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- Uncategorized
Luxury Wall Lights for Hotels
If you are thinking about adding new lights to your new establishment or a new Hotel and you want the most luxury wall lighting for your money? then you need to read this!
When i think of luxury i think of crystal, Designer and Glass for this lighting theme! here is four simple Wall lights that could change your hotel rooms from Shabby chic to Luxury!:
SCHULLER Flash Wall Lamp 2L
Wall lamp of 2 lights made of metal, chrome finish. Two double glass shades, exteriors of molded glass and the inners of faceted clear and smoke crystal. This item includes 2 G9 LED 6W
SCHULLER Argos Oval Glass Bowl Crystal Rain Drops Wall Light
Wall lamp made of metal, chrome finish. Shimmered glass shade. Crystal drops inside, Murano style. This item includes 1 G9 LED 6W
SCHULLER Quasar Copper Wall Uplighter Lamp Lamp with Star Effect
Wall lamp made of metal. Blown glass shade in copper colour with clear spotted decoration. This item includes 1 E27 LED 10W
SCHULLER Minerva Wall Lamp 2L
Wall lamp of 2 lights composed by fine metal chains, nickel finish. This item includes 2 G9 LED 6W
Visit our online shop for more lighting styles that might suit your businesses decor theme from Antique to Modern!
Clanrye Going Global
It's been an exciting few months for our international eCommerce division who last week launched an additional 3 websites in the US, UAE and Australian markets. The development of which was prompted by ongoing export success in over 40 international countries.
In 2017 we continued our investment by welcoming 2 additional members of staff onto our ideas4lighting team:
Ryan Sheppard, Commercial Director, had this to say: "a monumental amount of hard work has gone into the development of our eCommerce division and the building of our international brand and it gives me great pleasure to reveal 3 new websites catering for the US, Australian and Dubai markets. The entry to these markets has by no means been easy but I'm a firm believer in that famous saying 'if it was easy everyone would be doing it.'"
Our UK Lighting web-shop boasts over 16,000 products sourced from over 35 brands across Europe and further afield with delivery to 195 countries, something accomplished through a strong marketing plan, continuous sourcing and an ability to quickly adapt.
Tony McParland, Marketing Manager, has this say: "from recently joining the team at ideas4lighting and to see the company expanding to further countries within a short period of time is a proud and exciting time for not just myself but for all of us here at ideas4lighting."


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The Art of Ecology builds visual connections between people and the natural world we're a part of by blending the arts and environmental sciences. While we always have so much fun during the in-person programs designed to get your creative juices flowing while also teaching you about the marvelous ecosystems around us, you may not be local or not have a schedule that lines up with when the programs are scheduled. That doesn't mean you have to miss out though!
The Art of Ecology offers a handful of plant ecology, nature-art, and wildlife ecology programs as a "Workshop in a Box". Each box contains the materials and instructions needed to create your project and is delivered straight to you!
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subset: commoncrawl


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$ 21.00
Start by making Matcha part of your daily routine. Essential for anyone looking for a lifestyle centered around wellness, this fresh and delicious tea is perfect for your morning fix or afternoon lull. Your healthy habit will have you feeling vibrant in no time, but really, you love it just because it simply tastes refreshing and amazing.
Flavor profile: light aromatics of toasted vanilla. Creamy mouthfeel with full, milky notes of freshly churned butter. This matcha is sure to refresh.
Our matcha is exceptionally fresh- sourced, shade-grown & stone-milled to order at our 100-year old family matcha manufactory, in Uji, Japan.
Size: 40g Tin (20-30 servings)
Pictured also is our sesame chashaku - for measuring the perfect amount of Mizuba.
$ 45.60
Matcha Green Tea - Mizuba Tea Co. Looking for an easy way to start living the matcha life, or want to give the gift of matcha to a friend? Our #MatchaMoment...View full product details
$ 30.00
Organic Matcha Green Tea - Mizuba Tea Co. Can't get enough of our matcha green tea? Great, we can't either! Here's our secret to every matcha latte, smoothie, cookie, and...View full product details
$ 25.00
Organic Matcha Green Tea - Mizuba Tea Co. Our certified organic first flush artisanal Matcha. A more savory offering than our Daily Matcha, the House showcases fresh, traditional & enjoyable...View full product details
$ 35.00
Organic Matcha Green Tea - Mizuba Tea Co. Harvested only once a year, our first flush organic Matcha is certified by the Ministry of Agriculture, Forestry, and Fisheries of Japan (JAS)....View full product details


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Choose one of the Singapore tour packages below to get your holiday started.
Singapore is a peaceful and clean country with a plethora of prominent landmarks such as the Marina Bay Skyline. Singapore is also the world's number one competitive country, overtaking the United States in 2019. Located between Malaysia and Indonesia, Singapore is an island with flat terrains who enjoys a tropical climate that is hot and humid all year round.
A highly dense and urbanised country as Singapore has people coming from all around the world to experience some of the best attractions in South East Asia. With land that is 12 times bigger than the Manhattan city, some of the most unique places to visit in Singapore are Garden by the Bay, Orchard Road and Jewel Changi Airport.
Undoubtedly, Changi is the Best Airports in the world that has been holding on to the title for seven consecutive years. The Jewel is a nature-themed dazzling complex that spans across 137,000 square metres.
Garden by the Bay centres in nature, allowing visitors to appreciate the beauty of trees and plants alongside magnificent structures.
For a pleasant retail and gourmet therapy, Orchard Road is the place you cannot miss. The shopping belt stretches up to 2.2 kilometres and is lined up with over 30 malls.
For a fuss-free holiday, the Singapore tour packages come together with a list of top attractions that you will be visiting. It is extremely crucial to go through the planned itinerary before purchasing.
Every day is a good day to travel to Singapore as the weather is hot and humid throughout the year. However, the best time to visit is from February to April as the island-country will be experiencing lesser rainfall.
Another great time to visit Singapore is during the Grand Sales that starts from 21st June to 28th July. Participated by all retailers in Singapore, you will be able to purchase quality goods just for a just fraction of the price. During this period, there will also be plenty of fashion shows, pop up stores and festivals held primarily in the centre of Singapore.
Singapore comes alive during the year-end as Christmas is celebrated on a grand scale. Major parts of the country will be decorated with fantastic light displays, with lots of events happening in top locations in Singapore such as the Orchard Road, Garden by the Bay, Sentosa Island and many more.
Singapore tour packages will already have the best proposed activities based on what you are looking for. So you don't have to worry much and just go with the flow.
Singapore's transportation is one of the most efficient networks in the world. There are plenty of transport options that can take you to all parts of Singapore very quickly. The best and usual method is by taking the MRT; with an impressive average waiting time of just 2.5 minutes. Taxi, Grab, and busses are also available for hire.
As the island is small, you do not need to be on the road for long before you reach your destination.
As for your Singapore tour packages, your transportation is already included in enabling you a stress-free and wonderful time in Singapore. You are advised to plan out your own transportation during 'Free & Easy' days or if you would like to stray out of the proposed tour itinerary.
Singapore is a strong economy with a healthy currency. The living cost is high only if you are an expatriate or a visiting tourist. Though the country might be expensive, there are plenty of ways to stretch the dollar. Here is a simple breakdown of the top expenditure categories in Singapore:
Good news to those that have purchased one of the Singapore tour packages, you will not need to worry about all these costs as these are included into the package. However, you are advised to still prepare additional cash for souvenirs or your own activities outside of the planned itinerary.
With so many Singapore tour packages available out there, it is important to select the right package to ensure you have a wonderful trip. First and foremost, you need to know which month you will be visiting, the budget and also places that you would like to visit in the country. Identifying what kind of trip you are looking for is also vital ; be it a family vacation, honeymoon, a nature or adventure excursion.
Whether you are looking for a relaxing holiday or a filled exploration, you will be able to identify it when you take a look at the proposed itinerary. With all these points covered, you are now on your way to a stress-free, convenient, and money-well-spent happy holiday to Singapore.


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Samuel Holzner. City Life Milano
Arata Isozaki, Zaha Hadid Architects, Daniel Libeskind,
Free Time, Commercial Buildings, urban park, Loft, Shopping Centers, Housing,
Samuel Holzner, South Tyrolean, born in 1989 has a great passion - architecture photography. A passion he has been cultivating enthusiastically and with dedication since he first attended photography school in Hall, Tyrol, completing his studies as an assistant photographer first to Oscar da Riz in Bolzano, then to Florian Holzherr in Munich.
Since he became a freelancer in 2013, his mission has been to visualise the character of buildings as effectively as possible, and his response to this challenge is elegant, regardless of the weather conditions because Samuel Holzner really isn't concerned about "bad weather". Indeed, when you work in such an impressive natural context as South Tyrol, with its standout visual impact, the "bad weather" means he can focus more on the architecture itself, for example when clouds cover the Dolomites and the landscape is not reflected in the glazing.
However, it takes in-depth knowledge of the landscape - whether natural or manmade - to do this, because that is what forms the substrate of the visual narrative running through his work.
His sensitivity is particularly evident in one of his photographic projects, which took him from the rugged peaks of South Tyrol to Milan, more specifically to CityLife, the project for the redevelopment of the historical city hub of the Fiera di Milano exhibition centre. One of the largest urban redevelopments in Europe, with a total area of 366,000 square metres which includes works by Zaha Hadid, Arata Isozaki and Daniel Libeskind.
Although a number of images of this landmark project have been published in the different media, rarely do we get the feeling that the redevelopment area has actually been integrated into a real, lived-in urban context, or that it has a human dimension to it. So, Samuel Holzner set out to explore CityLife with some keywords in mind - sustainability, quality lifestyle and services. All to portray this project whose intention is to be a "green lung" in the city of Milan., thanks to its public park - the first new-build park in the city centre since the end of the 19th century - for now with 70,000+ square metres of the total 173,000 square-metre area completed and opened.
This is how the South Tyrolean photographer tells us all about this articulated, balanced mix of public and private functions, which includes residences, offices, shops and services, green areas, public and leisure spaces. And he does all of this with architecture photographs that do much more than just providing documentation, usually limited to shapes and materials. Holzner's photos really demonstrate the aesthetic and emotional thrust behind each building. Therefore, in Milan like in the Dolomites, Holzner uses contextualisation of the single buildings even when it's just a rough idea to bring out the character of each architectural element. Whether he photographs the Allianz tower, designed by Arata Isozaki with Andrea Maffei, and currently Italy's tallest building (202 metres high with 50 storeys), or the residential complex designed by Zaha Hadid or the CityLife Business & Shopping District, one of the largest urban shopping districts in Europe that opened on 30 November 2017, Holzner conveys sensations that spring from his skilful composition of the images.
In conclusion, like with the Dolomites, here Samuel Holzner doesn't stop at the beauty of nature, nor does he stop even before the visual impact of iconic architecture. Moreover, by including the human element both inside and outside the buildings, he emphasises their use and provides a narrative of the true essence of this new urban landscape in third-millennium Milan as a possible driver of social and cultural change based on architectural redevelopment.
Samuel Holzner


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Recent News and Updates:
09/27/2023: Podcasts updated for Week Six (6)
09/21/2023: Podcasts updated for Week Five (5)
09/19/2023: Player Profiles added to Roster Page
Troy Thomas
Coach Thomas returned to Servite in January of 2018 after coaching at his alma mater, Crespi from 2012-2017.
Coach Thomas previously served as head coach at Servite from 2005-2012 winning seven league titles, two CIF PAC 5 championships and one State title while going 75-25 overall in eight seasons. This puts Coach Thomas as the second most winningest coach in Servite history, only second to Coach Persons, with his one-year record of 10-3-0. Granted, if Coach Persons had coached more than one year, his percentage might not have been so high, but that leads to speculation.
Upon his return, Coach Troy Thomas said,
"I am excited to be back, thankful and humbled by the opportunity to return to Servite. I believe in what Servite stands for and resonate with the traditions established here over the years. There is nothing like the Servite community and their love for football. I am eager to get started and reconnect with the Servite faculty, staff and alumni."
Coach Thomas began his coaching career as a high school defensive coordinator and strength coach in 1992 at Crespi High School of Encino. After four years at Crespi, he spent the next three seasons as a college football assistant coach at the University Hawaii. In 1999 he spent a year at Westlake High School as a defensive coordinator and strength coach before returning to the collegiate ranks coaching under Pat Hill at Fresno State. The following season he earned his first head coaching job at Crespi where he spent four years before making the move to Servite in 2005.
Sean Koelle
Coach Koelle comes to Servite from Bishop Amat where he served on the coaching staff for the Lancers in a variety of capacities for 16 seasons. Most recently, he worked as the offensive coordinator taking over play calling duties in 2015. Prior to that he served as the quarterback coach and freshman head coach.
In addition, Koelle worked as Amat's strength and conditioning coordinator, head golf coach and has instructed theology.
In the last five seasons, Koelle helped lead the Lancers to a 24-4 league record while winning three Mission League Championships. In 2019, Amat finished 9-2 overall going undefeated in league and earning a CIF-SS Division 1 playoff berth.
Coach Koelle has helped mentor numerous college-bound players during his time with the Lancers including Tyler Vaughns (USC), Aaron Maldonado (Cal), Brandon Arconado (Washington State) and Trevon Sidney (Illinois).
Coach Koelle shared, "I love my Amat family and am thankful for my time spent with the Lancers. I am excited to take on this new opportunity and continue to challenge myself while further growing as a coach. I look forward to getting to work and building on the foundation already established with this talented group of student-athletes and coaches. It is evident that Servite is a special place and I am grateful to have the chance to further their mission and help in the formation of each young man."
A 1998 graduate of Amat, Koelle has been immersed in Catholic education for most of his life first as a student-athlete and now as a teacher and coach.
The Servite community would like to welcome Coach Koelle, his wife Stephanie and daughter Riley to the Friar family.


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Send your interns to Leadership Iowa University
Across industries, finding qualified, hardworking employees is difficult. Attracting top talent and finding ways to retain that talent is critical.
What better way to demonstrate your investment in young, potential employees than by sending them to leadership Iowa University (LIU)?
The Iowa Association of Business and Industry Foundation created the LIU program for college students eight years ago. It is modeled after the successful and highly revered leadership Iowa program.
Several companies, including Grinnell Mutual Reinsurance Co. and Principal, identify a handful of top interns to send to the program each year. It is a way to show a company's dedication to the intern's development while allowing the business to cultivate future leaders.
Throughout the three-session program, leadership Iowa university students gain a better understanding of the various opportunities to grow and succeed in Iowa. In addition to enhancing their personal and professional teamwork and leadership skills, students have the opportunity to network with Iowa leaders from across industries and across the state who will challenge their way of thinking and provide them a strong network of professional contacts.
Help your top young recruits jump-start their professional development and support their participation in leadership Iowa university.
The 2016 class begins with a session Aug. 7-11 in Des Moines. Nominate a student now at www.leadershipiowauniversity.com.
Looking for other ways to get involved? Each LIU student is paired with a mentor — a business professional in the student's area of career interest. If you are interested in learning more about how to become a mentor, contact Kay Neumann- Thomas at email@example.com.


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The first trade in Canada began in 1832 as a casual inventory change at the Exchange Coffee House in Montreal. In 1874, Lorn MacDougall, alongside with his brothers Hartland St. Clair MacDougall and George Campbell MacDougall, James Burnett and Frank Bond were the driving pressure behind the creation of the Montreal Stock Exchange (a reputation that was used till 1982 when it grew to https://www.coinbase.com/ become the Montreal Exchange). The shareholders voted Lorn MacDougall its first Chairman of the Governing Committee, a place he held until poor health pressured him to retire in 1883. TMX Group Limited and its associates do not endorse or recommend any securities issued by any corporations identified on, or linked via, this web site.
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- "Montreal Climate Exchange declares May 30 as date for launch of trading in MCeX carbon futures".
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- On November 29, 1999 the small-cap portion of the equities market of the Montreal Exchange was merged into the Canadian Venture Exchange (CDNX), along with the Alberta Stock Exchange (ASE) and the Vancouver Stock Exchange (VSE).
- In 1982, the Montreal Stock Exchange modified its name to the Montreal Exchange to reflect the growing importance of monetary devices aside from stocks–primarily choices and futures–on its buying and selling floor.
- Metal (MTL) is a peer-to-peer platform for exchanging fiat cash for cryptocurrency and vice versa.
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In 1974, the Canadian Stock Exchange merged with the Montreal Stock Exchange, retaining the larger trade's title. TypeRegional inventory change, curb marketLocationMontreal, CanadaFounded1926Closed1974 (merged)Market capSmall-cap equitiesThe Montreal Curb Market was a inventory exchange created in 1926 for trading in shares that were considered to be too speculative or junior to be traded on the Montreal Stock Exchange (MSE). As these companies matured, buying and selling of their shares was transferred to the MSE. In 1982, the Montreal Stock Exchange changed its title to the Montreal Exchange to reflect the growing importance of economic instruments aside from stocks–primarily choices and futures–on its buying and selling ground.
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By Gary Boyle
The Backyard Astronomer
For thousands of years, the night sky was just a splash of random dots. Over time, constellations were formed by connecting the brighter points of light of a certain area of sky. Here, imaginary shapes were formed representing an object, person, animal or even a god – the constellations. Then came the mythologic stories and how they interacted in the celestial theatre. Those that looked at the sky regularly would notice a brighter than usual star or stars traverse a path across the sky over weeks, months and years. Not known at the time, these are the members of our solar system.
The word planet came from the early Greeks meaning "wanderer" or "wandering star" and for obvious reasons. Seen with the unaided eye are Mercury, Venus, Mars, Jupiter and Saturn. Uranus and Neptune were discovered via the telescope in 1781 and 1846 respectively. Pluto was discovered in 1930 but demoted to minor planet status in 2006 so the count remains at eight major planets orbiting its parent star – the sun. Brilliant Venus is seen low in the southwest sky after sunset while bright Jupiter is seen in the southeast with dimmer Saturn about five inches to Jupiter's right at arm's length.
Once the planets were identified and studied, we thought we were the only solar system in our Milky Way Galaxy. Little did we know all that would change in the early 1990s. The first discovery of an exoplanet (a planet that orbits a star outside the solar system) was discovered in 1992. Three planets are orbiting this pulsar located 2,300 light-years away. Pulsars are very energetic stars resulting from the explosive death of a massive star called a supernova. If these three worlds had any life on them before the star blew its top, the shockwave from the supernova stripped away its atmosphere and is bathing the lifeless planets in deadly radiation.
However, the big discovery came in 1995 when the first exoplanet orbiting a sun-like star was discovered. The star named 51 Pegasi is located 50.8 light-years away in the constellation Pegasus – seen overhead on these cool nights. This star is visible with the unaided eye on a clear moonless night. Of course, you will not see the exoplanet named Bellerophon even with a telescope but knowing that a world is orbiting that tiny point of light is mind-blowing.
The search did not end in 1995. Thanks to ground-based telescopes and the orbiting Kepler Space Telescope, the count so far is 4,531 confirmed planets with 7,798 candidates. These discoveries were made from a small portion of the sky. Some astronomers have stated that every star in the night sky has at least one exoplanet around it. Many are too close to their star to support life as we know it but there are a few in the habitable or Goldie Locks zone where liquid water remains fluid, like the oceans here on earth. Finding an exoplanet with water is the key to finding life.
The Milky Way contains an estimated 300 billion stars. Imagine if a single grain of table salt represented a star, you can fill a sandbox 20 feet long by 20 feet wide by one foot high. There are an estimated two trillion galaxies in the observable universe. Think of all those worlds and the possibility of life.
Look up at the sky, look at a sky full of planets.
Till next time, clear skies.
Known as "The Backyard Astronomer", Gary Boyle is an astronomy educator, guest speaker and monthly columnist for the Royal Astronomical Society of Canada. He has been interviewed on more than 50 Canadian radio stations as well as television across Canada and the U.S. In recognition of his public outreach in astronomy, the International Astronomical Union has honoured him with the naming of Asteroid (22406) Garyboyle. Follow him on Twitter: @astroeducator or his website: www.wondersofastronomy.com
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Oversize / overweight
Case study
Haul 600 tonnes of telecom supplies
Hauling by barge of a 64-tonne reel for the oil industry from Manitowoc, Wisconsin, to the Port of Montreal, for subsequent transport to Scotland.
Loading at the supplier's warehouse, chartering of a barge to cross the Great Lakes toward the Port of Montreal for reloading onto a vessel destined for Scotland.
Despite a storm that hit the Great Lakes and brought the barge to a halt for two days, the shipment arrived on time to be loaded onto a Maersk ship toward its final destination.


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We're celebrating our quilting community with a free block of the week quilt along called the Sewcialites Quilt Along. We've joined forces with 18 talented designers to bring you a free 38-week quilt along with amazing sampler blocks and sew many options! If you're just joining us, you can find all of the details over on the Sewcialites Landing Page. We're sewing up block #14 this week!
This week's designer is Chelsi Stratton! Oh, who's that? Just part of the duo Sherri and Chelsi, designers for Moda Fabrics. You may have heard them dishing on all things quilting on A Quilting Life podcast! Chelsi is a talented quilter and fabric designer. Serenity is a graphic block. Don't worry if you are a beginner, Kimberly can help you sew this block today's video tutorial on YouTube.
Chelsi sewed this up with Balboa. Visit her on Instagram @chelsistratton or her blog for more details about her block!
Sewcialites Quilt Along
Kimberly is sewing with the Homestead collection by April Rosenthal for Moda Fabrics. She made her blocks in all three sizes for a fun challenge.
We invited some FQS staffers to join
The suggested fabric requirements and all the block patterns released so far will be posted on the Sewcialites Landing Page so be sure to bookmark it for later reference.
Sew Along Perks
Each month, you can enter to win a giveaway by posting your progress on Instagram using #SewcialitesQAL.
For blocks 13-15, we have a fabulous prize from Stella Lighting! They are giving away TWO Stella Two Desk Lamps! It's the perfect lighting solution for all of your crafting projects as it allows you to control light color, intensity and position with ease to get light right where you need it. It comes in three colors: white, pink and black.
To enter to win, share photos of any one of your blocks 13-15 on Instagram with the #SewcialitesQAL and tag @fatquartershop and @stellalighting. Make sure you're following both accounts! Post your photo by midnight on January 18, 2021. You can enter up to three times (once for each block)! We'll pick two lucky winners and announce them here on the blog on Friday, January 22. Thank you to our generous sponsor, Stella Lighting!
Terms: This contest is open to US residents only. Free shipping for the lower 48, and winners in HI and AK will need to pay for shipping.
Ready to chat? Meet us in the Sewcialites Lounge
Meet your fellow Sewcialites by joining the Sewcialites Lounge on Facebook (where we will also be posting weekly updates and where you can ask questions).
Follow us on Facebook, and Instagram for updates and share your progress with the #SewcialitesQAL hashtag so we can see and share your work. We hope to see you back here on the blog on Friday, January 15 for the fifteenth block release of our Sewcialites Quilt Along!
Happy Quilting!


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While F1 have been banning modern stuff like helmet changes, the World Endurance Championship have decided it's time to get rid of one of motorsport's oldest traditions; Grid Girls.
Yes, according to Reuters, the series has realised it's no longer 1950 and have decided to ditch the out-dated tradition.
"From Silverstone next week, you will see that for any race we will do — no grid girls like in the past," WEC chief executive Gerard Neveu told Reuters after a presentation on Thursday for the opening Silverstone six-hour race.
"For me that is the past. The condition of women is a little bit different now," he said.
It's a decision that will no doubt cause plenty of debate between race fans but one that last year's WEC champion, Anthony Davidson agrees with.
It's old school to have such a concept as grid girls. Surely the world's moved on? And motor racing should follow quite closely what the rest of the world's doing in that respect.
The WEC instead wants the focus to be on their awesome race cars instead of some dolled-up girls. It is said the series now will have a new start procedure too with the cars lining-up diagonally opposite the pit-wall like an old school Le Mans start before the drivers head onto their warm-up lap.
What do you think though, have WEC done the right thing ditching Grid Girls?


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Introduction: Portal Turret Scare Crow
"This instructable was created in fulfillment of the project requirement of the Makecourse at the University of South Florida (www.makecourse.com)"
The idea behind this project was to create a device that could act as a scare crow based on a proximity sensor. The design is based of a turret from the game Portal, which is one of the first games I played. The Portal Turret Scare Crow has proven itself to be a formidable opponent against Husky-Shepard mixes, and most certainly keep any other pet away from your ramen noodles
Step 1: Download the Parts
Download the zip-file that contains all the parts of the Portal Turret Scare Crow. All the files will be in .STL format, which is necessary for 3-D printers to work with the models.
Step 2: Print the 3-D Parts
The 3-D printers should come with software that allows you to print the parts. Make sure that the models are laying flat and the widest parts are on the bottom. You'll need roughly half a roll (1 roll being 1 kg or 2.2 lbs) of 1.75 mm filament. I used white because the original turret is white. However, since you are reading this, you probably live in the free world so you can do whatever.
Step 3: Build the Arduino Circuit
Build the circuit according to the circuit diagram in the pictures. Since this will be inside of the turret, you want to use a small breadboard in order to make it fit. You will need the following pieces of equipment:
1 x Arduino Uno
1 x HC-SR04 Ultrasonic Sensor
1 x SG90 9G Servo
1 x IR Receiver
1 x IRREC-02 IR Remote
A bunch of cables to connect stuff up
Step 4: Upload the Code to the Arduino
Attached is the Arduino sketch file. Upload the sketch to your Arduino. Make sure that the right board is selected and that the port is connected as well. The code is also down below for the Ctrl-C, Ctrl-V type of people. Make sure you add the IRremote library to the program. Luckily, I feel generous enough to include the library for your convenience as well.

#include <servo.h>
#include "IRremote.h"</servo.h>

Servo myservo; // create servo object to control a servo

const int trigPin = 7; const int echoPin = 6; int setting = 0;

/*-----( Declare Constants )-----*/ int receiver = 11; // pin 1 of IR receiver to Arduino digital pin 11

/*-----( Declare objects )-----*/ IRrecv irrecv(receiver); // create instance of 'irrecv' decode_results results; // create instance of 'decode_results' /*-----( Declare Variables )-----*/

void setup() { // initialize serial communication:

Serial.begin(9600); myservo.attach(9); // attaches the servo on pin 9 to the servo object Serial.println("IR Receiver Raw Data + Button Decode Test"); irrecv.enableIRIn(); // Start the receiver setting = 2; } void loop() { if (irrecv.decode(&results)) // have we received an IR signal? { // Serial.println(results.value, HEX); UN Comment to see raw values translateIR(); irrecv.resume(); // receive the next value } // and the distance result in centimeters:

long duration, cm; pinMode(trigPin, OUTPUT); digitalWrite(trigPin, LOW); delayMicroseconds(2); digitalWrite(trigPin, HIGH); delayMicroseconds(20); digitalWrite(trigPin, LOW); pinMode(echoPin, INPUT); duration = pulseIn(echoPin, HIGH);

// convert the time into a distance

cm = microsecondsToCentimeters(duration);

// the condition for the distance if (setting ==0){ myservo.write(30); } else if (setting == 1){

if ( cm > 15 && cm < 40) { myservo.write(70); // sets the servo position according to the scaled value delay(200); } else if ( cm < 15) { myservo.write(110); // sets the servo position according to the scaled value delay(200); } else if (setting ==2){ myservo.write(105); // sets the servo position according to the scaled value delay(200); } else { myservo.write(30); // sets the servo position according to the scaled value delay(200); }

//.print(setting);

//Serial.print("cm");

//Serial.println();

delay(100); } } long microsecondsToCentimeters(long microseconds) {

// The speed of sound is 340 m/s or 29 microseconds per centimeter.

// The ping travels out and back, so to find the distance of the

// object we take half of the distance travelled. return microseconds / 29 / 2; } /*-----( Declare User-written Functions )-----*/ void translateIR() // takes action based on IR code received // describing Car MP3 IR codes { switch(results.value) {

 case 0xFFA25D: Serial.println(" CH- "); break;

 case 0xFF629D: Serial.println(" CH "); break;

 case 0xFFE21D: Serial.println(" CH+ "); break;

 case 0xFF22DD: Serial.println(" PREV "); break;

 case 0xFF02FD: Serial.println(" NEXT "); break;

 case 0xFFC23D: Serial.println(" PLAY/PAUSE "); break;

 case 0xFFE01F: Serial.println(" VOL- "); break;

 case 0xFFA857: Serial.println(" VOL+ "); break;

 case 0xFF906F: Serial.println(" EQ "); break;

 case 0xFF6897: Serial.println(" 0 "); break;

 case 0xFF9867: Serial.println(" 100+ "); break;

 case 0xFFB04F: Serial.println(" 200+ "); break;

 case 0xFF30CF: Serial.println(" 1 "); myservo.write(90); // sets the servo position according to the scaled value delay(100); break;

 case 0xFF18E7: Serial.println(" 2 "); myservo.write(30); setting = 1; Serial.println(setting); break;

 case 0xFF7A85: Serial.println(" 3 "); setting = 0; myservo.write(30); Serial.println(setting); break;

 case 0xFF10EF: Serial.println(" 4 "); setting = 2; myservo.write(110); Serial.println(setting); break;

 case 0xFF38C7: Serial.println(" 5 "); break;

 case 0xFF5AA5: Serial.println(" 6 "); break;

 case 0xFF42BD: Serial.println(" 7 "); break;

 case 0xFF4AB5: Serial.println(" 8 "); break;

 case 0xFF52AD: Serial.println(" 9 "); break;

 default: Serial.println(" other button ");

 }

 delay(500);

} //END translateIR

Step 5: Assemble the Turret
You better get a hold on a fresh bottle of super glue because you are gonna need it. Once all parts are printed, assemble the parts using super glue. The circuitry will be placed at the bottom. There's room for a battery pack at the top in case you want to make a Portable Portal Turret Scare Crow.
Use the pictures as a reference on how to assemble the parts. The Ultrasonic sensor will go through the hole in the front. I used the default gear that came with the servo and glued the other gear on top of it.


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I was on the phone with my Momma a few weeks ago, and I was telling her about my Feast of the Seven Fishes blog. She mentioned that she would like to see a recipe for Pasta with Anchovies and Walnut Breadcrumbs. How could I say no? Honestly, this recipe is so super simple. It can be prepared in the time it takes to boil the pasta.
Per usual, when I was back in Pennsylvania a few weeks ago, I visited my favorite Italian store, Delallo. I gathered up a bunch of goodies in anticipation of making this. If you are near Jeanette, Pennsylvania, be sure to stop by and pay them a visit. You can also check their website for product availability in your area. Love that I was able to get everything there from the pasta, to the anchovies, and even the walnuts! You have to check out their nut section! Oh, and their olive bar, cheese shop and bakery. Pick up a few lobster tails (the pastry) while you are there.
Some of you might be thinking about how much you loathe anchovies. There would be no way you would be making this. However, the best part about this recipe, is that it does NOT taste like anchovies. I PROMISE! The anchovies just give the pasta an amazing level of flavor and saltiness. No doubt, if you prepare this for someone who does not like anchovies, they will never know they are in the dish. Of course, unless you tell them!
Start a pot of water boiling. As the the water is heating up, in a mini-chopper, add the breadcrumbs and walnuts. Pulse a few times. You want the nuts to be the same consistency as the breadcrumbs. Heat up a tablespoon or two of olive oil in a non-stick pan. Add the breadcrumb mixture and toast. Keep an eye on this, as they can easily burn. This should only take a few minutes. Stir constantly. Reserve.
Drop pasta. Be sure to salt the water! In a deep pan, heat up two tablespoons of olive oil and the anchovies. Break apart the anchovies. You will notice the anchovies will start to "melt." Add in the garlic, crushed red pepper flakes and a dash or two of black pepper. Allow to cook for another three minutes.
Lower heat on pan. At this point, the pasta should be al dente. Transfer the pasta directly from the pot to the pan. Do not drain, or rinse. You will also be using a ladle, or so full of the pasta water, so do not dump the pot. Coat the pasta with the pan mixture. Pour in a ladle of the pasta water. Toss again. Allow to warm up just a minute. Throw in the breadcrumb mixture and fresh chopped parsley. Toss again to coat. If the pasta seems a bit dry, add in a touch more pasta water. Slowly incorporate the Parmesan cheese.
Transfer the Pasta with Anchovies and Walnut Breadcrumbs to a bowl. Drizzle on a touch more olive oil and a pinch of crushed red pepper flakes (optional). Garnish with a touch more fresh chopped parsley and lemon zest. Serve and ENJOY!!!
I am more than just recipes. I love fashion and style too! Most importantly, I love my Family (my Hubby and my Fur Babies). My Husband (aka my "Kitchen Bitch") means the world to me. He's pretty damn cool too. Not only is he one of the nicest guys you will ever meet, he also has had a lengthy career in professional hockey. Not only winning two Stanley Cups with the Pittsburgh Penguins in the early '90's, but most recently winning the Calder Cup with the Charlotte Checkers, amongst many other accolades. If you live in Charlotte and play hockey, or have a family member who plays, be sure to contact him. He is known as one of the best skate sharpeners in the world!
Our life has changed dramatically in the past few years with the passing of our two goldendoodles, Vegas and Viva. We were lucky enough to have Vegas for five years (totally wish it was longer). Most recently, losing our Viva to a brain tumor in July of 2020. We welcomed our mini goldendoodle 7, almost seven years ago. We just added the amazing Hazel! Of course, I am always posting tons and tons of photos! Be sure to check out my recipe for Pet Bone Broth! This broth is super rich in nutrients and will provide your pet with a multitude of health benefits!
Be sure to follow me on social media! I'm always talking food, fashion, and family! I also love sharing some of my favorite Amazon Finds too. Click here to check out my Amazon page! Facebook, Instagram, TikTok, Twitter and Pinterest!


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Gorgeous soft colours in this precious print that sits within a vintage wooden frame.
Please remember this piece is preloved and unique, which means there may be slight signs of wear.
Be sure to scroll through to the last image for untouched colouring of garment and keep in mind every digital device varies slightly in their colour display.


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We define recovery as the personal journey people with different mental health experiences take to rebuild, re-discover their strengths and live meaningful, hopeful and satisfying lives.
For some people the concept of recovery is about taking and staying in control of their lives, despite experiencing mental or physical health challenges. Self-management and self-determination are the foundations of recovery as people define their own goals and plan their own journey towards these goals.
Having a sense of wellbeing is an integral part of the recovery journey. Wellbeing incorporates connecting with people, being active, taking notice of what is around you, learning and giving.
Although clinical recovery may be included in this journey the aims and aspirations of personal recovery are far more extensive. Recovery is holistic and embraces the whole person, including their mind, body, spirit and community. It gives people the opportunity to reach their full potential. People facing mental and physical health challenges develop their own definition of recovery.
Video: What recovery means to you
This video is a short montage of one-word answers by CNWL staff, services users and peer recovery trainers expressing their personal definitions of recovery.


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Almost every time I write the word 'patriarchy', people think I am attacking all men in general. Therefore, to those who believe an attack on patriarchy is an attack on all men, it is essential for me to reiterate the reference to patriarchy here is as of a social structure – the analysis of power-distribution within a society (and the abuse of it).
Patriarchs can be from any gender, it does not have to necessarily be the violent portrayal of a male. Similarly, the ones affected by patriarchy can be from any gender too, and typically extends to family members within a household. However, the take away from it as being a social structure is how does it affect children within a home? Does it teach us "not to question authority when the patriarch is in the wrong?" And does that eventually spill outside our homes too? Are our political leaders are patriarchs because perhaps they were raised in a patriarchal society? Lastly, if our current leaders learnt from their predecessors, are our future leaders learning the same too? And is better political accountability to the people in sight?
To understand this argument, perhaps this short fictional story would be better:
Once upon a time lived two brothers – circumstantially both were raised differently. One navigated political rallies, served jail time; the other took a much more drastic approach – including the death of several innocents. Both believed they were working for a reformed society.
Despite their differences while growing up, somehow in their later years, they reconnect – it is unclear if either has ulterior motives when they are joining hands. It is also important to note that both these heads have married and raised children – let's say their children are the people of Nepal.
These poor children, who have already lived through a horrific childhood (the Nepalese Civil War), are happy some stability (political) has finally arrived – therefore, they accept the union.
It is important to note that these children were not consulted before the two brothers united – and are all of sudden put in the same home and asked to live together in peace – without questioning the reasons for the unity.
Now, the brothers begin to bicker – both want the patriarchal seat (the chair of the Prime Minister). Initially, the fight is limited to the two brothers, and a few close elders, but eventually, because reconciliation isn't in sight, it spills on to the children.
And one day, with a snap of a finger, the two families separate – children of both families, thrust into confusion, join the blame game.
"Your father has undermined democracy", says the child of the younger brother.
"Your father has killed people for power", says the child of the elder brother.
Poor children, raised in a system where they are barred from questioning their own authoritative figure – therefore have to resort to accusations.
The fight however does not end there – both fathers take turns in showing off their power, completely ignoring the effects of their decisions.
One day, family members of the younger brother decided to protest the unilateral decision taken by the elder brother – they gather around the main gate effectively blocking the way. Children of both the brothers, many who had to leave the home on that day were faced with difficulties – but they silently accept their cursed fate.
The younger brother is still not satisfied. He wants to do something more concrete – then prevents family members from stepping outside their homes for a day, and instructs a few loyalists to enforce his decision. For his part, he takes a tour in his car around the neighbourhood, and enjoys the spectacle.
Yet again, members of both families were affected.
Then came the next day, the elder brother, who had been accusing the younger brother of inconveniencing other family members decides to put himself out there –just to see the kind of support he has.
A crowd gathers, and placing himself in the backdrop of an erstwhile patriarch – Nepal's monarch, he appeals directly to the public. Enjoying the spectacle, he declares himself the protector of the family – just like monarchs would do in the past.
Then comes today, there is another mass stage planned, and I, one of the member of the family, is highly inconvenienced, wondering how many hurdles I will have to face as I make my way around town to complete my tasks for the day.
All unwarranted.
All because the two patriarchs cannot come upon an agreement with each other – lacking complete accountability towards their family members.


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Local restaurants, wineries and micro brewers will be handing out generous samples of their signature dishes and spirits at the 10th Annual Barrington Taste'fest & EXPO next week on Thursday, Oct. 17.
Hosted by the Barrington Area Chamber of Commerce, this much-anticipated and popular dining event is the best way to sample foods from some of area's finest eateries all in one night and under one roof.
The 10th annual Taste'fest is taking place from 5:00 to 8:00 pm next Thursday, October 17th, at the Chicago Marriott Northwest in Hoffman Estates and the Chamber of Commerce just released the list of this year's participating restaurants which include…
Participating Taste'fest Restaurants
The Tilted Kilt
Cooper's Hawk Winery & Restaurant
Georgio's Chicago Pizzeria & Pub
Hawthorn Woods Golf Club, Pinstripes
PRP Wines
Meatheads Burgers & Fries
Stone Eagle Tavern
Francesca's Famiglia
Apple Villa Famous Pancake House
Wok 'n Fire; Blue Cherry Frozen Yogurt
Brunch Café
Fox & Hound Restaurant
Savory Salads
McGonigal's Pub
Chicago Northwest Marriott
Jewel-Osco; Pure Organic Juicery
Meals Like Mom's
Tastefully Simple
NEW THIS YEAR at the Barrington Area Taste'fest, several restaurants will also present cooking demonstrations throughout the evening including Frantonio's Italian Deli & Cafe, Hawthorn Woods Golf Club, Meals Like Mom's, Tastefully Simple and Pinstripes Bowling, Bocce and Bistro.
As you sample dishes, you will also have the opportunity to peruse displays set up by 40 Barrington area businesses there to answer questions and distribute items that showcase their products and services.
Guests will also take home souvenir photos from the photo booth (also new to this year's event), grab some fast cash in the Barrington Bank & Trust Money Machine, have a chance to win door prizes, raffles and games and enjoy live entertainment by the nationally renowned Amy Yassinger Jazz Ensemble.
Tickets cost $40 in advance and $50 at the door. They're on sale now, but selling fast!
To purchase tickets online, CLICK HERE.
You can also buy tickets during business hours at the Barrington Area Chamber of Commerce office, 190 James Street.
If you'd like to bring a group or your family and friends, you can buy nine tickets and get your tenth ticket free! The night out is a fun way to treat your business clients and prospects and it's also a great opportunity to make new business connections in a casual and social atmosphere.
The Chicago Marriott Northwest is at 4800 Hoffman Boulevard in Hoffman Estates.
Proceeds from Taste'fest & EXPO benefit local small businesses and the community through the Chamber's educational programs, networking groups, and business resources; and benefit the BACC's Lauren Brown Memorial Scholarship.
For more information, call the Barrington Area Chamber of Commerce at 847-381-2525 or visit their website at BarringtonChamber.com.


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Purpose of Review
Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.
Recent Findings
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise.
'Average surgical risk' patients with an asymptomatic carotid artery stenosis of 60–99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed 'high risk' for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.
Thromboembolic stroke is a major cause of morbidity and mortality in the United Kingdom (UK). It has been reported that, annually, more than 100,000 people have a stroke and 12.5% die within 30 days [1]. Strokes are the fourth largest cause of death and a substantial cause of disability in British adults [1]. In the recent Global Burden of Disease study, the number of global lost disability-adjusted life years (DALYs) due to cerebrovascular disease had increased by 18.9% from 1990 [2]. Indeed, by 2010, cerebrovascular disease was the third most common cause of lost DALY globally (compared to fifth most common in 1990) [2]. In the United States of America (USA) alone, strokes are the third most common cause of death, with atherosclerotic stenosis of the carotid artery implicated in 20–25% of all strokes [3]. Even when asymptomatic, stenosis of the carotid artery has been reported to place an individual at more than 3% increased risk of having a stroke in the next year (a greater than 50% increased relative risk) [4].
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are effective long-term stroke prevention strategies in symptomatic patients. However, uncertainty still remains regarding the optimal technique for long-term prevention of vascular events in asymptomatic patients and, indeed, whether either is sufficiently better than best medical therapy (BMT). This review article outlines the techniques of carotid intervention, presents the evidence for and against the use of CEA and CAS in stroke prevention in asymptomatic patients, summarises the role of BMT and highlights the current research focus in this important subject.
CEA: the Technique
CEA can be performed under local anaesthesia (LA) or under general anaesthesia (GA) with or without the use of a shunt. The General Anaesthesia versus Local Anaesthesia for Carotid surgery (GALA) trial reported no difference in stroke or mortality rates between the two types of anaesthesia in patients undergoing CEA [5]. The operation begins with an oblique incision, following the anterior border of the sternocleidomastoid muscle [6]. This is then retracted and the carotid bifurcation is dissected out. Heparin is administered intravenously and the internal, external and common carotid arteries are clamped [6]. A longitudinal arteriotomy is made, extending from the common carotid artery into the internal carotid artery [6]. The plaque is removed and the artery repaired. The repair may include either primary closure of the vessel or placement of a patch to widen the vessel or an eversion CEA may be performed [6]. Similar outcomes (relating to peri-operative major stroke and death rate) have been described between eversion and conventional CEA methods in the Eversion Carotid Endarterectomy versus Standard Trial (EVEREST) randomised clinical trial (RCT) [7]. The incidence of early carotid artery occlusion and re-stenosis at mean follow-up of 14.9 months was also similar between the two groups [7].
However, performing CEA also has local risks: cranial nerve injury, peri-operative myocardial infarction (MI) and post-operative haematoma are well-recognised potential complications [8]. Moreover, patients with concurrent coronary artery disease and contralateral carotid artery occlusion are considered high risk for CEA [9, 10]. Other factors that make CEA more technically difficult include a high carotid bifurcation, recurrent stenosis after previous CEA, contralateral cranial nerve palsies, radical neck dissection and previous radiation to the area [8]. In these patients, CAS may be a feasible alternative [11,12,13].
CAS: the Technique, Indications and Challenges
CAS is usually carried out under LA. A catheter is inserted percutaneously into the common femoral artery (or rarely via a brachial or even direct carotid access) and advanced until the common carotid artery is reached [6]. A guidewire is deployed across the stenosis so that a stent can be placed and a balloon may be used to expand the stent [6]. Embolic protection devices (EPDs) are often used to try to minimise embolisation of atherosclerotic material distal to the stenosis, preventing neurological ischaemia [6]. Carotid flow reversal can also be used to minimise the peri-procedural stroke risk.
CAS is less invasive than CEA and it may be performed in patients with co-morbidities that confer an unjustifiably high surgical risk for CEA whilst being able to potentially treat lesions that are inaccessible by surgery. However, various studies have shown that CAS may carry a higher stroke risk in symptomatic patients compared to asymptomatic patients [14, 15].
Registry data (as well as post hoc analysis of the RCTs comparing CAS and CEA in symptomatic patients) demonstrate that increased age is an independent predictor of poor outcome after CAS [15, 16]. This may be due to atherosclerotic disease being more advanced in old age, carotid vessels being more tortuous and plaques in the aortic arch being commoner. Engaging the common carotid artery may be technically challenging, causing distal embolisation of plaque and subsequent stroke or death.
Similarly to CEA, a learning curve also exists in acquiring the skills necessary to perform CAS. The Pro-CAS registry demonstrated a positive volume-outcome relationship: in centres performing less than 50 CAS procedures per year, the stroke or death rate was higher (at 5.9%) compared with centres performing more than 150 CAS procedures per year, whose stroke or death rate was 3.0% [14]. A similar relationship was demonstrated in the Stent-Protected Angioplasty versus Carotid Endarterectomy-1 (SPACE-1) study: centres performing less than 50 CAS procedures per year had a stroke or mortality rate of 4.6% whereas it was 2.9% in centres performing more than 50 CAS procedures per year [17]. This was also supported by the Carotid Stenting Trialists' Collaboration (CSTC) who pooled data from three randomised trials: the Endarterectomy Versus Angioplasty in patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the aforementioned SPACE-1 trial and the International Carotid Stenting Study (ICSS) [18,19,20,21]. The CSTC group reported that the 30-day risk of stroke or death was not related to operator lifetime experience but it was higher in patients treated by interventionalists who performed less than 6 CAS procedures per annum [18].
CEA in Asymptomatic Patients: the Evidence
Major RCTs comparing CEA versus BMT in asymptomatic patients are the Veterans Affairs (VA) Cooperative Study, the Asymptomatic Carotid Atherosclerosis Trial (ACAS) and the Asymptomatic Carotid Surgery Trial-1 (ACST-1), randomising patients between the 1980s and early 2000s [22,23,24]. The VA study (n = 444) reported an absolute risk reduction (ARR) in ipsilateral neurological events of 12.6% after CEA compared to BMT (8.0% versus 20.6% respectively; p < 0.01), in patients with a mean follow-up of almost 4 years [22]. However, there was no difference in the combined endpoint of stroke and death [22]. The ACAS study (n = 1662) reported that CEA reduced the 5-year risk of the combined endpoint of ipsilateral stroke and any peri-operative stroke or death by 53% compared to BMT (5.1% versus 11.0% respectively; p = 0.004) [23]. The ACST-1 (n = 3120) reported an ARR in stroke risk (when including peri-operative risks) of 4.1% at 5 years (CEA 6.9%, BMT 10.9%; p = 0.0001) and 4.6% at 10 years (CEA 13.4%, BMT 17.9%; p = 0.009) [24, 25]. This reduction in stroke risk was slightly improved when peri-operative events were excluded and half the reduction was in disabling and fatal strokes [25]. However, effective BMT was not available when these RCTs were undertaken.
The main findings of the above RCTs are summarised in Table 1.
CAS in Asymptomatic Patients: the Evidence
Unfortunately, the RCTs carried out comparing CEA with CAS have produced unreliable results due to heterogeneous patient populations, different endpoints being used, a variety of endovascular devices being used, varying use of EPDs between studies and varied endovascular experience of interventionalists participating in the RCTs.
The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial compared CAS with CEA in 334 patients at high operative risk [26]. This RCT included both symptomatic (n = 97) and asymptomatic (n = 237) patients [26]. Overall, there was no statistically significant difference in the composite endpoint of death, stroke or MI at 30 days with fewer CAS patients receiving re-intervention at 1 year than those undergoing CEA [26]. In asymptomatic patients specifically, the cumulative incidence of death, stroke or MI at 30 days was 5.4% for those receiving CAS and 10.2% undergoing CEA (p = 0.20) [26]. The equivalent outcome at 1 year was 9.9% in the CAS group and 21.5% in the CEA group and was statistically significant (p = 0.02) [26]. This is likely to be explained by the SAPPHIRE population having greater co-morbidities (75.5% of patients undergoing CEA had coronary artery disease), leading to a significantly higher rate of MI in the CEA compared to the CAS group (p = 0.03) [26]. At 3 years, stroke rates were comparable between asymptomatic patients undergoing CEA and CAS (9.2 and 10.3% respectively) whilst the combined endpoint of death, stroke or MI was also similar (29.2% versus 21.4% respectively) [27].
The Carotid Revascularisation Endarterectomy versus Stenting Trial-1 (CREST-1) was a large multicentre RCT, including 1321 symptomatic and 1181 asymptomatic patients [28]. Each surgeon and interventionalist was required to meet a minimum set of standards for experience and performance whilst EPDs were used in 96.1% of patients [28]. Overall, there was no statistically significant difference in the rates of the combined endpoint of stroke, MI or death within 30 days between CAS and CEA [28]. In asymptomatic patients, the combined endpoint at 30 days was 3.5% after CAS and 3.6% following CEA (hazard ratio (HR) 1.02 (0.55–1.86); p = 0.96) [28]. The peri-procedural stroke rate in asymptomatic patients undergoing CEA and CAS was 1.4% and 2.5% respectively (HR 1.88 (0.79–4.42); p = 0.15) [28]. Whilst the overall peri-procedural incidence of stroke or death was statistically significantly higher after CAS than after CEA in symptomatic patients (p = 0.02), this was not statistically significant for asymptomatic patients (p = 0.15) [28]. There were also more MIs following CEA in symptomatic than asymptomatic patients [28]. At 2 years, there was no statistically significant difference in the composite outcome of re-stenosis or re-occlusion and, at 4 years, there was no difference in ipsilateral stroke or death rate between CAS and CEA groups [28]. In asymptomatic patients specifically, the 4-year rate of stroke or death was 4.5% after CAS and 2.7% following CEA (p = 0.07) [28]. By 5 years, the rate of stroke in asymptomatic patients was 2.5% after CAS and 2.7% following CEA [29••]. Increased age, female sex, hypertension, diabetes and dyslipidaemia were independent predictors of re-stenosis or re-occlusion at 2 years after CAS whilst smoking was statistically significantly associated with re-stenosis after CEA [30]. At 10 years of follow-up, there was no statistically significant difference in the composite endpoint of stroke, MI or death and subsequent ipsilateral stroke between CAS and CEA groups in either symptomatic or asymptomatic subgroups [29••]. In asymptomatic patients, the rates of post-procedural ipsilateral strokes were similar at 5 and 10 years, regardless of the modality of revascularisation used [29••]. Therefore, symptom status may predict peri-procedural risk of complications but does not appear to be relevant in the long term.
The Asymptomatic Carotid Trial-1 (ACT-1) reported that CAS was non-inferior to CEA with regard to the composite endpoint of death, stroke or MI within 30 days of the procedure in 1453 asymptomatic patients with severe carotid artery stenosis (3.3% versus 2.6% respectively; p = 0.60) [31••]. Peri-procedural death was equivalent between CAS and CEA groups (0.1% versus 0.3% respectively; p = 0.60), as was peri-procedural MI (0.5% versus 0.9% respectively; p = 0.41) [31••]. CEA halved the risk of peri-procedural stroke compared to CAS, though this was not statistically significant (1.4% versus 2.8% respectively; p = 0.23) [31••]. By 1-year follow-up, 3.8% of patients receiving CAS and 3.4% of patients undergoing CEA had died or experienced a stroke or MI and, by 5 years, the ipsilateral stroke rate was 2.2% after CAS and 2.7% following CEA (p = 0.51) [31••]. This RCT reported its findings recently and broadly supports the findings of CREST-1. However, its results may not be fully generalisable to contemporary practise as they only used one type of stent and EPD [28].
The main findings of the above RCTs are summarised in Table 2.
BMT in Asymptomatic Patients: Recommendations
Many RCTs listed above were carried out before the advancement of modern medical therapies (e.g. widespread prescribing of statins) and, as such, it is unclear what effect this might have on outcomes. Most patients with carotid artery stenosis today should be prescribed a statin, anti-platelet agent and a blood pressure-modifying agent [32••]. However, in the early years of recruitment in the ACST-1, less than 10% of patients were taking lipid-lowering therapy at baseline [25]. This increased to 80% by the end of follow-up [25]. This could have potentially confounded outcomes as it has been demonstrated that a 1-mmol L−1 reduction in low-density lipoprotein (LDL) cholesterol reduces the 5-year risk of stroke by approximately 25% [33,34,35]. This might explain why statin use was associated with a halving of the risk of stroke following CEA in the ACST-1 [24, 25]. However, irrespective of statin use, CEA still halved the stroke rate in the ACST-1 [24, 25].
The recent guidelines published by the European Society for Vascular Surgery (ESVS) in 2018 recommend that a healthy diet, smoking cessation and physical activity should all be instituted for risk factor reduction in patients with known asymptomatic carotid artery stenosis [36••]. Low-dose aspirin was also recommended as the anti-platelet agent of choice despite a lack of adequately powered studies (with insufficient follow-up) showing benefits of anti-platelet agents in patients with asymptomatic carotid artery stenosis and conflicting results reported in RCTs [37, 38, 39••, 40]. Patients who are intolerant of aspirin should be prescribed clopidogrel instead [36••]. Anti-platelet therapy should be used peri-procedurally and long-term following both CEA and CAS, with dual anti-platelet therapy recommended for at least 1 month post-CAS [36••].
Lipid-lowering therapy in the form of statins has also been recommended for long-term prevention of cardiovascular disease in asymptomatic patients [36••]. This is evidence-based as a Cochrane review demonstrated a significant reduction in all-cause mortality, fatal/non-fatal strokes and revascularisation in patients randomised to statins [41]. The pharmacological agents that have been widely prescribed in RCTs are atorvastatin and rosuvastatin and attempts should be made to achieve targets of either a 50% reduction in LDL cholesterol or a level less than 1.8 mmol L−1 (70 mg dL−1) [42,43,44].
Whilst the effect of anti-hypertensive therapy on stroke prevention in patients with asymptomatic carotid artery stenosis has not been formally evaluated, treatment of high blood pressure is associated with reduction and regression of carotid artery stenoses [45]. Indeed, a meta-analysis demonstrated a reduction in stroke risk that was proportional to lowering of systolic blood pressure and a Chinese RCT reported reduced stroke risk associated with use of enalapril [46, 47•]. In reality, the type of pharmacological agent used is less important than achieving the target of reducing blood pressure below 140/90 mm Hg in non-diabetic patients with asymptomatic carotid artery stenosis [48]. Blood pressure should be maintained below 180/90 mm Hg peri-procedurally following CEA and CAS [36••].
In diabetic patients with asymptomatic carotid artery stenosis, tight glycaemic control is recommended as these patients are at increased risk of stroke [49]. Therefore, it is important that risk factor reduction and BMT is appropriately prescribed in diabetic patients. In a study of type II diabetes patients, the use of lipid-lowering therapy, anti-platelet agents and anti-hypertensive medications was associated with a 60% reduction in cardiovascular events and deaths [50]. Moreover, the UK Prospective Diabetes Study reported that intensive blood pressure control in diabetic patients reduced the relative risk of stroke by 44% compared to patients with a higher blood pressure [51]. The joint European Society for Hypertension/European Society of Cardiology guidelines (2013) recommend that the target blood pressure in diabetic patients with asymptomatic carotid artery stenosis should be less than 140/85 mm Hg [52].
Other Considerations
Carotid intervention is now much safer than at any time in the past with CEA outcomes significantly improved when patients are operated on by vascular surgeons compared with cardiothoracic surgeons, general surgeons or neurosurgeons [53,54,55, 56•, 57,58,59]. This might simply reflect that vascular surgeons perform CEAs more frequently than other specialists and are more familiar with the operation. This positive volume-outcome relationship in CEA has been proven to reduce both mortality and combined mortality/stroke [60•]. This trend of sub-specialisation has not been reflected when vascular surgeons, interventional radiologists, neurosurgeons and interventional neuroradiologists performed CAS in the CREST-1 [28]. This was shown to affect outcomes, with vascular surgeons and interventional radiologists having worse CAS outcomes than interventional neuroradiologists or interventional cardiologists [61]. This may reflect the varying complexity of cases referred to each specialty or the lack of experience with catheter-based procedures in some specialties at the time of the CREST-1. By contrast, the ACAS employed such strict credentialing that 40% of all applicants were rejected from participating in the RCT due to an unfavourable safety record [23]. So, these RCT findings may not be generalisable to contemporaneous practise.
Use of EPDs may reduce the peri-procedural stroke rate following CAS. A systematic review reported a reduced 30-day death or stroke rate from 5.5 to 1.8% in patients undergoing CAS without and with EPDs respectively [62]. Data from a large registry have also confirmed the finding that EPDs reduce the death or stroke rate in patients undergoing CAS, with the use of EPDs being an independent protective factor [63]. Varying use of EPDs in the RCTs, in contrast to modern practise, must be taken into account when interpreting findings.
Novel medical therapies may also show benefit in reducing the long-term stroke risk in asymptomatic patients. A subgroup analysis of the recently completed Cardiovascular Outcomes for People using Anticoagulation Strategies (COMPASS) RCT showed that addition of low-dose rivaroxaban to aspirin (in 1919 patients with previous carotid artery revascularisation or asymptomatic carotid artery stenosis of at least 50%) reduced the overall major adverse cardiovascular event rate (HR 0.63 (0.38–1.05; p = 0.07) [64••]. This was not at the expense of an increased bleeding risk [64••]. Therefore, whilst this subgroup analysis was inadequately powered to provide meaningful conclusions, larger RCTs may reveal a significant effect of adding low-dose rivaroxaban to aspirin in long-term stroke prevention.
Conclusions and Future Perspectives
It is clear that both CEA and CAS reduce the long-term stroke risk in asymptomatic patients. With regard to peri-procedural outcomes, a recent meta-analysis of 3901 asymptomatic patients randomly assigned to CEA (n = 1585) or CAS (n = 2316) reported that CAS was associated with a significantly higher risk of peri-procedural stroke than CEA (2.6% versus 1.3% respectively; p = 0.04) [65••]. This was largely driven by more minor strokes following CAS than CEA (2.2% versus 1.0%; p = 0.05) [65••]. Rates of death, major stroke, ipsilateral stroke and MI were comparable between CEA and CAS [65••].
ESVS guidelines (2018) therefore recommend that patients with an 'average surgical risk' and an asymptomatic carotid artery stenosis of 60–99% should be considered for CEA only in the presence of one or more characteristics that may be associated with an increased risk of late ipsilateral stroke [36••]. According to this guideline, imaging/clinical criteria that might confer an increased risk of stroke on BMT include silent infarction on computerised tomography, stenosis progression, large plaque area, plaque echolucency, intra-plaque haemorrhage on magnetic resonance imaging, impaired cerebral vasoreactivity, spontaneous embolisation on transcranial Doppler ultrasound and/or history of contralateral transient ischaemic attack [36••]. CAS is also a feasible alternative in these patients [36••]. However, in selected patients who are deemed 'high risk' for surgery with an asymptomatic carotid artery stenosis of 60–99%, CAS is indicated [36••]. Again, these patients must be deemed at increased risk of late ipsilateral stroke [36••]. Requirement for any intervention is a documented peri-procedural risk of stroke/death of less than 3% and the patient must have a life expectancy exceeding 5 years [36••]. These recommendations have also been supported by the European Society of Cardiology, who have reduced their threshold of acceptable complication rates following CEA and CAS from 6 to 3%, in line with the ESVS guidelines [44, 66••].
However, these guidelines are based on RCT findings which, due to the antiquated nature of the BMT and interventional techniques used, may not be generalisable to contemporary practise. There is therefore uncertainty regarding which technique is superior or, indeed, if advancements in BMT have replaced the need for performing carotid interventions.
In order to address this important issue, the Stent-protected Angioplasty in Asymptomatic Carotid Artery Stenosis versus Carotid Endarterectomy-2 (SPACE-2) trial was designed to compare BMT alone versus BMT with CEA versus BMT with CAS in asymptomatic patients. Unfortunately, however, due to slow recruitment of patients, the RCT was modified to compare BMT alone versus BMT with CEA and BMT alone versus BMT with CAS, with the initial results recently being reported [67••]. In 513 asymptomatic patients, there were no peri-procedural deaths recorded following CEA or CAS [67••]. This is the first RCT to report no peri-procedural deaths following CEA and CAS [67••]. There were also no deaths or strokes within 30 days of patients being randomised to BMT whilst the combined peri-procedural stroke and death rate was 2.0% after CEA and 2.5% following CAS [67••]. These results, whilst promising, have wide confidence intervals due to the small sample size and suggest a 'missed opportunity' to clarify uncertainty in this important subject. Long-term outcomes are awaited.
Ongoing RCTs such as the Carotid Revascularisation and Medical Management for Asymptomatic Carotid Stenosis trial (CREST-2) and the European Carotid Surgery Trial (ECST-2) will compare both CAS (with use of EPDs) and CEA with medical management in asymptomatic patients with severe carotid artery stenosis whilst the Endarterectomy Combined with Optimal Medical Therapy (OMT) versus OMT Alone in Patients With Asymptomatic Severe Atherosclerotic Carotid Artery Stenosis at Higher-than-average Risk of Ipsilateral Stroke (ACTRIS) trial will compare CEA, in conjunction with BMT, versus BMT alone [68••, 69••].
The Asymptomatic Carotid Surgery Trial-2 (ACST-2) will compare CAS with CEA for long-term stroke prevention in asymptomatic patients with severe carotid artery stenosis on BMT [70]. The ACST-2, due to complete recruitment by the end of 2019, is the largest RCT ever conducted comparing CAS with CEA and should provide reliable evidence as it is being conducted internationally with experienced collaborators and high-quality BMT in addition to modern carotid revascularisation strategies [70].
The results of these RCTs are eagerly anticipated and awaited in the 2020s as they will provide clarity, in a large number of patients (whilst also providing an opportunity for meta-analysis), regarding the effect of the increased use of statins, new stent designs and safer CAS techniques compared with CEA and BMT to better inform the management of patients with asymptomatic carotid artery stenosis.
Asymptomatic Carotid Atherosclerosis Trial
Asymptomatic Carotid Surgery Trial
Asymptomatic Carotid Trial
Endarterectomy Combined with Optimal Medical Therapy (OMT) versus OMT Alone in Patients With Asymptomatic Severe Atherosclerotic Carotid Artery Stenosis at Higher-than-average Risk of Ipsilateral Stroke
absolute risk reduction
best medical therapy
carotid artery stenting
carotid endarterectomy
Cardiovascular Outcomes for People using Anticoagulation Strategies
Carotid Revascularisation Endarterectomy versus Stenting Trial
Carotid Stenting Trialists' Collaboration
disability-adjusted life year
European Carotid Surgery Trial
embolic protection device
European Society for Vascular Surgery
Endarterectomy Versus Angioplasty in patients with Symptomatic Severe Carotid Stenosis
Eversion Carotid Endarterectomy versus Standard Trial
general anaesthesia
General Anaesthesia versus Local Anaesthesia for Carotid surgery
International Carotid Stenting Study
local anaesthesia
low-density lipoprotein
myocardial infarction
optimal medical therapy
randomised clinical trial
Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy
Stent-Protected Angioplasty versus Carotid Endarterectomy
United Kingdom
United States of America
Veterans Affairs
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Kamran Gaba received a grant from the Medical Research Council, during the conduct of the study. Peter Ringleb reports personal fees from Boehringer Ingelheim, personal fees from Bayer and personal fees from Pfizer, outside the submitted work. Alison Halliday declares no potential conflict of interest.
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Gaba, K., Ringleb, P.A. & Halliday, A. Asymptomatic Carotid Stenosis: Intervention or Best Medical Therapy?. Curr Neurol Neurosci Rep 18, 80 (2018). https://doi.org/10.1007/s11910-018-0888-5
DOI: https://doi.org/10.1007/s11910-018-0888-5
- Carotid endarterectomy
- Carotid artery stenting
- Best medical therapy
- Asymptomatic
- Carotid artery stenosis