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On my bookshelf, I have a book that I've been meaning to read called Kisses From Katie. It's about a 18 year old who left her comfortable upbringing in the United States and went to Uganda, adopting thirteen children and establishing a ministry that feeds and sends hundreds more to school while teaching them about Jesus. Her story (although I haven't yet read it) seems similar to that of Maggie Doyne, a 23 year old mother of 30 formerly orphaned children in Nepal. Although watching the video evoked many thoughts and much introspection, I couldn't help but think about how I would survive if I were living in Nepal. When I saw the little boy holding the goat, the first thought that came to my mind was, "What would I eat if I were there?" I suppose my life would consist of eating all of the edible plants that I could get my hands on, and seasoning them with… salt I guess? Not a very appetizing prospect. And what would I do about my protein source? Where would I find nuts and beans? Then it hit me. It's a privilege to think this way. It's a privilege to eat the way that I do. It's a privilege to be vegan.
We often hear about white privilege and male privilege and heterosexual privilege and American privilege, but we don't talk about vegan privilege. Because that's what it is – a privilege – a privilege denied to most and afforded and affordable to but a few.
It's a privilege to be able to shop for pricier food at Whole Foods or your local natural health food store. It's a privilege to have the choice not to eat meat since, in many parts of the world, meat is a necessary and accessible staple in one's diet. It's a privilege to have a "seasoning cabinet" like I do, to choose between Herbamare or kosher sea salt or Himalayan sea salt or iodized table salt.
It's a privilege to have such a wide variety of food to choose from when I go into a grocery or health food store. It's a privilege to live somewhere where I can easily have a special diet. One of my good friends is a vegetarian, and when she went to Nigeria for a wedding, she had to live off of rice, plantain and cassava. That's all that they could offer to a vegetarian. Being vegan or vegetarian is simply not an option in many places.
It's a privilege to live in a large city with health food stores within walking distance.
It's a privilege to have the choice not to buy animal based clothing or use honey.
It's a privilege to be able to afford my lifestyle.
Eating healthily (gluten-free, organic, locally sourced and/or in season) is, for the most part, expensive. Ever notice the placement of these health food stores? They are usually located in the downtown area, near to educated, financially well-off professionals and educated (and sometimes or somewhat radical) university students on campuses with their own food co-ops and vegan-friendly restaurants. That's their clientele. The only Whole Foods in Toronto is in the Bloor-Yorkville area on Avenue Rd – the most expensive residential area in the entire city and one of Canada's most exclusive shopping districts, close to the financial heart of Canada (update June 2015 — they now have one at Yonge and Sheppard in another affluent area of North York). On the contrary, there are very few health food stores in Scarborough (where I'm from) – a Torontonian borough filled with low-income and middle-income immigrant populations and humble townhouses in the suburbs.
Maybe it's just me, but health food stores do not have sales very often. Or maybe it's not me. A Big Mac costs less than one of my favorite burgers at a vegan restaurant. Lays chips are cheaper than Kettle chips. A Swanson meal is more "time efficient" than making a brown rice, vegetables and tempeh stir-fry. The Standard American Diet (SAD) is sad and it is killing us but it sadly becomes a viable option if we are hard-pressed financially. If we compare apples to apples here, we soon realize that although one of the apples may not be the best for us, it is more readily accessible. I remember what my mom told me one time: "I would go vegan, but it's too expensive." Maybe it was my fallible witness – I don't know. But I do know that to eat the way I do is just not feasible for low-income families in Canada or in Nepal or in many other places in the world. Some people don't have the opportunity to think about whether or not food is organic. Rather, they wonder whether buying bread means that they cannot buy milk this week. Some of us ask, "Is it gluten-free?" while many others have to ask, "Is it free?"
These are just my thoughts.
We should think more about this before we go zealously foisting our eating habits on others (something that many vegans need to stop doing), turning veganism into a cult, acting as if there are tenets to which one should vehemently adhere, and shunning (or, at least looking contemptuously onto) those who do not comply.
I am truly happy with the way that I eat and what I eat, but I must never take my prerogative for granted.


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Land Rule Reversed
Senate Resolution Keeps Local Control of Public Lands
OMAHA (DTN) -- President Donald Trump is expected to sign a Congressional resolution to overturn an Obama administration rule approved in December that would have changed the way public lands are managed in the West.
The U.S. Senate on Tuesday passed a resolution to kill what is known as the U.S. Bureau of Land Management Planning 2.0 rule, seen by Western land interests as taking away local control of public lands and giving the federal government more control.
Farmers and ranchers in the West have been concerned the rule would run contrary to Congressional intent for the BLM to promote multiple land uses in the West.
"This is strike two for 2.0," Dave Eliason, a Utah rancher and president of the Public Lands Council, said in a statement.
"Streamlining is needed in the planning process, but not at the expense of input from local communities and permittees or elimination of economic analysis requirements. The final rule also shifts away from BLM's mission to protect multiple uses of public lands, and it disregards both local input and economic analysis. We look forward to the president quickly delivering the third strike by signing this resolution so that BLM may begin a new, inclusive process."
In a Jan. 24, 2017, letter to Senate Majority Leader Mitch McConnell, R-Ky., and Speaker of the House Paul Ryan, R-Wis., the American Farm Bureau Federation and a number of farm bureaus in the West said the rule would undermine cooperative federalism on land management.
"Land management decisions and permitted uses under the agency's regulatory philosophy are vitally important to Western economies," the letter said.
"Western states and rural communities depend on their ability to use public lands for grazing, timber harvest, mining, energy development and recreation. The BLM, during the final days of the Obama administration, finalized a new rule specific to land-use planning on BLM-managed public lands. The rule demonstrated a clear overreach by the BLM, in spite of the agency's claim that the 'primary goal of the proposed rulemaking process is to improve the agency's ability to respond to environmental, economic and social changes in a timely manner.'
"... Under the guise of 'climate change' and 'landscape-scale' management, the agency's final rule will allow implementation of unilateral management schemes, mitigation, adaptive management and other internal agency pronouncements. As a group, we the undersigned are concerned that the Planning 2.0 rule will diminish the statutory requirements of multiple use and dismantle the cooperative ideals of federalism."
Congress used the Congressional Review Act, which gives the House and Senate 60 legislative days after a new rule becomes final to approve a joint resolution of disapproval. Once the resolution is signed by the president, the repeal becomes official. The House already passed the resolution of disapproval.
U.S. Sens. Mike Enzi and John Barrasso, R-Wyo., said in statements the resolution returns power to Western states.
"If you are from the West, you understand the great impact that rules over federal land management can have, whether you are dealing with grazing, energy and mineral development, or recreation. This Obama administration rule, finished right before he left office, would shift the power away from state and local government and into the hands of Washington, D.C.," Enzi said.
"In Wyoming, almost half of the land is owned by the federal government and most of that is overseen by the BLM. We should be empowering state and local voices in land management processes, not trying to sideline them. The current land management program has issues, but this is not the fix we need."
Barrasso said: "The Obama administration's BLM Planning 2.0 rule would have done more harm than good. We need to make management plans more cohesive among local offices, but giving local decision-making authority to the director's office in Washington, D.C., is not the answer.
"Wyoming, not Washington, is in the best position to ensure local land-planning decisions are right for our natural resources, wildlife, and communities. These local plans must include key input from county commissioners, sportsmen, local businesses and those who interact daily with these landscapes."
The action was hailed as a victory by the oil industry because it would make it easier to expand oil and natural gas production on public lands.
American Petroleum Institute Upstream and Industry Operations Group Director Erik Milito said in a statement to DTN the resolution creates market certainty.
"A balanced approach to resource management planning is imperative," he said.
"The checks and balances of Congress can help to foster oil and natural gas production, which benefits American consumers and strengthens our national security."
Todd Neeley can be reached at firstname.lastname@example.com
Follow him on Twitter @toddneeleyDTN
Copyright 2017 DTN/The Progressive Farmer. All rights reserved.


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Topic: Coronavirus and Pro/NCAA Sports; Marcus Smart tests positive (Read 58754 times)
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since the Link3 branch is merged into master we get a nasty build failure on Travis for clang. It's caused because boost::shared_ptr doesn't accept a std::unique_ptr as argument.
I am not sure what exactly the reason is. It could be that the boost version (1.55) is too old or the clang version (5.0) doesn't support certain features of C++11. Since the gcc builds for the same boost version don't fail I guess the culprit rather must be the clang compiler.
In either case the used Ubuntu system is 14.04 which is not supported any more. I wonder if we can upgrade the minimum Ubuntu version to 16.04.
Helpful would be also to upgrade the used OCCT version to 7.2 because this has fixed many warnings the clang compiler otherwise will complain about.
In the long-term I want to extend the list of warnings the compiler should complain about and therefore it would be good that the compiler won't report about issues of 3rd party libraries but only about FreeCAD code.


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Sturdee Residence is a beautiful upcoming development along Sturdee Road by developer - Sustained Land Capital. Sturdee Residences is within short walk to Farrer Park MRT, City Square Mall and upcoming Bendemeer MRT.
The recent announcement of the opening of the upcoming Downtown Line 2 will greatly benefit residents at the new Sturdee Residence because they can walk easily within 3 mins to the Bendemeer MRT station. The Downtown Line 2 is expected to open by 27 Dec 2015.
Sturdee Residence is strategically located in the city fringe that is not only near to the city, but also within short walking distance to eateries and amenities allowing owners of Sturdee Residences ultimate convenience and easy to rent to busy professionals working in the city.
More info at http://www.newpropertyreview.com/sturdee-residence/
Sturdee Residences next to Farrer Park MRT
District 8: Little India, Farrer Park, Serangoon Road.
New 6 digit postal code in District 8 : 20****, 21****
New 6 digit postal code in District 8 : 20****, 21****
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In the modern horror thriller A QUIET PLACE, a family of four must navigate their lives in silence after mysterious creatures that hunt by sound threaten their survival. If they hear you, they hunt you.
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Barb Fyvie is one of the Artists of Elk Run's painters. In the past she's been known for her amazing winter forest scenes, but these days she's excited to be doing more abstract work with the most amazing bright, bold colours.
I got to see a bit of her process when I visited her studio a couple of months ago and it was so inspiring to watch. I find her use of colour to be so gutsy and inspiring - I've always shied away from vibrant colour, but I am just so enamored with it in Barb's work!
I'm super sad this week because Barb is having to move out of her studio, which means I'm loosing my AER neighbour. Barb was the first Artist of Elk Run I met when I moved into my current studio. Her studio is just above mine and she welcomed me into the building and the area so warmly. She's been such an important part of the AER group; we are really hoping she'll move in to a new studio near by!
In the meantime, she has a big show coming up in October in Edmonton. Follow along with her on Instagram to see her current work and get more details about shows and what Barb is up to!
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Who We Are
CENTRA MONEY is a privately-owned Loan and Finance business and Authorised Credit Representative of an Australian Credit Licensee. It is part of The CENTRA WEALTH Group, a dynamic wealth creation and investment management business specialising in providing personal investment advice and planning services.
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text: When you open the door and walk into the room, it even smells like the 1960s. It reminds you of the old garage where your grandfather kept his twin Chevrolet Corvairs. But those aren't cars you smell. Those are computers. This is the "1401 Room" on the first floor of the Computer History Museum in Mountain View, California — the room where Robert Garner and his motley crew of volunteer technicians have spent the last decade reviving two of the massive IBM 1401 mainframe computers that littered the business world throughout the '60s and on into '70s. As the door opens, you can see not only the 1401s themselves, but the mechanical punch-card machine where they take instructions from the outside world, the towering drives where they store data on spinning spools of tape, and even the desk-sized printer where they funnel information onto good old-fashioned paper. There's a gentle hum in the room. You can feel the heat coming off the machines. And, yes, you can smell them too. Garner says it's the odor of the oils used in some of the mechanical equipment, including the printer and the punch-card reader. This assault on your senses is one of the chief reasons Garner and his cohorts have spent all these years restoring the two IBMs. They want to show a new generation what these machines were like -- and they want to show it as completely as possible. "This is the creation of a time machine," Garner says. "When people are here, experiencing this, it sparks their imagination. It transfers them back in time, but it also takes them forward in time. It makes them feel like they too can build new things." Garner and his team also work on the IBMs because it's fun. "Though you might say that people who do this kind of thing are crazy — and you wouldn't be wrong — we enjoy doing it together," says Stan Paddock, another member of the group. But Garner is right: there's a larger payoff. And you feel it as soon as you step into the room. In short, Garner and his team are historians — in the purest sense of the word. And thankfully, they're not alone. At the Computer History Museum, volunteers have toiled to revive a wide range of artifacts from an earlier age of American computing, including the IBM 1620 and the DEC PDP-1. Across the Atlantic, in Great Britain, the Computer Conservation Society has sponsored an even longer list of restoration projects, overseeing the revival of such seminal machines as the WITCH (the world's oldest digital computer) and the Colossus (used to crack German codes during the Second World War). And then there are hobbyists like Bill Degnan, people across the globe who spend their free time rebuilding whatever old machines they can get their hands on — and occasionally flaunting their work at events like the Vintage Computer Festival. Sadly, we can't show you what these machines smell like. Or what they sound like. Or what they feel like. But we can show you what they look like — or at least try. With the gallery of images above, we give you a few of our favorites. Above Behold, the 1401 Room. You can see the punch-card machine on the right, the tape drives against the wall at the back, the printer in the middle of the frame, and the 1401 itself on the left, with the blue stripe running across its top edge. This massive collection of machinery was the most popular business computer of the 1960s. Robert Garner — a modern-day IBM researcher who has also worked for such tech giants as Xerox and Sun Microsystems — bootstrapped the restoration project in 2008 when the Computer Museum History acquired the remnants of a 1401 from an outfit in Germany. He sliped an ad into a Silicon Valley newsletter for IBM retirees, and soon, he had a team of technicians with the know-how to rebuild the thing. A few years later, Garner was contacted by a man who who had a 1401 in his Connecticut home. This machine was built in 1961, but the man's family had used it to track expenses for the local country club through the mid-'90s. It was in slightly better shape than Garner's german 1401, so the museum bought it too. If you're a Stanley Kubrick fan, the printer may look familiar. It's an IBM 1403, which makes a cameo in Kubrick's Cold War black comedy, Dr. Strangelove. There's a 1403 at the Air Force Base where Sterling Hayden's General Jack D. Ripper unilaterally launches a nuclear attack on the Soviet Union, and his second in command, played by Peter Sellers, doesn't realize what has happened until he finds a transistor radio tucked inside the lip of the printer. If you visit the 1401 Room at Computer History Museum, you too will find a transistor radio — right where Sellers did. Images: Computer History MuseumThis is what you find when you open up the 1401 -- and it may help you understand why Robert Garner and his team have spent so many years repairing the thing. It's not the simplest of machines. And the team only meets on Wednesdays. Image: Computer History MuseumBig computer restorations are far more prevalent in the U.K. — as you might expect. "We have a history of history," says Google researcher John Wilkes, who grew up in Britain. According to Kevin Murrell, the secretary of the UK's Computer Conservation Society, the British have always had a certain affection for restoring old machinery -- from cars to trains -- and it only stands to reason that they would tackle computers too. Murrell was part of the team that restored the WITCH, a digital computer originally built in 1951 as a number-cruncher for the U.K.'s atomic research facility at Harwell. After six years at Harwell, it started a new life as a teaching tool at the nearby Wolverhampton and Staffordshire Technical College, and that's where it got the name. WITCH is short for Wolverhampton Instrument for Teaching Computing from Harwell. In the photo above, project leader Tony Fraser fine-tunes the WITCH inside Britain's National Museum of Computing at Bletchley Park. This past year, Fraser, Murrell, and the rest of the team actually rebooted the thing (see video below). Photo: John Robertson, for The National Museum of Computing. <script language="JavaScript" src="http://admin.brightcove.com/js/BrightcoveExperiences.js" type="text/javascript"></script> <object class="BrightcoveExperience" id="myExperience1982045137001"><param name="bgcolor" value="#FFFFFF"></param><param name="width" value="660"></param><param name="height" value="380"></param><param name="playerID" value="1577029897001"></param><param name="playerKey" value="AQ~~,AAAAAF1BIQQ~,g5cZB_aGkYZC26fBYKv5Nsnal0IamyGL"></param><param name="isVid" value="true"></param><param name="isUI" value="true"></param><param name="dynamicStreaming" value="true"></param><param name="@videoPlayer" value="1982045137001"></param></object> <script type="text/javascript">brightcove.createExperiences();</script>The WITCH — aka the Harwell Dekatron — as it appeared around 1963. It was built with gas-filled tubes and mechanical relays, and it weighed 2.5 metric tons. Photo: Wolverhampton Express & Star.Charles Babbage is known as "the father of the computer." Between 1847 and 1849, he designed a seminal calculating machine he called the Difference Engine Number 2. He never actually built the thing, but about 150 years later, Allan Bromley, Doron Swade, and others brought the machine to life at the London Science Museum. Photo: London Science MuseumIn the mid-1930s, Douglas Hartree of Manchester University built an early analogue computer known as the Differential Analyser. Eighty years on, Charles Lindsay — a noted computer scientist and programmer — helped restore the machine at the Manchester Museum of Science and Technology. Photo: Charles Lindsey, Manchester Museum of Science and TechnologyLindsey's Differential Analyser, as seen from above. Photo: Charles Lindsey, Manchester Museum of Science and TechnologyDuring World War II, the Colossus helped crack German codes at Bletchley Park, and Bletchley — reborn as Britain's National Museum of Computing — is now home to a rebuilt Colossus, completed in 2007. This is the rear of the machine. Photo: John Robertson, for The National Museum of Computing.And this is the Colossus from the front. The machine's original blueprints and hardware were destroyed after the war, but Tony Sale and his team were able to restore the machine using other materials, including notebooks kept by Bletchley engineers. Photo: John Robertson, for The National Museum of Computing.A look at some of the over 2,500 thermionic valves, or vacuum tubes, used in the restored Colossus. Photo: John Robertson, for The National Museum of Computing.But not all restorations find a home in a museum of computer history. This photo was taken inside the Delaware workshop of Bill Degnan, who belongs to a vintage computing restoration club known the Mid Atlantic Retro Computing Hobbyists, or MARCH. Degnan has restored more machines than we could possibly list, and this is one of them: a Vector Graphics MZ, originally built around 1980. Photo: Bill DegnanBill Degnan's IMSAI, a machine that made its debut in the mid-1970s. Here, he's talking to the machine using a Digital Decwriter II printer. A glass display would be too easy. Photo: Bill DegnanThe 1972 DEC PDP 11/05 that Degnan restored from old parts. Photo: Bill DegnanDegnan is also involved with the Vintage Computer Festival, where hobbyists from around the globe show off their old-school machines. This is an ASR 33 Teletype that Degnan restored and displayed at the seventh Vintage Computing Festival in 2011, at the Infoage Science Center in Wall, New Jersey. In the late '70s, a teletype was the standards means of trading information with the beefy computers of the day. It served as both keyboard and printer. Photo: Bill DegnanA "before shot" of a Friden Flexowriter, a teletype-like device that dates back to late 1950s and early 1960s. At the time, it was a radical departure — from punch cards. Photo: Bill DegnanAn IBM 1130 on display at Vintage Computer Festival 7. Photo: Bill DegnanA paper-tape reader used to read program data into a Burroughs minicomputer. Photo: Bill DegnanThe control console on the Ferranti Pegasus, believed to be the oldest working digital computer in the world. It wasn't restored to working condition. It was always in working condition, says Leonard Hewitt, who oversees the Pegasus at the London Science Museum. The system ran its first program in 1959 and Hewitt says it still runs on command. Photo: London Science MuseumA replica of the Manchester Mark 1 "Baby," on display at the Museum of Science & Industry in Manchester, England. The Baby made its debut in 1948 at the University of Manchester, the first computer to operate off a stored program. Image: Museum of Science & Industry.The Baby as it looked all those years ago. Image: Museum of Science & Industry.


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We're pleased to announce that Steve Sunshine has joined TruVisibility as Director of Marketing & Sales!
Let's let Steve introduce himself:
Hi everybody! I am excited to be part of such a forward-thinking company as TruVisibility. In my role as Director of Marketing & Sales, I am responsible for marketing our incredible AI-powered TruChat chatbot + live chat solution along with the full TruVisibility Digital Marketing product suite.
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Reader comment on item: How the West Could Lose
Submitted by Sohail (United Kingdom), Apr 6, 2007 at 10:46
The Iraq sanctions:
1 million to 2 million Iraqis may have died as a result of the sanctions, many of them children under the age of 5. This is more than were massacred in Rwanda in 1994, and on a par with the Armenian Holocaust of 1915-1919. UNICEF officials estimated in 2000 that 5,000 to 6,000 Iraqi children were dying each month primarily due to sanctions. That is equivalent to a World Trade Towers-scale calamity -- in a nation of only 18 million -- every month for the past decade or more.
This was a holocaust committed by the U.N and USA.
Instead of sanctions against Iraq, America could have removed Saddam during the first gulf war but there didn't. I wonder Why?
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1-Year Outcomes of FFRCT-Guided Care in Patients With Suspected Coronary DiseaseThe PLATFORM Study
Author + information
- Received March 25, 2016
- Revision received April 27, 2016
- Accepted May 3, 2016
- Published online August 2, 2016.
Author Information
- Pamela S. Douglas, MDa,∗ (pamela.douglas{at}duke.edu),
- Bernard De Bruyne, MDb,
- Gianluca Pontone, MDc,
- Manesh R. Patel, MDa,
- Bjarne L. Norgaard, MDd,
- Robert A. Byrne, MB BChe,
- Nick Curzen, BMf,
- Ian Purcell, MDg,
- Matthias Gutberlet, MDh,
- Gilles Rioufol, MDi,
- Ulrich Hink, MDj,
- Herwig Walter Schuchlenz, MDk,
- Gudrun Feuchtner, MDl,
- Martine Gilard, MDm,
- Daniele Andreini, MDc,
- Jesper M. Jensen, MDd,
- Martin Hadamitzky, MDe,
- Karen Chiswell, PhDa,
- Derek Cyr, PhDa,
- Alan Wilk, BSn,
- Furong Wang, MDn,
- Campbell Rogers, MDn,
- Mark A. Hlatky, MDo,
- on behalf of the PLATFORM Investigators
- aDuke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- bCardiovascular Centre Aalst, Aalst, Belgium
- cCardiovascular CT Unit, Centro Cardiologico Monzino, IRCCS, University of Milan, Milan, Italy
- dDepartment of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- eDeutsches Herzzentrum München, Technische Universität München, Munich, Germany
- fUniversity Hospital Southampton NHS Trust, Southampton, United Kingdom
- gFreeman Hospital, Newcastle upon Tyne, United Kingdom
- hUniversity of Leipzig Heart Centre, Leipzig, Germany
- iHospices Civils de Lyon and CARMEN INSERM 1060, Lyon, France
- jDepartment of Cardiology, Johannes Gutenberg University Hospital, Mainz, Germany
- kLKH Graz West, Graz, Austria
- lDepartment of Radiology, Innsbruck Medical University, Innsbruck, Austria
- mDepartment of Cardiology, Cavale Blanche Hospital, Brest, France
- nHeartFlow, Redwood City, California
- oDepartment of Health Research and Policy and Department of Medicine, Stanford University School of Medicine, Stanford, California
- ↵∗Reprint requests and correspondence:
Dr. Pamela S. Douglas, Duke Clinical Research Institute, 7022 North Pavilion, Duke University Medical Center, PO Box 17969, Durham, North Carolina 27715.
Background Coronary computed tomographic angiography (CTA) plus estimation of fractional flow reserve using CTA (FFRCT) safely and effectively guides initial care over 90 days in patients with stable chest pain. Longer-term outcomes are unknown.
Objectives The study sought to determine the 1-year clinical, economic, and quality-of-life (QOL) outcomes of using FFRCT instead of usual care.
Methods Consecutive patients with stable, new onset chest pain were managed by either usual testing (n = 287) or CTA (n = 297) with selective FFRCT (submitted in 201, analyzed in 177); 581 of 584 (99.5%) completed 1-year follow-up. Endpoints were adjudicated major adverse cardiac events (MACE) (death, myocardial infarction, unplanned revascularization), total medical costs, and QOL.
Results Patients averaged 61 years of age with a mean 49% pre-test probability of coronary artery disease. At 1 year, MACE events were infrequent, with 2 in each arm of the planned invasive group and 1 in the planned noninvasive cohort (usual care strategy). In the planned invasive stratum, mean costs were 33% lower with CTA and selective FFRCT ($8,127 vs. $12,145 usual care; p < 0.0001); in the planned noninvasive stratum, mean costs did not differ when using an FFRCT cost weight of zero ($3,049 FFRCT vs. $2,579; p = 0.82), but were higher when using an FFRCT cost weight equal to CTA. QOL scores improved overall at 1 year (p < 0.001), with similar improvements in both groups, apart from the 5-item EuroQOL scale scores in the noninvasive stratum (mean change of 0.12 for FFRCT vs. 0.07 for usual care; p = 0.02).
Conclusions In patients with stable chest pain and planned invasive coronary angiography, care guided by CTA and selective FFRCT was associated with equivalent clinical outcomes and QOL, and lower costs, compared with usual care over 1-year follow-up. (The PLATFORM Study: Prospective LongitudinAl Trial of FFRct: Outcome and Resource IMpacts [PLATFORM]; NCT01943903)
- economic outcomes
- fractional flow reserve using computed tomography
- major adverse cardiac events
- quality of life
Evaluation of chest pain is a common clinical problem, yet disagreement remains regarding optimal evaluation strategy, in part because of the many available testing options. Furthermore, most patients referred to elective invasive coronary angiography (ICA) are not found to have obstructive coronary artery disease (CAD) (1–4). The landmark PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial suggested that an evaluation strategy based on coronary computed tomographic angiography (CTA) was safe and clinically effective, but increased the rate of subsequent cardiac catheterization by almost 50% compared with functional testing (1). Moreover, despite a doubling of the rate of coronary revascularization after CTA, clinical outcomes in the PROMISE trial did not differ. In this context, it is notable that most interventions were performed without determining the functional significance of coronary stenoses, at variance with current practice guidelines (5).
A new noninvasive method uses routinely acquired CTA data to provide both anatomic and functional data about coronary stenosis, accurately estimating fractional flow reserve using computed tomography (FFRCT), on the basis of computational fluid dynamics and simulated maximal coronary hyperemia (6–9). In the PLATFORM (Prospective Longitudinal Trial of FFRCT: Outcome and Resource Impacts) study, we prospectively applied this method and demonstrated that, compared with usual care, FFRCT led to cancellation of 60% of planned ICA, a markedly lower rate of finding no obstructive CAD at ICA (from 73% to 12%) (10), and significantly lower 90-day costs of care in patients with a planned ICA (11). The present study tests the durability of these findings by comparing 1-year clinical, safety, economic, and quality-of-life (QOL) outcomes after FFRCT-guided management versus usual care. We hypothesized that compared to usual care, an FFRCT-guided strategy in patients with suspected CAD would continue to show low rates of major adverse cardiac events (MACE), similar QOL, and substantially lower medical resource utilization and cost.
PLATFORM was a prospective, consecutive cohort study whose design (12) and 90-day outcomes have been previously reported (10,11). Briefly, 11 European sites enrolled symptomatic outpatients ≥18 years of age without known CAD who had an intermediate likelihood of obstructive CAD (20% to 80%) and whose physician had planned nonemergent cardiovascular testing to evaluate suspected CAD. Relevant institutional review boards approved the study protocol, and all patients provided written informed consent.
Subjects in the first of 2 prospective cohorts received usual care testing as planned by their local clinicians, whether noninvasive or invasive (Figure 1). In the second, subsequently enrolled cohort, patients received CTA instead of planned noninvasive or invasive testing, followed by centrally performed FFRCT analyses if the CTA revealed ≥30% stenosis or if the patient was referred to ICA. Noninvasive and invasive diagnostic testing was performed and interpreted locally (10,12). Independent core laboratories performed quantitative coronary angiography and FFRCT measurements (7–9). Data provided to the clinical site included the lowest FFRCT numeric value in each coronary distribution and color-scale representations of the coronary tree showing FFRCT values in all vessels >1.8 mm in diameter (Online Figure 1). Local physicians made all subsequent clinical management decisions following standard practice including whether to alter care on the basis of FFRCT results. Optimal medical therapy was encouraged in all groups.
Clinical, economic, and QOL endpoints
The 1-year clinical endpoints were: 1) a composite of MACE (all-cause mortality, myocardial infarction [MI], and unplanned hospitalization for chest pain leading to urgent revascularization); and 2) MACE plus vascular events within 14 days of procedures. An independent clinical events committee adjudicated all MACE events in a blinded fashion using standard, prospectively determined definitions (13). Cumulative radiation exposure from all cardiovascular tests and invasive procedures was determined over the 1 year after enrollment, as previously described (10).
Use of key medical resources was tabulated from enrollment through 1 year, including CTA, noninvasive stress tests, invasive tests, coronary revascularization procedures, selected cardiac medications (aspirin, statins, antiplatelet medications), and clinical events. QOL was assessed at baseline, 90 days, and 1 year using the 7-item Seattle Angina Questionnaire (SAQ) (14), the 5-item EuroQOL scale (EQ-5D) with index calculation weighted for the United States (15), and the EuroQOL visual analog scale (VAS) (with 0 = worst and 100 = best health).
Cumulative medical costs over 1 year were calculated on a per-patient basis by multiplying a standardized cost weight for each medical resource by the number of times that resource was used (11). The 2015 Medicare reimbursement rates (national average of technical and professional fees) and online pharmacy costs for drugs were used as cost weights (Online Table 1). We did not discount costs over 1-year follow-up. Because the Medicare reimbursement rate for FFRCT has not yet been determined, in the base-case analysis we used a cost weight of zero to estimate the cost offset attributable to use of FFRCT—that is, the difference in subsequent costs between patients in the FFRCT strategy and in the conventional strategy. In sensitivity analyses, we recalculated 1-year costs after applying a series of cost weights for FFRCT that were multiples of the cost weight for CTA. We calculated "downstream costs" (i.e., those induced by the initial diagnostic test) by setting to zero the costs of the intended initial test (invasive stratum: ICA in the usual care arm or initial CTA in the FFRCT arm; noninvasive stratum: initial CTA or stress test).
Statistical analysis
Endpoints were compared between the FFRCT-guided and usual care management strategies separately in the planned noninvasive testing stratum and in the planned invasive testing stratum. Results were also compared in propensity-matched subpopulations created independently for the planned invasive and noninvasive groups using age, sex, diabetes, smoking status, and type of angina as predictors, applying a greedy matching algorithm (10,11).
Baseline characteristics were summarized and compared across usual care and FFRCT-guided care cohorts. Continuous variables were described as mean ± SD or median (interquartile range), and compared using the nonparametric Wilcoxon rank sum test. Categorical variables were summarized as counts (percentages) and compared using the Pearson chi-square test or Fisher exact test if cell frequencies were insufficient.
For economic analyses, unadjusted costs were compared in each stratum between strategies using the nonparametric Wilcoxon rank sum test on all patients and in the propensity-matched cohorts. A 95% confidence interval (CI) for the difference in mean per-patient cost between usual care and FFRCT-guided care cohorts was determined using empirical bootstrap resampling with 100,000 replicates. Additional information regarding the statistical analysis is in the Online Appendix.
All statistical assessments were independently performed by statisticians at the Duke Clinical Research Institute, and all patients were analyzed as allocated. Analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina). All preplanned comparisons of the secondary endpoints of this study are reported here, with no adjustment of the type 1 error rate made for multiple comparisons.
The 584 patients enrolled and consented in the PLATFORM study were followed for 12 months, including 204 in the planned noninvasive testing stratum (usual care noninvasive testing: n = 100; CTA followed by selective FFRCT: n = 104), and 380 in the planned invasive testing stratum (usual care [ICA]: n = 187; CTA followed by selective FFRCT: n = 193) (10). Patients averaged 60.9 years of age, and 40% were women. Other characteristics included diabetes (14%), hypertension (54%), history of smoking (54%), and dyslipidemia (35%) (Online Table 2). The mean pre-test probability of obstructive CAD was 49 ± 17%. Clinical characteristics were generally similar between the usual care and FFRCT-guided care cohorts and within the planned noninvasive and invasive test groups. One-year follow-up was obtained in 581 participants (99.5%), by clinic visit in 97.4%, and chart review in 2.1% (Figure 1). FFRCT data were measureable in 88% of studies; motion and misalignment accounted for 75% of failures, heavy calcification 13%, and missing data 13%. Comparison of FFRCT and invasively measured FFR in the 50 vessels in 29 patients for which both were available yielded an overall accuracy of 84.0% (95% confidence interval [CI]: 70.9% to 92.8%), similar to that reported in the NXT (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps) trial (9) (Online Table 3).
Planned invasive cohorts
In the planned invasive testing stratum receiving FFRCT-guided care, CTA was performed in 100% of patients, submitted for FFRCT in 134 cases (69%), and analyzed in 117 (60%). Among the 60% of patients who had a planned ICA cancelled, investigators reported that FFRCT data were considered in the treatment decision in 79%, including 55% of decisions based solely on FFRCT. Revascularization was performed in 28%, including coronary artery bypass grafting (CABG) in 5%. In comparison, in the usual care group, 100% had ICA as planned, resulting in a similar rate of 90-day revascularization (32%) and CABG (9%). The primary endpoint of catheterization without obstructive CAD at 90 days occurred in 12% of FFRCT-guided care and 73% of usual care patients, yielding a risk difference of 61% (95% CI: 53.0% to 68.7%; p < 0.0001) (10). Results were similar in the roughly one-half of patients in each strategy who had prior noninvasive functional testing before study enrollment: among those managed using FFRCT, the rates of no obstructive disease were 10% and 15% with and without prior functional testing, respectively; among those in the usual care group, the rates were 78% and 70%, respectively, including 79% for treadmill testing, 67% for stress echocardiography, and 84% for nuclear stress testing. Results were similar when analysis was limited to patients with typical angina or atypical angina (data not shown). Of note, at the time of revascularization, data regarding the functional significance of coronary stenosis were available in 95% of the FFRCT-guided group (56 of 59 revascularizations) versus 49% (32 of 65) of the usual care group.
Clinical outcomes and safety
During 1-year follow-up, 2 MACE events occurred in the FFRCT-guided care group, both within 90 days (1 periprocedural MI, and 1 hospitalization for urgent revascularization while awaiting CABG) (Table 1). Importantly, there were no events during 1 year of follow-up in the 117 patients whose planned ICA was cancelled on the basis of the CT/FFRCT findings, only 4 of whom underwent ICA during 1-year follow-up. Of these, 3 had no hemodynamically significant CAD at ICA and did not undergo revascularization, and 1 had percutaneous coronary intervention (PCI) for a circumflex lesion that had progressed to total occlusion over 9 months from an initial 50% to 70% lesion on CTA that had an FFRCT of 0.88. Of those who did have an initial ICA, 6 required a repeat ICA over the next 9 months, including 2 repeat PCIs. In contrast, in the usual care group, there were 10 repeat ICAs and 3 new revascularizations (2 PCI, 1 CABG). Vascular complications were infrequent (5 total).
In the usual care group, 2 MACE events (1 unexplained death and 1 nonfatal MI during cardiac surgery) and 2 vascular complications occurred over 1 year. The risk difference between the groups was nearly zero; however, there was insufficient evidence to conclude noninferiority due to low power (Table 1). The relative rates of MACE and vascular complications were unchanged in both groups in the propensity-matched cohort. Changes in medication use from enrollment to 1 year were similar in the 2 arms for aspirin (p = 0.56) and statins (p = 0.76) but were greater in the FFRCT-guided care than in usual care for P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor; p = 0.006). Cumulative 1-year radiation exposure in patients with an intended invasive evaluation was similar in the 2 cohorts (usual care mean: 10.4 ± 6.7 mSv vs. FFRCT cohort mean: 10.7 ± 9.6 mSv; p = 0.21).
Resource utilization
The mean 1-year per-patient cost of medical care was significantly lower in the FFRCT-guided strategy than in the usual care strategy ($8,127 vs. $12,145; p < 0.0001 [95% CI on the $4,018 difference: $1,590 to $6,577]). See Table 2 for resource use tabulation. Mean per-patient "downstream costs," excluding the costs of the initial tests, were $7,831 for the FFRCT group and $9,864 in the usual care group (p < 0.0001). More patients in the FFRCT-guided group had low costs (median = $546) than in the usual care group (median = $6,472) (Figure 2). The pattern of mean 12-month costs was similar whether patients had prior noninvasive testing ($8,534 vs. $11,228; p < 0.001) or did not ($7,680 vs. $13,033, p < 0.001). The cost difference at 12 months was slightly, but not significantly, greater among patients with atypical angina (interaction p = 0.16) (Online Table 4).
The difference in 12-month costs was similar in the propensity-matched cohort. The mean per-patient cost of the FFRCT strategy was 33% lower in the entire population and was also 33% lower in the 148 propensity score–matched patient pairs ($7,837 vs. $11,741; p < 0.001). In sensitivity analyses, we assigned a series of cost weights to FFRCT that were multiples of the cost weight for CTA. When the cost weight for FFRCT was set to 3 times the cost weight of CTA, the FFRCT-guided strategy had significantly lower costs in the invasive stratum ($8,812 vs. $12,145; p < 0.001). The FFRCT-guided strategy still had significantly lower costs at 1 year even when the cost weight for FFRCT was set to 15 times the cost weight of CTA ($10,861 vs. $12,145; p = 0.014).
Functional status and QOL improved from baseline to 12 months of follow-up in the planned invasive group, including mean increments of 21 units on the SAQ (p < 0.001), 0.07 units on the EQ-5D (p < 0.001), and 4.1 units on the VAS (p < 0.001). However, the improvements were similar in the patients in the FFRCT strategy and usual care groups (Figure 3). Findings were unchanged in the propensity score–matched population (data not shown).
Planned noninvasive cohorts
In the planned noninvasive testing stratum managed by FFRCT-guided care, CTA was performed in 100%, submitted for FFRCT in 67 patients (64%), and analyzed in 60 (58%). Catheterization was performed in 19 patients and revascularization in 10, compared to 12 and 5, respectively, in the usual care group. Catheterization without obstructive CAD at 90 days was found in 12.5% of FFRCT-guided care and 6.0% of usual care patients, a risk difference of –6.5 (95% CI: –14.4 to 1.4; p = 0.95) (Table 1). Results were similar when analyzed only in those patients with typical or atypical angina (data not shown).
Clinical outcomes and safety
One MACE event (a nonfatal MI) occurred in the usual care planned noninvasive group compared to none in the FFRCT-guided group over 12-month follow-up (Table 1), and only 1 patient had an ICA that was not performed as part of initial evaluation, due to myocarditis. In the FFRCT-guided group, 1 additional patient required an ICA after 90 days and 1 required repeat ICA; there were no additional revascularizations. In the usual care group, 3 additional patients required ICA and 1 PCI. Vascular complications were infrequent in both groups. The risk difference for MACE or vascular complications between groups was small; however, there was not significant evidence to determine noninferiority due to low power. Changes in medication use from enrollment to 1 year were similar in the 2 arms for aspirin, statins, and P2Y12 inhibitors (all p > 0.10). Cumulative 12-month radiation exposure in patients with an FFRCT-guided evaluation was higher than in the usual care cohort (mean: 9.6 ± 10.6 mSv vs. 6.4 ± 7.6 mSv; p < 0.001) as many patients received a noninvasive test that did not require the use of radiation.
Resource utilization
Mean 1-year per-patient costs of medical care were similar in the FFRCT-guided ($3,049) and usual care strategy groups ($2,579; p = 0.82 [95% CI on the $471 difference: –$2,129 to +$1,423]). Costs were relatively low overall in the noninvasive stratum, with median costs of $484 in the FFRCT group and $507 in the usual care group; the small minority of patients who had invasive procedures drove higher mean costs in both groups (Figure 1). Findings were essentially unchanged in the propensity score–matched population.
Mean per-patient "downstream costs," excluding costs of the initial tests, were similar: $2,755 for the FFRCT group and $2,260 in the usual care group (p = 0.47). In sensitivity analyses, a cost weight for FFRCT equal to that of CTA led to higher mean per-patient costs in the FFRCT group compared with the usual care group ($3,223 vs. $2,579; p < 0.01), as did a cost weight of 3 times that of CTA ($3,570 vs. $2,579; p < 0.001).
Functional status and QOL improved from baseline to 12 months of follow-up in the planned noninvasive group (p < 0.001 for all measures), with greater improvements in the FFRCT strategy group on the EQ-5D (mean change: 0.12 vs. 0.07; p = 0.02) with similar improvements on the SAQ and VAS scales (Figure 3). Findings were essentially unchanged in the propensity score–matched population (data not shown).
In this multicenter, prospective study of stable, symptomatic patients with suspected CAD, an evaluation strategy based on use of CTA selectively augmented by FFRCT was associated with a high rate of cancellation of planned invasive catheterization (Central Illustration); a significantly lower rate of ICA showing no obstructive CAD; improved information available to guide revascularization; and equivalent clinical outcomes, QOL, and radiation exposure as compared with a usual care strategy of ICA. Furthermore, the FFRCT-guided strategy was associated with significantly lower resource utilization and cost in patients with planned invasive evaluation. These findings suggest that the combination of anatomic and functional data provided by the FFRCT-guided testing strategy may safely reduce use of invasive catheterization and costs of care over 1 year in selected patients undergoing evaluation for suspected CAD.
Few adverse clinical events occurred over the year of follow-up in the entire PLATFORM cohort. Indeed, the overall 0.9% MACE rate at 12 months was lower than the 1.7% MACE rate at 12 months in the PROMISE trial using similar MACE components (1). These results suggest that the safety of an FFRCT-guided approach observed at 90 days (10) is durable over the longer term. These favorable clinical outcomes are further underscored by the absence of any late clinical events and only 1 late revascularization following an FFRCT-guided decision to cancel a planned invasive catheterization, comparing favorably to the 2 events and 3 late revascularizations seen in the usual care group. Of note, our finding that the vast majority of procedures and events were clustered in the first 90 days has not previously been documented using adjudicated events and has implications for trial design and reimbursement policy.
In the planned invasive stratum, FFRCT-guided management was associated with significantly lower costs over 1 year of follow-up. The absolute difference in mean per-patient costs at 1 year was numerically greater than at 90 days ($4,047 vs. $3,391), and similar in percentage (33% vs. 32%), consistent with the low use of cardiac testing and the low rate of costly clinical events after 90 days. With no Medicare reimbursement rates yet established for FFRCT, the base case analysis set the cost weight for FFRCT to zero, but our results were unchanged when this cost weight was varied systematically in sensitivity analyses. In particular, when the cost weight for FFRCT was set at 3 times that of CTA, consistent with early reimbursement decisions by some private payers, the FFRCT strategy still had significantly lower costs in the invasive stratum. Furthermore, the "downstream cost" comparison, which excluded the costs of all initial tests, also showed a significantly lower cost for FFRCT-guided care in the invasive stratum, largely because this strategy led to lower use of invasive angiography. By contrast, in the planned noninvasive stratum, the cost of FFRCT-guided management was similar to the cost of usual testing in both the base case and "downstream analysis" that excluded the costs of all initial tests. However, 1-year costs of FFRCT-guided management in the noninvasive stratum became significantly higher in sensitivity analyses when the cost weight of FFRCT was set equal to or above the CTA cost weight. In the noninvasive stratum, overall 1-year costs were lower than in the invasive stratum (Figure 2) and the costs of the initial noninvasive tests were a large proportion of total costs because of the infrequent use of subsequent invasive testing and revascularization.
QOL improved overall from baseline to 1 year of follow-up in the entire PLATFORM study population. After 1 year, the degree of improvement was generally not significantly different between the FFRCT-guided and usual care groups. The significantly greater degree of improvement found in the noninvasive group at 90 days disappeared at 1 year, apart from a persistent difference in EQ-5D scores (Figure 3). Symptoms and QOL generally tend to equalize over time in actively managed patient populations as clinicians respond to patient-reported outcomes and seek to control their symptoms. In most coronary revascularization studies, the initial differences in QOL scores early after randomization have also tended to equalize over longer-term follow-up (16,17).
The "value proposition" of an FFRCT-guided strategy is perhaps more nuanced in the noninvasive cohort, as QOL outcomes were improved as measured by the EQ-5D, but the rate of finding no obstructive disease was uniform and costs were similar-to-higher using a cost weight equal to CTA. Thus, as with all diagnostic tests, careful patient selection is paramount to realizing the potential value for clinical care.
Study limitations
Although the PLATFORM study has many strengths, including the simultaneous reporting of clinical, economic, and patient-reported outcomes, it is important to acknowledge its limitations, including a small sample size and relatively brief follow-up duration that may be insufficient to detect an impact on clinical outcomes in this low- to intermediate-risk population. Although patients were treated and analyzed as prospectively allocated using a carefully controlled "experimental" intervention in the FFRCT groups, this study was not randomized. However, propensity-matching analyses of all endpoints yielded similar results, suggesting that our findings were robust and not due to between-group baseline differences. Patient selection, enrollment in Europe, and use of Medicare cost weights might have had an impact on our findings, but the overall conclusions are unlikely to be sensitive to variations in practice pattern or cost weights. Because patients were enrolled in the planned invasive strategy group on the basis of a pre-existing physician order for cardiac catheterization, we could not address the efficacy or costs of prior noninvasive testing, or the direct-to-catheterization strategy chosen by local physicians in approximately one-half of patients. However, outcomes were similar regardless of prior noninvasive testing performance or type. Additionally, because the study's intervention was CTA followed by selective FFRCT, we did not evaluate the performance of CTA alone.
When used as an alternative diagnostic strategy to guide care in patients with planned invasive catheterization, CTA plus selective FFRCT was associated with a significantly lower rate of angiography showing no obstructive CAD, low rates of clinical outcomes, similar QOL, and significant cost savings. When used in those with planned noninvasive testing, clinical events were rare, and there were few differences in resource use or QOL, although the small sample size in this group precluded firm conclusions. Further testing in larger randomized settings in both groups is warranted to fully understand the impact of FFRCT-guided care in patients being evaluated for suspected CAD.
COMPETENCY IN SYSTEMS-BASED PRACTICE: In stable patients with suspected coronary disease, measurement of FFRCT provides functional and anatomical information comparable to that obtained by invasive testing but at lower cost.
TRANSLATIONAL OUTLOOK: Randomized trials are needed to compare the clinical utility of FFRCT with invasive strategies for evaluation of patients with suspected coronary disease.
The PLATFORM study was funded by HeartFlow (Redwood City, California). DCRI independently performed quantitative coronary angiography, adjudicated clinical events, and performed the analysis of the primary and secondary endpoint determinations. There were no data confidentiality agreements. An Executive Committee oversaw trial design and study conduct, final data review, and presentation and publication of results, independently making the decision to publish. The investigators independently drafted the manuscript and take full responsibility for the accuracy and completeness of data analyses. Dr. Douglas received grants from HeartFlow during the conduct of the study; and has previously received other support from GE Medical Systems outside the submitted work. Dr. De Bruyne has received grants from Abbott, St. Jude Medical, and Medtronic; and other support from St. Jude Medical, Boston Scientific, Opsens, Omega Pharma, Siemens, Edwards, GE, Sanofi, HeartFlow, and Bayer outside the submitted work. Dr. Patel received grants from HeartFlow during the conduct of the study; has previously received grants from Janssen, Johnson & Johnson, AstraZeneca, Genzyme, NHLBI, and AHRQ; and personal fees from AstraZeneca, Bayer, and Otsuka outside the submitted work. Dr. Norgaard has received unrestricted institutional research grants from Siemens, Edwards Lifesciences, and HeartFlow. Dr. Byrne received grants from HeartFlow during the conduct of the study; has previously received grants from Boston Scientific; and lecture fees from B. Braun, Biotronik, and Boston Scientific outside the submitted work. Dr. Curzen has received grants from Boston Scientific and Medtronic; and grants and personal fees from HeartFlow, Haemonectics, and St. Jude Medical outside the submitted work. Dr. Gutberlet has received speaker honoraria from Siemens, Philips, Bracco, and Bayer. Dr. Feuchtner received grants from HeartFlow during the conduct of the study; and has previously received personal fees from St. Jude Medical and Boston Scientific outside the submitted work. Dr. Andreini has received grants and personal fees from GE Healthcare outside the submitted work. Dr. Jensen has received speaker honoraria from Bracco Imaging. Dr. Hadamitzky has received an unrestricted institutional research grant from Siemens Healthcare outside the submitted work. Dr. Chiswell received support from HeartFlow during the conduct of the study. Mr. Wilk is an employee of HeartFlow. Dr. Wang received personal fees and other support from HeartFlow during the conduct of the study. Dr. Rogers is an employee of and owns equity in HeartFlow; and received personal fees and other support from HeartFlow during the conduct of the study and previously outside the submitted work. Dr. Hlatky received grants from HeartFlow during the conduct of the study. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Ronald Karlsberg, MD, served as Guest Editor for this paper.
Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.
- Abbreviations and Acronyms
- coronary artery bypass grafting
- coronary artery disease
- confidence interval
- computed tomographic angiography
- 5-item EuroQOL scale
- fractional flow reserve using computed tomography
- invasive coronary angiography
- major adverse cardiac events
- percutaneous coronary intervention
- quality of life
- Seattle Angina Questionnaire
- visual analog scale
- Received March 25, 2016.
- Revision received April 27, 2016.
- Accepted May 3, 2016.
- 2016 American College of Cardiology Foundation
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text: WikiLeaks reported Tuesday morning that they would be releasing new documents every week leading up to the November 8th election. With that, they have yet to actually deliver the major blow to the Clinton campaign as they promised, but they have released a document file covering a shady corporate firm in Paris, France that is linked to both Hillary Clinton and ISIS. Paris struck a partnership with French industrial giant, Lafarge, which has now been exploited for funding ISIS for profit. Documents indicate that Lafarge paid taxes to ISIS so that they can operate its cement plant in Syria, and they even bought oil from ISIS for many years. Hillary Clinton has been connected to Lafarge for decades. She sat on the Board of Directors and conducted legal business dating back to the 1980's. She is well in tune with this terrorist sponsor, and she helped build them into what they are today. In fact, Hillary's connection to connection to Lafarge was exploited when the firm was implicated in facilitating a CIA-backed covert arms export network to Saddam Hussein. In 2013, Lafarge's Executive Vice President for Operations, Eric Olson, was a "featured attendee" at the Clinton Global Initiative's annual meeting. Ok I have to personally admit first that his early Tuesday mourning presser really confused me, like I'm sure it confused most Americans and the world. But it looks like the Assange we were use to is back, after his miserable Tuesday mourning failure of a broadcast. It looks like Hillary Clinton may be connected to the Islamic terror group known as ISIS in more ways than one, this now shows that Clinton flows money into ISIS itself or ISIS money flows to Hillary Clinton directly...Now being connected to a private firm in Paris that is linked to both Hillary and ISIS. If Lafarge has now been exploited for profiting from ISIS, since Hillary Clinton was on the Lafarge board of directors...Could this mean that as Secretary Of State that Hillary Clinton was supplying transactions of American weapons to ISIS in exchange for ISIS black market cash? Hillary Clinton had to of known that there was a connection to ISIS at Lafarge as a member of the board, but to Hillary and the Clinton Foundation that likely doesn't matter when cash or black market cash from ISIS totaling millions is at stake. Lafarge in French also means to cock block someone, so has Hillary Clinton cock blocked America...As in a form of us taking any action to destroy ISIS so she can profit from a terror group at a French corporation with ties to the terror group?


text:
Delivery times and costs are an essential component and differentiator between eCommerce retailers, and it seems that a growing number of businesses are vying for first place in this delivery race. While delivery times have certainly become quicker in the past few years, the advertising claims made by eCommerce businesses have not been as quick to adapt and provide customers with the full picture. Amazon has built up a reputation as the "go-to" online retailer, renowned the world over for its high-speed delivery services, however, the online giant was recently banned from promising one-day delivery in its advertisements by the Advertising Standards Authority (ASA) – precisely for not delivering on this very promise.
The recent ASA adjudication specifically relates to Amazon's claims of "Unlimited One-Day Delivery on millions of eligible items" used in its advertising for Amazon Prime memberships. The ASA opened its investigation following complaints of hundreds of disappointed Prime members in the run up to Christmas 2017. After failing to receive their Amazon orders by the following day, many Prime customers believed that the "one-day delivery" claims made in Amazon Prime advertisements were ultimately misleading.
Amazon gave two lines of defence against these complaints. The first of these was that the promise of a "one-day delivery" did not necessarily mean a one-day delivery after ordering, rather a promise to deliver the products a day after products had been despatched. Unsurprisingly, the ASA did not agree with this since consumers were highly unlikely to interpret the claim in this way. This is not to mention that the copy explaining the specific details of the claim were placed on a separate page on the Amazon website. The ASA also took the view that in reality, promising a delivery date that could indeed amount to a similar wait time as expected by non-Prime users, was hardly a selling point to Prime customers.
Amazon went on to suggest as its second line of defence that customers were always provided with delivery timing forecasts throughout every customer journey and product order, and that these were accurate. The ASA however argued that while this was true, it did not verify Amazon's use of the "One-Day Delivery" statement to describe and significantly, promote its services. The unique selling point of Amazon Prime memberships quite clearly is this delivery speed claim, and the fact that this was not always met meant that it was judged to be misleading customers.
This ruling demonstrates that retailers (and eCommerce retailers in particular) must be cautious when making claims about their services. Even when customers' expectations are met in most cases, retailers should still be careful not to make claims that can be in any way disproven or found to be misleading. Amazon could be said to be a victim of its own success, having cultivated an identity as one of the fastest retailers when delivering products.
It is likely that we will continue to see further clampdowns by the ASA in its dealings with eCommerce businesses, since the eCommerce market is still in a state of rapid development, with new actors continuing to emerge. As retailers' services and deliveries move to adapt to changing technologies and consumer demands, so too must advertising practices and messaging. eCommerce retailers must be transparent in their claims on delivery services and where delivery cannot be 100% guaranteed in one-day, this must be made absolutely clear to avoid being misleading.


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My forthcoming collection of essays, edited with Thomas L. Thompson (book details here), is being featured at the Equinox Publishers table at SBL this year! Here are some pictures provided by the estimable Jim West:
UPDATE 11/20/11: Joel Watts Sent along this photo!
UPDATE 11/22/11: Barnes and Noble is offering this book for pre-order at a discounted price! This book is available normally for $115. B&N is offering it for only $71 for a limited time! Pick up a copy at this discounted price now before it is too late! Click the link below:
[link removed when sale stopped]
UPDATE 12/2/11: Unfortunate the sale is over, but you can still get pre-order the book for $76 through The Book Depository.
Filed under: Is This Not the Carpenter?, Minimalism, Scholarship | Tagged: Equinox, Is This not the Carpenter?, Jim West, Roland Boer, SBL San Francisco |


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Preparation: Create a simple, poster-sized dot-to-dot of a house similar to this sample drawing. Lightly sketch the shape of the house in pencil. Add dots and numbers with a black marker at each corner. Erase the pencil lines. If you wish you can add a few details with the marker, such as a door or some windows.
Obtain a picture of each of the leaders quoted below from the meetinghouse library or print from lds.org. Familiarize yourself with their talks. Post the pictures and the poster at the front of the room.
Presentation: Tell the children that they are going to learn some important messages the prophet and other leaders have for us. Explain that when we follow the teachings of these leaders we will improve ourselves and strengthen our families. Tell them that as they learn, they will also be able to complete a dot-to-dot picture.
Have a child come up and select one of the pictures. Tell the children the name of the leader in the picture and summarize their message. Discuss the message by asking the children for examples that might illustrate the principle taught. Then, have a child draw the first line on the dot-to-dot. Repeat with another child—another picture, message, and dot-to-dot line until all ten have been discussed. You may have the children occasionally sing a song that reinforces a concept.
1. President Thomas S. Monson (see "Reach Out to Others," Friend, Aug 2009, 2-3). "Our daughter, Ann, turned five shortly after we arrived in Canada [when I was assigned there as mission president]. She saw the missionaries going about their work, and she too wanted to be a missionary. Ann [took] to class a few copies of the Children's Friend [magazine]. She also [took] with her a copy of the Book of Mormon so that she might talk to her teacher, Miss Pepper, about the Church.
Just a few years ago, long years after our return from Toronto, we [received] a note from Miss Pepper which read:
Dear Ann: I made a commitment that one day I would come to Salt Lake City and see why you talked as you did and why you believed in the manner you believed. Today I had the privilege of going through your visitors' center on Temple Square. Thanks to a five-year-old girl who had an understanding of that which she believed, I now have a better understanding of The Church of Jesus Christ of Latter-day Saints."
2. Elder Boyd K. Packer (see "Counsel to Young Men," Ensign, May 2009, 49-52). "When I was five years old, I became very ill. It turned out that I had polio. I lay for several weeks on a World War I army cot in our front room beside a coal stove. Afterward, I could not walk. I remember very clearly sliding around on the linoleum floor and pulling myself up on chairs, learning to walk again.
"As I moved into school, I found that my muscles were weak. I was very self-conscious. I determined to compensate in other ways.
"I learned that you should always take care of your body. Take nothing into your body that will harm it, such as we are counseled in the Word of Wisdom: tea, coffee, liquor, tobacco, or anything else that is habit-forming, addictive, or harmful.
"[In] section 89 [of] the Doctrine and Covenants. You will find great promises:
"'All saints who remember to keep and do these sayings . . . shall receive health in their navel and marrow to their bones; . . . And shall run and not be weary, and shall walk and not faint.'"
3. Elder Russell M. Nelson (see "Lessons from the Lord's Prayers," Ensign, May 2009, 46-49). "We can use 'right words' - special pronouns - in reference to Deity [when praying]. While worldly manners of daily dress and speech are becoming more casual, we have been asked to protect the formal, proper language of prayer. In our prayers we use the respectful pronouns Thee, Thou, Thy, and Thine instead of You, Your, and Yours. Doing so helps us to be humble. That can also enhance our prayers. Scripture so declares, 'Be thou humble; and the Lord thy God shall lead thee by the hand, and give thee answer to thy prayers.'"
4. Elder Richard G. Scott (see "Temple Worship: The Source of Strength and Power in Times of Need," Ensign, May 2009, 43-45). "Our son, Richard, was born with a heart defect. A few years later a daughter was born. She died after living only a few minutes. . . [Richard's] surgery was performed just six weeks after the birth and death of our baby daughter. . . . [After the surgery] the doctor came in and told us, 'Your son has died.' I embraced my wife and said to her, 'We do not need to worry, because our children were born in the covenant. We have the assurance that we will have them with us in the future. Now we have a reason to live extremely well. We have a son and a daughter who have qualified to go to the celestial kingdom because they died before the age of eight.' That knowledge has given us great comfort. We rejoice in the knowledge that all seven of our children are sealed to us for time and all eternity."
5. President Dieter F. Uchtdorf (see "The First Vision," Friend, Jun 2008, 2-3). "The chapel in Zwickau [Germany] had an old air-driven organ. Every Sunday a young man was assigned to push up and down the sturdy lever operating the bellows to make the organ work. I sometimes had the great privilege to assist in this important task.
While the congregation sang, I pumped with all my strength so the organ would not run out of wind. The bellows operator sat in a seat that offered a great view of a stained-glass window that portrayed the First Vision, with Joseph Smith kneeling in the Sacred Grove, looking up toward heaven and into a pillar of light.
"I often looked at this depiction of a most sacred moment in world history. I felt a special spirit while looking at the beautiful scene in this window. By the universal power of the Holy Ghost, I felt in my heart and in my mind that it was true, that Joseph Smith saw God and Jesus Christ and heard Their voices.
"The Spirit of God comforted my soul at this young age with an assurance of the reality of this sacred moment. I believed Joseph Smith's testimony of that glorious experience in the Sacred Grove then, and I know it now. God has spoken to mankind again!"
6. Sister Margaret S. Lifferth (see "Respect and Reverence," Ensign, May 2009, 11-13). "Ask yourself these questions: Am I an example of respect in my home by the way I treat those I love the most? [How do I act] during a sports event? Do I show respect for the property of others as well as take care of my own? How do I respond to others with whom I disagree?
"Respect for others and reverence for God are close cousins. Primary children learn this concept as they sing this verse from a Primary song: Rev'rence is more than just quietly sitting: It's thinking of Father above, A feeling I get when I think of his blessings. I'm rev'rent, for rev'rence is love. (Children's Songbook, p. 31)
"I know that I have a loving Heavenly Father and that His Son, Jesus Christ, is my Savior. Our increased reverence will reflect our deepest love for Them."
7. Elder Robert D. Hales (see "Becoming Provident Providers Temporally and Spiritually," Ensign, May 2009, 7-10). "When we were newly married and had very little money, I saw a beautiful dress in a store window and suggested to my wife that if she liked it, we would buy it. Mary went into the dressing room of the store. After a moment the salesclerk came out and returned the dress to its place in the store window. As we left the store, I asked, 'What happened?' She replied, 'It was a beautiful dress, but we can't afford it!'
"We all need to learn to say to one another, 'We can't afford it, even though we want it!' With all the love in me and with the Savior's love through me, I invite you to come unto Him and hear His words: 'Wherefore, do not spend money for that which is of no worth, nor your labor for that which cannot satisfy. Hearken diligently unto me, and remember the words which I have spoken; and come unto the Holy One of Israel, and feast upon that which perisheth not, neither can be corrupted (2 Nephi 9:51).'"
8. President Henry B. Eyring (see "Adversity," Ensign, May 2009, 23-27). "My friend served as our bishop [many years ago]. [As he aged] he was in constant pain. His health began a slow decline. Yet every time I visited him to give him comfort, he turned the tables; I always was the one comforted. His back and legs forced him to use a cane to walk. Yet there he was in church, always sitting near the door, where he could greet those arriving early, with a smile.
"I will never forget the feeling of wonder and admiration which came over me when I opened the back door at home and saw him coming up our driveway. It was the day we put out our garbage cans to be picked up by city workers. I had put the can out in the morning. But there he was dragging my garbage can up the hill with one hand while he balanced himself with a cane in his other hand. He was giving me the help he thought I needed when he needed it far more than I did. And he was helping with a smile and without being asked."
9. Elder Quentin L. Cook (see "Our Father's Plan - Big Enough for All His Children," Ensign, May 2009, 34-38). "In 1863 Charles Dickens, the English novelist, went on board the passenger ship Amazon, which was bound for New York. His purpose was to report on the Latter-day Saint converts who were emigrating to build up the Church in the American West. There had been thousands of converts who had already emigrated, and much had been written, particularly in the British media, about them and their beliefs. Most of what was written was [unkind].
"'I went on board their ship,' wrote Dickens, 'to bear testimony against them if they deserved it, as I fully believed they would; to my great astonishment they did not deserve it.'
"[Despite] our doctrinal differences with other faiths, our attitude toward other churches has been to refrain from criticism. They do much good. They bless mankind. Many help their members learn of the Savior and His teachings.
"Our leaders have consistently counseled us 'to live with respect and appreciation for those not of our faith. There is so great a need for civility and mutual respect among those of differing beliefs and philosophies.'"
10. Dallin H. Oaks (see "Sacrament Meeting and the Sacrament," Ensign, Nov 2008, 17-20). "The ordinance of the sacrament makes the sacrament meeting the most sacred and important meeting in the Church. It is the only Sabbath meeting the entire family can attend together.
"The modern revelation directing us to partake of the sacrament each week, tells us how we should prepare. Our manner of dress indicates the degree to which we understand and honor the ordinance in which we will participate.
"During sacrament meeting - and especially during the sacrament service - we should concentrate on worship and refrain from all other activities, especially from behavior that could interfere with the worship of others. Sacrament meeting is not a time for reading books or magazines. When we partake of the sacrament, we make a sacred covenant that we will always remember the Savior. How sad to see persons obviously violating that covenant in the very meeting where they are making it.
"The music of sacrament meeting is a vital part of our worship. How wonderful when every person in attendance joins in the worship of singing - especially in the hymn that helps us prepare to partake of the sacrament."
After all the messages have been presented, you will have finished the picture of the house. Bear testimony that as we follow the counsel of our leaders, we'll help build strong homes and families.


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Kim Jong-Il, otherwise known as Doctor Evil, was roundly condemned for North Korea's launch of its Tai Kwon Do, Taepodong-2 missile on the same day that President Barack Obama, in a speech in the Czech capital, pledged the United States to the long-term goal of ridding itself of other pisspot states with nuclear weapons.
North Korea's testing of a missile that analysts fear could someday clear the Sea of Japan and possibly contain an evil, highly trained psychotic "Manky Chinky" Or "Monkey warhead" underscored how hard that goal will be to achieve -- and the challenge Obama faces from North Korean leader Kim Jong-Il and his evil henchman "Knick Knack".
This morning, we were reminded again why we need a new and more rigorous approach to address this threat. North Korea broke the rules once more by testing a "shithouse"rocket that could be used for a long-range financial, material and economic blackmail attack,'' Obama said at the outdoor speech in central Prague.
"This provocation underscores the need for action, not just . . . at the U.N. Security Council but in our determination to prevent the spread of these weapons,'' he said. ''Rules must be binding. Violations must be punished. Words must mean something... Money must be handed to the Lord Voldermort to stop them firing more of these "ruse" missiles in future. 'Evil dictators must not be able to acquire these missiles from "Radio Shack" or" Cash Convertors" any longer.
Obama ordered doctor Evil to sit on the naughty step but he refused. Ernst Stavro Blofeld exclaimed, "As soon as you Capitalist pigs give me enough subsidies, material assistance, and handouts, I am going to fire another one and get another bailout".
The South Koreans and Japanese have resigned themselves to the sight of what amounts to little more than an advanced level science project bumbling through their air space. A Japanese fisherman claims to have seen what appeared to be a ramshackle construction composed of tea chests, vacuum cleaners and an industrial sized washing machine drum, plunge into the Sea of Japan at around 3.00PM GMT. A small primate scrambled out and flew away in a homemade gyro copter, which immediately crashed.
The U.N. Security Council met in emergency session Sunday afternoon to debate the launch. However, despite Obama's call for action, it seemed likely the 15-member council would only criticize North Korea and ask it to return the tools, barbecue set and garden equipment it borrowed last summer. Not only does Doctor Evil refuse to resume negotiations but the North Korean regime also hinted at the huge space monkey, killer laser beam station, they were planning.
The Security Council decided indefinitely to take no immediate action but agreed to continue taking diminishing amounts of" no action" on a daily basis to "ramp up" the pressure.
China, a veto-bearing permanent Security Council member, opposes any additional sanctions on North Korea. Foreign Ministry representative Jiang Yu called in a statement for ''cool-headedness and restraint. Anyone who messes with our next doors "Knick Knacks" will get their pork and chicken balls fried"!
The long-anticipated launch of the Ping Pong missile, which had been observed for weeks on the roof of Doctor Evil's garage, took place Sunday morning local time.
The rocket failed to put its payload, believed to be an experimental mix of whites, light coloureds and synthetics into orbit, but stalled on "spin cycle" just as the conditioner was being released for tumble dry. United States Northern Command were said to be in hysterics.
North Korea's state-controlled news agency, however, said the rocket succeeded in placing in orbit a satellite that was broadcasting revolutionary songs by Coldplay and Dido in an attempt to destroy the earth with boredom.
Estimates of the Ting Tong 2's range vary widely, but some put it at as much as a scale of 1:30 (Airfix standard scale) or 6,200 miles, in theory, enough to hit the Northern United States and cause its residents to die laughing.
The launch was the first challenge to Obama from Dr Evil, who has bedevilled past U.S. presidents and extracted concessions with its nuclear "bunkkmanship".


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Finding Poetry in Narrative Nonfiction
October 9, 2017 § 7 Comments
By Amanda Avutu
I was 21 and the worst kind of poet. By which I mean, I wore black dresses and had silver cat eye glasses. So, when a poet came to speak to my undergraduate poetry class about her novel, you can well imagine the twist my black knit stockings were in.
"How do you move back and forth between poetry and fiction??" I inquired during the Q & A session. It was not so much a question as an indictment.
Baseball players don't play football! Ballerinas don't dance tap! Hip Hop artists don't sing Country! Poets don't write fiction! So went my absolutist 20-something Poet logic.
Poets made each word justify not only its existence, but its placement, musicality, and visual appeal.
Poets were Allison from my fifth-grade class, nibbling tiny bites out of a bologna and cheese sandwich.
Other writers were competitive eaters, swallowing bologna and cheese sandwiches whole, not caring about the white bread stuck to the roofs of their mouths.
After the seminar, the visiting writer graciously signed copies of her book. In mine, she thoughtfully inscribed, "To Amanda, Wishing you luck navigating seamlessly between fiction and poetry." I remember thinking—rather uncharitably— that I would never need her "luck," because the only thing I wrote and the only thing I would write was poetry.
I'm 40, and while I still wear black dresses and glasses, I no longer consider myself a Poet or even a poet. I've written plays and short stories, novels and essays. I've also had brief—dark moments—where I was completely wordless. My god, those were terrifying. Generally, though I've become, quite simply, omnivorous where words are concerned. I consume them and produce them with vigor, regardless of their classification. What I've learned is that each form allows me to explore, and to expose, different pieces of myself. When I was writing poetry, my truth bobbed just below the surface of abstractions; bits of cereal swimming in the plausible deniability of milk. In my fiction, I anchored my tiny truth and then launched my readers and myself into an alternate reality. These days, I primarily write narrative nonfiction and I tell my truth as my truth. Nothing, however opaque, protects me from my reader's gaping maw. And as much as my younger self might scoff at the idea, I've learned that my truth is my truth is my truth, which becomes my art, regardless of how I tell it.
There was a sense, over these last two decades, of betrayal. My husband fell in love with the poet, my degree proclaimed my proficiencies as poetry centric, since junior high—when I began writing awful rhyming verse—poetry was my identity. Now, though, I realize my poet self is there, making sure there is room for catharsis and that there is the strength to be a conduit. Making sure each word in each sentence justifies its existence. She buries tiny, delicious, moments for my readers to happen upon and savor. She has always been there and will always be there to make sure that whatever I write, it sings.
Amanda Avutu's nonfiction appears or is forthcoming in the New York Times' Modern Love column, O, the Oprah Magazine, Atlanta Magazine, Bitter Southerner, and the New York Times' Family Ties column.
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The toughest part of a relationship could be knowing how and when to end it. When individuals in a marital relationship realize that they no longer want to remain legally married, there are usually two ways to cut the bond – divorce and annulment. Though everyone may not be eligible for an annulment, there are certain reasons why it is preferable.
Grounds for Annulment
Since annulment requires specific legitimate grounds, individuals cannot freely choose whether to get a divorce or annulthe marriage. Depending on the statutory laws, some states may only allow an annulment if there is an underage or incompetent spouse, bigamy, fraud or the marriage was coerced.
Legal Effect of an Annulment
Annulment completely voids the marriage as though it never existed. However, it generally affects neither the legitimacy nor the paternity of a child born during the marriage.
Matters Involved in Annulment Proceedings
There are fewer concerns to deal with in an annulment because it typically acts as if the marriage never happened. Consequently, the court may also not deal with complex property disputes which can take years to settle. Hence, an annulment can be a quicker way to repeal a marriage with fewer issues to resolve.
However, statutory laws in some states may still require other matters to be heard. Also, certain legal complications may arise when in pursuit of an annulment. For example, a thorough investigation into matters concerning the marriage may take additional time and resources.
Social Implications of an Annulment
An individual may try to annul a marriage on one or more legitimate grounds to avoid the negative social stigma attached to divorce. Annulment is also a preferable option compared to divorce which is usually frowned upon by the church or other religious institutions.
Advantages of Annulment
Getting a marriage annulled instead of terminating it through a divorce is advantageous in some situations, e.g. an annulment may protect an individual's property. In states where spousal support award is not granted in annulment cases, a person can potentially avoid such a judgement.
An annulment may also help an individual receive benefits to which he/she was previously eligible, which may not have been restored had the individual simply divorced.
Legal Assistance
It is crucial to consult a specialist, experienced family law attorney who can make the distinction between getting a divorce or annulment clearer when considering the two options. Also, the legal practitioner can describe the pros and cons of each approach,thereby helping clients determine which option would be in their best interest.


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The first small plate appetizer is Grilled Chicken Spiedini. The menu describes this as "two chicken breast skewers topped with your choice of a Tuscan-inspired sweet red wine sauce or creamy alfredo." I personally would go with the red wine sauce--you can always find alfredo in the store.
The second $4 appetizer is Crispy Risotto Bites. These are from Sicily, and, according to Olive Garden, are fried, bite-size blends of Italian cheeses and rice. They are served with marinara sauce. Think Fried Cheese with an Italian twist.
The third appetizer is Parmesan Roasted Asparagus. According to the menu, you can choose between oven-roasted asparagus with a drizzle of balsamic vinegar, or a crisp, lightly battered and fried option. Either way, your appetizer is served with a citrus aioli dipping sauce and topped with freshly grated Parmesan cheese. I personally could go either way with this--I like asparagus, although I've never had it fried. I must admit the citrus aioli dipping sauce sounds absolutely decadent--and like a perfect accompaniment to the asparagus.
The fourth appetizer is Pizza Fritta Napoli. This is lightly fried pizza dough topped with alfredo and served with your choice of dipping sauce: five-cheese marinara, meat sauce or sun-dried tomato. No, it's not what you see at the state fair--this is lightly fried, not deep fried. And it's topped with alfredo and served with your choice of dipping sauce, not sprinkled with a little cheap Parmesan. And at least one of the sauces has cheese, unlike the state fair option which comes with flat-out cheap tomato sauce of the day.
The fifth $4 appetizer is Tuscan White Bean Hummus. This is a cannellini bean hummus served with toasted ciabatta bread. I like hummus, but it doesn't tempt me since I usually make my own. Still, if you're a health nut, this is the option for you.
The sixth small plate appetizer is Tortelloni al Forno. This is cheese-filled tortelloni served in a Parmesan cream sauce and topped with prosciutto ham crumbles. It sounds intriguing, even though I'm not a fan of ham. But it also sounds really rich--cheese-filled pasta served with a cheese and cream sauce? Seriously? How much cheese do we need?
The last one is Chicken Meatballs. "A twist on an Italian favorite, two chicken meatballs seasoned with herbs and a hint of red pepper, sprinkled with Italian cheeses and served in a zesty marinara," reads the menu. I don't know how big these are, but they're not impressive in the menu's picture. I know you can't always judge by the picture, but I'm not going to pay $2 a meatball for a small meatball.
Is the deal worth it? The portions are small, but that's not a bad thing. They all sound intriguing, but if I had to choose, I'd go with the Crispy Risotto Bites, the Pizza Fritta Napoli and the Grilled Chicken Spiedini, in that order. It's worth noting I haven't had any of these, so take it with a grain of salt. I'm just going by what sounds good to me. Could you make a meal out of these? Probably not. But the purpose of an appetizer is to whet your appetite, not serve as an entire meal.
This offer is not valid in Canada, Alaska or New York City.