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Publications (39)172.39 Total impact
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ABSTRACT: Our objective was to review the long-term outcome of patients undergoing surgical repair of aortic coarctation. Surgical repair of aortic coarctation has been performed at Mayo Clinic for over 60 years. Between 1946 and 2005, 819 patients with isolated coarctation of the aorta underwent primary operative repair. Medical records were reviewed and questionnaires mailed to patients. Mean age at repair was 17.2±13.6 years. The majority (83%) had preoperative hypertension. Operations included simple and extended end-to-end anastomosis (n=632), patch angioplasty (n=72), interposition graft (n=49), bypass graft (n=30) and subclavian flap or other (n=35). Overall early mortality (<30 days) was 2.4%. In the last 30 years (n=225), there were no operative deaths. Mean follow-up was 17.4±13.9 years with a maximum of 59.3 years. Actuarial survival was 93.3%, 86.4%, and 73.5% at 10, 20 and 30 years, respectively. When compared to an age and gender matched population, long-term survival was decreased (P<0.001). Older age at repair (>20 years) and preoperative hypertension were associated with decreased survival (P<0.001). Patients less than 9 years at the age of repair had significantly less hypertension at 5-15 years of follow-up (P<0.001). Freedom from reintervention on the descending aorta was 96.7%, 92.2%, and 89.4% at 10, 20 and 30 years, respectively. Younger age at time of repair (P<0.001) and an end-to-end anastomosis technique (P<0.001) were independently associated with lower reintervention rates on the descending aorta. Primary repair of isolated coarctation of the aorta can be performed with low mortality. However, long-term survival is reduced compared to an age and gender matched population and many patients will require further reoperation. These findings emphasize that patients with aortic coarctation need early recognition and intervention, as well as life-long informed follow-up.Journal of the American College of Cardiology 06/2013; 62(11). DOI:10.1016/j.jacc.2013.06.016 · 15.34 Impact Factor
Chapter: Ebstein AnomalyDiagnosis and Management of Adult Congenital Heart Disease, 12/2011: pages 288-294; , ISBN: 9780702034268
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ABSTRACT: Patients who require aortic valve replacement are increasingly receiving biologic valves to avoid long-term anticoagulation. The thromboembolic risk of bioprosthetic valves is reportedly low. The study objective was to review the incidence of early valve thrombosis requiring reoperation in patients who received a bioprosthetic valve in the aortic position. We reviewed all adult patients who had a biologic valve implanted in the aortic position at Mayo Clinic between January 1993 and July 2009. Records were reviewed for all cases of reoperation that occurred less than 2 years postoperatively. Incidences of valve thrombosis were calculated including 95% Poisson confidence intervals. During the study interval, 4568 patients received biologic valves for aortic valve replacement. We identified 8 patients who underwent reoperation to replace the aortic prosthesis because of thrombus that resulted in functional aortic stenosis. The median age of patients at the time of reoperation was 77 years (range, 52-86), and the median time to reoperation was 398 days (range, 106-626). All patients with valve thrombosis received a stented porcine valve: St Jude Biocor (St Jude Medical, Inc, St Paul, Minn) in 4 patients, Medtronic Mosaic (Medtronic Inc, Minneapolis, Minn) in 2 patients, and Medtronic Hancock (Medtronic Inc) in 2 patients. The calculated incidence of valve thrombosis was 1.26% (confidence interval, 0.56-1.96) for the Biocor valve, 0.37% (confidence interval, 0.19-0.56) for the Mosaic valve, and 0.84% (confidence interval, 0.42-1.25) for the Hancock valve (P = .34). There were no cases of valve thrombosis in patients who received a pericardial valve (5923 patient-years) or stentless valve (172 patient-years). The incidence of early thrombosis of porcine aortic bioprostheses requiring reoperation was not insignificant. Potential causes and mechanisms for such thrombosis are unknown. Recognition of this unanticipated problem and reoperation resulted in a satisfactory outcome for patients.The Journal of thoracic and cardiovascular surgery 08/2011; 144(1):108-11. DOI:10.1016/j.jtcvs.2011.05.032 · 3.99 Impact Factor
Article: Relationship between left ventricular mass, wall thickness, and survival after subaortic septal myectomy for hypertrophic obstructive cardiomyopathy[Show abstract] [Hide abstract]
ABSTRACT: In natural history studies, increased left ventricular mass and wall thickness are strongly associated with increased late mortality in patients with hypertrophic cardiomyopathy. Our objective was to determine the impact of left ventricular mass and wall thickness on survival after myectomy for hypertrophic obstructive cardiomyopathy. We reviewed the case histories of 796 patients who underwent transaortic septal myectomy for hypertrophic obstructive cardiomyopathy from January 1993 to December 2006. We then selected for study patients who had transthoracic echocardiography within 30 days after myectomy, which included complete measurements of interventricular wall thickness, posterior wall thickness, and left ventricular end diastolic dimension. Late survival was determined for all patients using medical records and surveys. Our study group included 416 patients with a mean age of 50±15 years, and 58% were male. Eight percent of patients had coronary artery disease, 17% had a history of arrhythmia, and 17% had a previous or concomitant insertion of an internal cardioverter defibrillator. All patients had successful myectomy, and 17% required an additional mitral valve procedure, most often mitral valve repair. On predismissal echocardiography, the average interventricular wall thickness was 16±5 mm, the posterior wall thickness was 13±3 mm, and the left ventricular end diastolic dimension was 45±6 mm. The indexed left ventricular mass was 135±46 g/m2. Late survival at 1, 5, and 10 years was 99%, 97%, and 85%, which was similar to that of an age- and gender-matched population (P=.453). On multivariate analysis, preoperative and postoperative wall thickness and left ventricular mass were not associated with death; only a history of coronary artery disease (hazard ratio 4.9) was predictive of late mortality. Left ventricular mass and wall thickness were not predictors of late survival after myectomy for hypertrophic obstructive cardiomyopathy, and this is in contrast to natural history studies of patients who were not treated surgically. Late survival was similar to that of an age- and gender-matched population.The Journal of thoracic and cardiovascular surgery 02/2011; 141(2):439-43. DOI:10.1016/j.jtcvs.2010.04.046 · 3.99 Impact Factor
Article: Axillary arteriovenous fistula for the palliation of complex cyanotic congenital heart disease: Is it an effective tool?[Show abstract] [Hide abstract]
ABSTRACT: Patients with complex cyanotic congenital heart disease and a bidirectional cavopulmonary connection who are not candidates for or had failed Fontan operation may experience progressive cyanosis. An axillary arteriovenous anastomosis may be constructed to augment pulmonary blood flow. This report reviews our results with this approach in this complex group of patients. The records of patients with previous cavopulmonary connections who underwent a surgical anastomosis between the axillary artery and the vein for palliation of severe progressive cyanosis were reviewed. Eleven patients were identified. The median age at the time of the axillary arteriovenous anastomosis was 19.2 years (7.97-41.75 years). Seven patients were not candidates for the Fontan operation, and 4 patients had failed Fontan surgery. Three of the anastomoses were constructed with a side-to-side technique, and 8 anastomoses were constructed with a short interposition graft. Median fistula size was 5 mm (3-6 mm). There was no operative mortality and 1 late death. Median survival was 2.85 years (0.01-7.22 years). All fistulae were patent at follow-up. Median preoperative arterial oxygen saturation was 84% (80%-86%) and 82% (76%-88%) at follow-up (P = .38). Median preoperative hemoglobin was 18.5 g/dL (11.7-22.6 g/dL) and 19.2 g/dL (14.6-22.6 g/dL) at follow-up (P = .97). Median preoperative systemic ventricular ejection fraction was 51% (27%-60%) and 46.5% (28%-60%) at follow-up (P = 1). Significant functional improvement was seen in only 1 patient. In patients with complex cyanotic congenital heart disease who are not candidates for or had failed Fontan operation, palliation with an axillary arteriovenous fistula did not improve cyanosis or polycythemia. Functional outcome and ventricular ejection fraction did not improve or deteriorate.The Journal of thoracic and cardiovascular surgery 01/2011; 141(1):188-92. DOI:10.1016/j.jtcvs.2009.12.059 · 3.99 Impact Factor
Article: Can the Impact of Change of Surgical Teams in Cardiovascular Surgery Be Measured by Operative Mortality or Morbidity? A Propensity Adjusted Cohort Comparison[Show abstract] [Hide abstract]
ABSTRACT: Our objective was to examine the impact of team changeover and unfamiliar teams in cardiovascular surgery on traditional clinical outcome measures. The importance of teamwork in the operating room is increasingly being appreciated, but the impact on more traditional outcome measures is unclear. Methods: Elective or urgent cardiovascular procedures were divided into categories: team D (patients who had an operation with a day team); team E (patients who had an operation with an evening team); team C (patients who had an operation which included changeover between a day and evening team). Comparison groups were adjusted using propensity scores. We identified 6698 patients who met inclusion criteria (team D, n =3781; team E, n = 518; team C, n = 2399). After propensity score adjustment,there was an increased skin–skin time of 28 minutes in team C when compared with team D (P < 0.001) and of 21 minutes when compared with team E (P <0.001). There were also more episodes of septicemia among team C patients(OR 1.85, P = 0.013) when compared with team D. Patients operated by a day team had a statistically significantly lower number of ventilated hours and shorter hospital length of stay when compared with team E and team C (P < 0.001 and P < 0.001, respectively). There was no difference between teams in operative death, reoperation for bleeding, blood transfusion, renal failure/dialysis, neurologic events, or deep/superficial wound infections. The change in operating room personnel from the day team to the evening team added significant length to the total operating department time in cardiovascular surgery; however, its impact on most traditional outcome measures was difficult to demonstrate. More sensitive outcome measures may be required to assess the impact of teamwork interventions.Annals of surgery 12/2010; 253(2):385-92. DOI:10.1097/SLA.0b013e3182061c69 · 7.19 Impact Factor
Article: Clinical Outcome of Asymptomatic Severe Aortic Stenosis With Medical and Surgical Management: Importance of STS Score at Diagnosis[Show abstract] [Hide abstract]
ABSTRACT: The Society of Thoracic Surgeons (STS) score aims at predicting operative mortality in cardiac surgery. The value of this score in predicting short- and long-term survival with medical or surgical management in patients with asymptomatic severe aortic stenosis (AS) is unknown. In a cohort of 694 patients (aged 71 ± 11 years) with isolated, asymptomatic severe AS (velocity ≥4 m/s), STS score was calculated at baseline and its link to survival analyzed. Patients were stratified by STS score less than 4%, 4% to 6.5%, and 6.5% or greater. The STS score showed no association with operative mortality within 1 year of diagnosis or any time (1%, 2.9%, and 6.1%, respectively, by strata; p = 0.08) and a weak association with 1-year survival (p = 0.04). Conversely, long-term survival (10-year) was strongly predicted by STS score strata (78%, 47%, and 16%, respectively; p < 0.0001). In multivariate analysis, STS score independently predicted mortality (hazard ratio/1%, 1.15 [1.12 to 1.18], p < 0.0001) or cardiac death (1.21 [1.17 to 1.25], p < 0.0001). Aortic valve replacement within 1 year of diagnosis markedly improved survival (adjusted hazard ratio, 0.58, p < 0.001). However, benefit of early surgery varied according to strata, with no overt benefit with low score (p = 0.83), whereas early surgery considerably improved survival in the intermediate strata (p < 0.001). For patients with asymptomatic severe AS, STS score is a powerful tool for predicting long-term outcome and for selecting patients (particularly those at intermediate risk) who benefit markedly from early surgery. Hence, risk-scoring using STS score should be routinely performed in patients with AS to support the clinical decision-making process.The Annals of thoracic surgery 12/2010; 90(6):1876-83. DOI:10.1016/j.athoracsur.2010.07.070 · 3.65 Impact Factor
Article: Regression in Left Ventricular Mass after Aortic Valve Replacement for Chronic Aortic Regurgitation Is Unrelated to Prosthetic Valve Size[Show abstract] [Hide abstract]
ABSTRACT: We examined the role of prosthesis-patient mismatch on left ventricular mass regression after aortic valve replacement for chronic aortic valve regurgitation. We selected patients who had complete preoperative and follow-up echocardiograms with measurement of left ventricular mass. Patients were excluded who had moderate or greater aortic valve stenosis, concomitant coronary artery bypass grafting, or mitral valve procedures. Patients' mean age was 55 ± 17 years; 21% were female. The mean preoperative indexed left ventricular mass was 150 ± 45 g/m(2). Patients with mildly (n = 44; mean indexed mass, 126 ± 15 g/m(2)), moderately (n = 31; mean indexed mass, 168 ± 11 g/m(2)), or severely (n = 15; mean indexed mass, 241 ± 34 g/m(2)) increased preoperative indexed left ventricular mass, were similar, except for lower ejection fractions, larger end-diastolic dimensions, and larger ventricular wall thicknesses in the severely enlarged group (P < .001). Thirteen patients had prosthesis-patient mismatch and were similar to patients without prosthesis-patient mismatch, except for a greater body surface area, fewer mechanical valves, and smaller valve sizes in those with prosthesis-patient mismatch (P < .05). At a mean follow-up of 3.2 ± 2.4 years, the average reduction in indexed left ventricular mass was 50 ± 38 g/m(2); late mass regression was unrelated to labeled valve size, prosthesis-patient mismatch, or measured indexed effective aortic valve area. A greater preoperative indexed left ventricular mass (P < .001) was an independent predictor of greater left ventricular mass regression. Despite having greater left ventricular mass regression, patients with severe preoperative indexed left ventricular mass did not return to normal values (mean, 142 ± 25 g/m(2)). Left ventricular mass regression after aortic valve replacement for chronic aortic regurgitation is unrelated to indexed prosthetic valve area. Although incomplete, regression is greatest in patients with the largest preoperative indexed left ventricular mass.The Journal of thoracic and cardiovascular surgery 11/2010; 142(2):e5-9. DOI:10.1016/j.jtcvs.2010.08.043 · 3.99 Impact Factor
Article: Data entry and data accuracyThe Journal of thoracic and cardiovascular surgery 11/2010; 140(5):960-1. DOI:10.1016/j.jtcvs.2010.09.006 · 3.99 Impact Factor
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ABSTRACT: After repair of aortic coarctation, patients may develop restenosis, aneurysms, and pseudoaneurysms at the site of prior repair. We assessed the outcomes of late reintervention on the descending aorta after aortic coarctation repair. From March 1954 to July 2008, 130 patients had operations or endovascular procedures on the descending aorta after previous coarctation repair. We excluded patients who had complex left-sided cardiac lesions or interrupted aortic arch. Mean age at reintervention was 32±24 years and 28% were female. The interval between coarctation repair and reintervention was 17±13 years. Seventy-four percent of patients had hypertension. Reasons for reintervention were restenosis (n=122 [94%]), aneurysm (n=4 [3%]), and pseudoaneurysm (n=4 [3%]). Ninety-five patients (73%) underwent operative procedures including an extra-anatomic conduit (n=41), patch repair (n=32), interposition graft (n=14), end-end anastomosis (n=6), and subclavian flap (n=2). Thirty-five patients underwent endovascular treatment (balloon dilatation, n=22 or stenting, n=13). There was no early mortality. In the surgical group, 5 patients required early reoperation for bleeding and 5 patients had early vocal cord paralysis. One patient in the endovascular group had aortic rupture at the time of intervention requiring urgent operation. Survival was 97% at 10 years. At 5 years, freedom from a second repeat procedure on the descending aorta was 96% in the surgical group and 72% in the endovascular group (P<0.001). Five years after reintervention, fewer patients required treatment for hypertension (57% versus 74%, P<0.001) and a median of 1 antihypertensive medication was prescribed compared with a median of 2 medications preintervention. Operative and endovascular management of recoarctation can be performed safely with good late outcomes.Circulation 09/2010; 122(11 Suppl):S81-4. DOI:10.1161/CIRCULATIONAHA.109.925172 · 14.95 Impact Factor
Article: Variability in data: The Society of Thoracic Surgeons National Adult Cardiac Surgery Database[Show abstract] [Hide abstract]
ABSTRACT: Since 1989, data have been reported to the Society of Thoracic Surgeons National Adult Cardiac Surgery Database for quality improvement. This information is also data mined for national quality indicators, policy initiatives, and research. Such use has important limitations, because data elements cannot be verified for accuracy. We determined variability of disease etiology and operative data database elements when abstracted by untrained physician abstractors. We selected 30 patients who underwent cardiovascular surgery from January to December 2005 (10 each of coronary artery bypass grafting, mitral valve repairs, and aortic valve and associated aortic procedures). Four abstractors (2 cardiothoracic residents and 2 fellows) abstracted 28 variables. Results were compared with abstraction performed by a professional abstractor. Median percentage agreement among all cases was 89% (range, 42%-100%). Agreements were 94% (28%-100%) for mitral valve, 84% (48%-100%) for aortic valve, and 93% (35%-100%) for coronary artery bypass grafting. Among the aortic valve group, etiology of aortic valve disease had poor agreement (68%) because of cases in which multiple definitions could apply. Degree of valvular regurgitation also had poor agreement (median, 67%; range, 28%-95%). Number of internal thoracic artery grafts and absence of significant valvular disease were reported consistently. Agreements between types of aortic valve procedure and between methods of mitral valve repair (65% and 83%, respectively) were less than expected. We found variable agreement among untrained data abstractors. This has important implications regarding interpretation of database studies with de-identified data. Without good quality control and consistent standardized definitions, aggregate data in clinical databases may be suspect.The Journal of thoracic and cardiovascular surgery 08/2010; 140(2):267-73. DOI:10.1016/j.jtcvs.2010.02.052 · 3.99 Impact Factor
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ABSTRACT: The management of chronic stable angina has undergone considerable evolution over the past two decades. This review highlights the need for a comprehensive approach to management, which includes careful identification of cardiac risk factors, use of therapeutic lifestyle interventions (especially in high-risk patients with diabetes mellitus or metabolic syndrome), aggressive, multifaceted medical therapy, and the judicious use of myocardial revascularization. Traditional anti-ischemic therapy continues to comprise aspirin, beta-blockers and calcium channel blockers, along with adjunctive therapies that include statins and ACE inhibitors. Ranolazine is a novel anti-anginal and anti-ischemic agent that has promise in reducing refractory ischemia and as add-on therapy for patients who ischemia cannot be optimally controlled with standard anti-ischemic agents. The role of coronary artery bypass graft surgery and percutaneous coronary intervention (PCI) in the management of the chronic stable angina patients is discussed, as are the clinical implications of the COURAGE Trial. The combined use of both a "focal" approach (PCI to treat the culprit stenosis) and a "systemic" approach (lifestyle intervention and aggressive pharmacotherapy with comprehensive secondary prevention) may afford the best opportunity to enhance event-free survival and optimize clinical outcomes in patients with chronic coronary artery disease and stable angina.Evidence-Based Cardiology, Third Edition, 05/2010: pages 379 - 391; , ISBN: 9781444309768
Article: Apical myectomy: A new surgical technique for management of severely symptomatic patients with apical hypertrophic cardiomyopathy[Show abstract] [Hide abstract]
ABSTRACT: Apical hypertrophic cardiomyopathy is a morphologic variant in which the hypertrophy is primarily localized to the apex of the left ventricle. A subset of patients have progressive, drug-refractory diastolic heart failure with severely limiting symptoms caused by low cardiac output. Heart transplantation has been the only therapeutic option available for such patients. This study analyzes clinical and hemodynamic outcomes of a novel surgical technique to improve diastolic filling by means of left ventricular cavity enlargement. Forty-four symptomatic patients underwent apical myectomy to augment left ventricular end-diastolic volume. Myectomy was performed through an apical incision, and hypertrophic muscle was excised at the apex and midventricle. Information from a prospective database was supplemented by surveys, patient contact, and medical records. The mean age of the patients was 50 +/- 17 years, and 66% were women. All patients were severely limited with dyspnea, 61% had angina, and 59% had syncope/presyncope. Ninety-one percent of patients were in New York Heart Association class III or IV. A mean of 16 +/- 7 g of muscle was removed. Preoperative and postoperative hemodynamic catheterization (n = 14) showed a decrease in left ventricular end-diastolic pressure from 28 +/- 9 to 24 +/- 7 mm Hg (P = .002) and an increase in end-diastolic volume index from 55 +/- 17 to 68 +/- 18 mL/m(2) (P = .003). Invasive measurements of stroke volume increased from 56 +/- 17 to 63 +/- 19 mL (P = .007). Of the 42 patients who survived to hospital discharge, 41 had improvement in symptoms. Mean peak maximum oxygen consumption with exercise (n = 5) increased from 13.5 +/- 4.4 to 15.8 +/- 4.6 mL/kg per minute. Survival at 1, 3, and 5 years was 95%, 81%, and 81%, respectively. At follow-up of 2.6 +/- 3.1 years, 23 (74%) patients were in New York Heart Association class I or II. One patient underwent heart transplantation 5 years after apical myectomy. Apical myectomy improves functional status by decreasing left ventricular end-diastolic pressure, improving operative compliance, and increasing stroke volume. This procedure might be of value in other patients with hypertrophic cardiomyopathy who have severe hypertrophy and small left ventricular end-diastolic volume.The Journal of thoracic and cardiovascular surgery 03/2010; 139(3):634-40. DOI:10.1016/j.jtcvs.2009.07.079 · 3.99 Impact Factor
Article: A pilot study of electronic cardiovascular operative notes: qualitative assessment and challenges in implementation.[Show abstract] [Hide abstract]
ABSTRACT: Our objectives are to describe the contents of cardiovascular surgical operative notes and to develop and test a standards-based structured electronic operative note that might be used for secondary purposes. Operative notes were selected for patients who underwent primary, isolated coronary artery bypass grafting (n = 33); aortic valve replacement (n = 33); reoperative coronary artery bypass grafting (n = 11); or aortic valve replacement (n = 11). The content was qualitatively assessed and categorized into 3 sections, ie, technical/procedural, anatomic/physiologic description, and judgment/opinion. An electronic operative note was developed using a standards-based approach to categorize the type of operation. Average length +/- SD of the operative note was 495 +/- 186 words (range 243 to 1,267 words). The procedural category made up a mean proportion of 73% +/- 12% (range 32% to 95%). The descriptive category was the second largest category in the operative note; mean percentage 22% +/- 8% (range 5% to 43%). The dictation of the judgment portion made up 6% +/- 6% (range 0% to 25%) of the operative note. In the pilot electronic note system, 5 surgeons entered 23 procedures performed on 18 patients (14% of eligible patients). Seventeen (74%) procedures entered by surgeons were in complete agreement with the data for the Society of Thoracic Surgeons database collected by professional abstractors. Freeform dictation of cardiovascular notes varied by individual surgeon style and case complexity. Up to 25% of the operative note was dedicated to judgment/opinion, which would be difficult to recreate in a structured data-entry format. An electronic system for entering procedural details can improve efficiency for secondary purposes of data collection but must be carefully implemented to avoid loss of important information.Journal of the American College of Surgeons 02/2010; 210(2):178-84. DOI:10.1016/j.jamcollsurg.2009.10.009 · 4.45 Impact Factor
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ABSTRACT: Ebstein anomaly is a myopathy of the right ventricle that results in variable degrees of failure of delamination of the tricuspid valve leaflets from the underlying endocardium, leading to severe tricuspid valve regurgitation and some degree of right ventricular dysfunction. In neonates or infants who remain in congestive heart failure or profoundly cyanotic while receiving appropriate medical therapy, operation is required. Current strategies include biventricular or single-ventricle repair. In children and adults, medical management may be used, but most patients eventually require surgery. Tricuspid valve repair is preferred; we believe the cone repair is the most anatomic repair and is the operation of choice. Tricuspid valve replacement may be necessary in cases in which the valve is not repairable. A bidirectional cavopulmonary shunt is useful in patients with severe right ventricular dilatation and/or dysfunction. Transplantation rarely is necessary.Current Treatment Options in Cardiovascular Medicine 10/2009; 11(5):396-402. DOI:10.1007/s11936-009-0041-5
Article: The adult with congenital heart disease: medical and surgical considerations for management[Show abstract] [Hide abstract]
ABSTRACT: The purpose of the present review is to outline some of the challenges of surgical and medical management in the adult with congenital heart disease (CHD). The number of adult patients with CHD continues to grow. These patients require specialized care and there are few cardiologists and surgeons, as well as other subspecialists (e.g., anesthesia, hepatology, nephrology, etc.) with training who are comfortable in the management of this patient population. When operations on adults with CHD are performed by surgeons trained in congenital cardiac surgery, mortality rates and hospital costs are significantly lower than when performed by adult cardiac surgeons. Reoperations are frequent; peripheral vascular access may be compromised and sternal reentry is more likely to result in cardiac injury. End organ dysfunction, particularly liver and kidney, is not uncommon, further complicating perioperative care. Finally, adults with CHD may have complex psychosocial issues. A comprehensive multidisciplinary team approach can best address all of these issues. Adults with CHDs present difficult challenges in the preoperative, intraoperative, and postoperative setting. Regional centers of excellence with congenitally-trained cardiac surgeons, cardiologists, and other medical subspecialists are required to optimize outcome.Current opinion in pediatrics 08/2009; 21(5):561-4. DOI:10.1097/MOP.0b013e3283302685 · 2.74 Impact Factor
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ABSTRACT: Fibrosing mediastinitis is a rare disease characterized by an excessive fibrotic reaction in the mediastinum, which may entrap mediastinal structures including the pulmonary arteries. Our objectives were to assess the surgical strategies and outcomes of repair of pulmonary artery occlusion attributable to mediastinal fibrosis. With approval from the Mayo Clinic Institutional Review Board, we identified all patients with fibrosing mediastinitis who underwent an operation for relief of pulmonary artery obstruction between 1980 and 2008. Perioperative data were collected using medical records and late follow-up surveys. Operative procedures to bypass or reconstruct an obstructed pulmonary artery were performed in 5 patients. Patients' median age was 40 years (range, 27 to 51 years), and all patients were symptomatic and had right ventricular hypertension. In 3 patients, a double-outlet right ventricle was constructed using a valved conduit (porcine valved conduit, n = 1; aortic homograft, n = 2) from the right ventricle to the right pulmonary artery. Two patients required complete reconstruction of the pulmonary artery confluence using a pulmonary homograft in 1 patient and a hybrid technique of autologous pericardial reconstruction and intraoperative stenting in another patient. All patients had a reduction in right ventricular pressures after operation. One patient died perioperatively owing to respiratory failure; the remaining 4 patients were alive at a median follow-up of 7.4 years (range, 0.5 to 14.7 years). One patient required late balloon dilatation of the conduit and distal pulmonary arteries 10 years after initial operation, but the remaining conduits were widely patent at late follow-up. Late functional improvement was limited owing to other complications from mediastinal fibrosis or other comorbidities. Treatment of pulmonary artery occlusion attributable to mediastinal fibrosis can be challenging. Successful operative strategies include both creation of a double-outlet right ventricle and complete reconstruction of the pulmonary artery confluence. Hybrid techniques of both conduit placement and stenting should also be considered for patients with occluded pulmonary arteries.The Annals of thoracic surgery 08/2009; 88(1):233-7. DOI:10.1016/j.athoracsur.2009.04.012 · 3.65 Impact Factor
Article: Results of mitral valve annuloplasty with a standard-sized posterior band: Is measuring important?[Show abstract] [Hide abstract]
ABSTRACT: This study was undertaken to determine hemodynamic and clinical outcomes of annuloplasty with a standard-sized (63 mm) posterior band in adult patients undergoing mitral valve repair for degenerative valve disease. We studied 511 patients who underwent isolated mitral valve repair for degenerative disease with a 63-mm posterior band used for annuloplasty. Operations were performed between 1994 and 2001, and average follow-up was 4.8 +/- 3.1 years. Echocardiographic data were reviewed, with specific focus on the relationship between patient size and residual mitral regurgitation and gradient. Mean age at the time of operation was 59.3 +/- 13.5 years, and 72% were male. Body mass index was 25.8 +/- 4.1 kg/m(2), and body surface area was 1.97 +/- 0.24 m(2). Preoperative mean ejection fraction was 64% +/- 7%, and 96% of patients had severe mitral regurgitation on preoperative echocardiography. The 30-day mortality was 0.8%. At hospital discharge, the mean gradient was 4.7 +/- 3.1 mm Hg. Body surface area, body mass index, and weight were not associated with postoperative gradients or residual regurgitation at discharge. At last follow-up, 89% of patients had no or mild regurgitation, and the mean ejection fraction was 58% +/- 9%. At 5 years, survival was 95% and cumulative risk of reoperation was 3%. A standard-sized (unmeasured) posterior annuloplasty band provided excellent intermediate results with good durability. There were neither excess gradients in larger patients nor excess regurgitation in smaller patients. Measured annuloplasty is unnecessary for most adults undergoing mitral valve repair.The Journal of thoracic and cardiovascular surgery 05/2009; 138(4):886-91. DOI:10.1016/j.jtcvs.2009.01.022 · 3.99 Impact Factor
Article: Indexed Left Ventricular Dimensions Best Predict Survival After Aortic Valve Replacement in Patients With Aortic Valve Regurgitation[Show abstract] [Hide abstract]
ABSTRACT: Indications for valve replacement in patients with aortic regurgitation include diminished ejection fraction and increased left ventricular dimensions. Our objective was to examine the effect of preoperative ejection fraction and left ventricular dimensions on survival and return of normal systolic function (ejection fraction > or = 0.50) after valve replacement for aortic regurgitation. Between 1996 and 2006, 301 patients had aortic valve replacement for moderate or greater chronic aortic regurgitation, and 29% had concomitant replacement of the ascending aorta. We reviewed clinical and echocardiographic variables as well as late vital status. Patients' mean age was 55.2 +/- 16.5 years, and 78% were male. The mean preoperative ejection fraction was 0.56 +/- 0.12, the mean left ventricular end-systolic dimension was 43 +/- 10 mm, and the mean left ventricular end-diastolic dimension was 63 +/- 9 mm. Operative mortality was 1.7%, and survival at 1, 5, and 10 years was 96%, 90%, and 77%, respectively. This was similar to an age- and sex-matched population (p = 0.214). The level of ejection fraction preoperatively did not predict late survival, nor did absolute values for left ventricular end-systolic dimension and end-diastolic dimension. Indexed left ventricular end-systolic dimension and end-diastolic dimension were predictors (p < 0.01) of late survival. Data from late echocardiography were available for 159 patients (56%) at a mean follow-up of 3.3 +/- 2.6 years. Preoperative ejection fraction, left ventricular end-systolic dimension, indexed end-systolic dimension, end-diastolic dimension, and indexed end-diastolic dimension were univariately predictive of late ejection fraction. In a multivariate model the only predictor of late normal ejection fraction was a higher preoperative ejection fraction (odds ratio, 2.85; p < 0.001). In patients who received a valve replacement for aortic regurgitation, decreased ejection fraction and increased left ventricular dimensions were not associated with late mortality. However, larger indexed left ventricular systolic and diastolic dimensions were associated with late mortality. Preservation of late ejection fraction is best if the operation is performed in patients with near normal preoperative left ventricular function.The Annals of thoracic surgery 05/2009; 87(4):1170-5; discussion 1175-6. DOI:10.1016/j.athoracsur.2008.12.086 · 3.65 Impact Factor
Article: Ministernotomy versus conventional sternotomy for aortic valve replacement: A systematic review and meta-analysis[Show abstract] [Hide abstract]
ABSTRACT: Most aortic valve replacements are by conventional full median sternotomy. Less invasive approaches have been developed with partial upper sternotomy (ministernotomy). Systematic review and meta-analysis were performed with studies comparing ministernotomy and full sternotomy for aortic valve replacement. Twenty-six studies were selected, with 4586 patients with aortic valve replacement (2054 ministernotomy, 2532 full sternotomy). There was no difference in mortality (odds ratio 0.71, 95% confidence interval 0.49-1.02). Ministernotomy had longer crossclamp and bypass times (weighted mean difference 7.90 minutes, 95% confidence interval 3.50-10.29 minutes, and 11.46 minutes, 95% confidence interval 5.26-17.65 minutes, respectively). Both intensive care unit and hospital stays were shorter with ministernotomy (weighted mean difference -0.46 days, 95% confidence interval -0.72 to -0.20 days, and -0.91 days, 95% confidence interval -1.45 to -0.37 days, respectively). Ministernotomy had shorter ventilation time and less blood loss within 24 hours (weighted mean difference -2.1 hours, 95% confidence interval -2.95 to -1.30 hours, and -79 mL, 95% confidence interval -23 to 136 mL, respectively). Randomized studies tended to demonstrate no difference between ministernotomy and full sternotomy. Rate of conversion from partial to conventional sternotomy was 3.0% (95% confidence interval 1.8%-.4%). Ministernotomy can be performed safely for aortic valve replacement, without increased risk of death or other major complication; however, few objective advantages have been shown. Surgeons must conduct well-designed, prospective studies of relevant, consistent clinical outcomes to determine the role of ministernotomy in cardiac surgery.The Journal of thoracic and cardiovascular surgery 04/2009; 137(3):670-679.e5. DOI:10.1016/j.jtcvs.2008.08.010 · 3.99 Impact Factor
Top Journals
Mayo Clinic - Rochester
Рочестер, Minnesota, United States
- Department of Cardiovascular Surgery
University of Alberta
Edmonton, Alberta, Canada
- Department of Anesthesiology and Pain Medicine
McMaster University
Hamilton, Ontario, Canada
- Faculty of Health Sciences
Mayo Foundation for Medical Education and Research
Рочестер, Michigan, United States
- Division of Vascular Surgery


text:
Hey, I've seen posts about people with their reds room, I just finished up my Bengals/Buckeyes/Reds room, and added pics for all of it, since I figured a lot of people around here are Bengals, and Buckeyes fans as well. :D
Printable View
Hey, I've seen posts about people with their reds room, I just finished up my Bengals/Buckeyes/Reds room, and added pics for all of it, since I figured a lot of people around here are Bengals, and Buckeyes fans as well. :D
Nice autographed items you got there. The family room at my house is our "Reds Room." I will try to upload some pics to share too.
I think it looks great apart from all that football stuff! ;)
Pretty coll MRoby, you ahve shared some pics with em before, but looks good finished! You have an easier route then I do, finding a color to use as main color, when I do my room (soon :pray:) I will have my Reds stuff, and my UNC stuff, trying to decide what color to paint the room that goes with red and Carolina Blue......
Real nice. I also love Troy Smith :thumbup:
Naturally I like the Bruce pic!
Dude, you need more Reds stuff in that room, I feel like Ohio State and the Bengals? are taking precendent over the beloved Reds!
But then again the Reds are my favorite on my totem pole of favorite teams.
1. Reds
2. WV Mountaineer Football
3. NASCAR-I don't have a driver since #3 passed away, but i still love the sport
4. WV Basketball-and I HATE basketball!
5. Bengals-only because they were my favorite growing up, now I basically flip back and forth on my direct ticket and cheer for whose on my fantasy team, so I could really care less if the Bengals win or lose! :thumbup:
^thats a hard call, I was a Reds fan early on in life, think I was a UNC fan before anything; but then I also have pics of me as a small, small kid in Steelers gear, so not sure who is 1 in my heart overall. I love baseball the most, so the Reds win out for me there, but then again, I live in CH and know some of those guys, have access to more UNC stuff so my collection def is stacked there, and not bandwagoning by any means, but they have had more recent success which can def be more fun to follow. So, guess I would go:
Reds 1A
UNC anything 1AA,
Steelers 3. Dont really have any favs after that....
Speaking of OSU, there is a thread on another board making fun of this guy :)
Nice! I need some Reds stuff for my friends bar. One of these days....

subset: commoncrawl


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#ifsherlockhadgoogleglass was off to an early lead with four correct answers at the one hour mark in the Tech Search Party. But when the clock had finally run its course two hours from the moment the scavenger hunt had begun, it was the Immersion Mamas who won the annual fundraising competition. The real winners, however, were the technology programs in three schools in San Francisco that would split the $15,000-plus raised.
The Tech Search Party was one parent's idea for generating the money his kids' schools needed to get their hands on technology. But it's not the only way that people are raising the funds they need to buy new gear and training to add technology into the classroom. A teacher in Oregon used crowdfunding site DonorsChoose to generate some of the funding she needed to bring Chromebooks into her fourth grade; and a seventh grade English teacher in Memphis used PledgeCents, a lesser known crowdfunding site, to raise the money to buy a new classroom projector.
In each case the district couldn't provide the technology budget needed for these acquisitions, so individuals took on the job of doing it themselves. The lesson they've all learned: If they can do it, the rest of us can too.


text:
Pitfalls and how to avoid them
This simple concept has several barriers to implementation. You can overcome them by being aware of the most common mistakes.
- Confusing motion with results: All too frequently, I see companies busy with Do, a loosely defined Plan that doesn't clearly articulate the underlying assumptions, and virtually no Check. In those businesses Act/Adjust is just react – often with poor results and little knowledge gained.
- Lack of discipline in follow up: Just because you believe it's true doesn't mean it is. Similarly, just because you assigned someone a task doesn't mean they executed it when, where, and how you expected. Fight the urge to check actions off a list and move on. Schedule the Check step when the Plan is defined, and then follow up at that appointed time.
- Aversion to details: Yes, they can be messy, but in that muck is where learning occurs. Generic targets like "improve" have no meaning. "Reducing the scrap rate at Machine #1 from 50 parts per day to 10 parts per day within 2 weeks after implementing our plan" does have meaning. You either did or you didn't. Assuming you didn't, let's figure out which assumption was wrong.
- Reluctance to admit ignorance: If you or your employees are too smart to learn, your business will never be better than it is today.
Why should every business integrate PDCA into its management process?
- It facilitates learning.
- It keeps you moving forward.
What makes it hard?
- It takes discipline at every step.
- It requires clearly articulating assumptions and asking good questions.
Pick any challenge you are working on, and follow this process. It will work well — if you let it.
Owners of manufacturing businesses ranging in size from $20 million to $1 billion value the advice of operations strategist Becky Morgan and her Finish Strong thinking. With 14 years experience working in corporations and more than 23 years consulting with manufacturers, Morgan has contributed to the success of aerospace, food, machining, assembly, electronics, tool and die, jewelry, and process industry businesses. Morgan presents workshops and frequently speaks with audiences from 35-150 attendees.


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Shaw Stainless carries a large inventory of Threaded Stainless Steel Pipe Crosses in 304 stainless steel and 316 stainless steel. We are experts in Threaded and Socket Weld Pipe Crosses and carry high-quality stainless steel pipe products that perform across many industries. Contact one of our stainless steel fittings expert to help you select the right Threaded Pipe Cross for your application needs.


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You can now invite anyone to meet at your favorite Starbucks.
Limited-time feature
33 year old woman | Arlington, VA, USA | Seeking men 30-44 within 30 miles
Let your freak flag fly!
I grew up a military brat so I've lived in places from Italy to Hawaii. I love the beach but was spoiled by the clear waters of Hawaii and don't find the East Coast beaches so pleasing. I have lived in Virginia since I was 15, went to college at Virginia Tech (Go Hokies!), moved to Key West for 8 months, then back here to northern VA. I love animals. I have a horse, dog, and a cat. I also foster dogs from time to time for a local rescue league. I love taking a dog out of a shelter and finding a good home and knowing I saved the dogs life. My friends would describe me as very sweet and down to earth. I like helping people out. I have a sarcastic sense of humor. Love to go out and dine but also love staying in. I wear my heart on my sleeve. Don't know what else to say. Contact me and hopefully we can hit it off!
Camping , Coffee and conversation , Business networking , Cooking , Dining out , Fishing/Hunting , Movies/Videos , Music and concerts , Nightclubs/Dancing , Playing sports , Volunteering , Watching sports , Wine tasting
Billiards / Pool, Cycling, Dancing, Swimming, Walking / Hiking, Yoga
I exercise 1-2 times per week.
I have Cats, Dogs, Horses
Middle of the Road
When I go out, I like going to either Clarendon, Adams Morgan, or Georgetown.
Virginia Polytechnic Institute and State University, Blacksburg, VA
Modern Family. Stupid reality shows. favorite color: blue. Chocolate. Dogs. Horses. Pedicures. Snow crab legs. Grey Goose and Club Soda with Lime. Movies like Wedding Crashers. People magazine. Scotch on the rocks.
I like to mingle with friends, trail ride, spend time with my dog, meet new people, travel...
Last thing I read was "Are You There Vodka? It's Me, Chelsea"
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What she is looking for
|5'8" (172cms)
|5'9" (175cms) to 6'5" (195cms)
|Body type:
|About average
|No preference
|No preference
|No preference
|No Way
|No Way
|Social Drinker
|No preference
|Administrative / Secretarial
|No preference
|I'll tell you later
|No preference
|Never Married
|No preference
|Have kids:
|No preference
|Wants kids:
|Definitely, Someday
|White / Caucasian
|No preference
|Christian / Other
|No preference
|No preference
|Bachelors degree
|No preference
I graduated from Virginia Tech in 2004 with a degree in sociology and a minor in equine studies


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Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
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16 Guidebook for Conducting Airport User Surveys Table 2-1. Advantages and disadvantages of each survey method. Survey Method Advantages Disadvantages Intercept Interviews � High data quality � High cost � High response rate � Allows for complex surveys Mail-back and Hand-back Intercept, � Lower cost than intercept � Lower response and data quality and Mail � Useful for short and simple than intercept surveys � Slow for mail and mail-back surveys Internet � Low cost � Low response rate � Automated data processing � Requires access to the Internet � Limited complexity Telephone � Allows representative sample of � Moderately high cost and time to large and dispersed populations implement survey such as business firms 2.3 Survey Frequency and Timing 2.3.1 Dealing with Seasonality Several aspects related to timing and frequency need to be considered in planning an airport user survey project. The pattern of air travel at most airports varies seasonally. Performing a pas- senger survey at only one time of the year will not reflect the variation in traveler characteristics and thus may give a biased picture of the composition of the air travel market over the year. On the other hand, if data on air traveler characteristics are needed for planning airport facilities for their peak use, then the survey should be performed during the peak demand period. While it is common practice to design airport terminal facilities for the average day of the peak month, some thought should be given to likely conditions during other peak periods, and it may be desir- able to collect passenger survey data at those times as well. The highest hourly demand on air- port facilities may not in fact occur during the busiest month, but rather may take place around holiday weekends at other times of the year, such as Thanksgiving. Seasonal changes in the composition of the air travel market can have a particular influence on airport ground transportation mode use. Figure 2-1 shows the monthly variation in use of short- term and long-term parking at Los Angeles International Airport over a two-year period in the early 1990s, expressed as parking exits per hundred passengers (Gosling, 1996). Use of short-term park- ing varies inversely with use of long-term parking: Short-term parking use is highest in the summer and in December and January, both times associated with higher levels of non-business travel. Long- term parking use is highest in the spring and fall, months with generally higher levels of business travel. Similar seasonal patterns have been observed at other airports and for other ground access modes. It is clear from Figure 2-1 that depending on the month in which an air passenger survey is performed, the use of airport parking indicated by the survey results would differ considerably. It should be noted that the monthly volume of passenger traffic through the airport and the com- position of the traffic are really two different issues, as illustrated in Figure 2-1, which has been adjusted for the variation in air passenger traffic. One approach to accounting for seasonal varia- tion in calculating the market composition for the year as a whole is to use a weighted average of results obtained during two survey periods, in a peak traffic month and an off-peak traffic month. While the market composition during the peak traffic month is usually different from that during the off-peak months, in fact the composition is likely to vary throughout the year. The market com- position for the year as a whole will generally be different from that given by the weighted average of results obtained during a peak traffic month and any one off-peak traffic month.
OCR for page 16
Planning a Survey 17 14 Parking Exits per Hundred Passengers 12 10 Short-Term Parking (up to 6 hrs) 1993 Long Term 8 1994 Long Term 6 1993 Short Term 1994 Short Term 4 Long-Term Parking (over 6 hrs) 2 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Source: Adapted from Gosling, 1996. Figure 2-1. Variation in parking use--Los Angeles International Airport. A number of methods can be used to deal with seasonality: � If the attributes being measured are for use in assessing facility requirements and capacity constraints, values of these attributes during the peak planning period may be of interest; if so, conduct the survey during this period. � Conduct the survey in a shoulder month that is considered to be the most representative of average traffic over the year. � Conduct the survey in several waves, such as each quarter, each month, or during peak and off-peak months. � Use continuous or rolling surveys conducted throughout the year to allow the seasonal vari- ation to be measured directly. The use of continuous or rolling surveys has a number of advantages besides providing good information on seasonal variation of market composition. These advantages include the need for far fewer survey personnel, who in consequence can be better trained and will become more expe- rienced, improving the quality of the survey results. This approach also makes the survey results far less vulnerable to distortion from atypical events that happen to occur during a survey con- ducted over a much shorter period, such as unusually bad (or good) weather, major sporting events, or labor unrest. A survey performed on an ongoing basis from year to year will also provide some early indication of trends in market composition that might be missed (or misinterpreted) if surveys are conducted only periodically. The continuous survey approach has been adopted by the United Kingdom Civil Aviation Authority (UK CAA) for its program of air passenger surveys undertaken at the 14 largest U.K. airports (UK CAA, 2006). The survey teams spend several days at each airport before moving on to another airport, returning to each airport every few weeks. 2.3.2 Multi-Year Considerations In addition to accounting for seasonal changes, a related consideration is how often airport user surveys need to be performed to identify changes in market composition that are occurring


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Leather Dream Catcher Group Craft Kits—25-PackOriginal Price:$39.99 Current Price: $34.994-6 Weeks. Shipped direct from Supplier.Pack provides 25 fully-equipped craft kits, each with everything needed to create an American Heritage-style dream catcher. Each kit includes pre-wrapped 3" hoop, feathers, and string. Made in the USA. Drop-shipped from New Albany, Indiana; please allow 3 weeks for delivery. Learn More
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Tanning in Spain
... up, we got ready for our last fancy dinner on the ship at a steakhouse called Cagney's. We each had lobster and shrimp as well as dessert that neither one of us could finish.
In order to have our luggage carried out of the cruise for us, we had to have had it packed and ready by midnight. Obviously, since we're never on time for anything, we didn't make the deadline. The few glasses of wine we each had probably didn't ...
La Rapita
A quick overnight stop and out for dinner before heading off to Alicante early next morning to get Mark to the airport. Very impressed with local sailing clubs as marina and bay full with 100's of youth sailers all competing in regattas. Out of season once again and choices of eating restaurants very limited but mooring very ...
Bonafacia and off we go
A lazy start as we need to leave about midday to ensure we arrive in Minorca in day light on Saturday so we head up to the old town. Obviously this can't be done without a beer at the top and bottom as it's hard work says Mark! Photos say it all but most amazing how the little ...
Stephen! Beach! Paella!
... of delicious cervezas while at the seaside with family – really can't beat it!
It was lovely to spend a day by the sea with Stephen and see Porto Cristo on the east coast of the island – fun and relaxing from beginning to end. Stephen's flat is right by the beach (beautiful and sandy) and we enjoyed lazing around for most of the day. Susan treated us all to a humongous Spanish lunch in a ...
Vall de mort?
... and behave at all of them. At this point he was ready to just swim and play and splash in the salt water. Marc and Alex went in too and all had fun, despite Alex's objections otherwise. Oh, teenagers.
Next stop, way up in the mountains, after many, many winding roads, was Lluc - a monastery with very pretty grounds, and a gorgeous old church. It was dinnertime by the time we left and started winding back down the mountains, ...


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Dear Editor:
After having read Mike Menders article in your papers Saturday, Sept. 1, edition, I take exception to his classification of people. It appears he has met some apparent rude people with different accents, and different color license plates, (well Mike havent we all) and because of this he has classified, if not all the people, then the majority of the people from New Jersey by his statement of people from that part of the world.
Well Mike I beg to differ with you. I have had the good fortune to have traveled to all fifty of the United States with my wife and children and have found a little bit of what you have described in your article of rudeness but mostly the people in America are friendly and courteous. I was born and raised in New Jersey and choose to continue to live there because its a wonderful State with wonderful people. I also choose to have a second home in the New York Adirondacks because of all the states I have visited this was one of the most beautiful. Although I also have put up with an occasional bad NY driver, and an occasional person in a rush at the checkout line, or counter of local store, I find the people in New York to be very friendly and helpful.
You know, Mike, if you took the time to read your own article you would have realized that your car, as well as the other out of state vehicles, were part of the problem of the traffic jam, not part of the solution, just as my vehicle is part of the problem when I travel to your roads while visiting or touring. I also believe everyone in the New York, New Jersey, and every other state for that matter, knows that the roads are more congested on Sunday nights from people returning home from traveling, especially during the summer months.
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I'm trying my best to not give up BF, but I'm in so much pain I'm not sure how much longer I can hang on. When DS first starts nursing it is pure hell...I'm talking tears streaming down my face and cursing and sobbing....after a few min. the pain subsides. I saw a LC in the hospital and was told I was doing everything correctly and he was latching well, so I don't know what is causing this pain. Any ideas, suggestions?? He is only 2 weeks old and I know how important this is for him, but I am in agony. Help me please ladies!!
I'm trying so hard...
In love with my sweet boy who arrived on 9/11/09 and looking forward to meeting my next sweet babe due 4/29/11!!!
so i am a ftm but i would suggest seeing a lc again just to make sure. i saw one in the hospital too and she said baby and i were doing well but i went back this week and she showed me some improvements. couldn't hurt. sorry you are in so much pain!
k, mom to pc (9.17.09), zr (10.05.11), and ae (5.8.13)
i would say the same i was doing great at hospital got home & would scream so i went back & had them help me again now its nice when she latches
yeah, everything with me was great for the first 3 days... then the pain came, it felt like someone was stabbing my nipples with needles. My neighbor brought me some lanolin nipple cream (itssafe for ingestion). If I apply after each feeding it makes my life so much more pleasant... when I stop applying the pain returns - I highly reccomend it
Happily married to my long haired hippie. I have kids. My house is a wreck.
Lanolin is heaven sent for sure. I think if it's just the first few minutes of nursing that it isn't really the latch. It's that your nipples aren't tough yet. I nursed my first DS for 26 months, so my nipples are tough. With my new DS I don't feel any pain at all, so it's all about those nipples. I would apply the Lanolin before and after you BF and hope that your nipples toughen up soon! You are doing great mama. :)
SAHM and Wife to Cory
Mom to Hunter - May 2, 2007 and Landon - Sept 21, 2009
I have been using the Lansinoh lanolin every time. It's not the outside skin that bothers me, it is "inside" the nipple that hurts so much. I'm seeing thrush come up in a lot of internet searches for nipple pain...does anyone know anything about thrush or experienced it? I am going to take your advice and call the LC. Thank you all for your suggestions and help!
In love with my sweet boy who arrived on 9/11/09 and looking forward to meeting my next sweet babe due 4/29/11!!!
Last week I was dealign with teh pain during initial letdown as well. Now I only have an issue if he's latched wrong. It could very well be your nipples just getting used ot things. Talk to a LC again, and if they say everything is fine, the only thing I can think of it the nipples are just neding to get used to it.
Stephanie, mom to 3 boys and 1 little girl!
Studio Out Back, LLC Facebook
Ok this happened to a friend of mine and the first question i asked her is... Have u ever had ur nipples pierced or had a breast augmentation? I ask because the scar tissue from both can cause extreme pain during breast feeding
Megan married to my soldier and soulmate!Jason 8-1-09
Mommy to MaxGabriel 5-16-00, Connor Evan 8-18-09, & Baby girl, Isla Grace 6-6-14!
Hang in there! My son is 3w1d and it still hurts for me too (though probably not as extreme)- latch on and let down. I definitely suggest getting the advice of another LC or two if need be. Try different feeding positions as well. It's not my experience that the Lansinoh stops the pain, but it does help out a lot.
Your baby thanks you for your sacrifice! God bless!
Mom to dd Haddiyah - 8, ds Najee - 4, and new ds Rayhan - born 9/3/9
Blessed and highly favored!!!
I agree with the PPs - your nipples are toughening up. LANOLIN LANOLIN LANOLIN, before and afrter every feeding, it helps immensely! Good luck and hang in there!
mom to Esther, born 9/01/09, and Iris due 6/18/12
I had a good recommendation from an LC, may be difficult logistically, get some sun and fresh air on your nipples at least once a day for 10 minutes. Works well for diaper rash, too!
laugh it up, fuzzball


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Privacy and Cookies
civil aviation should not rely on the Global Positioning System (GPS) as a
sole-source means of navigation, a long-awaited report from the Department of
Transportation's Volpe research center concludes.
Volpe National Transportation Systems Center in Cambridge, Massachusetts was
asked by the President's Commission on Critical Infrastructure Protection in
October 1997 to assess the implications of GPS signal interference and
disruption for civilian users.
commission also asked Volpe to assess how GPS signal vulnerability should
affect federal decisions on the mix of radionavigation systems and the final
architecture for the modernization of the US National Airspace System (NAS).
GPS system cannot serve as a sole source for position location or precision
timing for certain critical applications," it states.
for positioning and precision timing are necessary for all GPS applications
involving the potential for life-threatening situations or major economic or
environmental impacts.
backup options involve some combination of: 1) terrestrial or space-based
navigation and precision timing systems; 2) onboard vehicle/vessel systems; and
3) operating procedures. Precision timing backups including cesium clocks or
Loran-C for long-term equivalent performance, or rubidium or quartz clocks."
Volpe Center presented its original draft to the DOT back in the summer of
2000, but the DOT has kept a tight lid on its contents until now. In recent
months accusations have flown from high-profile critics such as former FAA
Administrator Langhorne Bond – a skeptic of GPS sole-source navigation – that
the DOT and FAA were covering up the report.
a recent speech to an Air Traffic Control Association conference in Dublin,
Bond publicly repeated rumors the two agencies were trying to pressure the
Volpe Center to redraft portions that would question the FAA's safety oversight
of the Volpe report was said to call into question the FAA's entire research
and development and capital spending effort on new radionavigation systems,
aimed as they are at relying exclusively on GPS for their positional signals.
in the report's executive summary the only possible indication that the Volpe
Center might have come under pressure from the DOT and FAA to change its draft
comes in the recommendation that maintenance of safety when GPS is lost "may
not necessarily require a backup system for every application".
a GPS backup will involve considerable government and user expense", it notes,
adding: "The transportation community [should] determine the level of risk of
each critical application is exposed to [and] what level of risk each application
can accept", as well as the associated costs.
report finds that even when the GPS signal is augmented by systems such as the
local area augmentation system (LAAS), "use of GPS can still be disrupted and
transportation services thus impaired".
can be avoided "by awareness, planning and supplementing GPS with a backup
system or operational procedures when it is used in critical applications",
which the report describes as those "in which the consequences of GPS loss
could be catastrophic without ensuring that mitigating options are available".
addition to being "susceptible to unintentional disruptions", the report warns:
"The GPS signal is subject to degradation and loss through attacks by hostile
interests." Potential attacks "cover the range from jamming and spoofing
(falsifying) of GPS signals to disruption of GPS ground stations and
a result, the Volpe Center recommends the DOT "encourage the development of
affordable vehicle-based backups such as GPS/inertial receivers, and, in the
event Loran-C becomes a viable backup to GPS, aviation-certifiable Loran-C
receivers and GPS/Loran-C receivers".
"all GPS receivers in critical applications must provide a timely warning when
GPS positioning and timing signals are degraded or lost". The FAA should
conduct "a comprehensive analysis of GPS backup navigation and precise timing
options including VOR/DME, ILS, Loran-C, inertial navigation systems and
operating procedures".
recommends the FAA and US Coast Guard continue their modernization program for
Loran-C – a system the FAA had hoped to abandon – until it is determined
whether Loran-C can have a role as a GPS backup system. If the FAA finds that
it does, the agency should promptly say so publicly "to encourage the
electronics manufacturing community to develop new Loran-C technologies".


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29 year old man | Boulder, CO, USA | Seeking women 25-32 within 50 miles
I'm an awesome guy, I'm the best singer in my...
I'm an awesome guy, I'm the best singer in my car and I'm willing to lie about how we met. That said, I'm relaxed, but not apathetic. funny, awesomely down to earth and non-judgmental. I'm smart and centered and I have an incredibly strong will. I'm happy with a steady and stable life but I love to be impressed. I'm quick to laugh when the occasion calls for it and I love finding humor in mundane situations. I'm a mountain man born and bred in the hills above Boulder, Colo. and I'd love to get to know you. My ideal woman is creative but not delusional, smart, fun, and laid back. I'd prefer a woman who has a good heart and a good head on her shoulders, who's kind above all and who knows who she is and lives a genuine gentle life. If you think we'd get along, I'd love to hear from you.
Book club , Camping , Coffee and conversation , Cooking , Dining out , Hobbies and crafts , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Performing arts , Playing cards , Playing sports , Travel/Sightseeing , Watching sports
Billiards / Pool, Football, Other types of exercise, Swimming, Walking / Hiking, Weights / Machines
I exercise 3-4 times per week.
I like Dogs
I have a Labrador/Australian shepherd mix and a bloodhound.
Half Moon Bay, Santa Barbara, The Haight, Estes Park - The Rock Inn, The Fox Theatre, Eye Opener Coffee, Burnt Toast Cafe
University of Colorado at Boulder, Boulder, CO
Music - Blues, Hip Hop, Dubstep/Electro, Classic Rock Books - Short stories, new authors, compelling nonfiction
Live Music, Art Museums, Open Mics, Dinner and Drinks, Photography, Writing
Solitude by Robert Kull
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What he is looking for
|5'11" (180cms)
|5'0" (152cms) to 6'0" (182cms)
|Body type:
|A few extra pounds
|About average, Curvy, Athletic and toned, Full-figured, Heavyset, A few extra pounds
|No preference
|Dark blonde
|No preference
|I'll tell you later
|No preference
|Social Drinker
|Never, Social Drinker, Moderately
|Artistic / Creative / Performance
|Administrative / Secretarial, Artistic / Creative / Performance, Financial / Accounting / Real Estate, Legal, Medical / Dental / Veterinary / Fitness, Retail / Food services, Sales / Marketing, Self-Employed / Entrepreneur, Student, Education / Teacher / Professor, Travel / Hospitality / Transportation, Other profession, Nonprofit / Volunteer / Activist, Fashion / Model / Beauty, Architecture / Interior design
|I'll tell you later
|No preference
|Never Married
|Never Married
|Have kids:
|Wants kids:
|Definitely, Someday, Not sure, Probably not, No
|White / Caucasian
|No preference
I'm a mutt, Norwegian, Irish and probably some other stuff thrown in there.
|Agnostic, Atheist, Buddhist / Taoist, Christian / Protestant, Spiritual but not religious
|English, Spanish
|I'll tell you later
|Some college, Associates degree, Bachelors degree, Graduate degree, PhD / Post Doctoral


text:
Sporty Cars With Good Gas Mileage
List Criteria: Sporty cars that get above 25 mpg
Sporty cars with good gas mileage are the best of both worlds for people who want to drive a flashy car that also gets good mileage. Click on any car name to learn pricing and get more information! This user-voted gallery and list of sports cars with good gas mileage is based on MPG results provided by Consumer Reports. What are some fast cars with good gas mileage? This list includes cars like the Mazda Miata Grand Touring (MX-5), which gets 28 miles per gallon, and the awesome Lotus Elise, which gets a whopping 30 mpg. This list focuses primarily on small sporty cars and roadsters, from the Fiat 500 to the Honda Civic Si. While sporty cars tend to focus on horsepower and handling over fuel efficiency, these automobiles give you the best of both worlds. With light-weight bodies and clever engineering, these most fuel efficient sports cars will give you better miles per gallon than many hybrids on the road.
What sports cars have good gas mileage? What sporty cars have the best MPG? The MPG ratings found on this list are for "overall" fuel efficiency, as opposed to "highway" vs. "city". The cars on this list were also all equipped with a manual transmission during testing. Sporty cars are fun, no doubt about it. These cool cars with good MPG allow you to keep your fun, and also protect your wallet. Check out this list of the cheapest cars to insure for more details.
Source: Consumer Reports
- Tip: Navigate with your { left and right } arrow keys1+ 163- 5530 mpgl< << PREV 1 of 13 NEXT >>


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Update on iPad Academic Use
How I am using the iPad after about 8 months~
I have found that using the iPad has been good for research. I tend to queue up articles that I need to read in a dropbox folder that I have access to through a dropbox app. When I am at swim practice with my daughter, when […]


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News, trends and ideas we're tracking today.
Posts filtered on Category
36 pit bulls seized
Animal Care Services confiscated 36 pit bulls and two poodles Thursday in South Bexar County, saying the pit bulls might've been used for dog fighting. Officers at the Medina River Natural Area notified ACS after spotting the dogs at a property on Fest Road, KENS-TV says. One person was arrested. The dogs were taken to […] [Read More]
Live grenade found in N.E. Side home
A Northeast Side man helping a widow sort through her husband's belongings Thursday evening found what appeared to be a live grenade, KSAT-TV says. Jim Gardon said he initially planned to take the grenade down the street to Fort Sam Houston, but had a change of heart about a block away. "I figured it probably […] [Read More]
Toddler plunges from second-story window
A 3-year-old West Side boy was hospitalized Thursday after falling out of an apartment window, KSAT-TV reports. Jennifer Carrillo, who lives at the Las Palmas Garden Apartments off Castroville Road, told KSAT that when she saw the neighbor boy fall out of the second-story window, her heart dropped. "It was scary," Carrillo said. "I was […] [Read More]
Grandma dragged from car by cop
A North Texas police department is standing by an officer who dragged a 77-year-old grandmother out of her car after he stopped her for speeding and she repeatedly refused to give him her driver's license, NBCDFW.com reports The entire arrest was caught on video. Lynn Bedford of Cleburne was stopped in Keene on Aug. 19 […] [Read More]
Body confirmed as missing Austin woman
Police have confirmed a body found this week in South Texas is that of an Austin woman reported missing Sunday, KVUE-TV says. The body of Sarah Pettit, 31, was found in the back seat of her car in Gonzales, 70 miles east of San Antonio. Autopsy and toxicology reports are pending, but Austin police say […] [Read More]
Nephew accused of pawning ex-Spur's rings
A nephew of former Spurs point guard Johnny Moore is accused of stealing two NBA championship rings and a University of Texas ring and pawning them, KENS-TV reports. Jason Witherspoon, 34, was arrested Wednesday, charged with theft between $20,000 and $100,000, and freed on bail. Police said Moore had let his nephew stay with him […] [Read More]
Instead of TV, man gets jacked
A man who thought he getting a good deal on a television ended up losing his car instead, WOAI-TV says. Police said the man drove to Theo and Malone avenues Wednesday evening to meet with people selling a television. He told police that when he got there, the people pulled a gun on him and […] [Read More]
Is serial robber on the loose?
Police believe the same man tried to rob three San Antonio stores last night, WOAI-TV says. Driving a green Chevrolet Blazer, he first robbed a Valero gas station on Potranco Road about 10 p.m., getting away with about $30, police said. He then tried to rob a Wal-Mart off West Military Drive, police said, but […] [Read More]
Homeowner watches burglary live on computer
While sitting at his work computer last week, a Floresville homeowner got an alert from his home security system that someone was in the house, he told KENS-TV. He then watched as his house was burglarized by two men. Wilson County deputies were dispatched to the home, but the burglars were gone by the time they arrived. Wilson […] [Read More]
Crash clogging I-10
A wreck on Intertstate 10 near Woodlawn Drive is backing up traffic significantly. Traffic is stalled for miles on I-10, and the ramps from Loop 410 to eastbound I-10 are clogged as well. The crash doesn't appear to have caused any life-threatening injuries. Watch mySA.com for more. — Ana Ley Click her for traffic map, gas […] [Read More]
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Posts tagged content marketing
We create content and content also creates us
May 15th
Recently I was interviewed by my friend Elizabeth Sosnow and she asked me about an observation in Return On Influence: "We create content … but in a way, content is also creating us."
It had been a long time since I thought about this and I thought it was timely to reflect on this powerful concept. I think my friend Jason Falls put it very well when he stated in the book:
"Before the social web, there was always a ceiling or a velvet rope – a limit to where you could go with your influence unless you were somebody famous. Now anybody can be heard. Social media and the Internet makes it possible for every person to be published, find an audience, and become influential."
Let's face it, most of the people making an impact on the social web today would not have been heard from even a few years ago, including me. Yes, I create content. But as you see, content is also creating me.
A few months ago, I was cornered at a conference by a lady who kept telling me, "You're a rockstar! You're a rockstar!" I realize that "celebrity" is something that exists in a person's head and there is nothing I can do about it, but this kind of stuff makes me very uncomfortable. I'm no rockstar, trust me. This is a perception … a creation … manufactured entirely by what I publish.
And while I am occasionally unnerved by both the positive and negative extremes of fandom, I realize how very fortunate I am to live in a time when my voice can be heard and I can truly have an impact on a global audience.
And you know what? You can have an impact, too.
If you're not using this amazing, historic opportunity to publish, you're missing out on one of the greatest technological gifts of our generation. Free publishing tools. Access to the world. The ability to connect with people nearly anywhere.
If you're not a decent writer, try video blogs. If you don't like video, start a podcast. If you don't want to commit to podcasts, how about slide presentations on Slideshare, or even photographs on Instagram?
This is Jason's time because he found blogging and committed to it. This is my time because I have the courage to create conversational content.
If you haven't become a content creator, what are you waiting for? This is your time too! What are you going to do about it?
Five ways using "controversy" as a content strategy backfires
Apr 30th
I recently listened in on a webinar where a young guy was pontificating on the best strategies to build an audience for your content. A pillar of his presentation was "be controversial."
This struck me as odd. Is "controversy" really a sustainable position for a content marketing strategy? The more I thought about this, the more I disliked this advice.
First, let me distinguish content that is "conversational" or "thought-provoking" from content that is controversial. A definition of controversial is "a state of prolonged, contentious public dispute or debate." The keywords here for me are "prolonged," "contentious, and "public."
Sometimes controversy happens. Occasionally, it might even be unavoidable. But is this a tactic you should mindfully pursue as a long-term content strategy? Let's take a look at five reasons why the answer is NO.
1) It is naive.
I have this image in my head. I walk into my boss and I say, "Hey, I just attended this webinar and I'm convinced that we need to be more controversial to be build our company's blog audience."
What do you think the reaction would be?
Can you think of any respected, successful company that pursues a prolonged dispute as a social media marketing strategy? Of course not. Companies are built to avoid controversy. Most brands are not built on a negative emotion.
2) It is exhausting.
Have you ever been in the middle of an online controversy? Nothing can suck up more time and energy from your day. Do you really want a strategy with that impact on productivity?
3) It is not sustainable.
Reading "contentious" content is like watching a train wreck. In short doses, it might be gruesomely compelling, but it is not something you want to expose yourself to every day.
Study after study shows that positive, uplifting content gets more views and clicks over time. Who wants a steady diet of prolonged disputes?
4) It drives the "wrong" traffic.
Let's say you're the playground bully. Every time you start a fight, a crowd might gather to see what's happening, but then they walk away when the fight is over. The people who watch might even pretend to be your friend and say the right things but they're never going to totally trust you because if the bully is chronically contentious, it is only a matter of time before they turn on you too.
Controversial blog posts are like a schoolyard fight. It might drive a short-term spike in traffic through the "fascination" value, but is it going to make somebody want to befriend you? Become a customer? Or, are they just going to stay on the sidelines and walk away?
5) It's inauthentic.
Adopting "controversial" as a strategy is kind of like adopting "angry" or "love-struck" as a theme. If you are forced to aim for the same emotional tone every day, how do you avoid becoming a character instead of an authentic person?
So I hope some of this makes sense. I am NOT saying that you should never be controversial. If you bring your humanity to your blog, occasionally you may strike a chord in others that results in a dispute.
About 2-3 times a year I write a post that results in controversy. But my content strategy is not to purposefully churn up a dispute. My strategy is to be honest. And sometimes being honest requires the courage to say things that go against the grain of popular opinion and to take the heat that comes with it.
I'd love to hear your take on this in the comment section … at the risk of being controversial, of course. : )
How does controversy work for or against you?
An idea to help you create content — even if you can't write
Apr 18th
Click here if you cannot see my video interview with Scoop.it Founder Guillaume Decugis
Scoop.it is fun and valuable tool to curate content … and it seems to be exploding across the web. Although the company was founded less than two years ago, it already attracts more than 7 million unique visitors per month.
The user-friendly tool allows you to create a beautiful "social magazine" of your favorite content … even if you can't write a sentence. It's also starting to find its way into corporate environments as a way to curate along relevant business themes.
I recently caught up with the co-founder and CEO of this red-hot property Guillaume Decugis, and asked him a few interesting questions about his company:
- What is Scoop.it and how does it enable content curation?
- How are they going to make money off of this free service? (the answer surprised me!)
- If your blog post appears on a Scoop.it page is there a benefit for SEO?
I hope you enjoy the interview!
How to establish your company's Social Media Lead Team
Apr 9th
I have written a lot about the critical importance of company culture to social media marketing success. It's more important than desire, it's more important than vision, it's even more important than having a budget. If you don't have a leadership team supporting a culture that is actively transforming to a digital, open, responsive environment, you'll simply be frustrated and waste a lot of money.
For many companies this is a dramatic and difficult change. And that change is not going to come from earnest employees at the bottom of the organization, no matter how passionate and driven they may be. Organizational change has to come from the top — from the people who control the budget, strategy, and resources. There is no such thing as a grassroots organizational change.
One of the most important things a company can do is to create a Social Media Lead Team to help drive the change you need that will support your efforts. By the way, doesn't "Lead Team" sound a lot better than "committee?" Let's look at the steps you need to take to do this effectively …
Are you ready?
You cannot hope to drive change unless the leadership team is convinced that change is necessary. If that has not yet occurred, you're not ready. At this point, you don't need a Lead Team, you need executive education. Here are two things to try if your leadership team stubbornly has its head in the sand:
1) Every week, send one short article to your leaders to educate them on social media marketing benefits, case studies, and examples of what the competition might be up to.
2) Bring in an outside expert. Sadly, sometimes they just need to hear from the "outside" to convince them that change is necessary. In my experience, even a two-hour social media workshop can have a powerful impact on the tone of the organization.
Who should be on the team?
The make-up of the team can vary, but there is one person who is absolutely critical. Look at the organizational chart. Now, identify all the people who have to make this strategy work on a day-to-day basis. In some companies this might include Legal, HR, PR, IT, Marketing, and Sales. Now look up the chart for the one person who can tell all these people what to do. It could be a manager or VP, but in some companies you might have to go all the way up to the CEO.
That person must be on the team. Why? Because that is the person who controls ALL the resources needed to make this work. This is single person who can set the direction so that the team operates with lock-step efficiency. If you don't have this person's leadership on the team, you risk constant in-fighting.
After that, you can populate the team with representatives of the key functional areas who will be working on the social media strategy and tactics.
What does a Social Media Lead Team do?
In my experience, there are five obstacles to social media success across every company I have worked with: Company culture, measurement, resources, IT, and Legal. If you would like to read about this in more detail, here is a thorough article for your consideration: The Social Media Minefield: Five Factors Blocking Your Success.
The number one goal of this team is openly address any problem that is jeopardizing the digital transformation of the company so it seems that focusing on these five common issues would be an appropriate agenda for your meetings:
1) Measurement — Review the dashboard to report on successes, opportunities and competitive efforts.
2) Legal — How is the approval process going? Is Legal allowing you to be "human?"
3) IT — Are you getting the IT support you need? Are they responsive to new customer needs and ideas?
4) Resources — Do you have the people and budget to optimize your efforts? (Of course the answer to this will always be "no" but are you moving forward at the right pace?)
5) Culture/leadership — Is everybody rowing in the right direction? Any personnel or political issues?
In addition to these standing agenda items, the team should also:
- Review and enforce the company social media policy
- Provide positive reinforcement and recognition to those embracing change
- Actively demonstrate their leadership and interest in digital business through their work on this team
- Decide on the timing of significant new projects
How often should the Lead Team meet?
For the first year, I would suggest having a two-hour meeting once per month and then backing off to one hour every other month in year two.
In the first year, you might consider one hour devoted to problem-solving and one hour of digital education on a topic like opportunities in analytics, social influence, digital advertising, mobile marketing, content marketing, etc. The more knowledgeable your team is, the more likely you will maintain their sense of urgency to move forward.
So those are a few of my thoughts on the subject of social media and leadership. What has your experience been like? What would you add to this discussion?
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I need to vertically center the order_form div (light gray) and keep it on the very right side of each of the product boxes on our website. The div's height is non-fixed, and can occasionally fill most of its allowed vertical space (which is 160px because of the product image). The picture div vertical-aligns perfectly. I made an example out of one product box and simplified it as much as possible while leaving its html intact.
Here's a jsfiddle displaying the problem (sorry for the lack of images!)
I realize there are a lot of posts on this topic; I've read many of them. I've tried everything I could think of, and everything I have found in all the articles, solved questions, even every little clue I've found over the past three+ hours. Nothing has worked.
I'm completely lost on how to solve this, and I'm sorely tempted to change the picture and order_form divs to a table just for the sake of aligning ._.
Several things I've tried:
display: table-cell; vertical-align:middle;on the order_form div, and adding
display:tableto its parent.
- The above with
display:tableon an added wrapper div instead.
- adding a wrapper div and using margin + negative margin.
display:table-cell; vertical-align:middle;and adding a wrapper div with
left:160px; display:table. The wrapper div's width is never correct, breaking the order_form.
vertical-align:middleon the order_form and having
heightequal to
line-heighton its container
- several other approaches i do not remember
- saying please.
Background info: I've recently started working on our site and, among other things, I've since converted all the product boxes from tables to divs and cleaned up the css a bit. The problem is the tables, being tables, handled the aligning really well...
Also: The next step is to convert the buttons from images to prettyful css links so they scale nicely along with the text (and ditch the table there, too). Don't dock me points for what I haven't touched yet!


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Gizmoz, the animation company that lets people create lifelike avatars for sharing across social networks and virtual worlds, has merged with DAZ 3D, an animation technology provider, and online artists' community. Financial terms were not disclosed, but the merger comes with round of funding led by Benchmark Capital, Highway 12 Ventures and Columbia Capital; DoCoMo (NYSE: DCM) Capital and Village Ventures also participated.
Tel Aviv-based Gizmoz previously raised around $13 million over two rounds of funding from DoCoMo, Columbia, Benchmark, and others; its last round came in May 2008. Utah-based DAZ 3D raised an undisclosed amount of funding from Highway 12, Village Ventures and the University of Utah Venture Fund early this year.
The teams haven't decided what the newly-merged company will be called, but the goal is to create a one-stop-shop for game developers and animators that want quick access to character-creation technology. The marketplace will combine DAZ 3D's self-serve 3D modeling tools, which are applicable for use in mobile and social games, as well as PC and console titles, with Gizmoz's consumer-facing technology.
The company will also continue to offer free and premium avatar-creation tools for consumers. (People that go to the Gizmoz site, for example, can upload a picture and morph themselves into demons, panthers, rock stars, et al, and then upload that avatar to their social networks for free). It will keep both websites functioning in the interim, with plans to launch a new combined site and services in Q1 2010. Dan Farr, co-founder and president of DAZ 3D will serve as the newly-merged company's CEO; Gizmoz founder and CEO Eyal Gever is the company's president. Release.


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HunniePie_18 followed AmandaHocking
The Story Of Us
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Hiyah everyone :D xx
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╚══╝♫ music♫
Listening to music helps me concentrate on writing my book.
I have an amazing best friend:-)
Im a filipino and a proud one.
(+'.'+)copy and paste Bunny
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Please read my story its called The Story Of Us thank u xxx :)
I seem to be in love with Tangled ;) call me childish but I cannot help it :D xx
I love listening to music <3 It seems to calm me down and makes me relax ;)
Im currently writting The Story Of Us xx ;)
My fave colour is red, blue, purple and much more.......
I love painting, reading, writting and loads more :)
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Enjoy reading The Story Of Us hope u all like it also thanks for da people reading, voting nd becoming a fan Ill make sure to fan u bck ;) xxx
Bye Bye :D <3 Luv u all! xx <3
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Here's the link to my story The Story Of Us hope u enjoy it xxx :D LUV U GUYS
PLZ check out my new book coming out thank uh! :D
Here is the link to my new story Dearest Nerd, With Love Jock!
Btw guys I often change my username. xD xxx
Here are some of the bands and singer I love:
Sum 41
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And loads more..............xx
Enjoy my story :D xxxxxx
4EverLove_xx =D xxx
Description: Amelia Taylor is what you would consider a Nerd Girl. She is invinsible to everyone but her only friend her brother Dylan. She has never ever believed in love since what had happend in the pass. She always had her nose stuck in a book and had a hidd...
The day I first met her I knew she was the one I was going to marry, have a family with and die with hap...
It was my fault, I let her go...There's nothing I can do about it...It was my fault. Liam Thompson was...
Hey, I'm tryingvti regain all my followers as my other account on wattpad ElizabethDark1 is having major issues with my email. so I made another account and I'm trying to get all my followers back. please follow me back. thanks
hey! love Ur books!! there amazing, and Ur right, music is the best, there's no arguing there!
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Encountering Development: The Making and Unmaking of the Third World
Princeton University Press, Feb 15, 2001 - Social Science - 320 pages
How did the industrialized nations of North America and Europe come to be seen as the appropriate models for post-World War II societies in Asia, Africa, and Latin America? How did the postwar discourse on development actually create the so-called Third World? And what will happen when development ideology collapses? To answer these questions, Arturo Escobar shows how development policies became mechanisms of control that were just as pervasive and effective as their colonial counterparts. The development apparatus generated categories powerful enough to shape the thinking even of its occasional critics while poverty and hunger became widespread. "Development" was not even partially "deconstructed" until the 1980s, when new tools for analyzing the representation of social reality were applied to specific "Third World" cases. Here Escobar deploys these new techniques in a provocative analysis of development discourse and practice in general, concluding with a discussion of alternative visions for a postdevelopment era.
Escobar emphasizes the role of economists in development discourse--his case study of Colombia demonstrates that the economization of food resulted in ambitious plans, and more hunger. To depict the production of knowledge and power in other development fields, the author shows how peasants, women, and nature became objects of knowledge and targets of power under the "gaze of experts."
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Only read selected portions but is one of the eminent texts of the anthropology of development. Read full review