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An apparatus for the repair of a cardiovascular valve has leaflets comprising a grasper capable of grabbing and co-apting the leaflets of the valve. In a preferred embodiment, the grasper has jaws that grasp and immobilize the leaflets, and then a fastener is inserted to co-apt the leaflets. The apparatus is particularly useful for repairing mitral valves to cure mitral regurgitation.
1. A device for coapting cardiac valve leaflets, comprising:
a grasper having a first closure member with a first grasping surface and a second closure member with a second grasping surface, the first and second grasping surfaces being capable of releasably grasping cardiac valve leaflets between the first and second grasping surfaces; and
a fastener adapted to close over the closure members,
wherein, when the cardiac valve leaflets are grasped by the first and second grasping surfaces, one of the grasping surfaces in contact with the cardiac valve leaflets is configured to be movably displaced in a longitudinal direction relative to the other grasping surface in contact with the cardiac valve leaflets to reposition cardiac valve leaflets relative to each other, and
wherein the fastener is capable of being positioned to close over the closure members whereby the closure members coapt the cardiac valve leaflets.
2. The device of
3. The device of
4. An apparatus, which is capable of being inserted percutaneously, for the repair of a cardiovascular valve having leaflets, comprising:
a grasper having first and second grasping surfaces capable of grabbing and coapting leaflets of a cardiovascular valve,
a deployable fastening device integrally attached to the grasper,
means for operating the fastening device independently of the grasper, and
at least one control wire capable of actuating the grasper,
wherein the first and second grasping surfaces can be adjusted in a longitudinal direction relative to one another to reposition the cardiovascular valve leaflets to obtain optimum coaptation, and
wherein the fastening device is capable of being positioned to close over the grasping surfaces whereby the grasping surfaces coapt the cardiovascular valve leaflets.
5. The apparatus of
6. The apparatus of
7. The apparatus of
8. The apparatus of
This application is a divisional of commonly assigned U.S. patent application Ser. No. 10/883,412, filed Jun. 30, 2004, now U.S. Pat. No. 7,509,959, which in turn is a continuation of commonly assigned U.S. patent application Ser. No. 09/950,163, filed Oct. 15, 2002, now U.S. Pat. No. 7,758,596, which is a continuation of commonly assigned U.S. patent application Ser. No. 09/747,558, filed Dec. 23, 2000, now abandoned, which is a continuation of commonly assigned U.S. patent application Ser. No. 09/254,111, filed Feb. 25, 1999, now U.S. Pat. No. 6,269,819, which is a National Phase of co-pending, commonly assigned PCT Patent Application No. PCT/US98/13240, filed Jun. 25, 1998, which corresponds to U.S. Provisional Patent Application Ser. No. 60/051,078, filed Jun. 27, 1997.
The present invention relates generally to the field of circulatory valve repair. More particularly, the present invention relates to the field of the repair of heart valves and specifically for the repair of mitral heart valves, for patients suffering from mitral regurgitation.
There are four valves in the heart that serve to direct the flow of blood through the two sides of the heart in a forward direction. On the left side, the mitral and aortic valves direct oxygenated blood coming from the lungs, through the left side of the heart, into the aorta for distribution to the body. On the right side, the tricuspid valve, located between the right atrium and the right ventricle, and the pulmonary valve, located between the right ventricle and the pulmonary artery, direct de-oxygenated blood coming from the body, through the right side of the heart, into the pulmonary artery for distribution to the lungs. The anatomy of the heart and the structure and terminology of heart valves are described and illustrated in detail in numerous reference works on anatomy and cardiac surgery, including standard texts such as Surgery of the Chest (Sabiston and Spencer, eds., Saunders Publ., Philadelphia) and Cardiac Surgery by Kirklin and Barrett-Boyes, Pathology and Abnormalities of Heart Valves, incorporated herein by reference.
All four heart valves are passive structures in that they do not themselves expend any energy and do not perform any active contractile function. They consist of moveable "leaflets" that are designed simply to open and close in response to differential pressures on either side of the valve. The mitral valve has two leaflets and the triscupid valve has three. The aortic and pulmonary valves are referred to as "semilunar valves" because of the unique appearance of their leaflets, which are most aptly termed "cusps" and are shaped somewhat like a half-moon. The components of the mitral valve assembly include the mitral valve annulus; the anterior leaflet; the posterior leaflet; two papillary muscles which are attached at their bases to the interior surface of the left ventricular wall; and multiple chordae tendineae, which couple the mitral valve leaflets to the papillary muscles.
The problems that can develop with valves can be classified into two categories: (1) stenosis, in which a valve does not open properly, or (2) insufficiency, or regurgitation, in which a valve does not close properly.
Mitral regurgitation ("MR") is caused by dysfunction of the mitral subvalvular apparatus or direct injury to the valve leaflets. Multiple etiologies can lead to mitral regurgitation, with myxomatous degeneration of the valve and ischemic heart disease accounting for close to 60% of cases. Repair of the diseased valve requires major surgery on cardiopulmonary bypass to allow access to the valve. Consequently, some patients in the early or late stages of the disease are not considered appropriate candidates due to the high risk associated with the operation. Multiple studies have demonstrated that prosthetic replacement of the mitral valve can lead to significant postoperative left ventricular dysfunction and often requires lifelong treatment with anticoagulants. Mitral valve repair, using a posterior annuloplasty ring, has demonstrated improved results with better ventricular recovery. Nevertheless, recent studies performed by the inventors (Umana et al., Surg Forum 1997) have revealed that posterior ring annuloplasty causes changes in ventricular geometry that lead to paradoxical movement of the normal papillary muscles, further deteriorating ventricular performance. In contrast, the "bow-tie" repair in which the anterior and posterior leaflets of the mitral valve are fixed in opposition appears to enhance annular contractility while preserving ventricular architecture. This has resulted in improved postoperative ventricular function almost uniformly.
The present invention addresses the needs of all patients with mitral regurgitation without mitral stenosis, including those who heretofore may have been excluded due to having only moderate MR or being too sick to be candidates for major surgery.
The present invention finds utility not only for the repair of mitral valves but for all valves of the circulatory system, including aortic valves, tricuspid valves, and venous valves.
Techniques for improving the efficacy of corporeal valves are known. For example, Laufer et al., U.S. Pat. No. 5,609,598 describes a valving system for treatment of chronic venous insufficiency. The system has inherent limitations in terms of its effectiveness for the procedure described and its applicability, if any, to other valves, especially cardiac valves.
The present invention is directed to a method and apparatus for use in heart valve repair involving the use of an inserted device or grasper for grabbing and clasping together the anterior and posterior leaflets of the valve, by insertion into the left ventricle through the right chest via a thorascope, through the jugular vein, or through the femoral artery. The grasper will grab both leaflets, preferably after the heart has been stopped or slowed pharmacologically. The correctness of the initial grasp is assessed by, for example, intraoperative echocardiography, to ensure, for example, in the case of the mitral valve, that the mitral regurgitation is resolved. If not, the grasper will be able to "adjust" the leaflets to allow better coaptation or, if needed, re-grab the leaflets in a different location.
Either inherent to the grasper, as an integrally attached component or as a separate device, a fastening device is introduced and a fastener is deployed to securely hold the leaflets in place after the grasper has been released. The remaining portion of the device, or optionally any separate device, is then removed.
Accessory devices needed for the procedure include instruments for thoracoscopic or percutaneous approaches. While the preferred method and apparatus described hereinbelow is discussed with reference to its use in connection with mitral valve repair, it is contemplated that the same or substantially similar apparatus and methodology would also be useful in repairing other valves found in the human circulatory systems, particularly other heart valves, such as, for example, venous valves, aortic valves and tricuspid valves, amongst others.
It is an object of the invention to provide a method for the repair of heart valves to increase their efficiency.
It is a further object of the invention to provide for a method for the repair of mitral valves to, reduce mitral regurgitation.
It is also an object of the invention to provide for a method for the repair of the mitral valves which eliminates the need for cardiopulmonary bypass surgery.
It is a further object of the invention to provide for an apparatus for percutaneous insertion into the heart to effect the repair of a heart valve.
It is a yet further object of the invention to provide for the repair of a mitral valve by percutaneous insertion of a grasping and fastening device into the heart to repair a mitral valve and reduce or eliminate mitral regurgitation.
These and other objects of the invention will become apparent to one skilled in the art from the more detailed description given below.
The invention can perhaps be better appreciated by making reference to the drawings. In
Mitral valve 10 comprises anterior leaflet or cusp 22 and posterior leaflet or cusp 24, as well as two commissural cusps (not shown). The primary intent of the invention herein is to secure the distal sections 26 and 28 of cusps 22 and 24, respectively, together or substantially adjacent.
As can be seen in
The distal ends of the grasper means can vary greatly. It is contemplated that a variety of grasper means may be employed having differing grasper configurations and elements. For example, it is contemplated that the grasper means could be of the type wherein one side of the grasper is stationary and the other side movable. Alternatively, the grasper means might be of the type wherein both sides are movable in concert. Another alternative arrangement comprises a grasper means having multiple grasper elements to enable one to grasp and hold the leaflets of the valve in multiple locations. It is also contemplated that the grasper elements themselves might comprise one or more suction elements to secure and hold the valve leaflets in place. Preferably the grasper will have the capacity to adjust the leaflets of, for example, a mitral valve to obtain optimal coaptation.
In addition it is contemplated that the grasper may comprise additional technology to facilitate the operation of the grasper. For example, the grasper may have echo doppler probe or a similar visualization technology that would allow even better localization of the leaflets and confirmation of ideal coaptation.
Depicted in
As shown in
In another embodiment of the invention shown in
Rods 86, 90, and 92 are each operatively connected to one or more control mechanisms (not shown). Also, distal section jaws 82, 84 may be slidable within grasper sheath 81.
Another device 110 of the invention is shown in
Once jaws 112 are closed, the distal tip of sheath 114 is advanced distally to be adjacent grasping surface 118 and its cooperating grasping surface 122. A pusher 124 coerces fastener 116 to advance out of the distal end 126 of sheath 114 to form a circular shape. Fastener 116 in this shape will coapt valve leaflets 120, as can be seen in
The device 130 of the invention shown in
While a typical grasper means configuration would normally require the use of at least one control wire to actuate the grasper element(s), it is contemplated that multiple separate control wires could also be effectively employed and manipulated from the proximal end of the system to allow for the precise control of the individual grasper elements.
With regard to the fastening means employed, as noted above it is contemplated that the fastening means may be constituted as a single apparatus operating in concert with the grasper means. Alternatively, the fastening means may be constituted as an entirely separate device which is totally independent of the grasper means. More preferably the fastening means will be a separate device which will function using a monorail type system, wherein the fastening means will operate independently of the grasper means, but will ride via a loop over the same guidewire/catheter which houses and guides the grasper means.
While the preferred fastener depicted is in the form of a clip or staple, it is also contemplated that the fasteners employed to secure the leaflets of the valve may be of a variety of different configurations, each of which would function with greater or lesser effectiveness depending upon the operative conditions which prevail. In addition to clips or staples it is also contemplated that the following types of fasteners may also be effectively employed: coils, sutures, dual button fasteners, cufflink-like fasteners, and the like.
Suitable suture fasteners would include those which might require an appropriate mechanism to automatically suture tissue. Coil fasteners would generally be provided with sharpened ends to allow one to screw these fasteners into place by threading the sharpened end through the tissue of the valve leaflet.
With reference to
The overall diameter and/or the differential turns of coil 160 may be uniform or they may vary. For example, the diameter at each end of coil 160 could be the same as, greater than, or less than the diameter of the middle portion of the coil. Similarly, the ratio of the turns of the coil to the length, i.e., the pitch, could be consistent or the pitch could be greater or less at each end of the coil. The diameter of the coil wire will preferably be consistent.
Each coil 160 would have a length of from about 3 to 7 cm, preferably about 5 cm, with a diameter of from about 1 to 3 mm, preferably about 2 mm, and a coil wire diameter of from about 0.2 to 0.4 mm. The winding of coil 160 should be from about 5 to 10 turns/cm in an unstressed condition.
The device and fasteners used according to the invention must be comprised of biocompatible, nonimmunogenic materials. The grasper is preferably comprised of rigid materials such as titanium, nitinol, stainless steel, or rigid polymeric material such as polyethylene or polyurethane. The clips, staples, coils, etc., are preferably comprised of titanium, nitinol, or stainless steel. In some instances fasteners comprised of molded polymeric material may also be useful.
There are four different approaches which one might take to effect a repair of the mitral heart valve according to the invention:
Such a procedure might be undertaken while the patient is on by-pass with an open-chest, either transapically or transatrially. A median sternotomy is performed and the patient is placed on cardiopulmonary bypass by cannulating the ascending aorta and the right atrium. A purse-string suture is then placed on the apex of the left ventricle and a stab incision performed to insert the instrument which will grasp and attach the mitral valve leaflets. Once adequate repair of the valve is attained, the instrument is removed and the air evacuated from the left ventricle through the apical incision. The ventricle is then repaired using conventional wound closure techniques.
Alternatively, the grasper can be introduced through a similar stab incision performed over the roof of the left atrium. The grasper will cross the valve and then be manipulated to revert to grasp the leaflets from the atrial side and place the suturing device, just as postulated from the transventricular approach. Once adequacy of repair is confirmed, the device is extracted and the atriotomy closed using conventional wound closure techniques.
This procedure can alternatively be performed with the patient off bypass, through either a left or right thoracotomy or a sternotomy incision. The technique would be similar to that outlined for repair of mitral regurgitation on cardiopulmonary bypass. After opening the chest, the patient is placed on medication (beta-blocker) to slow the heart rate to approximately 40 beats per minute. This allows adequate echocardiographic visualization of the leaflets in order to grasp and attach them.
Third, such a procedure can be undertaken thorascopically. The patient is intubated selectively in order to collapse the left lung, and percutaneous ports are inserted in to the left chest allowing visualization of the apex of the heart or left atrium. Through a separate port, the device is introduced into the thoracic cavity and subsequently into the left ventricle through the apex. Previously, a purse-string or triangular suture had been placed around the tip of the ventricle to control bleeding around the ventricular entry site. Subsequent steps of the repair are identical to those described for patients with an open chest, off bypass.
Should the operation require the patient to be placed on bypass, this can be attained percutaneously from the groin by cannulating the femoral artery and vein. This technique could prove particularly useful in the early stages of development of the technique, since the surgeon would be able to operate on a decompressed heart and slow or cease the heart rate as needed, without hemodynamic compromise.
Lastly, a percutaneous approach to repair of the mitral valve would be possible with this invention by inserting the device either through the femoral artery or jugular vein. When using the former, the left ventricle is reached by placing the device across the aortic valve. The leaflets will be grasped by turning the tip of the instrument approximately 160� from the entry angle. As previously stated, the grasper's tips are adjusted to obtain optimal apposition and the suturing device delivered. If a transvenous approach is employed, the left atrium is entered through the interatrial septum and the leaflets are handled as described for the transatrial technique.
To determine the relative efficacy of the method of the invention in effecting the repair of heart valves such as mitral valves a number of procedures were performed on both animal and human test subjects as follows:
Animal Testing
Six adult sheep underwent ligation of OM2 and OM3 through a left thoracotomy to induce chronic ischemic MR. After 8 weeks, animals were placed on cardiopulmonary bypass. Using a posterior approach to the left atrium, a bow-tie repair was performed. A posterior suture annuloplasty (DeVega) served as control. Snares were placed on both repairs to allow alternate tightening during measurements. Ten 2-mm piezo-electric crystals were sutured around the MV annulus and at the bases and tips of the papillary muscles. Six crystals were secured to the apex (1), septum (1), and epicardial short axis of the left ventricle (4) for 3-dimensional sonomicrometry array localization (3D-SAL) imaging. 3D-SAL measurements were performed after weaning from cardiopulmonary bypass at baseline and with each type of repair. Echocardiography was used to measure MR, MV area, and fractional shortening.
As shown from the results presented in Table 1, MR decreased significantly with both repairs compared with baseline. Post-operative improvements in fractional shortening was greater in the bow-tie group but did not reach statistical significance. MVA, measured by planimetry, decreased more with the bow-tie repair; nevertheless, the resultant areas were still substantial without evidence of a transvalvular gradient. Mitral valve annular contractility (% area change=(maximum area−minimum area)/maximum area) by 3D-SAL increased from 19.7%�4.0% at baseline to 21.5%�3.2% after bow-tie repair (P=0.026). Suture annuloplasty decreased annular contractility to 15.7%�3.6% (P=0.0011 vs. baseline, and P=0.0001 vs. bow-tie).
The results obtained suggest that current techniques of mitral valve repair in ischemic MR may further impair left ventricular performance by limiting systolic function of the annulus and base of the heart. The bow-tie repair technique which is the subject of the present invention controls MR and directly addresses subvalvular dysfunction resulting in improved annular and left ventricular function.
Human Testing
The charts of eleven patients (five males and six females) undergoing mitral valve repair in conjunction with a central leaflet suture ("bow-tie" repair) were reviewed. Patients were operated on between August 1996 and April 1997. Mean age was 68 years (range, 44 to 78). Etiology of mitral regurgitation (MR) was ischemic in nine patients and degenerative in two. Mitral regurgitation was attributed to ischemia if any of the following criteria proposed by Radford et al. was met: (1) rupture of a papillary muscle chord or head (n=3); (2) infarction of the papillary muscle in the absence of leaflet pathology (n=3); (3) clear history of new onset or worsening of mitral regurgitation after documented myocardial infarction (n=3).
The diagnosis of MR was established by echocardiography in 10/10 patients, and semiquantitatively graded as severe (4+), moderate/severe (3+), mild/moderate (2+), mild (1+), and trace. Left sided cardiac catheterization confirmed the presence of MR in nine patients and the presence of critical coronary artery disease (CAD) invariably involving the circumflex and posterior descending artery territories in all patients with ischemic MR. Preoperative diagnoses and hemodynamics obtained during catheterization are shown in Table 2. All patients were in NYHA class III or IV at the time of surgery.
With the patient under anesthesia, the valve is visualized on transesophageal echocardiogram (TEE) and the likely mode of failure determined, with special emphasis on the presence of leaflet prolapse and site and direction of the regurgitant jet. After the heart was stopped, a bulb syringe with cold saline is used to distend the left ventricle and confirm the mode of valve failure. A conventional repair using an annuloplasty right is generally performed and the valve is reinspected with saline injection. If the leaflet edges do not oppose each other in a concentric circle parallel to the annuloplasty ring, and continued regurgitation is observed, then a "bow-tie" repair is initiated. If the repair is performed from the transventricular or transaortic exposure, a single figure of eight 4-0 prolene-suture is placed without screening leaflet eight 4-0 prolene suture is placed without screening leaflet coaptation. Using a 4-0 prolene suture, the anterior leaflet is attached to the corresponding posterior leaflet at the site of malapposition. The figure of 8 suture is placed through each leaflet just as the edge turns down to attach to the primary chordae. This is usually the most cephalad site where the 2 leaflets would touch during systole and creates the largest area of coaptation possible.
At time the suture is very close to a commissure and the result is a narrowing of single valve orifice. More commonly, the suture is closer to the center of the valve and a double orifice valve is created which resembles a "bow-tie". After visually confirming that the repair is satisfactory with cold saline injection, the atrium is closed, the patient weaned from CPB, and an intraoperative TEE used to confirm the adequacy of the repair. Standard as well as exercise transthoracic echocardiograms were performed prior to discharge to establish the competency of the "bow-tie" repair as well as the absence of a significant gradient across the valve.
Six patients were operated on electively for worsening MR leading to intractable congestive heart failure or unstable angina. Four patients underwent emergent operation due to acute worsening of MR secondary to ischemic anterior papillary muscle rupture (n=2), acute MI with cardiogenic shock requiring intraaortic counterpulsation balloon, severe MR and malignant arrhythmias (N=1), and acute worsening of chronic degenerative MR (n=1). One patient had moderate (3+0 MR in association with critical aortic insufficiency. Mean degree of preoperative MR by echo was 3.5�0.7, with mean ejection fraction (EF) of 42%�17%. Nine patients underwent preoperative cardiac catheterization. Mean pulmonary capillary wedge pressure was 23 mmHg�8 mmHg, with mean atrial v-wave of 39 mmHg�25 mmHg; mean CO as measured by thermodilution technique was 3.9 l/min (range 2.4 to 4.5 l/min) (Table 2). Concomitant procedures performed at the time of MR included coronary artery bypass grafting (CABG) in eight patients. Of the two patients, with a degenerative etiology of valvular disease, one required aortic valve replacement, whereas the second underwent posterior leaflet quadrangular resection and annuloplasty. Two patients, not included in this series, with end-stage congestive heart failure (CHF) secondary to ventricular dilation had "bow-tie" repairs during partial left ventriculectomy. Nine patients had a posterior ring annuloplasty as primary procedure for treatment of MR (Table 3). One patient required repair of ischemic ventricular septal defect (VSD) through a ventriculotomy, which made insertion of an annuloplasty ring impractical. This patient's mitral valve was successfully repaired with a "bow-tie" alone. A second patient presented with acute MR secondary to rupture of the anterior head of the ppm. Repair of the papillary muscle was performed using pericardial pledgets. Due to the lack of annular dilatation and persistence of MR a "bow-tie" suture was placed without an annuloplasty ring. Control of MR assessed intraoperatively by direct cold saline injection and TEE was satisfactory in all patients.
It will thus be seen that the objects set forth above, among those made apparent from the preceding description, are efficiently attained and, since certain changes may be made in the constructions set forth without departing from the spirit and scope of the invention, it is intended that all matter contained in the above description and shown in the accompanying drawings shall be interpreted as illustrative and not in a limiting sense.
It is also to be understood that the following claims are intended to cover all of the generic and specific features of the invention herein described and all statements of the scope of the invention which, as a matter of language might be said to fall therebetween.
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By Linda D. KozarynAmerican Forces Press Service
OBERAMMERGAU, Germany, Feb. 24, 1998 Learning one nation's military acronyms is hard. Imagine being assigned to NATO or SHAPE, where military personnel from 16 allied nations, plus 28 Partnership for Peace countries now work.
Help is available.
Last year, about 5,800 military men and women, including more than 1,000 Americans, studied at the NATO School, which is specifically designed to teach them how to communicate and cooperate in the international environment.
The school introduces students to operations. Tucked away in this pristine Alpine village in Bavaria, about 50 miles southwest of Munich, it is far from the phones, faxes and e-mail of any military headquarters. That's the way it's intended to be, officials here said. Their goal, they said, is to give students a solid week, without interruption, to listen and learn, and to bond with foreign counterparts.
Instructors teach courses in NATO command and control, multinational crisis management, peace support operations, electronic warfare, nuclear surety and other specialties. Courses introduce students to the allied military community; advanced courses build upon the basics. General and flag officers attend courses on policy, planning and analysis as well as more technical areas.
Supreme Headquarters Allied Powers Europe publishes the school calendar annually and distributes it throughout NATO and the allied commands. The most popular class is the NATO Staff Officer Orientation Course, taught 12 times a year and always full, said U.S. Air Force Lt. Col. Christopher "Red" Campbell, NATO School academic director.
"Ideally, an officer should attend that course in the first six months of his posting," he said. They may make contacts that can last throughout a military career.
"I still have networks with people I met at my first staff officers orientation course here 10 years ago during my first NATO posting," Campbell said. "That's really important, and we try to encourage the development of those contacts."
NATO School courses are aimed at teaching one thing, interoperability -- one of the most difficult problems NATO has faced throughout its nearly 50 year history, Campbell noted. Interoperability applies not only to equipment, but to personnel.
"If I land an American airplane at a British base, I need to ensure that gas nozzle fits in that aircraft," Campbell said. "Likewise, I need to be able to ensure I can plug a German officer into a U.K.-based NATO headquarters. That's where we come in. We introduce people to different nationalities, different uniform colors, different accents, and give them a good foundation from which they can then function in their appointment."
Who's eligible to attend classes depends on the course. Most courses are classified. Some are for NATO general and flag officers only; most are for officers on multinational staffs.
About 10 percent of the students are NCOs. "Some of our courses are somewhat more technical in nature. Those tend to be the ones NCOs are eligible to attend," Campbell said.
School officials are considering adding courses for NCOs in the future -- possibly as early as this year, he said. "We think there is a need for courses such as an introduction to NATO for senior NCOs, or perhaps a course for senior NCOs who are going to be posted to NATO's stabilization force in Bosnia."
Each course has anywhere from 20 to 100 students. Four classrooms hold a maximum of 237 students. Students come from national headquarters as well as from NATO and SHAPE, Campbell said. Many of the Americans who attend are from U.S. Army Europe, U.S. European Command and the Joint Staff.
A typical class begins at 8 a.m. and ends at about 5 p.m. Most work is done in the classroom through lectures and seminars. Normally, no homework is assigned because most students are not native English speakers.
"It is very difficult as a non-native English speaker to sit in a classroom for eight hours and pay attention to a different language and assimilate that information," Campbell said. "We try to give the student time to listen. We try to speak slowly and clearly. One of my key efforts is to get our native-English speakers to slow down."
German Air Force Lt. Col. Manfred A. Linder, NATO School operations director, knows what it's like to be a newcomer in a multinational assignment. He's trained in the United States several times and spent four years as an instructor in the United Kingdom.
"The hardest part of adjusting to the NATO environment, for a non-native speaker, is the language," Linder said. "Using a foreign language can cause unintentional misunderstandings, misinterpretations. In NATO, even when we use the same words, we sometimes mean different things. We all have national terminology and acronyms. Then, on top of that, NATO creates its own acronyms."
Working in the NATO world requires keeping an open mind, Linder advised. "You have to listen to how other nations do the same things. All of a sudden you find there is not only one way to do something, there are a couple of ways -- or certainly, in NATO, 16 different ways of doing it. They are all right. No one way is the ultimate. When we keep that in mind, we don't have problems."
The school teaches leaders to prepare for and run an operation like NATO's stabilization force in Bosnia. "When it's a NATO operation, we have to use policies agreed upon at NATO headquarters in Brussels," Linder said. "When you work with NATO, you have to know NATO doctrine and policies and work accordingly."
About 30 of the school's permanent party of 110 are Americans. U.S. Army Maj. Cindy Connally is an electronics warfare instructor in Oberammergau. It is her first NATO assignment, and she said it's proving to be a rewarding one.
"Most of my education has been focused on U.S. forces and it didn't really include a lot about the other nations we now work with," she said.
Teaching nonnative English speakers often affects the pace of her class. "Sometimes we have students whose grasp of English is not quite as good [as others]," Connally said. "Sometimes the student will ask a question, and the individual on the podium doesn't understand the question."
Overall, Connally said, learning from other people is exciting. "One of the great things about here is just the exposure to the various nations and how they do things a little bit differently. Making sure we use the NATO-approved language is certainly another challenge. This is a wonderful tour. I'm not sure if I've learned more here, or I've actually taught more."
U.S. Air Force 1st Lt. Tara Keene of the 52nd Operations Support Group at Spangdahlem Air Base, Germany, is one of three Americans who attended the Command and Control Warfare in mid- January. Her 24 classmates were from Italy, Norway, France, Spain, the Netherlands, Belgium, United Kingdom and Denmark .
Keene, an intelligence officer who hails from Tallahassee, Fla., said attending the course gave her a broader understanding which will lead to better interaction with other agencies, be it NATO or U.S. Air Force Europe.
"There are different terms that every country uses," Keene said. "Not everybody means the same thing by the same terminology." The course aims to "reach a common ground so everybody is on the same footing and speaking the same language."
U.S. Air Force 1st Lt. Mike Malone, a fighter pilot assigned to the 22nd Fighter Squadron at Spangdahlem, attended the NATO Advanced Electronic Warfare Course in mid-January. "It's a job requirement," said the Grants Pass, Ore., native. "I'm taking over as electronic combat officer in my squadron, so they were looking for schools for me to go to. I already had the basic school, so they offered the NATO advanced course and I said, 'Sure.'"
Malone's squadron works frequently with the German military and participates in exercises and missions with other NATO allies. Although, he said this is his "rookie tour" in Europe, it's not his first exposure to the multinational environment. Malone said he attended NATO pilot training at Sheppard Air Force Base, Texas, where he learned to overcome language and terminology differences "One air force may call something something different," he said, "but usually it's comparable."

subset: commoncrawl


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LYBURN — A Davin woman was killed in an vehicle accident on Route 10 Wednesday morning.
20-year-old Kayla Brown of Davin was driving along Route 10 near the intersection of Hanging Rock Road near Lyburn when she lost control and crashed into a hillside. She was pronounced dead at the scene.
Route 10 was closed down in both directions while emergency responders attended to the scene.
The accident is still under investigation by the Logan County Sheriff's Department.


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Fine Arts Senior Thesis Exhibition Featuring Sylvia Kim and Juliana Magnifico, BMC '09
Bryn Mawr College seniors Sylvia Kim and Juliana Magnifico will display their senior thesis fine arts projects at Haverford's Cantor Fitzgerald Gallery, May 9-31, 2009. An opening reception will be held Saturday, May 9, from 5:30-7:30 p.m. in the Gallery.
The Fine Arts Department is pleased to present thesis exhibitions by Sylvia Kim (Drawing Concentration) and Juliana Magnifico (Photography Concentration).
All majors in Fine Arts are required to prepare a thesis exhibition as part of an intensive, year-long Senior Seminar. Group critiques, slide presentations, individual advisory meetings, and creative practices constitute the core curricular elements of this process.
Presenting work created during the Senior Seminar in the College's Cantor Fitzgerald Gallery provides seniors valuable experiences: they learn to create a coherent body of work in their own themes and to master techniques in each concentration. Exhibiting in a public venue helps them to self-critique their work, while viewer feedback equips seniors to study in graduate programs and to work in professional fields.
Seniors are still student artists, but they are artists to be. We invite viewers to experience their freshly budded ideas and to applaud their efforts in these accomplished works.
Hee Sook Kim Chair, Fine Arts Department 2009
Sylvia Kim is a double major in Fine Arts with a concentration on drawing and Growth and Structure of Cities with a concentration in architecture. Kim was born in San Francisco but moved at age four with her family to South Korea, where she spent the bulk of her childhood and teenage years. She has been a visiting student at the Rhode Island School of Design studying landscape architecture. Her work focuses primarily on large-scale tree drawings inspired by her recent studies of traditional Asian landscape paintings.
Juliana Magnifico is a Fine Arts major concentrating on photography and printmaking, and began studying photography in seventh grade. She works as a teaching assistant for printmaking classes and as staff manager for the Cantor Fitzgerald Gallery at Haverford. Her multimedia work explores the themes of desertion and connection.
Located in Whitehead Campus Center, the Cantor Fitzgerald Gallery is open Monday-Friday 11 a.m.-5 p.m., Saturday and Sunday noon-5 p.m., and Wednesdays until 8 p.m.
For more information, contact Matthew Seamus Callinan, Campus Exhibitions Coordinator, at (610) 896-1297 or email@example.com.
Haverford College is located at 370 Lancaster Avenue, Haverford, PA 19041.
Originally posted at: http://www.haverford.edu/news/stories/20101/11


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Year of publication
- 2003 (1) (remove)
- Probing the minimal length scale by precision tests of the muon g-2 (2003)
- Modifications of the gyromagnetic moment of electrons and muons due to a minimal length scale combined with a modified fundamental scale M_f are explored. Deviations from the theoretical Standard Model value for g-2 are derived. Constraints for the fundamental scale M_f are given.


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|69 posts found
From here:
"We choose to reveal the game to this extent and this early simply because we wanted to get input from the players."
So - what kind of input are you interested in?
It's understandable that there is a lot of information that can't be shared at the moment - but what sort of areas are of the most use for discussion?
I'm sure that there are a number of systems that are basically designed and set, and others that are pretty much wide open. I guess I'm just asking if there are any broad areas that the team is interested in soliciting specific input on.
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General Correspondent
Joined: 2/11/08
"We cannot change the cards we are dealt, just how we play the hand" - Randy Pausch
Originally posted by jakin
Well, I am no dev for the game, and I'm sure Jatar will be here to further answer your question...But I'm going to take a little guess...
I'm guessing they wanted to see a reaction from the MMO crowd about a game like this. It is very important to get the community's opinion, even when they do not give much information about the game. But with a quest system like this, you have to know about how people feel. These are only the rough details of what seems like a very interesting game, and you have to make sure people like the concept.
Also, we do not know how long this game will be in development, you never know if anyone will take the ideas?
Those are my guesses, but what they doing is keeping me on the seat of my chair :D
Mike470 is correct, partly we wanted to see if there was much interest in a dynamic world game that is primarily quest based. The sheer quantity of emails we have received supporting this idea is encouraging. It seems there are a LOT of players wanting to break out of the old mold and try something new. Our hard work has not been in vain.
However, there are many areas of our game that could benefit from additional discussion. One of these would be player Abilities. Although we have the player Abilities system designed, it is in no way written in stone at this juncture. Here are just a couple issues we have to face:
1) We are allowing players to seek any new Ability they want. This gives players the freedom to plan ahead and create the character of their choice. The issue: will this be too confusing or difficult for the casual player? If the answer is yes, in what ways could we do this, yet make it easy for casual players to understand and enjoy?
2) Once they have an Ability, we are allowing player to improve these Abilities with both study and practice, without cap. The issue: Eventuall god like characters that unbalance the game. In what ways should we limit the growth of players (if at all)?
We already have solutions for these problems, but it might be interesting to hear from players and see their solutions or alternate options.
Another completely different area worth discussing is death. We are currently planning some penalties for death. However, we are also planning on offering players more than one way of paying those penalties. Rather than explain our exact plans, we would love to hear people weigh in on the idea of 'free' death vs. death penalties, and how sever they think penalties (if any) should be to make the game intersting, without making it annoying.
Additionally, we have only just opened discussion on the game. Over time we will be adding new information that will then spark new discussion about how the game should and will work. We value everyone's opinion, and do take the time to read them all.
General Correspondent
Joined: 2/11/08
"We cannot change the cards we are dealt, just how we play the hand" - Randy Pausch
I would like to make several suggestions (although I am sure they have already been gone over)
One is that you say people must study to learn the skill. Possibly a less experienced person of that skill could learn under another player who knows how to use the skill better. For instance, I am a new player. As I walk into the city I meet a friendly player who has a high (I am not sure how these abilities will work, so I will just say level for the time being) level in the skill I am working on. So I train under him and study up on the skill, like he is the master and I am the apprentice. Not only would this encourage players to group up, but it would also be a good way for people to communicate in the game.
As for death penalties, I always liked dying with a penalty. It puts a little more risk and thought into what your plans are in battle.
Good luck on your work!
Novice Member
Joined: 8/30/04
In many games Death penaltes seem to be a punishment for playing solo. Groups usually have a class to can ressurrect dead players and offset health penalties. Death is a normal result of players pushing themselves and they should be encouraged.
I suggest death is a matter for Divine intervention. Either you build up favour with your god in which case you could ask it to ressurect you. If you can not call due to lack of favour or to limit cost, be portted to the nearest shrine and a small loss of favour is removed. If you are out of favour with your God then a penalty in terms of ability and or health is incurred until you are back in favour. Allowing favour to be "bought" by contributing or sacrificing money or items at altars would prevent penalties getting too harsh. you could still have class/characters who could use their favour to get you resurrected.
I dont like corpse runs they tend to be time wasters and disincentives. they punish solo players again. no problem getting corpse run group after a group wipe. harder to find help when there is nothing in it for the helper.
Originally posted by Jatar
Thank you Jatar. I was framing it from the mindset of someone that closely followed the pre-alpha of SWG and was remembering the various discussion threads that cropped up on basic game systems for sake of player feedback. I was hoping it was likely similar for Citadel.
As to your specific points:
1) I believe that the "casual player" often gets underestimated in their ability to understand game systems. Basically - I'm of the opinion that the amount you play the game has little bearing on how well you understand the systems provided:
a) there is a well-structured and polished tutorial experience, and
b) systems are well and fully documented on either the website or in the game manual. (Such documentation can even be solicited from the active playerbase)
With those elements in place I truly believe that anyone can learn a system if they are willing to.
Facing basic facts, the only way an MMO gets away with poorly documented / introduced systems is to model their systems so closely to other popular choices that the players see very little to adapt to. As CoS is attempting to break the current MMO mold (or maybe mould?) I don't see this as a desired avenue.
In sum - I'd suggest designing as complex a system as is required to achieve the design goal. Then devote a significant amount of development resources to ensuring a very very polished and thorough newbie experience. Sure there will be people that complain about the complexity - but there will likely be just as many that cherish it.
While on the topic of casual players and skill progression - I would strongly suggest considering a real-time progression model (similar to the one EVE uses). It is - bar none - the most casual friendly advancement system I've yet encountered, and comes with a couple of other hidden benefits:
- players tend to stay longer because they can keep progressing their character even when they don't have the time or motivation to play. In fact I've seen people maintain accounts for months after they've moved on to other games because they're not sure if they're done and want to keep progressing their character "just in case".
- it takes a large step towards changing the "grind" mentality of players fostered in other leveling systems. In EVE you can simply log in and do what you want rather than facing the choice of "grinding out your last bit of XP for a level". I'm not saying there's no grind in EVE, not by a long shot - but a key element of CoS will be breaking the conventions newer MMO players take as granted. The concept of a "leveling grind" really must be the first on the chopping block IMO.
2) Very difficult to discuss without more specific information on how the skill system works (i.e. are skill levels additional discrete abilities, or are they mathematical improvements on the ability granted when the skill was first chosen).
If the former (i.e. pick the Ability: CAST FIRE, and get cast fire dart at level 1, fireball at level 2, etc) then I think you're stuck with a hard limit. I'd go with a system like UO's in this case - where you can choose X number of abilities to take to max level and then be able to drop current abilities in favour of new ones as time goes on.
If the latter (i.e. pick the Ability: CAST FIRE, and each level gives you a more powerful / longer range / etc. spell effect) then there is really no need to hard cap the player. Simply allow unlimited progression but on an exponential scale of diminishing returns - such that there would be an effective cap, but one that is decided by the player in how they choose to allot their time / skill points.
Finally - the death penalty (apologies for the wall of text).
IMO, death penalties only exist because traditional MMO design emphasises a static world. If the player wasn't punished for failing they would simply zerg-rush any given objective until they finally win through. In and of themselves death penalties don't really help the game.
Given that CoS is being designed from a dynamic standpoint - the death penalty can very easily simply be failure in whatever task you were attempting. If you die and can't return (mechanics of death aside), the village burns to the ground and whatever reason you had to try and prevent that outcome is rendered nul and void.
From this point of view, stacking on a penalty (i.e. loss of items or experience) would really be rubbing salt in a wound.
Now - depending on whether there is a player-crafting system and how it functions, item decay on use and/or on death might be a crucial function. I would personally go with the use penalty - but that's really integral to any discussion of a crafting system.
Equally - depending on the mechanics involved, there may be a requirement for "rez sickness" or similar to prevent zerg-like effects. Honestly I was actually a fan of the accumulated "combat fatigue" effect SWG had. It imposed some downtime (which many people hated) but imposed downtime also seemed to increase community interaction in many cases.
Novice Member
Joined: 9/03/07
In thinking about how to make a complicated ability system "casual friendly", I started thinking about how I put together a build when playing an RPG (MMO or not). I often take out a piece of paper and write out possibilities for character builds. I'll crunch the numbers, pick the skills, write down notes for ideas or possibilities to explore, etc. With MMOs, there are often web based stat calculators (like the WoW talent calculators) that help you to do this, but at a pretty basic level.
What if a tool like this was integrated into the game itself? But it would need to be more comprehensive than just a stat calc (would need to be able to save builds, make notes, it would probably need to even be able to make suggestions based on your desired play-style, etc.), and it would have to be integrated into the tutorial such that you would have to use it early on to get the hang of planning out a character. It could be a "training journal" of sorts. A tool like this, if done well, would be an MMO-dream-come-true for me.
And Jatar, I'm sure you guys are hearing this a lot, but thank you (you being MMO Magic) for daring to be different and daring to dream big. The paradigm shift that you are proposing for this genre is a huge one, but it is definitely the direction that I'd like to see things go. So far, what I've read has described my dream game. Some of what has been said sounds so different and so difficult to implement that I'm hesitant to get too excited, but I'm rooting for you and can't wait to see what you've got hidden up your sleeves.
You know - it just struck me. A great deal of the percieved complexity in MMO skill systems (and combat systems, etc) might be due to the proliferation of numbers and stats in most games.
I have this feeling that a great many players start missing the forest for the trees when it comes to picking skills. They're so worried about picking a "wrong" build - having less than optimal DPS or an inefficient skill point layout - that they don't pick a build based on what they like or what they'd like to do.
My old DM tried to limit the idea of min/max'ing characters by hiding a lot of the stats - perhaps the same thing would be good for the MMO scene?
Originally posted by Jesse01
Thanks for the suggestion, but the good news is that our Journal already includes a planning system to shape your character's development. You can use one of our University Cadres to get a basic plan for the general type of character you want to build, then personalize it with your own modifications. Or, you can just start from scratch and plan out your own.
These plans you create are saved in your journal so you can use them for reference each time you need to improve your character (which is fairly often). You also need this plan to shape your personal story, as you must quest for each ability that you will eventually want to study, so planning ahead is crucial. After all, you don't want to have some study tokens to distribute into your character and not have the ability you want ready to study.
Originally posted by jakin
Originally posted by mike470That is an excellent suggestion, and shows that you are thinking along the same lines. You will be able to Master an Apprentice in the game. We tie this into the 'practice' to improve your abilities system. Players who enjoy helping other players will like this system and it will encourage people to group up without penalizing solo players. (More on that later.)
General Correspondent
Joined: 2/11/08
"We cannot change the cards we are dealt, just how we play the hand" - Randy Pausch
A quick suggestion about merchanters/traders-
Say it is the main town. In the main town, there are rows of empty, unused buildings owned by NPC's. Now if I were a wealthy merchant, I would want to rent out one of these buildings, that way people know where to buy my items. Now that I have my shop, work is becoming busy, so I decide to hire an actual player to work for me. This way it saves time and makes the job easier.
The point- Would it be possible for people to actually rent out buildings and use them as shops. They will have to pay rent to the NPC and everything a normal shop must do. Also, if they would like to advertise their product, is it possible that there is a newspaper, and people can pay to advertise their product in the newspaper?
For some reason, I always liked the idea of learning a language in a game. For instance, one day I am traveling through the lands, and I come across a run down dungeon. As I explore this dungeon, I come upon an ancient script with an unknown language on it. I take my fascinating discovery back to the University. There, actual players and possibly NPC professors (who already are programed to know the language) who help me decode the language.
Which leads me to the next idea I always thought was interesting, writing books. Now that I know this language, I write a book about it, and once I am completed I possibly sell it to the library or a person.
(it is possible if I let my imagination run a little wild on the scribe one )
Novice Member
Joined: 11/19/03
The enemy is so dumb! They believe that WE are the enemy! - A famous orc commander.
About the deaths...
I humbly think that giving options and choices to the players is good. However, I don't like the idea of giving choice everytime, since basically, each time you died, you have a choice about something negative. Focus on negativity is always bad. You don't want the player to feel this: YOU LOSE A or B, PICK SOMETHING TO LOSE!
I would prefer a system where the death penalty is different on every server, and maybe you can switch server anyway you want, or not. But if you died on server A, then this happen. If you died on server B, then something else happen. The choice is linked with the server selection.
If you see that all players pick 1 server, well, expend this death penalty to an unpopular server, open up a new server with this same death penalty....or make a variation of the most popular death penalty.
Although the advertisement about the death penalty on each server should be clear and easy to find and figure out (kinda no brainer), the first differenciation shouldn't be the death penalty, it might be other rules, or the name, the setting, the popularity of a dev (Jatar server!!!). Nobody has to be fooled, the death penalty must be easy to see for each server, but again, focus on the positive (Jatar server is positive, while a Permanent Death server for example, even if possibly a good idea, you should promote the positive, it is Jatar selection for example).
- "If I understand you well, you are telling me until next time. " - René Levesque about the denial NO on the poll to his dream, project and goal. (Free translation)
There are no separate servers in CoS, so that idea is not possible. As in many things, Citadel of Sorcery is not what you are used to in other MMO games. (I've explained some about the server system of CoS in other threads, so you can read about it if you want).
As to our death penalty 'choice' system, we don't believe letting a player choose the type of penalty is a negative.
I can give you an analogy though, you get a ticket for speeding and the judge fines you $200.00, or you can spend 8 hours in Traffic School, or 8 hours community service. Which would you like to do? No matter which you pick, you are paying in some fashion for your mistake. However, people who have money would like the choice of paying that way, while people who don't would rather donate time. Taking away the choice would not be good.
Unfortunately, I'm not at liberty to explain the system yet, so you'll have to wait to find out the actual details.
Novice Member
Joined: 11/19/03
The enemy is so dumb! They believe that WE are the enemy! - A famous orc commander.
Originally posted by Jatar
Then maybe the choice could be premade by the player in a way or another.
In your example, you get a ticket, you know what the consequences are, you still got that choice when you take your license, but it isn't ask later on. This proceed a lot faster to the consequences, and it doesn't make you focus on the negativity as badly...since when you made that choice, it was rhetoric, hypothethic.
I really dislike the idea to pick every time I died. I am angry, I died, then you talk to me about what my choice is? Not a good idea. :P You should ask me, prior I experience it, what my preference is...maybe I could change that choice at any time, but it shouldn't ever be asked again. If I died, it is applied, you don't put that choice in front of me there.
- "If I understand you well, you are telling me until next time. " - René Levesque about the denial NO on the poll to his dream, project and goal. (Free translation)
Originally posted by Anofalye
Perhaps a different explanation will help. Upon death the game does not pop up a choice box. Your actions decide how you pay. Your choice is made by what you do, not by a multiple choice question. My analogy of the ticket wasn't very good at explaining that part. It's very hard to explain this without being able to tell you the system, so this is the last I'm going to post about this subject. But you are slightly on the wrong track, so your objection will kind of be a moot point. Sorry I can't be clearer right now.
Greymain's suggestion could bridge the two viewponts perhaps.
Depending on what divinity your character curries favour with - your death penalty could be different.
i.e. If you do works in the name of Oompa Loompa - god of wealth and commerce (for instance) then you gain favour by amassing money (and donating some of it as well of course).
Should you storm the barricade and not do so well Oompa Loompa will grant your resurrection at the cost of some of your favour (which you could earn back over time).
If you don't have enough favour with your divinity, there could be a universal default consequence (probably slightly harsher or more time-consuming to encourage gaining favour).
The only potential problem with allowing for multiple death penalties is the careful balancing act that would need to be done - lest there be Flavour of the Month penalties.
Inevitably (I'd suggest) there would be one method of payment that's easier than others (either through exploit of game system, RMT, out of balance designs or whatever) - leading to everyone choosing that method and rotating with the nerf / balancing.
General Correspondent
Joined: 2/11/08
"We cannot change the cards we are dealt, just how we play the hand" - Randy Pausch
Death is a very important issue. I will be looking forwards to when Jatar will be able to give more info
Novice Member
Joined: 2/21/07
An interesting death penalty I've seen discussed recently in other games it not a penalty so much as the removal of a bonus.
As you play, you build up a bonus of some kind (stats, XP rate, whatever). But that goes away when you die.
So there you have it -- an incentive not to die, but nothing permanent is really taken away from you if you do.
Of course, this really is about the same as XP loss or XP debt when you look at it mathematically, but I guess the psychological reaction is not quite so harsh.
Whatever you decide to use as a death penalty, my only request is that it not be extremely time-intensive. I actually like the penalty of failing your quest. Life goes on, better luck next time. There will be other quests.
I do have a question, though. In a world where resurrection is commonplace, why would I be in any rush to save a prisoner from being executed? Can't I just collect his parts and patch him up the next day?
Originally posted by HexxeityThe problem I see with bonus removal is that once you die you have lost your bonus, and now there is nothing stopping you from zerg-rushing your opponents. However, our system (you know, the one I'm not allowed to explain yet) does have aspects to it that you will like based on what you mentioned. There, I danced around that without actually saying anything!
As to your question about resurrection... that I can answer outright. As one of the Fallen Heroes, you can be resurrected at any time. However, it is EXPENSIVE for other people in the world. So expensive that most could never afford it, and you aren't going to want to pay for them either. But your resurrections are paid for by the Sorcerers, your commanders. Thus, most people out there must be saved, and letting them be rendered into parts for later collection would be a very bad (and expensive) thing to do.


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Toronto, ON (Sports Network) - Ryan Sweeney drove in the go-ahead run in the ninth inning on a single as Boston rallied for a 4-2 win over Toronto in the opener of a three-game set.
Dustin Pedroia hit a solo home run and scored twice while David Ortiz added two hits for the Red Sox, who got their first win under new manager Bobby Valentine after dropping all three games in Detroit to start the season.
"Great effort by a whole group of guys out there tonight and they're trying their butts off to get that first win and we got it," Valentine said.
Felix Doubront lasted five innings and gave up two runs on four hits with three walks and six strikeouts. Scott Atchison (1-0) pitched three scoreless innings to pick up the win.
Kelly Johnson and Edwin Encarnacion both drove in a run for the Blue Jays, who took two of three from Cleveland to begin the season. Henderson Alvarez was strong in the start, giving up one run on four hits over six innings. Sergio Santos (0-1) was tagged with the loss.
Pedroia started the rally with a double and went to third on a passed ball. Adrian Gonzalez followed with a sac fly to left to tie the game. After Kevin Youkilis struck out, Ortiz and Cody Ross worked consecutive walks with Darnell McDonald coming on to run for Ortiz.
Sweeney then singled to right and Jose Bautista fielded it cleanly, but he two-hopped the throw to the play and Arencibia couldn't field it, allowing McDonald to score. Ross then scored on a wild pitch for an insurance run.
Alfredo Aceves set the Jays down in order in the ninth for his first save of the season.
"It wasn't just one bad pitch it was a bunch of bad pitches," said Santos. "It's tough because I feel like I let the rest of the guys down. Against a team like Boston, you don't want to be giving them any chances."
The third inning saw the Blue Jays push two across for the lead. With one out, Colby Rasmus tripled and Yunel Escobar followed with a walk. Johnson then hit a slow roller to the first base side of the mound that Doubront fielded and went home, but Rasmus slid around the tag. Encarnacion later hit a single to left to score Escobar for a 2-0 lead.
Boston threatened in the fifth when Ross hit a single and Sweeney followed with a ground rule double with one out, but Jarrod Saltalamacchia grounded out to first and Mike Aviles grounded to third to end the frame.
Pedroia, though, got the Red Sox on the board in the sixth with a one-out, solo shot to left.
Boston won 10 of 18 against Toronto last season...Toronto had just five hits in the game and left six men on base.


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This article is the eighth in the Tricycle blog series 10 Misconceptions about Buddhism with scholars Robert E. Buswell Jr. and Donald S. Lopez Jr. More »
June 13, 2014
No Try, Just Do
They make a fairly odd couple. The television and film star Steve Buscemi (Boardwalk Empire, The Big Lebowski) sits alongside Shambhala nun Karma Trime Lhamo, the director of Princeton Buddhist Meditation Group. The setting is incongruous, too: a park bench in the middle of an exhibit at the Rubin Museum of Art. But this strange alchemy—comprising episode six of Buscemi's web series Park Bench—is an unequivocal delight. Buscemi asks sincerely felt, straightforward questions, while Ani Trime responds with wisdom reminiscent of her late teacher, Chögyam Trungpa Rinpoche. Watch as she shares her thoughts on dukkha, meditation, and the importance of being kind. More »
June 12, 2014
Only the Occasional Brothel
This article is the seventh in the Tricycle blog series 10 Misconceptions about Buddhism with scholars Robert E. Buswell Jr. and Donald S. Lopez Jr. More »
June 11, 2014
Mipham Chokyi Lodro, the 14th Shamarpa, Dies at 61
Shamar Rinpoche passed away suddenly this morning in his center in Renchen Ulm, Germany, at the age of 61. The 14th Shamarpa, Mipham Chokyi Lodro, was born in Tibet and recognized and enthroned there by his uncle, the 16th Gyalwa Karmapa, supreme head of the Karma Kagyu lineage of Tibetan Buddhism. More »
June 10, 2014
Painting the West Saffron
Scholars have known for some time that Buddhism is the largest religion in Hawaii after Christianity, the majority religion in all US states. Now—according to an article in last week's Washington Post—Buddhism has also attained second-place status in a dozen Western states. More »
June 06, 2014
The Graduates
Kelsang and his friend Tenzin are both graduating seniors from the Tibetan Children's Village, commonly known as TCV. In their spare time they publish Exile World, a small newspaper that serves as an important voice for young Tibetan writers living in exile. Watch more short films about Tibetans living in exile at the Tibetan Stories website. More »
June 05, 2014
God or Human?
This article is the sixth in the Tricycle blog series 10 Misconceptions about Buddhism with scholars Robert E. Buswell Jr. and Donald S. Lopez Jr. More »
June 04, 2014
Sole Beauty
"Lone contestant Tenzin Yangzom to be crowned Miss Tibet 2014." That's the headline straight from the Miss Tibet home page, and it means exactly what it says: the India-based competition received eight total applications, five confirmed, and four "withdrew at the last minute expressing various personal problems." The automatic winner was Tenzin Yangzom, 23, who the pageant organizers hope will draw awareness to the plight of the Tibetan people by going on to international competitions. More »
June 02, 2014
June 01, 2014
Tricycle | BuddhaFest Online Film Festival FAQ
What is the Tricycle | BuddhaFest Online Film Festival? The Tricycle | BuddhaFest Online Film Festival is an online film festival hosted by Tricycle featuring six Buddhist films selected from the BuddhaFest film festival held in the Washington, DC area. We're also featuring six talks from this year's event. Learn more about the Washington-area event here. More »
May 29, 2014
Buddhism: Philosophy or Religion?
This article is the fifth in the Tricycle blog series 10 Misconceptions about Buddhism with scholars Robert E. Buswell Jr. and Donald S. Lopez Jr. More »


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|Assistant Athletic Trainer
|15th season
Cindy Michaud, a 1997 graduate of
UNH with a B.S. in Kinesiology, joined the UNH athletic training
staff in 1999. Michaud's primary responsibilities include;
management, evaluation and care of athletic injuries and record
keeping. Michaud works primarily with football and men's
basketball. Michaud is also the insurance coordinator for UNH
Athletic Training.
She received her Master of Arts in Teaching and Teacher Education in Sports Psychology from the University of Arizona in 1999. She was a graduate assistant while at Arizona.
Michaud is an approved clinical instructor for CAATE Accredited Athletic Training Education Program. She has been a certified member of the National Athletic Trainers' Association since 1997 along with a certification in American Red Cross – Professional Rescuer & AED Training.
In addition, Michaud has been a licensed massage therapist since 2009.


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Ontheminute.com Football Forum » Spain » Vidic to Real Madrid?
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Real Madrid have again been linked with a move for Nemanja Vidic.
Do you believe the Manchester United ace will be joining Real Madrid?
Would he be a hit in the Spanish league?
Strong defenderhe will be a hit anywhere but manyoo just silenced the rumourshe signed a new contract
he happily signed a new deal with United instead what a good lad!!
another guy played the trick to pocket a hefty contract?very brainy and this trick almost always works


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Issue 49 / March 2015
- National coverage assessment in Mali
- Inter-sectoral programming in Burkina Faso
- Agriculture & nutrition in Nepal
- Pastoral resilience in Kenya
View issue 49 contents Download as PDF (11.8mb)
View issue 49 contents Download as PDF (11.8mb)
ENN invites you to participate in a survey of our publication Field Exchange, as part of an organisation-wide evaluation. We would be really grateful if you would spare 20 minutes to contribute your feedback by clicking here. Many thanks from the FEX team.
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Donna Lee is the emergency services program manager for the Central Georgia Chapter and lives in Jones County. She spoke to the club at its March 12 meeting.
She began her presentation with the story of why she began volunteering. She said her father was run over by a drunk driver on a four-wheeler while he was walking down the road.
It took an ambulance 22 minutes to arrive at the scene, but local rescue volunteers were there quickly and made the difference in his survival.
"They took care of him and had him stabilized when the ambulance arrived," Lee said.
The manager said she started volunteering at with the fire department and was actually approached by the Red Cross to be a liaison between the fire department and the agency to get help for families who have suffered a disaster.
For the full story, pick up a copy of this week's newspaper or subscribe to our e-Edition at http://ee.jcnews.com.


text: Mr. Andrea Comini is from Gavardo, a village in Italy between the cities of Brescia and Verona, where, since 2006 he has worked in different capacities for several sport organizations and professional athletes. Mr. Comini has developed strong competencies both as a strength and conditioning coach and in athletes' technical development through his extensive educational background, culminated in a Master of Arts in "Sport science and techniques" at the University of Verona. He has hands-on experience in planning yearly Strength and Conditioning programs for teams and individual athletes and personally leading training sessions. He is CSCS and NSCA-CPT certified. Since last October Mr. Comini has joined the UNI's Sports and Conditioning program, under the supervision of Head Coach, Jed Smith and his Assistant Coach, Nick Davis. Since joining UNI's Sports and Conditioning program, he has enjoyed learning and sharing different coaching methods.


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Welcome to the online alumni community. This site is restricted to the alumni of the school. Most of the features on this site are free, however there are some features that require a fee. You will be given the opportunity to upgrade your account if you attempt to access part of the site that requires a premium subscription.
New users click here to register. You need to do this first even if you have received an email or postcard.
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I am on the east coast of Florida (the "Space Coast" as my username indicates!)...just wondering if there are any other forum members in this area or perhaps in Orlando/Daytona/Vero Beach. I'd love to hear from you.
Jocelyn - mommy to Michelle Elizabeth, 8/25-9/1/04, 24w1d, 1 lb 3 oz, severe PE/HELLP syndrome


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Create and rename documents, spreadsheets, and presentations
You can create and name documents, spreadsheets, and presentations in the Google Docs, Sheets, and Slides home screens. Your Google Docs, Sheets, and Slides are then available to edit, share, and work on with others.
Create a document, spreadsheet, or presentation
To create a new document, spreadsheet, or presentation:
- Open the Docs, Sheets, or Slides home screen that matches the type of file you want to create. For example, open Google Sheets to create a spreadsheet.
- Click the + button in the bottom-right corner of the screen. This will create and open your new document, spreadsheet, or presentation.
You can also open up new documents, spreadsheets, and presentations straight from the following URLs:
- Docs: docs.google.com/create, google.com/docs/create
- Sheets: sheets.google.com/create, google.com/sheets/create
- Slides: slides.google.com/create, google.com/slides/create
Rename a document, spreadsheet, or presentation
When you create a new document, spreadsheet, or presentation, it'll be named "Untitled" by default. To rename the file:
- Open the document, spreadsheet, or presentation.
- Go to the File menu.
- Select Rename.
- Type a name for your file.
- Click OK.
You can also edit the name by clicking the title displayed at the top of the page, and making your changes in the box that appears. Titles can be up to 255 characters long.
Matt is a Docs & Drive expert and author of this help page. Leave him feedback below about the page.


text:
Britt and Maxie make a deal, Patrick and Sabrina have a heart-to-heart, and Doc catches Lucy escaping Ferncliff with Heather and Todd.
At The Floating Rib Mac kisses Felicia and steps out as Frisco enters. He explains why he's just getting back to her after two months. Mac returns surprised to see him. Frisco offers his hand. Mac hesitates before shaking. Mac asks what he's doing there. Frisco says he's there to see Maxie. Mac is upset Felicia didn't say she contacted Frisco. Mac tells Frisco that he and Felicia are back together. Frisco leaves to get cleaned up and Mac asks why Felicia didn't tell Frisco about him. She says she is not embarrassed by Mac. She professes her love and kisses Mac. Frisco comes in ready for a drink to make a toast. Maxie joins them and is surprised to see her father.
Michael comes home to find Starr preparing a romantic evening. They share wine and Starr asks about Michael's day at ELQ. Starr explains her encounter with Todd at Ferncliff to make sure he was found competent and would be sent to prison. They decide to enjoy the evening. Starr teases Michael with the sundae bar she planned. They get distracted with each other and disappear to the bedroom. They leave the bedroom to find more whip cream.
At the hospital Maxie agrees to do whatever Britt wants to keep her secret. Britt asks her to destroy Sabrina. Maxie questions why. Britt explains that Sabrina is filling Emma's head with lies about her to get to Patrick. Maxie tries to get out of helping as Britt explains how pathetic Sabrina is. Britt calls Lulu and tells her she has information about the baby. Maxie interrupts and Britt ends the phone call. Britt says she'll be in touch with Maxie and threatens her not to tell anyone.
At the apartment Lulu and Dante decide where to get food. Lulu explains about her day and the appointment with Dr. Westbourne. She receives Britt's call and thanks her for the information. Dante discusses the recent murder and then they get romantic, retiring to bed.
In the hospital showers, Olivia hears Steve singing and walks in to see him showering with Sabrina. Olivia asks what he is doing with her and rushes off leaving Steve confused.
At the nurses' station Patrick interrupts Elizabeth and Sabrina's discussion. Liz says Sabrina has something to tell Patrick. Olivia shows up and tells Sabrina to stay away from her fiancé. Olivia argues her visions come true. Olivia is mad and asks what they know when they smirk at her. Steve confesses Sabrina has a crush on him. Olivia gets upset. Patrick tries to calm everyone down. Sabrina says she is not interested in Steve. Patrick apologizes to Sabrina for what happened with Britt. He says he will not be having anymore relationships at work and thanks her for being there for Emma. He leaves and Liz says that must have been hard for Sabrina to hear but Sabrina understands him. Patrick bumps into Britt at the elevators. She apologizes and claims she will not make it difficult for them to work together. He leaves. Britt turns to the nurses' station and plots revenge on Sabrina.
At Ferncliff, Heather, Todd and Lucy argue about if it is safe to break out with cops around. Heather drags them out and Doc shows up. He wants to meet Lucy's friends and find out where they are going. Heather and Todd make excuses about being deputized and on strike. Doc explains they can't walk out with patients. Heather and Todd act surprised that Lucy is a patient. Lucy gets mad and gives them all up to Doc. Doc becomes a problem as he negotiates successfully with Lucy. Heather hits Doc over the head with a flower pot and high fives Todd. Lucy argues with them that they can't leave without Doc. She bribes them with Doc's car keys. Todd takes the keys and leaves with Heather. Lucy says bye to Doc who is still unconscious. She tells him she loves him but has to go take care of Caleb.
Back in the doctors' locker room Steve and Olivia discuss what happened. Steve finishes up dressing and Olivia sees Heather coming out of the showers. She tells Steve and asks if she is really locked away safe at Ferncliff.
Tomorrow's Port Charles spoilers for General Hospital:
Starr is surprised to see Todd at her door.
Heather gets rough with Lucy.
Sam questions why Rafe accused John.
Molly visits Rafe in lockup.
Sean talks to Sonny. "Connie is the only witness, do you want me to make her disappear."
**Please be aware we have a link-only policy.**
Please abide by the Soaps.com guidelines when posting and contact us if moderation is required. Don't forget about our General Hospital News Room, Comings and Goings, and General Hospital Spoilers!
Join Soaps.com on Twitter @soapoperafan, "like" Soaps.com on Facebook to dish on "General Hospital," all the other soap operas, "Dallas," "Glee," "Grey's Anatomy," "Pretty Little Liars," "Revenge," "Vampire Diaries," and "Venice The Series."
All screen shots courtesy of ABC.
- Violette DeSantis


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The SilverFast Ai Studio 8 Scanner Software for Nikon LS 9000ED from LaserSoft Imaging helps you get high-quality captures from your scanner. It is optimized for your particular model, so you can rest assured that you get the most out of your scanning hardware.
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ERZ10575 In Stock
These classic sterling silver diamond CZ stud earrings are ideal for any man. The white cubic zirconias measure 4mm each and carry a total carat weight of .9 carats. Each earring weighs .3 grams and they're perfect for those who want something to catch the eye without being too over the top. The sterling silver adds that last little edge to these earrings to make this pair of sterling silver cubic zirconia mens stud earrings earrings that one can be proud of. Shop with confidence knowing that the quality of our sterling silver cubic zirconia cz earrings is backed by our 60 day jewelry return policy to assure complete satisfaction.
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