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Recommendations and Guidelines for Preoperative Evaluation of the Surgical Patient with Emphasis on the Cardiac Patient for Non-cardiac Surgery
- Clyde Melvyn Wells
- 3 years ago
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1 Recommendations and Guidelines for Preoperative Evaluation of the Surgical Patient with Emphasis on the Cardiac Patient for Non-cardiac Surgery
2 Recommendations and Guidelines For Preoperative Evaluation Of the Surgical Patient With Emphasis on the Cardiac Patient For Non-cardiac Surgery John H. Tinker, M.D. Professor and Chair Anesthesiology Department University of Nebraska Medical Center Richard R. Miles, M.D. Associate Professor and Chief, Section of Cardiology Myrna C. Newland, M.D. Associate Professor Anesthesiology Barbara J. Hurlbert, M.D. Professor, Anesthesiology Medical Director, Anesthesia Preoperative Evaluation Unit Barbara J. Sink, MPAS, PA-C Anesthesia Preoperative Evaluation Unit Kathi M. Healey, R.N., M.S.N. Nurse Practitioner Clinical Director, Lipid Clinic Stephen J. Froscheiser, B.S. Computing Support Bill Wassom, B.A. Graphic Designer University of Nebraska Medical Center
3 Preoperative preparation of the patient for non-cardiac surgery may be complex. The variety of presenting conditions may be difficult to define prior to surgery: What tests should be ordered? When is a long-standing condition in satisfactory control, or should some additional study or medication be added prior to operation? What are the risks of anesthesia and of the operation for the patient? The following collection of information from many sources is designed to be a quick reference for anyone who is involved in the preparation of the patient for non-cardiac surgery. These are proposed guidelines and in no way should supersede good clinical evaluation and assessment. The following information has been reviewed by Richard R. Miles, M.D., Cardiology; Myrna C. Newland, M.D., Anesthesiology; B. Timothy Baxter, M.D., Vascular Surgery; and Frank O. Hayworth, M.D., Anesthesiology. Compilation of the following references was through the efforts of Barbara J. Sink, PA-C, Anesthesia Preoperative Evaluation Unit; Kathi M. Healey, R.N., M.S.N., Cardiology; and computing support from Stephen J. Froscheiser, B.S., Anesthesia Preoperative Evaluation Unit. Myrna C. Newland, M.D. Associate Professor Anesthesiology University of Nebraska Medical Center 2
4 Table of Contents Classification Conditions for Preoperative Evaluation Preoperative Algorithm Surgical Classification ASA Classification Cardiovascular Cardiovascular Evaluation Guidelines Vascular Surgery Addendum Preoperative Physical Exam Cardiac Murmurs Reading an EKG NYHA Classification of CHF Pathology-Unstable Angina Syndromes with Associated Cardiovascular Involvement.. 35 Down s Syndrome Antihypertensive Therapy Pheochromocytoma Ischemic Heart Disease Echocardiography Prophylaxis Guidelines for Endocarditis Anesthesia Cardiac Risk Stratification Difficult Airway Algorithm (Note also: Down s Syndrome, 30) States That Influence Airway Management NPO Status for Surgical Patients Pulmonary Function Tests The Assessment of Dyspnea Labs Preoperative Test Recommendation Guidelines Patient Charges: Inpatient/Outpatient Information for Blood Typing Normal Lab Ranges Medications/Chemotherapy Medications to Be Avoided Prior to Surgery Drug Allergy vs. Drug Intolerance Chemotherapy/Toxicity Blood Product Risks General Information Telephone Number List Reference Chart
5 Conditions for Which Preoperative Evaluation Is Strongly Recommended Prior to the Day of Surgery General Medical condition inhibiting ability to engage in normal daily activity Medical conditions necessitating continual assistance or monitoring at home within the past 6 months Admission within the past 2 months for acute or exacerbation of chronic condition Cardiocirculatory History of angina, coronary artery disease, myocardial infarction Symptomatic arrhythmias Poorly controlled hypertension (diastolic >110, systolic >160) History of congestive heart failure Respiratory Asthma/COPD requiring chronic medication or with acute exacerbation and progression within past 6 months History of major and/or lower airway tumor or obstruction Upper and/or lower airway tumor or obstruction History of chronic respiratory distress requiring home ventilator assistance or monitoring Endocrine Non-diet controlled diabetes (insulin or oral hypoglycemic agents) Adrenal disorders Active thyroid disease Neuromuscular History of seizure disorder or other significant CNS disease (e.g., multiple sclerosis) History of myopathy or other muscle disorders Hepatic Any active hepatobiliary disease or compromise 4
6 Musculoskeletal Kyphosis and/or scoliosis causing functional compromise Temporomandibular joint disorder Cervical or thoracic spine injury Oncology Patients receiving chemotherapy Other oncology process with significant physiologic residual or compromise Gastrointestinal Massive obesity (>140% ideal body weight) Hiatal hernia Symptomatic gastroesophageal reflex Clinical Anesthesia Updates. Preanesthesia Evaluation of the Surgical Patient, vol. 6, #2, p. 5. L. Reuven Pasternak, M.D., M.P.H. 5
7 Preoperative Evaluation by Primary Team Determine: ASA status (table 9-3) surgery classification ASA 1 ASA 2-4 order appropriate labs, CXR, EKG (per table 23.11) order appropriate labs, CXR, EKG (per table 23.11) Normal findings PTC visit schedule pt. in O.R. abnormal findings other than correctable labs ( refer to ASA #2 Correctable labs (or normal) Corrected w/no further abnormalities *PTC visit * PT SHOULD BRING H&P, CHART, SURGICAL CONSENT, BLOOD CONSENT AND ORDERS WITH THEM TO THE P.T.C. abnormal findings LABS CXR EKG labs requiring further work-up (i.e. consult) appropriate follow up w/ corrections where needed *PTC visit schedule in O.R. normal w/ no other abnormalities PTC visit Schedule in O.R. abnormal CT or Pulmonary consult as indicated appropiate follow up completed *PTC visit schedule in O.R. normal abnormal or abnormal findings on cardiac exam refer to algothithm (10-2) cardiology consult required pt. cleared for surgery *PTC visit scheduled pt. in O.R. further follow up by cardiology required prior to scheduling pt. for surgery normal findings PTC visit schedule in O.R. if no consult required *PTC visit schedule pt. in O.R. U.S.C. weight limit 300 lbs Page 7777 if over 300# PFT'S: intrathoracic or extrathoracic mass lobectomy w/ possible pneumoetomy. Bedside PFT'S: thoracic procedure or major abdominal procedure with preexisting pulmonary disease (moderate-severe). ABG'S: suspected CO2 retainer (if abnormal, obtain PFT's) 6
8 (Guide to Estimation of Physiological Trespass) Category 1 Minimal risk to the patient independent of anesthesia Surgical Classification System Minimally invasive procedures with little or no blood loss Often done in office setting with the operating room used principally for anesthesia & monitoring Includes: Breast biopsy Removal of minor skin or subcutaneous lesions Myringotomy tubes Hysteroscopy Cystoscopy Vasectomy Circumcision Fiberoptic bronchoscopy Excludes: Open exposure of internal body organs Repair of vascular or neurologic structures Placement of prosthetic devices Entry into abdomen, thorax, neck, cranium, or extremities Postoperative monitored care setting (ICU, ACU) Open exposure of abdomen, thorax, neck, cranium Resection of major body organs 7
9 Category 2 Minimal to moderately invasive procedure Blood loss less than 500 cc Mild risk to patient independent of anesthesia Surgical Classification System Includes: Diagnostic laparoscopy Dilation & curettage Fallopian tubal ligation Arthroscopy Inguinal hernia repair Laparoscopic lysis of adhesions Tonsillectomy/adenoidectomy Umbilical hernia repair Septoplasty/rhinoplasty Percutaneous lung biopsy Laparoscopic cholecystectomy Extensive superficial procedures Excludes: Open exposure of internal body organs Repair of vascular or neurologic structures Placement of prosthetic devices Postoperative monitored care Major vascular repair (e.g., aortofemoral bypass) Planned postoperative monitored care setting (ICU, ACU) 8
10 Category 3 Moderately to significantly invasive procedure Blood loss potential 500 1,500 cc Moderate risk to patient independent of anesthesia Surgical Classification System Includes: Thyroidectomy Hysterectomy Myomectomy Cystectomy Cholecystectomy Laminectomy Hip/knee replacement Nephrectomy Major laparoscopic procedures Resection, reconstructive surgery of the digestive tract Excludes: Open thoracic or intracranial procedure Major procedure on the oropharynx Major vascular, skeletal, neurologic repair 9
11 Category 4 Highly invasive procedure Blood loss greater than 1,500 cc Major risk to patient independent of anesthesia Surgical Classification System Includes: Major orthopedic-spinal reconstruction Major reconstruction of the gastrointestinal tract Major genitourinary surgery (e.g., radical retropubic prostatectomy Major vascular repair without postoperative ICU stay Category 5 Highly invasive procedure Blood loss greater than 1,500 cc Critical risk to patient independent of anesthesia Usual postoperative ICU stay with invasive monitoring Includes Cardiothoracic procedure Intracranial procedure Preanesthesia Evaluation of the Surgical Patient, Vol. 6, No. 2, Pg. 4, Table 2. 10
12 Physical Classification of the American Society of Anesthesiologists (ASA) Status ASA Class 1 ASA Class 2 Disease State No organic, physiologic, biochemical, or psychiatric disturbance. Mild to moderate systemic disturbance that may or may not be related to the reason for surgery Examples: Heart disease that only slightly limits physical activity, essential hypertension, diabetes mellitus, anemia, extremes of age, morbid obesity, chronic bronchitis ASA Class 3 Severe systemic disturbance that may or may not be related to the reason for surgery, (does limit activity) Examples: Heart disease that limits activity, poorly controlled essential hypertension, diabetes mellitus with vascular complications, chronic pulmonary disease that limits activity, angina pectoris, history of prior myocardial infarction ASA Class 4 Severe systemic disturbance that is life-threatening with or without surgery Examples: Congestive heart failure, persistent angina pectoris, advanced pulmonary, renal, or hepatic dysfunction ASA Class 5 Moribund patient who has little chance of survival but is submitted to surgery as a last resort (resuscitative effort) Examples: Uncontrolled hemorrhage as from a ruptured abdominal aneurysm, cerebral trauma, pulmonary embolus. Emergency Operation (E) Any patient in whom an emergency operation is required Example: An otherwise healthy 30-year-old woman who requires a dilation and curettage for moderate but persistent hemorrhage (ASA Class 1 E) From information in American Society of Anesthesiologists 11
13 ANESTH ANALG 2002: 94: SPECIAL ARTICLE ACC/AHA TASK FORCE ON PRACTICE GUIDELINES ACC/AHA TASK FORCE PERIOPERATIVE CARDIOVASCULAR EVALUATION GUIDELINES STEP 1 Need for noncardiac surgery Emergency surgery Operating Room Postoperative risk stratification and risk factor management *Vascular Surgery pt. * Pheochromocytoma * Down's Syndrome (see attachments) Urgent or elective surgery No STEP 2 STEP 3 STEP 4 Consider delay or cancel noncardiac surgery Coronary revascularization within 5 yr? No Recent coronary evaluation No Major clinical predictors** Yes Clinical predictors Consider conorary angiography Yes Yes STEP 5 Recurrent symptoms or signs? Recent coronary angiogram or stress test? Unfavorable result or change in symptoms Intermediate clinical predictors Go to step 6 favorable results and no change in symptoms Operating Room Minor or no clinical predictors Go to step 7 Major Clinical Predictors** Unstable coronary syndrome Decompensated CHF Significant arrhythmias Severe valvular disease Medical management and risk factor modification Subsequent care dictated by findiings and treatment results 12
14 STEP 6 Clinical predictors Intermediate clinical predictors Functional capacity Poor (<4 METs) Moderate or excellent (>4 METs) Surgical risk High surgical risk procedure Intermediate surgical risk procedure Low surgical risk procedure STEP 8 Noninvasive testing Noninvasive testing Low risk Operating room Postoperative risk stratification and risk factor reduction High risk Invasive testing Consider coronary angiography Subsequent care* dictated by findings and treatment results Intermediate Clinical Predictors Mild angina pectoris Prior Ml Compensated or prior CHF Diabetes mellitus Renal insufficiency 13
15 STEP 7 Clinical predictors Minor or no clinical Predictors Functional capacity Poor (<4 METs) Moderate or excellent (>4 METs) Surgical risk High surgical risk procedure Intermediate or low surgical risk procedure STEP 8 Noninvasive testing Noninvasive testing Low risk Operating room Postoperative risk stratification and risk factor reduction High risk Invasive Testing Consider coronary angiography Subsequent care* dictated by findings and treatment results Minor Clinical Predicators Advanced age Abnormal ECG Rhythm other than sinus Low functional capacity History of stroke Uncontrolled systemic hypertension Stepwise approach to preoperative cardiac assessment. Steps are discussed in text. *Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care. 14
16 Cardiovascular Evaluation for Noncardiac Surgery Name: Vitals: Cardiac Meds: Surgery Risk: High Intermediate Low (Emergency surgery; (Carotid endarterec- (Endoscopic; super- Aortic & major vascu- tomy; head & neck; ficial procedure; lar; PV surgery; proce- intraperitoneal; intra- cataract; breast dures & blood loss or thoracic; orthopaedic; surgery) large fluid shifts) prostate) Existing Cond: CHF: Angina Stable/Unstable (Compensated/decompensated) MI Arrhythmias >5 PVC/min CABG 5 yrs 5 yrs AICD Valvular Disease w-w/o repair/replacement Pacer AAA w-w/o repair IHSS Cardiac Arrest BBB/Sick Sinus Risk Factors: Age Sex Obesity Smoking Family Hx. HTN Hypercholesteremia Comorbid Conditions: DM COPD PVD TIA/CVA Poor General Med. Condition 1. Electrolyte abn. (K meq/l or HCO 3 meq/l) 2. Renal insufficiency (BUN 50 mg/dl or creat. 3.0 mg/dl) 3. Abnormal ABG s (PO 2 60 mmhg or PCO 2 50 mm Hg) 4. Abnormal liver status 5. Chronically bedridden Meds: (possible cardiac toxicity) 15
17 Symptoms/findings: dyspnea palpitations rales orthopnea syncopal episodes peripheral edema chest pain lightheadedness cardiomegaly pulmonary edema/ tortuous or calcified abnormal EKG infiltrates aorta on CXR in past yes Duke Activity Status Index: 1 4 METS(Eating, dressing, walking around house, dishwashing) 4 10 METS(Climbing stairs 1 flight, walking level ground 6.4 km/hr, running short distance, game of golf) 10 METS(Swimming, singles tennis, football) MET: metabolic equivalent. 1 MET = 3.5 ml of O 2 /Kg/min. Results: EKG ECHO CATH STRESS CXR 1. Have you had any chest pain? yes/no 2. Have you experienced breathlessness on exertion? yes/no 3. Have you experienced breathlessness lying flat? yes/no 4. Has any form of heart disease ever been diagnosed? yes/no 5. Have you had rheumatic fever? yes/no 6. Have you ever been found to have a heart murmur? yes/no Paterson K. Retal: The preoperative electrocardiogram: an assessment. Scot Med J 28: ,
18 Response to: Recommendations and Guidelines for Preoperative Evaluations This is a very inclusive document which covers the basics of anesthesia preoperative evaluation. The crux of this handout is the algorithm which outlines the preoperative cardiac assessment. Although I generally agree with this outline, there were a few places which may result in unnecessary preoperative noninvasive testing: 1. Under Step 6 in patients with moderate or excellent functional capacity undergoing high-risk surgical procedures. I am assuming that the high-risk procedures may include lower extremity bypass, aortic aneurysm repair, and carotid endarterectomy. Noninvasive testing will invariably be positive in many of these patients. There is, to my knowledge, no good data to support a role for coronary revascularization in a patient with moderate or excellent functional capacity. I would suggest at this decision point that a second option would be to undergo an operation with invasive preoperative monitoring and optimization. 2. Under Step 7 in the high surgical risk procedure group with minor clinical predictors, I would also suggest that a decision be made prior to noninvasive testing to consider a surgical procedure with invasive preoperative monitoring. These decisions should be made between the surgeon and the patient with the understanding of what the risk entails. An article published in the Journal of the American Medical Association, which used computer modeling to assist the outcome of vascular surgery in patients who were moderately or mildly symptomatic, demonstrated an increased mortality in patients who underwent a preoperative evaluation. This was related to the fact that coronary revascularization, because of its own inherent risks, does not lower the overall operative mortality. Therefore, I would submit that we may be doing patients a disservice in these categories by not giving them the option of going directly to surgery. I think the data from the Portland group published in the Journal of Vascular Surgery, in which none of these patients with intermediate or minor clinical predictors were evaluated, and the overall operative mortality was <2%, clearly shows that it is unnecessary to subject these patients to noninvasive testing and possible coronary angiography. Especially considering the cost of this and the probability that the overall recommendation would simply be to use invasive monitoring. Sincerely, B. Timothy Baxter, M.D. Associate Professor Department of Surgery 17
19 Preoperative Physical Examination Vital Signs: Current values and range while hospitalized Height, Weight: For calculation of drug dosages and pump flows Airway: Anatomic features that could make mask ventilation or intubation difficult Neck: Jugular venous distention (CHF) Carotid bruit (cerebrovascular disease) Landmarks for jugular vein cannulation Heart: Murmurs characteristic of valve lesions S 3 (increased LVEDP) S 4 (decreased compliance) Click (MVP) or rub (pericarditis) Lateral PMI displacement (cardiomegaly) Precordial heave, lift (hypertrophy, wall motion abnormality) Lungs: Rales (CHF) Rhonchi, wheezes (COPD) Vasculature: Sites for venous and arterial access Peripheral pulses Abdomen: Pulsatile liver (CHF, tricuspid regurgitation) Extremities: Peripheral edema (CHF) Nervous System: Motor or sensory deficits Clinical Anesthesia, 2nd ed. Barash, Cullen, Stoelting. Chapter 36, pp
20 Preoperative Findings Suggestive of Ventricular Dysfunction History: History of MI, intermittent or chronic CHF Symptoms of CHF: fatigue, DOE, orthopnea, PND, ankle swelling Physical Examination: Hypotension/tachycardia (severe CHF) Prominent neck veins, laterally displaced apical impulse, S 3, S 4, rales, pitting edema, pulsatile liver, ascites (tricuspid regurgitation) Electrocardiogram: Ischemia/infarction, rhythm, or conduction abnormalities Chest X-ray: Cardiomegaly, pulmonary vascular congestion/pulmonary edema, pleural effusion, Kerley B lines Cardiac Testing: Cath data LVEDP >18, EF <0.4, Cl <2.0 l/min 1 /min 2 Echocardiography low EF, multiple regional wall motion abnormalities Venticulography low EF, multiple areas of hypokinesis, akinesis, or dyskinesis Clinical Anesthesia, 2nd ed. Barash, Cullen, Stoelting. Chapter 36, pp Grading of Cardiac Murmurs I. Faintest audible; can be heard only with special effort II. Faint, but easily audible III. Moderately loud IV. Loud; associated with a thrill V. Very loud; associated with a thrill. May be heard with a stethoscope off chest VI. Maximum loudness; associated with a thrill; heard without a stethoscope Practical Guide to the Care of the Medical Patient, 2nd ed. Fred F. Ferri, M.D. Chapter 3, p
21 CARDIAC MURMURS MURMUR LOCATION CHARACTER DIFFERENTIAL Still s benign pediatric Murmur LLSB to apex Coarse, vibrating early systolic; S 2 splits and closes normally, murmur diminishes with sitting or deep inspiration VSD, MVP, IHHS Venous hum benign pediatric murmur Neck, USB apex just above the clavicle either medial to the sternocleidomastoid or between its insertions, more on right side Continuous, gone when supine PDA, AVMs MVP (Mitral Valve Prolapse) (Barlow s syndrome), associated with various inherited connective tissue diseases including Ehlers-Danlos, Marfan s, Osteogenesis imperfecta, von Willebrand s Heard best at apex Midsystolic click (92%), Crescendo mid-to-late systolic murmur (85%) that moves toward S 1 with standing or other decrease in venous return Sx: Palpitations (PACs, PVC s, premature junctional) Cmplc: Sudden death rarely, PVC, TIA/CVA EKG: normal 76%, may show inferior and/or, apical ischemia or PVCs Aortic Stenosis- most common in elderly now. Rarely (10%) due to RHD, most is calcific aortic stenosis on bicuspid or previously normal valve Loud ejection murmur maximum at base and transmitted into neck vessels, often associated with a thrill or ejection click; no MR unlike in IHSS; ejection click (split first heart sound) radiates into carotids The ejection murmur may be soft, distant in patients with low cardiac output, obesity and/or COPD Strong apical impulse Narrowing of pulse pressure later stage may have a necrotic notch on carotid upstroke Loud rough systolic diamond shaped murmur Sx: Often asx, fatigue, exertional dyspnea, Angina, CHF, syncope,dysphagia Si: BP normal; narrow pulse pressure; Cmplc: Angina, sudden death, GI-angiodysplasia with GI bleed, ischemia, Vtach/fib CHF, SBE, heart blocks EKG: normal, or LVH and strain, ST-T wave changes CXR: May show 4 chamber enlargement, valvular calcifications usually only with significant disease, LVH, poststenotic dilation of ascending aorta, pulmonary congestion R/O bicuspid aortic valve Accentuation: Valsalva release Sudden squatting Passive leg raising Decrease: Handgrip Valsalva Standing Significant if area <0.8cm 2 /M 2 or mean gradient > 35mmHg Aortic Insufficiency, severe rarely due to RHD, usually due to trauma, syphilis, dissecting aneurysm, endocarditis, SLE, RA, ankylosing spondylitis S 3 heard over the apex, LSB at 3 rd or 4 th intercostal space Displacement of cardiac impulse downward and to the patient s left the aortic regurgitant murmur is difficult to hear if the heart rate is greater than 90 bpm Decrescendo, blowing diastolic murmur, early systolic apical ejection murmur Sx: Gradual CHF Austin Flint murmur (low pitched apical diastolic rumble heard in severe AR), syncope, chest pain, dyspnea on exertion SI: widened pulse pressure, bounding pulses, head bobbing with each systole, water hammer: or collapsing pulse Corrigan s pulse) at the wrist, capillary pulsations (Quincke s pulse) base of nail beds, double Duroziez a to and fro murmur over femoral arteries EKG: LVH CXR: LVH, aortic dilation Accentuation: Sudden squatting Isometric handgrip Sitting up and leaning forward 20
22 CARDIAC MURMURS MURMUR LOCATION CHARACTER DIFFERENTIAL Mitral Stenosis, most common in females age 20-40, always present in RHD to some degree, Significant if valve diameter <1.2cm 2 History of and/or high risk for peripheral arterial embolus especially if Afib is present mid-diastolic murmur with presystolic accentuation even in Afib; opening snap; loud S 1, rumbling, Right ventricular lift over lower sternum Si: Exertional dyspnea, orthropnea, hemoptysis due to shunts from pulmonary veins to bronchial veins, PND Atrial fibrillation Cmplc: CHF, SBE, emboli, pulmonary edema with exertion EKG: Afib, RVH, Rt Axis, LAE CXR: large left atrium, pulmonary artery, and right ventricle and may show valvular calcifications Accentuation: Exercise Left lateral position Isometric handgrip Coughing After Valsalva stranding Squatting Mitral Regurgitation, most common in females age 20-40, 70% with chronic MR in 1960s was due to RHD, 30% due to chordae rupture from MI, endocarditis and trauma Holosystolic murmur at apex with radiation to base or left axilla and Left posterior intrascapular area Hyperdynamic apex often with palpable left ventricular lift and apical thrill Apical early-to middiastolic rumble In chronic mitral regurgitation the murmur maybe heard midial to left scapula secondary to severe left atrial enlargement Sx: Exertional dyspnea, orthopnea, fatigue, Frank CHF, hemoptysis (caused by pulmonary hypertension) EKG: LAE, LVH, Atrial fibrillation CXR: LAE, LVE, possible pulmonary congestion Accentuation: Sudden squatting Isometric handgrip Decrease: Valsalva Standing Tricuspid Stenosis, usually accompanies mitral or aortic disease but occurs in only 2-4% of patients with RHD Can also be seen with carcinoid sydrome as an isolated finding RV area Diastolic, scratchy Increase during moving inspirations Jugular venous distension with failure to collapse on inspiration Accentuation: Inspiration Passive leg raising Right lateral decubitis Decrease: Expiration Tricuspid Insufficiency, usually accompanies mitral or aortic disease but occurs in only 2-4% patients with RHD May be present with any cause of severe pulmonary hypertension or carcinoid syndrome Best at LLSB, occasionally best at epigastrium, at the RSB or if the RV is very large, over the mid-left thorax at the site of the usual LBV apex usually accompanied by RVS 3 Pansystolic that increases with inspiration at the LLSB, (or wherever a palpable RV lift is felt-carvallo sign) Accentuation: Inspiration Passive leg raising By exercise By pressure over or just below the liver Decrease: Expiration 21
23 CARDIAC MURMURS VSD MURMUR LOCATION CHARACTER DIFFERENTIAL LLSB, Apical Frequently left chest will be mor prominent than right with larger VSDs Loud harsh pansystolic murmur at lower left sternal border, widely transmitted over precordium. Apical diastolic rumble if large shunt loud P 2 if pulmonary hypertension Causes a left-to-right shunt, which in end stage disease reverses to right-to-left shunt (Eisenmenger s syndrome) with clubbing and cyanosis Sx: Usually asx; can develop dyspnea, fatigue, and pulmonary infections Cmplc; SBE, CHF, pulmonary hypertension,with Eisenmenger s 2/3 die in pregnancy EKG: normal unless huge left-to-right causing LVH; RVH suggests fixed pulmonary hypertension and left atrial enlargement CXR: usually normal, large defects causing LVH and prominent pulmonary vasculature and large left atrium. Small aortic knob. Pulmonic Stenosis Systolic murmur ULSB, neck and back 2 nd Left interspace P 2 diminished; loud ejection murmur at upper left sternal border neck and back ; ejection click, decreases with inspiration RV lift is gradient is significant Sx: fatigue dyspnea, cyanosis, CHF Si: CHF including hepatomegaly in children Cmplc: SBE, CHF EKG: normal, or LVH +strain; P pulmonale CXR: PA dilatation, RVH, diminished pulmonary vasculature Accentuation: Valsalva release Decrease: Expiration Pulmonary Regurgitation Slight delay after the P 2 before any murmur is heard, even if it starts with the P 2, the murmur tends to be short and rough, decrescendo Graham-Steell murmurhigh pressure in the pulmonary artery LSB > RSB Diastolic decrescendo murmur heard in severe pulmonary hypertension, secondary to pulmonary regurg High pitched, often increases with inspiration IHSS (Idiopthic hypertrophic subaortic stenosis) Genetic positive family history in 1/3 Abnormal Intraventricular septum produces dynamic aortic root obstruction and subaortic stenosis; mitral regugitation is due to anterior mitral leaflet being distorted by the septum Admistration of inotropic drugs may cause/worsen shock and/or cardiac arrhythmias Loud systolic LSB murmur after inotropes given SAM (systolic anterior motion of the mitral leaflet) Intolerent of decreased blood volume, & venous return, as it increases murmur intensity and outflow tract gradient Diphasic arterial systolic pulse, best palpated in the carotid arteries Aortic murmur without radiation into neck Si: LVH by palpation and double PMI Sx: dyspnea, syncope chest pain, angina that starts when exercise stops, palpitation Cmplc:Sudden death by Vtach/fib,endocarditis Afib EKG: LVH, big Qs in V 1-2 (hypertrophied septum) Holter for malignant PVCs. Nonspecific EKG changes CXR: LVH R/O: athlete s heart w LV wall thickness always <16mm, rarely > 13mm, which overlaps w IHSS in men but not in women Accentuation: Valsalva strain opposite of A.S. Standing Exercise Etoh Decrease: Handgrip Squatting Leg elevation 22
24 CARDIAC MURMURS MURMUR LOCATION CHARACTER DIFFERENTIAL Coarctation of the aorta Associated with PDA, bicuspid aortic valve Left upper back or pulmonic area Systolic murmur Sx: CHF, leg pains, & fatigue, headachesrarely in childhood; CHF in 3 rd -4 th decades Si: hypertension in arms, normal or low BP in legs; decreased/delayed femoral pulses compared to radial pulses Cmplc: SBE, intracranial bleeding, hypertensive encephalopathy; ruptured/dissected aorta; hypertensive cardiovascular disease Risk of aortic dissection remains even after repair EKG: normal, or LVH; RVH, suggests a PDA beyond the coarc CXR: normal heart, and pulmonary vasculature; coarc visible on plain chest occasionally notch in aortic root shadow; rib notching in older patients PDA (Patent Ductus Arteriosus) Left base Machinery murmur or Gibson murmur or to & fro murmur L-to-R shunt, which in end-stage disease reverses to R-to-L shunt (Eisenmenger s syndrome) with clubbing and cyanosis; bounding pulses indicate wide pulse pressure; pink fingers, blue toes with Eisenmenger s Cmplc: SBE, CHF, pulmonary hypertension; with Eisenmenger s, 2/3 die in pregnancy EKG: normal; occasionally LVH: if has RVH, suggest fixed pulmonary hypertension CXR: Normal, with small PDA; or w larger one, LVH, enlarged aortic knob with dilatation of the proximal relative to the distal aorta, and a large LA with prominent vasculature R/O : coronary AV fistula, Ruptured sinus of Valsalva, Coarctation of aorta AS/AR ASD(Atrial Septal Defects) Primum: AV canal defects including low ASD, high VSD, cleft mitral and/or tricuspid valves or a common AV valve Increased risk in Down s Syndrome Apical Harsh systolic murmur, pansystolic from MR (33%), TI or VSD (75%) P 2 increased; Fixed Split S 2 ; Si: cyanosis mild or absent, CHF, RVH Sx: dyspnea, fatigue, CHF, pulmonary infection Cmplc: CHF, pulmonary hypertension, SVT arrhythmias, SBE rarely, Increased incidence of rheumatic fever EKG: L axis, prbbb, R and LVH, counterclockwise rotation CXR: Small aortic knob; RVH and increase pulmonary flow, if MR, then large left atrium and LV; gooseneck deformity of LV outflow tract on angiography; serrated MV leaf 23
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text:
My Altar
Animal Reiki Dai Ko Myo Tibetan Dumo Master Huge 30x40mm Talisman Antique Gold Bronze Pendant
Pendant Size is 2" and Includes 24" chain. There is a clear glass cabochon dome over the artwork. Handmade by Artist Shoushan. It includes Gift Box.
Dumo is the kundalini master fire. It raises the sacred flame of the kundalini energy. It pulls, releases and removes all negative energy and disease from the body and from a room or space. It brings forth spiritual growth. Talismans promote "green environmentally friendly magic". Keeping a talisman is a great way to help manifest of your desires.

subset: commoncrawl


text:
Prime Urban Properties
University Row
Unit 224
Unit Details
2 Bedrooms
1 Bathroom
1028 Square Feet
Unit Type: B1
Private Balcony/Patio
Walk-in Closet
Corner Unit
9' Ceilings
Hard Surface Flooring
Floor-to-Ceiling Windows
In-Unit Washer/Dryer
Central Air
White Cabinets
$1675 (Includes Parking and a One-Year Anytime Fitness Membership) / month
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Community Room with Full Kitchen, Bathroom, Flat-Screen TV, free WIFI, and Gas Fireplace
Package Delivery Room
Interior Access to Anytime Fitness and EVP Coffee Shop
Complimentary Breakfasts
Planned Social Events
Laundry and Dry Cleaning Pick-Up/Drop-Off Services On Site
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Pitch in for Emory Cares International Service Day Nov. 12 (10-31)
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Lillian Carter Center marks 10 years of global outreach in nursing (10-31)
Sound policy makes good economic sense, say conference organizers (10-31)
Dipity online tool helps tame timelines (10-28)
Digital repository offers unrestricted access to scholarly articles (10-28)
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Social media experts connect at CNN Dialogues (10-07)
Glendon: Is religious freedom a second class right? (10-07)
Hospital bed tower gets zoning approval (10-07)
Second volume of Beckett Letters debuts in America at Emory (10-07)
Exhibit illuminates artistic freedom in 1920s Paris (10-05)
A soldier betrayed in Cuba's struggle for freedom (10-05)
Nominate an 'Unsung Heroine' (10-05)
Services for J. Willis Hurst, presidential cardiologist, are Oct. 8 (10-04)
Fair dishes up food, fun, knowledge and awards (10-04)
25 years of breast cancer awareness features a month of events (10-04)
Massage therapy offered to employees (10-03)
1920s 'Lost Generation' in Paris is talk topic Tuesday, Oct. 4 (10-03)
Explore Master of Arts in Teaching at free info sessions (10-03)
Pilot program seeks to enrich patient care (10-03)
Grand Rounds showcases public health faculty's work (10-03)


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The PNC Financial Services Group, Inc. is a diversified financial services company. The Company has businesses engaged in retail banking, including residential mortgage, corporate and institutional banking and asset management. The Company operates through four segments: Retail Banking, Corporate & Institutional Banking, Asset Management Group, and BlackRock. Retail Banking provides deposit, lending, brokerage, investment management and cash management products and services. Corporate & Institutional Banking provides lending, treasury management and capital markets-related products and services. Asset Management Group includes personal wealth management for high net worth and ultra-high net worth clients and institutional asset management. BlackRock, in which the Company holds an equity investment, is a publicly traded investment management firm providing investment and risk management services to institutional and retail clients across the world.
|Ex-dividend date
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|June 1, 2018
|February 13, 2018
|February 14, 2018
|March 1, 2018
Earnings Calendar and Events Data provided by |Terms of Use| © 2018 Wall Street Horizon, Inc.
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Reuters content is the intellectual property of Reuters. Any copying, republication or redistribution of Reuters content, including by caching, framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters is not liable for any errors or delays in content, or for any actions taken in reliance on any content. Reuters, Reuters Logo and the Sphere Logo are trademarks and registered trademarks of the Reuters Group of companies around the world.
Data is provided for information purposes only and is not intended for trading purposes. Reuters shall not be liable for any errors or delay in the content, or for any action taken in reliance on any content. The RIC or Reuters Instrument Code set has been developed and maintained by Reuters and is the intellectual property of Reuters.


text:
About us
Where we have been
About this website
Received spam?
Movie collection
Music collection
About us
Jan Zoetekouw works as portfolio manager and project manager at Capgemini on the portfolio of projects in the regions Benelux, Central Europe and Nordic. His hobbies are amongst others music, photography en travelling.
Diana Zoetekouw works as marketing & sales manager at Peter Hahn. Her hobbies are reading, travelling, gardening en cooking.
Where we have been
About this website
This website started in 1996. Originally hosted at the Digitale Stad Eindhoven, but since 2000 on our own Zoetekouw.com domain. In 2006 the website got tranformed into a weblog.
All photo's on this site are my own and should not be reproduced electronically or in print without my written permission. If you are interested in using any of the photo's, either for personal or business use, please contact me at jan(at)zoetekouw.com.


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Posts Tagged 'Min Wax'
What's the BeefMarch 25, 2015
This is a figurative and literal complaint with tenants and
homeowners alike. The kitchen is the most used room in the house and
wear and tear is evident on cabinetry, countertops, walls and floors.
It also appears as the most substantial room in the house; it is designed to be so.
Other rooms have walls, windows, a floor and perhaps a door.
kitchen comes equipped with walls covered in cabinetry, appliances and a
design you did not choose unless you designed the home or remodeled it
to your taste. It is also the one place in your home when a deciding on a
new design is sure to cost plenty.
Let's assume you don't make that decision. Remodeling your kitchen is an expensive proposition.
Homeowners dream about it and plan for it; tenants attempt to shrug it off, believing there is nothing they can do about it.
Worse, many people assume their own style in a home is defined by the cabinetry.
If you are a homeowner review these potential solutions for Cabinetry:
Painted cabinets
The most obvious fix is painting the cabinets. If this is the choice
you are making you may be surprised at the myriad of paint treatments
available. Study them carefully and choose one that fits your new design
plan. These pictures represent a before and after preview of a kitchen.
The angles are different but you can easily see they are the same
kitchen. While working with one couple we decided to paint the cabinetry
and switch the hardware and add new appliances; their completed design
appeared to be a brand new kitchen. The savings on this room alone was
b) To get a good finish that you will be proud of, plan on removing all the cabinet doors and hardware.
c) The hardware can be sprayed in a color or finish that compliments your cabinet paint selection.
d) If your cabinets are wood you can rent a small hand sander and rough up the existing finish and smooth out any blemishes.
e) If your cabinets are plastic coated (this is another shocker, a
lot of the newer cabinets are coated with plastic to appear wood) look
for the application that will adhere to the smooth finish allowing your
paint to adhere to the current finish.
f) Primitive and Country designs look great with the bases painted a
dark or neutral color; then add barn siding with adhesive and change
out the hardware to match.
g) Cottage designs work perfectly with the bases painted white and bead board adhered to the doors.
h) Southwestern designs look great with the spray on treatment that
looks like sandstone. Just apply and then spray the poly as a top coat.
i) Budget permitting, you can purchase new doors and finish them
with a stain or Min Wax. You will need to sand the bases and apply the
same stain treatment or purchase the covers for the bases when you buy
the doors.
This process will produce an entirely new kitchen when it is completed.
you are ready to tear out walls and redesign the kitchen;, you will
want to get bids and consult with at least two contractors, including
the stores who sell cabinetry or appliances They all offer ideas and
If you have the space, look for a table with drawers,
a buffet that is substantial or prep table and paint it a contrasting
color to create an island.
Add wood or Plexiglas chopping blocks
across the section you want to use for food prep and dramatically
increase your counter space.
Take a look at the trim pieces that Lowe's and Home Depot feature.
best rule of thumb abut arranging cabinets is this; Walk through your
kitchen and imagine preparing a meal, making and serving coffee or
snacks and all the activities you do in your kitchen. Without thinking,
go to the cabinet where you would expect the items necessary to complete
that tsk would be, not where you have them, but where you expect them
to be without thinking. This is where they go!
Cabinets should be arranged so that glasses, coffee cups and the items most used are around the sink area.
Plates, serving bowls and other place setting dishes and the larger bowls used for food preparation should be near the stove.
base cabinets should be used for canned goods, each placed near the
area where you keep the proper bowls to prepare or serve the items.
Small appliances and pans should be stored in the base cabinets near the area where they will be used.
ideal kitchen sports a triangular layout with the sink at mid point,
the range and refrigerator across from the sink to complete the triangle
layout. This is a step saving and time saving layout.
Your 'Plain
Jane' cabinets become rich, new and can even appear Tuscan by adding
the corner trim pieces to the base of your cabinet corners and the edges
of your upper cabinetry.
They appear to be deep and thick but
actually adhere to and wrap the corners of the cabinets; this completely
alters the appearance of the cabinets making them appear far more
Purchase the trim pieces that extend to the floor for
Tuscan, Spanish and Mediterranean designs. The wood is intricately
carved or super simple; choose the one that works with your design plan.
These are all available in faux wood with a foam backing to save money.
Matching decorative trim pieces can be used to replace the tiny one inch trim at the tops of the cabinets.
Trims To Change Your Style
Take a long, close look at the toe kickboards (the trim at the bottom
of the cabinets by the floor). If yours are wood, paint or touch up the
stain if they are scuffed.
b) If your kitchen cabinets are finished with the rubber trim that
has been used for many years in less expensive cabinetry, tear it off
and replace it.
c) Home improvement stores all offer this very affordably. Pick up a
can of adhesive while you're there. You need it in your 'tool kit!'
d) You must have your own tool kit!
e) If you have more than ample base cabinet space think about
leaving the doors and hardware off of one set of strategically placed
base cabinets; fill the screw holes with wood filler, sand and paint or
stain to match the cabinets and add decorative baskets that hold
vegetables and fruit.
f) This also works if you have located that perfect accessory table
to use as an island (one with a shelf). Look for baskets or containers
that compliment your style.
g) This is a space and time saver, providing easy access for food preparation.
h) If you have open wall space that does not offer anything you are
interested in using consider this option to add storage and interest to
that area.
Check your favorite thrift stores and Craig's List for a hutch that compliments or contrasts with your kitchen design.
Another storage solution:
thrift stores and yard sales for a hutch that is no more than 48″ wide;
find one that fits the style you have chosen. Anchor the hutch to the
wall with screws and add trim boards that match your kitchen trim.
Presto! You have a gorgeous new addition to your kitchen. You can paint
or finish this in a contrasting color or match to your cabinets with
Adding an eating area:
If you have a 'breakfast nook'
or eat in kitchen consider using a contrasting or matching base
cabinetry as your table base by simply adding a piece of glass to the
This also works with pieces of furniture such as accent
tables if they are the correct height. If you can imagine it, you can
make it happen!
Find seating that compliments your design and works for your family at thrift stores.
Adding an office area to your kitchen:
you have extra wall space in your kitchen, usually near a corner, and
need a computer workspace or small office; look for base cabinet drawers
or upper cabinets that add a look you want in your kitchen.
Measure the height! Too low is a back breaker and too high will make your arms so tired you never want to come back.
Place one cabinet at each end of the space and anchor them to the wall.
local cabinet installers and granite shops and ask about remnant pieces
and go out to check them out. They can cut it down for you to fit your
space; granite remnants are available in the $100.00 price range.
Use adhesive to anchor the top to the bases.
granite is not your style, look for glass pieces or narrow table tops
that can be disconnected from the legs and anchor the top to the
If your desktop is long enough, look for matching or
contrasting upper cabinets and anchor them at each end to complete your
private office with loads of storage.
If not, look for the
compartmentalized shelving units typically used for display and anchor
them to the wall above to maximize the use of space and increase
You can utilize an unused closet with these same tips.
are at the top of the list of things people hate about their kitchens.
They are either worn, burned, dated or just plain ugly.
the following solutions; if these do not seem feasible you may at least
have expanded your idea of what changes can be completed easily. If so,
apply a fix that feels right to you.
If you are planning a complete remodel of your kitchen
all of the tips and pitfalls, including pricing and arrangement, take
the time to get quotes and ideas from contractors as well as the home
improvement stores. Knowledge is power and will save you money!
Solid surface and granite countertops are the most desirable. If you
want them, then spend some time pricing and budgeting for the
As a rule of thumb; light cabinetry goes will with darker surface
countertops; dark cabinetry is compliment by lighter surface
countertops. The exception to this rule is when you want to create a
white on white kitchen. White granite is rare and expensive but there
are solid surface solutions that work nicely.
b) Formica is glued onto plywood to create your countertops. The
Formica can be removed and replaced with a new color and design that
compliments your style.
Just measure and head back to your favorite online search engine and
look for the best pricing. The adhesive is sold at hardware and home
improvement stores, typically the same stores that offer the Formica.
c) Stainless steel is sold in rolls. If this is your choice, use
adhesive to attach it to the wood that is exposed from removing the
If you choose not to remove the Formica, you must sand the existing
Formica countertop before applying adhesive. If you fail to do this it
will pop up in the heated kitchen and become a dismal failure.
d) Strip off the old Formica and install a tile that makes your
statement. If you use tile don't leave off the sealer coat when you are
If you fail to follow this advice you will soon notice grout that
lifts and falls out or changes color, giving your new countertop a
completely different look.
e) Tiling a countertop is not a new idea; however, you can also use
20″ pieces of marble and install exactly as the tile is installed.
Pick a complimentary grout color, seal and you have marble countertops.
f) Contemporary and a few other design styles work well with concrete countertops.
While this is more typical for lofts and very contemporary spaces,
concrete comes in colors now and a whole new set of design ideas spring
from that change. This also requires a sealant.
g) Whimsical designs and cottages work nicely with mosaic tiles on
the countertops. Again, peel the Formica off and then buy scraps of
colored tiles that match your d


text: Where'd you learn to walk like that? so every muscle shows itself and every curve beckons -- where'd you get that knowing look? I still remember torn bluejeans and angry battles over backyard turf; I didn't think much then of your undeveloped charms -- guess it's been a while But enough about history; my attention is completely mesmerized by now. Why don't you just walk that walk right on over here tangle those legs with mine and catch me up a bit? -ACM


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from American Way Magazine, February 1, 2004
The "It" List
The Craigslist (http://www.craigslist.org/) online community, founded by Craig Newmark in 1995, features lists of jobs, apartments, services, and all kinds of odds and ends for more than 23 U.S. cities. Newmark, a former computer programmer at Charles Schwab in San Francisco, wanted to help people connect on the Internet, so he started an electronic mailing list about cool events in the San Francisco area. It was such a hit that Newmark created a website, and in 1999 quit his job to run Craigslist full time.
Today, his company has 14 employees and is turning a profit, though its only revenue stream is a $75 charge to employers and recruiters for job postings in San Francisco. And while he is adamant about not running ads on his web pages, he is considering charging for other listings.
While the self-proclaimed computer nerd had no initial mission for Craigslist, Newmark now hopes to show people that social responsibility and profitability are not mutually exclusive. "We're helping preserve the original vision of the 'Net by helping make peoples' lives easier and changing the way they do things," he says.
Craigslist added almost a dozen new cities before the end of 2003 and plans to keep adding as requested by users. "We're restricted to the planetary surface," says Newmark, "but for people in any city who want one, our goal is to get them a Craigslist."


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If you would like to read what our customers have to say, here is a link to our review page on the Local Business Feedback website.
If you would like to leave a review or if you have a complaint that we need to address, please take this link.
Be assured that we want you to have a GREAT customer experience.
Your reviews are much appreciated!
Your criticisms help us to refine our customer service.


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With a new executive director, new office space, and heightened energy, Headwaters RC&D approached us with the intriguing task of developing a refreshed look and creating a more intuitive message for their growing brand. The organization offers a broad spectrum of services. Its Small Business Development Center guides new businesses to success, while its Natural Resource programs reduce fuels on fire-prone land. Such diversity raised the question of why one roof housed so many services. Although each program is unique, many blend in a recipe of resources and assistance for launching great ideas. That mix is a valuable resource for Southwest Montana ' all of it. The Headwaters Economic Development Region is the state's largest, spanning eight counties and 17,486 square miles.
VauthierFerguson listened to Who, What and Why we are Headwaters. They not only captured the essence of our organization, they helped us recognize old assets and new strengths.
Jim Davison
Executive Director
We approached this challenge with small town, long streets as a guiding theme. We developed ideas shaped around grassroots energy, neighbors helping neighbors and the beneficial blend of services with one primary idea: Success Begins Somewhere. Afterall, a river's meandering path begins at its headwaters, an idea from which the strapline 'Start Here' was born.
We created a new mark: a forward-motion start symbol with vibrant colors representing the brand's many offerings. A new anthem film simplifies the brand's message and invites energy and awareness from viewers. A Website overhaul focuses on avenues for discovering the brand's offering with a high level of connectivity. The new presence, teamed and executed with a host of collateral material, has made a sizeable splash in the communities Headwaters serves and among the organization's colleagues.


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If there's one thing we love to do is make cookies!, the older granddaughters more or less like to make them on their own but will join in on the Holidays but the little ones still hang in there with me lol! I had mentioned that there will be a cabinet designated for cookie/candy/ice cream making at any given moment, this made their eyes lit up along with some wows!
so what goes in such a cabinet? Pinterest is good for such dreams lol!
just look at all those sprinkles! lol!
by this weekend we will hold the key in our hands & plans of many memories will begin
the owner took a few pictures of the sunrise, I can't wait to wake up to to see this glorious sight
this will be our view every morning, we can see it from the kitchen, the sun room or having coffee on the deck, I am still so over whelmed with joy & the awesomeness of God's blessings , his plans for me in this home are so much more than mine & I can not wait to begin this journey


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Libraries Catalog Updates
By Marketing and Communications | 11-22-2016
The University Libraries main two catalogs, LibCat and the MSL Catalog, will be upgraded during the first week in January 2017. During the upgrade, LibCat and the MSL Catalog will be still be available for use, but will be using back-up data.
Users will be able to search for books, but the check-out details may be out of date. Additionally, online recalls, renewals, and Get It For Me will be unavailable through the catalogs. Your MyLibrary account will also be using the back-up data and some of the details may be out of date.
Should you require any assistance or answers, contact Get it for Me or AskUs services via the main website.


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Barnes & Noble has released version 1.3 of its Nook software, adding new capabilities to its dual-screen, Android-based e-reader. Among the new capabilities are a "read in store" feature—currently in beta—that enables users to browser complete eBooks titles while they're physically in Barnes & Noble retail stores. The update also adds a chess and sodoku games, an updated, home screen, and a "basic" Web browser that enabled users to load Web sites and check email on the device's E Ink display while connected to the Internet via Wi-Fi.
"Our digital customers will feel at home in our stores with Read In Store, which puts a digital spin on the popular Barnes & Noble bookstore experience that millions of our customers enjoy each day. At no cost, NOOK customers can browse through our robust collection of digital content while enjoying their favorite beverage in our cafe," said Tony Astarita, Vice President, Digital Products, Barnes & Noble.com.
"We know our customers enjoy discovering great reads in our bookstores. So, we worked closely with our valued publishing partners to offer this innovative digital experience," said Barnes & Noble's VP for digital products Tony Astarita, in a statement. "We also included new games and many other entertaining features to continue to deliver on our promise to make Nook the most fun, easy-to-use eBook Reader for people who love to read."
One upshot of adding the basic Web browsing capability is that Nook users will be able to connect to the Internet using a greater variety of Wi-Fi hotspots, such as those that require users to enter connection credentials through a Web browser. While using the Web browser, pages are displayed on the black-and-white (and slow) E Ink display, while users use the Nook's color touch screen for navigation and a virtual keyboard.
The update is free and available for download from Barnes & Noble's Web site; users who connect their Nooks to the Internet via Wi-Fi should automatically receive the update during the next week.


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History is saturated with stories of controversial genetic experiments. Cloned sheep. Human-animal crossbreeding. Cats that glow in the dark. Those aren't "X-Files" re-runs, they're actual genetic experiments that have taken place in scientific labs around the globe. Sometimes secretive, sometimes within the public's radar, genetic experimentation has been notoriously embedded in controversy since the pseudo-science of eugenics became common practice during the 1930s and '40s. In the spirit of genetic cleansing and purity, many believed they could discern a person's level of intelligence, religion, sexuality and ethnicity through specific measurement ratios, like head circumference to nose length. By casting away those who failed to pass the threshold for purity standards, doctors, researchers and politicians hoped to create a superior race. Opponents of genetic experimentation argue experiments are often racially and ethnically charged, cite moral concerns and say it devalues natural life. So are there any positive takeaways?
Indeed it appears as if experimenting with genetic makeup has allowed doctors and scientists to team up in some beneficial (and fascinating) ways: growing artificial organs for transplant patients, helping hopeful parents artificially conceive and pushing the scientific envelope by cloning animals. So what do you think about genetic experimentation? Can stem cell research save lives, or is trying to control fate dangerous? Watch, learn and decide for yourself here.


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AUSTIN, Texas, Jan. 11, 2013 (GLOBE NEWSWIRE) -- Bazaarvoice, Inc. (Nasdaq:BV)issued the following statement in response to the antitrust action filed by the U.S. Department of Justice (DOJ) regarding Bazaarvoice's acquisition of PowerReviews:
We are disappointed with the filing of yesterday's lawsuit. We provided the DOJ with extensive documents, data, and information demonstrating that our acquisition of PowerReviews was procompetitive and did not result in a lessening of competition. We spent more than six months explaining that there is robust and ample competition in the market for social commerce engagement tools. We disagree with the DOJ's decision to ignore that evidence and we will now shift our attention to a court of law where we expect to be fully vindicated.
There are a number of problems with the DOJ's complaint but perhaps none more so than their overly narrow definition of the product market. There is no single market for "product ratings and review platforms." Ratings and reviews are but one of many tools that brands and retailers can use to engage with their customers as part of an overall social commerce strategy to increase awareness of their products. Other prominent tools include Facebook, Twitter, question and answer, and community forums, and many others. We believe the testimony of Bazaarvoice executives, customers, and competitors will demonstrate this to a judge. But even assuming the validity of the DOJ's product market definition, there is still robust competition for ratings and reviews all over the social commerce landscape – the market is much bigger and more nuanced than the DOJ appreciates.
More generally, we are surprised that the DOJ chose to base this case on a series of dated documents. In doing so, they ignored virtually all of our recent ordinary course documents and substantial economic evidence. The documents excerpted in the complaint, when taken out of context as the DOJ did in its complaint, paint an inaccurate picture of the marketplace. During the litigation, we will focus on rectifying the DOJ's inaccuracies.
Moreover, contrary to earlier reports, Bazaarvoice complied with the letter and spirit of the Hart-Scott-Rodino Act. Bazaarvoice was not required to report this transaction under the Hart-Scott-Rodino Act because PowerReviews was so small it failed to meet the government's own required "size-of-person test" that triggers mandatory notification and pre-clearance process. We are surprised that the DOJ would choose to invest scarce and valuable resources in challenging a consummated transaction of an entity that made under $12 million in revenues in its most recent fiscal year. Put simply, at the time it was acquired, PowerReviews was in no way the viable competitive threat the DOJ's complaint tries to suggest.
Although we are preparing for our day in court, our principal focus is to continue to serve our clients with a full range of social software that helps them engage powerfully with their customers.
About Bazaarvoice
Bazaarvoice, a leading social software company, assists clients in bringing the voice of the customer to the center of business strategy. With over 2,000 clients globally, including over half of the Internet Retailer 500, over 20 percent of the Fortune 500 and over one-third of the Fortune 100, Bazaarvoice helps clients to leverage social data derived from online word of mouth content to increase sales, acquire new customers, improve marketing effectiveness, enhance consumer engagement across channels, increase success of new product launches, improve existing products and services, effectively scale customer support, decrease product returns and enable retailers to launch and manage on-site advertising solutions and site monetization strategies. This online word of mouth content can be syndicated across Bazaarvoice's global network of client websites, shopper media sites and mobile devices, making the user-generated content that digital consumers trust accessible at multiple points of purchase. Headquartered in Austin, Texas, Bazaarvoice has offices in Amsterdam, London, Munich, New York, Paris, San Francisco, Stockholm and Sydney. For more information, visit www.bazaarvoice.com, read the blog atwww.bazaarvoice.com/blog, and follow on Twitter at www.twitter.com/bazaarvoice.
The Bazaarvoice logo is available at http://www.globenewswire.com/newsroom/prs/?pkgid=13784
CONTACT: Media Contact: Matt Krebsbach Bazaarvoice, Inc. Ph: 512-551-6612 E: firstname.lastname@example.com Investor Contact: Seth Potter ICR, Inc. on behalf of Bazaarvoice, Inc. Ph: 646-277-1230 E: firstname.lastname@example.com


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Selecting your vehicle's make, model, and year allows us to display only parts and items specific to your car's model and year.
Part# BR00855
2 Reviews
OPGI Price: $45.99
Part Type: (R) = Authentic reproduction of the original GM product
Years: 1971-72
Sold As: EACH
2018 Riviera Catalog Page: 62
This accurate reproduction features bright chrome-plating as well as hand-painted gloss black details making it ideal for any 1971-72 trunk panel. With original style studs, the emblem is ready for mounting in the stock location.


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14 Google Calendar Tricks You're Probably Not Using
Even if you're not a daily devotee of Google Calendar, you've undoubtedly used the productivity tool at some point in the last nine years to organize your personal and/or professional lives. And with good reason: It's really useful.
But as useful—if not indispensable—as Calendar has become to our digital lives, it can sometimes feel like the unloved stepchild in Google's family of Web tools. Mountain View hasn't gotten around to giving Calendar any kind of noticeable makeover since it exited beta in 2009. (Though one desperate way to frame this neglect is "If it ain't broke, don't try to fix it.")
Even Google's marketing team seems to have forgotten about Calendar: The official Calendar Twitter account mostly talks about the Inbox app these days, and there's not even an official Calendar blog (the last official Calendar press release I can find is a post on the Gmail blog about the new Calendar app).
But just because the Web incarnation of Calendar hasn't gotten as much investment from Google as, say, an unnecessarily elaborate Easter Egg, that doesn't mean it isn't still a super powerful organizational tool. In fact, Calendar—as seemingly neglected as it is—has a bunch of tricks you probably didn't even know about. I consider myself to be a big fan of Calendar, and even I came across a few surprises while researching this piece.
So, if you consider yourself a true 400-pound orangutan of organization, a profit of productivity, a caballero of collaboration, then take a look through our slideshow of 14 neat little tricks that you can do inside Google Calendar. There will definitely be some you didn't know.
1 Add Holidays and Other Helpful Info to Your Calendar
2 Quick Add an Event
3 Learn Yer Keyboard Shortcuts
4 Get a Daily Agenda Email
5 Enable and Use Tasks
6 Add a Friend's Calendar to Yours
7 Create a New Calendar
8 Share Your Calendar (Even to People Not Using Google Calendar)
9 Embed Your Calendar
10 Access Your Calendar Offline (Chrome Only)
11 Enable a Bunch of Forgotten Experiments
12 Schedule an Event, Find a Time That Works For Everyone
13 Create a Link for People to Sign Up With Appointments to See You
14 Add Google Hangout to an Event