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Article Text
Objectives To identify the determinants and the impact on outcome of brain natriuretic peptide (BNP) in asymptomatic patients with degenerative mitral regurgitation (MR).
Method Comprehensive transthoracic echocardiography including two-dimensional speckle tracking quantification was performed in 135 consecutive asymptomatic patients (60±14 years, 56% men) with moderate to severe degenerative MR and preserved left ventricular (LV) function. Blood samples were collected at the time of the echocardiography and plasma BNP levels were measured.
Main outcome measures BNP level and cardiac events.
Results BNP was correlated with age, indexed LV end-systolic diameter, indexed left atrium (LA) volume, estimated LV filling pressure with E/Ea ratio, systolic pulmonary arterial pressure and global longitudinal strain (GLS). In multiple regression analysis, indexed LA volume (p=0.008), mitral deceleration time (p=0.003) and GLS (p<0.0001) were independently associated with BNP. During follow-up (mean=23±19 months), 54 events occurred resulting in 4-year event-free survival of 50±6%. There was a graded relationship between the increase in BNP (ie, according to quartile) and reduced event-free survival (p<0.0001). In Cox multivariable analysis, indexed LA volume (HR=1.04, p=0.003), GLS (HR=1.14, p=0.007) and 3rd and 4th quartiles of BNP (HR=8.5, p=0.002 and HR=8.8, p=0.002) were independent determinants of event-free survival.
Conclusion In asymptomatic degenerative MR, LV longitudinal function and LA volume are the main determinants of BNP release. BNP is a powerful independent predictor of cardiac events. Measurement of plasma BNP may help to improve risk stratification and management of asymptomatic patients with degenerative MR.
- Valve
- mitral regurgitation
- echocardiography
- brain natriuretic peptide
- speckle tracking
- aortic valve disease
- exercise echocardiography
- dobutamine echocardiography
- valvular heart disease
- valve disease
- aortic stenosis
- prosthetic heart valves
- cardiomyopathy restrictive
- diastolic function
- congestive heart failure
- heart failure
- stress echocardiography
- echocardiography
Statistics from Altmetric.com
- Valve
- mitral regurgitation
- echocardiography
- brain natriuretic peptide
- speckle tracking
- aortic valve disease
- exercise echocardiography
- dobutamine echocardiography
- valvular heart disease
- valve disease
- aortic stenosis
- prosthetic heart valves
- cardiomyopathy restrictive
- diastolic function
- congestive heart failure
- heart failure
- stress echocardiography
- echocardiography
The management and timing of surgery of patients with asymptomatic degenerative mitral regurgitation (MR) remain controversial. In severe MR, both the current European Society of Cardiology (ESC)1 and American College of Cardiology/American Heart Association (ACC/AHA)2 guidelines recommend mitral valve surgery when symptoms, left ventricular (LV) dysfunction, atrial fibrillation or pulmonary arterial hypertension occur (class I and IIa). In the absence of such criteria, patients with chronic severe MR may undergo surgery only when the likelihood of successful repair is high (>90%). However, surgeons may be reluctant to operate on patients without symptoms, even in the absence of comorbidities. Indeed, although operative mortality of mitral valve repair may be very low in selected series and centres, it is still significant and these excellent operative results are not necessarily generalisable to all centres. Furthermore, despite the improvement in the awareness and technical skills of the surgeons for this procedure, a substantial proportion of the valves that are potentially repairable are ultimately replaced by a prosthesis. In this regard, some authors recommend referring patients for prophylactic mitral surgery only to high-volume and experienced surgical centres.3 4 Nevertheless, this strategy is not always feasible for various reasons including availability, local context, patient preference and insurance restrictions.5 Consequently, the selection of appropriate asymptomatic patients with severe MR (ie, in whom the benefit/risk ratio (RR) of early surgery may be expected to be optimal), is the cornerstone of the management of these patients.
Brain natriuretic peptide (BNP) and its inactive amino terminal portion are neurohormones released by the ventricles in response to increased LV wall stress. A recent study reported that assessment of BNP levels and quantification of MR may provide complementary prognostic information in acute coronary syndromes.6 In patients with organic MR, BNP is known to be related not to MR itself but rather to the consequences of MR, mainly on LV, left atrium (LA)7 and systolic pulmonary arterial pressure (SPAP).8 Accordingly, a few studies have suggested that BNP level measurement may be useful for risk stratification of asymptomatic severe MR.9 10
Recent echocardiographic advances have introduced the use of two-dimensional speckle-tracking (2DST) analysis to quantify longitudinal LV myocardial function and detect subtle and subclinical LV dysfunction. Because LV ejection fraction is well recognised as a poor echocardiographic parameter to assess LV systolic function in ≥ moderate organic MR,11 12 the evaluation of LV longitudinal function may help to detect early LV dysfunction. However, the relationship between LV longitudinal function and BNP is, to the best of our knowledge, unknown in this population.
The aim of this study was to identify the determinants and the impact on outcome of BNP in asymptomatic patients with degenerative MR.
Study population
A total of 135 consecutive asymptomatic patients with at least moderate degenerative MR (defined as an effective regurgitant orifice (ERO) area ≥20 mm2 and/or a regurgitant volume (RV) ≥30 ml) were prospectively included in two centres (University of Liège, CHU Sart Tilman, Liège, Belgium, n=106; Quebec Heart and Lung Institute, Quebec, Canada, n=29). Patients with one of the following criteria were excluded: (1) LV end-systolic diameter >45 mm; (2) LV ejection fraction <60%; (3) atrial fibrillation; and (4) concomitant >mild valvular stenosis or regurgitation.
The present protocol was approved by the relevant institutional review boards and all patients gave written informed consent.
Demographic and clinical data
Demographic and clinical data included age, gender, height, weight, history of smoking, documented diagnosis of hypertension (patients receiving antihypertensive medications or having untreated hypertension (blood pressure ≥140/90 mm Hg)), hypercholesterolaemia (patients on cholesterol-lowering medication or, in the absence of such medication, low-density lipoprotein cholesterol level >160 mg/dl) and diabetes (patients currently receiving oral hypoglycaemic medication or insulin).
Echocardiographic measurements
Echocardiographic examinations were performed with a Vivid 7 or 9 imaging device (GE Healthcare, Little Chalfont, UK). All echocardiographic and Doppler data were obtained in digital format and stored on a workstation for offline analysis (EchoPAC, GE Vingmed Ultrasound AS, Horten, Norway). All measurements were averaged over three cardiac cycles. MR was quantified as previously described13 and recommended.14 The RV and the ERO area were reported as the average of the proximal isovelocity surface area and of Doppler volumetric methods. The LV diameters were obtained from the parasternal long-axis view by two-dimensional guided M-mode using the leading edge methodology at end diastole and end systole. The LV end-systolic and end-diastolic volumes as well as the LV ejection fraction were obtained using the modified biplane Simpson's method. The LV stroke volume was calculated by multiplying the LV outflow tract area by the LV outflow tract velocity–time integral measured by pulsed-wave Doppler. The LA volume was obtained using the area-length method. Mitral E- and A-wave velocities were measured with pulsed-wave Doppler, and Ea-wave velocity by tissue Doppler imaging in the septal position of the mitral annulus. The LV filling pressure was estimated using the E/Ea ratio. SPAP was derived from the regurgitant jet of tricuspid regurgitation using systolic transtricuspid pressure gradient calculated by the modified Bernoulli equation and the addition of 10 mm Hg for right atrial pressure as previously performed15 and validated.13 16
In order to comprehensively assess LV myocardial function, the global longitudinal strain (GLS) was quantified using 2DST analysis. From standard bidimensional grayscale recordings (frame rate >60/s), the endocardial borders were traced at the end-systolic frame, and an automated tracking algorithm outlined the myocardium in successive frames throughout the cardiac cycle. The tracking quality was verified for each segment (with subsequent manual adjustment of the region of interest if necessary), and myocardial motion was analysed by speckle tracking within the region of interest bound by endocardial and epicardial borders. Inadequate tracked segments were automatically excluded from analysis. In this situation, local strain in each segment was calculated.17 18 GLS was obtained by averaging all segment strain values from the apical 4-, 3- and 2-chamber views.
The reproducibility of MR quantification and GLS have been previously reported.16 19
Plasma BNP level measurement
Venous blood samples for baseline BNP measurement were drawn before echocardiography, after 20 min of supine rest. Chilled ethylenediamine tetra-acetic acid tubes were centrifuged immediately at 4000 rpm (4°C) for 15 min. Separated plasma samples were processed by immunofluorescence assay (Biosite, Beckman Coulter, San Diego, California, USA). The inter- and intra-assay variations were 5% and 4%, respectively. The assay detection limit was 1 pg/ml.
Cardiac event-free survival
Patient follow-up was performed according to current guidelines. Follow-up information was obtained from interviews with the patients, physicians or eventually next of kin every 6–12 months. Cardiac event was defined as the occurrence of cardiovascular-related death, mitral valve surgery (indicated only by the development of symptoms or LV dysfunction, according to current guidelines) and hospitalisation for acute pulmonary oedema or congestive heart failure. Surgery performed on the basis of the presence of pulmonary hypertension was not considered as an event. At the end of this study, patients with a last follow-up of >6 months were re-evaluated by telephone calls from physicians or next of kin.
To ensure blinding and avoid bias in clinical decision-making, the results of BNP levels were not transmitted to the treating physician or surgeon.
Statistical analysis
The results are expressed as mean±SD or percentage unless otherwise specified. Patients were studied in two groups according to the median of BNP level. Differences between groups were analysed for statistical significance with the Student t test, Mann–Whitney U test, χ2 test or Fisher exact test as appropriate. Correlations between echocardiographic data and BNP level were assessed with linear regressions. Independent predictors of BNP level or BNP >median were obtained with the use of stepwise multiple linear regressions or logistic regression, respectively. Probabilities of cardiac event-free survival were obtained by Kaplan–Meier estimates and then compared with a two-sided log-rank test. Cox proportional hazards models were used both in individual and multivariable analyses to identify the independent predictors of cardiac event-free survival. The impact of BNP level on outcome was assessed according to quartile. Variables with a univariate value of p<0.10 were incorporated into the multivariable models. Gender was forced into the multivariate models regardless of the p value on univariate analysis because it has been show to influence plasma BNP levels.20
Values of p<0.05 were considered significant. All statistical analyses were performed with STATISTICA version 6 (StatSoft, Tulsa, Oklahoma, USA).
Among the 135 included patients (60±14 years, 56% men), 82 (61%) had severe MR with RV >60 ml. The BNP varied widely (figure 1) from 5 pg/ml to 439 pg/ml (median 40 pg/ml, mean 61±70 pg/ml) resulting in a normality test failure (p<0.0001). After log transformation the BNP distribution was normal (p=0.35). According to the median BNP level (40 pg/ml), patients with high BNP were significantly older (p=0.02) and there was no other significant difference between the two groups regarding demographic and clinical data and risk factors, medication and mitral valve prolapse localisation (table 1).
In severe MR, patients with high BNP also tended to be older (p=0.08).
Echocardiographic data in patients with high versus low BNP
There was no significant difference between low and high BNP level groups regarding LV dimensions and systolic function (table 2). Patients with a high BNP level had a significantly higher E/Ea ratio (p=0.049) and longer deceleration time (p=0.0045). The LA volume and LA volume indexed for body surface area were significantly higher in patients with a BNP level >40 pg/ml (both p=0.0001). Of note, there was no significant difference in ERO and RV between the two groups (p=0.58 and p=0.64, respectively). Patients with severe MR had a statistically similar BNP level to those with moderate MR (69±84 vs 56±58 pg/ml, p=0.28). The SPAP was significantly higher in the high BNP group (table 2, p=0.03) and patients with pulmonary hypertension (ie, SPAP >50 mm Hg) had a significantly higher BNP level (122±129 vs 53±54 pg/ml, p=0.0002). LV longitudinal myocardial function, as assessed using the GLS, was significantly impaired in patients with BNP level >40 pg/ml (−17.7±3 vs −22.3±3, p<0.0001). In addition, there was a direct relationship between increased BNP level and increased GLS (ie, impaired LV longitudinal function) (p<0.0001, figure 2).
In patients with severe MR a high BNP was associated with higher indexed LV end-systolic volume, indexed LA volume, SPAP and GLS (all p<0.03).
Determinants of BNP level
The log transformation of BNP was significantly correlated with age, indexed LVES diameter, E/Ea ratio, deceleration time, LA and indexed LA volume, and with SPAP (table 3). The best correlation with log BNP was found with the GLS (r=0.64, p<0.0001; figure 2B). In multiple linear regression, mitral deceleration time, indexed LA volume and GLS were independent determinants of log BNP (table 4).
A multiple logistic regression model was then built (table 4) in order to identify the independent determinants of elevated BNP level (>40 pg/ml). In this model, long deceleration time and high indexed LA volume were independently associated with high BNP level. GLS was identified as the strongest determinant of BNP level >40 pg/ml (p=0.001), with a 33% increased risk of having elevated BNP for each increase of 1% (ie, impairment of LV longitudinal myocardial function) of GLS (OR=1.33, 95% of CI 1.12 to 1.59).
Impact of BNP on cardiac event-free survival
During follow-up (mean 23±19 months, median 17 months), 54 patients (40%) had a predefined cardiac event. Mitral valve surgery (70% of mitral valve repair) was motivated by the occurrence of symptoms in 18 patients, the presence of LV dysfunction or dilation in 5 patients or by the combination of both in 20 patients. Among the 11 remaining patients in whom a cardiac event other than surgery occurred, 10 were hospitalised due to syncope, congestive heart failure or acute pulmonary oedema and one died. Cardiac event-free survival was 77±4% and 59±5% at 1 and 2 years, respectively.
According to the median BNP level (40 pg/ml), patients with low BNP had significantly higher cardiac event-free survival (1 year: 92±3 vs 61±6%; 2 years: 81±5 vs 35±7%; p<0.0001). Using receiver operative characteristics curve analysis, a BNP level >40 pg/ml yielded the best results for predicting outcome (sensitivity 74%, specificity 65%, positive predictive value 59%, negative predictive value 79%). Compared with quartile 1 of BNP level, the 2-year event-free survival was significantly reduced in quartile 3 and 4 (Q1: 83±7% vs Q3: 35±11% and Q4: 35±10%, respectively, p<0.0001, figure 3).
In patients with severe MR, the high BNP group had significantly lower cardiac event-free survival (1 year: 54±8% vs 87±5%; 2 years: 37±9% vs 78±7%, p<0.0001).
In the univariate Cox proportional hazard model (table 5) a high BNP level (>40 pg/ml) was associated with an increased risk of cardiac event (HR=5.01, 95% CI 2.7 to 9.4, p<0.0001). Compared with the lowest BNP level quartile (quartile 1: 5–19 pg/ml; quartile 2: 20–40 pg/ml; quartile 3: 41–70 pg/ml; quartile 4: 71–439 pg/ml), quartile 3 and quartile 4 were significantly associated with a higher risk of cardiac events (HR=8.9, 95% CI 2.9 to 26.3, p<0.0001 and HR=10.3, 95% CI 3.4 to 30.8, p<0.0001, respectively; figure 4A). There was a trend for a significantly higher risk in quartile 2 compared with quartile 1 (HR=3.05, 95% CI 0.95 to 9.8, p=0.06). In the Cox proportional hazard model, multivariable analysis showed that the BNP level was an independent predictor of cardiac event-free survival (table 5). Independently of age, sex, MR severity, LV dimension and function, LA volume and LV filling pressure estimation, patients with a high BNP level (>40 pg/ml) had a fourfold increase in the risk of having a cardiac event during follow-up. Similarly, quartiles 3 and 4 of BNP were independently associated with significantly worse cardiac event-free survival (figure 4B) compared with quartile 1. In this multivariable model there was also a trend for quartile 2 to be at higher risk than quartile 1 (HR=3.5, 95% CI 0.9 to 14.1, p=0.075).
Other predictors of cardiac-event free survival
Indexed LA volume >40 ml/m2 was associated with significantly reduced cardiac event-free survival (2 years: 57±7% vs 66±7%, p=0.037, figure 5A). Patients with GLS <−20% (ie, median value) had significantly better 2-year event-free survival (73±6% vs 44±7%, p=0.0004, figure 5B). In the multivariate analysis reported in table 5 (Model 2), indexed LA volume (HR=1.04, 95% CI 1.01 to 1.07, p=0.003) and GLS (HR=1.14, 95% CI 1.04 to 1.26, p=0.007) were the other factors besides BNP level identified as independent predictors of cardiac event-free survival.
The results of the present study show that BNP level may vary considerably in asymptomatic patients with moderate to severe degenerative MR and preserved LV function. The main independent predictors of BNP level are mitral deceleration time, LA volume and LV longitudinal myocardial deformation. A high BNP level is independently associated with reduced cardiac-related event-free survival. Furthermore, LA volume and LV longitudinal myocardial deformation are also independent predictors of cardiac events.
Determinants of BNP
In a previous study including a wide range of MR severity, symptomatic status and LV function, Detaint et al7 underlined the relationship between BNP activation and LV volume overload. The presence of MR leads to LV and LA enlargement in response to volume overload and, consequently, to BNP activation and release independently of MR severity. Moreover, LA dilation contributes to the development of atrial fibrillation which is associated with an increased level of BNP.
Our results extend those of previous studies7 10 and indicate that LV end-systolic and LA dimensions are associated with elevated BNP levels. However, after further multivariate adjustment, only indexed LA volume remains independently associated with BNP. In addition, we identified LV longitudinal myocardial deformation (ie, a marker of subclinical myocardial dysfunction) as the main determinant of BNP. In degenerative MR, favourable loading conditions may mask a subtle degree of LV dysfunction.21 Subclinical LV dysfunction relates to the structure-function relationship and characterises a preclinical stage of myocardial damage that can be detected by a decrease in longitudinal myocardial function. The alteration of LV longitudinal kinetics is related to the vulnerability of subendocardial fibres and occurs before the development of dilation or abnormality observed with conventional measures of LV such as LV end-systolic diameter and ejection fraction.19 22 We found that, in the absence of LV dilation or reduced LV ejection fraction, GLS may be significantly reduced in asymptomatic degenerative MR and is well correlated with BNP level. In fact, GLS may be considered as a highly sensitive marker of both LV volume overload and LV wall stress which are, in turn, associated with BNP release.
Interestingly, we also found that a longer deceleration time is independently associated with BNP level. This suggests that prolonged LV relaxation indicates subclinical LV diastolic dysfunction, subtly increasing LV wall stress and thus participating in BNP activation. The results of our study show that, even in the absence of symptoms and reduced LV ejection fraction, patients with moderate to severe MR may have both subclinical LV systolic and diastolic impairment that is expressed by a rise in BNP level.
BNP release was reported as age- and gender-related in the general population20 and in patients with primary MR.7 The mechanisms whereby age influences BNP are unclear. Previous studies have reported that levels of natriuretic peptides are higher in elderly subjects, but these studies included patients with altered cardiac structure or function, not allowing differentiation of the impact of age and its consequences on the ventricle.23 24 Nevertheless, these investigators suggested that age-related changes in diastolic dysfunction or in renal function influence BNP. On the other hand, Redfield et al20 found that the relationship between age, gender and BNP was independent of clinical factors, renal function and cardiac structure parameters.
In our cohort the identification of the independent determinants of BNP in multivariable analysis (table 4) was performed with an age and gender adjustment. Whereas age was univariately associated with BNP level (r=0.32, p<0.0001, table 3), there was no significant difference between men and women with regard to BNP levels (p=0.13). Furthermore, neither age nor gender was an independent predictor of BNP in multivariable analysis.
BNP as a predictor of outcome
Several previous studies have found that BNP level is associated with outcome in patients with primary MR.7 9 10 Detaint et al7 showed that a median BNP level of ≥31 pg/ml was associated with reduced survival in a population including approximately one-third of patients with symptoms. Recently, Klaar et al10 reported that a BNP level of 44 pg/ml provides an almost 100% (99.5%) negative predictive value in predicting the occurrence of symptoms or LV dysfunction during follow-up. Pizarro et al9 validated a cut-off value of 105 pg/ml, corresponding approximately to the fourth quartile of BNP in their asymptomatic population, as a strong independent predictor of cardiac events in asymptomatic patients. However, the studied population included a significant proportion of patients with LV dilation.
In the present study we found that, in asymptomatic patients with moderate or severe degenerative MR, normal LV ejection fraction (>60%) and no LV dilation or atrial fibrillation, BNP level measurement represents a strong independent predictor of cardiac-related events. A BNP level >40 pg/ml was associated with an independent fourfold increase in the risk of cardiac event at 3 years. This association between BNP level and outcome is most likely the consequence of the close relationship between BNP activation and early and subclinical LV dysfunction and LA enlargement. Indeed, LA dilation is now well established as a good marker of poor outcome in patients with primary MR.25 26
Interestingly, we also found that reduced LV longitudinal myocardial function is an important predictor of cardiac events. The increased risk associated with BNP was unaffected by adjustment for other clinical and echocardiographic parameters, which included LV dimensions (as is generally done in previous studies7 9) and also LA size and GLS. This finding suggests that BNP activation is probably a surrogate for the consequences or degree of MR and is also additional to other descriptors of MR severity and predictors of outcome, which lends support to the clinical usefulness of this biomarker.
LV longitudinal function as a predictor of outcome
To the best of our knowledge, this study is the first to report that LV longitudinal function, as assessed by 2DST imaging, is an independent predictor of poor outcome in asymptomatic degenerative MR without LV dysfunction or dilation. Each 1% decrease in GLS (ie, impaired LV longitudinal function) is associated with a 14% increase in the risk of a cardiac event. Both GLS and BNP are therefore of high clinical value to enhance risk stratification and management in patients with asymptomatic MR. By improving the individual risk stratification and identifying LV dysfunction at an earlier stage, these parameters could be helpful for tailor-made therapeutic decision-making. Of note, LV longitudinal function has previously been identified as an accurate marker of postoperative LV dysfunction19 and recovery of functional capacity.27 Given that LV ejection fraction is known to remain normal or supranormal for long in the presence of moderate to severe MR11 12 and that LV dilation often occurs after the onset of symptoms,28 GLS—which is a rapid, simple and reproducible echocardiographic measure—should be integrated in the routine evaluation of patients with MR.
Clinical implications
The management of asymptomatic severe degenerative MR remains controversial.3 5 A 'watchful-waiting' strategy was previously reported as safe,28 with good perioperative and postoperative outcome. On the other hand, several authors have suggested that early intervention (ie, before the occurrence of a guidelines-recommended trigger for surgery), by increasing the rate of repairability, decreasing the operative mortality or complications and improving the postoperative LV function and outcome, should be recommended in the presence of severe MR.29–35 Nevertheless, early surgery is not without risk, and some surgeons may be reluctant to operate on asymptomatic patients only on the basis of the echocardiography-quantified severe MR. Consequently, risk stratification of these patients should be improved in order to optimise the benefit/RR of surgery. Recent studies from our group emphasised the usefulness of exercise stress echocardiography16 and the measurement of exercise pulmonary arterial hypertension13 to identify a subset of patients at high risk of more frequently and more rapidly developing symptoms. Unfortunately, stress echocardiography is not always available and feasible, underlining the profound need for new markers of risk. In this regard, BNP level is a low cost, simple, easily and rapidly measurable biomarker that may provide important incremental prognostic value and take a central role in the clinical armamentarium offered for the management of asymptomatic MR.
A high BNP level was associated with a more than eightfold increase in the risk of cardiac events compared with a very low BNP level (<19 pg/ml), suggesting that early intervention could be beneficial in such patients. In contrast, patients with a low BNP level had a reasonable 3-year cardiac event-free survival rate of 75±6%. These patients could therefore be closely followed up or, when possible, referred for exercise echocardiography in order to investigate LV contractile reserve19 36 and exercise-induced changes in MR16 and SPAP.13
Interestingly, in patients with moderate MR a high BNP level (greater than median) was also significantly associated with reduced cardiac event-free survival. As current guidelines do not recommend surgery in patients with moderate MR, our data therefore favour a closer clinical and echocardiographic follow-up of this subgroup of patients in order to identify promptly changes in clinical status, LV dimensions or function, pulmonary pressure and heart rhythm.
Limitations of the study
Our population consisted of relatively young patients with pure degenerative MR (ie, due to mitral valve prolapse or flail leaflet). The findings cannot therefore be extrapolated to all patients with MR. In particular, BNP level measurement should be used cautiously in patients with concomitant aortic stenosis or myocardial disease, atrial fibrillation, hypertension, renal failure or other known causes of increased neurohormones. In addition, the relatively young age of our patients may have influenced the outcome analyses.
The BNP measurement was performed only at baseline inclusion. Serial measurements of BNP and analysis of the progression of consequences of MR could be of interest. Further studies in larger cohorts are needed to address this point.
A substantial proportion of the cardiac events reported were mitral valve operations which are in part driven by the occurrence of symptoms for which the evaluation remains subjective. However, the symptomatic status is a class I indication for surgery in both the ACC/AHA and ESC guidelines.
In asymptomatic patients with degenerative MR, normal LV ejection fraction and no LV dilation, the BNP level may vary considerably among subjects. The main determinants of BNP in this population are the consequences of MR on LA size and on LV longitudinal myocardial function. The BNP level is a powerful independent predictor of reduced cardiac event-free survival. Measurement of the BNP plasma level may thus be useful to enhance risk stratification and better define the optimal timing of surgery in asymptomatic patients with degenerative MR.
We thank M Carmine Celentano for excellent technical assistance.
Funding JM is research associate from the FRS-FNRS, Brussels, Belgium and received grants from the Fonds Léon Fredericq, Liège, Belgium and from the Fond pour la Chirurgie Cardiaque, Belgium. This study was also supported by a grant (MOP #102 737) from the Canadian Institutes of Health Research, Ottawa, Ontario, Canada. PP holds the Canada Research Chair in Valvular Heart Diseases, Canadian Institutes of Health Research, Ottawa, Ontario, Canada.
Competing interests None.
Patient consent Obtained.
Ethics approval Committee/Institutional Review Board of CHU Sart Tilman, Belgium and of Laval Hospital, Quebec, QC, Canada.
Provenance and peer review Not commissioned; externally peer reviewed.
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2015 Domaine de la Grange des Peres Rouge
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TWO of the Denmark Shire council's senior personnel have coincidentally announced their resignations in the interests of advancing their respective careers.
CEO Bill Parker's resignation comes three years into a five-year contract.
Deputy shire president Peter Caron announced that he would resign in October to take up a job overseas.
Mr Parker (39) will take up a position as general manager of corporate services with the City of Perth on October 21.
His resignation has sent ripples through the Denmark community, where he is a popular figure on the sporting field as well as a key presence at council meetings. He is quick to point out that his imminent departure is not related to council issues. "The position in Perth came up, and I saw it as a great opportunity for advancement," Mr Parker said. "Besides, one of my three boys already lives in Perth, and the two younger ones have indicated that they want to pursue tertiary studies when they leave school, so the time is right for my family to make the big move."
Under Mr Parker's leadership a sweeping compliance framework program has been introduced for the first time in the shire's history. The foundational, forward-looking program links a series of strategic documents which reflect and adapt to the community's changing needs and aspirations over time, simplifying decision-making into the future. Leading local governments have been adopting the compliance framework approach since the early 2000s, even though it was not legislated until 2008. Mr Parker said that the introduction and implementation of the program represented the high point of his professional contribution to Denmark. "It's a challenging process, because you're changing the whole culture of your business – and that takes time, energy and relearning, by council, staff and the community. "People can come and go but the processes remain the same – though quite often you're not around to see your work bear fruit." He expects the plans to
be completed very soon – though possibly not all in time for council's special budget meeting on July 30.
As for his replacement, Mr Parker says he will suggest to council that it defer appointing a new CEO until after local government elections in October. This would allow new councillors time to settle into their roles without the added pressure of a new CEO also finding his or her way around. "We have the capacity within the organisation to provide an acting CEO until the time comes to advertise the position," he said.
The opportunity to live and work in Denmark had been wonderful, personally and professionally. In partnership with the elected group, staff had built a great team – highly motivated and genuinely wanting to make Denmark a better place to live. "I've been very fortunate to work with such a committed group of people, and it's been great to be part of the Denmark community," he said.
Shire president Ceinwen Gearon said that losing two key team members at the same time was regrettable, but it reflected the quality of the individuals involved. Teamwork and accord between council and administration was at the highest level for many years. Cr Caron agreed, saying that councillors and staff were 'well aligned'. "We have a clear strategic direction and play our parts in working towards the objectives that the community has set for us," he said.
A spokesperson for the Denmark Ratepayers and Residents Association wished Mr Parker well in his new role. Mr Parker had generously attended and answered questions at all the association's general meetings during his time here.
Categories: Featured news, POLITICS


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Moog just trotted out a new version of its popular Sub Phatty synth that has a braille overlay to help the visually impaired. It's hard to believe it took the legendary manufacturer this long to get around to it, especially given that it's actually a pretty simple modification to the panel's design.
OK, so when you're jamming on synth, some people just feel it out. Fine. But look at all those damn knobs on the Sub Phatty. They make the bass monster endlessly versatile, but it also makes the thing a little confusing to set up — even if you can see. If you can't see, well, I imagine it's gotta be pretty challenging to play it. With braille, it will be a whole lot easier.
It's pretty cool of Moog to offer the option, which you can purchase now for $US900 at Sweetwater — the same price as the original. [Sweetwater]


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Creating a System i database security policy: Implementation
Your System i security is only as good as your security policy. Implementing your policy can be made easier if you set up your object level security based on group profiles. Once a group profile has been created, you can then add individual profiles... Continue Reading
A guide to System i security: Descending into the heart of darkness of IT security
Developing your company's System i security policy starts with taking a look at what needs to be accomplished. Communication and appropriate access for personnel to data centers are keys to a robust policy. Continue Reading
Checking on System i disk space requires creating a new command: XRTVSYSSTS
Monitoring System i disk space is imperative to keeping your system up and running. If a process begins to loop endlessly without notice, it can fill up a working file and bring everything to a halt. XRTVSYSSTS can save the day. Continue Reading
Creating a System i database security policy: First steps
Your System i security is only as good as your security policy. If you don't have a policy in place, Rich Loeber explains the first steps for creating your AS/400 security policy. Getting end-user input is key to smooth security policy ... Continue Reading
Using SQL on System i to color source code and inline comments
Without use of an advanced emulator, how do you color source code? SQL. This tip provides a complete table of valid hex values for display colors and the SQL queries to implement it on your system. Continue Reading
High availability planning and testing for iSeries: Notes, gloats, and moats
Having a high availability (HA) plan is necessary to keep your company productive during adverse conditions. But testing the plan and paying attention to all the minor details is equally important. Fax toner could cause a crisis in communication, ... Continue Reading
Enhancements in the intrusion detection system for i5/OS V6R1
The newest i5/OS release, V6R1 offers an Intrusion Detection System that logs information to your security audit journal about intrusion and extrusion activity. It can also be configured to notify you about violations of your established policies. ... Continue Reading
Six common System i security lapses
Using the most secure processor available doesn't ensure a secure system. A recent survey identified six common System i security lapses, including a failure to change default passwords and a lack of audit journaling. Continue Reading
Controlling spool files with APIs
Use application programming interfaces, or APIs, to send spool files from your iSeries. Users can alter the source code in this tip to fit their needs. Continue Reading
Become a self-taught System i guru
If you want to shore up your AS/400 knowledge and career, there are many resources to turn to, including the Common user group, iSeries classes and IBM manuals. Continue Reading
Working with exit programs in i5/OS V6
The latest release of i5/OS comes with new security features, including an array of exit programs. In this System i security tip, expert Rich Loeber discusses new V6 exit programs. Continue Reading
New password-control security features for i5/OS V6R1
The new version of i5/OS for System I includes three notable new password-control security features. Here we outline the new V6R1 system values and their potential for enhancing system security. Continue Reading
System i document management tips
Different businesses have different document management needs. And if you're an iSeries shop, there's a good chance that you're always in the market for more efficient ways to send, save and output from your server. Here are three tips to help ease ... Continue Reading
Selective SPOOLFILE copy to CSV files and e-mail
This command allows you to send any iSeries report in CSV file format without its headings to an e-mail account. Continue Reading
System i Resume Building 101
Get advice on the best way to build your System i resume from a recent IT job seeker. If you're between IT jobs or looking to boost your career, this tip is for you. Continue Reading


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Just four more inaugural Hall of Fame inductees! Who will they be? To be continued...
Ruiace?Jamonwindeye?=) =)
But I say this now, and I will never recant it: There will never ever be a fee required to access FSN. FSN will always be free for every VCE student to use... This website, after all, provides FREE study notes. May this website prosper for many years to come.
at the end of this year ill have tonnes of notes but I don't know anyone who does my subjects. but now I can put them up here (right?) so they don't go to waste!
I wanted to give an enormous thank you to Nina for everything she's given to the forums - which is a lot. A lot a lot. Without her efforts, ATAR Notes would be much shitter. Legitimately. That's just how it is. She's put a lot of effort into the upkeep, maintenance and development of the community, such that it simply wouldn't be the same, enjoyable place without those efforts.
P.S. Which current or past users do you tip to be inducted into the Hall of Fame in the future?
I'm sensing J41, jamonwindeyer, brenden... maybe heids, insanipi, and k888? It would be great to see the contributions of all these people who have given up their time to spread their words of wisdom to the coming generations of VCE/HSC students recognised!


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USA Football is seeking bids to hosts its 2020 Flag Football Nationals. The event draws 150-200 teams each July. Here are the details.
Deadline to Bid: June 15
Preferred Dates: July 24-26, 2020
Venue Requirements: 24-30 flag fields, 70 yards x 30 yards (preferably turf)—3 fields fit on a regular soccer field and 2-4 fields can fit on a football field depending on width.
Number of attendees: 2,000 participants; 200 coaches; 2,500 spectators
Hotel requirements: 1 room that can seat 40 classroom style for staff HQ; 1-2 rooms that can seat 60 theater style for coach meetings
Room Nights: 965 (Anthony Travel will secure and manage all hotel rooms.)
For the complete RFP, click here.
For more information, email Elizabeth Faust, event manager at USA Football, at email@example.com.


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Timeless The Classics Michael Bolton
You could watch that video, or you could watch "Sex Tonight," an SNL sketch from 1988 in which the irreplaceable Jan Hooks plays Jessica Hahn and single-handedly turns a mediocre sketch into a classic.
Sade's breakout success in the 1980s owed much to the advent of adult contemporary radio, where huge hits like Smooth Operator and The Sweetest Taboo eventually got sandwiched between selections from.
Browse the top michael bolton albums to find new music and discover artists. Scrobble songs to get. Timeless: The Classics, Vol. 2 · Michael Bolton.
Listen to the biggest hits from Michael Bolton, including When a Man Loves a Woman, He further responded with Timeless: The Classics in September 1992,
Reportedly, this is his sequel to the beat-heavy "Odelay." Nov. 9 Michael Bolton, "Timeless: The Classics" (Columbia). No, not Mozart. Bolton's greatest hits. Nov. 9 Doors, "Complete Recordings".
Check out Michael Bolton on Amazon Music. Stream. The Soul Provider: The Best Of Michael Bolton · The Soul. CD: £5.53. Timeless (The Classics) Vol. 2.
The Price Of Salt Author The Annotated Oscar Wilde Byatt, Sara Maitland, Italo Calvino, Kate Bernheimer, Angela Carter, Oscar Wilde. Mike Barnes' The Reasonable Ogre. In her introduction to The Annotated Hans Christian Andersen, Maria Tatar writes. The annotated Oscar Wilde : poems, fiction, plays, lectures, essays, and letters / Author: edited, with introductions and notes, by H. Montgomery Hyde.
Hold On, I'm Coming by Michael Bolton – discover this song's samples, covers and remixes on. Timeless (The Classics). Background Vocals: Michael Bolton
Michael Bolton lyrics with translations: When a Man Loves a Woman, A Time for Letting Go, How Am I Supposed to Live Without You?, To Love Somebody, Said I Loved You. But I Lied Lietuvių
Dec 7, 1992. Michael Bolton is doing well: His album of pop standards, Timeless (The Classics ), went to No. 1. bumping off country behemoth Garth Brooks.
Michael Jackson is an all-time phenomenal artist, both timeless and contemporary. His 2006 release, "Bolton Swings Sinatra," features his versions of 12 Frank Sinatra classics. In 2009, he recorded.
Michael Bolton plays the Grand Theatre on Friday, November 30, 2018 at the. Get ready for a night of timeless hits and holiday classics with Michael Bolton in.
1999 Michael Bolton – Timeless: The Classics Vol 2. admin 1999, Albums Dann Huff, Greg Phillinganes, Michael Bolton, Michael Thompson, Neil Jason, Steve Lukather 0. Timeless: The Classics Vol. 2 is an album of covers by Michael. More. June 3 2015. 1989 Michael Bolton –.
Complete List Of Oprah Book Club Books Greek Myth Action Figures Investors who would drool at the chance to turn a $1,000 investment into $10,000 in just a year are likely in no better position than the Greek mythological figure Tantalus unable. creditors using. Love Poems For Her In Hindi Font "Love one another, but make not a bond of love: Let
Michael Bolton. Piano/Vocal/Chords Book. Titles are: Bring It On Home To Me * Drift Away * Hold On, I'm Coming * Knock on Wood * Reach Out I'll Be There * Since I.
Timeless – The Classics Wikipedia article Album by Michael Bolton. Since I Fell For You To Love Somebody Reach Out I'll Be There You Send Me Yesterday Hold On, I'm Coming Bring It On Home To Me Knock on Wood Drift Away White Christmas External links Amazon: buy Timeless – The Classics.
"Word is out," quipped Michael Bolton, "that I might have a sense of humor. Love & Tenderness" and "Timeless (The Classics)" earned multiplatinum status. During the Nielsen SoundScan era, he has.
Guitar tabs for the album Timeless The Classics Vol.2 of Michael Bolton at Ultimate-Tabs.
Paul Gambacini told the BBC that When a Man Loves a Woman was "one of the all time classic songs". "This was the essence. The song found new life in 1991 when Michael Bolton's cover of the song.
Amazon.de/musik: Michael Bolton – Timeless (the Classics) jetzt kaufen. Bewertung 5.0,Label: Columbia.Published: 1992. Pop, Mainstream Pop, Import- Eu,
Best Of Live (Dvd) Michael Bolton 'Til The End Of Forever Michael Bolton; Time Love & Tenderness Michael Bolton; My Secret Passion (The Arias) Michael Bolton; Til The End Of Forever Michael Bolton; Timeless: The Classics, Vol. 2 Michael Bolton; The One Thing Michael Bolton
Athena Images Greek Mythology Ancient Greek artists working. But when he raped her in Athena's temple, the goddess punished the girl by transforming her enviable locks into hideous snakes. Sympathetic artists took note, and. Created with an incredible attention to historical accuracy—and boasting a 42-foot-tall gold-coated sculpture of Athena—Nashville's Parthenon. which depict various scenes from Greek mythology. Over. GREEK
Aug 20, 2018. Doors open at 6:30 p.m. and the show starts at 7:30 p.m. Michael Bolton will be performing his timeless hits along with holiday classics. Tickets.
She was looking over my shoulder, and she was silently mouthing one word, over and over: "Michael. Bolton lays it out to his audience. "Sometimes some critics just don't get it," he tells them.
Timeless: The Classics is an 1992 album of cover versions by Michael Bolton. It was #1 on the Billboard charts when it was released. After a rather long chart run the album has been certified 4x Platinum in the US and has sold over nine million copies worldwide.
Best Of Live (Dvd) Michael Bolton 'Til The End Of Forever Michael Bolton; Time Love & Tenderness Michael Bolton; My Secret Passion (The Arias) Michael Bolton; Til The End Of Forever Michael Bolton; Timeless: The Classics, Vol. 2 Michael Bolton; The One Thing Michael Bolton
Guitar tabs for the album Timeless The Classics Vol.2 of Michael Bolton at Ultimate-Tabs. fresh tabs top tabs lessons submit videos. subscribe share tweet. Michael Bolton. 23 tabs and chords. More. You are viewing Michael Bolton Chords in the album Timeless The Classics Vol.2 More Albums. Quick Access.
Michael Bolton – Pandora. If problems continue, try clearing browser cache and storage by clicking here.This will cause a logout.
Timeless: The Classics (back cover: CB 701, CDM, 02-4723302-10; CD-medium: BIEM) CD: 10: 1992; XE; Columbia (imprint owned by CBS between 1938–1990 within US/CA/MX; owned worldwide by Sony Music Entertainment since 1991 except in JP) 01-472302-10, 02-4723302-10, 472302 2, COL 472302 2: 5099747230226: Timeless: The Classics: Digital Media: 10: 2009-08-21; US
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MONTGOMERY—Grammy Award-winning vocalist Michael Bolton will take. gospel music and classic rock and roll. Season tickets can be purchased by calling the theatre office at (334) 241-9567. Bolton.
Frey: Michael Bolton — fine singer — comes over to me a couple nights. AP: What makes the Eagles so timeless? Frey: When we were making records, our only goal was to make something good, something.
Famous Horses In Mythology Poseidon was the god of the sea, earthquakes and horses. Although he was. Poseidon was not so well-disposed toward another famous hero. Because. Pegasus was the legendary winged horse of Greek mythology. Pegasus is probably the most famous creation to appear in the tales of Greek mythology with. Things looked pretty hopeless until Odysseus, a
This item: Timeless (The Classics) by Michael Bolton Audio CD 399.00. Only 1 left in stock. Gems: The Duets Collection by Michael Bolton Audio CD 1,057.58. Customers who bought this item also bought. Page 1 of 1 Start over Page 1 of 1. This shopping feature will continue to load items. In order to navigate out of this carousel please use your.
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22. Michael Bolton offers an album of oldies, dubbed "Timeless (The Classics)," on Sept. 29. Bon Jovi reunites for its first album in four years when "Keep the Faith" lumbers out of New Jersey Nov. 3.
Oct 16, 1992 · And now that he's finally a star after years in the wings, Bolton isn't taking any chances: Timeless (The Classics) is an entire album of cover versions, making it one of the safest follow-ups.
Poem On Pink Colour Oh Who Is That Young Sinner. Oh who is that young sinner with the handcuffs on his wrists? And what has he been after that they groan and shake their fists? Deeply saturated color portraits from that archive are presented as grids. intimate drawings commenting on the country's. Coloressence Mesmerizing Lip Colour Poetry Pink Review,
Two-time "Best Pop Male Artist" and multi-Grammy Award Winner Michael Bolton, known for his sensational vocal. is coming back to The Ridgefield Playhouse, after last year's sold-out event, tonight,
Michael Bolton, A Symphony of Hits mp3 A Symphony. Michael Bolton, Songs of Cinema mp3 Songs of. Michael Bolton, Timeless: The Classics, Vol. 2 mp3.
Being on your own with no direction home is no picnic, but compared to hearing Michael Bolton aggressively dry-hump a Bob Dylan classic, it feels pretty great. There's no telling what was really going.
Though the references are often very '90s, the guest stars are mostly timeless, as the show's show-biz setting and classic sitcom sensibilities. Chevy Chase, Scott Baio, Michael Bolton, Dick Martin.
*** MICHAEL BOLTON "Timeless (The Classics)" Columbia. CONNIE JOHNSON. Given the knocks and pans he gets from critics old enough to know what these songs are supposed to sound like,
Baby Hand And Footprint Poems Thanks to Melissa for sharing her footprint poem with us: Daddy, daddy I have made, Prints of my little feet. Then you can remember when, I was so small and sweet. I will grow and baby days will all be in the past, But you can know my love for you, Daddy will always last.
Two-time "Best Pop Male Artist" and multi-Grammy Award Winner Michael. CT, Bolton continues to tour the world while writing, recording and taping for a wide array of music, film, television and.
Sledge performed at his induction into the Alabama Music Hall of Fame in March 2010 Paul Gambacini told the BBC that When a Man Loves a Woman was "one of the all time classic songs. found new life.
Oct 10, 2017. Michael Bolton is a Grammy Award winning singer and songwriter. 'Time, Love & Tenderness', 'Soul Provider', 'Timeless: The Classics' and.
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Oct 16, 1992 · And now that he's finally a star after years in the wings, Bolton isn't taking any chances: Timeless (The Classics) is an entire album of cover versions, making it one of the safest follow-ups.
Timeless: The Classics, Vol. 2, an Album by Michael Bolton. Released 16 November 1999 on Columbia (catalog no. COL 496078 2; CD). Genres: Blue-Eyed Soul, Yacht Rock.
But, as with all Sinead O'Connor albums, gems are to be found here. MICHAEL BOLTON; "Timeless (The Classics)" (Columbia). * * I liked Bolton's remake of "Sittin' on the Dock of the Bay," initially.
14: Classic Albums Live: Led Zeppelin's "Houses of the Holy. AVENTURA. 7: Ten Grands. KRAVIS. 8: Michael Bolton: The Symphony Sessions. KRAVIS. 8: Jazz Roots: Jazz in the Key of Ellison. ARSHT. 8:.


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|Cyber warfare is already with us today — distributed denial-of-service (DDoS) attacks have been launched against many military and government computer systems around the world in recent years. Advancements in information technology have made tech-dependent countries more vulnerable to disruption — physical security is now tied to cyber security.Cyber weapons are a relatively new type of weaponry. Most of the them are freely available on the internet but some more sophisticated and newer ones are kept privately or are commercial.Securing infrastructure against cyber-attacks has become one of the highest priorities for every nation. To do this, networks, systems and operations teams that support them must be fully trained and aware of the possible threats and how to defend against them.
The objective of this course is to provide practical and usable information to professionals on how to protect both infrastructure and data from the destruction of cyber terrorism and associated cybercrimes.
What you'll take away from this course:


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design diversity does not appear to be a reasonable use of USNRC research funds.
Conclusion 5. Although many in the software community believe that there are more cost-effective techniques for achieving high software reliability than redundancy and diversity, there is no agreement as to what these alternatives may be. The most promising of these appear to be the extension of standard safety analysis and design techniques to software and the use of formal (mathematical) analysis. (See Recommendation 3 in Chapter 4.)
Conclusion 6. The use of self-checking to detect hardware failures and some simple software errors is effective and should be incorporated. However, care must be taken to assure that the self-checking features themselves do not introduce errors.
Recommendation 1. The USNRC should retain its position of assuming that common-mode software failure is credible.
Recommendation 2. The USNRC should maintain its basic position regarding the need for diversity in digital instrumentation and control (I&C) systems as stated in the draft branch technical position, Digital Instrumentation and Control Systems in Advanced Plants, and its counterpart for existing plants.
Recommendation 3. The USNRC should revisit its guidelines on assessing whether adequate diversity exists. The USNRC should not place reliance on different programming languages, different design approaches meeting the same functional requirements, different design teams, or using different vendors' equipment ("nameplate" diversity). Rather, the USNRC should emphasize potentially more robust techniques such as the use of functional diversity, different hardware, and different real-time operating systems.
Recommendation 4. The USNRC should reconsider the use of research funding to try to establish diversity between two pieces of software performing the same function. This does not appear to be possible. Specifically, it appears the USNRC funding of the Unravel tool is based on the use of this tool for this purpose and, as such, is unlikely to be useful.
AECB (Atomic Energy Control Board, Canada). 1996. Draft Regulatory Guide C-138, Software in Protection and Control Systems. Ottawa, Ontario: AECB.
Bowman, W.C., G.H. Archinoff, V.M. Raina, D.R. Tremaine, and N.G. Leveson. 1991. An Application of Fault Tree Analysis to Safety-Critical Software at Ontario Hydro. Presentation at Conference on Probabilistic Safety Assessment and Management (PSAM), Beverly Hills, Calif., April.
Brilliant, S., J.C. Knight, and N.G. Leveson. 1990. Analysis of faults in an N-version software experiment. IEEE Transactions on Software Engineering 16(2):238–247.
Brunelle, J.D., and D.E. Eckhardt. 1985. Fault-Tolerant Software: Experiment with the SIFT Operating System. Presentation at AIAA Computers in Aerospace Conference, Dallas, October.
Eckhardt, D.E., and L. Lee. 1985. A theoretical basis for the analysis of multiversion software subject to coincident errors. IEEE Transactions on Software Engineering 11(12):1511–1517.
Eckhardt, D.E., A.K. Caglayan, P. Lorczak, J.C. Knight, D.F. McAllister, M. Vouk, L. Lee, and J.P. Kelly. 1991. Robustness of software redundancy as a strategy for improving reliability. IEEE Transactions on Software Engineering 17(7):692–702.
DOD (U.S. Department of Defense). 1993. Military Standard 882C, System Safety Program Requirements. Washington, D.C.: U.S. Department of Defense.
FAA (Federal Aviation Administration). 1992. DO-178B, Software Considerations in Airborne Systems and Equipment Certification. Washington, D.C.: FAA.
FDA (Food and Drug Administration). 1991. Reviewer Guidance for Computer Controlled Medical Devices Undergoing 510(k) Review. Washington, D.C.: FDA.
Knight, J.C., and N.G. Leveson. 1986. An experimental evaluation of the assumption of independence in multi-version programming. IEEE Transactions on Software Engineering 12(1):96–109.
Leveson, N.G. 1995. Safeware: System Safety and Computers. New York: Addison-Wesley.
Leveson, N.G, S.S. Cha, J.C. Knight, and T.J. Shimeall. 1990. The use of self checks and voting in software error detection: An empirical study. IEEE Transactions on Software Engineering 16(4):432–443.
Miller, B.P., L. Fredrikson, and B. So. 1990. An empirical study of the reliability of UNIX utilities. Communications of the Association for Computing Machinery 33(12):32–44.
Reese, J.D. 1996. Software Deviation Analysis. Ph.D. dissertation, University of California, Irvine. January.
Sci.math. 1990. Various authors posting to this Usenet newsgroup, Feb. 3–8.
Scott, R.K., J.W. Gault, and D.F. McAllister. 1987. Fault tolerant reliability modeling. IEEE Transactions on Software Engineering 13(5):582–592.
USNRC (U.S. Nuclear Regulatory Commission). 1992. Draft Branch Technical Position on Digital Instrumentation and Control Systems in Advanced Plants. Washington, D.C.: USNRC.
USNRC. 1996. Draft Branch Technical Position on Defense-in-Depth and Diversity. Washington, D.C.: USNRC. (Also USNRC staff presentation to the Committee on Application of Digital Instrumentation and Control Systems to Nuclear Power Plant Operations and Safety, Washington, D.C., October 1995.)
Safety and Reliability Assessment Methods
Appropriate methods for assessing (as distinct from achieving or assuring) safety and reliability are the key to establishing the acceptability of digital instrumentation and control (I&C) systems in nuclear plants. Methods must be available to support estimates of reliability, assessments of safety margins, comparisons of performance with regulatory criteria such as quantitative safety goals, and overall assessments of safety in which trade-offs are made on the basis of the relative importance of disparate effects such as improved self-checking acquired at the cost of increased complexity. These methods must be sufficiently robust, justified, and understandable to be useful in assuring the public that using digital I&C technology in fact enhances public safety.
Statement of the Issue
Effective, efficient methods are needed to assess the safety and reliability of digital I&C systems in nuclear power plants. These methods are needed to help avoid potentially unsafe or unreliable applications and aid in identifying and accepting safety-enhancing and reliability-enhancing applications. What methods should be used for making these safety and reliability assessments of digital I&C systems?
In nuclear power plants, reliability and safety are assessed using an interactive combination of deterministic and probabilistic techniques. The issues that the committee considered were the extent to which these assessment methods are applicable to digital I&C systems and the appropriate use of these methods.
Deterministic Techniques
Design basis accident analysis is a deterministic assessment of the response of the plant to a prescribed set of accident scenarios. This specific analysis constitutes a major section of the nuclear plant safety analysis report that is submitted to and reviewed by the U.S. Nuclear Regulatory Commission (USNRC) in the licensing process. In a design basis accident analysis an agreed-upon set of transient events are imposed on analytical simulations of the plant. Then, assuming defined failures, the plant systems must be shown to be effective in keeping the plant within a set of defined acceptance criteria. Consider, for example, the analysis of the thermal response of the reactor following a postulated pipe rupture. In this case, the deterministic safety analysis considers:
the size of the rupture (the cross-sectional area of the pipe)
the geometry of the systems and components affected, such as volumes and elevations of pipes and vessels
the initial conditions (conditions at the time of the rupture), such as initial power, pressures, and temperatures
the response logic of the active and passive safety systems, such as the sensing of the event by the instrumentation systems, the subsequent actuation of valves that isolate the fault, and the subsequent opening of backup feedwater system valves
All these considerations are used as parameters or forcing functions in the equations that model the physical behavior of the affected systems (mainly nuclear, thermal, mass, and momentum conservation equations) to calculate the response of the system. Of particular importance is the calculation of the resultant pressures and temperatures in the cooling systems and in the core to assess the integrity of the fuel and the multiple physical barriers that contain radionuclides.
Probabilistic Techniques
Probabilistic risk assessment (PRA) (or probabilistic safety assessment [PSA]) techniques are used to assess the relative effects of contributing events on system-level safety or reliability. Probabilistic methods provide a unifying means of assessing physical faults, recovery processes, contributing effects, human actions, and other events that have a
high degree of uncertainty. These analyses are typically performed using fault tree analysis; but other methods, such as event trees, reliability block diagrams, and Markov methods, are also appropriate. In PRA, the probability of occurrence of various end events, both acceptable and unacceptable, is calculated from the probabilities of occurrence of basic events (usually failure events). For example, the USNRC has established a quantitative safety goal that the probability of a core damage event shall not exceed 10-5 per reactor year. The results of a particular PRA, of course, have wide bands of uncertainty; but on a relative basis they allow searching out the most important failure modes (''weak points") and allow the designer to balance the design appropriately between mitigation and prevention and to avoid unhealthy dependence on single systems or components.
The development of a fault tree model serves several important purposes. First, it provides a logical framework for analyzing the failure behavior of a system and for precisely documenting which failure scenarios have been considered and which have not. Second, the fault tree model has well-defined Boolean algebraic and probabilistic basis that relates probability calculations to Boolean logic functions. That is, a fault tree model not only shows how events can combine to cause the end (or top) event, but at the same time defines how the probability of the end event is calculated as a function of the probabilities of the basic events. Thus the fault tree model can evolve as the system evolves and can at any time evaluate the effect of proposed changes on the reliability and safety of the nuclear power plant. In this manner the fault tree analysis can be used to support engineering tasks such as illuminating the design "weak points," facilitating trade-off analyses, or assessing relative risks.
As mentioned above, the probabilistic analysis of reliability and safety is dependent upon an assignment of a probability of occurrence for each basic event in the fault tree. In addition to addressing the probability of an event, however, probability analysis may also address probabilities of variability and uncertainty. For example, an estimation may be made of the probability that a component will fail (probability of an event). But this failure probability may vary as a result of statistical variation in external conditions, such as temperature, or statistical characteristics of the source of the component. A second probability concept describes this variation as a probability distribution around a "point estimate" for the failure probability. Furthermore, the failure probability may not be known with perfect confidence. A third probability concept uses a distribution to express the degree of uncertainty associated with the point estimate reflecting the differences and uncertainties among experts solicited for judgments on probabilities (see below). Thus current risk assessment practice distinguishes between probabilities of events, variability, and uncertainty (NRC, 1994).
An uncertainty analysis using the fault tree model reflects the degree to which the output value is affected by the uncertainty in an input. This analysis helps the designer determine the extent to which an unknown input can affect the reliability or safety of the system and thus the extent to which the system must be able to withstand such uncertainty (Modarres, 1993).
But the fundamental concept in probabilistic analysis remains the concept of the probability of an event. There are several interpretations of the probability associated with an event (Cooke, 1991; Cox, 1946; McCormick, 1981; Modarres, 1993). The classic notion of the probability of an event is the ratio of the size of the subspace of sample points that include the event to the size of the sample space. A frequency interpretation of the probability of an event is the one most commonly understood; it defines the probability of an event as the limit of the ratio of the number of such events observed to the number of trials as the number of trials becomes large. Many events considered in a probabilistic safety assessment in the nuclear field are, however, classifiable as rare events, which complicates the estimation of occurrence probabilities for the basic events. If failure probabilities are to be estimated from life testing or field experience, many samples must be studied over long periods of time in order to gain any statistical significance in the data (Leemis, 1995). Several databases and handbooks exist to help with the estimation of failure probabilities for basic events (Bellcore, 1992; DOD, 1991; Gertman and Blackman, 1994; RAC, 1995). Within the nuclear engineering community, failure data for nuclear-specific systems and components are available from several sources, including summaries of licensee event reports (USNRC, 1980, 1982a, 1982b) and other handbooks (IEEE, 1983; USNRC, 1975). The existence and use of such handbooks helps address the problems associated with obtaining failure data for many of the basic events.
But for some basic events, where there are few or no applicable data on frequencies, subjective interpretations of probability may be used and may, in fact, be all that is available. Subjective probabilities may be sought in formal and informal processes in which groups of experts weigh available evidence and make judgments. This approach to probability is not of course based on relative frequencies and does not require samples or trials except as they may be available to inform subjective engineering judgment. Rather, subjective interpretations are commonly described as measures of the degree of belief that an event will occur. For example, Apostolakis (1990) states that "probability is a measure of belief." He continues: "The primitive notion is that of 'more likely': that is, we can intuitively say that event A is more likely than event B. Probability is simply a numerical expression for this likelihood." However, as more information becomes available, the subjective distribution (see discussion of uncertainty analysis above) can be adjusted to reflect the current state of knowledge.
There is extensive experience in nuclear risk studies and elsewhere with such elicitation of expert judgments on probabilities. Bayesian analysis (Leemis, 1995) tells how past observations (i.e., frequency data) influence the subjective
judgment. Certain characteristic biases, such as tendencies toward overconfidence, are known to occur (Cooke, 1991). Notwithstanding its limitations, the subjective interpretation of probability is the usual basis for the analysis of rarely occurring events and forms the basis of many risk evaluations (McCormick, 1981). As such, it is important to the committee's consideration of the applicability of probabilistic analysis to digital systems.
Hazard analysis (i.e., experts thinking about what might go wrong) has been validated as effective for at least 50 years. Random testing has been suggested as an alternate approach. However, truly random testing is not particularly good for finding hazards as it is more of a "needle-in-a-haystack" approach. Tests might also be randomly generated from an abstract description of a rare-event scenario. However, significant expertise is needed to formulate such a description.
Applicability to Digital Systems
Deterministic analysis techniques for digital systems are a generalization of the design basis accident methodology used in the nuclear industry and include such techniques as hazard analysis and formal methods (Leveson, 1995; Rushby, 1995). The use of deterministic analysis techniques for the analysis of digital systems is not controversial, as long as they are applied with care to consider the failure modes attributable to digital systems. More controversial is the applicability of probabilistic models to digital systems. The committee spent much of its effort on this issue in assessing the applicability of probabilistic analysis methods to digital systems.
Although well-accepted techniques exist for the analysis of physical faults, probabilistic analysis of design faults in critical systems is more problematic. Because software faults are by definition design faults, the discussion will focus on probabilistic techniques for assessing software. It should be noted that much of the discussion is applicable to similar systems that may be implemented in hardware, using programmable devices or application-specific integrated circuits.
There is controversy within the software engineering community as to whether software fails, whether it fails randomly, and whether the notion of a software failure rate exists. Some would assert that software does not "fail" because it does not physically change when an incorrect result is produced. Others assert that software either works or does not work, and thus its reliability is either zero or one (see, e.g., Singpurwalla, 1995, and the published discussion accompanying that reference).
Some who accept the notion of software failure disagree as to whether software failure can be modeled probabilistically. Some argue that software is deterministic, in that given a particular set of inputs and internal state, the behavior of the software is fixed. The most common justification for the apparent random nature of software failures is the randomness or uncertainty of the input sequences (Eckhardt and Lee, 1985; Laprie, 1984; Littlewood and Miller, 1989). For example, Finelli (1991) identifies "error crystals" (regions of the input space that cause a program to produce errors); a software failure occurs when the input trajectory enters an error crystal. Recent experimental work (Goel, 1996) seems to suggest that the reliability of some software can be modeled stochastically as a function of the workload.
For nonsafety-critical software systems, statistical analysis techniques are being used in the software reliability engineering process (Lyu, 1996). For example, the statistical analysis of the results (i.e., detected failures) of a good set of tests can, based on the operational profile, help managers answer questions such as "When can I release this version?" or "When can I consider this phase of testing complete?" The basic premise is that a set of random tests of a large software system provides data as to the probability of failure for a particular version of software.
Many of the methods developed for software reliability engineering of large-scale commercial systems are not directly applicable to embedded systems for critical applications. One problem with the software reliability engineering approaches is that a very large number of test cases must be considered to statistically validate a low probability of failure (Butler and Finelli, 1993).
For very reliable software, the software would be expected to pass every test, making statistical analysis even more difficult. If software for a safety-critical application were to fail a test, the software would be changed in such as way as to correct the error and the testing would be restarted. Thus, a point would be reached when the software would have passed a very large number of tests. Miller et al. (1992) describe several methods for estimating a probability of failure for software that, in its current version, has not failed during random testing. Bertolino and Strigini (1996) propose a method for estimating both the probability of failure and the probability of program correctness from a series of failure-free test executions. Parnas et al. (1990) describe a methodology for determining how many tests should be passed in order to achieve a certain level of confidence that the failure probability is below a specified upper bound. A similar approach is described in NUREG/CR-6113 (USNRC, 1993a). In this case, the operating range of a safety system is considered to be the transition region between safe and unsafe operation. Thus it is recommended that random tests be selected in this transition region, and a mathematical formula is given for determining the number of test cases needed for statistical confidence that the failure probability is below a given upper bound.
The validity of these methods is dependent on the quality of the test cases chosen. The test cases should be representative of the inputs encountered in practice and should certainly include all boundary conditions and known potentially hazardous cases. Random testing should, however, be only a
part of a complete program for safety assessment and quality assurance, a program that includes formal methods (Rushby, 1995) or other analysis techniques throughout the development and assurance process. Testing and formal methods, besides being complementary, can be mutually supportive as well. Analysis can help determine potentially hazardous conditions that should be tested, and testing can help validate critical assumptions made in the analysis (Walter, 1990).
Some failure data from operational systems in the nuclear and other industries are available (Paula, 1993). Failure rates for microprocessor-based programmable logic controllers used in emergency shutdown systems are reported by Mitchell and Williams (1993). Fault-tolerant digital control systems failures are analyzed by Paula et al. (1993), who also present a quantitative fault tree analysis that helped a group of owners decide whether to replace existing analog control systems with fault-tolerant digital control systems. In 90 system years of operation, 279 single-channel failures and 55 multiple-channel failures were reported. Of the 55 multiple-channel failures, nine were attributed to software deficiencies. The fault tree analysis included such failure modes as inadvertent operator actions, software failures, physical damage from external events, lack of coverage, and hardware component and communication failures.
The criteria under which a utility can make plant changes without prior USNRC approval are established in 10 CFR 50.59. One of the specified criteria for determining whether a change requires approval (i.e., involves an unreviewed safety question) is whether the probability of occurrence or the consequences of an accident or malfunction of equipment important to safety previously evaluated in the safety analysis report may be increased.
The USNRC is increasingly incorporating probabilistic risk assessment into all of its rulemaking activities as it develops a risk-informed, performance-based stance (Newman, 1995). The current USNRC regulatory position on the probabilistic analysis of digital systems, however, is not clearly established or well documented. In an October 1995 presentation to the committee, USNRC staff described their position as follows (USNRC, 1995a): "It is the responsibility of the licensees to ensure appropriate reliability and safety of the digital I&C system. The design life-cycle activities permit both qualitative and quantitative methodologies for assessing reliability and are sufficiently adaptable to consider the evolving aspect of digital technology." However, although qualitative software assurance techniques are presented in several NUREG publications prepared by the Lawrence Livermore National Laboratory (USNRC, 1993b, 1995b), these contain no discussion of probabilistic analysis. In fact, in the October 1995 presentation, the USNRC staff also stated that "quantitative reliability assessment methods for digital systems are not believed to be sufficiently developed to be acceptable as standard practice" (USNRC, 1995a). In further discussions with the committee in April 1996, in addressing the evaluation of relative frequencies of occurrence for use in 10 CFR 50.59 determinations, the USNRC staff indicated they did not consider current evaluation methods to be sufficiently accurate to be meaningful (USNRC, 1996b).
In the U.S. nuclear industry, the use of probabilistic analysis for digital systems (particularly software) is mixed. The analysis of a fault-tolerant digital control system by Paula et al. (1993) used a fault tree and included software failures; however, this approach is not common. A discussion of key assumptions and guidelines for PRA from the Electric Power Research Institute's Utility Requirements Document (EPRI, 1992) shows no mention of software or of failure modes peculiar to digital systems. When several industry representatives were asked by the committee about the use of probabilistic analysis, the responses were mixed or inconclusive. Asked about the probabilistic risk assessment for the General Electric (GE) Advanced Boiling Water Reactor design, the GE representative told the committee that the GE analysis assumed that the software quality assurance and V&V (verification and validation) methodologies addressed the software failure issue (Simon, 1996). Thus software failures were not explicitly included in the PRA. However, it is interesting to note that the PRA for the protection and safety monitoring system of the (Westinghouse) AP600 used a software common-mode unavailability of 1.1 × 10-5 failures per demand for any particular software module, and a software common mode unavailability of 1.2 × 10-6 failures per demand for software failures that would manifest themselves across all types of software modules derived from the same basic design program in all applications (Westinghouse/ENEL, 1992).
As discussed in earlier chapters, the Canadian Atomic Energy Control Board (AECB) is currently formalizing an approach for software assessment in a new regulatory guide (AECB, 1996). The AECB assessment of software focuses on four aspects: review of software requirements specifications, systematic inspection of software development and implementation, review of software testing, and confirmation of software development process and management. The AECB approach requires an analysis of software criticality to assess the role of software in plant safety. A probabilistic analysis is not required since it "is difficult to produce a


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Winsome's Wednesday – 5th Day of Lendy Cowes Week
Today was another great day for Winsome and the Winsome crew, with another 1st, including both line honours and first on corrected time. We were delighted as the winning margin today, was our largest yet and we won by over 6 minutes despite the race being less than 2 hours. The divers came this morning […]
Post by Boj | August 2, 2017 | 4 Comments | Comments RSS
3rd day Lendy Cowes Week 2017
After having sailed very well in the first two days of this Cowes week, we knew it would take hard work to copy the two first places we scored until now. Weather forecast was perfect, promising a sunny day with wind 15-19 knots. So no massive rain like yesterday! The no.2 genua was very well […]
Post by Boj | August 1, 2017 | 4 Comments | Comments RSS
Lendy Cowes Week 2017 – Day 2
Following yesterday's excellent result, we were all keen on getting another good result in today. Whereas yesterday was a day of little breeze, winds for today were forecasted to be between 18-22 knots. Our start was on the fixed line at the Bramble end, near the Williams Shipping buoy. It was indeed breezy out on the Solent […]
Post by Boj | July 31, 2017 | 1 Comment | Comments RSS
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How to take BETTER PORTRAITS NOW!! A quick guide to better photos!
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Light Stands: http://amzn.to/2nudPqR
Whats up guys! Today, we're talking about how to take better portraits. We don't necessarily need new gear or high quality equipment to do this, we just need to learn how to communicate with our subjects better.
The key to taking a good portrait is being able to connect and pull the personality FROM your subject and learn to portray that within a single frame. It takes practice, but its more about the relationship with you and your talent VS just *snapping photos*
Hope you guys enjoy it! Now, go start taking better portraits!
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Hi Voodun,
Let me just pick up on this comment:
Hi Voodun,
Let me just pick up on this comment:
Sic Bisquitus Disintegrat...
Marc W.D. Tyrrell, Ph.D.
Institute of Interdisciplinary Studies,
Senior Research Fellow,
The Canadian Centre for Intelligence and Security Studies, NPSIA
Carleton University
My neighbors had nothing to do with it, they simply unwittingly tithed to a mosque that misdirected their money. The father of that family was a dedicated family man who came to America to marry the wife of his brother who already had 3 kids but had been shot and killed at the small corner store he ran.
Today the kids are HAMAS sympathizers and feel alienated by the US government.
Desire to bring down western civilization does not equal capability, and I didn't argue that they could do it. I was simply offering some insight.
I also never made any comparisons to the KGB's financing and AQ's financing.
I'm not saying AQ has the capacity to do what it wants to do.
But I will also point out that 50 years ago NO ONE would have thought that Turkey would have an Islamic party in power. 50 years ago the Lebanese would never have believed you if you told them that Christians would be a tiny minority.
If the people of the Middle East were primarily Hindu we would be facing a "radical Hindu" problem right now.
The question is, why are these people so upset, and why are they directing that in our general direction? Those who contribute it to differences of religion, or jealousy, or any one of another dozen favorites that get wheeled out to avoid taking any responsibility back on ourselves are why we are 8 years into this problem, with little headway to show for it. This is not to say it is our fault, for I am with the President here, and will not apologize. But recognizing ones responsibilities are a far cry from accepting blame for a complex problem that many factors have contributed to.
Robert C. Jones
Intellectus Supra Scientia
(Understanding is more important than Knowledge)
"The modern COIN mindset is when one arrogantly goes to some foreign land and attempts to make those who live there a lesser version of one's self. The FID mindset is when one humbly goes to some foreign land and seeks first to understand, and then to help in some small way for those who live there to be the best version of their own self." Colonel Robert C. Jones, US Army Special Forces (Retired)
Why would those kids feel that way - because wingnuts like the ones I quoted have told them that they do not belong and are not welcome in western society, and are to be distrusted as potential AQIZ moles. Our worldwide "war against terror" is nearly universally seen in the muslim world as a "war against islam", no matter how we market it.
People tend to perform to society's expetations of them.
What we fail to realize is that our fear and actions are losing this war for us, and exposing the darker sides of America.
I remember chatting with one of my students in 2002 about this. His university tuition, along with living expenses, were being paid for by Hamas which, BTW, he was quite open about. Now they had agreed to pay his university costs if he agreed to go back to Lebanon and do civil engineering for 4-5 years in some of the areas they controlled (which, BTW, he had grown up in).
Was he a terrorist? Not in my opinion at that time, but I wouldn't be surprised if he is still a Hamas supporter.
Sic Bisquitus Disintegrat...
Marc W.D. Tyrrell, Ph.D.
Institute of Interdisciplinary Studies,
Senior Research Fellow,
The Canadian Centre for Intelligence and Security Studies, NPSIA
Carleton University
In the Middle East, we made everything our business as well.
- In the Philippines, the HN conducts COIN and CT, the US conducts FID
- In the Philippines there are no U.S. detainees, only Philippino detainees
- In the Philippines there are no U.S. bases, only Philippino bases
- In the Philippines, U.S. soldiers don't kill Philippinos, Philippino soldiers do
- In the Philippines the U.S. was invited in by the HN, in the Middle East we invaded
This can go on and on. Clearly not all of this is applicable, but if I was going to summarize the one key difference it is that we tend to treat the Philippine populace more as we would treat the American Populace; but we do not extend that same respect to the Populaces of many of the places we engage elsewhere.
Robert C. Jones
Intellectus Supra Scientia
(Understanding is more important than Knowledge)
"The modern COIN mindset is when one arrogantly goes to some foreign land and attempts to make those who live there a lesser version of one's self. The FID mindset is when one humbly goes to some foreign land and seeks first to understand, and then to help in some small way for those who live there to be the best version of their own self." Colonel Robert C. Jones, US Army Special Forces (Retired)
Col Jones,
I was saying that if reshaping the middle east is our goal, then cultural fluency is necessary. I'm not making a right/wrong judgement on reshaping the middle east - I draw clear lines for myself on that sort of policy advocacy. My focus is on matching policy to goals, not determining the righteousness of goals. Maybe 20 years from now I'll get to that point, but right now I try to restrict my lane.
Cavguy - fear mongering conspiracy theory minded people on both sides of the political aisle are a big pet peeve of mine. I do think that you're not giving the Islamists enough agency here - US perceptions abroad and by first generation Americans (of which I am one) are not actively controlled by the USG or its actions. The propaganda efforts of Islamists, particularly Palestinians (who learned it from the secular Palestinian organizations being trained by the KGB) are AMAZING. Their harb al nafsiyah may be the most sophisticated and successful that the world has ever seen.
Aside from the Phares text, Ron Schliefer's Psychological Warfare in the Intifada: Israeli and Palestinian Media Politics and Military Strategies is a doozy.
As you can imagine, when I have conversations with my childhood friend, the talk usually turns to US policy, the military, etc. As an American, he believes no Jews died on 9/11. This is a college educated (computer science) businessman who tells me that bin Laden works for CIA, and was trained by them in Afghanistan. He tells me that the US has been stealing oil from Iraq. He tells me that Bush is being played by the Zionists (funny enough, like many American Arabs I meet, he seems to have a soft spot for Bush) who control Congress.
These are not perceptions logically deduced from US actions.
Well I suppose 'suddenly' happens any time something goes from one category to another.
I don't know how many new organizations were added to the FTO list since 9/11 - lets look.
36 in 2004 vs 28 in 1999.
Of those 8 I'd have to dig deeper to find out how many existed before 2001.
I'd say this thread is straying a wee bit off course. The whole AWC thing seems to have played itself out, so what say we leave its bones and move on?
"On the plains and mountains of the American West, the United States Army had once learned everything there was to learn about hit-and-run tactics and guerrilla warfare."
T.R. Fehrenbach This Kind of War
Ok, I wont make any more attempts at humorous jabs - nor did I realize that my PSYOP skills were being put to the test on an online bboard. Good to know, thanks. I'm on it.
Last edited by Voodoun; 01-23-2009 at 10:01 PM.
Infinity Journal "I don't care if this works in practice. I want to see it work in theory!"
- The job of the British Army out here is to kill or capture Communist Terrorists in Malaya.
- If we can double the ratio of kills per contact, we will soon put an end to the shooting in Malaya.
Sir Gerald Templer, foreword to the "Conduct of Anti-Terrorist Operations in Malaya," 1958 Edition


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Possum Magic from page to stage
July 10 12:00 am - 11:59 pm $13 – $35
Australia's top-selling picture book the iconic Possum Magic has sold more than five million copies. Possum Magic has captivated and enchanted us all for generations. This brand-new adaptation from Monkey Baa Theatre Company, Australia's leading theatre company for young audiences, promises an unforgettable experience for children and adults.


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And if the Wine you drink, the Lip you press,
End in what All begins and ends in--Yes;
Think then you are TO-DAY what YESTERDAY
You were--TO-MORROW you shall not be less.
There is a simple script that displays a random message from a database of quotes (as in well-know fortunes game).
This version is bundled with quotations from The Bible, The Talmud, The Koran, poetry, prose, famous people and books, humorous items.
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