina) is the main sign of a heart attack. It can feel like pressure, squeezing, fullness, or pain in the center of the chest. Patients with coronary artery disease who have stable angina often experience chest pain that lasts for a few minutes and then goes away. With heart attack, the pain usually lasts for more than a few minutes and the feeling may go away but then come back.
- Discomfort in the upper body. People having a heart attack may feel discomfort in the arms, neck, back, jaw, or stomach.
- Shortness of breath can occur with or without chest pain.
- Nausea and vomiting
- Breaking out in cold sweat
- Lightheadedness or fainting
Symptoms That Are Less Likely to Indicate Heart Attack
The following symptoms are less likely to be due to heart attack:
- Sharp pain brought on by breathing in or when coughing
- Pain that is mainly or only in the middle or lower abdomen
- Pain that can be pinpointed with the tip of one finger
- Pain that can be reproduced by moving or pressing on the chest wall or arms
- Pain that is constant and lasts for hours (although no one should wait hours if they suspect they are having a heart attack)
- Pain that is very brief and lasts for a few seconds
- Pain that spreads to the legs
However, the presence of these symptoms does not always rule out a serious heart event.
Silent Ischemia
Some people with severe coronary artery disease do not have angina pain. This condition is known as silent ischemia. This is a dangerous condition because patients have no warning signs of heart disease.
What to Do When Symptoms Occur
If you are having chest pain or other symptoms that may indicate a heart attack, you should:
- Call 911 right away and wait for an ambulance. Do not attempt to drive yourself to the hospital.
- After you call 911, chew an adult-size (162 - 325 mg) non-coated aspirin. Be sure to tell the paramedics so an additional aspirin dose is not given.
- For angina patients, take one nitroglycerin dose as prescribed at the first onset of symptoms. If symptoms do not go away or worsen after 5 minutes, call 911.
When a patient comes to the hospital with chest pain, the following diagnostic steps are usually taken to determine any heart problems and, if present, their severity:
- The patient or caretaker will report all symptoms so that a health care provider can rule out either a non-heart problem or possible other serious accompanying conditions.
- An electrocardiogram (ECG) reading is taken, recording the electrical activity of the heart. It is the key tool for determining if heart problems are causing chest pain. Paramedics perform ECG in the ambulance on the way to the hospital.
- Blood tests showing elevated levels of certain factors (troponins and CK-MB) indicate heart damage. (The doctor will not wait for results, however, before administering treatment if a heart attack is strongly suspected.)
- Imaging tests, including echocardiogram and perfusion scintigraphy, help rule out a heart attack if there is any question.
Electrocardiogram (ECG)
An electrocardiogram (ECG or EKG) measures and records the electrical activity of the heart. The waves measured by the ECG correspond to the contraction and relaxation pattern of the different parts of the heart. Specific waves seen on an ECG are named with letters:
- P. The P wave is associated with the contractions of the atria (the two chambers in the heart that receive blood from outside).
- QRS. The QRS is a series of waves associated with ventricular contractions. (The ventricles are the two major pumping chambers in the heart.)
- T and U. These waves follow the ventricular contractions.
Doctors use a term called the P-Q or P-R interval, which is the time taken for an electrical impulse to travel from the atria to the ventricle.
The most important wave patterns in diagnosing and determining treatment for a heart attack are called ST elevations and Q waves.
Elevated ST Segments: Heart Attack. Elevated ST segments are strong indicators of a heart attack in patients with symptoms and other indicators. They suggest that an artery to the heart is blocked and that the full thickness of the heart muscle is damaged. The kind of heart attack associated with these findings is referred to as either a Q-wave myocardial infarction or a STEMI (ST-segment elevation myocardial infarction).
However, ST segment elevations do not always mean the patient has a heart attack. For example, an inflammation in the sack around the heart (pericarditis) is another cause of ST-segment elevation.
Non-Elevated ST Segments: Angina and Acute Coronary Syndrome. A depressed or horizontal ST wave suggests some blockage and the presence of heart disease, even if there is no angina present. It occurs in about half of patients with other signs of a heart event. This finding, however, is not very accurate, particularly in women, and can occur without heart problems. In such cases, laboratory tests are needed to determine the extent, if any, of heart damage. In general, one of the following conditions may be present:
- Stable Angina (blood test results or other tests show no serious problems and chest pain resolves). Between 25 - 50% of people who have angina or silent ischemia have normal ECG readings.
- Acute Coronary Syndrome (ACS). This includes severe and sudden heart conditions that require aggressive treatment but have not developed into a full-blown heart attack. ACS refers to either unstable angina or NSTEMI (non ST-segment elevation myocardial infarction), also referred to as non Q-wave myocardial infarction. Unstable angina is potentially serious, and chest pain is persistent, but blood tests do not show markers for heart attack. With NSTEMI, the blood testsindicate a heart attack, but in most cases, injury to the heart is less serious than with a full-blown STEMI heart attack.
An echocardiogram is a noninvasive test that uses ultrasound images of the heart. Your doctor can see whether a part of your heart muscle has been damaged and is not moving. An echocardiogram may also be used as part of an exercise stress test, to detect the location and extent of heart muscle damage at the time of discharge or soon after you leave the hospital after a heart attack.
Radionuclide Imaging (Thallium Stress Test)
Radionuclide procedures use imaging techniques and computer analyses to plot and detect the passage of radioactive tracers through the region of the heart. Such tracing elements are typically given intravenously. Radionuclide imaging is useful for diagnosing and determining:
- Severity of unstable angina when less expensive diagnostic approaches are unavailable or unreliable
- Severity of chronic coronary artery disease
- Success of surgeries for coronary artery disease
- Whether a heart attack has occurred
- The location and extent of heart muscle damage at the time of discharge or soon after you leave the hospital after a heart attack
The procedure is noninvasive. It is a reliable measure of severe heart events and can help identify if damage has occurred from a heart attack. A radioactive isotope such as thallium (or technetium) is injected into the patient's vein. The radioactive isotope attaches to red blood cells and passes through the heart in the circulating blood. The isotope can then be traced through the heart using special cameras or scanners. The images may be combined with an electrocardiogram. The patient is tested while resting, then tested again during an exercise stress test. If the scan detects damage, more images are taken 3 or 4 hours later. Damage due to a prior heart attack will persist when the heart scan is repeated. Injury caused by angina, however, will have resolved by that time.
Angiography is an invasive test. It is used when doctors require a detailed "roadmap" of coronary artery blockages. In the procedure:
- A narrow tube is inserted into an artery, usually in the leg or arm, and then threaded up through the body to the coronary arteries.
- A dye is injected into the tube, and an x-ray records the flow of dye through the arteries.
- This process provides a map of the coronary circulation, revealing any blocked areas.
Biologic Markers
When heart cells become damaged, they release different enzymes and other molecules into the bloodstream. Elevated levels of such markers of heart damage in the blood or urine may help predict a heart attack in patients with severe chest pain, and help determine treatment. Tests for these markers are often performed in the emergency room or hospital when a heart attack is suspected. Some markers include:
- Troponins. The proteins cardiac troponin T and I are released when the heart muscle is damaged. Troponins are the best biomarkers for diagnosing heart attack.
- Creatine kinase myocardial band (CK-MB). CK-MB has been a standard marker, but the MB fraction is not as accurate as troponin levels, since elevated levels can appear in people without heart injury.
Heart attack is usually treated by:
- Providing supportive treatments (oxygen, morphine) to relieve pain and stabilize the patient
- Opening up the artery that is blocked as soon as possible, by performing emergency angioplasty or using medicines that dissolve the clot (thrombolytics)
- Blocking further clotting (if possible), using an anti-platelet drug such as aspirin or clopidogrel (Plavix, generic), or other clot-fighting drugs (heparin, glycoprotein IIb/IIIa inhibitors, bivalirudin
- Helping the heart muscle and arteries work better by giving the patient beta blockers, calcium channel blockers, or ACE inhibitor drugs
- Controlling any arrhythmias (abnormal heart rhythms)
Immediate Treatments to Support the Patient
Early supportive treatments are similar for patients who have acute coronary syndrome (ACS) or those who have had a heart attack.
Oxygen. Oxygen is almost always administered right away, usually through a tube that enters through the nose.
Aspirin. The patient is given aspirin if one was not taken at home.
Medications for Relieving Symptoms.
- Nitroglycerin. Most patients will receive nitroglycerin during and after a heart attack, usually under the tongue. Nitroglycerin decreases blood pressure and opens the blood vessels around the heart, increasing blood flow. Nitroglycerin may be given intravenously in certain cases (recurrent angina, heart failure, or high blood pressure).
- Morphine. Morphine not only relieves pain and reduces anxiety but alsorelaxes blood vessels, aiding the circulation of blood and oxygen to the heart. Morphine can decrease blood pressure and slow down the heart. In patients in whom such effects may worsen their heart attacks, other drugs may be used.
Opening the Arteries: Emergency Angioplasty or Thrombolytic Drugs
With a heart attack, clots form in the coronary arteries that supply oxygen to the heart muscle. Opening a clotted artery as quickly as possible is the best approach to improving survival and limiting the amount of heart muscle that is permanently damaged. New guidelines recommend that communities have emergency systems in place to ensure that heart attack patients are directed to appropriate medical centers equipped to treat them as quickly as possible.
The standard medical and surgical solutions for opening arteries are:
- Angioplasty, also called percutaneous coronary intervention (PCI), is the preferred emergency procedure for opening the arteries. Angioplasty should be performed promptly for patients with STEMI heart attack, preferably within 90 minutes of arriving at a hospital capable of performing the procedure. In most cases, a stent is placed in the artery to keep it open after the angioplasty. Guidelines recommend PCI for all patients with STEMI attacks who have experienced symptom onset within the past 12 hours.
- Thrombolytics (clot-busting drugs) are the standard medications used to open the arteries. A thrombolytic drug needs to be given within 12 hours after the onset of symptoms. Patients who arrive at a hospital that is not equipped to perform PCI should receive clot-busting therapy within 30 minutes of arriving at the hospital and then be transferred to a PCI center without delay.
- Coronary artery bypass graft (CABG) surgery is sometimes used as an alternative to angioplasty. Emergency CABG should be performed within 6 hours of symptom onset.
Thrombolytic, also called clot-busting or fibrinolytic, drugs are recommended as alternatives to angioplasty. These drugs dissolve the clot, or thrombus, responsible for causing artery blockage and heart-muscle tissue death.
Generally speaking, thrombolysis is considered a good option for patients with full-thickness (STEMI) heart attacks when symptoms have been present for fewer than12 hours. Ideally, these drugs should be given within 30 minutes of arriving at the hospital if angioplasty is not a viable option. Other situations where a clot-busting drug may be used include when:
- Prolonged transport will be required
- Too long of a time will pass before a catheterization lab is available
- PCI procedure is not successful or anatomically too difficult
Thrombolytics should be avoided or used with great caution in the following patients after heart attack:
- Patients older than 75 years
- When symptoms have continued beyond 12 hours
- Pregnant women
- People who have experienced recent trauma (especially head injury) or invasive surgery
- People with active peptic ulcers
- Patients who have been given prolonged CPR
- Current users of anticoagulants
- Patients who have experienced any recent major bleeding
- Patients with a history of stroke
- Patients with uncontrolled high blood pressure, especially when systolic is higher than 180 mm Hg
Specific Thrombolytics. The standard thrombolytic drugs are recombinant tissue plasminogen activators or rt-PAs. They include alteplase (Activase) and reteplase (Retavase) as well as a newer drug tenecteplase (TNKase). Other types of drugs, such as a combination of an antiplatelet and anticoagulant, may also be given to prevent the clot from growing larger or any new clots from forming.
Thrombolytic Administration. The sooner that thrombolytic drugs are given after a heart attack, the better. The benefits of thrombolytics are highest within the first 3 hours. They can still help if given within 12 hours of a heart attack.
Complications. Hemorrhagic stroke, usually occurring during the first day, is the most serious complication of thrombolytic therapy, but fortunately it is rare.
Revascularization Procedures: Angioplasty and Bypass Surgery
Percutaneous coronary intervention (PCI), also called angioplasty, and coronary artery bypass graft surgery (CABG)are the standard operations for opening narrowed or blocked arteries. These procedures help restore blood flow (perfusion). They are known as revascularization procedures:
- Emergency angioplasty/PCI is the standard procedure for heart attacks and should be performed preferably within 90 minutes of a heart attack. Studies have shown that balloon angioplasty and stenting fails to prevent heart complications in patients who receive the procedure 3 - 28 days after a heart attack.
- Coronary bypass surgery is typically used as elective surgery for patients with blocked arteries. It may be used after a heart attack if angioplasty or thrombolytics fail or are not appropriate. It is usually not performed for several days to allow recovery of the heart muscles.
Most patients who meet the criteria for either thrombolytic drugs or angioplasty do better with angioplasty (although only in centers equipped to do this procedure).
Angioplasty/PCI involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery. A typical angioplasty procedure involves the following steps:
- The cardiologist threads a narrow catheter (a tube) containing a fiber into the blocked vessel.
- The cardiologist opens the blocked vessel using balloon angioplasty, in which a tiny deflated balloon is passed through the catheter to the vessel.
- The balloon is inflated to compress the plaque against the walls of the artery, flattening it out so that blood can once again flow through the blood vessel freely.
- To keep the artery open afterwards, doctors use a device called a coronary stent, an expandable metal mesh tube that is implanted during angioplasty at the site of the blockage. The stent may be bare metal or it may be coated with a drug that slowly releases medication.
- Once in place, the stent pushes against the wall of the artery to keep it open.
Complications occur in about 10% of patients (most complications occur within the first day). Best results occur in hospital settings with experienced teams and backup. Women who have angioplasty after a heart attack have a higher risk of death than men.
Reclosure and Blockage During or After Angioplasty. Narrowing or reclosure of the artery (restenosis) often occurs during or shortly after angioplasty. It can also occur up to a year after surgery, requiring a repeat angioplasty procedure.
Drug-eluting stents, which are coated with everolimus, sirolimus, or paclitaxel, can help prevent restenosis. They may be better than bare metal stents for patients who have experienced a STEMI heart attack, but they can also increase the risks of blood clots.
It is very important for patients who have drug-eluting stents to take aspirin and clopidogrel (Plavix, generic) for at least 1 year after the stent is inserted, to reduce the risk of blood clots. Clopidogrel, like aspirin, helps to prevent blood platelets from clumping together.
Prasugrel (Effient) is a newer antiplatelet drug that may be used as an alternative to clopidogrel for select patients with acute coronary syndrome who are undergoing angioplasty. It should not be used by patients who have had a previous stroke or transient ischemic attack. Another option for patients is the new antiplatelet drug ticagrelor (Brilinta). Like clopidogrel, prasugrel and ticagrelor are taken in combination with aspirin.
If for some reason patients cannot take a second antiplatelet along with aspirin after angioplasty and stenting, they should receive a bare metal stent instead of a drug-eluting stent.
Coronary Artery Bypass Graft Surgery (CABG). Coronary artery bypass graft surgery (CABG) is the alternative procedure to angioplasty for opening blocked arteries, particularlyfor patientswho have two or more blocked arteries. It is a very invasive procedure, however:
- The chest is opened, and the blood is rerouted through a lung-heart machine.
- The heart is stopped during the procedure.
- Segments of veins or arteries taken from elsewhere in the patient's body are fashioned into grafts, which are used to reroute the blood. The blood vessel grafts are placed in front of and beyond the blocked arteries, so the blood flows through the new vessels around the blockage.
Treatment for Patients in Shock or with Heart Failure
Severely ill patients, particularly those with heart failure or who are in cardiogenic shock, will be monitored closely and stabilized. Oxygen is administered, and fluids are given or replaced when it is appropriate to either increase or reduce blood pressure. Such patients may be given dopamine, dobutamine, or both. Other treatments depend on the specific condition.
Heart failure. Intravenous furosemide may be administered. Patients may also be given nitrates, and ACE inhibitors, unless they have a severe drop in blood pressure or other conditions that preclude them. Clot-busting drugs or angioplasty may be appropriate.
Cardiogenic Shock. Cardiogenic shock is a dangerous condition that includes a drop in blood pressure and other abnormalities. A procedure called intra-aortic balloon counterpulsation (IABP) can help patients with cardiogenic shock when used in combination with thrombolytic therapy. IABP involves inserting a catheter containing a balloon, which is inflated and deflated within the artery to boost blood pressure. Left ventricular assist devices and early angioplasty may also be considered.
Treatment of Arrhythmias
An arrhythmia is a deviation from the heart's normal beating pattern caused when the heart muscle is deprived of oxygen. Arrhythmia is a dangerous side effect of a heart attack. A very fast or slow rhythmic heart rate often occurs in patients who have had a heart attack, and is not usually a dangerous sign.
Premature beats or very fast arrhythmias called tachycardia, however, may be predictors of ventricular fibrillation. This is a lethal rhythm abnormality, in which the ventricles of the heart beat so rapidly that they do not actually contract but quiver ineffectually. The pumping action necessary to keep blood circulating is lost.
Preventing Ventricular Fibrillation. People who develop ventricular fibrillation do not always experience warning arrhythmias, and to date, there are no effective drugs for preventing arrhythmias during a heart attack. Preventive strategies include:
- Potassium and magnesium levels should be monitored and maintained.
- Intravenous beta blockers followed by oral administration of the drugs may help prevent arrhythmias in certain patients.
Treating Ventricular Fibrillation. Treatment strategies for ventricular fibrillation include:
- Defibrillators. Patients who develop ventricular arrhythmias are given electrical shocks with defibrillators to restore normal rhythms. Some studies suggest that implantable cardioverter-defibrillators (ICDs) may prevent further arrhythmias in heart attack survivors of these events who are at risk for further arrhythmias.
- Antiarrhythmic Drugs. Antiarrhythmic drugs include lidocaine, procainamide, or amiodarone. Amiodarone or another antiarrhythmic drug may be used afterward to prevent future events.
Managing Other Arrhythmias. People with an arrhythmia called atrial fibrillation have a higher risk for stroke after a heart attack and should be treated with anticoagulants such as warfarin (Coumadin, generic), dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis). Other rhythm disturbances called bradyarrhythmias (very slow rhythm disturbances) frequently develop in association with a heart attack and may be treated with atropine or pacemakers.
Aspirin and Other Anti-Clotting Drugs
Anti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either anti-platelets or anticoagulants. Both anti-platelets and anticoagulants prevent blood clots from forming but they work in different ways. Anti-platelets prevent blood platelets from sticking together. Anticoagulants are "blood thinners" that stop blood from clotting. Anti-platelets and anticoagulants carry the risk of bleeding, which can lead to dangerous situations, including stroke.
Appropriate anticlotting medications are started immediately in all patients. Such drugs are sometimes used along with thrombolytics, and also as on-going maintenance to prevent a heart attack.
Anti-Platelet Drugs. These drugs inhibit blood platelets from sticking together, and therefore help to prevent clots. Platelets are very small disc-shaped blood cells that are important for blood clotting.
- Aspirin. Aspirin is an antiplatelet drug. An aspirin should be taken immediately after a heart attack begins. It can be either swallowed or chewed, but chewing provides more rapid benefit. If the patient has not taken an aspirin at home, it will be given at the hospital. It is then continued daily (usually 81 mg/day). Using aspirin for heart attack patients has been shown to reduce mortality. It is the most common anti-clotting drug, and most people with heart disease are advised to take it daily in low dose on an ongoing basis.
- Clopidogrel (Plavix, generic), a thienopyridine, is another type of anti-platelet drug. Clopidogrel is started either immediately or right after angioplasty/PCI is performed. It is also begun after thrombolytic therapy. Patients who receive a drug-eluting stent should take clopidogrel along with aspirin for at least 1 year to reduce the risk of clots. Some patients may need to take clopidogrel on an ongoing basis. Clopidogrel can increase the risk of upper gastrointestinal (GI) bleeding. Discuss with your doctor whether you should take a proton pump inhibitor (PPI). PPIs can reduce the risk of GI bleeding but they also can interfere with clopidogrel's anti-clotting effects. .
- Prasugrel (Effient) is a newer thienopyridine that may be used instead of clopidogrel in patients with acute coronary syndrome (ACS). It should not be used by patients who have a history of stroke or transient ischemic attack.
- Ticagrelor (Brilinta) is another new antiplatelet approved for patients with ACS. It works differently than thienopyridines.
- Glycoprotein IIb/IIIa Inhibitors. These powerful anti-platelet drugs include abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban (Aggrastat). They are administered intravenously in the hospital and are used with angioplasty/PCI or coronary artery bypass graft (CABG) surgery.
Anticoagulant Drugs. Anticoagulants thin blood. They include:
- Heparin is usually begun during or at the end of treatment with thrombolytic drugs and continued for at least 2 days if not the whole time in the hospital.
- Other intravenous anticoagulants that may be given in the hospital include bivalirudin (Angiomax), fondaparinux (Arixtra), and enoxaparin (Lovenox).
- Warfarin (Coumadin, generic). Dabigatran (Pradaxa),rivaroxaban (Xarelto), and apixaban (Eliquis) are other options for patients with atrial fibrillation. (Pradaxa should not be taken by patients who have mechanical heart valves.)
All of these drugs pose a risk for bleeding. Some research indicates that the newer anticoagulants (dabigatran, rivaroxaban, apixaban) may pose a higher risk for bleeding in patients with acute coronary syndrome than the older anticoagulant warfarin.
Beta Blockers
Beta blockers reduce the oxygen demand of the heart by slowing the heart rate and lowering pressure in the arteries. They are effective for reducing deaths from heart disease. Beta blockers are often given to patients early in their hospitalization, sometimes intravenously. Patients with heart failure or who are at risk of going into cardiogenic shock should not receive intravenous beta blockers. Long-term oral beta blocker therapy for patients with symptomatic coronary artery disease, particularly after heart attacks, is recommended in most patients.
These drugs include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc). All of these drugs are available in generic form.
Administration During a Heart Attack. The beta blocker metoprolol may be given through an IV within the first few hours of a heart attack to reduce damage to the heart muscle.
Prevention After a Heart Attack. Beta blockers taken by mouth are also used on a long-term basis (as maintenance therapy) after a first heart attack to help prevent future heart attacks.
Side Effects. Beta blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL ("good") cholesterol. Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, can narrow bronchial airways. Patients with asthma, emphysema, or chronic bronchitis, should not take non-selective beta blockers.
Patients should not abruptly stop taking these drugs. The sudden withdrawal of beta blockers can rapidly increase heart rate and blood pressure. The doctor may want the patient to slowly decrease the dose before stopping completely.
Statins and Other Cholesterol and Lipid-Lowering Drugs
After being admitted to the hospital for acute coronary syndrome or a heart attack, patients should not be discharged without statins or other cholesterol medicine unless their LDL ("bad") cholesterol is below 100 mg/dL. Some doctors recommend that LDL should be below 70 mg/dL.
Angiotensin Converting Enzyme Inhibitors
Angiotensin converting enzyme (ACE) inhibitors are important drugs for treating patients who have had a heart attack, particularly for patients at risk for heart failure. ACE inhibitors should be given on the first day to all patients with a heart attack, unless there are medical reasons for not taking them.
Patients admitted for unstable angina or acute coronary syndrome should receive ACE inhibitors if they have symptoms of heart failure or evidence of reduced left ventricular fraction echocardiogram. These drugs are also commonly used to treat high blood pressure (hypertension) and are recommended as first-line treatment for people with diabetes and kidney damage.
ACE inhibitors include captopril (Capoten), ramipril (Altace), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil, Zestril). All of these drugs are available in generic form.
Side Effects. Side effects of ACE inhibitors are uncommon but may include an irritating cough, excessive drops in blood pressure, and allergic reactions.
Calcium Channel Blockers
Calcium channel blockers may provide relief in patients with unstable angina whose symptoms do not respond to nitrates and beta blockers, or for patients who are unable to take beta blockers.
Secondary Prevention
Youcan reduceyour risk for a second heart attack by following secondary prevention measures. No one should be discharged from the hospital without these issues being addressed and appropriate medications prescribed. Lifestyle choices, particularly dietary factors, are equally important in preventing heart attacks.
Blood Pressure. Aim for a blood pressure of less than 140/90 mm Hg.
Cholesterol. LDL ("bad") cholesterol should be substantially less than 100 mg/dL. If triglycerides are greater than or equal to 200 mg/dL, then non-HDL-C should be less than 130 mg/dL. [Non-HDL-C is the difference between total cholesterol and HDL ("good") cholesterol levels.] Nearly everyone who has had a heart attack should receive a prescription for a statin drug before being discharged from the hospital. It is also important to control dietary cholesterol by reducing intake of saturated fats to less than 7% of total calories. Increased omega-3 fatty acid consumption (by eating more fish or taking fish oil supplements) can help reduce triglyceride levels.
Exercise. Exercise for 30 - 60 minutes 7 days a week (or at least a minimum of 5 days a week).
Weight Management. Combine exercise with a healthy diet rich in fresh fruits, vegetables and low-fat dairy products. Your body mass index (BMI) should be 18.5 - 24.8. Waist circumference is also an important measure of heart attack risk. Men's waist circumferences should beless than 40 inches (102 centimeters), while women's should bebelow 35 inches (89 centimeters).
Smoking. It is essential to stop smoking. Also, avoid exposure to second-hand smoke.
Anti-Platelet Drugs. Your doctor may recommend you take low-dose aspirin (75 - 81 mg) on a daily basis. If you have had a drug-coated stent inserted, you must take another anti-platelet drug along with aspirin for at least 1 year following surgery. (Aspirin is also recommended for some patients as primary prevention of heart attack.)
Other Drugs. Your doctor may recommend that you take an ACE inhibitor or beta blocker drug on an ongoing basis. It is also important to have an annual influenza ("flu") vaccination.
Physical Rehabilitation
Physical rehabilitation is extremely important after a heart attack. Patients with recent episodes of acute coronary syndrome also generally need some sort of supervised exercise training. Cardiac rehabilitation may include:
- Leg exercises may start as early as the first day. The patient usually sits in a chair on the second day, and begins to walk on the second or third day.
- Most patients undergo low-level exercise tolerance tests early in their recovery.
- After 8 - 12 weeks, many patients, even those with heart failure, benefit from supervised exercise programs. Health care providers should give the patient schedules for low-level aerobic home-activity. Strength (resistance) training is also important. In general, the risk for serious heart events during rehabilitation is very low.
Patients generally return to work in about 1 - 2 months, although timing can vary depending on the severity of the condition.
Sexual activity after a heart attack has a low risk and is generally considered safe, particularly for people who exercised regularly before the attack. The feelings of intimacy and love that accompany healthy sex can help offset depression.
Emotional Rehabilitation
Major depression occurs in many patients who have ACS or who have had heart attacks. Studies suggest that depression is a major predictor for increased mortality in both women and men. (One reason may be that depressed patients are less likely to comply with their heart medications.)
Guidelines now recommend depression screening for all patients who have had a heart attack. Psychotherapeutic techniques, especially cognitive behavioral therapies, may be very helpful. For some patients, certain types of antidepressant drugs may be appropriate.
- www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
- www.acc.org -- American College of Cardiology
- www.heart.org -- American Heart Association
2012 Writing Committee Members, Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2012 Aug 14;126(7):875-910. Epub 2012 Jul 16.
Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB, et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation. 2010 Dec 14;122(24):2619-33. Epub 2010 Nov 8.
American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions, O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-140. Epub 2012 Dec 17.
Antman EM and Morrow DA. ST-Elevation myocardial infarction: management. In Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Saunders; 2011:chap 55.
Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007 Mar 27;115(12):1634-42. Epub 2007 Feb 26.
Baber U, Mehran R, Sharma SK, Brar S, Yu J, Suh JW, et al. Impact of the everolimus-eluting stent on stent thrombosis: a meta-analysis of 13 randomized trials. J Am Coll Cardiol. 2011 Oct 4;58(15):1569-77. Epub 2011 Sep 14.
Bradley EH, Nallamothu BK, Herrin J, Ting HH, Stern AF, Nembhard IM, et al. National efforts to improve door-to-balloon time results from the Door-to-Balloon Alliance. J Am Coll Cardiol. 2009 Dec 15;54(25):2423-9.
Cannon CP and Braunwald E. Unstable angina and non-ST elevation myocardial infarction. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Saunders; 2011:chap 56.
Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011 Dec 6;58(24):e123-210. Epub 2011 Nov 7.
Keller T, Zeller T, Ojeda F, Tzikas S, Lillpopp L, Sinning C, et al. Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA. 2011 Dec 28;306(24):2684-93.
Komócsi A, Vorobcsuk A, Kehl D, Aradi D. Use of new-generation oral anticoagulant agents in patients receiving antiplatelet therapy after an acute coronary syndrome: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2012 Nov 12;172(20):1537-45.
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011 Dec 6;58(24):e44-122. Epub 2011 Nov 7.
Newby LK, Jesse RL, Babb JD, Christenson RH, De Fer TM, Diamond GA, et al. ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2012 Dec 11;60(23):2427-63. Epub 2012 Nov 12.
Schjerning Olsen AM, Fosbøl EL, Lindhardsen J, Folke F, Charlot M, Selmer C, et al. Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction in patients with prior myocardial infarction: a nationwide cohort study. Circulation. 2011 May 24;123(20):2226-35. Epub 2011 May 9.
Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol. 2011 Nov 29;58(23):2432-46. Epub 2011 Nov 3.
Stone GW, Lansky AJ, Pocock SJ, Gersh BJ, Dangas G, Wong SC, et al. Paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med. 2009 May 7;360(19):1946-59.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Joint ESC/ACCF/AHA/WHF Task Force for Universal Definition of Myocardial Infarction; et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012 Oct 16;60(16):1581-98. Epub 2012 Sep 5.
Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P, et al. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e637S-68S.
Wagner GS, Macfarlane P, Wellens H, Josephson M, Gorgels A, Mirvis DM, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009 Mar 17;53(11):1003-11.
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Review Date: 6/28/2013�
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.


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USGlobalSat GPS Forums > Engine Modules
New Facebook Contests
Hey members, I thought I would let you in on some events were having on our facebook page!
1) Were having a contest, A "Photo Hunt Contest". Name the photo display on our facebook page under the post name "Photo Hunt Contest" and the 1st person to get the answer right will win a GD-101.
2) Tag/Poke us in one of your photos on facebook and you can be entered to win a GD-101. The winner will be chosen at random.
Like our facebook page here: http://www.goo.gl/P8km1
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July 05, 2008 at 22:31:09 Jul 05, 2008 @ 22:31
^ man stfu....ok i am lazy. lol
name ?
Inactive User
havana ginger
lela star
sativa rose
tory lane
eva angelina i actully saw here at raging waters yesterday with no makeup she ok
Jaelyn Fox is one of my favorites right now.
too lazy to post up/find any others because im pretty sure they're all known. don't know if many of you know who jaelyn is though.
Richard Cumming: word if your dick aint wet 24/7 you're a simp. if theres no pussy around bess b'lee dat i got my dick in a glass of water
Kim Kardashian &)


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(Sequoia) "Inside the Teenage Brain: Trials, Transitions, and Triumphs"
Sequoia Parent Education Series
Wednesday, November 13, 2013 from 7:00 PM to 8:30 PM (PST)
Event Details
"Inside the Teenage Brain: Trials, Transitions, and Triumphs"
with Lisa Medoff, Ph.D., Stanford University
Wednesday, November 13, 2013, 7:00 - 8:30 p.m.
Sequoia High School, Carrington Hall
In this special presentation, Dr. Medoff will describe the cognitive and social-emotional developmental changes of adolescence and discuss ways that parents can communicate effectively with their teenagers during this time of rapid change. She will also discuss how parents can help their children develop communication and coping skills to reduce stress and build resilience.
Lisa Medoff is a developmental psychologist who specializes in adolescent mental health. She teaches courses on adolescent development in the Program in Human Biology at Stanford University, where she is an Associate Dean of Residential Education. Dr. Medoff is the research consultant for Acknowledge Alliance (formerly The Cleo Eulau Center), where she provides workshops and trainings on social and emotional issues in the classroom. She also works privately with students who have learning disabilities and emotional disorders, consulting with families and schools to help them provide the optimal home and school environments for their children with special needs. Her books include the Stressed Out Students Guide To... series and Resilience in the Classroom: Helping Students with Special Needs.
Dr. Medoff holds a B.A in psychology from Rice University, an M.S.Ed. in school counseling from the University of Pennsylvania, and a Ph.D. in child and adolescent development from Stanford University.
Sequoia Parent Education Series events are free, sponsored by the Sequoia High School Education Foundation and the Sequoia Healthcare District.
Events are open to parents and students in the SUHSD community. Simultaneous Spanish interpretation will be provided.
For more information, contact Charlene Margot, Parent Education Series, Program Director, at email@example.com or 650-868-0590. For Spanish information, contact Mayela Ramirez, Parent Center Coordinator, 650-369-1411 x 6420
When & Where
Sequoia High School
1201 Brewster Avenue
Redwood City,
Wednesday, November 13, 2013 from 7:00 PM to 8:30 PM (PST)
Add to my calendar
Sequoia Parent Education Series
Sequoia Parent Education Series events are free and open to parents, students, faculty/staff, and community members. Events are sponsored by SHSEF, the Sequoia Healthcare District, and the Sequoia Union High School District.


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Wed 7:00 PM
1111 S. Figueroa Street
Los Angeles, CA 90015
Children age 3 and older require a ticket. A child under the age of 3 is considered a lap child and does not require a ticket.
Tickets will go on-sale through AXS.com or over the phone with AXS at (888) 9-AXS-TIX on the first day of the on-sale. The Box Office will sell them at the Staples Center starting the next business day we are open. For more details feel free to call the Staples Center Box Office at (213) 742-7340.
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So today I had the parts of my new computer arrive (excited giggle). It got me thinking about what you lot have in your rigs.
So what have you lot got?! Here's mine:
The Dark Night:
- Intel i7 3770K
- Noctua NH-D14 CPU cooler
- 16gigs Ram (Soon to be 32)
- EVGA GTX 670 FTW Graphics cards
- 256gb Kingston SSD
- 2TB Barracuda (Also have a 6TB NAS)
- Fractal Design define R4 case
This isn't just aimed at Windows users. Mac guys, whatcha specs!?
- P E5400 2.70 GHz
- 2 GB Ram
- No video card
and i working very comfortable
Intel i5 Quadcore 16GB DDR3 1TB 5400 RPM HD Radeon HD 6530 Dual 23" LED Monitors Running Great
There are 6 machines running right now, not counting phones and pads. LOL
The main worker bee has Quad Core P4 running at 2.4 GH with dual 2 TB internal drives and 4 external 2 TB drives. 8 Megs RAM, dual 23 inch monitors.
And, it apparently needs some work on one of the fans.
Christopher_Boswell said
8 Megs RAM, And, it apparently needs some work on one of the fans.
With all that RAM, no wonder the fans up and die… really!
i7 3610QM – 12 gigs of RAM – GT 630M card – 15.6" HP DV6 + 24" Samsung SyncMaster.
Love it.
- Intel i7 3770K @ 4.4GHz
- Coolermaster Hyper 212+ Cooler with 3x AC F12 PWM fans
- Gigabyte GA-Z77X-UD5H (I'm strong gigabyte fan, their MoBos are reliable)
- DDR3 16GB Corsair Vengeance LP 1600MHz CL10 (I'll buy another 2×8 next year)
- Sapphire HD4850 512MB DualSlot
- SSD 128GB OCZ Agility 3 Sata3
- 500GB WD HDD Sata2 (working already for four years, 15 hours a day, our sixth WD in family)
- Fortron Blue Storm II 500W
- Acutake Viper B/S
- LCD 22" Samsung SyncMaster 2233BW (Want to add another 29" 2560×1080 IPS monitor with 21:9 aspect ratio next year)
2x Xeon E5 2650 8-core, 92GB RAM DDR3 1666Mhz, nVidia Quadro 4000, 2×2TB HDD, 1×256MB SSD, yadda yadda yadda.
Well if you bring out the big guns… I might as well come with my peashooter > 2x Xeon x5650 2.67 < hexacore (24 actual render cores) @ 3.1GHz + 2x Antec Kuehler H2O 920 + 24 GB DDR3 ECC ram @ 1333 + Asus server mb + PNY nvidia quadro 4000 + 1×128GB SSD, 2×2TB @7200, external stuffs probably worth more put together than what's on the inside… meh. Oh yah, 26" LG LCD + 24" LG LED


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Lupita Nyong'o joins cast of 'Star Wars'
Three months after winning an Oscar, Lupita Nyong'o is going galactic!
The Walt Disney Co. announced Monday that Nyong'o is joining the cast of Star Wars: Episode VII. Rumors began swirling back in March when Lupita's name was in the running to play Princess Leia and many questioned whether her race and skin color would be an issue for die-hard fans. Nevertheless, it looks like the powers that be have spoken and her skills are undeniable.
John Boyega, Daisy Ridley, Adam Driver, Oscar Isaac, Andy Serkis, Domhnall Gleeson, and Max von Sydow will join the original stars of the Saga Harrison Ford, Carrie Fisher, Mark Hamill, Anthony Daniels, Peter Mayhew, and Kenny Baker in the new film.
Though at the time we don't know who she is playing, Lupita was previously rumored for the part of Obi-Wan Kenobi's granddaughter.
Production is underway for the film, which is being directed by J.J. Abrams. It's slated to open in December 2015.
Photo Credit Getty Images


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I'm recently back from a long weekend in Auckland, hanging with parents and friends, visiting grandparents, drunk skyping with my brother in Perth, shopping at Gorman, and eating a million treats. It was really, really lovely.
The weather was a charmer.
The very first thing I did was go to Little and Friday, where I LOST MY SHIT over how perfect and amazing every detail is.
I hung out with my Grandmas. Nana showed us her and my Grandad's sixty-year-old engagement annoucement.
I drank wine and was merry with old friends.
After this, I required eggs and hollandaise to fix me.
The night before I left, I joined an enormous queue at Ollie's for the first time in years. SO IMPORTANT. I caused a sensation in the line when I ordered the outrageous banana split.
As you can see, it's as big as my (very large) face. Mum and I had about 1/5 of it each, it's probably still in the freezer.
On my last day we popped back to Little and Friday to try their famous doughnuts. Yes.
And then I came home.
All pictures from my instagram, _pocketwitch.


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Results 1 to 4 of 4
Thread: What are my birth choices?
18th January 2012 04:20 AM #1
- Join Date
- Jan 2012
- Posts
- 1,936
What are my birth choices?
When it comes to planning your birth, most women think about a "birth plan" which is documenting how you want the actual birth experience to be.
But there are some big decisions that need to be made even before you start thinking about the actual birth, and those decisions involve choosing the best birthing attendants (i.e. doctor/midwife/doula etc.), choosing where you will give birth, and choosing what kind of a birth you want (i.e. planned C-Section, all natural, waterbirth, where you want to labour, etc.).
Once you've decided what kind of a birth you want, and where you want to labour (i.e. water, in your bedroom, in a hospital bed, etc.) then you can begin thinking about what you want the actual birth to be like. Do you want the option to give birth squatting? Do you want the option of being able to give birth in the water?
There are a lot of different things to consider in planning your ideal birth, and this is the area to discuss those things.
For starters, take a look at the Birth Choices page to start learning about your choices (there are some you may not have even thought would be an option for you).
Then ask your questions and we'll support you in creating the birth experience that you want - the one that will be best for your unique circumstances.
20th February 2012 02:34 PM #2
- Join Date
- Feb 2012
- Location
- Cronulla, Sydney NSW
- Posts
- 17
Hi Kate, such an important thread to start, thank you! A great resource for women and their partners in Australia is the Choices for Childbirth information sessions. Choices for Childbirth is a not-for-profit organisation (branch of the Maternity Coalition) and they run information sessions to educate and support couples in making an informed choice for pregnancy, birth and the postnatal period. Here is the link to their website for more information: http://www.choicesforchildbirth.org.au.
So often I see women come through my clinic that just don't have access to anything other than the information/experiences relayed to them by friends and family. It would be wonderful to make the informed choices and options more easily accessible!
21st February 2012 08:11 PM #3
For my next 'birth plan' I think I'm going to have an ideal birth plan (or ideal birth hopes) and then some plans for other options. For example, if I needed an unplanned c-section what would I want to happen then (e.g. my husband with me at all times, no talking when the baby was coming out, music in the room, some perfume to smell to try and make it less hospitalised). Then I can relax, knowing I've talked through all the options with my birthing partner.
Thanks for sharing these resources: the more informed we are the more likely we are able to have the birth we hope for.
26th February 2012 07:21 PM #4
- Join Date
- Feb 2012
- Location
- Cronulla, Sydney NSW
- Posts
- 17
Hi Ljmarsden, sounds like a plan That's the best thing about birth plans/ideas - you can discuss things that aren't 'in the plan' but may happen so that in the event that they do occur you and your partner don't have to make big decisions when you are definitely not in the right head space to do so!


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Bernard works part-time at Melbourne Museum devising and delivering presentations for visitors. The other part of the time he writes and draws and edits and publishes comic books, and also teaches and broadcasts about them.
Gilgamesh. What a guy.
In The Epic of Gilgamesh, we learn that he's the son of a human man and the goddess Ninsun.
A hero overpowering a lion (left) and Lamassu in the Louvre. These bas-relief sculpures are huge - the man figure is about three times life-size. Lion-taming spirits are often identified with Gilgamesh. Image: caribbSource: Used under CC BY-NC-ND 2.0 from caribb.
He's two-thirds god and one-third human, and single-handedly built the city walls of Uruk to protect his people.
Cast bronze sculpture of Gilgamesh at The University of Sydney. It was made by Lewis Batros and donated by the Gilgamesh Cultural Centre on behalf of the Assyrian community celebrating the university's sesquicentenary in 2000.Image: D. Gordon E. RobertsonSource: Wikimedia Commons
He fought and befriended the wild man Enkidu. Enkidu and Gilgamesh fought the monster Humbaba (or Huwawa). They defeated Humbaba and brought his head back to Uruk on a raft.
Clay mask of the demon Huwawa or Humbaba. The cuneiform inscription on the back says that if the intestines of a sacrificed animal are looped around to resemble Humbaba, it is an omen of 'revelation.' Gruesome.Source: © The Trustees of the British Museum
Gilgamesh and Enkidu also defeated the Bull of Heaven, who was sent to destroy Uruk by the furious goddess Ishtar after Gilgmesh said that he wouldn't go to the prom with her.
The 'Queen of the Night' Relief, possibly a representation of the goddess Ishtar. It might also be her sister and rival, the goddess Ereshkigal, or the demoness Lilitu, known in the Bible as Lilith.
Old Babylonian, 1800-1750 BC, from southern Iraq.
Source: © The Trustees of the British Museum
Sure, Gilgamesh is the legendary demigod hero-king of Mesopotamia, but is he actually the first comic book superhero? Of course he is. There were definitely legendary heroes and gods before Gilgamesh, but he's the first one we have a publication for. That publication weighs a little more than your standard comic book, because it's made of tablets of baked clay. But there are 12 of those tablets, each telling of a separate episode, so each could be considered an 'issue' of the Gilgamesh comic mini-series.
The one possible argument against it being a comic book is its total and utter lack of pictures. However, this objection is easily overcome by holding the tablets of cuneiform up against the large narrative Mesopotamian wall-carvings. The tablets thus become word balloons, containing a tale that the characters on the carvings are telling to one another. THEN it's a comic book. A weighty comic book. It might even, given the scope of the story, be a 'graphic novel' (=long comic book). Ooh la la!
Three thousand years after that original clay publication of the adventures of Gilgamesh, the brilliant Jack Kirby, 'King of Comics', who virtually invented the visual language that we associate with American superhero comics, put the Babylonian demigod on paper. BK (Before Kirby), comic books used the restrained compositions and drawing styles that they had inherited from newspaper comic strips. Kirby changed all that. His characters burst through the frames. They leapt from the page.
Me ensconced in the classic Jack Kirby comic book series The Eternals, which features his character Gilgamesh.
Source: Museum Victoria
Gilgamesh shows up in issue #13 of The Eternals (1977), a comic book series that Kirby created for Marvel Comics. In the intervening years, the character has been drawn and written by various writers and artists. Sometimes he's working under a different name (simply 'Hero' or 'The Forgotten One'), sometimes he's costumed in the hide of the Bull of Heaven, and sometimes he's fighting alongside the team called The Avengers, but I'm pretty sure he won't have a cameo in the film of the same name directed by Joss Whedon (the Buffy the Vampire Slayer creator) coming from Marvel Studios later this year. More's the pity, eh?
Hi Omega,
The objects in this post are not on display in The Wonders of Ancient Mesopotamia, but the exhibition does include lamassu created by MV preparators.
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It says nothing of birth control. The only "barriers" mentioned are those faced by parents anxious about having – you know, "the talk."
But an abstinence education website http://talking2teens.utahcounty.gov launched Tuesday by the Utah County Health Department does contain frank talk about the sexual habits of teenagers.
"Studies show that parents have the greatest influence on their child's sexual behavior – more than their friends or the media – but they often avoid talking to their children about sex because it's uncomfortable or they feel unprepared," said county health educator Sofia Ybarra in a prepared statement.
From 2006 to 2011, 1,269 teenage girls between the ages of 14 to 18 delivered babies in Utah County, 75 percent of them out-of-wedlock, according to county health officials. Many of these mothers reported wishing they had received more education about sex than what was taught at school, officials say.
The "Talking2Teens" website, offered in English and Spanish, cost about $3,200 and was funded with a federal grant. It is a self-paced guide designed for parents of teenagers, but also has information about how early to broach the subject.
"Conversations about love, relationships, and sex could begin as early as six and should continue through the teenage years," it recommends.
True to its "abstinence only" focus, the site contains no information about different forms of birth control, about which work best or how to obtain them.
But there's also detailed information about the consequences of premarital sex, teen pregnancy and sexually transmitted diseases, including national statistics that show:
• Almost one out of every three ninth graders has had sex at least once.
• The United States continues to have the highest teen pregnancy rate in the developed world.
• One out of seven high school students reports having had sex with four or more partners.
• One in every four teen girls has a sexually transmitted disease.
For more information, call 801-851-7095, or email firstname.lastname@example.com.
Help for parents
Abstinence only based website > http://talking2teens.utahcounty.gov
For more information, call 801-851-7095, or email email@example.com.


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INTERVIEW: Paramore Talks 'Hard Times' & Reveals 'After Laughter' Meaning
Paramore is back with their first new material in four years. The band released their brand new single "Hard Times" on April 18, the lead single from their upcoming fifth studio album AFTER LAUGHTER (to be released in May), and fans will definitely notice a difference in the sound from Paramore's previous songs. On "Hard Times," Paramore takes a step back from their punk/pop/alternative style, and step into more of an '80s vibe, reflected in their very colorful accompanying music video.
One could take "Hard Times" to mean many things, especially with all that is going in the world today. But there's not doubt that Paramore has been through some hard times as a band over the past few years. In fact, the group's own Hayley Williams tells iHeartRadio of what they've been up to since they released their last album in 2013:
"We pretty much haven't done a whole lot, other than make an album called After Laughter, and we went through a bunch of hard times, which is why we have a song called 'Hard Times.'"
After Laughter is Paramore's first since founding member/bassist Jeremy Davis' departure in 2015. The band said in a statement of his leaving at the time, "To be honest, this has been really painful" also adding "We're really thankful for the people who have helped see us through hard times before and what we've discovered is that those people are just as much a part of this as we will ever be."
"Hard Times" is different from Paramore's previously released music, and Hayley tells us, "This is a really big step for us as a band, and it's definitely a new sound. We're really proud of it. I feel like it really reflects exactly who we are right now in real time, and hopefully people will be into it."
So why After Laughter? Hayley explains the meaning behind Paramore's new album title:
"After Laughter is about the look on people's faces when they're done laughing. If you watch somebody long enough, there's always this look that comes across their face when they're done smiling, and I always find it really fascinating to wonder what it is that brought them back to reality. So, that's what After Laughter is."


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GOP to Darrell Issa: Calm Down
(NEWSER) – When Darrell Issa called White House press secretary Jay Carney a "paid liar" on Sunday, House Republican leadership was aghast. They immediately called Issa's staffers, sources tell Politico, and their message was simple: Tell your boss to calm down. The staff agreed that the remark was out of line, but Issa himself has refused to publicly backtrack. "The White House has tried to vilify me rather than getting into the facts," he says. When asked about leadership's rumored gripes, he replied, "I didn't hear anything."


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TMS Appliance Upgrade
Hi all,
I have a TMS appliance. Its version is 13.0. And I want to upgrade it to the version 13.1.2. First of all, I want to learn if it is possible or not. If it possible, how can I do that? I tried to upgrade by running TMS 13.1.2 exe, and I had an error saying "It is harmful operation" and it didn't allow me to install it. What do you think is the problem?
Hi Tufan
Look at the HTTP exception by clicking it. Does it say that it cannot find any phonebooks? Try creating some users and enable access to the phonebooks in phonebook management under access control. Do you still see the error after a full synchronization?


text: Hey guys, new here and also Just started training in MMA about a month ago. while I have felt the benefits of training (even lost 2 stone just in the first month!) I still get "pre class jitters" and straight up feel unmotivated to get to the gym. Its nothing to do with the people there as they are mostly friendly and helpful. Its defiantly my pussy lazy ass haha but I wanted to know if anybody else has been through this starting out and if they can give me any advice on conquering it? THANKS! :D


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Salk Institute Board of Trustees Elects Leaders in Venture Capital and Publishing
The Board of Trustees of the Salk Institute unanimously voted to elect three new members during its Nov. 13 meeting in La Jolla.
Fred Dotzler is co-founder and Managing Director of De Novo Ventures in Palo Alto, Calif. The company currently manages $650 million and invests in early stage medical device and biotechnology companies. During his career as a medical and biotechnology sector venture capitalist, Dotzler has invested in four companies that achieved market values greater than $1 billion. They include: San Diego-based Biosite (acquired by IMC), Inhale Therapeutic Systems, Omnicell, and Tularik Inc. (acquired by Amgen).
Prior to venture capital, Dotzler served in positions in marketing, finance, and operations for Searle, Millipore, Merrimack Laboratories, and IBM. Dotzler earned an MBA from the University of Chicago, a master's equivalent in Economics from the University of Louvain, Belgium, and a bachelor's degree in Engineering from Iowa State University, where he received a Professional Achievement Citation in Engineering in 2000.
The Salk Board of Trustees also elected literary agent Linda Chester. She begins her three-year term after having served as liaison to the Board for the Institute's International Council. Chester is founding president of the Linda Chester Literary Agency, which has bi-coastal offices (New York City and La Jolla, Calif.) and has represented many bestselling authors. Her agency represents a wide variety of adult literary and commercial fiction, as well as an array of non-fiction projects in areas that include science, business, finance, history, popular culture, spirituality, and biography.
Mary Jane Salk, who also comes from the publishing world, is replacing Chester as International Council liaison. She has served as editor of Magazine Management and editorial director of Transworld Feature Syndicate, an international magazine consortium. The widow of Dr. Lee Salk, brother to Dr. Jonas Salk, she is the author of five young adult books for Chelsea House Publishers, and was associate producer of the feature films Goodbye, New York and Forever Lulu.
She currently is a board member of several organizations, including Daytop Village Foundation, the oldest drug-free self-help program in the United States, and The Doe Fund, a cost-effective, holistic program that breaks the cycles of homelessness, addiction and criminal recidivism in New York City and Philadelphia.


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The 23-199 8 in. Variable Speed Grinder has patented toolless quick change wheels and variable speed control offering you convenience and versatility in your grinding, sharpening, buffing and polishing operations
|Motor: 5 AMP, 120 Volt, 1 Phase
|Shaft Diameter: 5/8 in.
|Wheel Dimensions: 8 in. Diameter x 1 in. Thick
|Wheel Speed: 2,000 to 3,400 RPM
|Wheel Grit: 36 Grit Coarse and 60 Grit Friable
|Cord Length: 6 feet
|Assembled Depth: 11 in.
|Assembled Width: 16 1/2 in.
|Assembled Height (not including light): 12 1/2 in.
|Base Dimensions: 7 1/2 in. Depth x 9 3/4 in. Width
|Tool Weight: 41.1 lbs.
|Shipping Weight: 45.5 lbs.
DELTA will repair or replace, at its expense, and its option, any new DELTA machine, machine part, or machine accessory which in normal use has proven to be defective in workmanship or material, provided that the customer returns the product prepaid to a DELTA factory service center.Get more info on DELTA's Warranty
You will need a free copy of Adobe Acrobat Reader to view DELTA Manuals & Drawings.Download Adobe Acrobat


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Wednesday Night Skate
Meet at 7:45pm at the south end of Union Square. At this hump-day social, dozens of skaters cruise around the city for two hours along a different route each week—the group has previously wheeled through Central Park, Queens, Brooklyn and even Jersey. All skill levels are welcome as long as you can stop and turn, and because you'll be rolling on the road, helmets and wrist guards are obligatory. The hobnobbing continues postskate at Mumbles bar and restaurant (179 Third Ave at 17th St; 212-477-6066, mumblesnyc.com), which is also where the gang heads if the event gets rained out.
|Venue name:
|Union Square
14th St to 17th St between Union Sq West and Park Ave South
New York
|Subway: L, N, Q, R, 4, 5, 6 to 14th St–Union Sq
|Event website:
To improve this listing email: email@example.com


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Results 1 to 2 of 2
Thread: Silly city slicker...
Silly city slicker...
the sticks are for hicks!
DALLAS The way Bobby Williams tells it, his ranch on 100 acres of rural piney hills in East Texas was supposed to be a quiet way to enjoy retirement after a career in the insurance business.
But for years now, he's instead woken up to the roaring engines of all-terrain vehicles, midnight fireworks shows and thousands of drunken revelers who every so often gather across the narrow county road from his property at events like the "Texas Redneck Games" and the "Texas Redneck Muddy Gras."
"We're just a nice calm community and nobody can get any rest, nobody can get any sleep," says Williams, 76. "We've got a problem and I don't know what we're ever going to do to get rid of it. We need something to ban these things."
The latest event ended Sunday with more than 50 arrests and citations, and authorities said Wednesday that they're considering charges against the show's organizer.
Modeled after similar games that have been going in Georgia for more than a decade, the four-day "Redneck Games" took place about 70 miles southeast of Dallas and included an estimated 6,000 people, live music and competitions such as an ugly "butt-crack contest" and the "Mattress Chunk."
The goal in the mattress contest was to see how far a team of two people could throw a mattress from the back of a pickup truck.
By the time the event was over, more than 54 arrests and citations had been issued on charges ranging from public intoxication to speeding, according to the Henderson County Sheriff's Department. Officials are considering charges against the organizer and landowners where the event was held.
"I'm an old fuddy duddy and all that, but you got a vehicle, you got alcohol, and you got illegal dumping, and you're making a contest out of that?" said Lt. Pat McWilliams, public information officer for the sheriff's department. "We are very fortunate that we didn't have a fatality."
McWilliams said the organizer, Oscar Still of Kilgore, could face a misdemeanor charge for not having a permit. Telephone messages left with Still weren't immediately returned Wednesday.
Texas law requires any gathering of more than 2,500 people to get a permit, which McWilliams said Still didn't have.
Adults had to pay an admission fee of $25 plus $15 for each ATV. Children were free.
McWilliams said the misdemeanor charge carries a fine of $1,000 and 90 days in county jail.
He said it was less clear if there was any wrongdoing by Garland Pool, the owner of the 3,000 acre Pool Ranch ATV Park, a mix of sand, mud bog, prairie and forest where the events were held.
The Pool family was described by many as longtime residents in the area.
Pool, who lives about 5 miles from the ATV ranch, said he was aware of neighbor complaints but hadn't heard anything from the sheriff's department.
"That's all I know. Since I leased the property I'm not in charge of whatever happens out there," he said. "Maybe the neighbors don't particularly like the traffic, but it seems like most of the businesses in town had a lot of success."
During the event, some two dozen troopers with the Department of Public Safety, a dozen agents with the Texas Alcoholic Beverage Commission, 38 sheriff's deputies and other local law enforcement were on hand at one point or another to maintain crowd control, McWilliams said.
On its Web site, the Redneck Games has a list of rules, including no underage drinking, a 10 mph speed limit and no fence cutting. "Being a REDNECK is allowed.....IGNORANCE is not," according to rule No. 5.
There were other competitions, including one to see which guy could throw an engine starter the farthest and a "Daisy Duke Show-Off" for women in cut-off blue jeans. Cash prizes ranged from $40 up to $200 per contest.
Williams said he and about 100 neighbors have started a petition to stop the gatherings. But he's not too optimistic, he said as a work detail made up of local inmates picked up discarded beer cans, bags of trash and hamburger wrappers across the street.
"We need someone to tell the people they can't do this, they can't destroy our lives," he saNo I'm not dead
Yeah.... I can't really say I would like that nonsence going on in my back yard.
People should be able to do what they want on there property but it sounds like it is invading the neighbors rights and that is a no-no.
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