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A review of the Nunn modified single patch technique for atrioventricular septal defect repair
Atrioventricular septal defect (AVSD) is a commonly encountered and challenging surgical problem, especially when associated with Tetralogy of Fallot (TOF). The definition, morphology and terminology of what constitutes an AVSD (canal defects, septal defects, etc.) are beyond the scope of this review. It is also agreed that the spectrum of AVSD from complete to incomplete have varying degrees of septal defects. The 'ventricular component' or 'ventricular septal defect' (VSD) of AVSD has numerous variations which are well known to surgeons and requires all of the care and attention to detail that any defect near the valves and the conduction tissue does. This VSD is an anatomical entity and stands in anatomical classifications of VSD's alongside perimembranous, inlet, muscular, etc. Similarly, the 'primum defect' or 'atrial septal defect' (ASD) in AVSD is very different to most other isolated ASD's and certainly again requires a great attention to detail to protect the inlet valves and conduction tissue. Different morphologists use different terminology to describe the 'atrial' and 'ventricular' components of AVSD. For the purpose of this review, we describe the atrial and ventricular 'components' of AVSD as ASD and VSD to make it easier for the reader.
Early surgical intervention is required to prevent future sequelae of mitral annular enlargement, ventricular dilation, pulmonary hypertension and cardiac failure. The goal of surgical repair is to eliminate significant residual shunting, especially any combination of interventricular communication and left atrioventricular valvar regurgitation (LAVVR) (1). Numerous techniques are described in literature based on number of patches used. Traditionally, a single patch or two-patch technique is used for repair of complete AVSD, of which the latter is more widely used. These repairs are complex with steep learning curve prompting Nunn and team to popularize the so-called modified single patch technique, which avoids the use of a VSD patch, thus greatly simplifying the repair. This procedure has different names: no patch technique, simplified single patch technique, Australian technique, modified single patch technique, and Nunn technique. The authors choose to use the term 'Nunn repair' as he (Dr. Graham Nunn) demonstrated the universal application of this procedure for all forms of AVSD and popularized the same.
In the last two decades, Nunn repair has revolutionized the operation for complete AVSD and has gained worldwide popularity. Many centers have adopted it as their procedure of choice. This technique involves bringing down the leaflets onto the crest of the ventricular septum, thus obliterating the VSD, and then closing the ASD with autologous pericardial patch. Long-term data is now available from various centers. Initially described for small VSD components, this technique is suitable for most, if not all, balanced AVSDs irrespective of VSD size, borderline left ventricular cavity, and associated TOF. Additionally, this method requires minimal manipulation of the valve leaflets, especially in Rastelli type C lesions. It also provides the advantage of being easily reproducible by surgeons at all levels on the learning curve. This review discusses all aspects of Nunn repair/modified single patch technique including the outcomes.
Historical perspective
Lillehei and colleagues [1955] reported one of the earliest repair of a complete AVSD using cross circulation (2). He directly attached the common atrioventricular (AV) valve leaflets to the crest of the ventricular septum, closing the VSD without a patch. This is probably the earliest account of 'modified single patch technique' and should be credited for performing the first procedure. In the late 1950's and early 1960's, Lillehei, Kirklin, McGoon, and Cooley all individually described using two separate patches of Ivalon or Teflon sponge to close both ASD and VSD. Maloney described the classic single patch technique in 1962 (3). They used a single Dacron patch to close both the ASD and the VSD and attached the leaflets to this patch (4). In the case of Rastelli type C lesions (which have a common superior leaflet), the leaflet had to be divided and re-attached to the single patch (5).
In 1976, Trusler described the so-called "conventional" two-patch repair consisting of Dacron patch closure of VSD, autologous pericardial patch closure of ASD, and repair of "cleft"/"zone of apposition" (6). The size of the ventricular patch used with the two-patch technique became smaller with time.
For the next two decades, the two-patch technique was the accepted gold standard. In 1997, Wilcox described their report of direct closure of small VSD's with leaflet tissue and patching the ASD (7). However, Nicholson & Nunn's team from Australia promoted the use of this technique irrespective of the size of VSD and published their 'novel' technique and initial experience in 1999 (8). In this technique, the common AV valves were attached to the crest of the ventricular septum obliterating the VSD and a patch of autologous pericardium was sandwiched between a small Dacron strip and the lowered AV leaflets to close the ASD. Dr. Nunn found that this method was applicable to alteration for variations in leaflet anatomy, sizes of VSD, and ventricular cavity. This technique is popularly known as the Australian repair or Nunn repair (1,9). Elimination of the extra suture line is associated with shorter total bypass and ischemic times (8). They subsequently published more of their experience in 2004 and 2007 (9,10).
Surgical technique
For the sake of this review, we would like to highlight the original steps described by Nunn and his colleagues (8-10).
Set up
The operation is performed through a median sternotomy using conventional full flow cardiopulmonary bypass (CPB) via aortic and bicaval cannulation with moderate systemic hypothermia. The aorta is cross-clamped and antegrade cold blood cardioplegia is delivered at 20-minute intervals. The left ventricle is vented through right upper superior pulmonary vein. A right atriotomy is performed parallel to the AV groove starting from the right atrial appendage to just above the inferior vena cava.
Steps of repair (Figures 1,2)
- Interrupted pledgetted 5-0 Polyester (Tevdek, Deknatel Inc, Fall River, MA, USA) mattress sutures are taken from the RV aspect of the inter ventricular septum (IVS) well away from septal crest. The first suture begins at the tricuspid annulus to right of AV node and lies within the leaflet rather than in the annulus (Figure 1A). The subsequent sutures are taken from the RV aspect of the septum starting from under the inferior bridging leaflet (Figure 1B). The sutures are then placed beneath the superior bridging leaflet progressing along the septum towards the middle (Figure 1C).
- These sutures are then taken through the superior and inferior bridging leaflets, thus separating the common valve into the left and right AV valves at the IVS crest. Attempt is made to preserve as much of left AV valve (mitral) as possible. If the bridging leaflets need division, then the suture is taken through the edges of both AV valve components thus approximating them at the septum (Figure 1D,E). Notice that the two ends of middle suture is passed through the apposing edges of the bridging leaflet (Figure 1F,G).
- These sutures are now brought through the pericardial patch edge passing them through the Dacron strip (is measured at 80% of the exposed crest of IVS) (Figure 1F,G). The shorter length of the Dacron strip reduces the annulus size and provides an anchor that allows better leaflet coaptation and acts as a mitral annuloplasty (this seems to be the most neglected step when doing this procedure). The Dacron strip also supports the suture line and aims at better coaptation of the bridging leaflets. The sutures are tied, approximating the atrioventricular leaflets to the crest of IVS thus closing the VSD (Figure 2A). The two ends of the central suture are left uncut (to be used subsequently to close the "cleft").
- The "cleft"/"zone of apposition" created by apposition of superior and inferior bridging leaflets is then closed. A nerve hook is used to retract and expose the chordal leaflet junction (Figure 2B). A temporary 7/0 Prolene (Prolene, Ethicon Inc. Somerville, NJ, USA) retraction suture is placed at orifice end of the "cleft" at junction of the chordae and the leaflet and placed on tension. This facilitates apposition of the two leaflet components for suture placement and prevents concertina effect (Figure 2B-D). The two ends of the central interrupted suture, which passes through both the apposing bridging leaflets in the previous step, are passed through the pericardial patch from the right side and used to close the left sided "cleft" in two continuous layers. The suture ends are then passed back through the pericardial patch and tied on the right side (this step ensures that there is no residual leak at the base of the "cleft") (Figure 2C,D). In addition, if there is a significant leak on the right side, the same suture is used to close the right sided "cleft" and tied together on the right side (Figure 2E,F). To expose the right sided "cleft" a retraction suture is placed at the edge of the "cleft" similar to the one above (Figure 2F).
- The valve is tested by filling the ventricle with saline. If necessary, commissural annuloplasty is performed to improve valve competence (per their report, Nunn and team do not routinely insufflate the ventricle prior to repair).
- The primum ASD is now closed with the pericardial patch using a continuous 7/0 prolene (Prolene, Ethicon Inc., Somerville, NJ, USA) suture starting from the annulus of the inferior bridging leaflet. Posteriorly the suture line courses around the AV node ensuring bites through the fibrous tissue, going straight onto the atrial wall and heading towards the anterior lip of the coronary sinus thus ensuring its drainage into the right atrium (Figure 3). The suture continuous around the inferior rim of the primum ASD. A second 7-0 Prolene suture is started from the annulus of the superior bridging leaflet and is used to close the superior rim of the primum ASD.
- The atrium is closed in standard fashion with running polypropylene suture in two layers. The patient is re-warmed, heart is de-aired, and cross clamp is removed. The patient is subsequently weaned off CPB. The pre and post-operative ECHO images are shown in Figure 4.
Nunn and colleagues reported the use of modified single patch technique to also successfully repair patients with TOF and AVSD (7). The steps include:
- Prior to septation, the infundibular resection is performed as usual in a case of TOF.
- Care is taken to preserve AV valve competence. More pledgetted sutures are usually taken through the right side of the VSD crest to account for the longer septal crest and to avoid possible left ventricular outflow tract (LVOT) obstruction (Figure 5A).
- A trans-annular patch with monocusp or a RV-PA conduit is commonly used to augment the right ventricular outflow tract (RVOT) (1).
Pre-operative and post-operative ECHO images following TOF-AVSD are shown in Figure 5B-D.
Nunn technique can also be applied for complete AVSD with borderline small LV (Figure 6A). Care is taken to preserve as much of the left AV valve tissue as possible, keeping the suture line on to the right AV valve tissue. The left ventricle cavity seems to improve post operatively (Figure 6B).
Over the years, surgeons all over the world have modified the steps in variance to the original technique described by Nunn and team. The common variations include using different suture materials, non-pledgetted sutures, not using the Dacron strip, using interrupted sutures for the closure of the cleft, redirecting the coronary sinus to the left atrium, using other patch materials for closure of ASD, and plication of the patch on the left side. However, the basic principles of Nunn technique or modified single patch technique remain the same.
Data for all AVSD repairs
McGoon was one of the first to describe a successful repair of AVSD in an infant under 12 months old. Since then, most patients with AVSD are advised repair in the first year of life. Most centers adopted the two-patch technique. The results are variable, with left AV valve regurgitation being one of the main complications. Ginde and team published their long-term follow up of 198 patients who underwent AVSD repair between years 1974 and 2000. The overall survival for the entire cohort was 85% at 10 years, 82% at 20 years, and 71% at 30 years and the freedom from reoperation was 88%, 83%, and 78% at those time intervals. Indications for reoperation included left AV valve regurgitation (7.1%) and LVOT obstruction (3.5%). The authors identified that a reoperation was a risk factor for late mortality (11).
Suzuki and colleagues retrospectively reviewed results of the two-patch technique in 116 patients from February 1997 through October 2002. Survival at 1, 3, and 5 years was 98%, 95%, and 95% respectively. At discharge, 68% had trivial to mild and 3% had moderate to severe left AV valve regurgitation. The overall freedom from reoperation at 1, 3, and 5 years for left AV valve dysfunction was 94%, 89%, and 89%, and for LVOT obstruction was 100%, 93%, and 90%, respectively. They concluded that the traditional two-patch technique is a reproducible and safe technique with low mortality and good midterm outcomes even in very young infants (12).
Other surgeons routinely used the "classic single patch" technique. Early experience with this repair showed difficulty in attaching the bridging leaflets to the patch, which led to post-operative left AV valve dysfunction, residual VSDs, conduction abnormalities, and pulmonary hypertension (4,8). However, there were some favorable long-term studies. Crawford reported a large series of 172 consecutive patients who underwent the above technique. The mean age at operation was 10.8 months. Operative mortality depended on decade of operation, use of crystalloid cardioplegia, and postoperative time on ventilator. Overall mortality was 8.7% and decreased significantly from 16.4% in the first decade to 3.0% in the second decade of performing the operation. Overall survival was 79% at 15 years. Freedom from late re-operation for severe mitral regurgitation was 89.9% at 15 years and did not decrease in the second decade (13).
Draulescu et al. studied 107 patients with complete AVSD who underwent the classic Rastelli one-patch repair between 1984 and 2005. They used a single autologous glutaraldehyde preserved patch for VSD closure, re-suspension of the leaflets, and closure of ASD. In 70 patients, the "cleft" was left open, 11 had RVOT procedure and three had coarctation repair. The overall in-hospital mortality was 13%, however in the latter years this decreased to 4% due to improvements in perioperative management. Early survival was 86%. Five patients had early reoperation (2 for residual VSD closure and 3 for mitral valve repair) and nine patients had late reoperations (4 for sub-aortic stenosis, 5 for mitral valve repair) with success. Overall survival at 10 and 15 years was 84%. Freedom from reoperation for mitral regurgitation was 94% at 10 years, and 91% at 15 and 20 years (14).
Emergence of data supporting the Nunn technique
Since 1999, multiple surgeons have published outcomes related to the Nunn modified single patch technique. Nicholson and colleagues reported in 1999 on 47 patients who underwent the Nunn technique with a mean age at repair of 5.6 months. They found no heart block, no significant residual VSDs, and no LVOT obstruction. There was no mitral valve incompetence in 28% of patients and minimal to mild incompetence in 66%. Only 6% had moderate mitral valve incompetence. They concluded that the modified single-patch technique simplifies the repair with preserved valve function with no LVOT obstruction (8).
Subsequently, Nunn published a more detailed long-term follow up of modified single patch technique for the repair of complete AVSD in 128 patients. Thirty-day mortality was 1.6% and incidence of mitral valve re-operation was 2.3%. There were no patients with residual VSD's or LVOT obstruction (10).
These results prompted other units to adopt this technique and the published data is positive. In 2010, Jonas and Mora examined 33 patients who underwent Australian repair irrespective of the VSD size (88% had moderate to large VSD). In the balanced canal subgroup, there was no early mortality and two patients required reoperation: one mitral valve repair for cleft dehiscence at 1 year and the other a patient with heterotaxy who required pacemaker implantation. In the unbalanced canal subgroup, two patients (22%) died in perioperative period. There were no late deaths or new LVOT obstruction in either subgroup (5).
In 2010, Halit and colleagues published their data of 26 patients who underwent AVSD repairs. Fourteen had traditional single patch technique (Group 1) and 11 had Australian technique (Group 2). The mean CPB and cross-clamp times in the Australian, technique group was 78.8 and 54.4 minutes, compared to 133.2 and 79.4 minutes in the traditional single patch group, which was a statistically significant reduction. There was no significant difference in early postoperative deaths or incidence of post-operative left AV valve regurgitation (LAVVR) and no patients from either group had LVOT obstruction (15).
Salihoglu and colleagues published their report of thirteen patients who underwent direct closure technique of partial and complete AVSDs. The median age at operation was 13 months for partial AVSDs and 7.5 months with complete type. There was no in-hospital mortality. At discharge, all patients had sinus rhythm with less than moderate AV valve regurgitation (16).
Tagliari et al. also published their results of Nunn technique in 16 patients. They had two hospital deaths (12.5%), three patients required reoperation for the left AV valve, and two patients had heart block requiring pace maker. No patient had LVOT obstruction. At a mean follow-up duration of 55 months, the 14 surviving patients remain asymptomatic and ten had mild LAVVR (71%) (17).
In 2014, Salah reviewed twenty patients with complete AV canal defects who underwent total repair using the modified single patch technique between January 2011 and March 2013. The breakdown by Rastelli type: 75% type A, 10% type B, and 15% type C. Follow up was 1 year. The mean cross-clamp, CPB, and total operative times were 59, 74, and 197 minutes respectively. At 1 year, 88% of patients had follow up echocardiography and none of these patients showed residual shunts or LVOT obstruction. Additionally, 93% had trivial to mild LAVVR and 6% showed moderate regurgitation. He commented that once it was determined that direct closure is feasible; the technical aspects were less daunting. However, the author expresses a concern that any left AV valve deformity, LVOT obstruction, or residual VSD would further deteriorate after repair with the modified single-patch technique (18).
More recently, a study by Li and colleagues early in 2017 included 15 publications involving 1,034 patients. Their results showed that the VSD size was significantly smaller in the modified single patch group. However, they also had lower cross-clamp and CPB times and a shorter length of stay compared to those who underwent two-patch repair. They found no significant differences between the two groups in other postoperative outcomes including mortality, LVOT obstruction, residual VSD, complete heart block, and need for reoperation, though they commented that these outcomes have been improving across all repairs (19).
Comparative literature
Others have compared this technique to the more established techniques and highlighted the ease of surgery, shorter clamp and bypass times and lower complication rates. Backer and colleagues published multiple papers on the topic. In 2007, they described 55 infants who underwent complete AVSD repair, 26 with a modified single patch technique and 29 with a two-patch technique. Rastelli classification breakdown was similar between the two groups, though more Rastelli C lesions underwent the two-patch technique. The mean size of the VSD by trans-esophageal echocardiogram was not significant. Cross-clamp times and CPB times in the modified single-patch group were shorter (97 vs. 123 minutes, P=0.0003; 128 vs. 157 minutes, P=0.03). The median postoperative length of stay was similar (10 vs. 8 days). There was one death in the modified single patch group and none in the other group. One patient from the modified single patch group had mitral valve re-operation in comparison to two in the latter group. No patient had a residual VSD or third degree atrioventricular block in the modified single patch technique group whereas there was one patient each who had the above complications in the two-patch group. No patient in either group had re-operation for LVOT obstruction. They concluded that the results of modified single-patch technique were comparable to the two-patch technique in younger patients with similarly sized VSDs and is performed with significantly shorter cross-clamp and CPB times (20).
In 2009, Backer performed a meta-analysis of modified single patch technique (combined experience of Dr. Nunn, Dr. Richard Jonas and their group) with the data for two-patch and classic single patch techniques. The rate of reoperation for LAVVR was only 2% in the former compared to 7% in the two-patch group and 9.7% in the classic single patch group. Similarly, the rate of reoperation for LVOT obstruction in the two-patch group was 5%. In the long-term follow up of Nunn's earliest patient, none required reoperation for LVOT obstruction. Backer argues that the prosthetic patch used to close the VSD in the two-patch technique may act as a rigid foreign body causing turbulence of blood flow and promote fibrosis leading on to LVOT obstruction (21).
Pan and colleagues published a comparative study of modified single patch technique (46 patients) and the two-patch technique (59 patients) between 2001 and 2011. There was one death in each of the groups. The aortic cross-clamp and CPB times were shorter in the modified single patch group (70 vs. 83 minutes, P=0.004; 95 vs. 110 minutes, P=0.011). There was no patient with heart block in the first group, but two patients required pacemaker in the two-patch group. Late deaths were one and three in respective groups. Four patients with modified single patch repair developed late LAVVR compared to six patients with two-patch repair. Three and five patients respectively in each group underwent late reoperation. One patient in the modified single patch group required reoperation for a residual VSD compared to no patients in the two-patch group. They concluded that the results in both groups are comparable and the modified single patch repair is a safe and reproducible technique (22).
As more data was available on Nunn technique, Backer published a more detailed meta-analysis of all three approaches: Nunn technique (272 patients), two-patch (889 patients) and classic single patch technique (350 patients). The mortality in the groups was 1.2%, 3.5%, and 4.9% respectively. Left AV valve reoperation rate was 2.2%, 7.2%, and 9.7%. Heart block requiring pacemaker was 0.4%, 1.9%, and 2.3% respectively. Given the shorter clamp and CPB times and associated low mortality and morbidity, the modified single patch technique is their recommended repair method. They also noted that the modified single patch technique is safe in small infants and may decrease the risk of late pulmonary hypertension (23).
Stephens et al. reviewed 139 patients who underwent complete AVSD repair from January 2005 to December 2012. They used a selective approach. Ninety-eight patients had two-patch repair for large VSDs and 41 patients had Nunn technique for "shallow" VSDs. Children with trisomy 21 were more likely to have had a two-patch repair with slightly increased cross clamp and CPB times, but the outcomes were similar. Three patients had in-hospital mortality and one patient had late mortality. Two patients required a permanent pacemaker and 11 patients needed left AV valve reoperation. There was no difference between patients repaired at age over 3 months compared to those repaired prior to 3 months of age (24).
A review of 11 series in 2015 containing 378 patients by El Rassi and colleagues concluded that the modified single patch technique is an alternative method for the repair of complete AV canal. They found reduction in both cross clamp and CPB times, with a mean reduction in both times of 30 minutes. Mortality and LAVVR were low and not different from standard techniques. However, there were no cases of LVOT obstruction needing operation following Nunn technique compared to 15% needing re-operation in standard treatment cohort. They did however comment that with the exception of the series published by Nunn himself, the long-term fate of the LVOT remains unclear following the modified single-patch technique as the follow is limited compared to the standard techniques (25).
Other considerations
TOF and double outlet right ventricle (DORV)
The use of modified single patch technique with associated TOF and DORV is evolving and the literature is scant. Complete AVSD with TOF is a difficult subset of patients. The overall mortality in this group from a meta-analysis of 50 studies is 9% (26). The VSD component is large and with anterior displacement, many worry about possible LVOT obstruction. Therefore, the two-patch technique has been preferred method of repair thus far. Clarke reported a cohort of 88 patients who underwent the Nunn repair and nine of these had TOF or pulmonary atresia anatomy requiring an additional RVOT procedure. There were three early deaths (3.4%) one with TOF anatomy, one with pulmonary atresia who needed an RV to PA conduit, and another with aortic stenosis (9). The Nunn technique could be used for AVSD with TOF, but as previously described; more pledgetted sutures are required on the right side of the VSD to account for the longer septal crest. Left ventricular outflow obstruction has not been a proven problem.
Backer and team used a modification of the modified single patch technique for TOF/DORV AVSD. They only brought the inferior bridging leaflet down and attached to the crest of the VSD as in the standard Nunn technique. A Gore-Tex patch is used to close the VSD under the superior bridging leaflet, which routes the left ventricular blood to the aorta (21).
In 2009, Jeong et al. examined 61 patients who underwent total correction for complete AVSD with either the Nunn technique (18 patients) or the classic single patch technique (43 patients). The aortic cross-clamp time was shorter in the Nunn group (110.8 vs. 134.4 minutes, P=0.03). Two patients needed reoperation and there was one late death in the Nunn group, compared to three reoperations and two late deaths in the classic single patch group. Overall, the outcomes in both groups were similar; however, the Nunn technique was simpler with shorter ischemic times. Despite this, the authors expressed concern that this technique may not be applicable for those with large VSD and associated TOF or valve abnormalities (27).
At this time, the debate continues as to whether Nunn technique is applicable for this subset of population.
Down's syndrome
Atz et al. published a multicenter observational study (June 2004 to 2006) of 120 children who underwent repair of complete AVSD using the three techniques: single patch (18%), double patch (72%), and a single ASD patch with primary VSD closure (10%). The study demonstrated that the outcomes did not differ by repair type or the presence of trisomy 21 (80% of cohort). The median age at surgery was 3.7 months. In-hospital mortality rate was 2.5% and the 6-month mortality was 4%. The incidence of residual VSD and LAVVR did not differ by repair type. The ICU stay, ventilator support, and total hospital stay were independent of the presence of trisomy 21. Younger age of operation and presence of associated anomalies were associated with longer hospital stay with no increase in the incidence of residual VSD or significant LAVVR (28).
Reoperations for complications
Left AV valve regurgitation
The most common cited reason for re-operation following AVSD repair is LAVVR. Kanani and his group showed that the most common reason for reoperation was dehiscence of the "zone of apposition"/"cleft". In their study, 33 patients underwent re-operations of the left atrioventricular valve (21 complete and 12 partial). Twenty patients had re-operation within 1 year of primary repair, and 13 patients had repair beyond 1 year. The group, which underwent repair within 1 year, did so because of leaflet tears or dysplastic valves. The latter group had several areas of valvar leakage, which included central regurgitation (29). Repair of LAVVR following previous surgery involves repair of the "zone of apposition" between the left sided bridging leaflets and may require annuloplasty to attain competence. They used a custom flexible partial annuloplasty ring made from a thin-walled 3.5-mm Gore-Tex graft shaped to fit the exact contours and morphologic composition of this annulus to account for the growth potential (29). It is interesting to note that the original Nunn technique may have fewer "cleft" disruptions because a continuous braided suture (Tevdek or Ticron) instead of interrupted polypropylene sutures were used. Additionally, the Dacron strip used to sandwich the leaflets and the pericardial patch would support the leaflets and act as an anterior annuloplasty.
LVOT obstruction
Echocardiography and autopsy studies demonstrate that up to 75% patients with AVSD are at risk for developing LVOT obstruction, of whom 35–45% will need reoperation. It is three times more common following partial AVSD repair compared to complete AVSD repairs. There is theoretical concern for LVOT obstruction following Nunn technique, but long-term studies have not demonstrated an increased incidence. In 2010, Stulak and associates reviewed 146 patients who underwent reoperation after previous repair of partial (n=96) and complete (n=50) AVSD. Reoperation for LVOT obstruction was much higher in the partial AVSD group compared with the complete AVSD group. They concluded that though early results of the Nunn repair did not demonstrate problems with LVOT obstruction, with longer follow-up, the potential for LVOT obstruction might become more evident, particularly with partial AVSD (30).
Other authors worry about LVOT obstruction specifically when the VSD component is large. Adachi and colleagues sought to better define the Nunn repair in hearts with a large ventricular scoop (distance from the ventricular crest to the atrioventricular valve during end-diastole). Thirty-one specimens with complete AVSD and 12 specimens with partial AVSD were evaluated. The scoop had a skewed shape with extension antero-superiorly beyond the AV junction in 16 hearts with complete AVSD. This extension resulted in narrower LVOT compared to complete AVSD with no extension. However, on stratification using the scoop depths there was no obvious differences between the complete with deep scoop vs. shallow scoop. This indicates that the antero-superior extension has more impact on the LVOT rather than the depth of scoop. This skewed extension could potentially lead to asymmetry in the valve leaflets and lead to LVOT obstruction. They concluded that the suitability of simplified single patch technique not only depends on the depth of the scoop but also on the antero-superior extension (31).
Adachi also stated that hearts with DORV are unsuitable for Nunn repair as the only LV outlet is the space between the bridging leaflet and the crest of the ventricular septum. They expressed concern that Nunn technique diminishes this space thus leading to LVOT obstruction. Adachi further quoted Wilcox who in 1997 speculated that if the scoop were too deep it would cause leaflet distortion and increased tension in bringing the leaflets on to the septum. The authors also quoted the 2007 paper by Backer et al. who based their decision to perform the modified single patch technique based on the scoop depth. If the depth were, 10 mm or less they would use the modified single patch technique and use the two-patch technique if the scoop depth was greater than 10 mm (31).
Despite these speculations, the data has not demonstrated increased LVOT obstruction using the Nunn technique. In the study published by Nunn, 30-day mortality was 1.6%, re-operation rate was 2.3% for mitral valve, and there were no residual VSD's or LVOT obstruction (10). This relative paradox of the perceived LVOT obstruction and the actual figures prompted Kanani and colleagues to reply to the above study in a letter to the editor stating that emerging data on the modified single patch experience indicates a lack of significance in the antero-superior extension demonstrated by Adachi. They instead point to the contribution of an obstructive sub-valvar apparatus where dysplastic leaflet material and papillary muscles extend into the LVOT. They concluded that, "the problem is a complex one in which morphology alone is unlikely to hold all the secrets. Nevertheless, it is gratifying to see, befitting the modern era, that it is the surgeon that is driving the understanding of this issue to cause a more perfect repair" (32).
In a more recent study by Becker and colleagues, modified single patch technique was used in 77 infants with complete AVSD between January 2000 and 2013. Eight patients had a prior coarctation repair in the newborn period. The mean and median follow-up times were 4.6 and 3.7 years, respectively. Only two patients (2.5%) who previously had coarctation repair had late reoperation for LVOT obstruction. The first patient had a discrete fibrous sub aortic membrane and needed reoperation at 3 and 7 years following primary repair. The second patient had LVOT obstruction from accessory chordae from the left AV valve and needed Mitral valve replacement 5 months following primary repair. They concluded that LVOT obstruction is not a significant complication after modified single patch repair of AVSD. Previous operation for coarctation of aorta is an important predictor of late LVOT obstruction following modified single patch technique (33).
The current literature is not clear on the above dichotomy given the fact that Nunn technique creates a 'primum defect' but still has a rare incidence of LVOT obstruction in comparison to an isolated 'primum" defect. The authors can only speculate the reasons for the same. Literature is limited on the influence that the age of repair of the two lesions (complete vs. primum) may have on this issue. If all isolated primum defects were repaired as early as the complete AVSD the incidence of later LVOT obstruction may be completely different and would probably be the same low number as the modified single patch technique post repair. This has not been tested as far as we know but may be the focus of future studies as patients are being operated at a younger age and the mortality for the same is very low. One fact that is clear from the existing literature is that the size of the VSD at repair does not predict the likelihood of LVOT obstruction in the modified single patch technique, and yet a case with a big VSD has a much greater anatomical realignment than a primum defect, which has none, after repair. Often the septum lengthens and the LV grows after complete repair with modified single patch technique. So we can only imagine how much better (different) these two structures would be if the primum defect were repaired at an equally young age. This leads us to a question does late operation (longer duration of 'goose neck') lead to future LVOT obstruction?
The Nunn technique for complete AVSD has universal application. It requires fewer decisions regarding geometry, size, and configuration of patches compared to the two-patch technique. This allows for reproducibility and training of other surgeons. Data has shown good preservation of atrioventricular valve function, no residual VSDs, low incidence of LVOT obstruction, preserved conduction, and improved perioperative and long-term mortality compared to other techniques.
Dr. Graham Nunn for the computerized images used in this review.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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- Mavroudis C. Atrioventricular Septal Defects (Atrioventricular Canal). In: Mavroudis C, Backer C. editors. Atlas of Pediatric Cardiac Surgery. London: Springer, 2015:117-29.
- Jonas RA, Mora B. Individualized approach to repair of complete atrioventricular canal: selective use of the traditional single-patch technique versus the Australian technique. World J Pediatr Congenit Heart Surg 2010;1:78-86. [Crossref] [PubMed]
- Trusler GA, Yamamoto N, Williams WG, et al. Surgical treatment of pulmonary atresia with intact ventricular septum. Br Heart J 1976;38:957-60. [Crossref] [PubMed]
- Wilcox BR, Jones DR, Frantz EG, et al. Anatomically sound, simplified approach to repair of "complete" atrioventricular septal defect. Ann Thorac Surg 1997;64:487-93. [Crossref] [PubMed]
- Nicholson IA, Nunn GR, Sholler GF, et al. Simplified single patch technique for the repair of atrioventricular septal defect. J Thorac Cardiovasc Surg 1999;118:642-6. [Crossref] [PubMed]
- Clarke A, Nunn GR, Nicholson IA. The simplified single patch repair of complete atrioventricular septal defect. Oper Tech Thorac Cardiovasc Surg 2004;9:233-9. [Crossref]
- Nunn GR. Atrioventricular canal: modified single patch technique. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2007;10:28-31. [Crossref] [PubMed]
- Ginde S, Lam J, Hill GD, et al. Long-term outcomes after surgical repair of complete atrioventricular septal defect. J Thorac Cardiovasc Surg 2015;150:369-74. [Crossref] [PubMed]
- Suzuki T, Bove EL, Devaney EJ, et al. Results of definitive repair of complete atrioventricular septal defect in neonates and infants. Ann Thorac Surg 2008;86:596-602. [Crossref] [PubMed]
- Crawford FA, Stroud MR. Surgical repair of complete atrioventricular septal defect. Ann Thorac Surg 2001;72:1621-8. [Crossref] [PubMed]
- Dragulescu A, Fouilloux V, Ghez O, et al. Complete atrioventricular canal repair under 1 year: Rastelli one-patch procedure yields excellent long-term results. Ann Thorac Surg 2008;86:1599-604. [Crossref] [PubMed]
- Halit V, Oktar GL, Imren VY, et al. Traditional single patch versus the "Australian" technique for repair of complete atrioventricular canal defects. Surg Today 2008;38:999-1003. [Crossref] [PubMed]
- Salihoğlu E, Özkan S, Özçobanoğlu S, et al. Preliminary results of direct closure of an atrioventricular septal defect: revisiting the original technique. Turk J Thorac Cardiovasc Surg 2012;20:699-704. [Crossref]
- Tagliari AP, Schröder DA, Teixeira Filho G, et al. Results of simplified single-patch repair for complete atrioventricular septal defect. Arq Bras Cardiol 2013;100:288-93. [Crossref] [PubMed]
- Salah T. Outcome of Australian Technique in Repair of Complete AV Canal Septal Defects. J Egyp Card Thorac Surg 2014;22:89-96.
- Li D, Fan Q, Iwase T, et al. Modified Single-Patch Technique versus Two-Patch Technique for the Repair of Complete Atrioventricular Septal Defect: A Meta-Analysis. Pediatr Cardiol 2017;38:1456-64. [Crossref] [PubMed]
- Backer CL, Stewart RD, Bailliard F, et al. Complete atrioventricular canal: comparison of modified single-patch technique with two-patch technique. Ann Thorac Surg 2007;84:2038-46. [Crossref] [PubMed]
- Backer CL, Kaushal S, Mavroudis C. Modified single-patch technique: Repairing complete atrioventricular septal defect. Ann Pediatr Cardiol 2009;2:51-4. [Crossref] [PubMed]
- Pan G, Song L, Zhou X, et al. Complete Atrioventricular Septal Defect: Comparison of Modified Single‐Patch Technique with Two‐Patch Technique in Infants. J Card Surg 2014;29:251-5. [Crossref] [PubMed]
- Backer CL, Eltayeb O, Mongé MC, et al. No Ventricular Septal Defect Patch Atrioventricular Septal Defect Repair. Oper Tech Thorac Cardiovasc Surg 2015;20:279-92. [Crossref]
- Stephens EH, Ibrahimiye AN, Yerebakan H, et al. Early complete atrioventricular canal repair yields outcomes equivalent to late repair. Ann Thorac Surg 2015;99:2109-15. [Crossref] [PubMed]
- El-Rassi I, Charafeddine F, Tabbakh A, et al. Surgical repair of complete atrioventricular defect (Nunn technique). Multimed Man Cardiothorac Surg 2015;2015. [Crossref] [PubMed]
- Prifti E, Bonacchi M, Bernabei M, et al. Repair of Complete Atrioventricular Septal Defect with Tetralogy of Fallot. J Card Surg 2004;19:175-83. [Crossref] [PubMed]
- Jeong IS, Lee CH, Lee C, et al. Surgical outcomes of the modified single-patch technique in complete atrioventricular septal defect. Interact Cardiovasc Thorac Surg 2009;8:435-7. [Crossref] [PubMed]
- Atz AM, Hawkins JA, Lu M, et al. Surgical management of complete atrioventricular septal defect: associations with surgical technique, age, and trisomy 21. J Thorac Cardiovasc Surg 2011;141:1371-9. [Crossref] [PubMed]
- Kanani M, Tsang V, Cook A, et al. Re-repair of the left atrioventricular valve in atrioventricular septal defects: the morphologic approach to the role of Gore-tex band reduction annuloplasty. Eur J Cardiothorac Surg 2010;37:273-8. [PubMed]
- Stulak JM, Burkhart HM, Dearani JA. Reoperations after repair of partial and complete atrioventricular septal defect. World J Pediatr Congenit Heart Surg 2010;1:97-104. [Crossref] [PubMed]
- Adachi I, Ho SY, McCarthy KP, et al. Ventricular scoop in atrioventricular septal defect: relevance to simplified single-patch method. Ann Thorac Surg 2009;87:198-203. [Crossref] [PubMed]
- Kanani M, Cook A, Kostolny M. Left ventricular outflow tract obstruction after the modified single patch repair of atrioventricular septal defects: teasing fact from fiction. Ann Thorac Surg 2010;89:1339-40. [Crossref] [PubMed]
- Backer CL, Eltayeb O, Mongé MC, et al. Modified single patch: are we still worried about subaortic stenosis? Ann Thorac Surg 2015;99:1671-5. [Crossref] [PubMed]


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Sweater weather is here! As such, it is time to break out our fall wardrobe as we approach a new season of crisp air, apples and pumpkin flavored everything. So today, I wanted to dedicate a post to petite friendly sweaters that are under $50.
Caslon Side Snap Tunic Sweater
This tunic sweater is what inspired me to write a blog post about petite friendly sweaters! I got this beauty during this year's Nordstrom Anniversary sale and I am so grateful. This sweater is so flattering for petites that can be worn as a dress or layers with jeans/shirt. In these images, I am wearing it in size S for extra coziness. If you want this piece to be true to size, size down.
Sweater: Nordstrom // Hat: Urban Outfitters // Boots: Steve Madden
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Brooklyn, how YOU doin' 🌇✨ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ It was my first time in Brooklyn last week and it was so much fun! @victoriasaperstein got me to conquer my fear of the subway and everything! 🤣 ⠀⠀⠀⠀⠀⠀⠀⠀⠀ As sad as it is to say goodbye to summer, I can't wait to wear this sweater tunic more! Has anyone purchased their first PSL of the year yet? I couldn't resist getting one during my Target run yesterday. 🙈🍂☕ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ http://liketk.it/2Evax @liketoknow.it #liketkit #LTKunder50 #LTKunder100 #LTKstyletip #LTKshoecrush ⠀⠀⠀⠀⠀⠀⠀⠀⠀ 📷: @victoriasaperstein
A New Day Any Day Casual Fit Long Sleeve Open Neck Ribbed Cardigan
I don't know if it is the color or the length but this cardigan sweater is absolutely lovely! I can't wait to pair this beauty with a booties and my favorite pair of jeans.
Sweater: Target // Dress: Target
A New Day Long Sleeve Cozy Sweater Cardigan
This sweater has it all. A beautiful color and oh so cozy!

subset: commoncrawl


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The most recommended tour in Budapest!
Learn all about the city's history and check out major sights including Buda Castle, Inner Pest, Heroes' Square, City Park and more.
Highlights and Themes
- Small-group walking tour
- Soft drink and homemade Hungarian dessert included
- Innovative stories, interactive participation encouraged
- Overview of Hungarian history and culture
- A visit to Heroes' Square and City Park with a peek into a bath house
- Inner Pest – Opera, Andrassy, Basilica and Chain Bridge
- Buda Castle District – Royal Palace, Fisherman's Bastion, Matthias Church
3.5 hours
Dates & Times
Year Round – Daily at 10:00 AM
Meeting Point
Absolute Tour Center
1065 Budapest, Lazar street 16,
located right behind the Opera House.
Conclusion Point: Tour ends in the Buda Castle District, near Matthias Church
Full Tour Description:Budapest Walking Tour
Duration: 3.5 hours
Pest Start
Our famous Budapest Walking Tour begins at the iconic Opera House, one of the most inspiring buildings in Budapest. From here we'll take a short ride on the Millennium metro – the oldest in Europe – out to Heroes' Square and City Park.
It's here that the history lesson begins, with a great introduction to Hungary's long history and rich culture through its different ages and many kings. Next, we'll stroll through the City Park to visit the Vajdahunyad Castle (outside only), a complex built for the World Fayre in 1896 that displays typical architecture found throughout Hungary.
Bath Stop
After a stop at Széchenyi Baths (with a peek inside when open) to learn about the Hungary's amazing spa culture, we'll hop back on the Millennium metro back towards the city center and stop at the end of Andrassy Boulevard. Here you'll hear about the significance the UNESCO-listed street and it's to cultural and noble influence on the history of Budapest.
Hungarian Dessert
Up next is St. Stephen's Basilica (outside only) for a few photos before we take a break, in a café for a taste of a Hungarian famous dessert. Here guests will each get some homemade dessert and a coffee or soft drink (included in the tour price). After our refreshment break we head down to the riverside to see the famous blue Danube. Here we will take in the spectacular view of Gellert Hill and the Citadel, Buda Hills and the Royal Palace as we cross the river via Budapest's Chain Bridge.
Buda End
For the final leg of the Budapest Walking Tour, we climb the steps up into the Buda Castle District and then wander through the old cobblestone streets and alleys to our finishing point in front of the Matthias Church and Fisherman's Bastion.
Our Budapest Walking Tours run with small groups and generally do not have more than 15 participants. This makes them interactive and personal and gives you plenty of chances to ask questions and get to know your guide. You can also hit them up for local tips on where to go and what else to do.
We reserve the right to alter and change the tour program without prior notice due to construction, city closures for events, festivals and so on throughout the year.
English speaking guide, coffee or soft drink with homemade Hungarian dessert, public transport tickets during the tour, many stops for photos and questions.
Entry fees to sights and museums, food and beverages except where noted, transport to the meeting point or from the conclusion point, gratuity/tip.
For additional information please see our Terms & Conditions and FAQ


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Baliem Valley
The Baliem Valley was once dubbed Shangri La and it is easy to see why. The Valley is incredibly lush and fertile and is surrounded on all sides by towering peaks of 2,500 to 3,000 metres.
The Baliem Valley, also spelled Balim Valley and sometimes known as the Grand Valley, of the highlands of Western New Guinea. The main town in the valley is Wamena. The valley is about 80 km in length by 20 km in width and lies at an altitude of about 1,600-1,700 m. There are three mains tribes inhabiting the Baliem Valley: The Dani in the base, the Lani to the west and the Yali in the south-east. Each tribe has a distinct culture. One sure and interesting way to distinguish between the tribes is from the Koteka, or penis gourd, sported by the male members.
Looking at the early history, as far as the outside world was concerned, the discovery of the Baliem Valley and the unexpected presence of its large agricultural population was made by Richard Archbold's third zoological expedition to New Guinea in 1938. On 21 June an aerial reconnaissance flight southwards from Hollandia, which is now Jayapura, found what the expedition called the 'Grand Valley'. Since then the valley has gradually been opened up to a limited amount of tourism.


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My Life
My full name is John Albert Ross Welchman. I was born on the 8th of May 1939. in Delhi, India. At that time my father was restaurant manager of the railway station in Delhi. Dad and Mum had also lived in Madras and Ralazpur. At the outbreak of World War 2 ( Sept '39 ) we moved to Rawalpindi (now in Pakistan). The reason for this was the enlistment of my father (Percy Albert) into the Indian Army Ordinance Corps as a commissioned Lieutenant. He served in the Corps until 1947. He had also served in the Somerset Light Infantry during the First World War. In total Dad lived in India for over 30 years as his Battalion was in India during World War One.
The only recollection that I have of those early years is the death of my mother in '47 from a haemorrhage after an operation on her Goitre. My two sisters, the youngest, Una, was 14 years older than me and Hilda, the eldest, both married in India. Una on the 10 December 1945 in Rawalpindi. Hilda, 27 December 1941 to a Freddy Moss (Army) and Una to Maurice Kent, (Royal Army Ordinance Corps). Only details I have of my two Brother-in-Law's is that Maurice joined the Army in August 1938. When Dunkirk was going on Maurice was rescued from St. Marlow. Una had three children. Two girls and very much later a boy when she was in her late 30's. Freddy Moss had been married before and had two teenage sons.
I do remember that I was looked after by an Iya (Indian female servant) who had to be given other duties in the household as I was speaking Urdu instead of English. School, at the age of 5, was as a day border at a Convent in Nowshera, North of Rawalpindi. I also remember our train journeys from Rawalpindi to Lahore to visit Hilda who was living in that city. There wasn't any air-conditioning in those days, so in our private train compartment we had a very large receptacle on the floor which contained a large block of ice. This was our 'air-conditioning'. At every station stop we would have the porter tip away the melted water and another large block of ice put into it to continue the process of trying to keep us cool.
In 1947 India became independent and partition took place and we had to move back to England. Travelling from Rawalpindi to Bombay by train, we could see the dead bodies piled up at the stations, which was the result of the Muslims and other denominations murdering each other as they each swapped over from Pakistan to India and visa versa. We travelled back from Bombay by Troop Ship. The ship was the SS Cythia and it took us , I think six weeks , as we had to stop at Port Said, Egypt, to disembark and embark troops. I remember two things about the trip. When we had left Bombay far behind us and were steaming through the Indian Ocean, I decided to sit up near the bow (front end ) and due to the motion of the ship I became violently seasick. This lasted for several days. Also, it was so hot travelling through the Red Sea and the Suez Canal, that the troops and us tried to find a place on deck at night to sleep. This journey took place without Hilda as she and her husband decided to stay in Lahore as Freddy was offered a civilian job with a transport company.
On arriving at Liverpool we journeyed down to Wateringbury, Kent. My Dad and I stayed with Maurice's parents until Dad could find a place to live. His first job was for the Dock Police in Queensbrough, Isle of Sheppey. We rented a room with an elderly couple who had no children of their own. I used to keep Mice in a hutch in the garden until there were too many and then no more!
I was taking piano lessons with a private tutor and also sang in the choir of the local church. I think the denomination was Wesleyan as my Dad was of that faith. I had to attend choir practice during the week, go to piano lessons, sing in the choir Sunday morning, attend school church in the afternoon and service again in the evening. No wonder I gave up piano and eventually church. The next time I had to go to church was during my Army career. When we had to find new accommodation and Dad a new job, we moved to the other end of the Island where we lived in a large Nissin Hut ( made out of corrugated sheeting ). This was near the town of Lansdowne.
When Dad moved to Leicester in 1952, to work at the Ministry of Defence Records Office, it was decided that Una and Maurice should become my Guardians. Dad was then living in a guest house for long term borders and living in one room was not appropriate for me.
At that time Maurice and Una with Meryl and Merice (daughters) and myself were living in Married Quarters near the village of Syston. We lived there for a short period and then moved to Budbrook Barracks, the home of the Royal Warwickshire Regiment. This camp was near Warwick and I remember going to Randolph Turpins house ( not too far away ) to see him, as he had just won the 1953 World Middleweight Boxing Championship. He had a pet monkey which used to sit on his front garden wall which we were allowed to play with.
In !953 we moved to Nairobi Kenya, as Maurice was appointed Warrant Officer, East African Ammunition Technician . As there was a shortage of married quarters we lived in a hiring which was in fact a hotel. You could hear the lions etc as the hotel was on the outsirts of Nairobi. When there was a shortage of food for the Hyenas we would get them rummaging around our dustbins at night. Every Saturday I would get my pocket money, 5 Kenyan Shillings (25p ) and catch the bus into Nairobi. In those days the buses were partitioned in the middle, white's at the front and you can guess who sat at the back! I would sit in the back as it was a lot cheaper. Before I went to the pictures I would go into the big Ice-cream parlour and have a knickerblocker glory. This was the time of the Mau Mau and there were always troops patrolling around with rifles etc.
We got a letter from Freddy Moss, in Pakistan, to say that Hilda had died that year ('53 ). She died giving birth to her 8th child. Through making contact with the Bishop of Lahore in 2008, I found out that she was buried in Lahore.
In 1954 ( 15 years of age ) I decided to join the Army. I took the entrants examination for the Engineer Boy's School at Chepstow. I failed and then decided to join the Royal Armoured Corps as a boy entrant. The Boys Squadron Royal Armoured Corps was stationed at Bovington, Dorset I picked them as I was interested in tanks. I took the Oath of Allegiance to the Queen and was given a pair of coveralls and boots and worked each day in Headquarters East Africa as a runner and general dogsbody ( Gofer ) I received the princely sum of 17 shillings and 6 pence per week. I had to wait several weeks before I could get a flight home. In those days it took up to two/three days as we had to call in at Khartoum ( Ethiopia ) / El Adam, Libya and I think Malta. The flight out and back was from Blackbush airport. Now a large car auction place. The reporting place prior to flying out and returning was at a place called Goodge Street, Central London. It was in fact underground and a real dismal place. Remember, I was only 15 and travelling a great distance, on my own, for the very first time in my life.
Boy's Service
I arrived at Wool Station in April '54 and proceeded to Bovington Camp. On arrival I was billeted in Dettingen Troop but there was only one other new 'Boy' as the rest of them were still on leave.. The boy was Chris Fox, who I still see today as he lives in Bridport. We slept in one of the large rooms of three that comprised Dettingen Troop. In each room was sixteen lads. Each Troop had a Boy Sgt, three Boy Corporals and 9 Boy Lance Corporals. The Troop was the responsibility of serving adult soldiers, an Officer and two Sergeants. These permanent staff were from the Regiments of the Royal Armoured Corps which at that time totalled twenty six. There were three other troops, named Alamein, Balaclava and Cambrai. The Commanding Officer was a Major. He was in the ( 9th Royal Lancers ) and his name, Hitchcock. I met him again in 1993 when he was a guest of honour at the very last parade before the disbandment of the then Junior Leaders Regiment, Royal Armoured Corps. It hade changed names in September of 1957.
Our wages each week for the first year was 5 shillings. The second year you became a Senior Boy and your pay went up to 10 shillings. The pay was in fact 17 shillings and sixpence so the rest went into a Post Office account. When we went on leave we were given two very large crisp WHITE £5 notes. This was taken from your account. Every Wednesday everybody had to go on a cross country run which was down the Morton track and across the tank driving area. I and a few of my mates formed a plan which was to take it in turns for one of us to be locked into one of our large lockers with a book and torch. This didn't last long as they started to stamp your hand when you reached the point where you turned for home and the finishing point.
In our last year we got into all sorts of tricks and the one that stands out involved another boy and his very small three wheeler car. He used to keep it locked up in one of the tank hangers which had a very large inspection pit and when not in use was covered over with wooden sleepers ( used on the railway ). One night when he was out we removed the sleepers so that on arriving back and driving straight into the hanger disappeared down the steps into the pit. As his car was a very tight fit he couldn't get out. We did release him in the morning.
One of our treats was to go up the hill to the cinema once a week . The first two rows of seats only cost four pence a ticket. Of course once we became senior boys we could afford the other seats which cost one shilling. One of the films we watched was Rock Around The Clock with Bill Haley. When it was shown in other parts of the country people were dancing in the aisles and some cinemas had their seats ripped to shreds by the hooligans of those days. They were called Teddy Boys. We being young soldiers were disciplined and conducted ourselves in an orderly manner.
At the start of my three years I had volunteered to join the band which performed on every parade that was held. I was a drummer and eventually became the leading tipper which meant that I played all the intricate bits ( i.e. drum solos' ) Every Wednesday evening we performed during the interval at the Speedway Stadium in Poole.
During my three years with the 'Boys' I went through the ranks to Boy Sergeant of the newly formed Troop called Tunis. This was in October '56. During those years we did the usual things of foot drill, weapons and a lot of physical training. Also, we were trained in the different aspects of trade training. Wireless ( Radio ) communication, tank gunnery and driver training ( both on tanks and wheeled vehicles. ) When I joined my Regiment I was qualified in all three and had both my tracked and car licences. The other main part of our training was in education. There were three levels, 3rd, 2nd and Senior Certificate. You needed the Senior to obtain the rank of Warrant Officer during your adult service. When I left I only had my 2nd. I did get my Senior Certificate much later during my next twenty two years.
I left the 'Boys' in April '57 and joined the 3rd Royal Tank Regiment who were stationed in Detmold, West Germany. At that time there were eight Tank Regiments. Why I picked the 3rd I do not know as I could have gone to any of the others including the Cavalry. I was put in 'B' Squadron and made friends quickly including a mate from the 'Boys', Barry Routledge. I was the gunner on the Troop Leader's tank (2nd Lt. Allen). During my two and a half years with the 3rd I was
promoted to full Corporal and at one time my gunner was a National Serviceman called Julian Courthold. His family are the owners of a very large international company in England. His friend was another NS who was also the son of the well known family company, H Samuel's, the very well known retail shops selling watches and jewellery. They received pocket money of £20 each every week on top of their Army pay ( 28 Shillings ) Every now and then their parents paid for them to fly home for a long weekend.
At this time my wages were £4 per week which was a vast difference to what they got! Because of Julian's background, his main failing was being able to wash himself properly after a dirty working day on tanks. Consequently we had to teach him what is required of a clean soldier by giving him a Regimental bath. Cold water in a bath and scrubbed with a bass broom and carbolic soap. He soon learnt! ( I think you would call it bullying today ). In those day we were paid in BAFVS ( British Armed Forces Special Vouchers ). This was currency used by serviceman stationed in Germany. They could not be used in any German shops etc. There were threepenny, sixpenny, one shilling, five shilling, ten shilling and pound notes. If we wanted to go into town we had to order the amount of German Marks we required on the Wednesday as pay day was each Thursday. By Sunday you would have run out of Marks and there were lads who made a good living from selling theirs for a good rate of exchange, for them but not so good for you.
One thing that I remembered vividly, was the Barbers. They were both German and some of the lads, including me, would have our hair permed by them just before we went on leave. Mine was swept back in waves. This stopped when I went onto a crew-cut.
In '58 I went to the gunnery training establishment in North Germany to do my Assistant Instructors Course. As I did so well I was sent to Lulworth in April '59 for my three months Instructors Course. The highest mark that you could achieve was an 'A'. I received a 'B' recommend which meant that I could be called back to Lulworth as an Instructor. More about this later.
On retuning to the Regiment I saw on daily orders that volunteers were required to join the 2nd Tanks who were being posted to Libya, North Africa with armoured cars and not tanks. As my regiment was amalgamating with the 6th Tanks, Barry Routledge and myself decided that there was more opportunity for promotion and adventure, so we put our names forward. In August of that year ('59 ) we joined the 2nd Tanks rear party in Tidworth. Before leaving the regiment , whilst on exercise we decided to visit a German pub that was out of bounds to British troops. As it was our last fling we both had too much to drink and during our session the Military Police decided to visit the pub. This resulted in both of us making , or trying to make a quick getaway, out the back through the kitchens. Barry was a bit more inebriated than me and unfortunately got caught. Barry had to see the Colonel next day, but he was lucky, as he was leaving the regiment and got off the charge.
Three weeks later we were in Homs, North Africa. This was a camp some eighty miles down the coast from Tripoli. We were fully contained with two cinemas, one with no roof and the other with a roof for the winter months. These were proper cinemas as you would get in England. Apart from all the latest releases we would also have the latest celebrities visiting and performing on either of the two stages. These was the forces entertainment group's that visited troops overseas. We also had our own beach virtually on our doorstep. As we only worked in the summer from 0700hrs to 1300hrs we were on the beach every day and at the pictures in the evening and then in our bar for a nightcap. My first year, of our three year posting was spent with Ajax Squadron in Benghazi. We were in an old Italian fort called D'Osta Barracks.
We still had our cinema but this was down town in Benghazi itself and also there was a soldiers bar. On a Saturday night we would have a few drinks ( hiccup! ) and then go to the Baranechi casino. This was a large establishment which had two roulette tables, poker tables and a night club downstairs. Remember now we were on Army pay so all we could afford was four blue chips worth 5 shilling each ( Libyan Piaster's was the currency ). The oil men were playing with the equivalent of £100 pound chips. Only one chap was successful at the roulette. In the year he won enough to buy himself a brand new 1960 Volkswagen Beatle, cost him £400.
During that year of training one of the things we did was to take the whole Squadron out of barracks with our vehicles and followed the route that was taken by our regiment in the desert campaign of the Second World War. We started in the East of Libya and the first port of call was to see the monument erected at the location where one of the biggest tank battles took place during that campaign. It was called the battle of Knightsbridge. Next, was Merkeeli. A very large old Italian fort some 200 miles south east of Benghazi, where an account was read out from our Regimental history. We found a large hole in the outer wall which was used by the then Commanding Officer to enter the fort and take the surrender from the occupants who were Italians. This hole was blown by the Royal Engineers! We also found trenches with old boots and barbed wire. Note: the then Colonel of our regiment was his son!
We were now on the last leg of our journey which was to a barren spot in the desert at Beda Fomm. It's location surrounds the only road that leads out of Benghazi to Tripoli. It was here that hundreds, yes hundreds, of Italian troops , along with their comfort girls, were caught retreating from the Allies who were advancing along the coast from Tobruk. Large convoys were seen coming down the road and after a few shots were fired the whole lot surrendered.
Our year was now up and we moved back to Homs after handing over to Badger Squadron. Once we settled into the billets we started training as a Regiment. The village of Homs had not changed except that a new hotel had been built. This is where I was introduced to the French Bidet. After many drinks with the lads one Saturday night we decided to try out this new piece of French wizardry. We were caught by the management lying on our backs with our bare feet in the bowl. How were we to know that it was designed to wash your privates! We also used a local village bar where we would get the local kids trying to swap Roman coins for our cigarettes. These coins came from Roman ruins ( Leptis Magna ) that was located just down the road. We never bothered to do the swap and I often wonder how much the coins would be worth today.
One of our own bars was on the beach and I remember one night one of the married lads saying that he was going to commit suicide as his wife was being unfaithful. As we were all under the influence of drink we took no notice. Sometime later a very wet and bedraggled chap came up to bar. This was the chap who was going to commit suicide by drowning in the sea but couldn't do it. He carried on drinking with us although he was soaking wet! On Sundays we would race around the regimental square in go-carts. During the Easter weekend in '61 I won the regimental Easter
trophy. For the last year of our three we had to hand back the camp to the Libyan Army and move up to Benghazi to Wavell barracks. I was only there six months and then had to take my troop to Mednine barracks in Tripoli. We did the journey of 800 miles by road. We were in the same
barracks as the Royal Scots, an infantry regiment. Six months later we were on the move again. Back to Omagh, Northern Ireland.
Northern Ireland
Northern Ireland was a complete contrast to the sun and desert. Rain, cold and more rain! The barracks were wooden huts but during our two years there they were pulled down and brick one's built to replace them. I wasn't there long as I was posted to the Junior Leaders Regiment at Bovington as one of the permanent staff gunnery instructors. I really didn't enjoy my year there. It was during that time that Maureen (my future wife ) and I decided to marry. We had met when I had arrived back from Libya. We met at the Locarno dance hall in Coventry. I always remember spotting her on the other side of the dance floor wearing a black dress with tassels. When she saw the tan and found out that I had a car she was hooked!
The Beginning of 45 Years of Married Life.
We were married in August ( I still have problems remembering the date, August ? ) 1963 in Coventry. It was a small affair as we didn't have much money. Our honeymoon was a week at Perranporth, Devon. The tyres on the car were worn thin and during our week we had a puncture. I think this just about cleaned us out, having to pay for repairs, but we made it home after a great week.
I then reported for work in Omagh leaving Maureen still living at home with her Mum. To get a married quarter you hade to accumulate points. These were worked out from your rank, children and time in the Army. We were half way down the list so we went into private accommodation which was a small caravan on a site opposite the camp.
It was winter time and the pipes leading from the water stop cock to our caravan froze solid. At night the condensation used to run down the walls and Maureen had to dry out the blankets during the day. All we had was a small coal fire. Talk about a baptism of fire! At Christmas a knock at the door revealed a little old Irishman who convinced us that we should buy the chicken that he was selling. Not knowing any better we did, but it must have been the oldest chicken in Ireland. We cooked it in our small one ring baby bell cooker but threw it away as it didn't smell to good and bought another one. It was in this caravan that we conceived our first child Tracy Jane.
Before Tracy was born we moved into a bungalow ( Army hiring ) on the Londonderry Road, just outside the town. This couldn't of come at a better time. Open fire and central heating. Peat was the fuel of the day. Tracy was born in Aug '64 and just two weeks later we had to move back to England. Perham Down near Tidworth, Hampshire. Our first married quarter was a Coronation street type of house which I am sure had been built before World War 1. You couldn't swing a cat around inside. It had a small backyard with a coal bunker and a communal path between the yard and the back garden. We had only been there a few months and then I had to leave Maureen on her own with our very young daughter as Ajax Squadron was posted to Cyprus with the United Nations in a peace keeping roll.
Our six months were spent in a small, old camp near a village called Zyggi. From here we had to go out on patrol in our armoured cars. The patrolling area was up into the Troodos mountains and west of Limmasol. Our job was to ensure that the Greek and Turkish population behaved themselves. Six months earlier to our arrival they had decided that they didn't want to live side by side and had started to kill each other. They eventually, much later, separated with all the Turks moving to the north of the island and having an imaginary boundary line drawn across the island from west to east. The northern part being governed by Turkey and the south by the Greeks.
No one ever fired at us and I only had one incident which took me by surprise. I was duty Troop Sergeant on guard one night and we had to go to the Turkish village overlooking the main Limmasol, Nicosia road. This village also overlooked our camp and the Turkish lads played football against us. Anyway, off I went to investigate the report that they were taking pot shots at the Greek taxi's as they drove along this road. I arrived at the village barrier to be met by a teenager with a rifle. When I told him that I wanted to see the headman of the village he sat on the back of my armoured car with his rifle pointing at me and took me into the village. Everything was sorted out and I returned to camp. The following weekend the lads came down from the village for our weekly football game and who should be one of the players, none other than rifle boy! Yes, they did carry him off the pitch during the game.
Another problem was the Limmasol Greek Police Sergeant who insisted that he should follow our troop up a narrow hillside road to a Turkish village. Conveniently, the armoured car that he was following ( last one in the convoy ) broke down and for some reason couldn't be started until the rest of us had drunk our coffee in the local's coffee shop, and came back down the road . The contrast in temperature that we experienced was how warm it was where we lived ( 5mins walk to the beach ) and three hours later in the Troodos mountains, snow! Our six months ended in May '65 and we moved back to England, to start converting to tanks before going to Germany.
Hohne, in North Germany was our new regimental home and would be for the next five years. The family moved into MB65 which was a flat on the first floor. This was in a block next to the central boiler house which at that time burnt coal and supplied the central heating and hot water for the whole camp. In '67 our son Gary John was borne in Hannover hospital. I was on an exercise and Maureen went into labour and had to travel for over an hour with the driver hoping to get to the hospital before he was born. When I arrived at the hospital I could hear this yelling not knowing that it was Maureen giving birth. When I first saw Gary he looked like Winston Churchill!
For a while after, when we were back at the flat, on and off he wasn't very well and used to suffer from chest problems (bronchitis). We thought the fall out from the boiler house chimney was the cause of this but we couldn't get a move. We then got a posting to the recruiting office in Finchley, North London. We had a maisonette at Mill Hill. Only did a year of the two year posting as I had to go back to the regiment on promotion to Staff Sergeant.
Arriving back at Hohne I became the Troop Leader of one of the troops in Cyclops Squadron. During this last year in Germany we handed over our Centurion tanks and received the new Chieftains that were being issued to the Royal Armoured Corps. This had a multi fuelled engine with a bigger 120mm gun. Not a big automotive success as it was always breaking down. This time we were living in a flat in the little town of Bergen, some three miles from the camp. Next move (1970) was to Bovington and Lulworth.
Lulworth Camp
When we arrived the quarter we were given was another one similar to the one we had in Periham Down so we refused it but we had to live in it for six weeks. The one we eventually moved into was a modern house with a garage and back garden. Didn't have any central heating only a fireplace. This took a lot of getting used to after the central heating of German flats. During the second Winter we had a chimney fire which was a bit hairy but one of our neighbours put it out by putting salt on it. The fire service cooled down the chimney with water and then cleaned up the mess.
My new job was the Manager of the Officers Mess. This was an International Mess as students from other world armies stayed there during their courses at the gunnery school. The cleaners were elderly civilian ladies who were always bickering. At one stage I was told by the President of the Mess to convey to them that if they didn't toe the line they would be sacked. Of course not knowing any better, I did so, and the next thing, they went on strike. I had the Union Rep come from Southampton and was told that I couldn't treat civilians like that. Storm in a tea cup!
Two years of this and then the regiment was off to Munster in Germany. We stayed at Lulworth for another couple of years as I became one of the Instructors at the school. In total we lived there for four years and then I joined the regiment on promotion to Warrant Officer2. I took over the job of Squadron Sergeant Major of Badger Squadron.
Germany Again
Swinton barracks, Munster was certainly a lot better than Hohne. We had a nice house and a large city a few miles down the road. I enjoyed my time as Sergeant Major and the squadron had a lot of nice lads who didn't cause me any major problems. During my three years we trained twice in Canada which was a nice break from the German training areas. We had an area near a place called Medicine Hat, and was half the size of Wales. The type of training that we carried out was as near to battlefield conditions as one could get, with live ammunition being used but no one firing back at us. The period of training was for six weeks and then four days rest and recuperation. During this time I visited a bit of the USA state of Montana, and also travelled through some of the Rockies. ( mountain range ).
The family took the opportunity to drive down from Munster to Italy on two occasions, for our holidays. It was a long drive, taking us about two days each way. The second of our trips we decided to travel back through Austria and it was there in Berchesgarten that Gary was taken ill with an appendicitis. He had his operation in a German Catholic hospital and five days later was on his way home with me as Maureen, Tracy and our friends had returned home earlier. The only complaint that he had during his stay in the hospital was the German tea! When Gary and I got home Maureen told me that she had had a pleasant surprise on arriving home from the holiday as we had won 1000 German Marks in a raffle that I had entered in our bank before we had left for our holiday. We also took advantage of the Regimental Ski Hut in southern Germany. We used the flat for families and spent two weeks on the ski slopes.
I also found out that I was to spend the last two years of my Army career in Bovington as the gunnery author. I would be writing the training books for the Royal Armoured Corps. These books would standardise the trade training and testing of troop officers, tank commanders and tank gunners. Whilst on my three month course Maureen took the family for another ski holiday but during the two weeks Gary came a cropper and broke one of his legs.
To conclude, I joined the ranks of the civilian population on the 8th May 1979 after 25 years in the Army and became the Contracts Manager for Marley Roofing & Tiling In Poole, Dorset.
Except for civie street I would do it all over again. All that comradeship I miss, but there is one consolation, I still have friends from those days and that is the reason I go to reunions and keep in touch through this website.
Fear Naught (RTR motto)
John 'Charlie' Welchman
Post Script
Some 3 years into civilian life I had a request from an old friend who asked me if I would like to work for an Italian arms company in Saudi Arabia. There were 5 Brits who taught the Saudi army how to use guided missiles mounted on a track vehicle. This was an eye opener as we had to adjust to both the Saudi and Italian culture and the way they worked. I managed to last two and a half years before I decided that was enough.
My next job was working for Dorset County Council as a training officer on youth training. When the goverment decided to end that scheme and move onto Appreticeships I did the same and worked at Bournemouth and Poole College for a further eighteen and a half years and then retired to the golf course.
One day in 2014 my phone rang and on answering it there seemed to be a time lag for the other party to speak. Thought it was a spam call and I was just going to put it down when I heard a womens voice asking me if I was John Welchman? On hearing my answer she said I was her Uncle.
Further conversation disclosed the reason for this. At the begining of this story I mentioned that my sister Hilda had stayed on in Pakistan and on passing away the family of six children and their step-mother had moved to Australia. Since then two of them had died and the remaing four were now living in Brisbain, Melbourne and Tasmania.
Ann, the third eldest had found me through one of Hilder's bridesmaid's who is living in Melbourne and a sprightly 91. Since this has come to light the three sisiters and brother have been to the UK to visit, and myself and Maureen plus my son Gary have just come back (2016) after an enjoyable visit to see everyone.
This reunion took place some sixty years later. All through the power of the internet!


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Here's the basics you need to know to update a barely-there look:
* Super-natural doesn't have to mean bare so even out skintone with a fine layer of tinted moisturiser and use concealer with a brush where needed and finish with a light dusting of powder from a puff.
* To accentuate eyes when going for the barely-there trend, use a soft eyeliner brush with an espresso brown eye-shadow to softly outline as close to the lash line as possible.
* Choose shades that are as close to your natural skin glow as possible. Cheeks should be one shade darker than your naturally pinched glow and lipstick should match your natural lip colour and look like a stain. You also need to see your lip texture through the lips not the lipstick sitting on top.
* Don't use a nude shades straight up – use your finger instead and press onto the lip so it looks like a stain rather than a solid colour. And don't be afraid of using gloss!
{Pic: Byrdie}


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Share the shopping list with AnyList
AnyList is a new iOS app from Purple Cover, Inc. It's available now as a free iPhone-centric app from the App Store, and is optimized for the iPhone 5. It's also currently featured in Apple's New and Noteworthy section on the App Store front page.
AnyList is a shopping list app. Users can create multiple lists and add items to them using an autocomplete search function, custom "starter" and "favorite" lists or simply adding custom items. There is a wide variety of common grocery shopping items built into the app, and if these are used, items are categorized by type — custom items are put into the "Other" category by default, but it's possible to change this if necessary. iOS 6 users may also import list items from the iOS or OS X Mountain Lion reminders app or the iCloud website. This facility also means that list items can effectively be added using Siri.
Once a list has been created, it can then be used as a simple and effective replacement for a paper shopping list while at the store. Tapping items while viewing a list automatically crosses them off, and it's possible to filter the display to only show items that have not yet been acquired.
This isn't all that AnyList offers, however. Users may automatically generate shopping lists by browsing recipes on the Internet. These may be retrieved simply by searching within the app, and are drawn from a wide variety of sources. Featured and popular recipes are presented to give aspiring chefs ideas, and those with a particular idea in mind can even get suggestions based on a proposed main ingredient — though there is not the facility to search for vegetarian or vegan options in this particular part of the app. Those who have favorite recipe publishers may also search by provider. Recipes may be saved for future reference and ingredients added to the shopping list simply by tapping on them. It is a simple and elegant solution that works extremely well.
On top of this useful facility, AnyList also offers users the ability to share shopping lists with their contacts via email or text message, though not via social networks. Shared lists sync changes between all users immediately — network connectivity permitting, of course — meaning that, theoretically, this has the potential to be a very useful app for families or shared households who like to split grocery shopping duties between them.
AnyList is a very well put together app. It is slick, well-designed and highly intuitive to use, and a number of nice little touches make it visually appealing despite its simplicity. The fact that when tapping on items in a recipe they "fall" into the user's shopping list rather than simply ticking themselves off is attractive, for example, as is the fact that "completed" list items get scratched off with what looks like a red marker pen rather than a simple strikethrough effect. It could perhaps be improved with clearer social functionality and/or Twitter/Facebook support, but as it stands it is one of the better shopping list apps out there, and as a free app it puts a lot of paid offerings to shame.
AnyList is not currently listed in any App Store leaderboards. Check back shortly to follow its progress with AppData, our tracking service for mobile and social apps and developers.


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Institute for War and Peace Reporting | Giving Voice, Driving Change
Foca Trial - Kunarac Cross-Examined Over His 'Investigation' Into Rapes
Kunarac, also known as Zaga, has denied raping women, but admitted in court the previous week to having had a sexual relationship with one of the women "against his will."
The defendant said he had on occasion been alone with some of the women, now prosecution witnesses, but claimed all he ever did was talk to them.
"Everything the witnesses said is an expression of their wish that I be punished for women being taken to be raped," the accused concluded.
Kunarac claimed previously he had investigated the rape allegations at the time. He said he had taken two girls to a house in Aladza to identify possible rapists. The prosecutor pointed out, however, Kunarac's efforts ended in tragedy for the two girls - one, witness DB, claimed Kunarac had sex with her, the other, witness 75, said she was gang raped in an adjoining room.
Kunarac admitted having sex with DB but said this was "against his will." He said he "did not know" what was happening to the other girl in the next room.
"You had known DB for only a few hours, you knew she had been raped before, you knew she was afraid, but, nonetheless, you confronted her with a group of soldiers and yourself had intercourse with her!" the prosecutor said.
Kunarac said he was "confused" and that "DB wanted intercourse."
As for the other girl, the prosecutor asked Kunarac to confirm he had left her "alone with soldiers whom, as you say, you suspected of raping women."
Kunarac said he "could not assume" they would rape her. The prosecutor then pointed out Kunarac's alleged investigation had borne no fruit - no report was ever lodged with the civilian police, and the accused failed to inform either the military police or the brigade commander.
"I did not have any tangible proof," Kunarac said.
According to defence witness, retired Yugoslav Peoples Army General Radovan Radinovic, Kunarac had no authority over soldiers from his unit when they returned to Foca from the field.
The prosecutor pointed out, however, Kunarac had told Tribunal investigators in an earlier statement, "I lined up all my men and said that whoever did that [rape] I will shoot him personally."
The prosecutor suggested such a statement was "consistent with the action of a commander who has authority over his men even though they are not in the field."
Radinovic claimed, however, Kunarac was "simply overstepping his authority."
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TORONTO — Ron Taverner will not be the next commissioner of the Ontario Provincial Police.
The provincial government on Wednesday said cabinet had accepted his request to withdraw from consideration amid accusations of political interference in the appointment.
In an emailed letter to Community Safety Minister Sylvia Jones, Taverner said he asked to be removed "to protect the integrity of rank and file police officers given the controversy surrounding my appointment."
Jones accepted that request and in a statement thanked him for his service.
A family friend of Premier Doug Ford, Taverner's appointment as commissioner in November quickly drew allegations of favouritism and executive overreach. It was put on ice the following month after Integrity Commissioner J. David Wake announced he was investigating the selection.
OPP deputy commissioner Brad Blair, who also applied for the top job, appealed to Wake to conduct a wider investigation into the appointment process and other allegations of political interference in the OPP. Blair has taken the ombudsman to court to force him to launch the probe and was fired on Monday from the OPP.
Wake's investigation was requested by the NDP after iPolitics first reported that the job qualifications for the position were lowered — paving the way for Taverner to apply for the job. His investigation is ongoing.
[READ MORE: Ford didn't recuse himself from decision to make his friend OPP commissioner]
Taverner has served with Toronto police for more than 50 years. He went back to the city's force after his appointment was postponed and holds the rank of superintendent.
In a statement from Ford, the premier defended his friend and took aim at the opposition.
"His fifty years of policing experience and support for the front-lines would have been a tremendous asset to the OPP and to the people of Ontario," Ford said about Taverner.
"It is very unfortunate that the opposition has chosen to politicize this process rather than focusing on how we can support our front-line officers."
A source in the premier's office said Ford shared Taverner's perspective that it was in the best interest of front-line officers for Taverner to quit.
[READ MORE: OPP deputy commissioner Blair says he was fired for speaking out]
Taverner's exit is a clear pivot from what the premier has previously said about Taverner's future with the OPP.
Since Wake's investigation was announced in mid-December, Ford has maintained that no matter what conclusions the commissioner makes, Taverner would still be the next commissioner of the OPP.
But allegations of political interference only intensified following Blair's dismissal on Monday.
The premier has missed every question period since then and his office hasn't said whether he will be at the legislature on Thursday.
The government said Blair was fired because he released confidential police information in his court case. However, Blair's legal counsel, Julian Falconer, told reporters Wednesday afternoon that the process used to fire Blair was "utterly illegal," an "abuse of power," and plagued by a "mind blowing" level of conflict of interest.
In a statement that didn't directly address Falconer's allegations, the government defended the process that led to Blair's firing. Ford's spokesperson Simon Jefferies pointed out that "some of the most senior civil servants from across government" were involved in the decision and many of them have served "governments of all political stripes."
The NDP and Green Party have been calling for a public inquiry into Blair's firing and Taverner's hiring. The government has so far rejected those calls.
"Supt. Ron Taverner did what Doug Ford has continuously refused to do, and preserved the OPP's integrity with his withdrawal," NDP Leader Andrea Horwath said in a statement.
"This mysterious and abrupt about-face makes a full public inquiry into Doug Ford's meddling in the OPP all the more critical. "
Green Party Leader Mike Schreiner thanked Taverner for his decision. In a statement he said he expects the next appointment process for OPP commissioner to be independent, transparent and conducted with "absolutely no conflict of interest or meddling from the Premier."


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I have taught for 14 years in grades 5 - 8 in content areas of science, literacy, math, social studies, art, and computer literacy. I was a team leader in my middle school for 10 years, I have been a mentor teacher for many years and have supervised student teachers. I am on my school's improvement committee, the science curriculum committee, and I manage the school's Facebook page.
I use varied instructional techniques and integrate content from various subject areas as much as possible in the subjects I teach. I work hard at getting students to realize how what they are learning connects to the "real-world". I integrate technology instruction and use as much as possible.
Yet to be added
My undergraduate degree is in Elementary Education with a minor in Biological Sciences. I have my Master's in Teaching and learning with a specialization in Differentiation. My Doctorate is in Educational Leadership with a specialization in Curriculum and Instruction.
My husband and I were blessed with twin girls. They are currently five years old and began Kindergarten this year. We love to camp and share our love of nature with our girls. I love to do arts and crafts with the twins, I love to scrapbook, and I love to read. With my newest degree I am trying to get adjunct jobs teaching at the college level or developing my own classes/workshops to teach at conferences. I am passionate about helping other teachers gain new ideas and insights in how to improve upon their current strengths.
English Language Arts, Specialty, Math, Applied Math, Fractions, Other (Math), Science, Astronomy, Biology, Chemistry, Environment, Physics, Social Studies - History, Computer Science - Technology, For All Subject Areas, Literature, Reading Strategies, Informational Text


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Breakfast Brief Dr. Solange Peters
Prof. Solange Peters presents the newest data on immunotherapy in NSCLC.
Prof. Solange Peters, head of the Medical Oncology Service, Chair of Thoracic Oncology, Oncology Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, presents the newest data on immunotherapy in NSCLC.
Abstracts presented:
Kowanetz M et al., abstract CT076: IMpower150: Efficacy of atezolizumab (atezo) plus bevacizumab (bev) and chemotherapy (chemo) in 1L metastatic nonsquamous NSCLC (mNSCLC) across key subgroups
Gandhi L et al., abstract CT075: KEYNOTE-189: Randomized, double-blind, phase 3 study of pembrolizumab (pembro) or placebo plus pemetrexed (pem) and platinum as first-line therapy for metastatic NSCLC
Hellmann MD et al., abstract CT077: Nivolumab (nivo) + ipilimumab (ipi) vs platinum-doublet chemotherapy (PT-DC) as first-line (1L) treatment (tx) for advanced non-small cell lung cancer (NSCLC): initial results from CheckMate 227
Forde PM et al., abstract CT079: Neoadjuvant PD-1 blockade in resectable lung cancer