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Farming runs in the blood of three Saratoga County men who aim to open a distillery on Route 50 in Ballston. Peter Hatalyk Jr. of Ballston Spa is buying the former Mario's Ice Cream building at 1321 Saratoga Road and has spent the last year establishing High Rock Distillery with partners Jacob Hewson of Ballston Spa and Dan Cooper of Saratoga Springs. The partners are waiting on state and federal licenses to produce vodka, gin ...
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Mizani True Textures Moisture Stretch
- Overview
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- Define individual curls
- Reduces frizz and bulk
- Helps prevent dryness
- Helps eliminate shrinkage and frizz halo
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- About the brand
Mizani True Textures Moisture Stretch is a curl extending cream designed for coiled to extremely tight styles. This moisturizing, curl-smoothing cream helps to loosen and elongate tight, unruly coils without weight or residue. Defines highly textured strands by reducing frizz and shrinkage and revealing flexible, individualized spirals with a clean, touchable finish. Perfect for curl set and finger twist techniques.
The Mizani True Textures Styling Collection works on all curl types for more manageable, defined and frizz-free natural curls. Click here to find your natural curl type.
Apply to wet hair, saturating each section, as you define curls with your fingers. Diffuse or air-dry.
Mizani is a complete line of professional treatments, relaxers, shampoos, conditioners, and styling products designed to meet the expanding needs of today's global beauty. Through its advanced, patented technology, MIZANI has discovered new ways to care not only for the hair, but for the scalp as well.

subset: commoncrawl


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Check out photos from LAHS Alumni Weekend 2016!
To view all the the photos from LAHS Alumni Weekend 2016 click HERE
Register below for LAHS Alumni Weekend 2016, October 7th-9th
There are two options to register for Alumni Weekend 2016:
Follow this link to register online: LAHS Alumni Weekend 2016 Online Registration
Follow this link to print a registration form and mail with payment to
The Green Dragon Foundation: Printable LAHS Alumni Weekend 2016 Registration Form
Check to see what Alumni have signed up:
LAHS Alumni Weekend 2016 Registrations sorted by Last Name
LAHS Alumni Weekend 2016 Registrations sorted by Graduation Year
The Green Dragon Foundation
115 Farley Circle, Suite 306
Lewisburg, PA 17837
We hope to see you there!
LAHS Alumni Weekend 2016 will be held October 7-9
Please "like" the Lewisburg Area High School Alumni Weekend Facebook Page for up to date information alumni news and events: https://www.facebook.com/lahsalumniweekend.
Lewisburg Area Hotel Information for Alumni Weekend 2016 :
Need a place to stay?
Please call hotels directly to make your reservations.
Hotels in the area include:
All Suites Inn (570) 523-8882
Comfort Inn in New Columbia (570-568-8000)
Copper Beech Manor in Lewisburg (570-524-1460)
Country Cupboard Best Western (570-524-5500)
Country Inn & Suites (570-524-6600)
Days Inn in Lewisburg (570-523-1171)
Hampton Inn in Lewisburg (570-522-8500)
Hampton Inn in Selinsgrove (570-743-2223)
Holiday Inn Express in New Columbia (570-568-1100)
Lewisburg Hotel (570-523-7800)
Pineapple Inn (570-524-6200)
Rodeway Inn (570-523-1106).
If your class is planning a reunion, you are encouraged to consider holding it in conjunction with Alumni Weekend 2016 and participate in the weekend's activities. To those classes having a reunion at another time this year, consider contacting your classmates and coming back to join us for this Fall get-together. For those not having a reunion, this is a great opportunity to participate in various events and interact with other alumni. We have not scheduled any activities for Saturday evening so that individual classes, interest groups, and friends can gather to meet as they wish.
ALUMNI WEEKEND also has a group page on Facebook. Go to "Lewisburg High School Alumni Weekend" and click on "Like" to receive the most up to date information available or click on this link:http://www.facebook.com/pages/Lewisburg-High-School-Alumni-Weekend/197619546919559
LAHS Alumni Weekend was a great success with fun had by all!
To view photos from the entire weekend, click on the link below:
All Photos from LAHS Alumni Weekend 2014 are now available for your viewing!
Please visit our link on Shutterfly: lahsalumniweekend2014.shutterfly.com
Here, you may not only view all of the photos from the weekend but you may add photos or videos of your own you want to share with everyone. You can save, download or order any photos you like from this site for yourself. Feel free to leave a comment in the Guest book about ideas for next year!
The 2012 LAHS Alumni weekend was once again a great success with more than 200 alums in attendance! Here are few photos from the weekend.
The 2011 LAHS Alumni weekend was a great success! Here are few photos from the weekend.


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This screenshot of the new home page banner shows a bold new W "patch" hanging off of a light tan "band" that features links to some of the most popular destinations on the UW Web. If you're a UW designer, you can learn more about the new brand guidelines on our secure Web page > (Net ID required).
Here's a look at the new banner with a gold patch:


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Related quotes
"I think a veteran team never panics, and we did not panic. They made a run, and we expected they would make a run. We answered it and kept being aggressive."
"People should avoid that mind-set and not engage in panic buying. That would be overreacting at this point. Consumers likely will see increases, but it is difficult to say just how high prices will get."
"The last thing you need when you're not going well is to look over and see panic on your manager's face. With Joe, he always looks like he's in control. I mean, from being around him so long, I can tell when he's angry. But panic, that's something you'll never see from him."
"It seemed like not only we couldn't get the shots to fall, we started to panic a little bit. We turned the ball over more so than we've done all year."


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This product has been archived and is no longer available for purchase.
Friend Earring
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Friend Earring
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text: Annoying Use Of Vuvuzela Throughout History: Act IVDavid Matthews7/02/10 5:15pmFiled to: Deadspin presentsVuvuzelas in historyVuvuzelasWorld CuppageWorld CupSoccerVuvuzela memesTop251EditPromoteDismissUndismissHideShare to KinjaToggle Conversation toolsGo to permalink It's Friday, which means it's time to tack on a vuvuzela to various indelible moments in world and cultural history. Enjoy and suggest more for next week's final edition. Reply25 repliesLeave a reply


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All hotels in Bagnoles-de-l'Orne, France
1 room, 2 adults
12 Avenue Philippe Du Rozier, Bagnoles-de-l'Orne, Orne, 61140, France, 1-877-214-4288
Bois Joli - Bagnoles-de-l'Orne
Lowest price$71
Just a 10-minute walk from Bagnoles de l'Orne Casino and Firefighters Museum, Bois Joli offers 4-star Bagnoles-de-l'Orne hotel accommodations. Staying here, you'll also be within a 20-minute walk of Le Bois Parcours Nature and Bagnoles de L'Orne en Normandie Golf Club.
This hotel offers a restaurant, free self parking and an elevator (lift).
This hotel offers a restaurant, free self parking and an elevator (lift).
Reviews & ratings
See all 4 Venere.com reviews
Fantastic service
Delicious food
Room needs to be redecorated
TripAdvisor Traveller Rating: 4
From 98 reviews
Bois Joli - Bagnoles-de-l'Orne
Hotel Info: 1-877-214-4288from $71
- Standard Twin Room
- Superior Twin Room
- Superior Double Room
- Double Room
- Standard Double Room
- Single Room
Also popular with travelers from the USA
At a glance
Key facts
Hotel size
- This hotel has 20 rooms
- Check-in time starts at 3 PM
- Check-out time is noon
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Pets allowed *
- Free WiFi in rooms
- Free self parking
In the hotel
Food and drink
- Breakfast (surcharge)
- Restaurant
Things to do
- Bicycle rentals nearby
- Golfing nearby
Working away
- Meeting rooms
- Elevator/lift
- Garden
In the room
Freshen up
- Hair dryer
Be entertained
- Cable TV channels
Stay connected
- Free WiFi
Bois Joli - Bagnoles-de-l'Orne's small print
Also known as
- Bois Joli
- Bois Joli Bagnoles-de-l'Orne
- Bois Joli Hotel
- Bois Joli Hotel Bagnoles-de-l'Orne
Mandatory fees
You'll be asked to pay the following charges at check in or check out:
- A tax is imposed by the city: EUR 1.10 per person, per night
Optional extras
Rollaway beds are available for EUR 12 per day
Breakfast is offered for an extra charge of EUR 11 per person (approximately)
Pets are allowed for an extra charge of EUR 9 per pet, per night
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.


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No time for chest thumping
See more in Climate Change; Arctic; United States; Canada
See more in Climate Change; Arctic; United States; Canada
See more in Arctic; Treaties and Agreements; Antarctica; Russian Federation
As the North Pole's ice cap gives way to global warming, countries bordering the formerly inaccessible Arctic are now vying to claim its untapped resources.
See more in Arctic; Climate Change; Oil
The UN Intergovernmental Panel on Climate Change reports on the rapid rates of warming in recent years in the sub-regions of the Arctic and Antarctic.
See more in Antarctica; Arctic; Climate Change
Ice, snow and climate change are closely linked. The Global Outlook for Ice and Snow investigates those connections, the current situation of ice and snow and the global significance of changes, now and in the years to come.
See more in Environmental Policy; Polar Regions; Climate Change
NOAA has published a report on the decline in Arctic snow and ice coverage.
See more in Arctic; Climate Change
This report by World Wildlife Fund catalogues the damaging effects of climate change on glaciers and offers possible solutions.
See more in Polar Regions; Climate Change
"The Arctic Human Development Report is the first comprehensive assessment of human well-being covering the entire Arctic region."
See more in Polar Regions; Society and Culture; Development
See more in Antarctica
With this agreement (also known as the Ottawa Declaration) the Arctic Council was established on September 19, 1996, by Canada, Denmark, Finland, Iceland, Norway, Russia, Sweden, and the United States. The Arctic Council is a forum to promote collaboration among the Arctic States, Arctic Indigenous communities, and other Arctic inhabitants on issues such as sustainable development and environmental protection.
See more in Arctic; Environmental Policy; Ethnicity, Minorities, and National Identity
The Protocol on Environmental Protection to the Antarctic Treaty "was signed in Madrid on October 4, 1991 and entered into force in 1998. It designates Antarctica as a 'natural reserve, devoted to peace and science' ".
See more in Antarctica; Forests and Land Management
This strategy, also known as the Finnish Initiative, was signed on June 14, 1991 by Canada, Denmark, Finland, Iceland, Norway, Sweden, the USSR, and the United States, five years before the founding of the Arctic Council. The strategy aims to monitor, protect, promote sustainable development in the Arctic region and recognize the rights of indigenous peoples in relation to environmental issues.
See more in Europe; Arctic; Environmental Policy
General Secretary of the Community Party in the Soviet Union Mikhail Gorbachev spoke in Murmansk on October 1, 1967, at the ceremonial meeting on the occasion of the presentation of the order of Lenin (the Soviet Union's highest honor for service to the State) and the gold star to the city of Murmansk. This speech is often credited as the basis for intergovernmental cooperation in the Arctic.
See more in Russian Federation; Arctic; History and Theory of International Relations
The Convention on the Conservation of Antarctic Marine Living Resources (CCAMLR) was adopted on May 20, 1980 and entered into force on April 7, 1982.
See more in Antarctica; Environmental Policy; Global
See more in Antarctica; International Law
As Arctic sea ice continues to melt, this November marked the close of the longest Arctic sailing and shipping season ever recorded. Please join Scott Borgerson and Paula Dobriansky to discuss the economic, environmental, and security implications of a changing Arctic region and its significance for the United States.
See more in Arctic; Climate Change
Please join Icelandic president Ólafur Ragnar Grímsson to discuss the international economic, environmental, and security implications of a changing Arctic region.
See more in Arctic; Environmental Policy
To ensure the success of Myanmar's historic democratic transition, the United States should revise its outdated and counterproductive sanctions policy.
Blackwill and Campbell analyze the rise of Chinese President Xi Jinping and call for a new American grand strategy for Asia.
Williams argues that greater U.S. involvement is necessary to enhance the quality and success of peacekeeping missions.
Kurlantzick offers the sharpest analysis yet of what state capitalism's emergence means for democratic politics around the world. More
In a cogent analysis of why the United States is losing ground as a world power, Blackwill and Harris explore the statecraft of geoeconomics. More
Takeyh and Simon reframe the legacy of U.S. involvement in the Arab world from 1945 to 1991 and shed new light on the makings of the contemporary Middle East. More
Learn more about CFR's mission and its work over the past year in the 2015 Annual Report. The Annual Report spotlights new initiatives, high-profile events, and authoritative scholarship from CFR experts, and includes a message from CFR President Richard N. Haass.
Read and download »


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The day you've waited for your whole life is finally here - your wedding day! It's finally time to get your something old, something new, something borrowed, and something blue. There's no better way to surprise your favorite Texans fan on your wedding day with your "something new" than with this Houston Texans garter! It's fashioned with vibrant Texans colors and logos on the band with a fun, sassy lace border. This unique garter will give an extra "pop" to a very symbolic wedding day tradition and will most certainly have your hubby falling in love with you all over again!
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text: Located in Foz do Iguacu (Cataratas Avenue), Concept Design Hostel & Suite is minutes from Iguassu Boulevard and Adrena Kart. This hostel is within close proximity of Foz Do Iguacu Country Club and Cathedral of St. John the Baptist. Make yourself at home in one of the 10 air-conditioned guestrooms. Complimentary wireless Internet access is available to keep you connected. Bathrooms feature showers with rainfall showerheads. Conveniences include a turndown service and blackout drapes/curtains, and housekeeping is provided daily. Take advantage of recreation opportunities such as an outdoor pool, or other amenities including complimentary wireless Internet access and tour/ticket assistance. Enjoy a satisfying meal at a restaurant serving guests of Concept Design Hostel & Suite. Relax with your favorite drink at a bar/lounge or a poolside bar. Featured amenities include complimentary high-speed (wired) Internet access, a computer station, and complimentary newspapers in the lobby. Free self parking is available onsite.


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The Bank offers comfortable remote banking with iVTB and VTB Mobile.
For registration with the internet bank please visit any branch of JSC "VTB Bank (Georgia)".
In case of use of VTB Bank Call Service, registration might be arranged remotely:
By calling hotline of the bank: +995 32 2242424
From the internet bank authorization page: www.ivtb.ge
Please be informed that from 1 January 2016 present version of the Internet Bank will be terminated.
iVTB - New Internet Banking for retail clients


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Perhaps no team's selections will be more heavily anticipated in this year's NFL Draft than the Indianapolis Colts', who hold the No. 1 pick and are currently in the midst of a total team overhaul.
In fact, so much change has taken place in Circle City this winter that, at this point, it's easy to forget just how important the upcoming draft really is.
The Colts have already named a new general manager and head coach this offseason, after all, and with huge decisions still looming about the team's current roster, particularly the drama surrounding quarterback Peyton Manning, it's starting to feel like the draft itself is actually just a minor detail in this top-down rebuilding process.
It's not.
All great teams were built through the draft, including the one Indianapolis had been fielding for a decade straight before last season. And with both high-profile hires the team made this offseason appearing in their respective roles for the first time ever (Ryan Grigson as general manager and Chuck Pagano as head coach), a lot is clearly riding on those seven crucial picks this April.
What will the new management group do with this tremendous opportunity they've been given?
Have they bought into the Andrew Luck hype like everyone else?
And where do they begin to address all the other issues Indianapolis experienced last season when, on several occasions, they looked like one of the worst teams in the history of the game?
We probably won't have those answers anytime soon, but there are definitely clues available to help us predict just how it's all going to play out this spring, for better or for worse.
Here's a look at what we think we know so far about Indy's fresh new faces and, more importantly, the tough decisions they'll likely be faced with when this year's draft commences.


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n the season finale, Zoe tries to be a supportive friend to Wade, but when she makes a grand gesture, Wade is forced to make a tough decision about his future with the Rammer Jammer and BlueBell. Lavon and George meet their hero, Don Todd (guest star REGGIE HAYES - Girlfriends), who helps them see things in their life more clearly. Grandma Bettie (recurring guest star MAREE CHEATHAM) tries to convince Lemon that she has to take her search for a suitable husband more seriously. Meanwhile, AnnaBeth tries to picture her future with Davis (recurring guest star BARRY WATSON).Resumen IMDb.com
|Nombre del documento
|Hart of Dixie 3x22 - Second Chance (Español (España)).srt


text: Item is not available Find Another One Others Looked At... Eotech 512 A65, Holographic Weapon Sight... SELLER: Karl T 1 $350.00 ROMEO4C1X20 MM Solar/Battery Powered wit... SELLER: Texas Sawdust and Guns 1 $399.99 EO Tech Model 512™ Holo Sight $415 No Fe... SELLER: Ridgeback 0 $415.00 Aimpoint Micro T1 11830 - 4 MOA SELLER: EuroOptic 1 $719.00 NEW Leupold DeltaPoint Pro 2.5 MOA Red D... SELLER: DEGuns_net 1 $549.99 Aimpoint 9000L Free Ship! No CC Fee! SELLER: TXSporting 1 $436.00 Non Guns Scopes Mounts Rings Optics Tactical Scopes Red Dot Walther Red Laser XRL | 1112 | 0 | Lc | 875.0807ms Walther Red Laser XRL 635 For Sale from Dons Hobby Guns | Positive feedback: 98% View | Verified Seller | 1003 Completed Sales View Sellers Items This item is no longer available. /UserImages/1074/981652543 2078908.jpg /UserImages/1074/981652543 2078909.jpg /UserImages/1074/981652543 2078910.jpg Description Shipping and Payment More Info Walther XRL 635 Red Laser. Battery included. 635nm Wave Length. Weaver and Picatiny Rail Mounts Included. For rimfire firearms, air rifles and pistols. Item #:2245130 Included remote on/off switch. New in Box $5 via US Mail Flat Rate Box Trades Accepted: No Gun may/may not be the EXACT one pictured. (Wood grain/camo pattern may vary). Purchases are expected to be completed (payment and FFL received) within ten days of placing your deposit, unless you are using our 90 day layaway plan.Personal checks are accepted, however before shipping you must provide a copy of the check showing it has cleared (this can be obtained from your online banking).Used firearms are sold as is. Ask any/all questions before confirming sale. We advise the inspection by a qualified gunsmith before firing. Don's Hobby Guns assumes no liability. We do not test fire firearms, and can not possibly have a full history on each used gun we take in on trade/consignment.Don's Hobby Guns cannot possibly know all of the individual local, city and state restrictions for the products that we sell. Therefore, we do not warrant that you may legally purchase, own or use specific products offered by our company. You must be in compliance with local laws regarding your purchase. All BATF laws and regulations apply. Check with your local dealer before placing your down payment.All firearms must be shipped to an FFL dealer in your area. It is your responsibility to contact the dealer to have their license sent to us. We will not ship until we have payment in full and a copy of your dealer's license. Condition: New In Box Location: NE Share Item Item #: 981652543 This item is no longer available. Price: Shipping: $5.00 (or Arrange local transfer) Accepted Payment Methods: Returns: 3 Days Dons Hobby Guns Seller Since: Aug. 2006 Seller Level: Trusted Seller This seller is an FFL City: Kearney State: NE More Items from this Seller ( 504 items total | View All ) 84344 Remington 700 Varmi... $735.00 Full Details Add To Cart 84216 Remington Model 700... $577.00 Full Details Add To Cart 84226 Remington 700 SPS V... $577.00 Full Details Add To Cart Mc | 15.6191ms -- 1074 Your Recently Viewed Items


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Pro Hockey Talk "Arizona Coyotes fans anticipating Dave Bolland's debut for his new team will have to wait, and a long time, too, by the sounds of it. On Thursday, the Florida Panthers traded the 30-year-old Bolland and prospect Lawson Crouse to the Coyotes in exchange for draft picks. Bolland, who has an..." August 25
The Hockey Writers "With the NHL's buyout window set to open Wednesday at noon, news has come in that Florida's Dave Bolland has failed his physical, according to Sportsnet's Luke Fox. Failing his physical means that Bolland isn't healthy and that he cannot be bought out, as no injured player can be bought out...." June 15
Today's Slapshot "Florida Panthers forward and 29-year-old veteran Dave Bolland is signed to a monster contract with the Atlantic Division team, making a whopping $5.5 million per season for the next three seasons. He only played in 25 games this year, though, and spent two games at the AHL level on a..." April 26


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High-dose intracoronary adenosine for myocardial salvage in patients with acute ST-segment elevation myocardial infarction
Aims Previous studies have suggested that intravenous administration of adenosine improves myocardial reperfusion and reduces infarct size in ST-elevation myocardial infarction (STEMI) patients. Intracoronary administration of adenosine has shown conflicting results.
Methods and results In a prospective, single-centre, double-blind, placebo-controlled clinical study, we assessed whether selective intracoronary administration of adenosine distal to the occlusion site immediately before initial balloon inflation results in myocardial salvage and decreased microvascular obstruction (MVO) as assessed with cardiac magnetic resonance imaging (MRI). Using a combination of T2-weighted and contrast-enhanced sequences, myocardial salvage index (MSI) was defined as the percentage of the area at risk that did not become necrotic. We randomized 112 patients presenting with STEMI within 12 h from symptom onset to selective intracoronary administration of adenosine 4 mg or matching placebo. In 100/110 (91%) patients receiving study drug, MRI was performed on Days 2–3. No significant difference in MSI was found between adenosine- and placebo-treated patients: 41.3% (20.8, 66.7) vs. 47.8% (39.8, 60.9) [median (Q1, Q3)] (P = 0.52). The extent of MVO was comparable in both groups, with a trend favouring the placebo group: 2.4 g (0.0, 6.8) vs. 5.9 g (0.0, 12.8) after adenosine (P = 0.07). TIMI flow grade, TIMI frame count, myocardial blush grade, and ST-segment resolution after primary percutaneous coronary intervention were similar between groups. After 4 months, infarct size was similar in both treatment groups.
Conclusion We found no evidence that selective high-dose intracoronary administration of adenosine distal to the occlusion site of the culprit lesion in STEMI patients results in incremental myocardial salvage or a decrease in microvascular obstruction.
Clinical Trial Registration Information: ClinicalTrials.gov number, NCT00284323.
- Myocardial infarction
- Adenosine
- Primary PCI
- Magnetic resonance imaging
Over the past decades, primary percutaneous coronary intervention (primary PCI) has emerged as the best treatment modality for evolving acute myocardial infarction with ST-segment elevation (STEMI).1 However, despite successful restoration of epicardial flow, impaired myocardial reperfusion is frequently observed after primary PCI, resulting in larger infarct size and increased mortality.2–6 Embolization of atherothrombotic material,7 vasoconstriction, platelet aggregation, neutrophil adhesion, myocardial oedema, and cardiomyocyte necrosis all contribute to microvascular dysfunction upon reperfusion. The endogenous nucleoside adenosine may improve myocardial perfusion and protect against reperfusion injury by a potent vasodilatory effect and possibly anti-inflammatory and platelet inhibition properties.8,9
Large randomized trials have suggested that intravenous administration of adenosine during intervention for STEMI may reduce infarct size, especially at higher doses.10,11 As dosing of intravenous adenosine is limited by systemic side effects, including hypotension, bradycardia, and chest pain, it is conceivable that intracoronary administration may result in higher local concentrations with less systemic side effects. An intracoronary bolus of adenosine 30–60 µg is recommended for prevention and treatment of no-reflow by the ESC guidelines for the treatment of STEMI (class IIb; level of evidence C).12 A small open-label clinical study has shown that intracoronary administration of 4 mg of adenosine is safe in patients with STEMI, with favourable effects on TIMI flow grade, incidence of no-reflow, left ventricular function, and clinical course.13 Improved myocardial reperfusion as assessed by ST-segment elevation resolution after primary PCI was observed in a cohort of 79 patients treated with intracoronary adenosine compared with 200 historical controls14 and in a randomized trial of 51 patients.15
The aim of this study was to investigate the effect of high-dose (4 mg) selective intracoronary administration of adenosine immediately before initial balloon inflation on microvascular and myocardial salvage in an unselected population of patients with STEMI. In the design of the present study, we attempted to address some of the methodological limitations of earlier trials. First, we used magnetic resonance imaging (MRI) to assess the primary endpoint, myocardial salvage, because it is less influenced by differences in the extent of ischaemic myocardium at baseline between the two treatment groups (Figure 1).16–18 Second, all study personnel remained blinded to treatment assignment. Third, we administered the study drug sub-selectively to the ischaemic myocardium. Fourth, we used a very high dose of adenosine, and last, we administered the intracoronary adenosine before initial balloon inflation.
The 'beneficial effect of intracoronary adenosine on microvascular and myocardial SALVAGE in patients with acute myocardial infarction' study was a single-centre, prospective, randomized, double-blind, placebo-controlled clinical trial with blinded evaluation of endpoints. All consecutive patients presenting to the University Hospitals of Leuven suspected of an acute STEMI and candidates for primary PCI were eligible for participation. Inclusion criteria were symptoms of chest pain suggestive of myocardial ischaemia for at least 20 min, a time from onset of symptoms of <12 h, and an ECG showing ST-segment elevation of >0.1 mV in two or more limb leads or >0.2 mV in two or more contiguous precordial leads, or presumed new left bundle-branch block. Exclusion criteria were contra-indication to heparin, low-molecular-weight heparin or clopidogrel, anticipated difficult vascular access, cardiogenic shock, inability to give informed consent, high-grade atrioventricular block, severe asthma, treatment with theophylline, glibenclamide, or dipyridamole, prior coronary artery surgery, and participation in any investigational drug or device study within the past 30 days. After coronary angiography, patients were randomized when PCI was indicated. The study was approved by the medical ethics committee of our institution.
Randomization and treatment
After coronary angiography, eligible patients were randomized (1:1) to a high-dose bolus injection of intracoronary adenosine (4 mg in 5 mL of 0.9% NaCl) or placebo (5 mL of 0.9% NaCl). Study drug was constituted by the hospital pharmacy in numbered vials according to a computer-generated randomization list in blocks of four that was stratified according to the time from symptom onset to primary PCI (<4 vs. >4 h). This list was kept in a sealed envelope in the hospital pharmacy. Vials containing adenosine and those containing placebo had an identical appearance. Hence, all study personnel was blinded for treatment allocation until the study had been completed and all analyses had been performed.
After crossing the obstruction of the infarct-related coronary artery with a long guide wire, an over-the-wire balloon (Maverick 1.5 mm × 12 mm, Boston Scientific, Natick, MA, USA) was positioned at the level of the obstruction. The guide wire was removed and a small quantity of diluted contrast medium was carefully injected through the central lumen of the balloon catheter to confirm positioning of the catheter tip downstream of the obstruction and to assess patency of the distal vessel. Consequently, the study drug solution was injected by hand through the central lumen of the balloon catheter into the distal vascular bed over 1min. The guide wire was then reinserted through the balloon catheter and advanced to a distal position, and the balloon was inflated. After deflation of the balloon, the procedure was continued per operator preference. As the study was conceived and started in 2006, neither thrombus aspiration, nor the use of any other additional device except coronary balloons and stents was allowed per protocol.
All patients received aspirin (≥250 mg), heparin (5000 IU), and clopidogrel (600 mg) after confirmation of ST-segment elevation on the first ECG. Before commencing primary PCI, patients received a bolus of the glycoprotein IIb/IIIa inhibitor abciximab (0.25 mg/kg), followed by a 12 h infusion. Additional heparin was administered to maintain an activated clotting time of 200–250 s. The standard treatment after primary PCI included aspirin, clopidogrel, β-blockers, lipid-lowering agents, and angiotensin-converting enzyme inhibitors.
Endpoints and definitions
The primary endpoint was myocardial salvage, defined as the percentage of the area at risk (AAR), which was not necrotic on MRI on Days 2–3. Area at risk was assessed by T2-weighted images, while necrosis was assessed by late enhancement. Microvascular obstruction (MVO) on MRI at Days 2–3, expressed as a percentage of the AAR, was a major secondary endpoint.
Other secondary endpoints were TIMI flow grade, TIMI frame count and myocardial blush grade at the end of the primary PCI, ST-segment resolution on the ECG after PCI, major adverse cardiac events in-hospital, at 30 days and at 1 year, recovery of LV-function as assessed using MRI at 4 months, and evolution of cardiac markers in the first 24 h.
In a pre-specified analysis, all endpoints were assessed in patients presenting within 4h of symptom onset and in those presenting later.
Cardiac magnetic resonance imaging
Cardiac MRI studies were performed on Days 2–3 and after 4 months. Detailed methodology of image acquisition and analysis has been reported earlier.18
Angiographic analysis
Coronary angiograms obtained before and after primary PCI were reviewed by two experienced observers blinded to treatment allocation and clinical data. On the initial angiogram and on the angiogram after stenting, TIMI flow grade was assessed.19 In addition, TIMI frame count and myocardial blush grade were assessed after stenting, as described previously.20,21 Distal embolization was defined as a filling defect distal to the culprit lesion on the angiogram at any time point after the first balloon inflation.
Electrocardiographic analysis
ECGs were analysed quantitatively in the ECG Core Laboratory of the Katholieke Universiteit Leuven, using a custom-made in-house computer assisted program.22
Biomarkers reflecting infarct size
Serum creatine kinase (CK), myocardial band of CK (CK-MB), and troponin I measurements were collected in all patients during hospitalization. Blood was collected on admission, just before and after primary PCI, and at 8, 16, and 24 h after revascularization.
Follow-up data at 30 days and 1 year after primary PCI were collected from hospital records and telephone interviews.
Acute side effects
Acute side effects were registered by the interventional cardiologist during and directly after infusion of the bolus intracoronary adenosine or placebo.
Sample size and statistical analysis
The study was powered to detect a difference of 20% in the primary endpoint between the two groups (common STD 30%) with 90% power at a significance level of 5% using a two-tailed t-test, requiring 100 MRIs and assuming 10% of patients for whom no adequate MRI can be done. Data were analysed according to the intent-to-treat principle. Missing data for the primary and major secondary endpoint were imputed according to a worst-case scenario. These analyses yielded similar results to the non-imputed analyses, hence only the latter are presented here. Categorical variables are presented as frequency values and proportions and were compared by the Cochran–Mantel–Haenszel test stratified by time to primary PCI. Continuous normally distributed variables are presented as mean values and standard deviations. For skewed distributed variables, median values with interquartile range (IQR) are shown. Comparisons between the groups were done by means of an analysis of variance (ANOVA) using randomized treatment and stratum as factors in the model. For non-normally distributed variables, a Van Elteren test was also performed, but was in all cases found to be consistent with the results of the ANOVA. Therefore, only results obtained using the ANOVA are presented. For the primary and major secondary endpoints, the average treatment effect was estimated using the ANOVA and presented along with its 95% confidence interval. Subgroup analyses were performed for myocardial salvage index (MSI) and MVO by age, gender, time to PCI, diabetes, baseline TIMI, final TIMI, and infarct location. All tests were two-sided and assessed at the 5% significance level. In view of the exploratory nature of this study, no correction was applied for multiple testing. Statistical analysis was performed using the SAS/STAT® software, version 9.2 of the SAS system for Windows. The authors had full access to the data and take responsibility for its integrity. All authors have read the manuscript and agree to its content.
Between 17 February 2006 and 20 February 2009, 112 patients diagnosed with STEMI met the inclusion criteria and gave informed consent for participation in the study. After initial angiography, 110 patients underwent primary PCI and were randomized to intracoronary high-dose adenosine (n = 56) or matching placebo (n = 54) (Figure 2). Patients randomized to adenosine had a higher heart rate on admission when compared with patients randomized to placebo (76.6 ± 18.2 vs. 69.3 ± 18.3 b.p.m., P = 0.04; Table 1), and patients randomized to intracoronary administration of placebo more often had a medical history of diabetes mellitus (16.7 vs. 3.6%, P = 0.02) and previous PCI (11.1 vs. 1.8%, P = 0.05), as well as a longer stent length. TIMI flow 0 or 1 was present in 45 of the 56 patients (80.4%) randomized to intracoronary adenosine and in 34 of the 54 patients (63.0%) randomized to placebo (P = 0.044). All other baseline and procedural characteristics did not significantly differ between the two treatment groups.
|Adenosine (n = 56)
|Placebo (n = 54)
|Age (years)
|61.4 (12.3)
|60.6 (10.8)
|BMI (kg/m2)
|26.7 (3.9)
|27.1 (3.6)
|Male gender
|44 (78.6)
|46 (85.2)
|Heart rate (b.p.m.)
|76.6 (18.2)
|69.3 (18.3)
|Systolic blood pressure (mmHg)
|131.8 (23.8)
|135.5 (25.8)
|Diastolic blood pressure (mmHg)
|76.4 (15.2)
|78.5 (15.2)
|Current smoker
|25 (44.6%)
|29 (53.7%)
|Myocardial infarction
|0 (0.0)
|1 (1.9)
|Diabetes mellitus
|2 (3.6)
|9 (16.7)
|1 (1.8)
|6 (11.1)
|Family history
|20 (35.7)
|24 (44.4)
|22 (39.3)
|22 (40.7)
|Angina pectoris
|9 (16.1)
|12 (22.2)
|40 (71.4)
|33 (61.1)
|Ischaemic time (median, IQR), min
|215 (150, 296)
|193 (150, 305)
|Infarct-related vessel
|22 (39.3%)
|29 (53.7%)
|27 (48.2%)
|18 (33.3%)
|7 (12.5%)
|7 (13.0%)
|TIMI flow before PCI
|36 (64.3)
|28 (51.9)
|9 (16.1)
|6 (11.1)
|6 (10.7)
|13 (24.1)
|5 (8.9)
|7 (13.0)
|45 (80.4)
|34 (63.0)
|11 (19.6)
|20 (37.0)
|Stent diameter, mm
|3.2 (0.49)
|3.2 (0.42)
|Stent length, mm
|18.3 (5.52)
|21.6 (5.88)
|GPIIb/IIIa-inhibitor during PCI
|51 (91.1%)
|50 (94.3%)
PCI, percutaneous coronary intervention; RCA, right coronary artery; LAD, left anterior descending; Cx, circumflex artery; TIMI, thrombolysis in myocardial infarction.
Magnetic resonance imaging results
Of the 110 randomized patients, 10 did not undergo MRI during the initial hospitalization: 1 patient was in hypovolemic shock, 1 in cardiogenic shock, 1 patient deceased 12 h after admission, and 7 refused MRI because of claustrophobia. As a result, cardiac MRI was performed on the second or third day after primary PCI in 51 patients who had received intracoronary adenosine and 49 patients who had received placebo during PCI (Table 2). Oedema volume as a measure for the AAR was 43.0 g (22.8, 54.4) in the patients randomized to adenosine and 40.3 g (19.7, 55.8) in the patients randomized to placebo (P = 0.87). Infarct volume was 22.0 g (6.7, 38.8) in the adenosine-treated patients vs. 19.9 g (10.4, 29.0) in the placebo-treated patients (P = 0.26), or—expressed as a percentage of the left ventricular mass—18.1% (7.6, 29.3) vs. 16.1% (10.1, 21.3) (P = 0.13). This resulted in a MSI of 41.3% (20.8, 66.7) in the patients randomized to intracoronary adenosine and 47.8% (39.8, 60.9) in the patients randomized to intracoronary placebo (P = 0.52) (Figure 3). Microvascular obstruction was observed in 37 of the 51 adenosine-treated patients (72.5%) when compared with 33 of the 49 (67.5%) placebo-treated patients (P = 0.60). The extent of early MVO was 5.9 g (0.0, 12.8) in the patients randomized to adenosine and 2.4 g (0.0, 6.8) in the patients randomized to placebo (P = 0.07). This lack of treatment effect was present in both strata, hence irrespective of time from symptom onset. Other MRI-analyses were comparable between the two treatment groups, with the exception of a lower ejection fraction in the adenosine-treated patients.
|Adenosine (n = 51)
|Placebo (n = 49)
|Myocardial evaluation (median, IQR)
|Area at risk (g)
|43.0 (22.8, 54.4)
|40.3 (19.7, 55.8)
|Microvascular obstruction present
|37/51 (72.5%)
|33/49 (67.3%)
|Microvascular obstruction (g)
|5.9 (0.0, 12.8)
|2.4 (0.0, 6.8)
|Infarct volume (g)
|22.0 (6.7, 38.8)
|19.9 (10.4, 29.0)
|Infarct volume (% LV mass)
|18.1 (7.6, 29.3)
|16.1 (10.1, 21.3)
|Myocardial salvage index (%)
|41.3 (20.8, 66.7)
|47.8 (39.8, 60.9)
|LV function (mean, SD)
|LV EDV (mL)
|159.0 (36.5)
|159.1 (40.0)
|LV ESV (mL)
|83.4 (26.0)
|77.6 (30.2)
|SV (mL)
|75.6 (19.6)
|80.3 (18.7)
|47.6 (9.5)
|51.3 (8.7)
|LV mass (g)
|121.2 (34.8)
|124.0 (29.5)
MRI, cardiac magnetic resonance imaging; LV EDV, left ventricular end-diastolic volume; LV ESV, left ventricular end-systolic volume; SV, stroke volume; EF, ejection fraction.
At 4 months, ejection fraction slightly increased in both treatment groups despite a small increase in end-systolic LV volumes, primarily due to an increase in end-diastolic LV volumes (Table 3). Infarct volumes had roughly halved in both treatment groups, irrespective of symptom duration.
|Adenosine (n = 46)
|Placebo (n = 44)
|LV function (mean, SD)
|LV EDV (mL)
|171.0 (48.8)
|LV ESV (mL)
|87.1 (32.1)
|78.9 (33.6)
|SV (mL)
|87.0 (24.0)
|89.4 (19.3)
|50.5 (9.9)
|54.4 (9.4)
|LV mass (g)
|107.6 (30.5)
|110.1 (26.9)
|Infarct volume (g)
|11.5 (4.0, 25.0)
|8.9 (4.5, 13.9)
|Infarct volume (% LV mass)
|9.9 (4.8, 20.0)
|7.6 (4.5, 11.8)
Additional analyses, adjusted for baseline TIMI, diabetes, time to PCI, and infarct location, were performed for the main endpoints of interest and yielded results similar to the unadjusted analyses. Subgroup analyses for MSI revealed a statistically significant interaction between treatment and baseline TIMI flow grade (0/1 vs. 2/3) (P = 0.0056), whereby a statistically significant treatment benefit of adenosine was found for patients with TIMI 2/3 at baseline (P = 0.0486). A worsening effect of treatment was found in the group of patients with TIMI flow grade 0/1 at baseline, but this difference was not statistically significant (P = 0.0676). These results could not be reproduced for MVO (Figure 4).
ST-segment resolution
Two patients had a presumed new left bundle branch block on the qualifying electrocardiogram, and of the electrocardiograms of three patients, one was of insufficient quality to allow for reliable analysis. Hence, in 105 of the 110 patients (95.5%), residual ST-segment deviation could be assessed on the electrocardiogram after primary PCI. The median time between the completion of the primary PCI procedure to this electrocardiogram was 31 min (IQR, 19–41 min). ST-segment elevation resolution >70% was present in 24 of the 53 patients (45.3%) randomized to intracoronary adenosine and in 21 of the 52 patients randomized to intracoronary placebo (40.4%) (P = 0.45; Figure 5). Median ST-segment resolution was 65.5% (IQR, 46.9–77.4%) in the adenosine-treated patients when compared with 60.1% (IQR, 32.3–82.6%) in placebo-treated patients (P = 0.38). In the subgroup of 38 patients (37 pairs of evaluable ECGs) presenting more than 4h after symptom onset, ST-segment resolution was more pronounced in the patients randomized to intracoronary adenosine [median 73.8% (IQR, 55.9–79.5%)] than in the patients randomized to intracoronary placebo [median 32.6% (IQR, 15.3–53.8%), P = 0.008]. This resulted in a higher proportion of patients with >70% ST-segment resolution in those randomized to adenosine [11/19 (57.9%) vs. 2/18 (11.1%) for the placebo group, P = 0.003]. In contrast, in patients presenting within 4h of symptom onset, median ST-segment resolution tended to be lower in those randomized to adenosine when compared with the placebo group [63.6% (IQR, 31.3–77.4%) vs. 73.2% (IQR, 54.7–86.6%), P = 0.32], resulting in a proportion of patients with >70% ST-segment resolution of 13/34 (38.2%) patients randomized to adenosine and 19/34 (55.9%) patients randomized to placebo (P = 0.14).
Angiographic results
After primary PCI, TIMI flow grade 3 was present in 45 of the 56 patients (80.4%) randomized to intracoronary adenosine and in 47 of the 54 patients (87.0%) randomized to intracoronary placebo (P = 0.65; Table 4). In stratum 1 (<4 h), significantly more patients in the placebo group had TIMI flow grade 3 than in the adenosine group [33/36 (91.7%) vs. 27/36 (75.0%)] (P = 0.04). In stratum 2 (>4 h), 14 of the 18 patients in the placebo group had TIMI flow grade 3, when compared with 18 of the 20 patients in the adenosine group (P = 0.16). Median TIMI frame count was 30.3 (IQR, 19.0–53.0) and 28.0 (IQR, 18.5–45.0) (P = 0.52) for the adenosine- and placebo-treated patients, respectively. A myocardial blush grade 3 was observed after primary PCI in 18 of 52 (34.6%) patients treated with adenosine and in 21 of 51 (41.2%) patients treated with placebo (P = 0.98) (Figure 6). Myocardial blush grade 0 or 1 was present in 19 of 52 (36.5%) patients and 21 of 51 patients (41.2%), respectively (P = 0.98). This absence of significant differences in myocardial blush grade was independent of time from symptom onset.
|TIMI flow grade
|0/56 (0.0%)
|1/54 (1.9%)
|2/56 (3.6%)
|1/54 (1.9%)
|9/56 (16.1%)
|5/54 (9.3%)
|45/56 (80.4%)
|47/54 (87.0%)
|2/56 (3.6%)
|2/54 (3.7%)
|54/56 (96.4%)
|52/54 (96.3%)
|TIMI frame count
|(n = 47)
|(n = 44)
|Median (IQR)
|30.3 (19.0, 53.0)
|28.0 (18.5, 45.0)
Calculation of the area under the curve of cardiac markers as an estimation of infarct size was not performed if either the first or last measurement was missing. Other missing values were imputed by linear interpolation. The area under the curve for CK and CK-MB could be calculated for only 98 and for troponin I for 96 of the 110 patients and showed no differences between treatment groups (Table 5), irrespective of time from symptom onset.
|CK maximum (IU/L)
|2170 (1043; 3986) (n = 56)
|1878 (1234; 2967) (n = 54)
|CK-MB maximum (µg/L)
|244 (133; 441) (n = 56)
|227 (141; 405) (n = 54)
|Troponin I maximum (µg/L)
|91 (36; 176) (n = 56)
|78 (44; 112) (n = 54)
|CK-AUC (IU/L × h)
|43613 (19724; 68167) (n = 47)
|33220 (19695; 54298) (n = 51)
|CK-MB AUC (µg/L × h)
|3607 (2402;7194) (n = 47)
|3524 (1800; 6336) (n = 51)
|Troponin AUC (µg/L × h)
|1486 (753; 2696) (n = 45)
|1272 (666; 1959) (n = 51)
AUC, area under the curve.
Complications during primary percutaneous coronary intervention
An increase of chest pain during or immediately after selective administration of adenosine 4 mg distally to the occlusion site was not observed more frequently when compared with the intracoronary administration of placebo [5/56 (8.9%) vs. 5/54 (9.3%) (P = 0.97) (Table 6)]. Occlusion of a significant side branch, no reflow phenomenon, bradycardia, ventricular tachycardia, and ventricular fibrillation was seen in comparable numbers of patients in the two treatment groups. Distal embolization was numerically more frequent in patients randomized to intracoronary adenosine when compared with patients randomized to intracoronary placebo, the difference, however, not reaching statistical significance [6/56 (10.7%) vs. 1/54 (1.9%), P = 0.06]. The incidence of second- and third-degree atrioventricular block was also numerically higher in adenosine-treated patients [3/56 (5.4%) and 10/56 (17.9%)] than in placebo-treated patients [1/54 (1.9%) and 4/54 (7.4%)]. These conduction blocks disappeared within 2 min, without clinical sequelae.
|Adenosine (n = 56)
|Placebo (n = 54)
|Increase of chest pain during study drug administration
|5 (8.9%)
|5 (9.3%)
|Occlusion of side branch ≥2 mm
|1 (1.7%)
|1 (1.9%)
|Distal embolization
|6 (10.7%)
|1 (1.9%)
|No reflow
|2 (3.6%)
|2 (3.7%)
|5 (8.9%)
|7 (13.0%)
|Second degree AV block
|3 (5.4%)
|1 (1.9%)
|Third degree AV block
|10 (17.9%)
|4 (7.4%)
|1 (1.8%)
|1 (1.8%)
|1 (1.8%)
|2 (3.7%)
AV, atrioventricular; VT, ventricular tachycardia; VF, ventricular fibrillation.
Clinical outcome
Two patients died during initial hospitalization: one patient randomized to intracoronary adenosine developed electromechanical dissociation 12 h after stenting of the mid-left anterior descending (LAD), complicated by no-reflow phenomenon. Abciximab had been discontinued early because of a frontal epidural hematoma in the medical history. One patient randomized to intracoronary placebo died of multi-organ failure after 7 days as a consequence of protracted cardiogenic shock.
Between discharge and 30-day follow-up, an additional patient randomized to intracoronary placebo died of a recurrent myocardial infarction 9 days after the index infarction.
At 1 year, two patients had died in each treatment group, without any apparent differences in functional status between surviving patients (Table 7).
|At 30 days
|1/56 (1.8%)
|2/54 (3.7%)
|NYHA class
|46/55 (83.6%)
|43/52 (82.7%)
|9/55 (16.4%)
|7/52 (13.5%)
|0/55 (0%)
|2/52 (3.9%)
|At 1 year
|2/56 (3.6%)
|2/54 (3.7%)
|NYHA class
|48/54 (88.9%)
|47/52 (90.4%)
|5/54 (9.3%)
|4/52 (7.7%)
|1/54 (1.9%)
|1/52 (1.9%)
NYHA, New York Heart Association.
This prospective, randomized, double-blind, placebo-controlled clinical trial demonstrated that high-dose (4 mg) selective intracoronary administration of adenosine distally to the occlusion site and immediately before initial balloon inflation did not enhance myocardial salvage in patients with STEMI. There were no significant differences in MSI, MVO, and infarct size as assessed by MRI, nor in ST-segment elevation resolution, TIMI flow and myocardial blush grade, enzymatic infarct size, and clinical outcome at 30 days and 1 year after primary PCI between patients randomized to intracoronary adenosine or intracoronary placebo. On the contrary, a small non-significant trend favouring patients randomized to placebo was observed for most secondary endpoints.
Adenosine and adenosine analogues have been shown in animal models to mimic ischaemic preconditioning and to potentially prevent reperfusion injury.8,9,23–26 Lethal myocardial reperfusion injury is defined as myocardial injury caused by the restoration of coronary blood flow after an ischaemic episode, and is thought to account for up to 50% of the final size of a myocardial infarct. While the pathophysiology of this phenomenon is incompletely understood, an important role has been attributed to the reperfusion injury salvage kinase (RISK) pathway and the mitochondrial permeability transition pore (MPTP).27 These have become new targets for cardioprotection, and inhibition of the opening of the MPTP by means of cyclosporine seems to limit infarct size in humans.28 In two out of the three different proposed cardioprotective protein kinase pathways, adenosine is postulated to directly and indirectly activate protein kinase C, or to contribute to the activation of the RISK pathway.29 In addition, adenosine is a strong coronary vasodilator, and inhibits pre-synaptic release of norepinephrine from sympathetic nerves, platelet aggregation, and leucocyte adherence to the vascular wall.30
Clinical studies with adenosine in humans with STEMI have yielded mixed results. In the AMISTAD-II trial, conducted in patients with anterior STEMI treated by fibrinolysis or primary PCI, a 3 h intravenous infusion of adenosine did not reduce the primary clinical endpoint.10 However, in a post hoc subgroup analysis, a benefit was seen in those reperfused within 3 h, and a significant reduction in infarct size was reported in the high-dose adenosine subgroup.11 Several retrospective and prospective clinical studies with intracoronary administration of adenosine during primary PCI have shown favourable effects, such as increases in coronary blood flow, a reduction of no-reflow, improvement of signs of reperfusion on the ECG after PCI, and a reduction in infarct size.13–15 However, these favourable results should be interpreted with caution because they are limited by a small sample size, potential selection bias, or a non-randomized trial design. A recent single-blind study of 448 STEMI patients randomized to two bolus injections of intracoronary adenosine (2 × 120 µg) or matching placebo after manual thrombus aspiration did not show any difference in the primary endpoint of residual ST-segment elevation after primary PCI.31 In addition, all secondary endpoints (ST-segment elevation resolution, myocardial blush grade, TIMI flow after PCI, enzymatic infarct size, and clinical outcome at 30 days) did not differ between treatment groups. As a possible explanation, the authors argued that adenosine may have a maximal beneficial effect on ischaemic myocardial injury when given before reperfusion therapy, whereas they performed thrombus aspiration before administration of adenosine or placebo. Different methodologies to assess infarct size could also explain variable results in clinical studies. Magnetic resonance imaging is superior for determining spatial extent and transmural distribution of infarction over previously used techniques, including radionuclide imaging, wall motion at rest, enzymatic infarct size, and ST-segment resolution. In fact, MRI is the most accurate non-invasive technique to measure infarct size relative to risk area in humans.16–18 This measurement is a robust and clinically relevant indicator of therapeutic benefit, and is expressed as MSI. For example, in a patient with a very large AAR, final infarct size can be substantial despite significant salvage. Conversely, in a patient with a very small AAR, infarct size will always be very small, irrespective of degree of salvage.
In the present study, we attempted to avoid some of the methodological limitations of earlier trials. First, we used MRI to assess the primary endpoint, myocardial salvage, because it is less influenced by differences in the extent of ischaemic myocardium at baseline. Second, all study personnel remained blinded to treatment assignment until completion of all analyses. Third, we administered the study drug subselectively to the ischaemic myocardium, prohibiting inadvertent spill-over into other coronary branches. Fourth, we used a very high dose of adenosine, 4 mg, proven to be safe and well tolerated.13 And last, we administered the intracoronary adenosine before initial balloon inflation.
One may argue that the absence of a beneficial effect of intracoronary adenosine is due to differences in baseline clinical characteristics, favouring placebo-treated patients. However, there were no significant differences in baseline characteristics between the two treatment groups with the exception of a slightly higher heart rate on admission in patients randomized to adenosine and a higher incidence of diabetes mellitus and previous PCI in patients randomized to placebo. Also, we observed a greater incidence of LAD involvement in patients randomized to adenosine, but the possibility of larger AAR could not be substantiated by quantification of oedema volume on T2-weighted MRI images.16–18
In subgroup analyses for MSI, we found a statistically significant interaction between treatment and baseline TIMI flow grade (0/1 vs. 2/3) (P = 0.0056), whereby a statistically significant treatment benefit of adenosine was found for patients with TIMI 2/3 flow at baseline (P = 0.0486). While this finding concerns a small group of patients and may be due to multiple testing without correction of P-values, we cannot exclude the possibility of a true beneficial effect of adenosine in patients with spontaneous reperfusion, and of harm in patients without spontaneous reperfusion. One may hypothesize that an intact microcirculation before adenosine infusion allowing its distal delivery is important for an eventual beneficial effect to be seen. This would make it more difficult, however, to understand the positive outcome with intracoronary adenosine in a smaller but very similar study, in which patients with TIMI 3 flow at baseline were excluded.13
We observed significantly better ST-segment resolution in adenosine-treated patients presenting more than 4 h after symptom onset. However, in these patients, there was not even a trend of improved coronary blood flow, more myocardial salvage, decreased MVO, or smaller enzymatic infarct size. Therefore, and because there are no pathophysiological grounds to expect adenosine to be more beneficial in STEMI patients who present later, we assume that this observed difference is due to chance.
A possible explanation for the observed lack of beneficial effect of intracoronary adenosine may be that high-level endogenous production of adenosine during myocardial ischaemia already mediated maximal vasodilatation. Animal models demonstrate that adenosine concentrations may increase to levels producing maximal coronary arteriolar dilatation during ischaemia.32 Therefore, our study may be neutral because of the absence of vasodilatory reserve during and after reperfusion by PCI.
It is unlikely that the dose of adenosine in this study was insufficient to induce maximal vasodilatation because it is 40 times higher than the >100 µg intracoronary adenosine doses routinely recommended for fractional flow reserve measurements.33 The half-life of adenosine in human blood, 1 s, is apparently too short to protect from oxygen free radicals, which peak at 2–3 min of reperfusion, even if reperfusion is started only 15–30 s after adenosine administration. However, half-life may underestimate the duration of the biological effects of adenosine. After a bolus injection of adenosine in a non-stenotic coronary artery, coronary flow remains elevated for several minutes, suggesting persistent receptor activation well beyond half-life. In case of injection into a stenotic coronary artery, flow remains elevated even longer. In this study, adenosine was injected into a vascular bed with minimal, if any, antegrade flow, and under these circumstances, its biological effects could last much longer than expected on the basis of its half-life. The short half-life of adenosine, however, provides an intrinsic protection from possible side effects. In addition, ischaemic pre- and post-conditioning share a common signalling pathway that includes—among others—adenosine receptors. This signalling is thought to protect by suppressing the opening of MPTPs at reperfusion.
Alternatively, timing of adenosine administration may affect outcome. Previous studies have suggested that the window of opportunity is limited to the first 3–4 h after onset of ischaemic symptoms.11,34 Although most of our patients (65.5%) were treated within this time window, we failed to document benefit, even in a separate analysis of patients who underwent primary PCI within 4 h from symptom onset.
Limitations of the study
First, the primary endpoints were myocardial salvage and MVO and we cannot comment on clinical endpoints, for which the study was underpowered. Second, 28% of patients had limited spontaneous reperfusion before intracoronary administration of the study drug and in a few more mere passage of the guide wire may have mediated some degree of reperfusion. Hence, in these patients, adenosine was not truly given before reperfusion. However, for MSI, we identified a large interaction between treatment and baseline TIMI, whereby a statistically significant treatment benefit of adenosine was found for patients with TIMI 2/3 flow at baseline and an almost statistically significant worsening effect of adenosine in the TIMI 0/1 group. Although it is not clear to us how this finding can be explained, it makes it very unlikely that some degree of reperfusion before the administration of adenosine abolished an eventual beneficial effect. Third, the trial included a significant proportion of patients with small and/or completed infarcts. Fourth, infarct size cannot be reliably assessed when biomarkers are drawn every 8 h as in this study. And finally, adenosine boluses may be too short acting for any beneficial effect and we cannot exclude efficacy of prolonged intracoronary administration.
Conclusions and implications
We found no evidence that selective intracoronary administration of high-dose adenosine as adjunctive therapy to primary PCI enhances myocardial salvage or reduces MVO in patients with STEMI. Future attempts at improving myocardial reperfusion, preventing reperfusion injury, and salvaging ischaemic myocardium should focus on pharmacological therapies with other modes of action or non-pharmacological approaches.
Conflict of interest: none declared.
- Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: firstname.lastname@example.com


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Crazy Ripple Blanket
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Use up leftover yarn with this Crazy Ripple Blanket. Let your imagination go crazy as you complete this free crochet afghan pattern. Use light worsted weight yarn to complete this cozy blanket. The pattern is presented as patterns to create the individual sections because the design can be customized and created as you go. Construction guidelines are also included in the instructions.
Crochet Hook: H/8 or 5 mm hook
Yarn Weight: (3) Light/DK (21-24 stitches to 4 inches)
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Member 1378421
Feb 09, 2016
I tried making this afghan for my nephew who has been diagnosed with leukemia. I did the first row and then the second row made no sense. The stitches don't line up. Guess I will have to try another afghan.
pjoeyj 9466050
Feb 22, 2013
This pattern is too confusing. It does not tell you how many rows to complete in each section and nothing about changing colors. I am very disappointed in this. I have tried for hours to figure it out and just gave up. I crochet for charity and thought this would be a colorful one to brighten someone up. This should not be on this site.
Mar 06, 2013
She gave the basic patterns of the sections to help you build your own afghan. It's meant to be personalized with your own color changes, where and how you place the diamonds, etc etc.
sea929 3288587
Feb 21, 2013
I really like this one .Cant wait to give it a try. The pattern looks well writen and easy to fellow. thanks for sharing
Feb 18, 2013
I love this pattern! The variations are endless...wonderful stash buster too!
quiltgirl25 786374 4
Feb 05, 2013
Love this!! Very modern. I reminds me of a quilt!
robinsoncat 830083 5
Jan 09, 2013
Nice pattern - but links don't work for me, either.
atfof1965 3209367
Jan 09, 2013
Love the look, of the afghan! The link will not load. :( I will try again later. When AFC featured my pattern, my bandwidth overloaded and my site went down! :)
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MSU moving on to the next one
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McGuire, Franklin R. MD*; Michael Kerley, J. MD†; Ochran, Timothy MS†; Bedekar, Ajay R. MD‡; Swafford, Rachelle LVN‡; McLemore, Theodore L. MD, PhD‡
Electromagnetic navigational (EMN) bronchoscopy is a novel approach to the diagnosis of pulmonary nodules and masses. The EMN allows the bronchoscopist to perform biopsies under virtual computed tomography guidance. This avoids the obstacles associated with real-time computed tomography guidance and the complications associated with percutaneous transthoracic needle aspiration. After diagnosis, if the lesion is found to be malignant, it is possible to implant coiled linear radiotherapy monitoring devices (RMDs), fiducial markers, into the lesion. This is carried out by using a 5-french angulated catheter. The catheter allows RMD placement in a radial pattern, which is ideal for focused radiotherapy. RMD implantation can allow fluoroscopic guidance for surgical resection as well. This technical vignette describes a therapeutic utility of EMN bronchoscopy in the implantation of RMDs into malignant lung nodules.
© 2007 Lippincott Williams & Wilkins, Inc.
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My birthday isn't until June; is it too early to be thinking about presents? Hardly! When I was a boy, I spent the first half of the year dreaming about what I'd receive for my birthday. And the second half dreaming about Christmas.
And of what did I dream? Action Man. Action Man was not a doll; he was an "action figure" made for adventure. Don't believe me? Well consider the outfits I eventually collected, thanks to my parents' largesse. There was the deep-sea diver's outfit, with a full helmet and real lead diving belt and shoes. And the astronaut's outfit that matched Neil Armstrong's in precise detail.
The parachutist's outfit came with a very real parachute. I spent a wonderful day rushing up the fire escape stairs at the Sydney Adventist Hospital, launching my Action Man off the top of the building and watching him float gracefully to the ground. Until a killjoy came along and informed me that the San fire escapes were not designed to be a second-grader's play area. Well then, what precisely is their point?
But there came a day I concluded I didn't want Action Man gear from my parents. The reason wasn't that I'd outgrown my favourite toy. It was that I was particular. Very particular. And rather than cede the choosing to my parents, why not just get cold hard cash? And then buy precisely what I wanted.
As I've grown older, however, I've run into a limitation with cash. Take the Australian dollar, for example. When we moved back to Australia, one Aussie dollar was worth almost $US1.10. Today? Well it's down to 70 cents. In relative terms, my Aussie cash is now worth well over one-third less! Ouch!
So maybe there are other treasures that better hold their value? Precious metals? Bitcoins? Diamonds? But all of these vary widely in value over time. So what should be on my wish list this birthday?
Professor Robert Waldinger, of Harvard University Medical School, states that 50 per cent of millennials want to be famous and more than 80 per cent want to be rich. So should I pine for a little bit of fame and a lot more moola?
Apparently not. In presenting the findings of a 75-year study on human happiness, Professor Waldinger concludes:
So what have we learned? What are the lessons that come from the tens of thousands of pages of information that we've generated on these [people Harvard studied for 75 years]? Well, the lessons aren't about wealth or fame or working harder and harder. The clearest message that we get from this 75-year study is this: Good relationships keep us happier and healthier. Period.1
Healthy, loving relationships are more important to our physical and emotional health than any other factor. Indeed, Harvard University found loving relationships are more important to longevity than such physical markers as mid-life cholesterol levels! Instead of prescribing pills, should we be prescribing love? The answer from the data is yes: "all you need is love!"
But is this any surprise to the Christian?
"I am giving you a new commandment," said Jesus, "Love each other . . . Your love for one another will prove to the world that you are my disciples" (John 13:34,35). Really? That's the best sign we have got? Wouldn't miracles be a more impressive sign? How about brilliant Bible knowledge? Or maybe freakishly accurate prophecies? Apparently not if you read 1 Corinthians 13.
Why love? Maybe because through love we heal more people than through our medicine; through love we teach more people than through our schools; through love we enrich more people than through our money. Maybe because God is love, love is the only currency with value in His kingdom.
So what to wish for this birthday? To be an authentically more loving person. To be a more loving husband and father. To foster a deeper love in my local church family. For God's love to reign supreme! All that, and a boat . . .
1. I highly recommend watching Professor Waldinger's TED Talk in full.
James Standish is Communication director for the Seventh-day Adventist Church in the South Pacific.
3 commentsAdd Comment
When I was a kid a doller was worth ten dollers - now a doller couldn't buy you fifty cents, so James is right as usual, there is no point sense putting your hopes in money.
what is true LOVE
we have this presidential race in the USA and many are using CHRIST as a example
and we have Christianity in many fractions and all claim LOVE
in the end
Revelation 22:11
'God is love' is the central point to everything. It is Christianity '101'. You can teach doctrine, keep the Sabbath, pay tithe, go to church, eat tofu and spinach, but if you don't understand 'God is love', if you don't encounter 'God is love', then it is all meaningless. The answer to life, the universe and everything is not the number 42 as Douglas Adams once joked. Many wasted years and massive effort trying to ascribe some deep, symbolic significance to this number when the answer all along is really quite simple yet so deep and profound - 'God is love'.


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I received Item USB hub it lasted one hour before it crashed my window 7 Computer and it took several hour trouble shooting before I unplugged and the the Computer works Fine . So now I can`t use anything I had using usb now have to go to find one . I feel it too much trouble to send back SO I will think about this anytime I need some other product and will probably go some where else. Thanks Ralph
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The Saratoga Casino and Raceway is so eager for trained employees that it will offer a scholarship to the four best students taking casino classes at Schenectady County Community College. The scholarships will begin next year and will go to students in their second year of the new casino and gaming management program. The two-year program leads to an associate degree and, hopefully, a career at a casino. Starting wages at Saratoga would be in ...
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Property Name: Baby- und Kinderbauernhof Riegler
Property Address: Roßleithen 11 Rossleithen, , 4575
Property Description: Roßleithen's Baby- und Kinderbauernhof Riegler is located in the Kalkalpen National Park. The property has a garden with a small children`s pool, a playground and trampoline. Table tennis facilities, children's tractors and go karts can also be used on site. Units at the Kinderbauernhof have 1 or more bedrooms, a living room, kitchen or kitchenette and satellite TV. Most have a washing machine, and some have a balcony with mountain views. Wi-Fi is available free of charge. The local bus stop is 500 metres away, and the nearest restaurant is 1 km away. Roßleiten's town centre and the main train station are both within 5 km of the Kinderbauernhof. The closest ski lift is 12 km away, and a ski storage room can be used at the Kinderbauernhof. A sauna can be used on site against a surcharge, and free private parking is offered to all guests.
Property Facts: Total Number of Rooms: 5Year of Last Renovation: N/A


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text: Neil Lennon has confirmed plans to secure a new striker for Celtic even if Gary Hooper stays at Parkhead. And Sportsmail understands Hamburg's Latvian international Artjoms Rudnevs is under consideration as an option. The player was the subject of a Celtic bid when he quit Lech Poznan last summer but the 25-year-old opted for the Bundesliga instead. Read more: http://www.dailymail.co.uk/sport/fo...oopers-future--Neil-Lennon.html#ixzz2ZomqHIcU Follow us: @MailOnline on Twitter | DailyMail on Facebook


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Controlled Release Insect Repellent - 4 oz
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Although workers' compensation insurance plays an important role in protecting employees against financial burdens caused by workplace injuries and illnesses, and also protecting businesses from lawsuits filed by injured workers, workers' compensation insurance companies are for-profit businesses and are not generally in the habit of spending more money than they have to. You may feel wary of accepting any settlement offer your insurer makes.
Typical Settlement Length
Workers' compensation insurance companies consider many factors when they determine your settlement amount. They must tally all the bills, anticipate all future potential bills, litigate for and defend you when necessary, and often coordinate with the federal government if you are eligible for Medicare. This can take a long time. Some insurers have been accused of unnecessarily delaying claims in the hopes their customers will lose the will to fight and accept a small settlement. A common complaint among workers' compensation customers is that their settlements don't come fast enough.
Insurance Benefits
Unlike most types of insurance, workers' compensation has no specific maximum dollar limit for the benefits available to injured workers. The insurance adjusters set limits for each claim by managing the medical care, such as authorizing a certain number of doctor visits. However, the policy doesn't have a maximum benefit, and injured workers could potentially receive benefits for the rest of their lives. Offering a quick settlement may save an insurer from paying higher, costlier benefits later on.
Administration Costs
Claim delays are an alleged settlement tactic used by insurers to achieve smaller payouts, and many states have claims settlement laws forbidding unnecessary delays. Despite this, claims cost money each day they remain open. An adjuster, often paid an hourly wage, must work the claim until it is concluded. If too many claims are open at once, the insurer must hire additional adjusters to manage the workload. A rapid claims settlement may be a way to stem administrative costs by closing a file quickly.
You always have the right to hire a lawyer, though your insurer may discourage you from doing so. You also may be cut out of the negotiation process if you choose to hire one since all communication generally goes through the lawyer's office once she is involved. However, workers' compensation lawyers generally know more about the law and the insurance system than you do, and may be able to work with your insurance company to get you better treatment or a higher settlement. The insurer may benefit from closing your claim before lawyers get involved.
Customer Service
Each claim situation is different, so you have to judge your insurer's motives based on the circumstances of your claim. While there may be selfish motives at work, your insurer may genuinely believe that your claim is finished and may be trying to help you get on with your life. Handling your claim in a timely manner is good customer service -- as long as your illness or injury has been properly treated.
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