text:
Patch closure of muscular ventricular septal defects with a new hybrid therapy in a pig model.
ABSTRACT We evaluated a novel technique for hybrid patch closure of muscular ventricular septal defects (mVSDs) without cardiopulmonary bypass (CPB) in a pig model.
So far, surgical and interventional therapies for mVSDs have been associated with significant morbidity, especially in newborns and infants. Thus, it is essential to develop new techniques. Hybrid therapy is an innovative approach for mVSDs that combines the advantages of surgical and interventional techniques.
Six pigs underwent left anterolateral thoracotomy to expose the left ventricle (LV). The mVSDs were created under echocardiographic guidance with a 7.5-mm sharp punch instrument that was forwarded via an LV incision. A special designed patch system composed of a patch with a Nitinol frame was passed across the carotid artery into the LV and positioned in front of the mVSD. An instrument resembling a stapler was introduced across the LV wall on the beating heart without use of CPB. The patch was fixed with Nitinol anchors on the septum under echocardiographic and fluoroscopic guidance. Finally, the Nitinol frame was detached from the patch.
The locations of the defects were apical (n = 1), midmuscular (n = 3), and anterior muscular (n = 2). Closure of the mVSD was successful in 5 of 6 animals confirmed by echocardiography, hemodynamic measurements, and explantation of the heart. Animals were hemodynamically stable throughout the experiment.
Here, we present a novel technique for hybrid closure of mVSDs without use of CPB. Further development of the patch system is necessary to assess applicability in humans, especially for the target group of newborns and infants.
Article: Techniques and results in the management of multiple muscular trabecular ventricular septal defects.[Show abstract] [Hide abstract]
ABSTRACT: The management of patients with multiple muscular trabecular ventricular septal defects (VSDs) remains controversial. In the past two decades, innovative techniques including a right ventricular apical infundibulotomy and transcatheter, intraoperative and perventricular device closure have been exploited, and essential right atrial approach and limited apical left ventriculotomy have also been refined. However, specific management guidelines for this difficult disease have not been established. In this article, the benefits and drawbacks of each technique are reviewed and discussed. Primary repair for infants with multiple muscular trabecular VSDs was associated with good late outcomes. The right atrial approach was satisfactory for all muscular VSDs, excluding apical defects that were well seen through a limited apical ventriculotomy. Surgical closure of apical defects could be achieved safely and completely in early infancy through a limited apical left ventriculotomy or a right ventricular apical infundibulotomy. Further follow-up and prudent evaluations of ventriculotomy-associated morbidities are needed. Pulmonary artery banding should be limited to a small infant with complex associated defects. Percutaneous device closure, the most desirable option, is impractical due to limitations between the delivery system and access route. Intraoperative device closure appears less successful than device closure in the catheterization laboratory. Perventricular device closure has a significant advantage of being a non-bypass procedure approach. A less invasive strategy for "true" Swiss cheese septum is needed. All may have an important role, and results obtained by using these techniques are encouraging. These hybrid approaches will promise future success on management guidelines of multiple muscular trabecular VSDs.General Thoracic and Cardiovascular Surgery 06/2013;
Article: Bacterial nanocellulose as a new patch material for closure of ventricular septal defects in a pig model.[Show abstract] [Hide abstract]
ABSTRACT: Current materials for closure of cardiac defects such as ventricular septal defects (VSDs) are associated with compliance mismatch and a chronic inflammatory response. Bacterial nanocellulose (BNC) is a non-degradable biomaterial with promising properties such as high mechanical strength, favourable elasticity and a negligible inflammatory reaction. The aim of this study was the evaluation of a BNC patch for VSD closure and the investigation of its in vivo biocompatibility in a chronic pig model.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 07/2014; · 2.40 Impact Factor
Article: Modification of a hybrid technique for closure of muscular ventricular septal defects in a pig model.[Show abstract] [Hide abstract]
ABSTRACT: Closure of muscular ventricular septal defects (mVSDs) beyond the moderator band is still a challenge for both surgeons and interventional cardiologists. We evaluated a new technique in a pig model for hybrid patch closure of mVSDs via 2 stab wound incisions in the left ventricle (LV) without cardiopulmonary bypass. Ten pigs underwent left anterolateral thoracotomy to expose the LV. mVSDs were created via a stab wound incision of the lateral wall of the LV under epicardial echocardiographic control. The patch system was forwarded through a second puncture of the LV apex and positioned in front of the mVSD. The stapler for fixation of the patch was introduced through the same incision as used for VSD creation. Finally, the patch was attached to the septum with nitinol anchors under epicardial echocardiographic and fluoroscopic guidance. Finally, detailed echocardiographic evaluation was done. All hearts were explanted, and macroscopic evaluation was done, either immediately after patch implantation (n = 4) or after 90 days (n = 6). mVSD creation was successful in all pigs. Closure of mVSDs was successful in 8 of 10 pigs, as confirmed by echocardiography, hemodynamic measurements, and macroscopic examination. One patch embolized through the mVSD into the pulmonary artery because of insecure fixation, and 1 animal died during the procedure because of ventricular fibrillation. The final echocardiographic evaluation revealed good LV function and no damage to the valves. Closure of mVSDs can be successfully performed in a hybrid technique on the beating heart with 2 stab wound incisions; however, further modifications need to be developed before clinical application.Heart Surgery Forum 10/2010; 13(5):E299-304. · 0.63 Impact Factor
Page 1
Patch Closure of Muscular Ventricular Septal
Defects With a New Hybrid Therapy in a Pig Model
Rainer Kozlik-Feldmann, MD,* Nora Lang, MD,* Regine Aumann, MD,* Anja Lehner, MS,*
Darius Rassoulian, MD,† Ralf Sodian, MD, PHD,† Christoph Schmitz, MD, PHD,†
Martin Hinterseer, MD,‡ Rabea Hinkel, MD, PHD,‡ Eckart Thein, MD,§ Franz Freudenthal, MD,?
Nikolay V. Vasylev, MD,¶ Pedro J. del Nido, MD,¶ Heinrich Netz, MD, PHD*
Munich, Germany; La Paz, Bolivia; and Boston, Massachusetts
We evaluated a novel technique for hybrid patch closure of muscular ventricular septal defects (mVSDs) without
cardiopulmonary bypass (CPB) in a pig model.
So far, surgical and interventional therapies for mVSDs have been associated with significant morbidity, espe-
cially in newborns and infants. Thus, it is essential to develop new techniques. Hybrid therapy is an innovative
approach for mVSDs that combines the advantages of surgical and interventional techniques.
Six pigs underwent left anterolateral thoracotomy to expose the left ventricle (LV). The mVSDs were created un-
der echocardiographic guidance with a 7.5-mm sharp punch instrument that was forwarded via an LV incision. A
special designed patch system composed of a patch with a Nitinol frame was passed across the carotid artery
into the LV and positioned in front of the mVSD. An instrument resembling a stapler was introduced across the
LV wall on the beating heart without use of CPB. The patch was fixed with Nitinol anchors on the septum under
echocardiographic and fluoroscopic guidance. Finally, the Nitinol frame was detached from the patch.
The locations of the defects were apical (n ? 1), midmuscular (n ? 3), and anterior muscular (n ? 2). Closure of
the mVSD was successful in 5 of 6 animals confirmed by echocardiography, hemodynamic measurements, and
explantation of the heart. Animals were hemodynamically stable throughout the experiment.
Here, we present a novel technique for hybrid closure of mVSDs without use of CPB. Further development of the
patch system is necessary to assess applicability in humans, especially for the target group of newborns and
infants.(J Am Coll Cardiol 2008;51:1597–603) © 2008 by the American College of Cardiology Foundation
Ventricular septal defects (VSDs) are one of the most
common congenital cardiac defects and account for approx-
imately 30% of all congenital heart diseases (1). They are
classified according to their location in the septum (2).
Muscular ventricular septal defects (mVSDs) account for
approximately 10% to 15% of all VSDs (3).
Until now, therapy for mVSDs beyond the moderator
band has been challenging, especially in newborns and
infants, and is associated with increased morbidity and
mortality. Both surgical and interventional approaches have
their limitations. Surgical repair of these defects beyond the
moderator band might frequently require left ventriculot-
omy or the division of multiple important right-sided
muscle bands. These procedures are often associated with
significant morbidity and mortality (4). Moreover, surgery is
associated with prolonged hospital admission, a scar, and
patient discomfort (5). Furthermore, surgery requires the
use of cardiopulmonary bypass (CPB), which might be
associated with various adverse effects, such as impaired
neurologic development (6,7) or systemic inflammatory
response syndrome (SIRS) (8).
Recently there has been an increase in the use of alternative
interventional strategies. These interventions are limited by
infants (9–11). Currently, the devices used in these interven-
tions are still at an investigational stage. In addition, there are
several reports about significant arrhythmias, hemodynamic
compromises, valve injuries, or incomplete closure (12,13).
Hybrid cardiac surgery, a combination of interventional
and surgical techniques, has been demonstrated as a new,
From the Departments of *Pediatric Cardiology, †Cardiac Surgery, and ‡Cardiology,
University Hospital Grosshadern, Munich, Germany; §Institute of Surgical Research,
Ludwig-Maximilians-University, Munich, Germany; ?Department of Pediatric Car-
diology, Kardiozentrum, La Paz, Bolivia; and the ¶Department of Cardiac Surgery,
Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts.
This work was supported by Elterninitiative Großhadern e.V., and Heart for Heart
Foundation, Munich, Germany. Philips Medical Systems, GmbH, provided the
3-dimensional echocardiography.
Manuscript received July 26, 2007; revised manuscript received October 10, 2007,
accepted October 23, 2007.
Journal of the American College of Cardiology
© 2008 by the American College of Cardiology Foundation
Published by Elsevier Inc.
Vol. 51, No. 16, 2008
Page 2
innovative approach for therapy
of mVSDs, because it reduces
operation times, complexity, op-
erative trauma, and avoids use of
CPB (10,14). Several authors re-
ported off-pump closure of
mVSDs with an Amplatzer de-
vice via a perventricular ap-
proach. Advantages over open
repair included avoidance of
trans-section of the moderator
band or other right ventricular
muscle bundles without limita-
tions of vascular access or pa-
tient weight (14). Nevertheless,
authors also reported valve in-
juries, device embolization into
the aorta, and rhythm distur-
bances (10).
Thus, new therapeutic strate-
gies have to be developed. Here,
we present a new method for
closure of mVSDs with a patch delivery device and mini
Nitinol anchors in a hybrid technique.
Animals. We used 6 German Landrace piglets of either
gender (20 to 30 kg), which were purchased from the farm
of the university (Oberschleissheim, Germany). The exper-
imental protocol was approved by the local Governmental
Commission on the Care and Use of Animals. The animals
received care in compliance with the Guide for the Care and
Use of Labarotory Animals. All experiments were per-
formed in the laboratory of Surgical Research, Walter-
Brendel-Center for Experimental Medicine, at the Ludwig-
Maximilians-University of Munich.
Anesthesia. First, the piglets were fasted overnight and
pre-medicated with an intramuscular injection of 500 mg
ketamine, 10 mg/kg body weight azaperone, and 0.5 mg
atropine. After cannulating an ear vein, midazolame (0.1
mg/kg body weight intravenously) was administered. The
animals were intubated with a 6.5-F (Charriere scale) tube
and ventilated with a inspiratory oxygen concentration of
50%. Anesthesia was induced and maintained with propofol
(induction 1.5 to 2 mg/kg body weight, maintenance 10
mg/kg body weight/h) and fentanyl (induction 0.02 mg/kg
body weight, maintenance 0.045 mg/kg body weight/h).
The respiratory rate and tidal volume were adjusted to keep
the arterial partial pressure of carbon dioxide (pCO2)
between 35 and 45 mm Hg. Arterial blood samples were
obtained for analyses of partial pressure of oxygen (pO2),
partial pressure of carbon dioxide in the arterial blood
(PaCO2), and pH. Before performing thoracotomy, muscle
paralysis was induced with pancuronium bromide, 0.1
mg/kg body weight intravenously; additional doses were
administered when necessary.
Intravenous fluids (Ringer solution) were given at a rate
of 10 ml/kg body weight/h and increased when necessary.
Hydroxy ethyl starch 6% was given in case of relevant blood
loss. Oxygenation, electrocardiogram, and temperature
were also monitored and recorded continuously. Amioda-
rone (20 mg/kg body weight/d) and magnesium were
administered throughout the procedure to prevent ventric-
ular arrhythmias.
Device and stapler. The patch delivery device consisted of
a self-expanding frame made of a 0.25-mm ? 0.75-mm
Nitinol wire (wire 1) covered by a polyethylene tube (1.5
mm in diameter) and a grip. A 0.1-mm polyester patch was
appropriately trimmed and then attached to the Nitinol
frame by a 0.1-mm Nitinol wire (wire 2) (Fig. 1, upper
panel) (15). A custom-designed stapler was used to fix the
patch on the septum with mini-anchors made of Nitinol
(Fig. 1, lower panel).
Figure 1
Basic Construction of the Patch Delivery
Device and the Custom-Designed Stapler
The upper panel shows the polyester patch and the patch delivery device (B).
(A and C) Enlargement of B, whereas A shows the back and C the front. The
lower panel presents the custom-designed stapler. (E) Enlargement of the
front of the custom-designed stapler and a mini Nitinol anchor. (F) Demon-
strates how the mini Nitinol anchor is fixated in the plier contained in the
and Acronyms
CPB ? cardiopulmonary
CVP ? central venous
LV ? left
mVSD ? muscular
ventricular septal defect
PAB ? pulmonary artery
PCWP ? pulmonary
capillary wedge pressure
RVP ? right ventricular
SIRS ? systemic
inflammatory response
VSD ? ventricular septal
1598 Kozlik-Feldmann et al.
Patch Closure of VSDs
JACC Vol. 51, No. 16, 2008
April 22, 2008:1597–603
Page 3
Imaging. For imaging, 2-dimensional (2D) and 3-
dimensional (3D) echocardiography were used. For 2D echo-
cardiography (Sonos 5500, Philips Healthcare, Andover,
Massachusetts), a 5-MHz transesophageal echocardio-
graphic probe was placed behind the beating heart via an
incision of the 6th intercostal space. The 3D echocardiog-
raphy was performed epicardially by using the X7-2 matrix
transducer of the IE33 Ultrasound System (Philips Health-
care). Additionally, closure of the mVSD was performed
under fluoroscopic guidance.
Surgical preparation. All animals were shaved for thora-
cotomy and neck dissection on the right side. Afterwards,
the right-sided external carotid artery and the jugular vein
were exposed. The external carotid artery was cannulated
with a 9-F and the jugular vein with an 11-F introducer
sheath. Arterial pressure and central venous pressure (CVP)
were measured continuously.
Animals were placed in dorsolateral recumbency with the
left side upward. A left fourth intercostal thoracotomy was
performed, and the heart was exposed by incising the
pericardium. The following steps were performed without
CPB. Two 4-0 polypropylene purse-string sutures on the
LV wall were applied for instrument insertion.
Creation of mVSDs. Creation of mVSDs was achieved
under 2D and 3D echocardiographic guidance with a special
designed punch instrument via an LV incision (7.5 mm)
(Fig. 2). Successful creation of an mVSD was confirmed by
echocardiography and oxymetric measurement of the shunt
volume by the Fick method.
mVSD closure. A 7-F introducer sheath shortened to 2 cm
was inserted through the incision in the LV wall, which was
also used for creation of the mVSDs in order to minimize
LV trauma during the closing procedure. Contrast medium
was applied to detect the mVSD in fluoroscopy.
The patch delivery device was inserted into a custom-
designed, 30-cm-long 7-F sheath. It was forwarded over a
6-F pigtail catheter via the 9-F introducer sheath across the
carotid artery into the left ventricle (LV). The patch was
deployed and positioned over the defect under fluoroscopic
and echocardiographic guidance.
The custom-designed stapler was introduced through the
shortened 7-F sheath inside the lateral LV wall. Then, the
patch was fixed with 8 to 10 Nitinol mini anchors (Fig. 1)
under echocardiographic and fluoroscopic guidance. After
secured fixation the Nitinol frame was detached from the
polyester patch by releasing the sutures (pulling the Nitinol
wire 2) (Fig. 1) and was drawn back into the long 7-F
Finally, animals were killed by an intracardial injection of
40 mval potassium chloride.
Autopsy of the hearts revealed the location of the mVSD
as well as the position and fixation of the patch.
Measurements and echocardiography. Arterial blood
samples were obtained continuously to control appropriate
ventilation. Heart rate (HR), arterial pressure, and CVP
were measured and recorded. The following hemodynamic
parameters were obtained as baseline before performing
thoracotomy: CVP, pulmonary arterial pressure, and pul-
monary capillary wedge pressure (PCWP). Echocardiogra-
phy was performed to exclude congenital defects such as
septal defects and valve insufficiencies.
After creating the shunt the same hemodynamic param-
eters as described previously were obtained. Blood samples
were taken to measure the shunt volume. Echocardiography
was used to assess the diameter of the created VSD.
After closure the residual shunt volume was measured by
obtaining the required hemodynamic parameters. Addition-
ally, echocardiography was performed to detect potentially
existing residual shunts and valve insufficiencies.
Statistical analysis. Values are presented as mean ? SD.
For comparison of paired observations, the paired t-test was
used without correction for multiple comparisons. A p value
?0.05 was considered statistically significant.
Creation of mVSDs. Echocardiography and hemody-
namic measurements before the procedure excluded valve
insufficiencies and cardiac defects as well as relevant shunt-
ing in all animals. Creation of an mVSD under echocardio-
graphic guidance was successful in all animals (n ? 6) (Fig. 3).
The mean size of the created mVSDs was 6.0 ? 0.7 mm, as
determined by 2D echocardiography (Table 1, Fig. 3).
Successful creation of the defects was also confirmed by 3D
color Doppler echocardiography (Fig. 3). Shunt volumes
ranged from 10.2% to 41.3%, mean 20.1%. The defects
were located in the apical (n ? 1), midmuscular (n ? 3), and
anterior (n ? 2) septum revealed by explantation of the
heart at the end of the experiment (Table 1). Animal 6
needed dopamine in a dose of 3 ?g/kg/min after creation of
the defect, because the LV showed a volume overload.
Ventricular septal defect closure. Figure 4 demonstrates
the main principle of our hybrid therapy. The patch delivery
device was inserted into the long 7-F introducer sheath and
Figure 2 The Special Designed Punch Instrument
JACC Vol. 51, No. 16, 2008
April 22, 2008:1597–603
Kozlik-Feldmann et al.
Patch Closure of VSDs
Page 4
forwarded across the carotid artery into the LV. Because the
patch delivery device consists of Nitinol, the patch expanded
easily to its original form after deploying through the end of
the sheath. Maneuvering of the patch in the LV and
positioning in front of the defect was performed without any
Successful closure of the mVSD was completed under
echocardiographic and fluoroscopic guidance in 5 of 6 animals
(Fig. 5). The absence of residual shunts in these animals was
confirmed by 2D and 3D color Doppler echocardiography. No
left to right shunt could be detected after closure in 5 of 6
animals. The patch in the sixth animal was positioned too
medially. Echocardiography and hemodynamic measurements
showed significant residual shunting. None of the animals
needed catecholamines at the end of the procedure. However,
Additionally, 1 animal had mild to moderate aortic valve
Examination of the explanted hearts. Examination of the
explanted hearts revealed substantial mVSDs. The diam-
eters of the mVSDs were in accordance with the echo-
cardiographic measurements in all investigated hearts
(Table 2).
Furthermore, appropriate position and fixation of the
patch could be confirmed in 5 of 6 animals (Fig. 6). In the
sixth animal the patch did not cover the defect completely,
and a residual defect of 3 mm remained.
No structures of the mitral and tricuspid valve apparatus
were injured during patch closure. No damage was seen at
the side of the aortic valve even in the animal with the mild
to moderate aortic insufficiency.
Hemodynamic measurements. Pigs were hemodynami-
cally stable throughout the whole experiment (Fig. 7).
Dopamine was administered in only 1 animal (Table 1). All
hemodynamic data did not show any significant difference.
Although not statistically significant, pulmonary arterial
pressure and PCWP measurements showed a tendency to
increase after creation of the mVSD. At the end of the patch
closure there was no additional increase of these values.
We present a new technique for hybrid closure of mVSDs
without using CPB. In general, hybrid therapy, a combina-
tion of interventional and surgical techniques, seems to be a
new innovative approach for therapy of mVSDs (10). So far,
both surgical and interventional therapies for mVSDs have
their limitations.
Figure 3 A Representative mVSD
A midmuscular ventricular septal defect (mVSD) is shown
in 2-dimensional echocardiography. LV ? left ventricle; RV ? right ventricle.
Relevant Data About Animals 1 to 6
Table 1 Relevant Data About Animals 1 to 6
(mm) VSD Location
Need of
1 6.0Anterior muscular NoYes
26.0 MidmuscularNo Yes
3 5.1Anterior muscularNo Yes
4 6.3MidmuscularNoYes
5 6.7MidmuscularNo No
6 6.0 ApicalDopamine (3 ?g/kg/min
after creation of the
mVSD and during
mVSD ? muscular ventricular septal defect; VSD ? ventricular septal defect.
Figure 4
Demonstration of the Main
Principle of Our New Hybrid Therapy Ex Vivo
(A) The patch delivery device is put on a piece of muscular septum. (B and C)
Fixation of a mini Nitinol anchor on the muscular septum with the custom-
designed stapler. (D) Fixation of the patch with 7 mini Nitinol anchors.
(E) After releasing the sutures the Nitinol frame detaches from the patch. (F)
The patch remains with the mini Nitinol anchors in the muscular septum.
1600 Kozlik-Feldmann et al.
Patch Closure of VSDs
JACC Vol. 51, No. 16, 2008
April 22, 2008:1597–603
Page 5
Surgical repair of these defects continues to represent a
significant challenge. Incidence of residual mVSDs still
remains high after surgery (4). Reoperation rates up to 10%
have been reported (16). Owing to technical difficulties, for
many mVSDs below the moderator band pulmonary artery
banding (PAB) is the preferred therapy in order to postpone
corrective surgery. Interventional therapies are often limited
by poor vascular access, low patient weight, and rhythm
disturbances (10).
First hybrid procedures for other cardiac defects have
already been described in the 1980s, such as intraoperative
balloon occlusion of the Blalock Taussig shunt and intra-
operative balloon dilation of critical aortic stenosis in neo-
nates and infants (17,18). Newer hybrid procedures are
pulmonary valve replacement or duct stenting combined
with bilateral PAB as an alternative first-step approach for
children with hypoplastic left heart syndrome (19,20).
Recently, several authors reported off-pump closure of
mVSD with an Amplatzer device via a perventricular
approach (10,21). Besides the advantages, they also had to
Hemodynamic Data Throughout the Experiment
deal with a set of complications, such as valve injuries,
device embolization into the aorta, and rhythm disturbances
(10). But the authors believe children will profit from
improving hybrid therapy, especially patients with complex
defects beyond the moderator band.
Because previous therapeutic strategies for mVSD closure
have had their limitations, we performed a pilot study to
Figure 5Implantation and Fixation of the Patch
(A) Fluroroscopic images before (left panel) and after (right panel) pulling the
Nitinol wire 2. (B) Three-dimensional (3D) echocardiography of the patch and
the patch delivery device put on the muscular septum. (C) Three-dimensional
echocardiography of the patch and the mini Nitinol anchors after the patch
delivery device was drawn back into the 7-F sheath.
Table 2 Hemodynamic Data Throughout the Experiment
After Creation of
the mVSD
After Closure of
the mVSD
MAP (mm Hg)80.0 ? 13.374.5 ? 20.871.5 ? 13.9
CVP (mm Hg)8.0 ? 2.79.6 ? 4.68.6 ? 3.7
Systolic PAP (mm Hg)27.3 ? 4.233.83 ? 6.134.5 ? 9.4
PCWP (mm Hg)7.75 ? 1.2 15.2 ? 4.7 14.0 ? 3.2
CVP ? central venous pressure; MAP ? mean arterial pressure; mVSD ? muscular ventricular
septal defect; PAP ? pulmonary arterial pressure; PCWP ? pulmonary capillary wedge pressure.
Figure 6Explantated Heart of Animal 2
Appropiate position and fixation of the patch. The ellipse
points to the location of the muscular ventricular septal defect.
Figure 7 Hemodynamic Stability During the Whole Experiment
Mean arterial pressure (red circles) and central venous pressure (black cir-
cles) during the course of the experiment. Application of catecholamines was
not necessary. 1 ? skin cut; 2 ? creation of the muscular ventricular septal
defect; 3 ? implantation of the patch; 4 ? fixation of the patch.
JACC Vol. 51, No. 16, 2008
April 22, 2008:1597–603
Kozlik-Feldmann et al.
Patch Closure of VSDs
Page 6
evaluate a new hybrid therapy for mVSD closure. The
construction of the patch delivery system and the custom-
designed stapler have been described recently (15). In
principle, a patch with a Nitinol frame was delivered across
the carotid artery into the LV and positioned over the
defect. Afterwards, it was fixed with a custom-designed
stapler. Finally, the Nitinol frame was detached from the
patch and could be easily drawn back into a 7-F sheath, so
that only the patch with the mini Nitinol anchors remained
in the muscular septum. The mVSDs were successfully
closed in 5 of 6 animals without a residual shunt.
Our method combines surgical and interventional advan-
tages, because it can be performed without the use of CPB.
First of all, the use of an LV approach might have some
advantages over repair from the right ventricular side. Many
mVSDs are very difficult to detect from the right ventricular
side, because of muscular trabeculations. The margins of an
mVSD are much easier to define from the LV side, owing
to the smooth surface of the septum. Furthermore, the
pressure gradient between left and right ventricular side
supports the patch alignment to the muscular septum. But
until now, LV approaches were rarely undertaken because of
the risk of development of impaired LV function. In our
proposed hybrid therapy, a minimal LV incision, approxi-
mately 2 mm, has to be made for fixation of the patch by the
custom-designed stapler. Thus, the approach proposed in
this report might offer the benefits of closure of a VSD
through the LV without the complications of a large LV
incision. We believe that the risk of development of LV
dysfunction will be significantly reduced.
Combination of echocardiography and fluoroscopy in our
new technique is reasonable, because the exposure to radi-
ation can be reduced. Recently, several therapeutic strategies
proposed implantation of the Amplatzer device as a hybrid
technique (9,15). The Amplatzer device is quite stiff and
inflexible. There is a potential risk of damage for adjacent
anatomical structures, especially valves and the conduction
system (9,22,23). Thus, we believe implantation of a patch
in hybrid technique is an innovative approach, because a
patch shows a high flexibility and has a lower risk of hurting
adjacent anatomical structures.
In the future, a chronic setting of these experiments is
needed to evaluate how the patch will integrate with the
myocardium and whether LV dysfunction or pulmonary
hypertension develops. In this set of experiments, PCWP
doubled at the end of the experiment after VSD procedure.
This effect was not statistically significant, but we believe
this is due to the small sample size. This indicates stress to
the ventricles due to the VSD creation. After the patch
implantation no additional increase of the PCWP was seen.
A future chronic investigation must address whether there is
a considerable, long-term depression of the myocardium.
Furthermore, it is important to observe whether the valve
insufficiencies we have seen at the end of the procedure will
accelerate, level off, or deteriorate. Insufficiencies of the
atrioventricular valves were mostly seen after mVSD cre-
ation. An additional negative effect due to the implantation
procedure could not be seen. The mild aortic valve insuffi-
ciency observed in 1 animal is probably related to the
extension of the valve by the implantation sheath. A damage
of the valve itself could not be seen in the autopsy.
Some might argue that we used the external carotid artery
as peripheral vascular access instead of the femoral artery,
which would be the typical access in humans. We believe
that the implantation can also be done from the femoral
artery. Thus, further experiments are needed to evaluate the
feasibility of patch implantation across the femoral artery.
Study limitations. In our study, we used animals weighing
20 to 30 kg. Large arterial and venous sheaths were
required. For this first feasibility study we decided to use
large patches, carrier systems, anchors, and application
systems in order to evaluate a general applicability of this
system. We plan to modify this system to 5-F in order to
make it usable in smaller piglets weighing approximately 5
to 10 kg. We are aware that only a minimized working
system will allow us to treat newborns and avoid a
primary PAB.
Shunt measurements sometimes were unexpectedly small,
although echocardiographic assessment of the mVSD and
explantation of the heart revealed moderate to large VSDs.
We believe that swelling of the surrounding area of the
created mVSD could be responsible for quite small shunt
volumes. Nevertheless, explantation of the heart revealed
that we created substantial defects. Thus, myocardial swell-
ing is a problem of this acute animal model. Conversely, we
believe that creation of bigger mVSDs could have resulted
in the death of the animal, because an acute creation of
VSDs is associated with a large hemodynamic compromise.
However, the explanted heart revealed that the mVSDs
were covered by the patch completely in 5 of 6 animals.
Therefore, without swelling, closure of the defects would
have also been successful.
Appropriate imaging was essential for this study. To date,
implantation is mainly done under guidance of fluoroscopy
and 2D transesophageal echocardiography. Epicardial 3D
echocardiography might be theoretically beneficial, because
an on-face view of the VSD and patch can be produced.
However, simultaneous epicardial echocardiography and
fixation of the patch is challenging at this time. Therefore,
imaging has to be developed further. We believe that a
3D transesothat a 3Dphageal probe placed behind the
heart will improve implantation significantly. There is a
potential risk of embolization of the Nitinol anchors.
This might be dangerous for patients. In this series, of 49
Nitinol anchors, 3 embolizations occurred. For this
reason, further development of the application device is a
major issue and the staplers will be modified. We plan to
incorporate a stop mechanism before the anchors are
released. Besides, we believe angled staplers will facilitate
implantation significantly.
1602Kozlik-Feldmann et al.
Patch Closure of VSDs
JACC Vol. 51, No. 16, 2008
April 22, 2008:1597–603
Page 7
In conclusion, we present a novel hybrid technique for
mVSD closure without using CPB and with a minimal LV
incision, which might be an alternative therapeutic option
for newborns instead of PAB. However, further evaluation
and development of the patch delivery device and the
custom-designed stapler is necessary to assess their applica-
bility in humans, especially in newborns and infants.
Reprint requests and correspondence: Dr. Rainer Kozlik-
Feldmann, Department of Pediatric Cardiology, University Hos-
pital Grosshadern, Marchioninistr. 15, D-81377 Munich, Ger-
many. E-mail: firstname.lastname@example.com.
1. Hein R, Buscheck F, Fischer E, et al. Atrial and ventricular septal
defects can safely be closed by percutaneous intervention. J Interv
Cardiol 2005;18:515–22.
2. Soto B, Becker AE, Moulaert AJ, et al. Classification of ventricular
septal defects. Br Heart J 1980;43:332–43.
3. Anderson RH, Lenox CC, Zuberbuhler JR. The morphology of
ventricular septal defects. Perspect Pediatr Pathol 1984;8:235–68.
4. Kitagawa T, Durham LA, III, Mosca RS, Bove EL. Techniques and
results in the management of multiple ventricular septal defects.
J Thorac Cardiovasc Surg 1998;115:848–56.
5. Minette MS, Sahn DJ. Ventricular septal defects. Circulation 2006;
6. Bellinger DC, Wypij D, Kuban KC, et al. Developmental and
neurological status of children at 4 years of age after heart surgery with
hypothermic circulatory arrest or low-flow cardiopulmonary bypass.
Circulation 1999;100:526–32.
7. Zeitlhofer J, Asenbaum S, Spiss C, et al. Central nervous system
function after cardiopulmonary bypass. Eur Heart J 1993;14:885–90.
8. Madhok AB, Ojamaa K, Haridas V, et al. Cytokine response in
children undergoing surgery for congenital heart disease. Pediatr
Cardiol 2006;27:408–13.
9. Bacha EA, Cao QL, Starr JP, et al. Perventricular device closure of
muscular ventricular septal defects on the beating heart: technique and
results. J Thorac Cardiovasc Surg 2003;126:1718–23.
10. Bacha EA, Hijazi ZM, Cao QL, et al. Hybrid pediatric cardiac
surgery. Pediatr Cardiol 2005;26:315–22.
11. Thanopoulos BD. Catheter closure of congenital muscular ventricular
septal defects. Pediatr Cardiol 2005;26:220–3.
12. Holzer R, Balzer D, Cao QL, et al. Device closure of muscular
ventricular septal defects using the Amplatzer muscular ventricular
septal defect occluder: immediate and mid-term results of a U.S.
registry. J Am Coll Cardiol 2004;43:1257–63.
13. Thanopoulos BD, Karanassios E, Tsaousis G, et al. Catheter closure
of congenital/acquired muscular VSDs and perimembranous VSDs
using the Amplatzer devices. J Interv Cardiol 2003;16:399–407.
14. Diab KA, Cao QL, Mora BN, Hijazi ZM. Device closure of muscular
ventricular septal defects in infants less than one year of age using the
Amplatzer devices: feasibility and outcome. Catheter Cardiovasc
Interv 2007;70:90–7.
15. Vasilyev NV, Martinez JF, Freudenthal FP, et al. Three-dimensional
echo and videocardioscopy-guided atrial septal defect closure. Ann
Thorac Surg 2006;82:1322–6.
16. Wollenek G, Wyse R, Sullivan I, et al. Closure of muscular ventricular
septal defects through a left ventriculotomy. Eur J Cardiothorac Surg
17. Bhati BS, Nandakumaran CP, Shatapathy P, et al. Closure of
patent ductus arteriosus during open-heart surgery. Surgical expe-
rience with different techniques. J Thorac Cardiovasc Surg 1972;63:
18. Hjortdal VE, Redington AN, de Leval MR, Tsang VT. Hybrid
approaches to complex congenital cardiac surgery. Eur J Cardiothorac
Surg 2002;22:885–90.
19. Akinturk H, Michel-Behnke I, Valeske K, et al. Hybrid transcatheter-
surgical palliation: basis for univentricular or biventricular repair: the
Giessen experience. Pediatr Cardiol 2007;28:79–87.
20. Boudjemline Y, Schievano S, Bonnet C, et al. Off-pump replacement
of the pulmonary valve in large right ventricular outflow tracts: a
hybrid approach. J Thorac Cardiovasc Surg 2005;129:831–7.
21. Diab KA, Cao QL, Mora BN, Hijazi ZM. Device closure of muscular
ventricular septal defects in infants less than one year of age using the
Amplatzer devices: feasibility and outcome. Catheter Cardiovasc
Interv 2007;70:90–7.
22. Amin Z, Gu X, Berry JM, et al. New device for closure of muscular
ventricular septal defects in a canine model. Circulation 1999;100:
23. Gu X, Han YM, Titus JL, et al. Transcatheter closure of membranous
ventricular septal defects with a new nitinol prosthesis in a natural
swine model. Catheter Cardiovasc Interv 2000;50:502–9.
JACC Vol. 51, No. 16, 2008
April 22, 2008:1597–603
Kozlik-Feldmann et al.
Patch Closure of VSDs


text:
T.I.'s Reality Series Draws Big Ratings for VH1
"T.I. & Tiny: The Family Hustle" has a strong start in its hourlong debut on the cable network.
Hip-hop star T.I.'s new VH1 reality series T.I. & Tiny: The Family Hustle proved to be a ratings draw for VH1.
Launching with two back-to-back episodes, the docu-series averaged 2.8 million total viewers for the 9 p.m. airing and a 1.9 rating among adults 18-49 on Monday evening. Combined with the 11 p.m. encore, the premiere episode lured a total of 4.3 million viewers.
The second episode was an even bigger draw, improving upon its debut to attract 3.1 million viewers at 9:30 p.m. and a 2.0 rating in adults 18-49. With the 11:30 p.m. encore, the second episode drew more than 4.5 million viewers.
T.I. & Tiny: The Family Hustle powered VH1 as the top-ranked cable network (excluding sports) among the adults 18-49 and women 18-49 demos. To compare, VH1's Basketball Wives closed out its third season in August luring 2.6 million viewers after starting off its first season averaging more than 1 million viewers.
T.I. & Tiny: The Family Hustle traces T.I.'s family life, including his reunion with his wife Tameka (aka Tiny) and children after serving time in prison on a weapons charge, and his attempt at returning to the top professionally.
The series was created and executive produced by 51 Minds' Cris Abrego, Christian Sarabia, Rabih Gholam and Ben Samek, in addition to Category 5 Entertainmnet's Brian Sher and Stella Bulochnikov. VH1's Jill Holmes, Kristen Kelly and Jeff Olde also serve as executive producers.
What Hollywood Earns
Top Galleries
What's Hot in TV
Hollywood's Notable Deaths of 2014
'Sherlock' Co-Creator Tells Fans to Expect "Tragedy" in Season 4
Watch Johnny Depp's Bizarre, Curse-Filled Speech at Hollywood Film Awards
Bill Cosby: His Career and Family Life in Pictures
Glen A. Larson, Creator of TV's 'Quincy M.E.,' 'Magnum, P.I.' and 'Battlestar Galactica,' Dies at 77

subset: commoncrawl


text:
Data Structures
Refers to the way information can be organized. Different types of data structures include tree structures, drill down, as well as binary trees. From stacks to vectors, our data structures dictionary offers a glossary of terms you should know.
- array
- array processor
- B-tree
- big-endian
- binary tree
- BPDU - bridge protocol data unit
- character string
- data marshalling
- data structure
- drill down
- heap
- hierarchical
- IRPStackSize
- leaf
- linked list
Stay up to date on the latest developments in Internet terminology with a free weekly newsletter from Webopedia. Join to subscribe now.
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text:
Moto X Now Available at Verizon Wireless
The Moto X is now officially available at Verizon Wireless' website. Note that I said website, as word is that it won't be available in store for the coming weeks, at least according to Gotta Be Mobile.
You can nab the 4G LTE enabled handset for 200 bones with a 2-year agreement. Color choice, unlike AT&T which will customize your handset according to your penchant for individualism, is black or white (that is assuming you consider black or white a color).
Made right here in the US of A (woot, woot), the Moto X uses Motorola's X8 chip, which boasts two low powered chips that support "always on" Google Now that allows you to speak to your phone without hitting a button. There is also a 10MP camera, LTE connectivity, WiFi a/b/g/n/ac, NFC, Bluetooth 4.0, 16GB of storage, and Android 4.2.2.
Christen Costa
Grew up back East, got sick of the cold and headed West. Since I was small I have been pushing buttons - both electronic and human. With an insatiable need for tech I thought "why not start a blog focusing on technology, and use my dislikes and likes to post on gadgets."
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text:
Find records of Melvin Queenen
Find birth, death, marriage, military, and other records of Melvin Queenen at Ancestry.com.Search for records
Biography & Family History Add details
Melvin Queenen (1904 - 1952) was born on January 18, 1904. He was born into the Queenen family.
There are no known spouses or children on file for Melvin. Melvin died in March 1952 at 48 years of age.
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Princess Lee Radziwill (the title came with her 1959 marriage to Polish prince Stanislaw Albrecht Radziwill) appeared on our July 1963 cover to introduce T&C's portfolio of beautiful furs, an annual feature in those pre-PETA days. The younger sister of Jackie Kennedy has worn many hats over the decades, dabbling in interior decorating, acting, and public relations, but her status as an internationally best-dressed society doyenne has remained constant. She was photographed throughout the sixties sunning with her sister in Capri, traipsing around Manhattan on the arm of Truman Capote, or lounging in that deliciously decadent Turquerie Room of her London home. Even today, as the most stylish octogenarian around, Radziwill can always be spotted at high-wattage fashion shows and parties on both sides of the Atlantic, her hair in that ever perfect coif, a cigarette often perched between her fingers in that elegant way only a Bouvier can.
Lee Radziwill
George H.W. Bush and Barbara Bush Get Caught Smooching on the Kiss Cam
The presidential pair puckered up at the Houston Texans game.
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A yellow lab for Prince Harry, all the details here!
You Officially Can't Dress Like a Slob if You Want to Meet the Royals
U.S. journalists have been issued a strict dress code.
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As a billion dollar divorce makes headlines - still not the most expensive, that honor goes to Rupert Murdoch - we look back on the prenuptial disputes, illicit substances and side action behind the most hellish splits.
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text:
The owners of this resort have gone to great lengths to create a quality "international" standard 4 star facility, albeit in a remote location. The service is excellent, and being a small boutique resort, guests are treated with delightful personal service (as if we were the only people staying). There is superb attention to detail from top to bottom -... More
- Reservation Options:
- TripAdvisor is proud to partner with Agoda and Despegar.com so you can book your Vivere Azure reservations with confidence. We help millions of travelers each month to find the perfect hotel for both vacation and business trips, always with the best discounts and special offers.
- Also Known As:
- Vivere Azure Hotel Mabini
- Vivere Azure Batangas/Mabini, Philippines


text:
The Belle Fleurs
- 3 part Close Harmony, with patter and Humour;)
- Costume changes if required. From Black Lace to Steam Punk/Goth.
- Most suited to 'different' corporate functions. Birthday Parties, Anniversary Parties, Alternative Weddings, Modern Cabaret shows
- Burlesque events, alternative festivals/areas, Halloween and other alternative balls and parties.
Price Range
Prices range from £600 to £2000
The Bellefleurs are 3 experienced professional singers with one desire, to take classic rock, pop, punk and metal songs, throw in a few old standards, Fleurt with them and make them their own!
Despite their beautiful vintage harmonies, they are NOT a Vintage sound a like group, nor do they have a repertoire of 40's numbers/war time favourites.
Dressed in beautiful corsets and clothing designed especially for them, this Trio will make you laugh and gasp at the audacity of their tracks and the beauty of their voices.
From Birthday parties for 30-70 year olds, Glamorous weddings, Glastonbury & Rebellion Punk Festival, Bath Comedy Festival Gala, Burlesque shows , Pride London to Corporate events...they now have their own 'plug n play' lit and directed show "A Night With The BelleFleurs" suitable for theatres.
Tanya Rich, chief Fleur on Alto, madcap ideas from this former manager of the punk band Discharge, ex session singer and pro voice over artist for 25 years, Tanya has an encyclopaedic knowledge of music, and is queen of the mash ups! Tanya's colour is green and her hair is purple!
Kate Harbour, ex Ballet Dancer and West End performer, now voice over artist most famously known as Wendy in Bob the Builder, takes the middle line, is chief choreographer and seamstress! Kate's colour is Blue and she is beautifully Blonde.
Emma 'Bluebell' Spark, pro singer on the Northern Club Circuit for 20 years, Bass and Cello player and musical prodigy on top Soprano. Yellow is Emma's colour which goes beautifully with her Blue hair:)
From Metallica to Motorhead, Katy Perry to Discharge, The Buzzcocks to Electric 6 no one is safe!
They are slowly re-writing The Andrew's Sisters song book, revealing the 'truth' behind their famous songs
The Bellefleurs are a top quality, beautiful sounding act, with some lovely moves and comedy patter!
They look different and they sound great
Where are they based?
They are based in Bath, but will perform anywhere!
Contact This Act
Check availability details & receive a free no-obligation quote directly from this Act... or simply ask any questions you might have...
Alternatively, send a single enquiry to multiple acts by adding this act to your shortlist before requesting a free quote...
This profile was compiled by +Freakster


text:
There is a common misconception that environmental law enforcement in South Africa is a low risk to parties evading environmental legislation requirements or causing pollution. However, from recent statistics released, it is clear that those polluters and companies avoiding their environmental law … [Read More...]
US and China Shake Hands on Carbon Deal
The United States and China are the world's two biggest economies, the largest emitters of greenhouse gas emissions (GHGs), and the largest … [Read More...]
Natural system investments crucial for food and water security
Healthy, well-functioning natural systems play a vital role in supporting the country's food and water security, whilst also maintaining healthy … [Read More...]
War on waste makes local business more sustainable
Partnerships are the key to success in the waste management and recycling industry, is the conclusion that was arrived at during a workshop in the Eastern Cape. Early in November PETCO hosted a workshop with some … [Read More...]
Let fossil fuel divestment set you free
"People of conscience need to break their ties with corporations financing the injustice of climate change," said Archbishop Emeritus Desmond Tutu during the countdown to the launch of Fossil Free SA, which started … [Read More...]
Natural Building part 3: Plaster & mortar mixes
Plasters and mortars are by far the process that I get asked about the most, and for good reason as plasters are what protect the building from the elements and give them their beautiful finish. Understanding how … [Read More...]
People politics and gossip – relationship workshop
If personal and environmental transformation is your thing you might like to join me for a Relationship Building workshop called "People Politics and Gossip," offered by Michele Hinds on Wednesday, 19 November in … [Read More...]
Last decade saw greatest emission volumes ever
Climate change is unequivocal, affects all continents and will continue to the end of the century regardless of even the toughest emissions cuts, warned a landmark UN science report today. Greenhouse gases … [Read More...]
David Barnard beats Last Desert Race for solar energy
Thumbs up to David Barnard who completed the Last Desert Race 2014 on Antarctica today in good shape, determined to keep running for a good cause. "We returned to Deception Island (venue of stage 1), although in … [Read More...]
A good time to frack the ocean?
Here is an intelligent look at what lies ahead for SA if we push forward with the plan to frack the ocean near Mossel Bay, by Andreas Wilson-Späth, a freelance writer with a PhD in geochemistry: If you're a … [Read More...]
New deal to help Mozambique combat wildlife crime
A historic deal between the Government of Mozambique, Joaquim Chissano Foundation and Peace Parks Foundation will strengthen Mozambique's efforts to combat wildlife crime by supporting the development of dedicated … [Read More...]
Proposed new rules slash timeframes for EIA
There is grave concern about the threat to our environment posed due to the proposed shortening of the period for the completion of Environmental Impact Assessments, (EIAs) before a new development can go … [Read More...]
Natural healers speak out against proposed new restrictions
More than 300 traditional healers and many other guests crowded into the Old Assembly Hall of Parliament last week to listen as the Traditional and Natural Health Alliance (TNHA) presented its views on an amendment … [Read More...]
Long-term solution needed to address acid mine drainage
Members of Parliament have heard that acid mine drainage is affecting the Vaal River system and causing problems in Mpumalanga and Limpopo. The Water and Sanitation Department has briefed Parliament's Portfolio … [Read More...]
Expect worst load shedding since 2008 after silo collapse
Eskom has embarked on unprecedented stage 2 load shedding on Sunday after a silo storing coal at its Majuba power station in Mpumalanga collapsed. Stage 2 load shedding requires users to reduce electricity demand … [Read More...]
Centre pioneers food waste composting
There are those who would only adjust their life and business if they are forced by a law. Then there are the pioneers who understand the link between the health of the planet and their own personal bliss and … [Read More...]
Kogelberg coast – a blueprint for sustainable fisheries
South Africa's oceans made headlines this month for their potential to contribute up to R177 billion to the national GDP and create over one million jobs by 2033. This, however, can only be realised if the oceans … [Read More...]
Partnerships drive the plastic recycling industry to success
"The focus of waste management in South Africa is changing. No longer is the emphasis on the disposal of waste, but rather on avoiding its generation and minimizing and recycling the waste stream wherever … [Read More...]


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Select () or exclude () categories to narrow your recipe search.
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1/1 Photo of Zuppa Toscana, Magri Style
Prep Time:
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A soup worthy of our Italian heritage. A hearty, soup with Italian Sausage, Potatoes, Kale and a spicy little "kick"!
Units: US | Metric
Serving Size: 1 (689 g)
Servings Per Recipe: 6
Every recipe, menu, tip and how-to is right here, at your service.


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I spend tons of time shopping around/comparing. That's why I buy here. You have the best service and prices. Extremely fast email communication and...Read More ->
Jeff and Brandi deliver products promptly (yep to Australia within 7 days at a fair cost). Highly recommend MJM magic to all. Products are as...Read More ->


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To feel sad every time I put away baby clothes that my DS has grown out of. I am not sure we will ever have a dc#2.(26 Posts)
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Shader Optimization Back-End Might Go In For R600g
Published on 19 April 2013 01:25 PM EDT
Written by
Michael Larabel
15 Comments
For many months
there has been a
"shader optimization" branch of Mesa/R600g
that sought to rather noticeably boost the performance of the AMD R600 Gallium3D driver. While this work by Vadim Girlin didn't look like it would be merged, after being revived and cleaned-up, it might reach mainline Mesa/Gallium3D as a new performance-boosting option.
Vadim Girlin had been working on shader optimizations for some time to more efficiently generate shader code and the back-end has evolved quite a bit in recent months. Diminishing prospects for this code has been that it doesn't use the R600 LLVM GPU back-end, which will eventually become the default for AMD's Gallium3D driver as it's needed for OpenCL/GPGPU support. With this custom back-end not using LLVM, it looked like it wouldn't be merged, but now the story is different.
Some time has been spent cleaning up the code and also to better isolate this shader optimization back-end from the rest of the R600g driver. Now this back-end is in a rather standalone state that only hooks into the R600g driver in a few spots and the shader code passed to/from the "r600-sb" component is hardware bytecode. With this lower maintenance burden, it stands better chances of being merged for at least a temporary and experimental Mesa build option.
Vadim writes, "this branch already works and provides good results in many cases. That's why I think it makes sense to merge this branch as a non-default backend at least as a temporary solution for shader performance problems."
Aside from faster performance over the open-source Radeon driver's current default back-end and the LLVM back-end, there's also debugging benefits and other advantages to toying with this "r600-sb" implementation.
Some initial benchmark results and other information on the proposal to merge r600-sb into mainline Mesa can be found with
this mailing list message
. So far the feedback is fairly positive about being able to merge this as at least an experimental option that can be turned on by interested users/developers.
15 Comments
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Gallium3D Drivers Might Lose The EGL State Tracker, OpenVG
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Michael Larabel is the principal author of Phoronix.com and founded the web-site in 2004 with a focus on enriching the Linux hardware experience and being the largest web-site devoted to Linux hardware reviews, particularly for products relevant to Linux gamers and enthusiasts but also commonly reviewing servers/workstations and embedded Linux devices. Michael has written more than 10,000 articles covering the state of Linux hardware support, Linux performance, graphics hardware drivers, and other topics. Michael is also the lead developer of the
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Part Time Jobs in Lilburn, Georgia ( GA )
If you're looking for part time jobs, student jobs or jobs for teens in Lilburn, Georgia, you've come to the right place! Chances are that GrooveJob.com has the right job for you and wants to be your only source for finding part time jobs in Lilburn, Georgia.
We've got plenty of part time and summer jobs in Lilburn, Georgia. Check out the list of employers below who are accepting applications for part time jobs in your town. Remember to check back with Groovejob.com on a regular basis. We add new part time job listings to our database every week, so you'll find new opportunities every time you check back with us.
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Jobs by Title
Assistant Teacher
…group of full- time employees (32-40 hours per week) as well as numerous part - time employees (20-30 hours per week). When full-...
Lilburn, GA
Team Member
…schedule to fit around your life. Competitive Pay: Along with a competitive hourly wage, you'll have opportunities to participate in...
Lilburn, GA
Shift Manager
…industry! Bojangles' has great opportunities for Shift Managers. Earn $9.00 to $13.00 Hourly Work with fellow employees, peers and...
Lilburn, GA
Child Care Van Driver
…care teacher, early childhood teacher, early childhood educator, child development associate, part time teacher, training Address:...
Lilburn, GA
Team Leader Operations (Store Management)
…paperwork and maintain employee files. Conduct new hire orientation for all hourly associates. Ensure that benefit information is...
Lilburn, GA
Pharmacy Technician Trainee / Pharmacy Service Associate
Work as part of the Pharmacy Team to ensure that each customer has a positive shopping experience at CVS and to ensure customer...
Lilburn, GA
Photo Lab Technician
…products and services to customers. To carry out all duties delegated by the Photo Lab Supervisor and Store Management Team. Job...
Lilburn, GA
AVON Independent Sales Representative
AVON Independent Sales Representative Location: Work from home; Work online; Part - time or Full Time Opportunity : At a time when...
Lilburn, GA
Home Workers Wanted: Part Time /Full Time (Data Entry, Work From Home Positions)
…are dependable and looking to make as much as $350-$1,200 per week, or more working part time or full time . You work on your own...
Lilburn, GA
Need a Handyman
…week. Best days to meet: Other (Best to communicate by email). More info: I am looking for hourly rates. I have multiple work orders...
Tucker, GA
UberX Driving Partner ( Part - Time )
…your own car. Driving with Uber is a great way to earn cash whether you're working part time , going to school, or seeking out an...
Atlanta, GA
Part Time Jobs Up To $27 Per Hour (Apply Now)
Part time or full time positions available. Must have decent typing skills and helpful to be a good self starter. Start...
Lilburn, GA
Bloggers Wanted: Get Paid To Share Your Opinion Blogging ( Part Time /Full? Time )
…We are looking for people nationwide interested in working from home who are dependable and looking to make as much as $350-$1,000...
Lilburn, GA
Work From Home Business Opportunity PT/FT - Make up to $5,000 per Sale. Not MLM, No Cold Calling
…Highly Lucrative Make Up To $5,000 Per Sale Learn To Make 2 Sales Per Week Part Time / Full Time Opportunity would suit the...
Lilburn, GA
Package Handler - Part - Time
UPS is hiring individuals to work as part - time Package Handlers . This is a physical, fast-paced position that involves continual...
Doraville, GA
Part Time Store Clerk
…smile, a genuine Hi and offering to help. Does this sound like you? As a part of our team, you could: Prepare gourmet dishes, make...
Lawrenceville, GA
Hourly Shift Manager
Hourly Shift Management This is it. It's time you joined a company that'll give you the tools to learn, grow and be what you want to be...
Norcross, GA
Part time security needed Ellenwood area Saturday and Sunday $9.50 1st shift
…Security Officers are a cornerstone at AlliedBarton Security Services. Our officers allow us to accomplish our companys core purpose,...
Part Time Packaging Associate
*Title: Part Time Packaging Associate* *Location: GA-Norcross-6455 Best Friend Rd* The part - time Packaging Associate will report to...
Norcross, GA
Need audio recording
…Pre-production. More info: Looking for music producer for hire or someone to collaborate with on my current projects. Include your ...
Lawrenceville, GA
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One-Off Workout: 6 Moves to Larger Legs
Build yourself up to be a powerhouse with this 6-move leg routine for size.
MOVE ONE: Isolated Jumping Lunges
Perform 4 sets of 2 minutes each leg. Take 1 minute rest in between switching legs.
Exercise Instructions > Begin by standing in the lunge position. Your lead leg should bend at a perfect 45 angle. The quad of your trailing leg should be aligned with the rest of your body.
> Jump in air from lunge position and return to lunge position after jump.
> Continue the jumps for time, rest 1 minute, then switch.
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- 10 Reasons We Love J-LawCheck out why we love the 'Hunger Games' hottie.
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- The 5 Toughest Yoga Positions for GuysTackle them to achieve the ultimate in strength and balance.


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Justin Herman and his 'shutdown beard,' which he's been documenting on Twitter since the shutdown began. (Image from Herman's Instagram.)
FCW posted its top seven feds to follow on Twitter on Day One of the government shutdown. At first glance that might seem counterintuitive -- many agencies tweeted that they would be unable to update their accounts during the shutdown. But some feds are keeping the Twitterverse illuminated with their shutdown stories and opinions via their personal accounts.
Justin Herman, social media guru for the General Services Administration, is providing updates on his #shutdownbeard. A day before the shutdown, Herman tweeted "I've taken 3 oaths of office in 10 years: military officer; Congressional aide; Fed executive. Public service demands an Iron Price sometimes".
Beth Beck, open innovation program manager at NASA, signed off with a flourish. "Shutting down my NASA iPhone + iPad during furlough = forced digital detox. Let the cleanse begin," she tweeted.
Some feds tend toward comedy, others toward opinion. Dan Munz, deputy assistant director for consumer engagement at the Consumer Financial Protection Bureau, tweeted, "Basically, there's now a strong incentive to fill legislation with minor symbolic things you can bargain away later to protect the core."
Munz's agency is fairly new, so he can perhaps be forgiven for ignoring the fact that using legislative leverage to get what you want has been a staple of congressional affairs since the days of Hamilton and Jefferson trading the states' debt for a capital on the Potomac.
Others eschewed politics for simple good manners. After tweeting about data.gov not being accessible during the shutdown, Jeanne Holm of NASA tweeted, "I've never wanted to say 'I'm sorry' to so many people in one day. Thanks for your patience and understanding."
Posted by Reid Davenport on Oct 07, 2013 at 1:57 PM
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Steve Kelman considers the costs of corruption in Mexico, China, and most developing countries -- and argues that Americans should keep their own government troubles in perspective.
Agency leaders must proactively invest time, energy and resources to shape the future rather than reactively wait for change to happen.
Meet 24 men and women who are driving key changes in federal IT -- and shaping up as the community's likely leaders of tomorrow.
GSA's administrator talks with FCW about short-term hiring, long-term planning and Robert Frost.
Without a future vision and an appetite for risk, reforms lead down a rabbit hole. There is a better way.
VA's top tech official says he is balancing risks while trying to keep the department's online services open for business.
After five years on the job, the founding director of the Office of Government Information Services believes that a deeper understanding and acceptance of FOIA is seeping into the federal government.
The September attack, made public Nov. 10, potentially puts customer and employee personal information at risk, including addresses, Social Security numbers and emails.
The General Services Administration's Matthew Goodrich predicts more agency-driven authorizations and previews a new two-year road map.
Are you serious, FCW? You're now writing stories about Justin Herman's "shutdown beard"? Aren't there more important things to be covering?
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© 1996-2013 1105 Media, Inc. All Rights Reserved. This copy is for your personal, non-commercial use only.To order presentation-ready copies for distribution to colleagues, clients or customers, visit: www.1105Reprints.com


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Bob Dylan's Handwritten 'Like a Rolling Stone' Lyrics Up for Auction
The lyric sheets are part of a Sotheby's auction called 'A Rock & Roll History: Presley to Punk.' They could sell for between $1 million and $2 million.
The lyric sheets are part of a Sotheby's auction called 'A Rock & Roll History: Presley to Punk.' They could sell for between $1 million and $2 million.
Sweet's breakthrough album, 'Sweet Fanny Adams,' was released in the U.K. April 1974.
We won't be able to get our hands on the new Led Zeppelin boxes until June, but the BBC didn't have to wait -- and they've shared some of their good fortune with the rest of us.
Robert Plant has quashed any discussion of a possible Led Zeppelin reunion.
The history of the pub rock supergroup Ron Wood and Keith Richards of the Rolling Stones formed in the late '70s.
Ron Wood's third solo album, 'Gimme Some Neck,' was released on April 20, 1979.
Did Robert Plant once serve as Dee Snider's opening act? It sounds crazy, but it actually happened.
Sammy Hagar isn't finished inviting friends along for summer shows. In addition to shows with his normal backing band the Wabos, Hagar will be joined by a new lineup featuring Michael Anthony and Jason Bonham during select appearances in 2014.
The first full taste of the bonus live material from the upcoming re-releases of Led Zeppelin's first three albums is now available in the form of a blistering 1969 take on 'Communication Breakdown.'
Paul Stanley lit up Hall of Fame co-founder Jann Wenner and company tonight, labeling them "spineless weasels" and saying the band were treated like "uninvited guests" during Thursday night's induction ceremony.
Led Zeppelin have created a teaser video featuring two of the live tracks from the upcoming reissue of 'Led Zeppelin.'
The organizer of the Glastonbury Festival is holding out for a Led Zeppelin reunion.


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- NGA Releases Hi-Res Elevation Data — 30-meter topographic data for the world.
- Soft Robotics — a collection of shared resources to support the design, fabrication, modeling, characterization, and control of soft robotic devices. From Harvard.
- OpenGov — In many domains, it's not so much about "big data" yet as it is about "clean data."
- Mitnick's Zero-Day Exploit Shop — marketplace connecting "corporate and government" buyers and sellers of zero-day exploits. Claims to vet buyers. Another hidden economy becoming public.
"security" entries
Stop hacking random stuff. It's getting trivial.
Once we acknowledge nearly everything is insecure, we can engage in a more nuanced discussion about security.
I was gratified to read Dave Aitel's rant about junk hacking last week [via Peter Lewis and abridged below]:
"Yes, we get it. Cars, boats, buses, and those singing fish plaques are all hackable and have no security. Most conferences these days have a whole track called 'Junk I found around my house and how I am going to scare you by hacking it.' That stuff is always going to be hackable whetherornotyouarethecalvalry.org.
"Yes, there is Junk in your garage, and you can hack it, and if
you find someone else who happens to have that exact same Junk, you can probably hack that, too, but maybe not, because testing is hard.
"Cars are the pinnacle of junk hacking, because they are meant to be in your garage. Obviously there is no security on car computers. Nor (and I hate to break the suspense) *will there ever be*. Yes, you can connect a device to my midlife crisis car and update the CPU of the battery itself with malware, which can in theory explode my whole car on the way to BJJ. I personally hope you don't. But I know it's possible the same way I know it's possible to secretly rewire my toaster oven to overcook my toast every time even when I put it on the lowest setting, driving me slowly but surely insane.
"So in any case, enough with the Junk Hacking, and enough with being amazed when people hack their junk."
Four short links: 25 September 2014
Elevation Data, Soft Robots, Clean Data, and Security Souk
Four short links: 19 September 2014
Deep Learning Bibliography, Go Playground, Tweet-a-Program, and Memory Management
- Deep Learning Bibliography — an annotated bibliography of recent publications (2014-) related to Deep Learning.
- Inside the Go Playground — on safely offering a REPL over the web to strangers.
- Wolfram Tweet-a-Program — clever marketing trick, and reminiscent of Perl Golf-style "how much can you fit into how little" contests.
- Memory Management Reference — almost all you ever wanted to know about memory management.
Four short links: 18 September 2014
Writing Testable Code, Magical UIs, High-Performance ssh, and BASIC Lessons
- Guide to Writing Testable Code (PDF) — Google's testable code suggestions, though C++-centric.
- Enchanted Objects (YouTube) — David Rose at Google talking about the UX of magical UIs. (via Mary Treseler)
- hpn-ssh — High Performance SSH/SCP.
- Lost Lessons from an 8-bit BASIC — The little language that fueled the home computer revolution has been long buried beneath an avalanche of derision, or at least disregarded as a relic from primitive times. That's too bad, because while the language itself has serious shortcomings, the overall 8-bit BASIC experience has high points that are worth remembering.
Four short links: 15 September 2014
Weird Machines, Libraries May Scan, Causal Effects, and Crappy Dashboards
- The Care and Feeding of Weird Machines Found in Executable Metadata (YouTube) — talk from 29th Chaos Communication Congress, on using tricking the ELF linker/loader into arbitrary computation from the metadata supplied. Yes, there's a brainfuck compiler that turns code into metadata which is then, through a supernatural mix of pixies, steam engines, and binary, executed. This will make your brain leak. Weird machines are everywhere.
- European Libraries May Digitise Books Without Permission — "The right of libraries to communicate, by dedicated terminals, the works they hold in their collections would risk being rendered largely meaningless, or indeed ineffective, if they did not have an ancillary right to digitize the works in question," the court said. Even if the rights holder offers a library the possibility of licensing his works on appropriate terms, the library can use the exception to publish works on electronic terminals, the court ruled. "Otherwise, the library could not realize its core mission or promote the public interest in promoting research and private study," it said.
- CausalImpact (GitHub) — Google's R package for estimating the causal effect of a designed intervention on a time series. (via Google Open Source Blog)
- Laws of Crappy Dashboards — (caution, NSFW language … "crappy" is my paraphrase) so true. Not talking to users will result in a [crappy] dashboard. You don't know if the dashboard is going to be useful. But you don't talk to the users to figure it out. Or you just show it to them for a minute (with someone else's data), never giving them a chance to figure out what the hell they could do with it if you gave it to them.
Four short links: 8 September 2014
Glasshole Wiper, Complex Failures, Mail Startup, and Digital Media Disappointments
- Cyborg UnPlug — sits on your wifi network and will alert you if it finds Google Glass, Dropcam, spycams, and other unwanted wifi Klingons. Or it can automatically send deauth packets to those devices to try and boot them off the network.
- How Complex Systems Fail (PDF) — That practitioner actions are gambles appears clear after accidents; in general, post hoc analysis regards these gambles as poor ones. But the converse: that successful outcomes are also the result of gambles; is not widely appreciated.
- Schnail Mail — exciting new startup idea.
- Mapping Digital Media (Open Society) — analysis of media, online and off, in various regions and discussion of how it's changing. Among the global findings: digitization has brought no pressure to reform state broadcasters, less than one-third of countries found that digital media have helped to expand the social impact of investigative journalism, and digitization has not significantly affected total news diversity.
Four short links: 4 September 2014
Makerspace Libraries, xkcd Author Profiled, On Victim Shaming, and Generated Covers
- Makerspaces Coming to Libraries (Wired) — [W]hile I'm just as sentimental about the primacy of hard copy, the librarians aren't. As they all tell me, their job is helping with access to knowledge—not all of which comes in codex form and much of which is deeply social. Libraries aren't just warehouses for documents; they're places to exchange information.
- Rolling Stone Feature on Randall Munroe — When you're talking about pure research, every year it's a longer trip to the cutting edge. Students have to spend a larger percentage of their careers catching up to the people who have gone before them. My solution to that is to tackle problems that are so weird that no one serious has ever spent any time on them. (via BoingBoing)
- Not Safe for Working On (Dan Kaminsky) — some things that needed to be said, and which couldn't have been said better, about security, victim shaming, and separating the 2% from the 98%.
- Generative eBook Covers — very cool (with code) system for programmatically generating aesthetic and interesting ebook covers. I particularly like the face-recognition-in-engravings look.
Four short links: 3 September 2014
Distributed Systems Theory, Chinese Manufacturing, Quantified Infant, and Celebrity Data Theft
- Distributed Systems Theory for the Distributed Systems Engineer — I tried to come up with a list of what I consider the basic concepts that are applicable to my every-day job as a distributed systems engineer; what I consider 'table stakes' for distributed systems engineers competent enough to design a new system.
- Shenzhen Trip Report (Joi Ito) — full of fascinating observations about how the balance of manufacturing strength has shifted in surprising ways. The retail price of the cheapest full featured phone is about $9. Yes. $9. This could not be designed in the US – this could only be designed by engineers with tooling grease under their fingernails who knew the manufacturing equipment inside and out, as well as the state of the art of high-end mobile phones.
- Sproutling — The world's first sensing, learning, predicting baby monitor. A wearable band for your baby, a smart charger and a mobile app work together to not only monitor more effectively but learn and predict your baby's sleep habits and optimal sleep conditions. (via Wired)
- Notes on the Celebrity Data Theft — wonderfully detailed analysis of how photos were lifted, and the underground industry built around them. This was one of the most unsettling aspects of these networks to me – knowing there are people out there who are turning over data on friends in their social networks in exchange for getting a dump of their private data.
Four short links: 28 August 2014
Visual Python, Scraping and Screenshotting, Un-free Speech, IP Law Textbook
- PlotDevice — A Python-based graphics language for designers, developers, and tinkerers. More in the easy-to-get-started + visual realm, like Processing. (via Andy Baio)
- Scumblr and Sketchy Search — Netflix open sourcing some scraping, screenshot, and workflow tools their security team uses to monitor discussion of themselves.
- Should Twitter, Facebook and Google Executives be the Arbiters of What We See and Read? (Glenn Greenwald) — In the digital age, we are nearing the point where an idea banished by Twitter, Facebook and Google all but vanishes from public discourse entirely, and that is only going to become more true as those companies grow even further. Whatever else is true, the implications of having those companies make lists of permitted and prohibited ideas are far more significant than when ordinary private companies do the same thing.
- Intellectual Property: Law and the Information Society; Cases and Materials (PDF) — James Boyle and Jennifer Jenkins' open law textbook on IP (which even explores the question of whether that's a valid and meaningful term). (via James Boyle)


text: Some people just want to do that stuff because they either think they're to young or they don't want a child from that person who got them pregnant. If they want to "destroy" their child, mind as well, NOT do anything until you are forsure that that man is the man of your life. Stupidly, people do things like that for the fun of it, not knowing that they are creating or killing an innocent and precious thing.


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Author Archives: Peter Smith
CPOs at ProcureCon Talk About Supplier Innovation – and How to Capture It
Innovation has become one of the very hottest of hot topics in procurement circles over the last couple of years. At the recent ProcureCon conference in Berlin, it was covered over several sessions, with a number of CPOs giving us the benefit of their views and experience around supplier innovation and how to capture it. Based on this wealth of input, what conclusions or thoughts can we draw from the 2 days of thinking and talking around the topic? Here are some key take-aways that CPOs and others might want to consider.more ▸
Securing the Future of Procurement – Peter Smith at the Zycus CPO Connect Dinner
Procurement has been a great success story over the last 20 years or so. Most of us in that function would agree, and even our colleagues in other areas might grudgingly accept that the profile of procurement is higher than when those of us of a certain age first come into the profession. Is that down to our own brilliance though? Or the sterling efforts of ISM, CIPS and other professional bodies, academics and writers on the topic?more ▸
Spend Matters Stock Portfolio – A Bleak October for IBM, SAP, Tungsten, E2Open (and Jason Busch)
Oh dear! October was certainly not a month of mists and mellow fruitfulness (or is that November?) for our stock portfolio. Stock markets had a nervous month after the falls of September, with further falls in the first half of October. However, some confidence returned, and many stocks recovered to finish slightly up on the month. But IT stocks continued to be treated with caution – or worse – and the evidence for that was clear in our portfolio of 21 companies with an interest in the procurement software space. The portfolio lost 3% of its value on the month, and again, it is basically back where we started, just a fraction above its Jan. 1 total value.more ▸
Top 4 Ways CPOs Will Use Social Media
In Part 1 of this series we looked at the principles of social media, which give an insight into how and why it has been such a phenomenon. Aspects such as the way it enables users to feel a sense of belonging and to share knowledge, information and their passions so quickly and easily, play to ancient human needs. So now let's look in a more practical manner at the areas where social media tools, or tools that at least use these principles, will increasingly play an important role in the lives of CPOs and indeed all procurement professionals. There are 4 principle areas that we can consider, although there is overlap between them in some cases.more ▸
Social Media and the CPO
For a recent workshop in London, I prepared a session titled "From Facebook to Supplier Collaboration - how social media is changing procurement." As well as being one of the more enjoyable topics to research (I got to know far more about vloggers and Haul Girls than I really needed to), it is actually a huge and fascinating topic once you really get into it. And it goes way beyond just keeping your LinkedIn profile up to date, which is about as far as many CPOs and senior professionals get. So in this piece we will get into an overview of the subject and start focusing on the key principles of social media, which then suggests what CPOs, procurement directors or similar should be considering in terms of actually making use of the tools - we'll cover that in Part 2.more ▸
Global Market and Future Goals: BravoSolution's New CEO Speaks Out – The Spend Matters Interview (Part 3)
Jim Wetekamp, BravoSolution's recently appointed CEO, is no stranger to the depths of procurement solutions and technology. Jason Busch, Spend Matters founder and managing director, first got his taste of Jim's handiwork when he was working for a competitor to FreeMarkets, Atlas Commerce, which was acquired by VerticalNet. Jim has since focused on a variety of solution and commercial areas as that original entity morphed into something that would have been difficult to imagine at the time of the original analyst research into the procurement market. In this three-part interview series, Jason and Peter Smith, managing director of Spend Matters UK/Europe, delve into Jim's and BravoSolution's current focus in global markets and its future plans.more ▸
Expanding Into Upstream Supply Management: BravoSolution's New CEO Speaks Out – The Spend Matters Interview (Part 2)
Jason Busch, founder and managing director of Spend Matters, has known BravoSolution's new CEO Jim Wetekamp for nearly 15 years, meeting around the time when they both first entered the procurement market. In this three-part interview series, Jason, along with Peter Smith, managing director of Spend Matters UK/Europe, quiz Jim on his background and discusses BravoSolution's current position in the market and it's ambitions. Also see Part 1 of the interview as well. Spend Matters: What is the largest solutions-focused opportunity for BravoSolution today? Jim Wetekamp: This very much depends upon a market-by-market case since each region is different. However, […]more ▸
BravoSolution's New CEO Speaks Out – The Spend Matters Interview (Part 1)
Spend Matters Founder and Managing Director Jason Busch recently sat down with BravoSolution's new CEO Jim Wetekamp at his office in Chicago. Peter Smith, managing director of Spend Matters UK/Europe, was also part of the discussion via teleconference. In this three-part series, Jason and Peter asked Jim to provide some insight on his background for our readers, where he sees BravoSolution today and opportunities for the future. Enjoy!more ▸
The Spend Matters Stock Portfolio – Just Like the Ryder Cup
We are now three quarters of the way through the year and through our 2014 stock portfolio competition between Jason Busch, representing the mighty USA, and me, Peter Smith, representing Europe. And I'm afraid, just like the Ryder Cup, it is turning into a bit of a non-contest, with Europe clearly ahead.more ▸
CPO Insight: Procurement Transformation – Myth or Reality?
I'm writing this from the economy cabin of a very busy London to Dubai flight, on my way to run a couple of workshops in Dubai and Abu Dhabi for the BravoSolution joint venture in the region, Tejari. By the time you read this, the workshop will be completed, and the topic in Dubai is Procurement Transformation - Myth or Reality? One of the reasons we chose this as a topic is that "transformation" has become an over-used expression and procurement has not been immune to its charms. In this Plus article, Pierre Smith talks about what exactly a procurement "transformation" means.more ▸
Peter Smith (Spend Matters UK/Europe) on Procurement Lifecycle Engagement (webinar: Sept. 30)
On Sept. 30 at 12 noon UK time, software firm Zycus is hosting a webinar featuring Peter Smith, managing editor of Spend Matters Europe. The title is: How to make a "cradle to grave" contribution: connecting purchasing with the wider organization to drive end-to-end value. Register here.more ▸
CPO Insight: Procurement Transformation – Myth or Reality?
"Transformation" has become an overused expression, and procurement has not been immune to its charms. It's hard to get far into any procurement-related publication, or report from a consulting firm, without running up against the "T" word. Virtually every managerial-level candidate now has "transformed" something in their past career. Even if it was just the process for ordering office supplies. In this Spend Matters Plus Research brief, Peter Smith, lead editor of Spend Matters UK/Europe, explores what transformation really means, and if we can agree that it does have some genuine meaning (in some cases, at least) – and how chief procurement officers (CPOs) and other procurement leaders can go about making it happen.more ▸


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Dr. Jeffrey W. Henderson, DO
Internal Medicine - Geriatrics, Gino Mercadante DO
- 200 Center St Ste 18
Ludlow, MA 01056
- 1 Office Location
- (413) 589-7176
Dr. Jeffrey W. Henderson has been practicing medicine for 12 years. Dr. Henderson graduated from the Kansas City University of Medicine and Biosciences College of Osteopathic Medicine in 2002. He practices medicine in Ludlow, MA and specializes in Internal Medicine - Geriatrics and Internal Medicine. Dr. Henderson is affiliated with Baystate Medical Center and Mercy Medical Center. He speaks English, Portuguese and Spanish.
Gender: Male
Years in Practice: 12 Years
Languages Spoken: English, Portuguese, Spanish
Medical School: Kansas City University of Medicine and Biosciences College of Osteopathic Medicine
Graduation Date: 2002
Hospital Affiliations: Baystate Medical Center, Mercy Medical Center
Specialties: Internal Medicine - Geriatrics, Internal Medicine


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Harbour Light Bistro is a locally owned Nelson restaurant based on Wakefield Quay, one of Nelsons beautiful waterfronts. Harbour Light offers a selection of locally and internationally inspired dishes. All dishes are made fresh and our menus change seasonally as we use locally sourced fresh produce when possible for our restaurant.
Harbour Light Bistro & Restaurant offers spacious indoor dining with picturesque waterfront views, suitable for large groups or an intimate lunch or dinner for two. Our wines are also locally sourced from Nelson, Tasman and Marlborough regions and are all carefully selected to accompany our many fine dishes.
Harbour Light Bistro & Restaurant is open weekdays from 11.30am to late. On the weekend we open at 9.30 for brunch then through to close with dinner. Please call us on 03 546 6685 for a reservation so as not to be disappointed.
Serving only the best...Flight Coffee.
We had a fantastic Wine Workshop with Simon Nunns this month view our pictures on the Harbour Light Bistro Facebook page.
Check out our new Monthly Newsletter, To subscribe Click here
For the month of October we are featuring the lovely Coopers Creek select vineyard range tasted at the workshop which include ; SV Gruner Vetliner, Albarino, Arneis, Viognier and Malbec all at fantastic prices.


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Gently used Monte Design Luca Glider and Ottoman for sale. Retails for $1,385. Selling for $600. Available immediately for pickup from elevator building in the LES.
Photo of actual glider is attached (though color is not coming through so well due to lighting in my ...
Nov 16 -
New York City :
New York - Everything else
Dark Brown Ottoman, purchased from Macy's . Excellent condition. Changed design in our living room and does not match our new decor.
Great price..go online and you will see this quality leather for $600 and up.
Dimensions: 35" x 35" x 16"
Oct 25 -
New York City :
Oakland Gardens - Everything else
Nursery ottoman . Good condition
Oct 16 -
Boston :
Methuen - Everything else
46x46 in Leather Storage Ottoman
Good condition
Shows signs of wear/ biggest defect is superficial scratch up top (can easily be repaired)
Top opens to reveal large amount of storage
Originally paid $399
This ad was posted with the eBay Classifieds mobile app.
Sep 27 -
New York City :
Shirley - Everything else
Hi All,
Moving soon and planning to sell a list of items below!
SERIOUS INQUIRIES ONLY, if interested please give me a call or send a text for any further details, please!
Thank you
Monopoly board game (In like New condition, all pieces included) - $5
Sep 24 -
Newark :
Belleville - Everything else
We'll be sending text message alerts for your subscription to


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And vows to fight for people who got screwed by Wall Street.
How a US government loan enabled an environmentally destructive project plagued by lethal landslide, police repression and civil unrest.
Averting planetary disaster will mean forcing fossil fuel companies to give up at least $10 trillion in wealth.
Big Carbon is where Big Tobacco was, before it started losing.
The New York real estate market has become a private equity playground, and the result has been a disaster for tenants and the market alike.
Paul Singer is one of the Republican Party's most effective fundraisers—and a leading proponent of using military force against Tehran.
Now that household items connect to the Internet, what people do with their private lives will be monitored ever more closely.
The conservative businessman and activist talks to The Nation about his unlikely support for raising the minimum wage, his views on immigration and more.
By pouring money into politics, pesticide companies have beat back attempts to protect the public.
In the carbon wars, big oil is winning.


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November 21, 2014
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Wednesday, December 7, 2011
Fourth- and eighth- graders in several urban districts in America made progress in math on a national test known as the "Nation's Report Card," but their reading scores have mostly remained stagnant in the last two years.
The trend matches what's going on in schools around the country.
The results released Wednesday are from the National Assessment of Educational Progress. Twenty-one urban districts volunteered to have their scores separately reported for the release.
The districts had a wide disparity in performance. But overall, there were still gaps in how well students of different racial groups and income levels performed.
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