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Objectives: The aim of this paper was to review the literature on temporary abdominal closure (TAC) after abdominal aortic aneurysm (AAA) repair. Methods: This was a systematic review of observational studies. A PubMed, EM BASE and Cochrane search from 2007 to July 2015 was performed combining the Medical Subject Headings "aortic aneurysm" and "temporary abdominal closure", "delayed abdominal closure", "open abdomen", "abdominal compartment syndrome", "negative pressure wound therapy", or "vacuum assisted wound closure". Results: Seven original studies were found. The methods used for TAC were the vacuum pack system with (n = 1) or without (n = 2) mesh bridge, vacuum assisted wound closure (VAWC; n = 1) and the VAWC with mesh mediated fascial traction (VACM; n = 3). The number of patients included varied from four to 30. Three studies were exclusively after open repair, one after endovascular aneurysm repair, and three were mixed series. The frequency of ruptured AAA varied from 60% to 100%. The primary fascia] closure rate varied from 79% to 100%. The median time to closure of the open abdomen was 10.5 and 17 days in two prospective studies with a fascia] closure rate of 100% and 96%, respectively; the inclusion criterion was an anticipated open abdomen therapy time >= 5 days using the VACM method. The graft infection rate was 0% in three studies. No patient with longterm open abdomen therapy with the VACM in the three studies was left with a planned ventral hernia. The in hospital survival rate varied from 46% to 80%. Conclusions: A high fascial closure rate without planned ventral hernia is possible to achieve with VACM, even after long-term open abdomen therapy. There are, however, few publications reporting specific results of open abdomen treatment after AAA repair, and there is a need for randomized controlled trials to determine the most efficient and safe TAC method during open abdomen treatment after AAA repair.
Open abdomen therapy may be necessary to prevent or treat abdominal compartment syndrome (ACS). The aim of the study was to analyse the primary delayed fascial closure (PDFC) rate and complications after open abdomen therapy with vacuum and mesh mediated fascial traction (VACM) after aortic repair and to compare outcomes between those treated with open abdomen after primary versus secondary operation.
This was a retrospective cohort, multicentre study in Sweden, Finland, and Norway, including consecutive patients treated with open abdomen and VACM after aortic repair at six vascular centres in 2006-2015. The primary endpoint was PDFC rate.
Among 191 patients, 155 were men. The median age was 71 years (IQR 66-76). Ruptured abdominal aortic aneurysm (RAAA) occurred in 69.1%. Endovascular/hybrid and open repairs were performed in 49 and 142 patients, respectively. The indications for open abdomen were inability to close the abdomen (62%) at primary operation and ACS (80%) at secondary operation. Duration of open abdomen was 11 days (IQR 7-16) in 157 patients alive at open abdomen termination. The PDFC rate was 91.8%. Open abdomen initiated at primary (N=103), compared with secondary operation (N=88), was associated with less severe initial open abdomen status (p=.006), less intestinal ischaemia (p=.002), shorter duration of open abdomen (p=.007), and less renal replacement therapy (RRT, p<.001). In hospital mortality was 39.3%, and after entero-atmospheric fistula (N=9) was 88.9%. Seven developed graft infection within 6 months, 1 year mortality was 28.6%. Intestinal ischaemia (OR 3.71, 95% CI 1.55-8.91), RRT (OR 3.62, 95% CI 1.72-7.65), and age (OR 1.12, 95% CI 1.06-1.12), were independent factors associated with in hospital mortality, but not open abdomen initiated at primary versus secondary operation.
VACM was associated with a high PDFC rate after prolonged open abdomen therapy following aortic repair. Patient outcomes seemed better when open abdomen was initiated at primary, compared with secondary operation but a selection effect is possible.
Objectives: Thrombolysis has been reported to be suboptimal in occluded vein grafts and cryopreserved allografts, and there are no data on the efficacy of thrombolysis in occluded cold stored venous allografts. The aim was to evaluate early outcomes, secondary patency and limb salvage rates of thrombolysed cold stored venous allograft bypasses and to compare the outcomes with thrombolysis of autologous bypasses. Methods: This was a single center study of consecutive patients with acute and non-acute limb ischemia between September 1, 2000, and January 1, 2014, with occlusion of cold stored venous allografts, and between January 1, 2012, and January 1, 2014, with occlusion of autologous bypass who received intra-arterial thrombolytic therapy. Results: Sixty-one patients with occlusion of an infrainguinal bypass using a cold stored venous allograft (n = 35) or an autologous bypass (n = 26) underwent percutaneous intra-arterial thrombolytic therapy. The median duration of thrombolysis was 20 h (IQR 18-24) with no difference between the groups (p = .14). The median follow up was 18.5 months (IQR 11.0-52.0). Secondary patency rates of thrombolysed bypass at 6 and 12 months were 44 +/- 9% and 32 +/- 9% in patients with a venous allograft bypass and 46 +/- 10% and 22 +/- 8% with an autologous bypass, with no difference between groups (p = .40). Limb salvage rates at 1, 6, and 12 months after thrombolysis in the venous allograft group were 83 +/- 7%, 72 8% and 63 +/- 9%, and in the autologous group 91 +/- 6%, 76 +/- 9%, and 65 +/- 13%, with no difference between groups (p = .69). Conclusions: Long-term results of thrombolysis of venous allograft bypasses are similar to those of autologous bypasses. Occluded cold stored venous allograft can be successfully re-opened in most cases with a favorable effect on limb salvage.
Objective/Background: To achieve consensus on the minimum core data set for evaluation of peripheral arterial revascularisation outcomes and enable collaboration among international registries.
Methods: A modified Delphi approach was used to achieve consensus among international vascular surgeons and registry members of the International Consortium of Vascular Registries (ICVR). Variables, including definitions, from registries covering open and endovascular surgery, representing 14 countries in ICVR, were collected and analysed to define a minimum core data set and to develop an optimum data set for registries. Up to three different levels of variable specification were suggested to allow inclusion of registries with simpler versus more complex data capture, while still allowing for data aggregation based on harmonised core definitions.
Results: Among 31 invited experts, 25 completed five Delphi rounds via internet exchange and face to face discussions. In total, 187 different items from the various registry data forms were identified for potential inclusion in the recommended data set. Ultimately, 79 items were recommended for inclusion in minimum core data sets, including 65 items in the level 1 data set, and an additional 14 items in the more specific level 2 and 3 recommended data sets. Data elements were broadly divided into (i) patient characteristics; (ii) comorbidities; (iii) current medications; (iv) lesion treated; (v) procedure; (vi) bypass; (vii) endarterectomy (viii) catheter based intervention; (ix) complications; and (x) follow up.
Conclusion: A modified Delphi study allowed 25 international vascular registry experts to achieve a consensus recommendation for a minimum core data set and an optimum data set for peripheral arterial revascularisation registries. Continued global harmonisation of registry infrastructure and definition of items will overcome limitations related to single country investigations and enhance the development of real world evidence.
Objective: To develop a minimum core data set for evaluation of acute limb ischaemia (ALI) revascularisation treatment and outcomes that would enable collaboration among international registries. Methods: A modified Delphi approach was used to achieve consensus among international multidisciplinary vascular specialists and registry members of the International Consortium of Vascular Registries (ICVR). Variables identified in the literature or suggested by the expert panel, and variables, including definitions, currently used in 15 countries in the ICVR, were assessed to define both a minimum core and an optimum data set to register ALI treatment. Clinical relevance and practicability were both assessed, and consensus was defined as >= 80% agreement among participants. Results: Of 40 invited experts, 37 completed a preliminary survey and 31 completed the two subsequent Delphi rounds via internet exchange and face to face discussions. In total, 117 different items were generated from the various registry data forms, an extensive review of the literature, and additional suggestions from the experts, for potential inclusion in the data set. Ultimately, 35 items were recommended for inclusion in the minimum core data set, including 23 core items important for all registries, and an additional 12 more specific items for registries capable of capturing more detail. These 35 items supplement previous data elements recommended for registering chronic peripheral arterial occlusive disease treatment. Conclusion: A modified Delphi study allowed 37 international vascular registry experts to achieve a consensus recommendation for a minimum core and an optimum data set for registries covering patients who undergo ALI revascularisation. Continued global harmonisation of registry infrastructure and definition of items allows international comparisons and global quality improvement. Furthermore, it can help to define and monitor standards of care and enable international research collaboration.
Objectives: To study international differences in incidence and practice patterns as well as time trends in lower limb amputations related to peripheral arterial disease and/or diabetes mellitus. Methods: Data on lower limb amputations during 2010-2014 were collected from population based administrative data from countries in Europe and Australasia participating in the VASCUNET collaboration. Amputation rates, time trends, in hospital or 30 day mortality and reimbursement systems were analysed. Results: Data from 12 countries covering 259 million inhabitants in 2014 were included. Individuals aged >= 65 years ranged from 12.9% (Slovakia) to 20.7% (Germany) and diabetes prevalence among amputees from 25.7% (Finland) to 74.3% (Slovakia). The mean incidence of major amputation varied between 7.2/100,000 (New Zealand) and 41.4/100,000 (Hungary), with an overall declining time trend with the exception of Slovakia, while minor amputations increased over time. The older age group (>= 65 years) was up to 4.9 times more likely to be amputated compared with those younger than 65 years. Reported mortality rates were lowest in Finland (6.3%) and highest in Hungary (20.3%). Countries with a fee for service reimbursement system had a lower incidence of major amputation compared with countries with a population based reimbursement system (14.3/100,000 versus 18.4/100,000, respectively, p < .001). Conclusions: This international audit showed large geographical differences in major amputation rates, by a factor of almost six, and an overall declining time trend during the 4 year observation of this study. Diabetes prevalence, age distribution, and mortality rates were also found to vary between countries. Despite limitations attributable to registry data, these findings are important, and warrant further research on how to improve limb salvage in different demographic settings.
Is it possible by pharmacological methods to attenuate the expansion rate of abdominal aortic aneurysms?
An Internet-based systematic literature search was performed to identify published reports on pharmacological methods to influence aneurysmal expansion rate.
Of an original 450 articles, 21 remained to review: they included 15 cohort studies with 12,321 patients and seven randomised clinical trials (RCTs) with 1069 patients. Most studies are performed without a pre-study sample size calculation. There is no consistent pattern of pharmacological influence on expansion rate, but statins, non-steroidal anti-inflammatory drugs (NSAIDs) and macrolides should be further evaluated.
Properly designed RCTs are needed before conclusions can be drawn on the possibility to pharmacologically attenuate aneurysmal expansion and prevent rupture.
AIM AND METHOD: to analyze the presentations given at the annual meeting of European Society for Vascular Surgery: topic, geographical distribution, later publication. Three six-year periods from 1989 have been evaluated. RESULTS: case series dominates but randomized trials have increased somewhat. Papers on animal experiments and basic science have decreased. The most frequently reported diseases have been aortic aneurysm, carotid artery problems, lower extremity ischaemia and with an increasing number of papers on venous disease. Around two thirds of the presentations have been later published as full papers in European Journal of Vascular and Endovascular Surgery, but as many as one quarter has not been published. Geographical origin has varied over time with a decrease in the UK dominance. CONCLUSION: The presentations at the Annual meeting of European Society for Vascular Surgery contribute substantially to the contents of the Society Journal but a large proportion of the presentations never appear in print. Northern Europe dominates when papers per population unit is counted.
The surgical and hereditary risk factors for post-operative venous thromboembolism (VTE) are discussed and the heightened risk associated with particular risk factors quantified. Mechanical and pharmacological methods of prophylaxis are described, together with the different recommendations for use with general and regional anaesthesia. Prophylaxis may be started post-operatively and the duration of prophylaxis is discussed. The use of prophylaxis in vascular surgery is illustrated with case examples.
AIM: To systematically review the literature on vascular injuries caused by acupuncture. METHOD: Systematic literature search in Medline and PubMed. RESULTS: Twentyone cases were identified and the majority developed symptoms in direct connection with the acupuncture treatment. Three patients died, two from pericardial tamponade and one from an aortoduodenal fistula. There were five more tamponades, seven pseudoaneurysms, two with ischaemia, two with venous thrombosis, one with compartment syndrome and one with bleeding. The two patients with ischaemia had remaining sequeleae. Information on follow-up was suboptimal with no information in nine patients. CONCLUSION: Vascular injuries are rare, bleeding and pseudoaneurysm dominating. Follow-up is insufficient in the hitherto published papers.
OBJECTIVE: To analyze the problem of secondary arterioenteric fistulation, a rare but serious complication. METHODS: A systematic literature review was performed searching for case reports as well as patients included in articles analyzing especially infectious complications. RESULTS: 332 individual cases and 1135 patients from papers on complications were identified. All types of surgery involving aorta and its branches could precede the complication, endovascular procedures included. The development of a fistula can occur at any time after primary surgery, the longest delay being 26 years. Bleeding was the dominating symptom with herald bleeding in more than half of the patients, infectious problems present in around one quarter. Diagnostic delay was typical, although decreasing over time. The mortality was high, lowest after axillobifemoral revascularization and aortic graft removal. The information in the articles is often heterogeneous and incomplete, and follow-up time is often too short. Mortality after fistulation seems to have decreased over time. CONCLUSION: Secondary arterioenteric fistula continues to be an extremely serious complication after surgery on aorta and its branches. Every effort must be made to arrive at a rapid diagnosis. The best therapeutic option seems to be axillobifemoral revascularization and subsequent graft removal, which however, requires haemodynamically stable patients. Endovascular repair may serve as a bridge to open surgery.
With the ten WHO criteria for a screening program to be started, screening for abdominal aortic aneurysm is analyzed. Most of the criteria are fulfilled concerning the 65-year old male population, whereas concerning females we need more knowledge. Still the aneurysmal diameter is the most important factor to select patients for treatment meaning that many aneurysms are treated where rupture should never have occurred. Research projects giving more information on pathophysiological processes behind expansion and rupture should have priority.
AIM: To investigate a series of patients with secondary aortoenteric fistulas and compare it with a previous series (1985-93 vs. 1973-84).
DESIGN: Retrospective study of medical records.
SETTING: Sixteen vascular surgical centers in Sweden.
PATIENTS: Twenty-seven patients were identified making an overall incidence of 0.5% of all aortoiliac operations. Among aneurysm patients the incidence was significantly lower than in the previous series. One patient record could not be identified. Fourteen primary operations were for aortic aneurysm, 12 for occlusive disease and one was an aortorenal vein bypass.
RESULTS: Symptoms of the fistula occurred after a median interval of 90 months which is significantly later than the previous series (32 months; p<0.05). The commonest presentation was bleeding followed by septis. The median diagnostic delay was 10.5 days, which was significantly shorter than in the previous series. Most fistulas involved the duodenum (88%). One patient died before surgery. The postoperative mortality was 28%, significantly lower than in the previous series (58%) (p<0.05). At the end of follow up (median 43 months) significantly more patients were alive than in the previous series (42% vs 18%) (p<0.05).
CONCLUSION: Over a 21 year period there seems to have been a decrease in the frequency of secondary aortoenteric fistulas after aneurysm surgery, a longer interval before they occur, a shorter diagnostic delay, and a better survival.
OBJECTIVE: Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management.
METHOD: The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method.
RESULTS: Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives."
CONCLUSIONS: Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.
To study contemporary popliteal artery aneurysm (PA) repair.
Vascunet is a collaboration of population-based registries in 10 countries: eight had data on PA repair (Australia, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, and Switzerland).
From January 2009 until June 2012, 1,471 PA repairs were registered. There were 9.59 operations per million person years, varying from 3.4 in Hungary to 17.6 in Sweden. Median age was 70 years, ranging from 66 years in Switzerland and Iceland to 74 years in Australia and New Zealand; 95.6% were men and 44% were active smokers.
Elective surgery dominated, comprising 72% of all cases, but only 26.2% in Hungary and 39.7% in Finland, (p < .0001). The proportion of endovascular PA repair was 22.2%, varying from 34.7% in Australia, to zero in Switzerland, Finland, and Iceland (p < .0001). Endovascular repair was performed in 12.2% of patients with acute thrombosis and 24.1% of elective cases (p < .0001). A vein graft was used in 87.2% of open repairs, a synthetic or composite graft in 12.7%.
Follow-up was until discharge or 30 days. Amputation rate was 2.0% overall: 6.5% after acute thrombosis, 1.0% after endovascular, 1.8% after open repair, and 26.3% after hybrid repair (p < .0001). Mortality was 0.7% overall: 0.1% after elective repair, 1.6% after acute thrombosis, and 11.1% after rupture.
Great variability between countries in incidence of operations, indications for surgery, and choice of surgical technique was found, possibly a result of surgical tradition rather than differences in case mix. Comparative studies with longer follow-up data are warranted.
Patients with peripheral arterial occlusive disease (PAOD), in particular critical limb ischaemia (CLI), carry a high risk of thrombotic events. We hypothesised that patients undergoing conservative, endovascular, or open surgical treatment for CLI have increased levels of plasminogen activator inhibitor-1 (PAI-1), leading to a prothrombotic state. The objective was to determine levels of PAI-1 in patients with acute or chronic PAOD/CLI. Thirty-two patients with a median age of 74 (49–90) years were included. Three underwent thrombolysis for acute limb-threatening ischaemia. Twenty-six patients with chronic ischaemia received endovascular (n = 20) or open (n = 6) surgical treatment. Three were treated conservatively. Biomarkers and ankle brachial index (ABI) were measured before and up to 1 month after intervention. Patency was studied with repeated duplex ultrasound. Ankle pressure and ABI improved after intervention (p < .001). C-reactive protein (CRP) increased from a median of 7.90 mg/L at baseline to 31.5 on day 1 (p < .001), 28.0 on day 6 (p < .001), and returned to baseline levels on day 30. PAI-1 antigen and activity decreased from day 6 and onwards post-intervention compared with baseline (p < .05). A great individual variability in PAI-1 antigen and activity was observed. Although most actively treated patients had normal PAI-1 activity, 11/29 (38%) were above that level of normality at baseline, 10/24 (42%) on day 1, 3/23 (13%) on day 6, and 5/27 (19%) on day 30 after intervention. Endovascular and open surgical treatment resulted in improved ankle pressure and ABI. The intervention was followed by a transient increase in CRP and a sustained reduction in PAI-1 levels and activity.
Objectives: The management of the abdominal compartment syndrome (ACS) and the open abdomen (OA) are important to improve survival after major vascular surgery, in particular ruptured abdominal aortic aneurysm (RAAA). The aim is to summarize contemporary knowledge in this field. Methods: The consensus definitions of the World Society of the Abdominal Compartment Syndrome (WSACS) that were published in 2006 and the clinical practice guidelines published in 2007 were updated in 2013. Structured clinical questions were formulated (modified Delphi method), and the evidence base to answer those questions was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines. Results: Most of the previous definitions were kept untouched, or were slightly modified. Four new definitions were added, including a definition of OA and of lateralization of the abdominal wall, an important clinical problem to approach during prolonged OA treatment. A classification system of the OA was added. Seven recommendations were formulated, in summary: Trans-bladder intra-abdominal pressure (IAP) should be monitored in patients at risk. Protocolized monitoring and management are recommended, and decompression laparotomy if ACS. When OA, protocolized efforts to obtain an early abdominal fascial closure, and strategies utilizing negative pressure wound therapy should be used, versus not. In most cases the evidence was graded as weak or very weak. In six of the structured clinical questions, no recommendation could be made. Conclusion: This review summarizes changes in definitions and management guidelines of relevance to vascular surgery, and data on the incidence of ACS after open and endovascular aortic surgery. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Introduction: mRNA changes in the small intestine in response to acute mesenteric ischaemia (AMI) could offer novel diagnostic possibilities, but have not been described. The aim was to characterize the mRNA response to experimental AMI.
Materials and methods: Twelve pigs underwent catheterization of the superior mesenteric artery with injection of polivinylalcohol embolization particles or sodium chloride. Laparotomy and intestinal tissue sampling was performed. Microarray analysis was performed using the GeneChip® whole porcine genome array.
Results: Seven down-regulated cellular pathways were associated with protein, lipid and carbohydrate metabolism. Seventeen up-regulated pathways were associated with inflammatory and immunological activity, regulation of extracellular matrix and decreased cellular proliferation. Thrombospondin(THS), Monocyte Chemoattractant Protein 1(MCP-1) and Gap Junction Alpha 1(GJA-1) were consistently up-regulated in all embolized pigs. Genes encoding earlier proposed biomarkers for AMI were up-regulated, such as lactate dehydrogenase and creatine kinase, or down-regulated, such as intestinal fatty acid binding protein and glutathione S-transferase.
Conclusion: This study describes the intestinal tissue response on a gene expression level to AMI. THS, MCP-1 and GJA-1 were consistently up-regulated by ischemia, whereas earlier proposed biomarkers for AMI were not. Gene expression may not be directly linked to the use of the corresponding proteins as potential clinical biomarkers.
OBJECTIVES: To study smoking habits among men with abdominal aortic aneurysm at screening at 65 years of age, and during follow-up, as a base-line study to evaluate future interventions.
DESIGN: Nested case-control study.
PATIENTS AND METHODS: Between 2006 and 2011, 8150 65-year-old men (compliance 85%) were screened for AAA in Uppsala County, Sweden. Among 292 men with an aortic diameter of at least 25 mm, 77 were active smokers at the time of screening. At follow-up of smoking habits in 2012, 53 men (69%) participated in this study, 28 had an AAA of at least 30 mm and 25 a sub-aneurysmal aorta (SAA) 25-29 mm at baseline. For each case, one control was randomly selected, all active smokers with aortic diameter less than 25 mm at baseline, matched for age and year of screening. Telephone interviews were performed at a median 34 months (range: 4-67) after screening.
RESULTS: Men with AAA had hypertension more often than controls (68% vs. 23%, p < .001). Men with AAA and SAA reported more smoking years than controls (p = .017). Cessation rate among patients with AAA did not differ significantly compared with men with an aorta less than 30 mm (29% vs. 15%, p = .159), but they had reduced their consumption of cigarettes/day significantly more than men with SAA and controls (-8.2 vs. -3.0 vs. -4.5, p = .030). Men with AAA recalled having been informed about the importance of smoking cessation at the time of screening more often (p = .031). There was no difference in growth of the AAA between those who continued, and those who quit smoking (2.03 vs. 2.01 mm/year, p = .982), but the study was not powered to study AAA growth.
CONCLUSIONS: Although counselling in a normal healthcare setting had some effect, the results indicate a need to tailor interventions to further increase smoking cessation rates among men diagnosed with both AAA and SAA.
The aim of this study was to assess the feasibility and results of repeat surgery without preoperative angiography in limbs with patent infrainguinal bypass grafts. Between January 1995 and December 1999, 73 surgical interventions were performed for correction of inflow, graft, or runoff-related lesions in limbs with patent infrainguinal bypass grafts. Fifty-six of the 73 cases were operated on based on the findings obtained from duplex scanning alone. There were 53 vein and 3 prosthetic grafts in the series. The indications for intervention without angiography were stenotic or occlusive lesions in 35, graft aneurysm in 7, and arteriovenous fistulae in 14. There were no deviations from the preoperatively planned surgical strategy in patients undergoing surgery without preoperative angiography. Cumulative life table primary, (stenosis free) and primary-assisted patency rates, at 12 months following graft revisions (excluding arteriovenous fistulae ligatures) without preoperative angiography, were 64% and 85%, respectively. The corresponding figures for revisions performed with preoperative angiography were 58% and 84%, respectively. There were no significant differences between patients undergoing surgery with or without preoperative diagnostic angiography with regard to patency rates. Surgical interventions for correction of infrainguinal graft-related stenotic or aneurysmal lesions can be safely performed based on findings obtained from duplex scanning.
OBJECTIVE: to evaluate preoperative duplex as the sole investigation prior to lower limb reconstruction. Design retrospective analysis.
MATERIALS AND METHODS: between January 1995 and December 1999, 157 of 329 surgical interventions for chronic infrainguinal arterial or aneurysmal disease were performed without preoperative angiography.
RESULTS: in patients undergoing femoral artery endarterectomy, the extent of the stenosis and the status of the distal deep femoral artery were correctly diagnosed with duplex scanning in all but one patient. Duplex scan findings in patients undergoing infrainguinal bypass procedures were in agreement with the findings obtained from on-table angiography in regard to the selection of optimal outflow anastomotic sites in 123 (98%). Duplex scanning correctly evaluated the status of runoff in 113 (90%). There were no significant differences in 30-day occlusion rate and patency at 12 months between reconstructions performed with and without preoperative angiography.
CONCLUSION: in patients with conclusive duplex scan findings there is no need to perform angiography prior to lower limb reconstruction.
Objectives: Current management of ruptured abdominal aortic aneurysms (RAAA) varies among centres and countries, particularly in the degree of implementation of endovascular aneurysm repair (EVAR) and levels of vascular surgery centralisation. This study assesses these variations and the impact they have on outcomes.
Materials and methods: RAAA repairs from vascular surgical registries in 11 countries, 2010-2013, were investigated. Data were analysed overall, per country, per treatment modality (EVAR or open aortic repair [OAR]), centre volume (quintiles IV), and whether centres were predominantly EVAR (>= 50% of RAAA performed with EVAR [EVAR(p)]) or predominantly OAR [OAR(p)]. Primary outcome was peri-operative mortality. Data are presented as either mean values or percentages with 95% CI within parentheses, and compared with chi-square tests, as well as with adjusted OR.
Results: There were 9273 patients included. Mean age was 74.7 (74.5-74.9) years, and 82.7% of patients were men (81.9-83.6). Mean AAA diameter at rupture was 7.6 cm (7.5-7.6). Of these aneurysms, 10.7% (10.0-11.4) were less than 5.5 cm. EVAR was performed in 23.1% (22.3-24.0). There were 6817 procedures performed in OAR(p) centres and 1217 performed in EVAR(p) centres. Overall peri-operative mortality was 28.8% (27.9-29.8). Peri-operative mortality for OAR was 32.1% (31.0-33.2) and for EVAR 17.9% (16.3-19.6), p < .001, and the adjusted OR was 0.38 (0.31-0.47), p < .001. The peri-operative mortality was 23.0% in EVAR(p) centres (20.6-25.4), 29.7% in OAR(p) centres (28.6-30.8), p < .001; adjusted OR = 0.60 (0.46-0.78), p < .001. Perioperative mortality was lower in the highest volume centres (QI > 22 repairs per year), 23.3% (21.2-25.4) than in QII-V, 30.0% (28.9-31.1), p < .001. Peri-operative mortality after OAR was lower in high volume centres compared with the other centres, 25.3% (23.0-27.6) and 34.0% (32.7-35.4), respectively, p < .001. There was no significant difference in peri-operative mortality after EVAR between centres based on volume.
Conclusions: Peri-operative mortality is lower in centres with a primary EVAR approach or with high case volume. Most repairs, however, are still performed in low volume centres and in centres with a primary OAR strategy. Reorganisation of acute vascular surgical services may improve outcomes of RAAA repair.
Background: Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. Methods: Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. Results: A total of 83,253 patients were included. Over the two periods, the proportion of patients >= 80 years old increased (18.5% vs. 23.1%; p < .0001) as did the proportion of endovascular repair (EVAR) (44.3% vs. 60.6; p < .0001). In the latter period, 25.8% of AAAs were less than 5.5 cm. The mean annual volume of open repairs per centre decreased from 12.9 to 10.6 between the two periods (p < .0001), and it increased for EVAR from 10.0 to 17.1 (p < .0001). Overall, peri-operative mortality fell from 3.0% to 2.4% (p < .0001). Mortality for EVAR decreased from 1.5% to 1.1% (p < .0001), but the outcome worsened for open repair from 3.9% to 4.4% (p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p < .0001; open, 9.5% vs. 3.6%, p < .0001; EVAR, 1.8% vs. 0.7%, p < .0001), and women (overall, 3.8% vs. 2.2%, p < .0001; open, 6.0% vs. 4.0%, p < .0001; EVAR, 1.9% vs. 0.9%, p < .0001). Peri-operative mortality after repair of AAAs <5.5 cm was 4.4% with open repair and 1.0% with EVAR, p < .0001. Conclusions: In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AM treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture.
Previous comparisons between open and endovascular repair of popliteal aneurysms have focused on asymptomatic patients, and have short follow up. This study is strengthened by the fact that it is contemporary, population based, without any selection bias, reporting on all kinds of presentations, and has approximately 90% 1 year follow up data. It shows that endovascular repair has significantly inferior results compared with open repair, in particular in the group of patients who present with acute ischaemia. We believe these results will make many vascular surgeons think twice before they treat patients endovascularly in the future. Background: Popliteal aneurysm (PA) is traditionally treated by open repair (OR). Endovascular repair (ER) has become more common. The aim was to describe time trends and compare results (OR/ER). Methods: The Swedish vascular registry, Swedvasc, has a specific PA module. Data were collected (2008-2012) and supplemented with a specific protocol (response rate 99.1%). Data were compared with previously published data (1994-2002) from the same database. Results: The number of operations for PA was 15.7/million person-years (8.3 during 1994-2001). Of 592 interventions for PA (499 patients), 174 (29.4%) were treated for acute ischaemia, 13 (2.2%) for rupture, 105 (17.7%) for other symptoms, and 300 (50.7%) were asymptomatic (31.5% were treated for acute ischaemia, 1994-2002, p = .58). There were no differences in background characteristics between OR and ER in the acute ischaennia group. The symptomatic and asymptomatic groups treated with ER were older (p = .006, p < .001). ER increased 3.6 fold (4.7% 1994-2002, 16.7% 2008-2012, p = .0001). Of those treated for acute ischaemia, a stent graft was used in 27 (16.4%). Secondary patency after ER was 70.4% at 30 days and 47.6% at 1 year, versus 93.1% and 86.8% after OR (p = .001, < .001). The amputation rate at 30 days was 14.8% after ER, 3.7% after OR (p = .022), and 17.4% and 6.8% at 1 year (p = .098). A stent graft was used in 18.3% for asymptomatic PA. Secondary patency after ER was 94.5% at 30 days and 83.7% at 1 year, compared with 98.8% and 93.5% after OR (p = .043 and 0.026). OR was performed with vein graft in 87.6% (395/451), with better primary and secondary patency at 1 year than prosthetic grafts (p = .002 and < .001), and with a posterior approach in 20.8% (121/581). Conclusions: The number of operations for PA doubled while the indications remained similar. ER patency was inferior to OR, especially after treatment for acute ischaemia, and the amputation risk tended to be higher, despite similar pre-operative characteristics.
OBJECTIVES: To investigate spinal cord ultrastructure related to cerebrospinal fluid (CSF) oxygenation.
DESIGN: experimental aortic occlusion model with intrathecal oxygen tension monitoring.
MATERIALS AND METHODS: Two groups of pigs underwent proximal (P) or double (D) aortic occlusion for 30 min followed by 1 h of reperfusion. In a third group (I) segmental arteries distal to T3 were clamped for 90 min. A thin pO(2), pCO(2) and pH sensor was placed intrathecally for continuous monitoring of CSF. Spinal cord segments were studied by electron microscopy (EM).
RESULTS: In group P, CSF-pO(2)rapidly decreased during clamping and major changes in pH and pCO(2)were seen. EM demonstrated neuronal degeneration with loss of cellular integrity and severe affection of organelles. In the group D, CSF oxygenation decreased to about half, but with only moderate changes in the metabolic parameters. Group I showed no significant changes in CSF measurements. The latter groups were similar at EM, showing only mild mitochondrial changes.
CONCLUSIONS: The level of CSF oxygenation during aortic cross-clamping or segmental artery interruption seems to correlate with ultrastructural changes in the spinal cord. This online intrathecal monitoring technique may provide valuable information on spinal cord circulation during thoracoabdominal aortic surgery.


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Horse Boots and Bandages
Float Boots, Bell Boots, Horse Boots, Horse Bandages. All at Horseland
Horse boots
Boots and bandages can help protect a horse's legs and provide some support, but they shouldn't be relied on as a substitute for good conditioning.
No horse has perfect conformation, nor does every horse have the perfect job or the perfect footing in which to work. With this in mind, horse owners reach out to use every available technology to protect a horse's limbs against injury.
Manufacturers have risen to the challenge to produce a variety of protective wraps, support boots, and substitutes for horseshoes. Riders have high expectations for bandage protection and support.
Leg Bandages
Leg bandages are made to help protect the horses leg along with the horse boots.
In our Leg bandage range we have we have a good range of leg bandages in different brands and made with different materials, such as fleece and nylon.
The Horse boots and bandages should be replaced and cleaned every couple of days so that the debris and dirt that has collected there, is removed, and a new set of bandages and boots are put on the horse.
Earn rider points on your purchases when you join the rider rewards club.
Free shipping on orders over $150
Over the last 40 years Horseland has evolved into Australia's Equine retail store. They have 51 stores Australia wide.
Our friendly staff are trained to provide expert advice and customer service is our #1 priority.
Weatherbeeta Short Wide Travel BootsDurable and strong 1200 Denier outer shell for protection with soft boa fleece lining for comfort. 3 easy to use touch tape closures for security....$79.99Buy now Add to Wishlist Add to Compare
Roma Fleece Exercise BootsStylish and durable exercise boots perfect for training and protection in the paddock. Fleece lining for extra comfort with a PVC outer shell for protection and easy to use secure touch tape closure....From $34.99Buy now Add to Wishlist Add to Compare
Roma Neoprene Splint/cushion BootsExtra neoprene padding protects the leg and splint bone from knocks and bumps. Features three hook and loop touch tape fastenings with Dee rings for additional security....$39.99Buy now Add to Wishlist Add to Compare
Weatherbeeta Fleece Bandage 4 PackPack of four bandages, perfect for protecting your horse's legs from knocks and bumps during exercise. Made from a soft, high quality anti-pilling fleece, with a single touch tape fastening and machine washable. Complete with a re-usable carry bag...$39.99Buy now Add to Wishlist Add to Compare
- Buy now Add to Wishlist Add to Compare
Weatherbeeta Impact Bell BootsLightweight and durable outer, shapes to the horses hoof with a neoprene inner for maximum comfort and protection. Non twist design to help the boot stay in place. Quick and easy to use touch tape closure...$49.99Buy now Add to Wishlist Add to Compare
Saxon Contoured Fetlock BootsFeatures a shape to provide a better fit. Absorbent neoprene lining. Strong outer shell...
Saxon Open Front BootsFeatures a shape to provide a better fit. Absorbent neoprene lining. Strong outer shell....
Weatherbeeta Single Lock Brushing BootsSoft, durable and breathable neoprene conforms to the horses leg. Tough PVC strike pad for extra protection against knocks and brushing. Adjustable and easy to use touch tape closures....Buy now Add to Wishlist Add to Compare
Roma Neoprene Bell Boots IiDouble touch tape closures for extra security. Matches back to Neoprene Brushing boots. Perfect for every day use....

subset: commoncrawl


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An intelligent chatbot differs from the typical chatbot as it is able to learn both autonomously and from the customer service agent. Instead of providing the incorrect answer, the intelligent chatbot will ask for assistance from a customer service agent. Today, implementing this type of chatbot is easy.
giosg Blog
Chatbot projects often have a reputation for being time-consuming and costly to implement. However, chatbots today come in all shapes and sizes with various capabilities and levels of advancement. This is great news, as not every business will need a chatbot with AI capabilities! In fact, sometimes less advanced bots like button-based bots can be just as effective.
Chatbots are your first line of customer service and a crucial part of your virtual assistance solution. As exciting it might be to have a face to face conversation with a robot, the technology still doesn't live up to online users' expectations.
Implementing a chatbot is an excellent method for interacting with your (potential) customers 24/7/365 while keeping cost in check. If you are not yet considering jumping into a chatbot and AI bandwagon, you should!
However, before you reap benefits mentioned above, you need to do some work. Building a chatbot that delivers results requires both time and effort. We at GetJenny have helped our customers to launch dozens of chatbots (and quite a few of them on giosg platform), and we believe we've found the right steps to a successful chatbot launch. We hope that sharing some of our lessons helps you to carry out a successful chatbot project as well.
The hype around AI applications that is about to swipe through industries and the customer service function, in particular, is enormous, but so far we've seen little real-life experiences how the chatbots function, how's it like to implement one and what the results are. That's why we put together an interview with one of the early adopters of chatbots, If Insurance.
We sat down with Indrek Vainu who is the Product Manager at AlphaBlues, an artificial intelligence start-up that automates customer service with chatbots. Indrek answered some of the most common questions that we get from customers about chatbots.
Computer-controlled bots who can communicate with customers. That has been the dream of customer service professionals for quite a while now. Corporate giants have been testing them since the last decade but so far, we haven't seen them implemented at scale.
Once again, there's an industry-wide hype around chatbots but this time, that hype will pay off. And there are two simple reasons why they will actually make it.


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Item Info
More info about this item.
Canada. Painted by T. Mower Martin, R.C.A. Described by Wilfred Campbell LL.D. London: A. & C. Black, 1907. 9″ x 6.5″, 272p., burgundy decorative cloth with gilt, 77 full-color illustrated plates with tissue guards, folding map. First Edition. One of the scarcer titles in the A. & C. Black color series
A beautifully illustrated book of Canada, with vibrant color plates of from paintings by T. Mower Martin, Canadian artist, born in London, England. He was one of the founders of the Ontario art union, the Ontario society of artists, and the Royal Canadian academy, was president of the first society of artists in Canada, and in 1877 became director of the Ontario school of art, which he had established.
The author, Wilfred Campbell, describes the great natural features of the land, in its broader characteristics – its coasts, rivers, mountains, lakes, and prairies, those physical beauties and sublime effects of nature for which the region is specially famous.
Similar items available at "Coach and Kennel Galleries" on the web.
More info about this item.


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From new athletes to aspiring pros, tennis to basketball, we offer sport-specific camps for your kid to learn a new game or advance their skills in the one they love. Led by our experienced coaches and national and Olympic athletes, these camps provide kids with a unique opportunity to learn from — and get inspired by! — the best.
Ecoquest Kayaking Camp, Introduction – Ages 8-12
Paddle your way to becoming a kayak pro! This camp is great for first timers and those looking to develop more skills. Explore different locations on the water while learning safety, terminology, tips and tricks! All required safety equipment, kayaks and transportation included.
monday - friday
monday - friday
Soccertron has been bringing soccer to the community since 1978! Improve your 1-on- 1 skills and develop offensive and defensive skills. Out Tots program is great for introduction to the beautiful game. Classic half day program plus the full day for 7-14 year olds. Join us for a FANTASTIC week.
Eli Pasquale Champions Academy Basketball (ages 10-16)
Get ready for the basketball season with our complete basketball training program! Skill development includes: Eli Pasquale Shooting and Guard Series plus the Miracle Circuit. Receive specific instruction on improving footwork, shooting technique, ball handling, passing, rebounding and offensive and defensive individual and team concepts designed by Eli Pasquale (Two Time Olympian, Five Time National Champion).
Instructor: Manny Pasquale (Head Coach) & Coaching staff
Camosun Chargers Jr Girls Volleyball (ages 12-16)
Led by the Camosun Coaching staff, Chargers athletes and the PISE Strength & Conditioning Coaches, this camp will consist of skill work, physical training and game play. This camp is your chance to meet, connect and work directly with the 2019 edition of the Camosun Chargers Women's Volleyball team.
Camosun Chargers High Performance Girls Volleyball (ages 16-18)
The High Performance Girls' Volleyball Camp is an opportunity to train with the Camosun Chargers Women's Volleyball Team as you prepare for the next season. This camp is designed to improve the individual skills, team play, and physical and mental preparation of the experienced volleyball athlete. Athletes will train alongside the Chargers team under the direction of the Camosun Coaching Staff in an up-tempo and accelerated learning environment.
The camp is restricted to those involved in club-level volleyball. Registered athletes should be entering grade 11, 12, or first-year post-secondary to take part in this camp (exceptions may apply if high-level experience can be demonstrated).


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Support us when you shop!
Go to smile.amazon.com/ch/33-0717794 and Amazon donates to S C R A P Gallery.
S.C.R.A.P. Gallery is the only children's art and environmental conservation museum in the eastern Coachella Valley, and the only one of its kind in Riverside County, CA. The facility allows for creative expression and education to take place.
Children create art on-site by using donated discarded materials while at the same time learning about complex environmental issues, arts, culture, science and much more. The gallery exhibits works of art by renown artists alongside those of S.C.R.A.P. Gallery youth, and houses both permanent and temporary interactive exhibits on issues like GMOs, renewable energy, water scarcity and climate change. Field trips for K-12 students take place throughout the week. The S.C.R.A.P. Gallery serves as a resource for teachers and students alike
S.C.R.A.P. Van Gogh:
Going beyond borders of all kinds, S.C.R.A.P. Gallery travels to deliver innovative art and environmental education programs to kids and adults throughout the Coachella Valley. By going to schools, libraries, festivals and events as well as other educational venues, S.C.R.A.P. Gallery ensures that those unable to visit the physical location still have access to these. Through a hands-on effort stressing the Four R's - Reduce, Reuse, Recycle, Responsibility the S.C.R.A.P. Gallery actively engage youth as stewards of their environment.


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Gloria was born in Verona, Italy.She trained at John Cranko School in Stuttgart, Germany, during which time she won first prize in the 'Danza Europa' competition.
After graduating, she worked in Italy with Carla Fracci, touring 'Il Vespro Siciliano'.This was followed by sixteen years dancing professionally as soloist, principal, and guest, with contracts at Dresden Opera and Leipzig Opera in Germany and English National Ballet.
On her retirement from dancing, she joined the Artistic Faculty at Elmhurst.She teaches classical ballet, and has experience with all age groups through the school;her focus is her students' development of technical purity and performance quality.She also helps to choreograph, and rehearse, the various school shows.
In recognition of her career as an Italian Artist, she has been honoured 'Premio Rugantino' and 'Premio Rondini'.
She returns to Italy regularly as guest teacher, private coach, and competition judge.
Her students have been senior finalists in the Youth American Grand Prix, and many of them now work as professional dancers in ballet companies around the world.
As a dancer, her repertoire included works by:
Bournonville, Adam, Saint-Léon, Petipa, Ivanov, Fokine, Vainonen, Gsovsky, Cranko, Lazzini, Nureyev, Vassiliev, Balanchine, MacMillian, Tetley, Schilling, Neumeier, Scholz, Béjart, Kylián.
She danced:
La Fille Mal Gardée (Lise), Paganini (La Musa), Onegin (Olga),
Coppelia (Swanhilda), Paquita (Paquita), Raymonda (Raymonda),
Napoli (Teresina), Gaîté Parisienne (Flower Girl), Don Quixote (Kitry),
La Sylphide (The Sylph), Les Sylphides (Mazurka), La Bayadère (Shades),
Cinderella (Cinderella; The Autumn Fairy),
Swan Lake (Odette-Odile; Neapolitan Dance; Pas de Quatre; Cygnets),
The Nutcracker (Clara; Sugar Plum Fairy; Spanish Pas de Deux; Mirlitons),
The Sleeping Beauty (Aurora; Bluebird; Silver Fairy; Songbird; Pas de Quatre),
Giselle (Giselle; Peasant Pas de Deux), Romeo and Juliet ( Juliet; Juliet's Friends).
Grand Pas Classique, Diane and Acteon, Flames of Paris, Carnaval,
Flower Festival in Genzano, Le Corsaire, Esmeralda, The Talisman, Harlequinade.
Apollo, Jeu de Cartes, The Rite of Spring, Volontaries, Elective Affinities, The Great Mass,
Pax Questosa, Berlioz, Bach Creation, Rakmaninov Concerto, Seventh Symphony, America,
Oktet, Red & Black, As You Like It, Daphnis et Chloé, Bolero, Sinfonietta and Symphony in D.
She rehearsed with:
Vladimir Vassiliev and Ekatrina Maksimova, Vladimir Derevianko,
Uwe Scholz, Tom Schilling, Glen Tetley, John Neumeier, Marcia Haydée,
Ronald Hynd, Derek Dean, Michael Corder, Christopher Hampson, Matz Skoog,
Paul Chalmer, Patricia Rouanne, Fredric Jahn, Loipa Araujo, Rodica Simion,
Gabriel Popescu, Walter Cinquinella, Odoardo Bordoni.
She created roles with:
Michael Corder - 'Peanut Polka' in 'Melody on The Move'.
Caterina Figaia - Tribú, with premiere live on national television in Italy.
Gabriel Popescu - Afternoon of a Faun, with premiere at Teatro Olimpico, Vicenza.
She performed in many wonderful venues, including:
Staatsoper Stuttgart; Semperoper Dresden; Oper Leipzig; The Lincoln Centre, New York;
The Royal Albert Hall, Royal Opera House, and Coliseum, London; The Parthenon, Athens;
The National Opera and Ballet Theatre, Amsterdam; Palacio de Bellas Artes, Mexico City;
The Liceu Theatre, Barcelona; The New National Theatre, Tokyo; Sydney Opera House;
The Arena, Verona; Teatro Olimpico, Vicenza; La Fenice, Venice; The Vatican, Rome.
In 2000, she danced at Tartar State Opera and Ballet Theatre in Kazan, Russia, as the first ballerina from Italy to be invited to The International Nureyev Festival;her performance of 'Sugar Plum' in Nutcracker here was awarded the festival Gold Medal.
Back to Artistic Faculty list
ARAD, RAD Dip PDTD, RTS Ballet


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What to Consider When Looking for a New Home
There may be a point in your life where you will want to get out of the home that you are currently living in and you will want to find a new home to purchase and make your own. When that time comes, you have to know what options are open to you and how each one will work for you. You have to figure out what type of house is going to fit your needs. As you are searching the listings of houses in your area, make sure that you have a good idea of what you want from the one that you pick out to purchase.
Look for Houses with a Good Number of Bedrooms:
When you are searching for the home that could be perfect for your family, you have to think about the number of bedrooms that your family will need. You have to think about the minimum number of bedrooms that will work for you and the maximum number of bedrooms that you would like to have in your home. It is important that you think about all that you might use the bedrooms for, such as offices and workout rooms, as you think about how many you would like to have in your new home.
Look for Houses with the Extras that You Want:
When you are shopping for a home, you have to think about any extras that you would like to have in that home. If you are looking for a home that has a formal dining room, you should talk to your real estate agent and let them know that that is important to you. If you would like to have a pool on your property, you should look for a home that has a pool in its yard already. Make sure that the home that you purchase is one that has all of the extras that you are seeking and that will make your life happier.
Look for Houses that are in a Good Area:
There are going to be a number of new homes gluckstadt ms for you to consider and knowing which area you would like to live in can help you narrow down your options and find the one home that is perfect for you. Think about the area that is best for your family so that you can purchase a home in that area. Only consider those homes that are located in areas where you would feel comfortable making your home and raising your family.
Use a Good Real Estate Agent to Find a Perfect Home:
It is important for you to find a home that you will love, one that is affordable to you and that meets all of your needs. As you are searching for the home that you would like to purchase, think about what you want and make sure that the one that you decide on checks off all of the boxes on your list of needs. There is a perfect home out there for you.


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Service dogs are companion animals that help people who have physical or mental health conditions.
A service dog for anxiety can provide a sense of calm, anticipate anxiety attacks, and even fetch medication for their owner.
In this article, we look at the benefits of service dogs for people with anxiety. We discuss how to get an anxiety service dog, which breeds make the most successful anxiety service dogs, and how much they cost.


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You are able to log in as anyone. Be careful!
You are able to log in as anyone. Be careful!
n49 2000-2015 | N49 is proudly made in toronto
100 N Federal Hwy, Fort Lauderdale, FL
2211 Davie Blvd, Fort Lauderdale, FL
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300 SE 17th St, Fort Lauderdale, FL
... West Palm Beach, Hollywood, Delray Beach and Boynton Beach, Anidjar & Levine employs a full team of personal injury lawyers, investigators and medical/legal support experts who are well-equipped to handle all aspects of ... Read more
2727 NW 62nd St, Fort Lauderdale, Fort Lauderdale, FL
... most challenging times in their lives. Our main goal is to get injury victims everything they truly deserve. Every lawyer on our legal team is committed to fighting for the best interest of injury victims. Read more
500 East Broward Boulevard, Fort Lauderdale, FL
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... proven track record to bolster each client's opportunity for maximum monetary recovery. To learn more about whether you may have a valid claim, contact the personal injury lawyers at our Fort Lauderdale firm today. Read more
1 E Broward Blvd, Suite 1500, Fort Lauderdale, FL
... most extensive cases, reaching out to experts and professionals as necessary, yet we give each client the personal attention he or she deserves. Our goal is to make the law manageable for our clients. We ... Read more
100 SE 3rd Ave, Fort Lauderdale, FL
The Fort Lauderdale personal injury lawyers at Sibley Dolman Accident Injury Lawyers, LLP, regularly represents clients in the Fort Lauderdale area who suffered injuries in a wide variety of accidents. We can advise you of ... Read more
... over 30 years clients, have placed their trust in the law offices of Distefano Law, PLC to handle their legal matters. Our Florida personal injury lawyers have drastically impacted the lives of thousands of clients. Read more
Contact us today!
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At the law firm of Boone & Davis, Attorneys at Law, our Fort Lauderdale personal injury attorneys are dedicated to helping victims recover for injuries sustained in accidents caused by the negligence or wrongful acts ... Read more
707 Southeast 3rd Avenue, Fort Lauderdale, FL
2101 W Commercial Boulevard, #1500, Fort Lauderdale, FL
Located throughout South Florida, our personal injury law firm has four convenient locations – from Ft. Myers to Palm Beach, Ft.Lauderdale and all the way down to Miami, we can help. Since our case experience ... Read more
201 NE 2nd Street, Fort Lauderdale, FL
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900 Southeast Third Avenue, Fort Lauderdale, FL
401 E Las Olas Blvd, Fort Lauderdale, FL
100 SE 6th St, Fort Lauderdale, FL
... trial practice is devoted to the representation of injured persons and their families who have suffered an injury or death as a result of aviation disasters, railroad derailments & accidents, automobile accidents, marine/aquatic accidents ... Read more
100 SE 3rd Ave, Fort Lauderdale, FL
When you need an advocate, Yeboah Law Group is there for you. Our Fort Lauderdale personal injury lawyers represent people who have been injured due to car accidents, truck accidents, slip and fall accidents, medical ... Read more
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... also pride ourselves on our active involvement in the community we serve in order to bring fairness and just compensation for any personal injury case. Assistance is just a phone call away – (954) 626-0727. Read more
1212 Southeast Third Avenue, Fort Lauderdale, FL
If you were injured because of another's negligence, it is important that you contact the dedicated Fort Lauderdale personal injury attorneys at Schlesinger Law Offices, P.A. As a multigenerational law firm, they have ... Read more


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We're excited to announce support for new settings and updates that will be in place when iOS 13 releases around September. We'll update documentation as we make changes on our side but we wanted to consolidate information here for your convenience.
Some Unsupervised iOS Device Restrictions Change to Supervised-Only
Eleven iOS device restrictions will change from unsupervised to supervised-only with the iOS 13.0 release:
App Store, Doc Viewing, Gaming
Built-in Apps
Cloud and Storage
If these settings were configured and assigned to unsupervised devices prior to the iOS 13.0 release, the device restrictions will still apply to the unsupervised devices—even after the devices are upgraded to iOS 13.0. However, these device restrictions will be removed from unsupervised devices that are backed up and restored. These restrictions will not be applied to unsupervised devices enrolled after the iOS 13.0 release, even if they are running an OS version earlier than iOS 13.0.
For the complete list of supervised settings, see iOS device settings to allow or restrict features using Intune.
For more additional information about supervised mode, see Turn on iOS supervised mode.
New Device Restriction Settings
We're excited to announce that we are providing support for four new supervised-only iOS 13.0 settings and one new macOS 10.15 setting prior to the software releases. We want you to be able to use these restrictions as soon as Apple releases iOS 13.0 and macOS 10.15, so they are now available with the 1908 Intune release.
Note that these restrictions do not apply to devices that are enrolled through User Enrollment.
Keyboard and Dictionary
Built-in Apps
Cloud and Storage
For the complete list of macOS device settings, see macOS device settings to allow or restrict features using Intune.
New User Enrollment Device Restrictions
Apple has announced the introduction of a new type of enrollment called User Enrollment for iOS 13, iPadOS, and macOS 10.15 Catalina devices. To prepare for User Enrollment release, we are ensuring that your current Device Configuration policies will apply in a predictable manner to User Enrolled devices.
Some iOS/macOS profile types for Device Configuration that work for all enrollment types are listed below:
Settings Categorized by Enrollment Type
With the addition of User Enrollment alongside Device Enrollment and Automated Device Enrollment, we're going to make it easier for you to intuitively navigate our settings UI by adding categorization headers to clarify which settings apply based on each of the enrollment types.
In the September Intune update or 1909, we'll introduce categories that separate iOS and macOS settings by the enrollment type to which they apply. This new categorization pertains to device features and device restrictions for iOS and macOS profile types, along with the extensions profile type for macOS. This will make it easier to see which settings will apply to the devices you want to target based on how they were enrolled.
Note that these UI changes do not affect any existing profiles or Graph.
The new iOS/macOS enrollment headers and descriptions that will be on the blades are as follows:
Some additional changes
Post Updated
Great news!
Does this mean Intune now supports `Data Separation for BYOD` and `Modern Authentication for Device Enrolment` in iOS13?
Hi @Kengo Suzuki, thanks for reaching out, we're excited too!
We'd also like to clarify both of these features, "Data Separation for BYOD" will be referred as "User Enrollment", and "Modern Authentication for Device Enrollment" will only be applied to Automated Device Enrollment.
Both are currently In-Development, keep an eye out in our In-Development and What's New Docs for these features to be released!
@Intune Support Team Great to hear! and sorry for the belated reply.
Thanks for the answer. We can't wait applying it.
Hi @Intune Support Team, in the comment above you clarified that "User Enrollment" is still in development... can you please confirm that it definitely will not be supported day zero? And if that is true are you able to say that it might be "weeks" away or "months"?
@Robin Griffin User enrollment is rolling out at the moment!
Have a look in your tenant under Device enrollment, Apple enrollment if you see Enrollment Types.
@Peter Klapwijk Thanks for the heads up Peter! Sadly like many others I see the option but creating a profile fails with a generic error every time.
@Robin Griffin Yes same for me. Tried it on different tenants, located in Europe and Asia-pacific. Even now I cannot save a profile.
@Peter Klapwijk I got a reply in another thread that it should be fully rolled out to all tenants by Monday.
You must be a registered user to add a comment. If you've already registered, sign in. Otherwise, register and sign in.


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Importance of Commercial Loans
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Dhogs (2017) dir: Andrés Goteira DVD (Yume Pictures)
This multi-stranded Galician-language film is an engrossing and challenging effort, highly recommended for those who like to think while they watch. Starring Melania Cruz, Antonio Durán 'Morris', Miguel de Lira, Iván Marcos, Carlos Blanco and María Costas.
Click here to read review
The Last Movie (1971) dir: Dennis Hopper Blu Ray (Indicator)
Hopper's second film as director was - and, to be honest, still is - a rambling and self-indulgent mess. However, this disc is a must due to the sheer wealth of extras here, not least being an excellent Alex Cox documentary on its production.
Click here to read review
Irma Vep (1996) starring Maggie Cheung Blu Ray (Arrow Academy)
Olivier Assayas' underrated gem is an incredibly hard film to pigeonhole - at once a behind-the-scenes mockumentary jab at the arty pretensions of modern French cinema and an ode to the incomparable beauty of actress Maggie Cheung.
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Serge Bromberg's reconstruction and postmortem of Henri-Georges Clouzot's aborted would-be masterpiece presents us with some visually-striking footage but not enough depth. However, the extras help to fill in the blanks.
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As the joys and merriment of the holiday season were slowly becoming cherished memories, 2014 arrived brashly with its "gifts" of frigid weather and huge snowfalls. So, I think I'll just stay inside by the fire, read my colorful garden catalogs and dream of the arrival of spring. And, in eager anticipation, I'm starting my annual countdown early this year—only 69 days until one of my favorite seasons arrives on March 20.This coming August—the 17th to be exact—will be a special anniversary for me, marking eight years since my first column appeared in this newspaper. During that time I have always written my column in a neutral way, giving equal "ink" to all causes and organizations in our community.
That being said, I am going to stray a bit from my neutral stance moving forward. As you are aware, I treasure our environment: I use no chemicals in my garden and only environmentally sensitive products in my home; I plant native; and I love wildlife. If I were to have my way, I would live all by myself in the middle of a pristine forest. But that is not reality.
"The Links" and "The Hills" are the last big tracts of land left in East Quogue. "The Links" has already been preserved and proposals for development of "The Hills" have been made. During the last few months there has been much controversy and hyperbole in our hamlet and I have dear friends on both sides of the issue.
Speaking to some of my friends and neighbors, however, I have become concerned that decisions are being made about the proposed project without full knowledge of all of the facts. I count very few residents who have actually sat down with the developers to discuss the plans for "The Hills" in a calm and informative manner.
So, I am pleased to tell you that Robert Long, the principal of our East Quogue Elementary School, will be hosting an informational meeting in the school cafetorium sometime in February. The officers of Discovery Land Company will be there to explain their proposed project and to listen to the concerns of our community.
Stay tuned because I will have more information as it becomes available. Just make a note of it for now and plan on attending with an open mind.
And, on a fun note, belated happy birthday wishes are winging their way to those special twins Samantha and Taylor Oudeans who turned 17 on Monday, December 23. Taylor and Samantha are juniors at Westhampton Beach High School where they are Honor Roll students.
Saturday, January 11: "Birds of Prey Up Close and Personal" at the Quogue Wildlife Refuge, 1 p.m. For more information, call (631) 653-4771.
Saturday, January 18: East Quogue's Eileen Schwinn, past president of the Eastern Long Island Audubon Society, discusses the "Birds of Winter" at the Quogue Library, 10 a.m. For information, call (631) 654-4224.


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Ever since starting my Driving with John Chow video series, I've Most of the videos and photos you see posted on this blog was done with the. If your article is picked up by a lot of sites, the resulting traffic and . I had postings on photography on my site that had a lot of sample photos. in the blog world, some will use the photo to boost their credibility. The best way to get a post onto John Chow dot Com is to email me the full post. . I was pretty sure I was driving people away with all that transparency.
Let me share with you some of the SEO strategies you need to drive more traffic to your blog. You and I know that before you can build a. Yeison and John Chow dot Com went to New York early this month to the Affiliate Summit. John is one of the biggest active bloggers and he is always. Photo Credit: Kaique Rocha Left: Traffic I got from a guest post on Lifehack | Right: Traffic I got from a guest post on Growmap .. John Chow, the creator of this blog, shares his blogging success of earning $40, per.
How To Create Content That Won't Rely on Google for Traffic | John Chow dot Com. New free stock photo of city building wall. Find this Pin and more on Anti . Explore John Chow's board "Boats, Babes and Cars, But Mostly Cars" on Pinterest. like a Red Riding Hood and a wheelie prone Volkswagen microbus with an Instagram Users Can Upload Multiple Photos, Videos to Their Stories. Working on a card appropriate for the season to be entered in a contest at a local gallery, I decided to do something a bit unusual and. By Andrew R. Chow. Oct. 11, John Cale didn't spend very long in the Velvet Underground. Four years after . Cale laughed upon seeing a photo of Nico driving the band in a banged up Winnebago. "She was pretty. Photographer: John Gollings Bell Romero Houses Photographer: Chris Force, "Architecture – The People, Places, and Ideas Driving Contemporary Design,".
And a long list of defendants: Sirhan Sirhan, John DeLorean, Angela Davis, .. By the time I was 12, 1 knew all the models and the photographers that were . You'll get much more enjoyment from a place that's, say, a two-hour drive or flight from home base. Steak House Mr Chow N. Camden Dr. (). American military photographers representing all of the armed services covered the . Pfc. John F. Albert, March 26, .. Germans captured these American soldiers during the surprise enemy drive into Allied positions. Chow is served to American Infantrymen on their way to La Roche, Belgium. With Mark Dacascos, Kadeem Hardison, John Pyper-Ferguson, Brittany Murphy. A prototype enhanced Drive () Drive () · See all 14 photos». Enjoy bird photography tours. Image gallery of Susan Davis' bird photography. In general, the southern tour is more a driving tour with stops made when.
philip dykes john lee Chow Nok-hang Leung Wing-lai Wong Weng-chi The Hong Kong Free Press #PressForFreedom Funding Drive seeks to raise .. HKFP Lens: Stunning photojournalism from the World Press Photo contest .


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Yesterday, I hung up the phone and thought about my conversation with a groom who had just got engaged. He was clearly so excited about his upcoming wedding. It was really sweet and I felt myself get swept up in his energy. " I want to do this wedding!!", I thought. Of course we are in the business of getting excited about whatever your event is, whether it's a wedding reception, gala, fundraiser, or corporate meeting right here in Atlanta. We love it. It's why we do what we do. But I could tell this gentleman was really excited about music. And that is our kinda guy! We started discussing options for the ceremony and cocktail hour music and he mentioned that he'd like to have an acoustic guitar and ukulele duet for ceremony. And I started thinking about the time a few years back when my client had a close friend who played the violin and they asked us to work something up with her. In addition, this wedding was on the side of a mountain at a place called Splendor Mountain. Check it out: http://www.splendormountain.com. I loved the owner of this venue. Such an nice welcoming person and I vowed to get back there someday as a guest. It was an incredibly fun night that included a guest drinking champagne out of his shoe, but I digress. The thing that was really cool was putting the rustic acoustic guitar, keys and violin ceremony music together. I knew the musicians would enjoy this opportunity to do something a little different. In the end, our client was so happy and we enjoyed being able to put this little unique touch together for them. And that folks, is what it's all about.
This Pic Kinda Says It All
On June 25th, 2016, Platinum had the pleasure of celebrating the wedding of Cassie Umland and Keith Hagerich at the Fabulous Fox Theater in the Egyptian Ballroom. As with all weddings and events we do, we strive to help our clients put together a unique event that really speaks to their personalities their history and their vision. One of the really cool things about this event was that Keith is a DJ. So, he's "in the biz", so to speak. And Keith wanted to be able to DJ for a few minutes since music is a big part of their lives together. We set up a phone conference to see if we could coordinate getting his gear set up pre-reception and then making sure the equipment was ready to go on the band's last break. One concern was no downtime between band stopping and Keith beginning. Glen had music ready to DJ for a few minutes so that any technical issues would not be noticed. Sure enough, with every event, you have to be ready to problem solve and have a plan B as well and go with the flow. And this night was no different. It took a few minutes to figure out a couple of technical issues with Keith's board and our sound equipment but Glen was ready. Very quickly it got worked out and Glen backed off as Keith took over. Cassie handed out Glow Sticks. It was a lot of fun watching the two of them together on the stage, newly married and sharing this time with their closest friends and family. I loved it and was delighted we could help make this happen. You can find the "live" video I did on our FB page: https://www.facebook.com/platinumbandatlanta.
Other quick mentions that I MUST make are the wonderful people that I worked with: Dennis Dean Catering. So friendly, the band meals were dropped right no time and the food was truly excellent. The event planner I worked with was Staci Wright: 239-822- 1290. Staci and I had never worked together before. It takes a little bit to get a groove going between vendors when you haven't worked together. But Staci was so easy to work with, so professional and extremely organized. I highly recommend her!
Lastly, I haven't mentioned THE PIC as titled above so here it is. It says a lot. First, we now have T-shirts that we give out to our clients. Second, it says a lot when the bride and groom stick around just another minute at the end of the night to take a pic with their band. Third, we had such a fun night with these two families and their friends. It was a perfect night in every sense of the word and a great time was had by all!!
It's About Trust
In my previous ( and very first post) I talked about how long Platinum has been providing entertainment in the Atlanta and Southeast and our love of the job we do.
Now I want to talk about why we have been so successful and why most of our business comes from referrals and repeat business. I think any great band has to have a recipe of several things: first and foremost, impeccable integrity both on and off the stage. A band must be well rehearsed with superior musicians and vocalists. Platinum members have a high regard for their craft. Each person in our band is blessed with a raw talent they we have all honed with discipline and practice. 2. Teamwork. You cannot make magic if you don't have a "we are a team", mentality. As a long time performer, I have been in several situations where either the connection is there or not. Each person is either focused on themselves or the larger task at hand: putting on a great show. I'm proud that we have ALWAYS had a charisma that I believe comes from the attitude we each have about our end goal. Be the best, be the most fun, be the band that your guests say is , " the best band we've ever seen". 3. Attitude. I say this a lot but I believe it. It is my personal business philosophy: Don't boast just show up and do it. Be the best, be the most professional, best dressed especially with a great attitude and the rest will take care of itself!
Platinum Band Atlanta...Making You Dance for 14 Years Now..
Managing Platinum Band Atlanta has been both an honor and a privilege. Managing a variety dance band has it's challenges for sure but as a performer and a person who absolutely loves seeing the pure joy on a guest's face as they dance and celebrate, there are few things I love more than this job. Whether it's a year-end corporate celebration or the happiness on a father of the bride's face as I danced with him and sang his favorite song to him, those are the moments. That is our joy and why we do it, all of us in Platinum. We love this job!!! My second home is my work after my family.
What makes Platinum the "best band in the city' as I'm told very often by our colleagues and repeat clients? It's that love of music and performing that is in our blood and continues with the same passion after literally hundreds of gigs and and hundreds of miles traveled to walk into a building set up, dress up, warm up and show up to give you the "night of your lives". We hope that we continue to share our gifts with you for years to come and we thank each and every person that put your faith in us in years past. See you on the stage...Virginia


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Bamboobies are washable, reusable breast pads for the nursing mother. Bamboobies breast pads are better than disposable breast pads for so many reasons.
- Bamboobies are very thin and don't show through clothing.
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How many Bamboobies
Wondering how many bamboobies you need?
A good guideline would be 2 sets for the day and 1 or 2 sets for the night.
Of course this depends on how much you leak and how often you desire to change them. Another thing to consider is how often you plan to do laundry. If you can wash them every day then 1 bamboobies multipack might be good for you, if you wash less frequently then you may want to consider purchasing more than one pack so you can do laundry less often and still have clean bamboobies to change into.


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Imran Khan backed by Corbyn after election: 'New government can deliver social justice'
JEREMY Corbyn has given his backing to Pakistan's newly inaugurated prime minister Imran Khan, and said he hopes his new government can deliver "social justice". The Labour Party leader congratulated the Tehreek-e-Insaaf (PTI) Chairman after he was officially sworn in on Saturday.
Imran Khan inspects guard of honour on his arrival in the Prime Minister House
He tweeted: "Congratulations to @ImranKhanPTI, sworn in yesterday as Pakistan's Prime Minister. "We give our support to the people of Pakistan, and hope that the new government can deliver social justice and help build a country that works for all."
The words of support from the opposition leader came after Mr Khan vowed to transform Pakistan into an Islamic welfare state during his maiden address to the nation.
Mr Khan has promised the country a welfare state system based on the British model.
The Pakistani Prime Minister also announced a number of measures aimed at tackling austerity, including ditching loans, domestic resource mobilisation and reforms across the education, health and agriculture sectors.
But the former cricket star's leadership skills were already being put to the test - just hours after his inauguration - by a looming currency crisis which threatens to cripple the country.
The South Asian nation is currently enjoying economic growth of some six percent each year but urgently needs international help to service its debts.
Theresa May also spoke to the Pakistan leader on the first day of his job to discuss bilateral relations between the two countries.
Posting on Twitter, Mrs May wrote: "Pleased to talk to @ImranKhanPTI, Prime Minister of Pakistan.
"The UK and Pakistan share deep and important links. There is plenty for our two countries to work together on, not least increasing bilateral trade and mutual security issues."
Imran Khan was voted in during last month's election and his party, the Pakistan Tehreek-e-Insaf (PTI) party, won the most seats.
They hold 151 of the 342 seats in the national assembly and a vote was held at the country's National Assembly on Friday (August 17) to decide who would be asked to form a government.
He promises to fight corruption and drastically reduce poverty among Pakistan's 208 million mostly-Muslim people and has vowed to create a "new Pakistan".
Mr Khan's success ends decades of political dominance by two dynastic powerhouses, the Pakistan Muslim League-Nawaz (PML-N) of three-time premier Nawaz Sharif, who is now in prison, and the Pakistan Peoples Party (PPP), founded and led by the Bhutto family.
He is soon to face the difficult decision of either appealing to the International Monetary Fund (IMF) for help paying back loans or becoming further indebted to long-term ally China.
And the sports star, now 65, is also facing the task of keeping his election promises - which include costly economic reforms aimed at drastically reducing poverty among Pakistan's 208 million citizens.


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