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Mitral regurgitation (MR) is the second most common form of valvular disease requiring surgery. Correct identification of surgical candidates and optimising the timing of surgery are key in management. For primary MR, this relies upon a balance between the peri-operative risks and rates of successful repair in patients undergoing early surgery when asymptomatic with the potential risk of irreversible left ventricular dysfunction if intervention is performed too late. For secondary MR, recognition that this is a highly dynamic condition where MR severity may change is key, although data on outcomes in determining whether concomitant valve intervention is performed with revascularisation has raised questions regarding timing of surgery. There has been substantial interest in the use of stress echocardiography to risk stratify patients in mitral regurgitation. This article reviews the role of stress echocardiography in both primary and secondary mitral regurgitation and discusses how this can help clinicians tackle the challenges of this prevalent condition.
Mitral regurgitation (MR) is the second most common type of valve disease requiring surgery in Europe (1). Despite a reduction in the incidence of rheumatic heart disease, the frequency of MR is increasing due to an ageing population (2). Improvements in the diagnosis, quantification and operative techniques for mitral valve (MV) repair now allow the restoration of normal life expectancy after surgery (3). The timing and type of surgery depend upon a number of factors, one of the most important being whether the MR is primary or secondary (Videos 1 and 2). The balance in each case then lies between facing the risks of early surgery and risking left ventricular (LV) dysfunction if intervention is performed too late. In addition, consideration has to be given to the risk of mitral valve replacement in case of immediate failure of repair and the risk of re-intervention in the situation of late failure of repair. Unfortunately, a significant proportion of those with severe MR who have apparently normal LV function pre-operatively (LVEF >60%) continue to present post-operatively with reduced ejection fraction and congestive cardiac failure (4). This article outlines the discussion surrounding the timing of surgery and highlights the importance of exercise stress echocardiography in the management of primary and secondary MR.
Controversy in the timing of surgery for primary MR
Class 1 indications for surgery in primary MR have been unchanged for many years (5). In recent years, this 'conventional' approach has been challenged by advocates for early MV repair who have come to regard standard class I triggers such as heart failure and LV dysfunction as promoting 'rescue surgery' (6). Data to support this view originated in operative series from the 1980s, which highlighted improved surgical outcomes in patients operated with NYHA class I–II rather than NYHA III–IV symptoms (3). In the modern era, several observational series have consistently demonstrated adverse outcomes for each of the individual components of the current class I surgical indications. In a prospective surgical series of 840 patients with MR amenable to repair, worsening NYHA classification was associated with a stepwise reduction in late survival rates 20 years after surgery (7). In a retrospective case registry, mortality was increased by 80% at 10-year follow-up once EF had fallen to 50–59% compared with those in whom LVEF remained above 60% (8). Furthermore, LV dilatation above 40 mm in end-systole in primary MR predicted excess mortality and was an independent predictor of permanent post op LV dysfunction (9). Summarising the risks of delay to repair, a retrospective of 1512 patients undergoing isolated primary MR at the Rochester Mayo clinic between 1990 and 2000 found long-term survival at 15 years was only 42 ± 2% for patients with a class I indication, compared with 53 ± 4% for those with a class II surgical indication including presence of atrial fibrillation or pulmonary hypertension, with the highest survival (70 ± 3%) observed in subjects receiving early operation based on the presence of a high probability of successful repair. Furthermore, operative mortality was only documented in those with a class I indication for surgery (6). These data have led authors to suggest that current class 1 recommendations are criteria that do not promote optimal outcomes for patients with severe primary MR.
Outcomes of mitral repair in primary MR
Registry studies have established that the results of MV repair are superior to replacement, even in the elderly (10). Prosthetic valve replacement is associated with higher operative mortality, reduced life expectancy, higher long-term risk of stroke and complications specific to valve replacement such as valve thrombosis and structural valve degeneration (11). If repair can be successfully performed before the onset of advanced symptoms, data from expert centres report equivalent long-term outcomes to age- and gender-matched controls at >20-year follow-up (7). Both prospective and registry data support early repair before class 1 indications are reached. A single-centre prospective study of 610 consecutive patients with asymptomatic severe MR diagnosed with quantitative echocardiography compared outcomes between those referred for early surgery (235 patients; 94% repair rate) and those referred with conventional class 1 indications (375 patients; 82% repair rate), with the decision made at the discretion of the referrer. At a follow-up of 12 years, the early surgery group had significantly lower cardiac mortality (HR 0.109; 95% confidence interval (CI) 0.014–0.836; P = 0.033) and cardiac event rates (HR 0.216; 95% CI 0.083–0.558; P = 0.002) (12). The multi-centre, multi-national Mitral Regurgitation International Database included 2097 consecutive patients with primary MR due to flail segments and found improved survival at 10 years with lower rates of heart failure for those proceeding with early mitral repair compared with those managed medically until class 1 guidelines were triggered (13).
Mitral repair as a class 2A indication for surgery
Given the consistency of these data, why do current guidelines (5) not emphasise the importance of earlier repair for all patients with severe, degenerative MR? First, the data supporting early surgery are mostly from single-centre, non-randomised studies and many findings are from retrospective registries. These have tended to be high-volume centres with specialised, experienced surgeons performing large numbers of MV repairs. Such data on rates of repair and lower perioperative morbidity and mortality cannot always be extrapolated to lower-volume centres (14, 15). Randomised prospective studies in mixed populations are lacking; however, trials are under way (16). Secondly, the benefits of such long-term outcomes are mainly reserved for those with primary degenerative disease (Carpentier mechanism type II) and outcomes are less consistent for other causes, including rheumatic disease (17). Thirdly, it can be more difficult to persuade an asymptomatic patient in clinic to undergo major cardiothoracic surgery – by definition, prophylactic surgery in asymptomatic individuals does not improve how they feel (although this is not an issue in conditions when mortality benefit is clear, for example aortic aneurysm surgery). Finally, there are also data that suggest careful outpatient care may deliver outcomes that are as good. In a study of 132 consecutive patients with asymptomatic severe MR, a programme of annual review with referral based on class 1 indications also delivered outcomes equivalent to the general population over a follow-up period of 62 ± 26 months – but with the added advantage that 55 ± 6% of the population were able to avoid surgery completely at 8-year follow-up without complication (18). Of equal importance was that surgical outcomes were also excellent, with no compromise in symptomatic status or LV outcome from delay.
Moreover, referral for early surgery may often not be a straightforward decision – even with quantitative echocardiography, grading severe MR is subject to significant variation between operators (19). When severe MR is confirmed, the ability to identify a reparable MV is not perfect. Although in the US there has been a significant improvement in rate of repair with promotion of the 'mitral valve surgeon' and discouragement of lower volume centres so that repair is performed in excess of 90% cases (20), this is not universal across all surgeons and in all countries. In the randomised prospective study of Kang and coworkers, recruiting only those with presumed reparable valves, repair was actually carried out in 94% (12). In the UK, audit data from the National Institute for Cardiovascular Outcomes Research (NICOR) identified that 1558 isolated first-time MV repairs were carried out in 2013, compared with 789 isolated MV replacements. The 1-year and 5-year mortality rates for isolated MV repair in 2013 were 1.1% and 11% respectively, but double for MV replacement at 2.4% and 20% (21). Such diverse surgical practice is of major concern, especially when considering the higher mortality and morbidity with MV replacement compared with MV repair and has prompted a call for defined centres of excellence for mitral valve repair in the UK with the presence of a dedicated heart valve team (22). Finally, MV repair is not risk free. In the UK, NICOR data reported mortality in 2013 for the first time, isolated MV repair at 1.09% and 2.79% when combined with coronary artery bypass grafting (CABG) (21). Furthermore, although actual survival far exceeds expected outcomes (5.19%), MR can still recur after repair. In the most recent series, rates of recurrent MR were 13.3 + 1.2% patients at 15-year follow-up, with a reoperation rate of 6.9 + 1.0% (23). Although serial data from this study suggest that rates of late failure are falling, possibly as a result of technical improvements such as routine use of ring annuloplasty and peri-operative 3D transoesophageal echocardiography, recurrence of MR after MV repair is associated with adverse LV remodelling and increased risk of death (23). For an asymptomatic patient to run this risk, there has to be certainty for that person that his or her own operative risk is low, that valve repair will be durable and that their own life expectancy will be long enough to benefit in the long term from any prognostic gain.
Stress echocardiography: improving risk stratification in primary MR
In addition to markers of adverse outcome that include the onset of atrial fibrillation (24), pulmonary hypertension (6) and left atrial dilatation (25), objective testing of symptom status is a critical step in decision making. Studies in those with severe aortic stenosis have emphasised that patients often minimise their symptoms by avoiding exercise and that objective testing may reveal limitations unsuspected on history alone. Similarly, in severe 'asymptomatic' MR, 20% have a sub-maximal functional capacity on cardiopulmonary exercise testing (26). Event-free survival is lower in those asymptomatic patients with severe primary MR who have a reduced exercise capacity despite good LV function and normal LV dimensions (27). In a large study of 884 consecutive patients undergoing exercise stress echocardiography, exercise capacity (lower than 100% age/sex predicted metabolic equivalents (METs) achieved), heart rate recovery (HRR, <18 beats within 1 min after exercise) after stress- and exercise-induced atrial fibrillation were strong independent markers of adverse outcome in primary MR (28). These data emphasise the importance of monitoring apparently asymptomatic patients using a regular exercise test to provide objective assessment of symptom status. In those with no exercise limitation according to age- and gender-based predicted metabolic equivalents, delay in surgery does not impair outcome at one year (29).
If echocardiography is added to the exercise test, what further information can be gleaned? First, a change in severity of primary MR with exercise is common and occurs in over 30% of those with asymptomatic moderate-to-severe MR (Fig. 1A and B) (30). From a small study of 61 asymptomatic patients, those who have an increase in effective regurgitant orifice area (EROA) of more than 10 mm2 during exercise have a lower symptom-free survival compared with those with no change. Secondly, patients with moderate-to-severe MR who develop pulmonary hypertension above 60 mmHg on exercise are at greater risk of symptoms and adverse outcomes (Fig. 2A and B) (30, 31). Thirdly, an assessment of LV function during stress echocardiography can also be an important marker of post-operative outcome. The onset of symptoms is not only governed by severity of MR and its effect on pulmonary pressure but also on the capacity of the LV to respond to volume-loading. Resting LV ejection fraction can be a poor marker of myocardial contractility as over a third of patients with a 'normal' pre-operative EF >60%, develop LV dysfunction below 50% after successful mitral repair (4). Latent contractile dysfunction can be predicted by measuring a systolic tissue velocity (<10.5 cm/s at rest) (Video 3 and Fig. 3) (32) and by quantifying global longitudinal strain (<−20%) (33). Improved outcomes can also be predicted by the LV response to exercise. In 71 consecutive asymptomatic patients with isolated moderate-to-severe primary MR, those in whom the LVEF failed to increase by ≥4%, had poorer symptom-free survival and worse outcomes after MV surgery (34). Similarly, a failure in global longitudinal strain to improve by ≥2% with exercise (Videos 4 and 5) appears to be a more sensitive marker of latent contractile dysfunction when indexing strain to end-systolic volume (35).
Why does primary MR worsen during exercise?
It has been suggested that exercise promotes an increase in systolic blood pressure, but pressure increase alone should not have a major impact on regurgitation without increase in regurgitant orifice as well as flow varies only with the square root of the pressure change between the LV and atrium (30). It is more likely that this may be due to changes in LV and annular geometry (36). Exercise-associated reduction in end-systolic volume could redefine the relationship between the papillary muscles and the zone of apposition of the leaflets (37). A further possibility is that the repetitive prolapse of a degenerate MV leads to papillary muscle traction, resulting in the fibrosis that has been documented on late enhancement with cardiovascular magnetic resonance imaging (Fig. 4) (38). Fibrosis in turn could promote a failure of the papillary muscles to respond to exercise, resulting in additional MR, a possibility suggested by differences in papillary muscle velocity and excursion in those with prolapse (39). These factors require further investigation as an understanding of the mechanisms of exercise-related MR may in turn further define those valves that need early repair.
Current indicators for stress echocardiography in primary MR
Current US guidelines support the use of exercise testing in the assessment of patients with asymptomatic severe valvular heart disease to help identify those with latent symptoms and to clarify prognosis (40). European guidelines support the addition of echocardiography to exercise stress testing in experienced hands for the assessment of patients whose symptoms or LV dysfunction appear disproportionate to the severity of MR at rest (5, 41). In the future, use of stress may be more widespread because it is possible that careful assessment of the patient with asymptomatic severe MR with normal cavity dimensions and good LV function may define two groups of patients – (1) those who have a good prognosis who can avoid surgery despite having a repairable valve and (2) those who are more likely to progress to symptoms and LV dysfunction who need surgery earlier. Unfortunately, there are as yet no randomised data that compare the outcome of such a strategy.
Secondary MR
Secondary MR is a dynamic condition where the degree of MR at rest does not predict the degree of MR on exertion. In a study of 70 consecutive patients with ischaemic LV dysfunction, MR decreased in 13 (19%), increased by less than 13 mm2 when measured by effective regurgitant orifice area (EROA) in 38 (54%) and increased more than this in the remaining 19 patients (42). The primary determinants of exercise-related deterioration in MR appear to be systolic annular area, degree of tenting of the valve and the associated wall motion abnormalities (42). These are dependent on the extent of ischaemic damage, exercise-induced dyssynchrony and the presence or absence of viability within the myocardium and papillary muscles; indeed, the severity of MR may reduce in patients with viable myocardium due to myocardial recruitment (43, 44, 45). Whether secondary MR improves or deteriorates on exercise is important as an increase in severity of MR with exercise by EROA ≥13 mm2 is associated with a five-fold increased risk of subsequent cardiac death (46). These and other data have led to support for the role of stress echocardiography in the investigation of patients with shortness of breath on exertion but who have less than severe secondary MR at rest. As yet, however, the role of stress echocardiography in the timing of mitral valve surgery in secondary MR remains controversial. In part, this is due to the lack of data, but in addition, it is not yet clear how best to manage patients with secondary MR.
Timing of surgery in chronic secondary MR
Secondary (ischaemic) MR is usually defined as the presence of MR either at rest or on exertion present more than 2 weeks after myocardial infarction. Although the frequency with which MR is detected may vary according to the method of imaging and the time at which this is carried out after MI, the presence of secondary MR confers a graded inverse relationship with risk of cardiovascular deaths (RR 1.88, 95% CI 1.23–2.86). Even those with mild ischaemic MR have a significantly worse survival (47). Although either the presence of MR and/or deterioration after exercise identifies a group of patients at particularly high risk, there continues to be controversy over whether surgical correction improves either life expectancy or quality of life (48). MV repair plus CABG was found to improve NYHA class, oxygen consumption on exercise testing and end-systolic volume index compared with CABG alone in a multi-centre study randomising 73 moderate MR patients, although mortality rates were similar in both groups (49). A similar finding was noted in a trial of 102 patients with an improvement in NYHA class after combined CABG and MV repair (50). In contrast, a further randomised study of 301 patients did not demonstrate concomitant MV repair led to any improvements in LV remodelling at 2-year follow-up but instead was associated with longer bypass time, hospital stay and more neurological events (48, 51). There is also controversy over whether MV repair or MV replacement produces the better outcome, with no apparent difference in end-systolic volume or mortality between approaches but less recurrent MR with replacement (52). These studies have generated a debate on whether secondary MR is only a marker of poor LV function rather than independently contributing to adverse outcome (53). Despite the inconsistency of evidence, it remains a class 2A indication to include MV repair at the time of CABG if MR is severe, whereas repair or replacement may be considered only if patients are severely symptomatic despite optimal medical therapy (class 2B) (40).
Stress echocardiography in secondary MR?
Although secondary MR may vary during exercise and diagnosis is associated with outcome, the question arises as to whether stress echocardiography could play a role in clarifying treatment strategy in symptomatic patients. In clinical practice, the main potential appears to be in two groups of patients. First, there are those whose symptoms of breathlessness appear to be disproportionate to the extent of LV impairment or the severity of MR. Exercise echocardiography can be used both to confirm objectively the extent of physical limitation (54), together with an imaging strategy that can define the extent of resting LV impairment, presence of ischaemia, development of dyssynchrony and alteration in the degree of MR during stress (5, 40, 42, 43). Secondly, the degree of secondary MR that is considered significant is relatively minor (EROA ≤13 mm2). In those in whom there is discussion as to whether percutaneous or surgical revascularisation should occur, demonstration of a significant exercise-related change in severity of MR or pulmonary hypertension would perhaps support surgery in those with symptoms (55). The limitation once again is that this diagnostic and intervention strategy is based on single-centre, non-randomised studies and large scale, randomised data are needed.
Performing stress echocardiography in mitral regurgitation
Stress echocardiography in MR should be preceded by a full transthoracic echocardiogram. This baseline echocardiogram should include an assessment of LV volumes and function, wall motion, aortic root, assessment of right ventricular dimensions and function, pulmonary pressure and assessment of all valves.
Most published studies have used upright or semi-supine bicycle exercise as the stressor because this permits continuous imaging at all stages of exercise. MR tends to resolve rapidly with rest, so that although treadmill exercise is useful for assessing symptoms and ischaemia, it is less so for quantifying change in MR. Moreover, bicycle stress provides more isometric stress than aerobic exercise, which may be more useful in evaluating MR. Usually, patients are asked to maintain a cadence of around 60/min with increments in workload of 25 W made at 2-min intervals, although protocols can be altered to younger patients using higher load (56). Data to be acquired are listed in Table 1 with a standard MR exercise echocardiography protocol shown in Fig. 5, illustrating the typical sequence of data acquisition. This generic protocol can of course be modified if there is a specific clinical question – such as more emphasis on LV function if there is an interest in LV viability. It is also useful to be aware of some of the limitations of quantitative echocardiography in MR, specifically the proximal isovelocity surface area (PISA) method for calculation of effective regurgitant orifice. First, the configuration or shape of PISA changes as the aliasing velocity changes – the convergence zone is flatter with higher aliasing velocities and becomes more elliptical with lower aliasing velocities. Secondly, the regurgitant orifice may vary during the cardiac cycle, occurring for example in the latter half of systole in MV prolapse. Colour M-mode can be used to assess variation during the cardiac cycle, but this is often not practical during stress. Thirdly, the PISA method for quantification of MR is based on the assumption that the MR jet is hemispheric proximal to the jet lesion, but this is not always the case. This is of greatest practical importance in secondary MR, when the PISA orifice may become less hemispheric and more ellipsoid, which leads to underestimation of severity. There are limited data regarding the use of pharmacological stress in MR.
Standard exercise echocardiography parameters for MR assessment, with key prognostic cut-off values for primary and secondary MR.
|Key prognostic cut-off values in primary MR
|Key prognostic cut-off values in secondary MR
|Resting quantitative assessment of disease severity
|Resting BP and HR
|Prospective 456 patients: highest survival with EROA <20 mm2. EROA >40 mm2 increases 5-year mortality rate (risk ratio 2.9) (57).
|Prospective 303 patients: MR confers a graded inverse relationship with cardiac mortality (RR 1.88) (47).
|Regurgitant volume
|Prospective 456 patients: adjusted mortality risk ratio increases by 1.15 per 10 mL increase in regurgitant volume (57).
|Resting TR maximal velocity and calculation for PASP
|Prospective 437 patients: resting PASP >50 mmHg is predictor of cardiovascular death (HR 2.21) (58).
|LA volume
|Prospective 492 patients: LA volume >60 mL/m2 reduces survival (HR 1.3), reversible with surgery (59).
|Resting left ventricular assessment
|LV internal dimensions/volumes
|Class I indications for surgery: LVESD ≥45 mm in ESC or LVESD ≥40 mm in AHA/ACC guidelines (5, 40).
|Left ventricular ejection fraction
|Observational 884 patients: LVEF <55% predicted mortality (28).
|Wall motion score
|Inferoseptal and anterolateral s′ and e′ tissue velocity
|Retrospective 84 patients: resting systolic tissue velocity <10.5 cm/s predicts post-op reduction in EF (32).
|Global longitudinal strain
|Prospective 135 patients: resting GLS >−20% lowers event-free survival (33).
|Exercise parameters
|Exercise BP and HR
|Heart rate recovery post-exercise
|Observational 884 patients: HRR <18 bpm/min predicts adverse events (28).
|Duration and extent of exercise
|Observational 884 patients: <100% predicted METs predicts adverse events (28).
|Symptoms on exercise
|Quantitative MR severity
|Prospective 61 patients: EROA increase of >10 mm2 or regurgitant volume >15 mL predicts symptom onset (30).
|Prospective 98 patients: EROA during exercise ≥13 mm2 associated with increased cardiac mortality (60).
|Peak TR maximal velocity and calculation for PASP
|Prospective 102 patients: exercise induced PASP >60 mmHg increased risk of post-op events (31).
|Peak LVEF
|Prospective 71 patients: LVEF fail to improve by ≥4% have poorer prognosis (34).
|Prospective 159 patients: exercise induced PASP >60 mmHg increased rate of cardiac events (HR 5.9) (55).
|Global longitudinal strain
|Prospective 71 patients: GLS fail to improve by ≥1.9% predicts post-op EF reduction (35).
Stress echocardiography in the assessment of patients with mitral valve disease is one of the most technically demanding skills. It is expected that image acquisition requires complete training in transthoracic echocardiography, with accreditation through the British Society of Echocardiography or the reciprocal European Association of Cardiovascular Imaging credentialing. Furthermore, the individual should then have a period of supervised experience in stress echocardiography, with US recommendations for accumulation of 100 cases under supervision. The British Society of Echocardiography has introduced the first formal accreditation process in stress echocardiography that involves a written exam, acquisition of 5 cases on video for submission and a logbook of 200 cases acquired within 2 years. Candidates will also be examined while acquiring images during exercise stress. Image interpretation likewise requires extensive experience in echocardiography and those involved should have specific training.
Although guidelines for timing of intervention in both primary and secondary MR have been established for several years, there continues to be controversy as to the appropriate timing of surgery. Quantitative exercise stress echocardiography may be a useful adjunct to the management of patients with both conditions: in primary MR, testing helps to select those asymptomatic patients with repairable valves to undergo early surgery while supporting those patients who may choose to delay intervention. In secondary MR, the role of stress echocardiography is more controversial but can help to identify the mechanism of regurgitation and target therapy in disproportionately symptomatic patients.
Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this review.
Funding from BHF (grant no: PG/14/74/31056).
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MagneJLancellottiPPiérardLA 2010 Exercise-induced changes in degenerative mitral regurgitation. Journal of the American College of Cardiology 56 300–309. (doi:10.1016/j.jacc.2009.12.073)
- 31↑
MagneJDonalEMahjoubHMiltnerBDulgheruRThebaultCPierardLAPibarotPLancellottiP 2015 Impact of exercise pulmonary hypertension on postoperative outcome in primary mitral regurgitation. Heart 101 391–396. (doi:10.1136/heartjnl-2014-306296)
- 32↑
AgricolaEGalderisiMOppizziMSchinkelAFMaisanoFDe BonisMMargonatoAMaseriAAlfieriO 2004 Pulsed tissue Doppler imaging detects early myocardial dysfunction in asymptomatic patients with severe mitral regurgitation. Heart 90 406–410. (doi:10.1136/hrt.2002.009621)
- 33↑
MagneJMahjoubHPierardLAO'ConnorKPirletCPibarotPLancellottiP 2012 Prognostic importance of brain natriuretic peptide and left ventricular longitudinal function in asymptomatic degenerative mitral regurgitation. Heart 98 584–591. (doi:10.1136/heartjnl-2011-301128)
- 34↑
LeeRHaluskaBLeungDYCaseCMundyJMarwickTH 2005 Functional and prognostic implications of left ventricular contractile reserve in patients with asymptomatic severe mitral regurgitation. Heart 91 1407–1412. (doi:10.1136/hrt.2004.047613)
- 35↑
DonalEMascleSBrunetAThebaultCCorbineauHLaurentMLeguerrierAMaboP 2012 Prediction of left ventricular ejection fraction 6 months after surgical correction of organic mitral regurgitation: the value of exercise echocardiography and deformation imaging. European Heart Journal: Cardiovascular Imaging 13 922–930. (doi:10.1093/ehjci/jes068)
- 36↑
FlachskampfFA 2010 Mitral regurgitation is incompletely characterized at rest. Journal of the American College of Cardiology 56 310–313. (doi:10.1016/j.jacc.2010.02.052)
- 37↑
LeeT-MSuS-FHuangT-YChenM-FLiauC-SLeeY-T 1996 Excessive papillary muscle traction and dilated mitral annulus in mitral valve prolapse without mitral regurgitation. American Journal of Cardiology 78 482–485. (doi:10.1016/0002-9149(97)00002-7)
- 38↑
HanYPetersDCSaltonCJBzymekDNezafatRGodduBKissingerKVZimetbaumPJManningWJYeonSB 2008 Cardiovascular magnetic resonance characterization of mitral valve prolapse. JACC: Cardiovascular Imaging 1 294–303. (doi:10.1016/j.jcmg.2008.01.013)
- 39↑
HanYCPetersDCKissingerKVGodduBYeonSBManningWJNezafatR 2010 Evaluation of papillary muscle function using cardiovascular magnetic resonance imaging in mitral valve prolapse. American Journal of Cardiology 106 243–248. (doi:10.1016/j.amjcard.2010.02.035)
- 40↑
NishimuraRAOttoCMBonowROCarabelloBAErwinJP3rdGuytonRAO'GaraPTRuizCESkubasNJSorajjaP 2014 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 63 e57–e185. (doi:10.1016/j.jacc.2014.02.536)
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SharmaVNewbyDEStewartRALeeMGabrielRVan PeltNKerrAJ 2015 Exercise stress echocardiography in patients with valvular heart disease. Echo Research and Practice 2 89–98. (doi:10.1530/ERP-15-0015)
- 42↑
LancellottiPLebrunFPiérardLA 2003 Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction. Journal of the American College of Cardiology 42 1921–1928. (doi:10.1016/j.jacc.2003.04.002)
- 43↑
IzumoMLancellottiPSuzukiKKouSShimozatoTHayashiAAkashiYJOsadaNOmiyaKNobuokaS 2009 Three-dimensional echocardiographic assessments of exercise-induced changes in left ventricular shape and dyssynchrony in patients with dynamic functional mitral regurgitation. European Journal of Echocardiography 10 961–967. (doi:10.1093/ejechocard/jep114)
- 44↑
GigaVOstojicMVujisic-TesicBDjordjevic-DikicAStepanovicJBeleslinBPetrovicMNedeljkovicMNedeljkovicIMilicN 2005 Exercise-induced changes in mitral regurgitation in patients with prior myocardial infarction and left ventricular dysfunction: relation to mitral deformation and left ventricular function and shape. European Heart Journal 26 1860–1865. (doi:10.1093/eurheartj/ehi431)
- 45↑
SrichaiMBGrimmRAStillmanAEGillinovAMRodriguezLLLieberMLLaraAWeaverJAMcCarthyPMWhiteRD 2005 Ischemic mitral regurgitation: impact of the left ventricle and mitral valve in patients with left ventricular systolic dysfunction. Annals of Thoracic Surgery 80 170–178. (doi:10.1016/j.athoracsur.2005.01.068)
- 46↑
LancellottiPGérardPLPiérardLA 2005 Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation. European Heart Journal 26 1528–1532. (doi:10.1093/eurheartj/ehi189)
- 47↑
GrigioniFEnriquez-SaranoMZehrKJBaileyKRTajikAJ 2001 Ischemic mitral regurgitation – long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 103 1759–1764. (doi:10.1161/01.CIR.103.13.1759)
- 48↑
MichlerRESmithPKParidesMKAilawadiGThouraniVMoskowitzAJAckerMAHungJWChangHLPerraultLP 2016 Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation. New England Journal of Medicine 374 1931–1940.
- 49↑
ChanKMJPunjabiPPFlatherMWageRSymmondsKRoussinIRahman-HaleySPennellDJKilnerPJDreyfusGD 2012 Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the randomized ischemic mitral evaluation (RIME) trial. Circulation 126 2502–2510. (doi:10.1161/CIRCULATIONAHA.112.143818)
- 50↑
FattouchKGuccioneFSampognaroRPanzarellaGCorradoENavarraECalvarusoDRuvoloG 2009 POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. Journal of Thoracic and Cardiovascular Surgery 138 278–285. (doi:10.1016/j.jtcvs.2008.11.010)
- 51↑
SmithPKPuskasJDAscheimDDVoisinePGelijnsACMoskowitzAJHungJWParidesMKAilawadiGPerraultLP 2014 Surgical treatment of moderate ischemic mitral regurgitation. New England Journal of Medicine 371 2178–2188. (doi:10.1056/NEJMoa1410490)
- 52↑
GoldsteinDMoskowitzAJGelijnsACAilawadiGParidesMKPerraultLPHungJWVoisinePDagenaisFGillinovAM 2016 Two-year outcomes of surgical treatment of severe ischemic mitral regurgitation. New England Journal of Medicine 374 344–353. (doi:10.1056/NEJMoa1512913)
- 53↑
LancellottiPZamoranoJLVannanMA 2014 Imaging challenges in secondary mitral regurgitation unsolved issues and perspectives. Circulation: Cardiovascular Imaging 7 735–746. (doi:10.1161/circimaging.114.000992)
- 54↑
SzymanskiCLevineRATribouilloyCZhengHHandschumacherMDTawakolAHungJ 2011 Impact of mitral regurgitation on exercise capacity and clinical outcomes in patients with ischemic left ventricular dysfunction. American Journal of Cardiology 108 1714–1720. (doi:10.1016/j.amjcard.2011.07.045)
- 55↑
LancellottiPMagneJDulgheruRAncionAMartinezCPierardLA 2015 Clinical significance of exercise pulmonary hypertension in secondary mitral regurgitation. American Journal of Cardiology 115 1454–1461. (doi:10.1016/j.amjcard.2015.02.028)
- 56↑
LancellottiPMagneJ 2013 Stress echocardiography in regurgitant valve disease. Circulation: Cardiovascular Imaging 6 840–849. (doi:10.1161/circimaging.113.000474)
- 57↑
Enriquez-SaranoMAvierinosJFMessika-ZeitounDDetaintDCappsMNkomoVScottCSchaffHVTajikAJ 2005 Quantitative determinants of the outcome of asymptomatic mitral regurgitation. New England Journal of Medicine 352 875–883. (doi:10.1056/NEJMoa041451)
- 58↑
BarbieriABursiFGrigioniFTribouilloyCAvierinosJFMichelenaHIRusinaruDSzymanskyCRussoASuriR 2011 Prognostic and therapeutic implications of pulmonary hypertension complicating degenerative mitral regurgitation due to flail leaflet: a multicenter long-term international study. European Heart Journal 32 751–759. (doi:10.1093/eurheartj/ehq294)
- 59↑
Le TourneauTMessika-ZeitounDRussoADetaintDTopilskyYMahoneyDWSuriREnriquez-SaranoM 2010 Impact of left atrial volume on clinical outcome in organic mitral regurgitation. Journal of the American College of Cardiology 56 570–578. (doi:10.1016/j.jacc.2010.02.059)
- 60↑
LancellottiPTroisfontainesPToussaintACPierardLA 2003 Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction. Circulation 108 1713–1717. (doi:10.1161/01.CIR.0000087599.49332.05)


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Green Pea Salad with Feta and Mint! This fresh and crunchy salad features three kinds of peas, pea shoots, mint, and feta, an easy to make dressing, and some whole grains to add a bit of heft. Serve with boiled eggs if you please!
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2011 Volume 8 Issue 14 Pages 1174-1179
A low power receiver RF front-end operating in the 5GHz band according to the IEEE 802.11a WLAN standard is reported. This is based on the dual conversion architecture for the fully integrated receiver, in order to relax the problem of the direct conversion receiver. In the RF front-end, the power consumption is greatly reduced by using the dual conversion current-driven passive mixer with linear transconductor stage. The receiver RF front-end is fabricated with 0.13µm CMOS technology. An IIP3 of -15.8dBm with a gain of 37.2dB and a noise figure of 7.1dB are obtained at 16.8mW power consumption.


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Capacity and AutonomyAuthor(s):
Red Globe Press
Paperback - 9781137286451
05 June 2014
Free Shipping
In stock
Practice issues surrounding the legal concept of capacity are of fundamental importance to social work. The profession is committed to maximizing service users' autonomy yet vulnerable people may be at risk of abuse or...Show More
Practice issues surrounding the legal concept of capacity are of fundamental importance to social work. The profession is committed to maximizing service users' autonomy yet vulnerable people may be at risk of abuse or injury if they exercise complete independence – so practitioners need to know in what situations it is appropriate for that autonomy to be curtailed.This accessible and practically-grounded text equips social workers with the legal knowledge needed to work effectively with some of the most vulnerable people in society. It explores capacity in relation to minors, vulnerable adults and mental health, as well as covering complex issues such as refusal to accept treatment and deprivation of liberty. The book goes on to explore the different legal mechanisms that are available for promoting autonomy and safeguarding people's interests. The text is supported by a range of innovative features and boxed information to aid learning and stimulate reflection: - Key Case Analysis boxes summarize the details of particular legislation cases and outline the implications for social work practice.- Practice Focus boxes apply legal principles and processes to practice through the use of social work scenarios.- On-The-Spot Questions reinforce understanding and encourage critical reflectionShow Less
Provides a uniquely holistic focus demonstrating the application of the law on capacity across social work practice fields and specialisms
1. What can Children and Young People Decide for Themselves?
2. Human Rights and the Development of Law
3. The Mental Capacity Act 2005 Principles
4. Mental Health, Mental Capacity and Empowerment
5. Deprivation of Liberty
6. Advocacy and Safeguarding People's Interests
Useful Websites
New Publications
- Economics is Everywhere Daniel Hamermesh
- The Economics of Foreign Exchange and Global Finance Peijie Wang
- Economic Foundations for Finance Thorsten Hens, Sabine Elmiger
- Money: Theory and Practice Jin Cao, Gerhard Illing
- Safeguarding Adults Alison Brammer, Laura Pritchard-Jones
- Economic Principles Stephen Rubb, Scott Sumner
- Macroeconomics N. Gregory Mankiw
- A Guide to Statutory Social Work Interventions Mel Hughes
- Making Good Decisions Michael Preston-Shoot
- Child Protection Kim Holt
- LP for Macroeconomics 4e Paul Krugman
- Working Across Difference Donna Baines, Bindi Bennett, Susan Goodwin, Margot Rawsthorne
Best Sellers
- Doing a Successful Research Project Martin Davies, Nathan Hughes
- An Economic History of the United States Mark V. Siegler
- Social Policy in Britain P. Alcock, Margaret May
- Capacity and Autonomy Robert Johns
- Making Good Decisions Michael Preston-Shoot
- Youth Justice Jo Staines
- Court and Legal Skills Penny Cooper
- Social Policy Simplified Clive Sealey
- Global Social Policy Kepa Artaraz, Liz Cunningham, Michael Hill
- Critical Issues in Social Work Law Alison Brammer, Jane Boylan
- Practising Social Work Law Suzy Braye, Michael Preston-Shoot
- Safeguarding Adults Alison Brammer, Laura Pritchard-Jones


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Log In
Akimbo: A Podcast from Seth Godin
Akimbo: A Podcast from Seth Godin
Akimbo is an ancient word, from the bend in the river or the bend in an archer's bow. It's become a symbol for strength, a posture of possibility, the idea that when we stand tall, arms bent, looking right at it, we can make a difference.Akimbo's a podcast about our culture and about how we can change it. About seeing what's happening and choosing to do something.The culture is real, but it can be changed. You can bend it.
Apr 24 • 31 min
The space shuttle, Spiro Agnew and the homunculus
Pizza and sushi
Apr 17 • 28 min
The magic of inconvenience
Math Class Is Hard
Apr 10 • 28 min
The Monty Hall problem
Money Moves
Apr 3 • 32 min
Money is a story and money flows
Moore's law
Mar 27 • 26 min
It's not just a good idea…
False Merit, Appearing Real
Mar 20 • 25 min
The race to get picked
Mar 13 • 32 min
In the connection economy, what happens when we can't connect?
5 monkeys
Mar 6 • 24 min
Culture matters
Publish yourself QA
Feb 27 • 23 min
Thanks for your questions
Publish yourself
Feb 20 • 28 min
Books are the same, publishing has changed
Psephology and the science of voting
Feb 13 • 27 min
Let's vote on it
The big sort
Feb 6 • 37 min
White sculptures
Jan 30 • 23 min
Who decides what's beautiful?
Why did the chicken cross the road?
Jan 23 • 22 min
We know that too
The chicken and the egg
Jan 16 • 29 min
We know which came first
It's your turn
Jan 9 • 28 min
The power of 'no place to hide'
Sauce and Godiva
Jan 2 • 27 min
Adventures in the music business
On dignity
Dec 26, 2018 • 25 min
Not because we've earned it
Going going gone
Dec 19, 2018 • 24 min
The truth about auctions
How to get into a famous college
Dec 12, 2018 • 33 min
(and how to build a body of work)
Connect the dots
Dec 5, 2018 • 27 min
Answering your questions about education
Stop stealing dreams
Nov 28, 2018 • 30 min
What is school for?
All rights reserved
Nov 21, 2018 • 37 min
Beware the legal-industrial copyright complex
Nov 14, 2018 • 27 min
Seth talks about his new book
The wedding industrial complex
Nov 7, 2018 • 30 min
(slightly better than average)
Games matter
Oct 31, 2018 • 27 min
What game are you playing?
Anthems, pledges and change
Oct 24, 2018 • 26 min
Where does change come from?
Honest signals
Oct 17, 2018 • 31 min
Lessons from the poisonous dart tree frog
You're it
Oct 10, 2018 • 26 min
The power (and the myth) of getting picked
The deletionists
Oct 3, 2018 • 32 min
Who decides what we know?
The spirit of the game
Sep 26, 2018 • 32 min
Selfishness, altruism and our culture
Thrash now
Sep 19, 2018 • 28 min
(and ship early)
Your Bootstrapping Questions
Sep 12, 2018 • 20 min
Making a ruckus for the right people
Every day is labor day
Sep 5, 2018 • 25 min
Capitalism and culture
Ignore sunk costs
Aug 29, 2018 • 29 min
Watcha gonna do with the green iguana?
Shun the non-believers
Aug 22, 2018 • 24 min
They're not for you
Your call (isn't) very important to us
Aug 15, 2018 • 29 min
What happens when the operators aren't standing by any longer?
Don't just Do Something, Stand There
Aug 8, 2018 • 22 min
What's it for, who's it for and the magic of design thinking
Distribution and cultural destiny
Aug 1, 2018 • 27 min
We get the world our media wants
The mesh
Jul 25, 2018 • 32 min
The network keeps ratcheting forward.
This stinks
Jul 18, 2018 • 23 min
I mean it. It stinks.
Origin stories
Jul 11, 2018 • 27 min
Where did you get your special powers?
Juggling and bicycles
Jul 4, 2018 • 21 min
The best way we learn is rarely the best way to perform.
Coincidence and grilled cheese
Jun 27, 2018 • 24 min
What are the odds? Pretty good, actually.
Tips and gifts
Jun 20, 2018 • 26 min
Getting clear about the story we tell ourselves (and others)
It's not about the chocolate
Jun 13, 2018 • 27 min
Shawn Askinosie and the avoidance of 'more'
Blogs and Platforms and Permission
Jun 6, 2018 • 22 min
Sharecropping doesn't get you very far
Q&A, the season wrap up
May 30, 2018 • 32 min
A good question is half the project
The long term
May 23, 2018 • 25 min
Drip by drip, day by day, we change the culture.
May 16, 2018 • 27 min
You are one. Really. It's true.
Networks and lockin
May 9, 2018 • 29 min
Did you subscribe to Akimbo yet? We hope you do. Here's why.
May 2, 2018 • 31 min
Are you an entrepreneur? As fashionable as a 'yes' might be, you might find fulfillment as a freelancer instead.
Let's Do It Live
Apr 24, 2018 • 23 min
Live is different. We're not exactly sure why, but we respond differently when we're in real time. (a special episode, recorded live)
The Regular Kind
Apr 18, 2018 • 35 min
The status quo and the mass market continue to conspire to keep us from having nice things.
They're not trying to be creepy
Apr 11, 2018 • 26 min
Advertising has shaped our culture. Not the ads, but the money. And Facebook's woes are a symptom of that.
Quality and Wabi-Sabi
Apr 3, 2018 • 30 min
Perfect isn't the point, and our narrative about errors and effort is keeping us from being the humans we seek to become.
Game Theory and the Infinite Game
Mar 28, 2018 • 36 min
Games don't require dice or a Monopoly board. The games we all play distract, energize and enable us to create magic if we choose.
Don't fear placebos
Mar 21, 2018 • 26 min
The most effective intervention is also the least respected. Not just in medicine, but in every element of our culture. Yes, in fact, it's all in your head. That's a good thing.
Mar 14, 2018 • 28 min
Everyone wants to write a hit, own a hit, be in a hit. And the rest of us want to watch, read and engage with hits. But where do hits come from? And how?
No such thing (as writer's block)
Mar 7, 2018 • 26 min
A mysterious ailment, a convenient place to hide, and most of all, it's all invented.
I see you
Feb 28, 2018 • 32 min
Isn't this what we truly want? To be seen, to be heard, to be understood…
Status roles
Feb 21, 2018 • 31 min
Who's up, who's down? The drama of our lives is narrated by our perception of where we stand. Most of our energy, money and time goes into grooming ourselves into the status role where we believe we belong.
The Grand Opening
Feb 14, 2018 • 19 min
The successful grand opening is rare. But we keep trying. We make it dumber, louder, more predictable, sacrificing nuance in exchange for a chance at mass…
Feb 5, 2018 • 0 min
A new podcast from Seth Godin, premiering on February 14.
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One of my students today told me how excited she was about a new Club Penguin character because it farts sparkles. She said it completely seriously until the end of the sentence and she broke out into this joyous smile like this was quite possibly the greatest thing in the history of the world.
I hope that Tiffany has a day like that, a day where something as simple as farting sparkles fills you with complete happiness and wonder and light. Kids take joy in the smallest things while adults are weighed down by all the worries of the world.


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Calamity Day Make Up Work
February 5, 2019
Dear Parents/Guardians,
After several years of 'mild' winter weather, we currently find ourselves in the midst of another challenging winter. We thought it important to provide as much advanced warning as possible so parents/guardians could plan accordingly.
The Mount Vernon City School Board, administration, and staff values ongoing instruction and supports the limited use of calamity days. The board adopted a policy which states that days missed beyond five (5) would be made up in the following manner:
Calamity Days 6-8 – will be completed via online activities or Blizzard Bags
Calamity Days 9+ - will be made up at the end of the year beginning on Friday, May 31
There are several options that we have considered to meet the requirements to maintain ongoing instruction. The option of Blizzard Bags for calamity days 6-8 will be used primarily at the elementary level. We have asked teachers to be mindful of Quality vs. Quantity when assigning 'Blizzard Bag' work. It is not our intention to simply create 'busy work' for students and parents. The Middle School and High School will be primarily utilizing technology and their chromebooks to assign daily work.
We have currently utilized six (6) calamity days. Your child should have received/will receive
information regarding Blizzard Bag and/or online assignments for calamity day #6. When necessary, additional Blizzard Bag and/or online assignments will be issued for calamity days 7 and 8.
While we hope that we don't have to utilize calamity days 6-8 in the coming months, safety must always be our first priority. Please stay warm and be safe!
William Seder Jr.
Attachments Available To Download:
Calamity Day Letter from Superintendent William Seder
Posted: Wednesday, February 6, 2019


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Top 5 Marijuana Stocks for 2019
With individual stock selection now more critical than ever, this report is designed to bring you some of our top ideas in the marijuana industry this year.
One of the companies highlighted in this report offers a life-changing therapy that reduces the number of seizures in children with two rare types of childhood-onset epilepsy. It has the potential for the stock to sky-rocket. You need to find out the name of this company before the rest of the market does.
P.S. Not many retail investors pay attention to the marijuana sector. Use this complimentary guide and get a head start on your path to profiting from the booming cannabis industry!
Market Pulse
Crypto Groupings
More Crypto Groups


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Home •
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Travel Articles •
Aboriginal Tourism
A pioneer mountain town, Omeo has a fascinating pioneer history that can be
explored at the Omeo Historical Society Precinct and museum, whose exhibits
includes the mountain cattlemen diary pages which were used to keep track of the
men's movements around the High Plains, the condition of the stock, weather
forecasts or even a bit of local gossip.
Part of the Great Alpine Road travel
route, Omeo is ideally located to visit
Dinner Plain, Mount Hotham,
Anglers Rest, Falls Creek,
Benambra, Swifts Creek and Ensay.
Check out our listing of
Omeo accommodation
and the
Great Alpine Road accommodation. In addition to our listed online travel
guide information, contact the local tourism visitor centre for your destination
for more attractions, tours, local maps and other information.
GPS (Omeo): S 37º 06.050' E 147º 36.079'
Pioneer Lookout
GPS: S 37º 06.683' E 147º 34.481'
• Part of the Oriental Claims Historic Area,
Pioneer Lookout, provides a view down the cliff to see how the miners cut away
an entire hill changing the shape of the landscape forever.


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Glenmore River
Glenmore River
Glenmore River is a contemplative painting with oppositions, movement and balance, created by the opposing the riverbanks and their individual constituents.
- Oil on canvas / 61cm x 46cm / Framed
Glenmore River is a cool but playful painting based on one of the estuaries leading to Loch Morlich. I continue to experiment with multiple techniques to further enhance the sense of depth, as well as imbuing an ethereal quality to the piece by exaggerating the flow of the tree branches.
What was it like to paint?
With every painting, I always try something new and in this one, it was the water and the foreground grass.
With the water, I wanted to fill all the teeth of the canvas so that I could get a really smooth surface on which to paint the detail. So I blocked it in with a palette knife and then used a blending brush to smooth it out.
The foreground was achieved by loading up a syringe with green oil paint, applying it to the canvas in rows and then lopping the top bit of paint off with a palette knife,
How does it feel?
This painting has always felt quite playful to me. Perhaps because of the grass in the foreground or the sense of movement in the trees.
It's another one of those paintings where you're led into the painting and want to know what's around the corner of the river.
© Hamish Baird - All rights reserved


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Enjoy the outdoors on our largest veranda with table and chairs, or enjoy the indoors with TVs in the bedrooms or lounge area.
Imagery representative of grade.
If you have any questions, please give us a call on 01305 773233.
An incredible holiday home with a modern and stylish interior with double glazing, central heating throughout and additional heating in the lounge. Luxurious fixtures and fittings that include a 42" TV with DVD player in the lounge.
A fully fitted kitchen includes a full size fridge freezer, dishwasher and separate dining area to give you that great home from home feel.
The fantastic luxurious extras include an extra shower room and TVs in all bedrooms.
This exceptional holiday home also features doors onto the veranda with outside table and chairs to give you that ultimate space.
All our accommodation is a non smoking.
All beds are made up on arrival and a guaranteed check in of 2pm.


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We are so glad you decided to stop by. For The Love Of Fabric is an online fabric shop based in Kitchener, Ontario, Canada. While we love all types of fabric, our main focus is on providing high quality apparel and home decor fabric. Our stock consists of knits, canvas, and cotton lawn, each of which are perfect for various apparel, decor, quilting, and craft projects. We do stock some quilting weight fabrics, as well as double gauze, flannel, and others. You will notice that our fabrics are either 100% cotton or a cotton/spandex mix (in the case of knits). We also have a wonderful selection of organic fabric.
We hope you enjoy your shopping experience. Feel free to contact us with any questions or comments.
Happy Sewing!
Owner - For The Love Of Fabric


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HUAWEI Mate 20 Pro Currently Offered at $999.99
Not in vain, the Huawei Mate 20 Pro is called the flagship of the year. It combines all the latest and innovative technologies such as wireless charging, the on-screen fingerprint recognition, the 3D structured light, the 2K screens, etc. But there are too many interesting features that you can't find on other smartphones. Before we will get acquainted with them, you should know it is already available for purchase at $999.99. Not cheap, but believe in us – it is worth this price.
Also Read: HUAWEI Mate 20 Pro Review
The Huawei Mate 20 Pro still inherits the consistent business style of the Mate series. At the same time, it also adds a very fashionable and comfortable element to the details. The shape of the octa-curved body is quite good, and it is great in terms of ergonomics.
On the back, it carries a triple-camera module, which is officially called the 'matrix multi-focal imaging system'. It is inspired by the lights of the Porsche series sports car.
On the front side, the HUAWEI Mate 20 Pro uses a 6.39-inch OLED display has a resolution of 3120×1440 (2K resolution). It supports the DCI-P3 color gamut and has a pixel density of 538PPI.
This handset also combines the most advanced 3D structured light with screen fingerprint technology.
The HUAWEI Mate 20 Pro is the first to come with the Kirin 980 processor released at IFA. It is the first to be based on the 7nm process node, which can integrate 6.9 billion transistors in the chip. This brings lower performance while lowering power consumption and heat. Moreover, this is the world's first dual-core NPU processing chip has improved the AI performance by 226% and can identify more AI usage scenarios.
In terms of camera, it uses a 40MP wide-angle camera and a 20MP ultra-wide-angle camera with a combination of an 8MP telephoto camera. The HUAWEI Mate 20 Pro sports a built-in 4200mAh battery, which has a smaller capacity increase over the previous generation. But it supports a 40W wired fast charging and a 15W wireless fast charging.
Actually, in one article, we can't mention all the features the HUAWEI Mate 20 Pro comes with. So if you still doubt whether it deserves your money or not, it's better to read the review.


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Empirical research is the process of finding empirical evidence. However, literary evidence is only used in literature, essays, and research papers for and convincing purposes. What does evidence based practice mean? Without the best current and classic external research, practice and information become outdated and may be ineffective or even harmful. Link to this page: preponderance of the evidence On appeal, the Intermediate Court of Appeals concluded that, in contrast to the burden of proof allocation at competency hearings held before or during trial, at a retrospective competency hearing federal due process principles require the prosecution to bear the burden of proving by a preponderance of the evidence that the defendant is competent to stand trial. Without taking into consideration the mother's values, preferences, and realities of life, practice and information become irrelevant and may become unethical.
She responded with speed and motion. Meaning Simply stated, evidence based practice means that a practice has been proven effective. D; Phillips, B; Schünemann, H. Food, Nutrition, and Physical Activity, and the Prevention of Cancer: A Global Perspective. National Institutes of Health Library. There is no evidence that anyone was here earlier. Preventive Services Task Force Edition 1989.
Unfortunately, many programs that demonstrate initial success fail to show long-term impacts after the intervention or may even show a decline in effectiveness. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Scientists record and analyze this data. She ran, as she had done most of her life, but this time she was running for her own sanity. Sit-down meals are time to share and connect with others; however, that connection has become less valued, as families begin to prize individual activities over shared time, promoting self-centeredness over group identity. Over the past 16 years, Alina has covered everything from Ebola to androids while writing health, science and tech articles for major publications.
November 2014 In medicine, levels of evidence LoE are arranged in a used in to describe the strength of the results measured in a or research study. Sometimes, the results affirm what we already suspected to be true, and sometimes they are surprising. Unlike general medicine, there are no standards for treatment. The scientific method often involves lab experiments that are repeated over and over, and these experiments result in quantitative data in the form of numbers and statistics. Thus, it is important to assess impact, not just immediately following the program, but after sufficient time has elapsed. New practices become evidence based over time as they show to have effectiveness in treatment.
Who will pay for this kind of investigation into best breastfeeding practices? The Goal Evidence-based programs aim to not only impact outcomes for individual youth, but to change the population prevalence rates of a problem. An evidence-based practice not only presents the best information available but also respects the mother's right to evaluate that information and use it to make informed decisions for her family. Indeed, recent ultrasound studies seem to negate the very existence of the long-recognized milk sinuses that we thought and taught babies needed to compress in order to receive milk. For example, we no longer advise mothers to toughen up their nipples or to nurse their babies in only a few, very specific positions. Empirical laws are scientific laws that can be proven or disproved using observations or experiments, according to the.
Empirical, anecdotal and logical evidence Empirical, anecdotal and logical evidence should not be confused. In fact, there was no evidence of successful treatment of alcoholism until groups started to form preaching a spiritual solution. In philosophy, the study of evidence is closely tied to epistomology, which considers the nature of knowledge and how it can be acquired. Also, programs sometimes have delayed impact and the full effects are not seen by the end of the intervention. Counselors and health professionals should not routinely offer suggestions that many others have found are rarely successful. There are many common breastfeeding and medical practices that have no formal research to support them.
Empirical data is the information that comes from the research. The scientific method The begins with scientists forming questions, or , and then acquiring the knowledge through observations and experiments to either support or disprove a specific. It not only addressed therapy and prevention, but also diagnostic tests, prognostic markers, or harm. Stegenga has criticized specifically that meta-analyses are placed at the top of such hierarchies. Likewise, people also cannot survive in an unfriendly environment.
What are the implications for Breastfeeding Counselors? What does that statement mean? Mostly political speakers, research writers, and editorial writers use evidence extensively to turn public opinion for or against some issue. Deductive reasoning may be used to come to a conclusion to provide logical evidence. Thankfully, there is now a growing body of research on many aspects of breastfeeding. To identify these key features, review the website of the identified program and talk directly to the developer or program staff. Alina's goal in life is to try as many experiences as possible.
The is a great resource for finding out more about evidence-based research and practice. J; Edejer, T; Varonen, H; Vist, G. Evidence is given in research work, or is quoted in essays and statements, but is paraphrased by the writer. It also increases confidence that the program does not produce any iatrogenic or unintended harmful or negative effects. Aurora Recovery Centre employs evidence based treatment methods in addition to holistic healing methods, both which provide transformational results.
The process is a central part of the scientific method. Do Evidence Based Practices Change? In contrast, comprehensive, enduring, and effective prevention programs have strong study designs and scientific evidence that they reduce negative outcomes and lead to sustained positive impacts. There is evidence to support the use of the practice in treating the psychology of addiction. This also guards against scientists who unconsciously, or in rare cases consciously, veer from the prescribed research parameters, which could skew the results. These sites include programs with varying degrees of research and it is left to the reader to make their own judgment about whether the evaluation results represent an effective program.


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334, Richmond Rd.
Westboro, Ottawa West
$ & $$French, Breakfast, American, Fish & Chips, Poutine, Sandwiches, Tartare, Vegetarian, Mussels
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$$ & $$$French, Seafood/Fish, Breakfast, Tartare, Mussels


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Harpeth HS Alumni List
Last names starting with "Z"
Select letter of last name to filter the alumni list
Looking for Harpeth High School alumni not listed? If so, check out Classmates.com® - hundreds of more HHS alumni have posted their profiles.
About the Harpeth High School Alumni Directory
Check out all of the names of the Harpeth High School alumni that attended high school in Kingston Springs that are listed above. Registering will allow you to join the directory. If you haven't already, we also encourage you to register for free on this site. You may also want to check out the latest news and school memories.


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Clickfunnels Button Css: What You NEED To Know
Clickfunnels Review
I am an independent user of ClickFunnels, not an employee. The opinions and results expressed here are my own and are not official statements of ClickFunnels or its parent company, Etison LLC
As an online marketer, do you believe you spend a lot more time on building sales funnels from scratch instead of concentrating on the tasks that are more crucial using Clickfunnels Button Css?
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Do you discover the task of building a best sales channel too complicated and exhausting?
Do you ever ponder hiring a specialist who can produce and handle your sales funnels?
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Comprehending Marketing Funnels
Marketing funnels or sales funnels are the directed courses for the customer lifecycle and getting conversions. Marketing funnels are effective tools to increase conversions as they start with absolutely no to low commitment, familiarize them with your service or item and let them understand why do they require the Clickfunnels Button Css or items used by you.
What Is ClickFunnels?
ClickFunnels is a cloud-based marketing tool, specifically created to assist marketers attain their objectives. It comes filled with prebuilt funnels for all kinds of services, products and marketing campaigns. A common funnel includes opt-in pages, email autoresponders, order forms, member's location, sales pages, etc
. ClickFunnels merges numerous online marketing components together so you will never require separate tools for email lists, opt-in pages, notifiers, and so on. With this tool, you might customize your marketing funnels very easily and quickly. It will save your time and allow you to concentrate on other locations of your service.
Clickfunnels Button Css Characteristics
– Funnel Templates
You can select from numerous kinds of funnel templates, such as Lead Capture, Occasions, Sales, Subscription, Squeeze Page, and so on depending on your project.
– Actionetics
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The Backpack tool is an affiliate marketing app incorporated with the ClickFunnels. It is designed to make your life much easier as an affiliate online marketer. When you integrate the power of marketing funnels and Actionetics with Backpack, you must be able to find success quickly as an affiliate online marketer.
– Share Funnels
ClickFunnels permits you to share your funnels quickly with your associates, clients or good friends quickly. You could discover the URL to share the funnel under the 'Settings' tab.
ClickFunnels & Other Funneling Tools
Currently, there is no other funneling tool as effective and robust as ClickFunnels as it integrates the power of marketing tools developed for specific functions together. It is an integrated solution for your online marketing requirements.
LeadPages is a profoundly popular tool for building landing pages. It is incredibly restricted in scope and you can develop stunning landing pages with ClickFunnels as well using the drag and drop editor besides doing a lot more.
Another example is a tool called, SamCart. You can construct lovely checkout pages and it supports payment gateways like PayPal, Stripe, etc. ClickFunnels is much more effective than the SamCart as you can create any sort of checkout page with it. SamCart is very minimal and permits you a few customizations here and there on their prebuilt design templates.
In general, ClickFunnels is a total marketing service in itself which gives it an edge over its rivals. It does not have a competitor in a true sense as the other marketing tools are incredibly restricted in scope and you will be pressed to purchase a number of tools for various marketing jobs.
ClickFunnels Free Trial
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Daily Court Reporter - News Flyers run past Stetson in 21-10 win
Flyers run past Stetson in 21-10 win
University of Dayton Athletics
The University of Dayton ground out a victory over Pioneer Football League foe Stetson on Saturday afternoon, taking down the visiting Hatters 21-10 at Welcome Stadium.
This article is restricted per publishing limits. Soon we will offer the ability to buy the ability to read this content.
Date Published: November 4, 2016


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Blend Games:
First released in Japan for the Turbografx-16 in 1989, Military Madness was a breakthrough in console strategy gaming. The game was a huge hit in the land of the rising sun, but sales in the U.S. (much like sales of the Turbografx-16 itself) were not too hot. Years later, after another failed release of Military Madness for the Playstation, titled Nectaris, Nintendo released a a little game that they called Advance Wars. In 2006, Military Madness was released on the Wii's Virtual Console, and I may have been the only person that bought it.
I played/beat this game on Turbografx. It was a great game.


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Wherever possible I teach using real life examples. I also use a lot of past exam papers so students get used to the form and style of questions. So the final exam just looks like another bit of homework. I can also include some practical work if required.
My background is in electronics/electrical engineering. I have been tutoring for over 15 years. Very high success rate. Everything I teach I have used in the real world. I'll make it seem so easy you'll wonder why you ever found it difficult.
Distances over 10 miles I usually add a small charge but I also increase the time to mitigate travel costs.
algebra lessons closeby? Here's a selection of tutor listings that you can check out.
Superprof can also suggest trigonometry lessons to help you.
Learning isn't a problem, arithmetic lessons for all!
Taking geometry lessons has never been easier: you're going to learn new skills.
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WAKE FOREST, N.C. (WTVD) -- The Wake Forest Police Department continues to urge residents to be on the lookout for a suspicious person approaching children after another incident was reported to officers over the weekend.
Police say the latest incident happened Sunday around 10:45 a.m. in the Northampton subdivision. Police responded to the 6300 block of Ridgemount Street after two men in a work van approached a young girl.
She was walking her dog when the driver asked her to come over to the van. The girl ran away and told her mom, who immediately called the police.
The van is either gray or silver with no back windows and scratches along the front and back ends.
Authorities say both men are white. The driver was described as wearing a red and green baseball cap and the passenger may have had a short Mohawk-style haircut and a nose ring.
The girl's mother, Kimberly Ramos tells ABC11 she's proud of how her daughter responded to the dangerous situation.
"She was scared," said Ramos. "She was scared. She was shaken, but she did exactly what we would hope."
Ramos said she's taught all of her children since they were very young, to run when they feel they're in danger, and not to worry about coming across as rude or abrasive.
"It is paramount," she said. "And in this case, it saved her life I think."
Now Ramos hopes her community will realize the importance of being vigilant at all times.
"To parent as a community, keep a close eye out for each other's children and not just for your own," said Ramos. "But that's something we should be doing consistently not just when something concerning and alerting happens."
There have been three other reports of similar incidents in the Rolesville and Wake Forest areas since December. In one of the other cases, two men in an SUV offered rides to kids and were asking about a missing kitten. In a separate incident, a boy reported being approached by a man at the Factory Sports Complex.
Police urge parents to warn their children about the potential danger of talking to strangers.
Anyone who witnesses suspicious activity should call the Wake Forest Police Department at (919) 554-6150. The call can remain anonymous.
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Wake Forest Police Department reports suspicious person approaching children
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Affordable Medical Insurance In Michigan
If you are having difficulty discovering budget friendly medical insurance in Michigan, you might wish to check out enrolling in a discount-rate healthcare plan. Discount health care plans are not health insurance plans; medical insurance business does not normally provide discount rate healthcare plans. Rather, discount healthcare plans are offered by businesses concentrating on the insurance industry to plan members for a monthly or annual fee. These organizations have contracts with specific healthcare suppliers who have accepted honor the discount health care plan.
Obtaining cost effective health insurance in Michigan may appear hard at times. Fortunately is that you can discover discounts for medical, oral, and vision care, in addition to discounts on prescriptions with a discount rate healthcare plan. The healthcare suppliers to whom you have access with the discount rate healthcare strategy are typically in some kind of contract with the company from which you purchased the discount rate health-care plan. Ensure this holds true for you and your discount rate health care plan prior to you start signing or spending for anything. If there are no healthcare service providers in your location who participate with the discount rate healthcare plan in which you are registered, the strategy will be practically ineffective. Unless, obviously, you depend on taking a trip all over the state to see a healthcare expert who does honor the discount healthcare plan.
It is really important to keep in mind that a discount rate health care strategy is not a routine medical insurance policy. You can not get comprehensive healthcare coverage from a discount health care plan. If thorough healthcare protection is a concern, you must look somewhere else for budget-friendly health insurance in Michigan. If extensive healthcare protection is not a concern, and you have actually had trouble in the past finding budget-friendly health insurance coverage in Michigan, a discount rate health care plan might be simply to prepare for you.


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Program Overview
The U9-U12 program is a developmental program for younger players ages 8-12 years old. The emphasis of the game is on skills development and increasing the number of touches on the ball. Goalkeepers and referees are introduced at these ages. During registration, players are grouped by school as best as possible and are assigned a volunteer coach (normally a parent from the team).
When do I register?
Registration is now open!
What is the cost of the program?
The cost is $199 which includes 2 practices a week, 1 game a week for 8-10 weeks, game jersey, equipment, and referees for
What age group is my child in?
The Age Chart in the
Documents & Forms menu will help you determine which age group your child should play with. Please reference the second chart at the bottom of the Rec age groups. All Rec teams will be formed by School year format, NOT birth year.
Volunteer Coaches
All of the teams are assigned a volunteer coach, who is typically a parent from the team. Parent coaches are not required to have prior experience. Coaches need to
have enthusiasm and a willingness to be at each session to help guide and teach their players. Coaches interested in educational courses or viewing practice session ideas (including videos), should
view the material presented in the Coaches menu.
Team Format
The General Play Guide in the
Documents & Forms menu provides an outline of team size and number of field players by age group.
For U9-U10 teams, format is 7v7 on the field with max roster size of 12 players
For U11-U12 teams, format is 9v9 on the field with max roster size of 14 players
Teams in these age groups will play against other ISC Gunners recreation soccer teams, as well as recreation soccer teams from NPSA. The majority of games will be held in Issaquah (mostly LSSP and Costco Fields) with some games being played in Bellevue, Mercer Island and North Renton.
Time Committment
Teams may start practicing the second week of August, the week of August 12th. Games begin the first weekend after Labor Day and the league runs from 8-10 weeks,
usually ending the last weekend of October. Games this year will take place September 7,14,21,28, October 5, 12,19,26.
Practices are held anytime between 4pm and 8pm, Monday through Thursday and last from 60 to 90 minutes. Field usage for practices is usually cut back in October due to daylight, weather and field conditions. The practice schedules are determined by the coach of your team. As your coach has volunteered his/her time to organize the team, they get to decide when and where the practices will be in order to accommodate their schedule. Please do not request to switch teams because the practice time the coach has chosen does not fit your schedule. If you are concerned about this, then we encourage you to volunteer to coach.
Game times are from 8am to 5pm on Saturdays. Game times are determined randomly. The only exception to this is if a coach is in charge of multiple teams, or notifies us in advance that they have a work conflict we need to try and accommodate.
ISC Gunners Provide shirts for all participants of the program as part of the registration fee.
Field Locations
In many cases we utlilize Lake Sammamish State Park and Costco fields for practice and games. But we also use a number of fields within the Issaquah School District. For maps to specific fields, please see the Fields menu.
For questions about our recreational program, email our coordinators
Chere Anglin, Melanie Thomas
Rec Coordinators - email@example.com