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Blackface reignited his beef with 2face Idibia earlier this week following the release of his diss song.
Recall that TheNewsGuru had reported that Blackface released a single titled 'War'. In the song, the singer accused 2face of being gay.
The ruling of the court case filed by2face against Blackface was adjourned earlier in the week with a new date to be announced.
In the midst of the allegations, the management company managing 2baba have released an official statement in reaction to Blackface's accusations
The statement made available to TheNewsGuru and signed by Adejimi Oni for Now Muzik on Friday, March 22, 2019 reads:
"Contrary to the position held in some quarters that our client, Innocent Idibia, aka 2Baba has failed or refused to respond to the ridiculous accusations by Austin Ahmedu aka Blackface, we would like to state that this is untrue.
What 2Baba and our founder/CEO, Efe Omorogbe have done is refuse to create time to engage in an unproductive media banter with Blackface every time he wants to release new material.
Both 2Baba and Omorogbe have stated publicly that Blackface's claims of song theft and media/live performance blacklisting are unfounded and malicious.
"Blackface has been advised to seek legal redress if he believes his claims are true and if not, cease and desist from making unsubstantiated defamatory public statements about both 2Baba and Omorogbe.
Blackface's refusal to file a suit or discontinue the defamation forced our lawyers to institute a defamation suit against him at the Lagos State High Court. His lawyers have entered a defence and the case is currently on-going.
2Baba and Omorogbe are confident that the court will handle the matter. They will not fuel a media trial by commenting on a case that is already before a competent court of law.
The position advanced in a press statement issued on February 3, 2016 remains the same and no further response is deemed necessary"


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At Medtronic we love to hear from patients with Medtronic heart devices! If you have a pacemaker, implanted cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT) heart devices, or an insertable cardiac monitor (ICM) we want to hear from you!
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Information on this site should not be used as a substitute for talking with your doctor. Always talk with your doctor about diagnosis and treatment information.

subset: commoncrawl


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Vegan Brand The Meatless Farm Debuts In Canada
Vegan brand The Meatless Farm Co. has made its Canadian debut, after partnering with Toronto-based distributor Dolan Foods Inc.
The UK startup, which received a seven-figure investment from major broadcaster Channel 4, has launched its plant-based ground beef and burgers in more than 350 stores including Longo's and Stong's Marketin Ontario, British Columbia, and Newfoundland.
'Healthy plant-based alternatives'
"We're excited to continue building on the fantastic adoption we've seen in the UK, Europe, UAE, and most recently, the US," said the company's Founder, Morten Toft Bech.
"We believe that swapping to plant-based products should be simple and shouldn't require individuals to compromise on taste or texture. Our products have been recognized globally for their premium taste.
"Canadians looking to swap out meat for healthy, plant-based alternatives that taste great can now use our products in their everyday favorite home-cooked meals."
'A game-changer'
The Meatless Farm made its US debut this summer, after securing a six-month trial with Whole Foods.
"The market is really hotting up and it is a game-changer to be working with Whole Foods Market," said Rob Woodall, CEO of The Meatless Farm.
"The US meat alternative market is currently the largest in the world and is strategically very important for the category."


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Your web browser has been identified as Internet Explorer .
In the coming months this site is going to be updated to improve security, accessibility and mobile experience. Older versions of Internet Explorer do not provide the functionality required for these changes and as such your browser will no longer be supported as of September 2020. If you require continued access to this site then you will need to install a different browser such as Mozilla Firefox, Microsoft Edge or Google Chrome.
This article was published in Australian Dictionary of Biography, Supplementary Volume, (MUP), 2005
Robina Fordyce Cowper (1866-1948), church worker and women's rights advocate, was born on 18 August 1866 at Sandridge (Port Melbourne), eldest of twelve children of Scottish-born parents John William Inglis, Presbyterian minister, and his wife Mary, née Fordyce. Educated at Clarendon College, Ballarat, Robina trained as a teacher. On 10 December 1890 at St Andrew's manse, Parramatta, New South Wales, with her father officiating, she married Charles William Cowper, a ship-owner from Melbourne. The Cowpers were stalwarts of the Augustine Congregational Church, Hawthorn, where she became a member. A daughter, born in 1892, died in 1895; Robina and Charles had no other children.
A member of the Collins Street Independent Church by 1901, from 1912 Mrs Cowper was one of its delegates to the Congregational Union of Victoria. In 1913 she was elected to the union's home mission committee and the women's home mission committee executive. Her gifts were soon put to use as a speaker and as editor of the committee's journal, the Clarion. At the Congregational Union of Australia meeting in Adelaide in 1914 she gave a paper on home mission work, which work she maintained until 1921. She preached extensively in Victoria and in Congregational churches in New South Wales when she visited her parents.
In all her activities she advocated women's rights. She was the first woman on the Congregational Union executive committee (1922-25) and a founding member of the executive of the Congregational Women's Association in 1923. From 1921 she spent most of her time on the union's public questions committee as secretary and convenor. With delegates from other churches she lobbied the government on social justice issues such as the need for more women in the police force, protection of children, and temperance. As a representative of her Church she was the only woman on the united social services committee. She thought Congregationalists were to the fore in the representation of women, whereas some of the other denominations were 'pickled in sex as to their ideas'. She continued to preach and speak. A paper she presented at the union meeting in 1924 on 'The State and the Child Criminal' was published in the Woman (December 1924) and reprinted by the Honorary Magistrate, official organ of the justices of South Australia.
Cowper's temperance work began when she became an organizer for the Woman's Christian Temperance Union in August 1923. After a few months, funding for the post was cut and she was superintendent of the women's department of the Anti-Liquor (Prohibition) League until 1929. At the league's annual conference in 1926 it was reported that 'in a vigorous campaign amongst women and girls in factories', she had addressed '225 audiences as well as many church organisations'. In 1928 she was appointed a special magistrate of the Children's Court in Melbourne. Later that year she declined re-election as convenor of her Church's public questions committee.
In an era before women were ordained or admitted to church governance, Mrs Cowper was elected to pioneer leadership roles in the Congregational Union of Victoria, excelling as preacher and administrator as she put her Christian faith into action. After her husband died in 1936 she moved to New South Wales to live with her sister. Robina Cowper died on 3 August 1948 at Parramatta and was cremated.
Alison Head, 'Cowper, Robina Fordyce (1866–1948)', Australian Dictionary of Biography, National Centre of Biography, Australian National University, http://adb.online.anu.edu.au/biography/cowper-robina-fordyce-12865/text23231, published first in hardcopy 2005, accessed online 28 September 2020.
This article was first published in hardcopy in Australian Dictionary of Biography, Supplementary Volume, (MUP), 2005
View the front pages for the Supplementary Volume
18 August 1866
Port Melbourne, Melbourne, Victoria, Australia
3 August 1948
Parramatta, Sydney, New South Wales, Australia


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5 Signs that your body needs water
January 25, 2020 Read
Poor concentration: As the human mind holds around 90% water, it certainly gives hints when it is dried out. The absence of it in the mind can influence your mood and memory.
Dry mouth and bad breath: The absence of water creates less spit in the mouth, which contains antibacterial properties. This leads to more bacteria in the mouth, bringing about bad breath.
Food cravings: Whenever you have sudden cravings, drink a glass of water before eating something. Your body often sends false flags that you are hungry, when you are actually thirsty.
Lethargy and fatigue: When you are feeling lethargic and exhausted, it can be because of dehydration. The absence of water causes low circulatory strain and insufficient oxygen supply all through the body. The absence of oxygen causes lethargy and a lazy feeling.
5 Signs that your body needs water Reviewed by MuftGyan Guruji on January 25, 2020 Rating: 5


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Short term rental €4,300 - Villa
Luxurious villa in a community known for its magnificent walks and proximity to the beach, combines style with comfort area. It has 5 bedrooms, 5 bathrooms, 1 toilet visitors, a kitchen and a spacious living room and dining room open plan design leading to a large terrace. The interior is contemporary style penthouse with retro details. Simplicity, texture, subtle sophistication and attends clean to make it comfortable and cozy without being neither cold nor dark lines. The colors are natural, with some colorful accents. There are tropical gardens with two swimming pools. All that makes this place to enjoy comfortable and stylish – brings a feeling very light, modern furniture with a large terrace shaded.
In the rental price of the villa includes garden maintenance and psicina, clean check in and check-out, water consumption, internet, TV with satellite, systems of safety and video surveillance.
Additional Details
- Setting: Town - Beachside - Close To Golf - Close To Port
- Orientation: South
- Condition: Excellent -
- Pool: Private - Children`s Pool
- Climate Control: Air Conditioning
- Sea: Sea - Garden - Pool
- Features: Fitted Wardrobes - Near Transport - Private Terrace - Solarium - Satellite TV - ADSL / WIFI - Storage Room - Ensuite Bathroom
- Furniture: Fully Furnished
- Kitchen: Fully Fitted
- Garden: Private
- Security: Gated Complex
- Parking: Communal - -
- Utilities: Electricity - Telephone -
- Category: Holiday Homes - Luxury - Contemporary


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Barrett Manor
Julie Barrett is a freelance
writer and photographer based in Plano, TX.
Please note that some pictures may not show up here, but will be visible when you click on the link. If you still don't see the picture, leave a comment or drop me a line via the link in the footer.
Karen has bestowed the E for Excellent Award on this journal. Thank you, Karen.
It now befalls upon me to pass the award a
I've now broken out photography as a category. If your link used to be here and you don't see
(And yes, I have some Pownce invites. Drop me a line if you want one.)
Tags: 7/18/2007 8:57:31 PM
I have to plead guilty as charged to not following several of his tips. Perhaps I coul
Tags: 9/5/2006 4:06:15 PM
The Events page has been updated. We've got some more things going, but I'm not going to list them until we've got all the details nailed down.
I've also done a few "behind the scenes" sort of things.
Local Links
Sites of Interest
Writing Links
Photography Links


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Tag Archives: Round Up
Ritz-Carlton Hotels of Miami
Miami is a convenient getaway destination, especially for our Midwest and East Coast clients! It features warm weather, great food, nightlife, culture, and a plethora of luxury hotels and resorts and, as one of our key hotel partners, we are … finish reading Ritz-Carlton Hotels of Miami
Bhutan, Land of the Thunder Dragon
David and Jessica spent 9-nights exploring Bhutan on the Amankora journey and came home with memories, newfound senses of adventure, and an appreciation for the country's "Gross National Happiness." Read what they have had to say about their experience: Continue reading
The Four Seasons Hotels of Hawaii
I recently had the opportunity to travel to Hawaii on an educational trip with The Four Seasons Hotels of Hawaii. Over the course of a week we visited the Four Seasons properties in Maui, Lanai, and The Big Island. Hawaii has … finish reading The Four Seasons Hotels of Hawaii


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NEET coaching centres make hay in Trichy
With another season for the national eligibilitycum-entrance test (NEET) to select MBBS students looming, private coaching centres, some of them fly-by-night, have launched their spadework with new ideas. The new entrants are now hiring marketing executives to make their presence felt among schools across the city .Circulating advertisements in social media platforms, Guna academy at Karumandapam has called for marketing professionals to promote their activities in schools. With a couple of years into NEET coaching, director of the academy T Pugazhenthi says that "since the competition is going to be intense this year we need to make our presence felt."
Their idea was to promote the "talent search exam-2018" that the academy would be conducting in January . It would be a NEET-model test open for all and the high scorers would be offered free and concessional coaching.
While such strategies are adopted mostly by small coaching centres, established centres too are not ruling out the possibility of competition getting tough this season. Aakash, a well-known coaching centre which arrived in Trichy last year, has a three-member marketing team to promote its activities.
While admitting that Aakash was new to the city and that it did not have any tie-up with schools, branch manager Prashob Chandran C said that marketing activity did play a key role in the new market.They would change their strategy depending on how the scenario unfolds.
B Sudarkodi, director of Seekers, another NEET coaching centre in Trichy , said that they would intensify their campaign in the coming months. Marketing apart, she said that brands which main tained quality only could survive in the emerging market.She pointed out how around 500 students went to Kerala from Trichy alone last year for NEET coaching.
This meant that unless students were given quality coaching, no marketing strategy would work, she said.
Speaking on quality, S Sethuraman of Nivedita Career Academy , Thillai Nagar, said that marketing might not help the new entrants.
"Schools may not be interested in having a tie-up with lesser-known coaching centres," he said.
Sethuraman said he had observed the teaching methodology followed in Rajasthan and was trying to replicate it in Trichy.
The quality of faculty and the methodology had to be effective in producing results to remain in the market.


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Stainless Steel & Rose Gold Stainless Steel Bracelet
In Stock | STYLE: PINT7055
Available in 7-10 Business Days
Stainless Steel Pk"DON���������T LOOK BACK" with 0.005ct. Adjustable Friendship Bracelet*Prices are subject to change based on fluctuations in metal prices and currencies
Paul Maroof founded the Royal Chain Group in 1978. Under his meticulous leadership, he developed his family owned business bringing in his son and daughter as they work diligently together to run, develop, and grow the Royal Chain Group. Mr. Maroof maintains a personal involvement in everything that the Royal Chain Group represents. This commitment has made him the pre-eminent importer of quality jewelry.
General Details:
Stainless Steel & Rose Gold
Available in 7-10 Business Days
Secondary Diamond Details:
0.01 ct


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Disclosure : This site contains affiliate links to products. We may receive a commission for purchases made through these links.
Mens Corral Brown-Bone Wing & Cross Boots A1978
Most mens boots make you choose form OR function. With this new Corral Vintage boot_ you get BOTH. From heal to toe_ youll find hand finished details_ ensuring no two boots are alike.
This Distressed Brown Wing & Cross Boot is finished in a dark distressed brown goatskin leather with neutral cross inlays and brown inlayed wings.
Constructed with a leather sole featuring a Corral Vintage inlay_ double stitched outsole_ branded rubber heel_ and the popular square toe. Each pair of Corral Boots include a padded insole for additional comfort.
Dont compromise form or function. Get both with this high quality Corral Vintage boot crafted from the finest leather and expert craftsman in the business.
About HorseSaddleShop.com
"Western saddle and boot store. Shipping worldwide and stocking quality saddles, boots, tack and clothing. Friendly expert staff ready to assist you in you purchase of a saddle that fits! Because Quality Still Counts...Horse Saddle Shop, home town experts selling over 23,900 saddles: Click to see our awesomeness" --- HorseSaddleShop.com; More Details


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Hangover Hacks by Switch2Pure
Posted by Estela Cockrell on Dec 23rd 2019
The Holiday + New Year is coming up quickly! Can you BELIEVE we're entering a NEW decade...which is the perfect timing as we transition to our new location 3601 W Alabama 77027, expanding to a more experiential space, offering non-toxic treatments galore (like an infrared or ozone sauna to sweat out the toxins or THE PURE HYDROFACIAL or THE NOTOX FACE LIFT to plump that dehydrated skin.
BUT before all of that, we're dropping some of our TOP hangover hacks to get you through the 2019 to 2020 transition. Champagne fuzzy morning is upon is...but it's worth the celebration of a new year and new decade.
Hangover Recs from the #BossBabe herself:
1) Water, water, water - especially before bed! Plz stay hydrated, less headaches
2) Make sure you're taking quality vitamins, we LOVE our daily-must-haves, digestive enzymes, and super ooo-omegas to keep us in tip top shape!
3) Apply a Hangover patch before bed
4) Depuff eyes with our Well & Glow rejuvenating oil and any of our crystal rollers with a small side (PRO TIP: leave in the fridge over night for EXTRA coooling ahhhh)
5) Apply Be Chill to your temples and behind your neck for extra relief
6) Grab your fave sheet or clay mask to restore hydration
7) TOTAL POWER MOVE: Wash your face before bed with Bright + Shine, tone with Be Glowy, and moisturize with Well & Glow, you can do it!!
Stock up on our top hangover cures for extra R&R.
Plus, we totally recommend you continue your day moving, sweating it out, and nourishing your body with our powerful, packed with plant-based goodness Vegan Protein + kickstart that phase I & phase II liver detox (gentle, of course) with our detox packets.


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Join Santa Claus Anonymous as it holds its 5K and 1-Mile Walk to benefit kids throughout the Baltimore area!
Run the paths of beautiful Sparrows Point Country Club in Dundalk MD and stay for free tee shirts, awards and giveaways!
Click to reach the official site
Information about the event is available in : English


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September 6, 2019
People sit under broken palm trees outside the Leonard M. Thompson International Airport after the passing of Hurricane Dorian in Marsh Harbour, Abaco on Thursday. (AP Photo/Gonzalo Gaudenzi)
Stories this photo appears in:
Central Bank: Dorian will have negative, short-term impact on Bahamas economy
While the country's mid-term growth prospects are still positive, the Central Bank has noted that Hurricane Dorian will have a negative impact on the economy in the short-term.
Aid effort picks up momentum as some Bahamians seek way out
ABACO, Bahamas (AP) — A few meager possessions stuffed in plastic bags, some of the haggard Bahamians who lost homes to the ravages of Hurricane Dorian are waiting at a small airport hoping to catch planes out of the disaster zone as an international humanitarian effort to help the Caribbean country gains momentum and the death toll has risen to 30.
Use the comment form below to begin a discussion about this content.


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In order to remove the scratches from a CD with toothpaste, you will need: regular toothpaste, a towel or washcloth, and water. While holding your CD in one hand, being careful to avoid touching the center, coat the CD with toothpaste. You should try to cover one small area at a time, with a thin layer of toothpaste. Apply the toothpaste in a circular motion. After the entire playing area is covered with toothpaste, set it aside. Allow the CD to dry for 5 minutes. After it has dried, rinse it. Hold it under running water and gently rinse it. When all of the toothpaste has been washed away, dry it with a towel. Wipe it from the inside to outside. Do not dry it in a circular motion. It must be wiped from the inside to the outside.
Want to master Microsoft Excel and take your work-from-home job prospects to the next level? Jump-start your career with our Premium A-to-Z Microsoft Excel Training Bundle from the new Gadget Hacks Shop and get lifetime access to more than 40 hours of Basic to Advanced instruction on functions, formula, tools, and more.


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ALAP (As Late As Possible): Allow Begin Date Stretch While Keeping End Date
We have the need for End Dates to stay constant in ALAP and allow the Begin Dates to stretch. This is especially important for resourced roles because their availability is scheduled on hitting specific due dates. Current functionality moves Begin and End Dates forward when in-process and makes users look late if staying true to original due dates.This enhancement would increase the accuracy of Resource Capacity for our Project Planners.
Example of Requested Functionality:
Task 1 Original Dates: 6/20 to 6/22
Task 2 Original Dates: 6/22 to 6/25
- Task 2 finishes on 6/23
Task 3 Original Dates: 6/25 to 6/26
- Task Begins on 6/23 and still holds the 6/26 End Date
Note: The estimated hours will now be spread across 3 days instead of 1.
This functionality is available in PM release 114. Workflow templates and projects have a new field called ALAP Flexible Duration. By default this is set to No. When set to No, behavior will not change from what it was. If this field is set to Yes the new ALAP functionality described below will be available. If changing this in workflow template, the workflow will need to be validated and promoted after the change.
To further expand on what Eric said below, I have a few examples of the new behavior:
Scenario 1 (assume all tasks are ALAP):
- Task 1: Original dates: Dec. 1 - 5
- Task finishes on Dec. 4
- Task 2: Original dates: Dec. 6 - 7
- Task starts on Dec. 4 and user has until Dec. 7. User finishes on Dec. 6.
- Task 3: Original dates: Dec. 8 - 12
- Task starts on Dec. 6 and has until the 12th to complete her task.
Scenario 2 (with auto close tasks with duration of 0):
- Task 1: Original dates: Dec. 1 - 5
- Task finishes on Dec. 4
- Task 2: Original dates: Dec. 6 - 7
- Task starts on Dec. 4 and user has until Dec. 7. User finishes on Dec. 6.
- Task 3: auto-close with 0 duration
- Processed when Task 2 closes
- Task 4: auto-close with 0 duration
- Processed when Task 2 closes
- Task 5: Original dates: Dec. 8 - 12
- Task starts on Dec. 6 and user has until Dec. 12.
Scenario 3 (with auto close tasks with duration - this example has one month):
- Task 1: Original dates: Dec. 1 - 5
- Task finishes on Dec. 4
- Task 2: Original dates: Dec. 6 - 7
- Task starts on Dec. 4 and user has until Dec. 7. User finishes on Dec. 6.
- Task 3: auto-close with 1 month duration
- Starts when Task 2 closes and finishes 1 month later
- Task 4: Original dates: Jan. 8 - 12
- This task would start Jan 6 and they would have until Jan 12
This work is in development and targeted for release in Feb/March timeframe.
It will follow all the details outlines below except we ultimately decided that in the situation where the task is running LATE and not early if needed the system will reduce the duration of the next tasks all the way down to "0" if needed based on how late the previous tasks have become.
The expectation is that if a project is truly that far behind the Project Manager should be going in and making adjustment to the overall schedule to get it back on track so we do not expect that this will occur often. Given that we did not see a reason to keep any minimum duration level as previously discussed below.
First, to make sure others following this correctly we are discussing how task due dates should be managed when you configure your workflow to run "As Late as Possible (ALAP)" instead of "As Soon as Possible (ASAP)".
Aprimo has discussed this with the customer and we understand their use case. We are interested in hearing from MORE customers on this thread that either use ALAP today as well or would use ALAP in the future if these changes were made and please provide your thoughts on the options below.
I think the rules for how this behave make sense when tasks finish early as in the example above. So instead of moving up the original due date the next user just gets extra time to get the next task done.
However, there are questions about how this should be applied in the opposite direction when the tasks ahead of you close late. Do you keep the original due date and shrink the duration to match. Currently the due date would be adjusted out and the duration would be preserved. So if you have a 2 day task we keep the 2 day duration and push the due date based on when the task before it completes.
Example of late Tasks (How it works today)
Task 2 Original Dates: 6/22 to 6/25
- Task 2 finishes on 6/27
Task 3 Original Dates: 6/25 to 6/28
- Task 3 Begins on 6/27 and based on its duration the End Date is set to be 6/29 so in this case the next users still has the original amount of time to complete their task.
Options for how it could work instead.
- Nothing changes, we only adjust the duration when the tasks finish earlier
- We follow the same rules as above so we keep the due date and reduce the duration to instead
- However, we cannot push a duration of a task to be negative so this would have limits. Our thought is you reduce the duration based on the end date but not less than 1 day so the End Date could still be moved out to a later date to preserve a 1 day duration. So the shortest duration a task would be reduced to is a 1 day duration.
Example of late Tasks (Option 2)
Task 1 Original Dates: 6/20 to 6/22
- Task 1 finishes on 6/23
Task 2 Original Dates: 6/22 to 6/25
- Task 2 starts on 6/23 and based on the End Date of 6/25 we reduce the duration from 4 days to 3 days and keep the due date as 6/25.
- Task 2 finished even later on 6/28
Task 3 Original Dates: 6/25 to 6/27
- Task 3 Begins on 6/28. It used to have a 2 day duration but due to other tasks being so late to preserve the schedule we SHOULD reduce Task 3 duration to be -1 days. We cannot do this from a product structure. So instead we reduce the duration as low as we can (1 day) which sets a new End Date of 6/29 so the schedule does shift because other tasks are getting so far behind but we preserve at least 1 day for each task in the schedule.
Technically we could push the duration even lower (like as low as 1 hour or 30 mins, etc) but personally do not feel that is a good user experience but would squeeze as much time as possible out of the schedule.
Aprimo's view on this for at least the MVP might be to only do Option 1. Give more time when tasks complete early. Do nothing different than today when tasks complete late.
Please let us know your thoughts.
One thing to add to your explanation above, there is actually no Minimum duration in the workflow designer. You can enter a 0 day duration in your design, and I believe that would be a better fit for the situation you are describing. The issue we are addressing is pushing out users due dates and giving them a false sense of time left to complete the task. In the situation you are describing, I think it would make more sense to zero out the duration on the next task, so the due date is now, which accurate to the situation that has been created. The user is behind schedule and they do not have time to complete the task.
Ultimately this is where you want to see this happening, and then its the Project Manager's responsibility to adjust that duration by removing time from the other tasks.
Hopefully this helps.
Customer support service by UserEcho


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It always seemed to make sense that if I had
one star diagonal to correct up/down and then
another to fix left/right, the image should be
fully corrected...right?
So I built the simple arrangement,
and the test fonts read true, but the
way the image moved when I moved the scope
was disorienting...I even got dizzy/woozy.
Things did not move the way they should..
Maybe that's why you don't see people using this scheme.
I revisited this, months later (today).
I thought of it as a POV problem...if I changed
my point of view, maybe my brain would connect.
So...I stepped to the >>side<< of the scope and looked down
into the EP. Now things moved the way they should!
And it was just my POV that was messed up.
There is a virtual field to the side of the scope
that is the projection of the front view.
Feels natural, even though my mind has to
see something that is 90 degrees away.
And it only took standing to the side to feel right!
So...yes, you can use two star-diags to fully fix the view
(with no star spikes or phase hassle!)..
But....you have to change (physically) your point of view!
Edited by MartinPond, 13 December 2019 - 03:59 PM.


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We Are Charismatic!
December 9, 2012 Speaker: Tom Rempel Series: Wake Up
Topic: Sunday Morning Passage: 2 Corinthians 12
- Listen
- Downloads
More in Wake Up
May 26, 2013Man Up, For Heaven's Sake!
May 19, 2013As The Papyrus Runs Out
May 12, 2013We Must Be Changed, We SHALL Be Changed


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An in depth level of visibility and control is essential to an efficient, effective, and profitable manufacturing business. Unfortunately this is often times easier said than done. But cloud forecasting enables supply chain professionals to have just that and more. Utilizing cloud technology in your supply chain allows you to quickly gain end-to-end visibility in your supply chain and grant you optimal control through automation, real-time data, compliance, and much more so you can focus on innovation and quickly getting your products to market. Continue reading
Tag Archives: cloud supply chain
e2b anytime apps Announces Anytime Supply Chain Software for Intuit QuickBooks, Sage 100 ERP, Sage 500 ERP, and Intacct Financials
Chardon, OH May 09, 2013- e2b anytime apps, a division of e2b teknologies, announced today the release of Anytime Supply Chain, a supply chain management suite for Intuit's QuickBooks, Sage 100 ERP (fka Sage MAS 90 and Sage MAS 200), Sage 500 ERP (fka Sage MAS 500), and Intacct Financials. The cloud solution is provided as a Software as a Service (SaaS) subscription for distributors and manufacturers who need a better way to plan purchase orders and manufacturing work orders. Continue reading


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Mopar 2011 Challenger SRT-8 6.1L (Manual) Cat-Back Exhaust System, w/ New GTX Tips P5155957
Weight:50.0 lbs
Installation Skill Rating:
Manufacturer:Mopar Performance
Price: $1,985.00
Mopar 2011 6.1L Cat-Back:
Mopar's P5155957 is a Cat-Back Exhaust System, with Dual Rear Exit w/ New GTX Tips for the 2011 Dodge Challenger 6.1L SRT-8 (Manual). It comes with a Limited Lifetime Warranty, bolt-on installation, 304L stainless steel construction, RSC technology, and straight-through design. The included RSC(Reflective Sound Cancellation) technology eliminates interior drone.
- Dodge Challenger 6.1L SRT8 Manual 2011
- Straight-through. nonrestrictive design tuned specifically for the vehicle.
- Patented Reflective Sound Canceliation™ (RSC™) Technology ELIMINATES interior drone.
- 304L stainless steel construction. crafted with pride and precision in the USA.
- Dual rear exit with handcrafted. etched tips for enhanced appearance.
- No welding required; Bolt-on installation.
Additional Options:
Popular HEMI Performance Parts:


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Product Description
A 32 oz. deli container colonized with Pearl oyster mushroom mycelium, Pleurotus ostreatus, ready to start producing mushrooms in a matter of days. Instructions included.
This is a high-performing commercial strain, blue-gray in color with pale gray stems. I am starting pots now for shipment in mid-December – just in time for the holidays! Order now to make sure you get yours.
This is a beta-test release of the product. I don't expect to sell it for this low price for long, so help me out by trying it, and send me a picture and/or description of how it worked for you and I'll send you a coupon for a steep discount on your next purchase!
- Weight: 1.5 lb
- Width: 4.5 in
- Depth: 4.5 in
- Height: 5.5 in


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Teachers Get a Nice Welcome
Teachers in one Kentucky school district started the school year with a nice surprise. An anonymous woman had given each of the 143 teachers in Pendleton County $100 to buy supplies. She said that teachers "give so much more than they are compensated," and wanted to support them. Teachers are the best!


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BCH Booth at the musical event : Junoon 3- Experience Bollywood like never before
Musical night by Junoon & the proceeds will be donated to Breast Cancer Hub. Breast Cancer Hub is going to have an educational booth at the event and we would like to have student volunteers (middle school & above) or adult volunteers to speak about early detection & preventable measures & give out the handouts. Our BCH ambassadors can count the time as volunteer hours.
Marvin Ridge High School
Waxhaw,, NC 28173United States
February 23, 2020 -
4:00pm to 8:00pm


text: In Omaha, the Greek culture runs deep. And what better way to celebrate that culture than to attend the Omaha's Original 2019 Greek Festival? From delicious foods to tons of dancing to endless culture and entertainment, this is an event you want to make sure you make it out to... [read more]


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Learning & Development Coordinator
MALDIVES Sales
Job description
Learning and Development Coordinator is responsible for identifying and providing training to internal customers to deliver an excellent staff experience while working with and ensuring that all departments are achieving their training objectives.
What will I be doing?
As a Learning and Development Coordinator, you are responsible for identifying and providing training to internal customers to deliver an excellent staff experience. A Learning and Development Coordinator will also be required to assist departments in achieving training objectives. Specifically, you will be responsible for performing the following tasks to the highest standards:
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employee sign-ups and preparation of materials including certificates of completion
· Assist HR Department with recruitment and hiring of new team members
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· Identify training and development needs systematically throughout the hotel in conjunction with Line Managers/Head of Department, HR Manager, and Training Manager
· Assist Line Manager/Head of Department in achieving training objectives and review on a monthly basis
· Prepare, organize, administer and conduct in-house training courses i.e.. Recruitment and Selection, Discipline and Grievance
· Ensure new employees have received departmental and legal training
· Hold monthly Departmental meetings with trainers to ensure training needs are being covered
Ideal candidate profile
Qualifications :
What are we looking for?
A Learning and Development Coordinator serving Hilton brands is always working on behalf of our Guests and working with other Team Members. To successfully fill this role, you should maintain the attitude, behaviours, skills, and values that follow:
· Previous experience in HR/training
· Positive attitude
· Good communication and people skills
· Committed to delivering a high level of customer service, both internally and externally
· Excellent grooming standards
· Flexibility to respond to a range of different work situations
· Ability to work under pressure
· Ability to work on their own or in teams
It would be advantageous in this position for you to demonstrate the following capabilities and distinctions:
· CIPD qualified
· Knowledge of hospitality
What will it be like to work for Hilton?
Hilton is the leading global hospitality company, spanning the lodging sector from luxurious full-service hotels and resorts to extended-stay suites and mid-priced hotels. For nearly a century, Hilton has offered business and leisure travelers the finest in accommodations, service, amenities and value. Hilton is dedicated to continuing its tradition of providing exceptional guest experiences across its global brands . Our vision "to fill the earth with the light and warmth of hospitality" unites us as a team to create remarkable hospitality experiences around the world every day. And, our amazing Team Members are at the heart of it all!


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Basic Archery Instructor Course 2020
Basic Archery Instructor Course
USA Archery & NFAA, (formerly Level 1 Course)
This course is for adults who would like to run an archery program for their Troop or Crew, and to be Archery Merit Badge counselors. Upon completion, students will receive the Level I Archery Instructor certification, instructor card (valid for 3 years), the Instructor's Manual, and a Longhorn Council Archery Instructor's patch.
Open to registered BSA adults or youth age 18 and older, and to other participants with instructor's permission.
Saturday 8:30 a.m. – 6:00 p.m. AND
Sunday 8:30 a.m. – 1:00 p.m. (approx.)
Class Size is limited to 20 participants.
Lodging: You may camp at no cost. Food is not provided. Note that tobacco and alcohol products are not allowed on Scout ranches. Personal firearms are not allowed, and archery equipment may only be brought with the instructor's approval.
Those seeking re-certification (with proof of prior certification) need to contact Don Goldston (email@example.com or 817-403-4885) directly for a one-day class that Saturday.
Sid Richardson Scout Ranch
Friday 09-25-2020 8:30 AM CT to
Saturday 09-26-2020 1:00 PM CT
Coords: 33.1972058, -97.9017577
Boy Scout Rd
Runaway Bay, Texas 76425
Phone: 817-233-6760
Registration Closed:


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Visceral Vessels and Aortic Repair pp 147-161 | Cite as
Physiopathology of Intraoperative Visceral Ischemia and Anesthesiological Management of Supravisceral Aortic Clamping
- 486 Downloads
Vascular surgery, in which a supraceliac aortic clamp is required, is at highest risk of visceral ischemia and postoperative complications. The interruption of the blood flow to the organs, secondary to the artic cross-clamp, triggers cellular and molecular alterations with local and systemic effects. In particular, the tissues distal to the clamp become ischemic with a shift from aerobic to anaerobic metabolism. Since the reperfusion, following aortic clamp removal, may further increase the organ damage of the ischemic tissues, an ischemia/reperfusion (I/R) injury is usually observed during aortic surgery. The I/R injury is responsible for an extensive systemic inflammatory response which may trigger postoperative multi-organ failure. Polymorphonuclear neutrophils, oxygen radicals, nitric oxide, complement system, and cytokines are mainly involved in this double pathophysiological phenomenon.
In light of this, any technique, strategy, or drug able to mitigate the I/R injury may significantly affect the outcome. Although several perioperative medications have been proposed, the results remain elusive. On the contrary, left heart bypass, CFS drainage, and avoidance of nephrotoxic drugs, together with a maintenance of a mean arterial pressure above 80 mmHg, have shown to be the only measures effective in reducing perioperative morbidity and mortality.
14.1 Introduction
In patients undergoing aortic surgery, visceral ischemia is the leading cause of visceral dysfunction and injury [1, 2]. In fact, acute kidney injury (AKI), spinal cord ischemia (SPCI), and bowel ischemia are catastrophic complications which may occur during surgical procedures involving the supra- and juxta-renal aorta cross-clamping [2, 3]. Because of the fact that the higher the extent of the surgical aortic repair, the greater the risk of organ dysfunction, thoracoabdominal aortic aneurysm open repair (TAAAr) is more prone to developing visceral ischemia than infrarenal abdominal aortic aneurysm [1, 3]. The application of the aortic clamp, decreasing the blood supply to the organs, is associated with extensive physiological changes which may affect patient outcomes. Therefore, it is important for surgeons and anesthesiologists to understand the pathophysiologic changes occurring during aortic cross-clamping in order to mitigate the deleterious effect of ischemia-reperfusion injuries.
14.2 Physiopathology of Intraoperative Visceral Ischemia
Vascular surgery, in which the aorta is clamped proximally to the celiac artery, is one of the few surgical procedures producing ischemia of the liver, bowel, kidneys, spinal cord, and inferior limbs contemporarily. Aortic cross-clamping produces rapid hemodynamic changes and induces ischemic insults. Following the aortic clamp removal, the reperfusion itself may lead to a sudden drop in blood pressure and cellular damage. Therefore, aortic surgery shows double physiological phenomena named ischemia/reperfusion (I/R) injury which is the major determinant of an extensive systemic inflammatory response and the trigger for postoperative multi-organ dysfunction (MODS) [4, 5]. In particular, after aortic clamping in the district distal to the aortic clamp, visceral tissues suffer a sudden decrease of the blood flow with an acute hypoxic insult, shift from an aerobic to an anaerobic metabolism, production of lactate, and development of acidosis [6]. At the same time, cellular membranes increase their permeability, leading to cellular swelling [4, 7, 8]. Following aortic clamp removal, the reperfusion of tissue is responsible for additional injuries on the top of ischemia [4, 5, 6, 7, 8]. In some instances, the reperfusion damage may exceed the original ischemic injury; in fact, the restoration of the blood flow account for the activation of several inflammatory pathways and biochemical changes [4]. In the I/R syndrome, polymorphonuclear neutrophils, oxygen radicals (ROS), nitric oxide (NO), complement system, and various cytokines play a pivotal role, showing their effects in both re-perfused tissues and distal organs [9, 10]. The re-oxygenation enhances ROS production, which are associated with lipid peroxidation, complement activation, platelet aggregation, white cell activation, suppression of adenosine triphosphate synthesis, and inactivation of metabolic enzymes [10, 11]. Moreover, the ROS leading to the depletion of antioxidant reserves, disruption of cellular and mitochondrial membrane, derangement of intracellular electrolytes boost the phenomenon of apoptosis [12, 13].
A growing body of literature suggests that polymorphonuclear neutrophils play a central role in the pathophysiology of I/R [10]. In fact, the upregulation of adhesion molecules, chemoattractants, chemokines, and integrins due to I/R stimulates the migration of polymorphonuclear neutrophils from the postcapillary venules to the area of inflammation. Polymorphonuclear neutrophils, then, may disrupt the contiguous tissues by the secretion of proteolytic enzymes, production of free radicals, and microcirculation disarrangement [11]. Of note, the oxidative stress and ROS formation reach their peak during the ischemic attack (15–60 min of clamping), while PMN infiltration is at a maximum during reperfusion [10, 11, 12].
Notably, the NO has both cytotoxic and cytoprotective effects. In fact, it is an oxygen-free radical scavenger, maintains normal vascular permeability, inhibits the proliferation of smooth muscle, reduces PMN adherence, and decreases platelet aggregation [13]. However the release of large amounts of NO may account for tissue injury, bacterial translocation, mucosal apoptosis, and pulmonary injury [14, 15, 16].
The complement, acting together with ROS, NOS, and PNM, increases vascular permeability and tissue edema [17, 18, 19, 20]. It elicits a cascade of pro-inflammatory events with release of high concentration of TNF-α and interleukin (IL)-1 [18, 21]. Finally, the occurrence of edema in the interstitium of the injured organ further decreases the oxygen diffusion gradient from the microcirculation to the cells [9].
14.3 Postoperative Effects of Ischemia/Reperfusion Injury
Interestingly, the I/R injury has an effect on both the organs directly affected by the ischemia and the organs not involved in the ischemic insult, by a systemic release of inflammatory mediators [22]. Therefore, it is not surprising that during aortic surgery, along with the bowel and kidney, even the heart, lungs, and spinal cord may suffer I/R damage [4]. When the damage is extensive, multi-organ failure may occur [22, 23]. Each organ and apparatus has a specific sensitivity to I/R insult and deserves specific considerations.
14.3.1 Bowel
Since labile cells are settled at the tips of the villi and supplied by the end of the distribution of a central arteriole, they are much more vulnerable to the ischemia when compared to cells located within the crypts [24]. The various acute-phase proteins, hydrogen peroxide, hormones, and cytokines produced by intestinal mucosa during I/R injury have deleterious effects onto the intestinal microvasculature and may lead to bowel infarction, short-bowel syndrome, systemic inflammatory response syndrome, acute respiratory distress syndrome, and MOF [25]. Moreover, the impairment of the mucosal barrier allows the release in the systemic circulation of the endotoxin which induces the systemic activation of PMN, complement, and clotting pathways and further increase of the mucosal permeability [26].
14.3.2 Kidney
Acute renal failure (AKI) during aortic surgery is multifactorial and it may occur as a result of I/R damage, hemodynamic changes, bleeding, acute heart failure, and cytotoxic agents [27, 28, 29, 30, 31, 32, 33, 34, 35, 36]. The level at which the aortic clamp is applied affects the renal perfusion [37]. In fact, it decreases by 80% in the event of the suprarenal aortic cross-clamping, while it decreases by 45% when the aortic clamp is infrarenal [38]. To counteract the decrease of the renal blood flow, an increase of the renal vascular resistance is mediated by the hormone angiotensin II which redistributes the blood flow away from renal medulla and cortex, significantly decreasing renal perfusion [28, 39]. This effect persists after aortic clamp removal, despite a normal mean perfusion pressure [40]. Similarly, the glomerular filtration rate and renal blood flow may remain impaired for a long period of time after the surgery [31]. Besides this, ROS, complement, IL-1, IL 6, and IL8 released by the damaged mesangial cells increase the local inflammation worsening the renal function [41].
14.3.3 Heart
Aortic surgery is associated with the highest risk of myocardial infarction and cardiovascular complications compared to other noncardiac-related surgeries [42, 43]. The reasons for that include the increase of afterload and preload associated with the aortic cross-clamp, massive bleeding with consequent volume shift, and inflammatory response following I/R injury of abdominal organs [22]. Several authors have proposed that IL-2, IL-1β, IL-6, IFN-γ, and TNF-α may affect the cardiac function [44]. In I/R injury of the heart, the NO is probably involved in the decrease of ventricular compliance [4]. The activation of the NO synthesis leads to higher NO concentration which significantly affects the cardiac adrenergic and cholinergic stimulation [4]. A ventricle with low compliance is "difficult to fill," and it is associated with lower cardiac output and impairment of the coronary blood flow due to a decrease in the aortocoronary pressure gradient. Moreover, the ROS released from the injured myocytes and endothelial cells promotes membrane damage, endothelial injury, and vessel permeability [45, 46]. The treatment of the diastolic dysfunction is challenging: in fact, the administration of exogenous inotropes/vasopressors may further decrease a microcirculation already impaired by the endothelial swelling, exacerbating the ischemic damage [46]. In addition, activation of the coagulation cascade, formation of microthrombi, platelet aggregation stimulated by the use of vasopressors, and accumulation of reactive neutrophils act together impairing the microcirculation and decreasing the myocardial perfusion [47].
14.3.4 Lungs
The respiratory function after aortic surgery is commonly impaired. While in the vast majority of cases, damage is moderate with nonsignificant clinical manifestations; in several circumstances, it may be part of MOF [22]. Since in a physiological state the pulmonary vasculature is a neutrophil reserve, the respiratory system is at the highest risk of developing an inflammatory response during aortic surgery [11]. In fact, it is particularly sensitive to the circulating cytokines released from several organs during the postoperative period [48]. The I/R damage releases "per se" cytokines, which activate the pulmonary endothelium, stimulate the leucocytes migration into the interstitial and alveolar space, and promote inflammation [22]. Similarly, the anaphylatoxins C3a and C5a play a role in increasing the pulmonary vascular tone, favoring capillary leakage, and activating the mast cells which release histamine [49, 50]. The most severe clinical respiratory manifestation of this "vicious circle" is the acute respiratory distress syndrome which is associated with refractory hypoxia and death in a high percentage of patients [51].
14.3.5 Spinal Cord
Spinal cord ischemia is one of the most dreadful complications in aortic surgery [1, 2, 3]. The abrupt interruption of the blood flow to the spinal cord leads to ischemic injury [52–56]. Even when the thoracic aorta is not involved (abdominal aorta aneurysm open repair), a profound shock may impair the medulla perfusion pressure causing SCI [53]. The pathogenesis includes oxygen-free radical-induced lipid peroxidation, intracellular calcium overload, leukocyte activation, inflammatory response, and neuronal apoptosis. All these factors acting together cause the disruption of the blood-spinal cord barrier, which in turn exacerbates the spinal cord edema, increases the leukocyte infiltration, and amplifies inflammation and oxidative stress [57].
14.4 Anesthesiological Management of Supravisceral Aortic Clamping
Given the complexity of the physiopathology of the visceral ischemia in procedures involving supravisceral aortic clamping, the aim of the anesthesiological management is to avoid the hemodynamic fluctuations which may induce irreversible damage to organs and apparatus.
14.5 Hemodynamic Response to Cross-Clamping
Following aortic clamp removal, a transient increase in CO2 is commonly observed due to both CO2 washout from the ischemic tissues into the systemic circulation and increased CO2 production secondary to increased oxygen consumption of the re-perfused tissues [58, 59]. Carbon dioxide causes further vasodilation [68].
Hypotension after aortic cross-clamp release can be prevented and treated with volume loading, infusion of vasoactive medications, prompt treatment of metabolic abnormalities, and gradual release of aortic cross-clamp. In this dynamic setting, the anesthesiologist has to continuously assess the patient's global hemodynamic status, integrating cardiac function, intravascular volumes (estimated from transesophageal echocardiography, filling pressures, or both), blood loss, and the total amount of fluid administered [59, 60]. Moreover, adequate tissue perfusion is based on the availability of oxygen delivered. In situations where the blood flow is suboptimal, an arterial oxygen saturation as high as possible and a hemoglobin concentration above 10 g/dL are mandatory [69].
14.6 The Distal Perfusion Technique as a Strategy to Prevent Visceral Ischemia
There is no agreement on which is an adequate distal perfusion pressure when the LHBP is used. Some authors, for instance, suggest that a flow as high as 40 mL/kg/min is adequate to guarantee an optimal distal perfusion. On the contrary, others report that a flow ranging between 1.5 and 3 L/min with a mean femoral artery pressure of 70 mmHg can be considered sufficient for organ perfusion [81]. As practical rule, during aortic cross-clamping, a distal aortic pressure above 70 mmHg and a proximal perfusion pressure above 90 mmHg can be considered optimal for organ and spinal cord perfusion. Further indices of optimal organs perfusion are renal output above 1 mL/kg/h without diuretics and no lactate production [61].
14.7 Strategy to Prevent Postoperative Organ Dysfunction in Visceral Ischemia
Although the distal perfusion technique mitigates the effects of visceral ischemia, postoperative complications due to organ hypoperfusion remain relatively high [1, 2, 3, 4]. Several strategies have shown to be effective in mitigating organ ischemia following aortic clamp.
14.7.1 Renal Protection
Postoperative acute kidney injury (AKI) after vascular surgery is a major cause of morbidity and mortality [33, 82]. The etiology of renal failure in the setting of vascular surgery is multifactorial [83]. Ischemic injury (clamp time), nephrotoxic agents (antibiotics, anesthetic agent, contrast media, diuretics, myoglobin), and pre-existing renal failure are major factors related to the development of acute renal failure after aortic surgery [31, 34, 83, 84, 85]. In light of this, the avoidance of nephrotoxic insult, prevention of renal hypoperfusion by adequate cardiac output, and MAP have recently been reported as the only measures effective in decreasing the incidence of AKI [86, 87, 88]. On the contrary, the use of drugs such as dopamine and fenoldopam is not able to prevent perioperative renal dysfunction [89, 90, 91]. Since methylprednisolone, at a dosage of 30 mg/kg, may be a scavenger of free radicals with immunomodulatory proprieties, some authors have postulated that its administration may prevent renal ischemia/reperfusion injury [92, 93, 94, 95]. Unfortunately, the results are elusive [96]. Even mannitol (0.5 g/kg), which theoretically has a favorable profile in terms of renal failure prevention due to the induction of osmotic diuresis, the prevention of tubular obstruction, the decrease of epithelial and endothelial cell swelling, the action of free radical scavenger, and the stimulation of the synthesis of intrarenal prostaglandin with a renal vasodilation effect, has shown to be ineffective in preventing AKI [86, 97]. Moreover side effects such as volume depletion and an increased medullary consumption of O2 are very well known and may have a detrimental impact on renal function [98].
14.7.2 Spinal Cord Protection
Paraplegia caused by ischemic spinal cord injury is a devastating potential complication of aortic surgery [1, 99, 100]. Patients with SCI have poorer long-term survival compared to those who do not [1]. The position of aortic cross-clamping may affect the spinal cord perfusion, with the highest risk during extent II repair (7–10%) and the lowest risk in extent IV (1%) [1, 54, 55]. During surgery, the maintenance of a spinal cord perfusion pressure (SCPP) above 80 mmHG may prevent the development of paraplegia [101, 102]. Notably, the SCPP is the difference between the MAP and the cerebrospinal fluid (CSF) pressure. Interestingly, CSF pressure is influenced by the central venous pressure (CVP). After surgical occlusion of the spinal arteries, the perfusion of the spinal cord depends on the collateral network fed by hypogastric arteries, internal thoracic arteries, and branches from the subclavian arteries. The SCPP is a balance between the driving pressure affected by MAP, cardiac output, and blood volume and outflow pressure which depends on CSF and venous pressure. An increased CVP is associated with higher pressure in the extensive vertebral venous and impairment of spinal cord outflow. For the reasons mentioned above, the use of LHB, inotropes, and vasopressor, acting on the MAP and CVP, prevents paraplegia. The use of CSF drainage has been shown to decrease the risk of paraplegia reducing the CSFP [103]. In a large randomized controlled clinical trial the CSF drainage strategy in patients undergoing TAAA open surgery has shown an 80% decrease of postoperative paraplegia rate [104]. Recently Tshomba et al. observed that the use of the LiquoGuard automated device (Möller Medical GmbH, Fulda, Germany) during TAAA open repair is safe and effective in maintaining the desired CSF pressure values with a significant reduction in complication rates when compared with a standard catheter connected to a dripping chamber [105].
Somatosensory-evoked potentials are used to monitor the integrity of the posterior (sensory) spinal cord, and motor-evoked potentials (MEPs) are used to monitor dysfunction of the anterior (motor) spinal cord, detecting the spinal cord ischemia during the surgery [106, 107, 108]. Hypothermia has protective effects on the spinal cord and central nervous system by reducing both metabolic rate and oxygen requirement [109, 110].
14.7.3 Heart
Markers of left ventricle dysfunction are wedge pressure above 15 mmHg, ejection fraction below 50%, and left ventricular outflow tract velocity time integral below 20 cm/s with good RV function. In transgastric midpapillary short-axis view, the TEE allow to identify whether the hypotension depends on low preload (papillary kissing) or poor contractility (increase end-diastolic diameter) (Videos 14.3 and 14.4). Poor contractility is managed with epinephrine or dobutamine. Mean arterial pressure is a critical factor, and it is not unusual to observe a significantly altered ST segment and regional wall motion abnormalities with low MAP that become almost normal with adequate systemic perfusion pressure. When the increased afterload is associated with a systolic ventricular dysfunction, "inodilators" are suggested, while with an almost normal systolic contraction brief, acting vasodilator drugs (nitroglycerine) are recommended. As proximal aortic hypotension compromises the perfusion to collateral-dependent tissue beds distal to the aortic clamp, the use of short-term drugs are recommended. Short-acting beta-blockers are preferred agents when a hypertensive episode is associated with tachycardia.
14.7.4 Abdominal Viscera
Surgical occlusion by aortic clamp of the celiac axis and superior and inferior mesenteric leads to hypoxia of the abdominal viscera. The clamping time plays a pivotal role in the development of visceral ischemia, and the adoption of the selective perfusions of the visceral arteries with warm blood mitigates this phenomenon [78]. Even a transitory period of bowel ischemia, affecting the mucosal integrity, promotes the translocation of intestinal bacteria into the circulation promoting systemic infection and sepsis.
With the aortic clamp release, the washout of both the endotoxins produced by intestinal bacteria and the cardio-depressant metabolites from the ischemic area contributes to the systemic vasodilation and hemodynamic instability observed after visceral reperfusion [16]. Therefore, acid-base alterations occurring throughout the surgery should be promptly treated even by the administration of sodium bicarbonate.
In addition, visceral ischemia may be associated with systemic coagulopathy due to increased intestinal permeability, bacterial translocation, hepatic ischemia, and primary fibrinolysis. Therefore, the use of antifibrinolytic such as tranexamic acid or aminocaproic acid is strongly suggested [18].
14.7.5 Lungs
Postoperative pulmonary complications are common after aortic surgery [1, 3]. In addition to surgical trauma, diaphragm incision, and need of the one-lung ventilation (OLA), lung manipulation, blood transfusion, and fluid overload are very well-recognized risk factors. Furthermore, preoperative risk factors, such as COPD and history of smoking, significantly increase the chance of postoperative lung dysfunction. With this in mind, the adoption of a "protective ventilation" with low tidal volume, higher levels of positive end-expiratory pressure, and low plateau pressure is able to decrease the occurrence of acute lung injury [113]. However during the OLV, the priority is to guarantee oxygen saturation above 90%. A drop in oxygen saturation may lead to a significant decrease in the delivery oxygen with relative tissue hypoxia. A parsimoniously administration of blood products contributes to decreasing the risk of transfusion-related acute lung injury and transfusion-related immune modulation. To avoid large-volume transfusion, a ROTEM-guided protocol may be useful. Further studies are needed to confirm this data.
14.8 Conclusion
Visceral ischemia during supraceliac aortic cross-clamp is a multifactorial complex syndrome associated with an increased risk of developing severe postoperative organ dysfunction, requiring therefore an extensive and detailed anesthesiological and surgical workup. Often, visceral ischemia is devious, and only a prompt treatment may avoid severe postoperative complications. For all these reasons, adequate preoperative assessment and risk stratification, a skillful anesthetic technique, a meticulous intraoperative monitoring, and an appropriate postoperative course are all necessary measures to guarantee an uneventful procedure and avoid potentially fatal complications.
Supplementary material
Midesophageal four-chamber view. Severe right ventricle dysfunction (WMV 1325 kb)
Midpapillary transgastric view. Severe right ventricle dysfunction with left ventricle D-shape (WMV 1568 kb)
Midpapillary transgastric view. Severe left ventricle dilation and systolic dysfunction (AVI 1916 kb)
Mid-transgastric short-axis view. Empty left ventricle with papillary muscles "kissing" (AVI 14042 kb)
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