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Antiarrhythmia agents have been used in the treatment of cardiac arrest, and we aimed to review the relevant clinical controlled trials to assess the effects of antiarrhythmics during cardiopulmonary resuscitation.
We searched databases including Cochrane Central Register of Controlled Trials; MEDLINE, and EMBASE. Clinical controlled trials that addressed the effects of antiarrhythmics (including amiodarone, lidocaine, magnesium, and other new potassium-channel blockers) on the outcomes of cardiac arrest were included. Data were collected independently by two authors. The risk ratio of each outcome was collected, and meta-analysis was used for data synthesis if appropriate. Heterogeneity was assessed with the χ2 test and the I2 test.
Ten randomized controlled trials and seven observational trials were identified. Amiodarone (relative risk (RR), 0.82; 95% confidence interval (CI), 0.54 to 1.24), lidocaine (RR, 2.26; 95% CI, 0.93to 5.52), magnesium (RR, 0.82; 95% CI, 0.54 to 1.24) and nifekalant were not shown to improve the survival to hospital discharge compared with placebo, but amiodarone, lidocaine, and nifekalant were shown to be beneficial to initial resuscitation, assessed by the rate of return of spontaneous circulation and survival to hospital admission, with amiodarone being superior to lidocaine (RR, 1.28; 95% CI, 0.57 to 2.86) and nifekalant (RR, 0.50; 95% CI, 0.19 to 1.31). Bretylium and sotalol were not shown to be beneficial.
Our review suggests that when administered during resuscitation, antiarrhythmia agents might not improve the survival to hospital discharge, but they might be beneficial to initial resuscitation. This is consistent with the AHA 2010 guidelines for resuscitation and cardiovascular emergency, but more studies with good methodologic quality and large numbers of patients are still needed to make further assessment.
Keywords:Heart arrest; Cardiopulmonary resuscitation; Antiarrhythmia agents; Outcome assessment
Sudden cardiac arrest (SCA) is an emergency with high incidences but poor outcomes. Summary data indicate that the annual incidence of emergency medical service (EMS)-treated out-of-hospital cardiac arrest (OHCA) is about 50 to 55 per 100,000 persons in North America, and the annual incidence of in-hospital cardiac arrest (IHCA) ranges from three to six per 1,000 admissions. Fewer than 10% of them have been survived to discharge [1-4].
For the victims presenting with ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), antiarrhythmia agents are a kind of fundamental medication recommended by the resuscitation guidelines [5,6]. Some clinical trials studied the effects of antiarrhythmics on the outcomes of cardiac arrest. The number of participants in each study might be limited, and the individual studies might be different in methodologic quality, according to the study designs and methods. Several variables should be considered when evaluating the effects of resuscitation drugs, such as the scene of collapse or the quality of cardiopulmonary resuscitation (CPR). Although some antiarrhythmics have been recommended by the guidelines [5,6], evidence does not indicate that they could increase the survival from cardiac arrest, and more data are needed for the assessments of these drugs administered during CPR.
Besides the drugs recommended for routine use during CPR currently, such as amiodarone, lidocaine, and magnesium, we also supposed that the new potassium-channel blockers (such as ibutilide and so on), which emerged as important kinds of agents for various arrhythmias, might have the potential to be used during CPR [7-9]. Although reviews about antiarrhythmics used during CPR were undertaken as part of the ILCOR Consensus on CPR Science in 2010, however, new studies conducted after 2010 and also some new drugs were not included, and no meta-analyses were performed to evaluate the results quantitatively. Thus, we conducted the systematic review and meta-analysis to review the current literature, assess the relevant clinical trials quantitatively and qualitatively, and provide better evidence regarding the effects of antiarrhythmia agents on the outcomes of cardiac arrest.
Study eligibility
We indentified studies according to the following criteria: the studies were randomized controlled designs or prospective/retrospective cohort designs; the studies recruited adult (older than 18 years) cardiac arrest patients (OHCA and IHCA); all arrest rhythms were included; antiarrhythmic agents were administered during advanced cardiac life support (ACLS), including amiodarone, lidocaine, magnesium, other new potassium-channel blockers, such as nifecalant, ibutilide, dofetilide, and others, such as bretylium.
The studies had reported the following outcomes: ROSC; short-term survival: survival to hospital intensive care unit (ICU) admission for OHCA patients/survival to 24 hours for IHCA patients; survival to hospital discharge; and neurologic outcomes at discharge. Neurologic outcomes at hospital discharge were measured as cerebral performance category (CPC): good recovery (defined as a CPC score of 1 or 2) and unfavorable recovery (defined as a CPC score of 3, 4, or 5).
Data sources
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), and EMBASE. We also screened the reference lists of relevant trials and reviews. We searched the following databases for unpublished or ongoing studies: http://www.controlled-trials.com webcite and http://clinicaltrials.gov webcite.
We searched the combination of the keywords "heart arrest," "sudden death," "cardiopulmonary resuscitation," "tachycardia, ventricular," "ventricular fibrillation," "arrhythmias, cardiac," "advanced life support," "antiarrhythmia agents," "amiodarone," "lidocaine," "magnesium," and "potassium-channel blockers."
The searching was performed in October 2012, for all studies published in English between January 1948 and October 2012.
Study selection and data extraction
Two authors (Yu Huang and Qing He) independently screened all the titles and abstracts for eligibility. If we doubted whether a title or abstract should be included or excluded, then we read the full text to make a decision. The full texts were also read independently. Disagreements were solved by discussion with other authors, if any (Min Yang and Lei Zhan).
Two authors (Yu Huang and Qing He) extracted and collected data independently. The following data were abstracted: publication information mainly including first author's last name and publication year; the settings of the study; the study design; characteristics of types of the included patients and the rhythms of arrest; information about sample collecting; the regimens of drug administration; and outcomes reported. Disagreements were resolved by discussion.
Quality assessment of included studies
We assessed the methodologic quality of eligible trials by using the Risk of Bias tool recommended by the Cochrane Collaboration [10]. We assessed each trial across the following quality domains: (a) random-sequence generation; (b) allocation concealment; (c) blinding: according to special properties of CPR, we considered blinding adequate if the professional rescuers, the physicians in the hospital or the intensive care unit and the outcome assessors were blinded, regardless of the blinding of patients; (d) incomplete outcome data or loss to follow-up; and (e) selective reporting and any other potential threats to validity.
The assessment was performed by two authors (Yu Huang and Qing He) independently.
Synthesis of results
The ROSC and survival outcomes were measured and derived as risk ratios (RRs) with 95% confidence intervals (CIs). Neurologic outcomes, grouped into the two categories of good recovery and unfavorable recovery, were also measured as RR with 95% CI to adapt them for meta-analysis. We synthesized the data by meta-analysis if available. Meta-analysis was performed by using Review Manager (RevMan 5.1). Heterogeneity was tested by using the χ2 test, and P ≤ 0.10 was considered significant. The I2 statistic also was used (I2% ≤ 25% for low, 25% < I2% < 50% for moderate, and I2% ≥ 50% for high). According to the variability of practice of CPR, including the different comorbidities of the included patients, the different treatment strategies and so on, we expected that a random-effects model would be suitable for this meta-analysis.
Subgroup analysis
We planned to perform subgroup analysis of OHCA and IHCA patients when applicable.
Sensitivity analysis
We planned to perform sensitivity analysis by excluding trials with high risk of bias when applicable.
Our broad search identified 1,583 studies, and finally 14 were included after abstract screening and full-text reviewing (Figure 1) [11-24]. After analysis, we broadly categorized the studies into the following questions: antiarrhythmia agents (amiodarone/lidocaine/magnesium sulfate) versus placebo; amiodarone versus lidocaine; nifekalant versus lidocaine/amiodarone; and other drugs.
Figure 1. Flow diagram of literature search.
Antiarrhythmia agents versus placebo
We identified eight eligible studies that compared the effects of antiarrhythmia agents versus placebo for cardiac arrest. Five of the included studies were randomized designed trials, and the other three were retrospective observational studies [11-18]. The details of study characteristics are shown in Table 1.
Table 1. Study characteristics
One randomized controlled trial studied the use of amiodarone during CPR, and 504 patients were enrolled. Kudenchuk and colleagues performed a study conducted in urban and suburban emergency medical service (EMS) systems in the United States [11]; the CPR protocol was according to American Heart Association (AHA) guidelines published in 1982. OHCA patients (504) were enrolled, and 300 mg amiodarone or placebo was administered randomly if no resuscitation was gained after three shocks. The rescuers responsible for drug administration, advanced life support (ALS), or treatment in the emergency department (ED), and the investigators responsible for data collection and analyses, were all blinded adequately. The recipients of amiodarone were more likely to be resuscitated and survive to admission (RR, 1.27; 95% CI, 1.02 to 1.59); however, the proportion of patients who survived to discharge did not differ significantly in the two groups (RR, 1.02; 95% CI, 0.65 to 1.59). Thus although ROSC was not reported, amiodarone had significantly improved initial resuscitation compared with placebo, according to survival to hospital admission.
Another retrospective study conducted by the Helsinki EMS systems studied the use of undiluted amiodarone in the management of VF/pulseless VT resistant to three shocks [12]. No significant differences were shown in ROSC, survival to hospital admission, and discharge, but data demonstrated that the patients who received amiodarone had a more complicated prehospital course compared with those who did not receive amiodarone.
Four trials studied the effects of magnesium for cardiac arrest [13-16]; all were double-blinded randomized controlled trials. Three trials enrolled 370 OHCA patients [13-15]. In the case of Hassan et al. [13], the study was conducted in the county of Leicestershire, UK, and CPR was performed according to ERC guidelines published in 1992. Patients who had either VF resistant to three shocks or a second episode of VF during resuscitation were included. Magnesium sulfate (2 g) or placebo was given intravenously, and a repeated dose of 2 g magnesium sulfate might be given after six ineffective shocks. In the case of Allegra et al. [14], a multicenter prehospital study clinical trial conducted in New Jersey, USA. was found. Patients with VF refractory to three shocks were included, and magnesium sulfate (2 g) or placebo was given intravenously. In the case of Fatovich et al. [15], the study was undertaken at the ED of a large university hospital in Perth. OHCA patients were enrolled if they were still undergoing arrest when they arrived at the ED, and the patient management followed standard ALS guidelines (5 mg MgSO4 or 10 ml saline was given randomly at arrival at the ED). These three individual studies showed that no significant differences were found between magnesium and placebo groups in either ROSC or survival to discharge.
One trial was conducted by the Duke Hospital code team, and enrolled 67 IHCA patients from intensive care or general wards [16]. The primary diagnosis included circulatory/neurologic/respiratory disorders. The resuscitation protocol was according to AHA guidelines, MgSO4 (2-g bolus followed by an infusion of 8 g over a 24–hour period) or placebo given in a double-blinded manner. The results showed that in IHCA patients, no significant differences occurred between the magnesium and placebo groups in all outcomes.
Two retrospective studies compared lidocaine with placebo for OHCA patients with shock-resistant VF/VT [17,18]. In total, 406 patients were enrolled, and either individual study showed that lidocaine was superior to placebo in initial resuscitation but not survival to discharge.
We assessed the quality of the evidence by using the Cochrane Risk of Bias tool (see details in Table 2). In the five randomized trials, random sequence was generated by computer in the case of Allegra et al. [14], but no detailed information about the allocation concealment was found in the text. Sealed envelopes and central allocation were used for allocation in the case of Fatovich et al. [15], but no detailed information on randomized sequence generation was reported. No detailed information about random-sequence generation and allocation concealment could be found in the articles about other studies [11,13,16]. However, they are all randomized prospective designs, according to the texts, so unclear selection bias was considered [11,13-16]. Double-blinding was performed in all trials [11,13-16], and in the case of Kudenchuk et al. [11], the rescuers in the ED and the investigators for data collection and analyses were also blinded. Because considering the blinding of outcome assessors would not influence the analysis of ROSC or survival rate, a low risk of performing bias was considered. In the three retrospective studies, high risk of allocation and performing bias was considered [12,17,18]. Moreover, low risk of attribution and other bias was considered in all studies.
Table 2. Assessment methodologic quality
We performed meta-analysis by subgroups according to the different antiarrhythmics (Figures 2, 3, and 4). The rates of survival to hospital discharge were reported in all trials, whereas the other two outcomes were not. The pooled results showed that none of amiodarone (χ2 = 1.80; P = 0.18; I2 = 45%; RR, 0.82; 95% CI, 0.54 to 1.24) magnesium (χ2 = 0.89; P = 0.83; I2 = 0; RR,1.07; 95% CI, 0.62 to 1.86) or lidocaine (χ2 = 1.16; P = 0.28; I2 = 14%; RR, 2.26; 95% CI, 0.93 to 5.52) had improved the survival to discharge. In the evaluation of outcomes of initial resuscitation, no difference was found in ROSC and survival to admission/24 hours between magnesium and placebo, but lidocaine was shown to improve initial resuscitation, according to the pooled results.
Figure 2. Comparison of the effects of antiarrhythmics versus placebo. Outcome: ROSC (return of spontaneous circulation). Subgroup analysis was performed according to different medications.
Figure 3. Comparison of the effects of antiarrhythmics versus placebo. Outcome: survival to hospital admission/24 hours. Subgroup analysis was performed according to different medications.
Figure 4. Comparison of the effects of antiarrhythmics versus placebo. Outcome: survival to hospital discharge. Subgroup analysis was performed according to different medications.
No trials reported data of neurologic outcomes assessed with CPC, so no meta-analysis was performed. In addition, only two trials reported data of neurologic outcomes measured by Glasgow Coma Scale score in OHCA and IHCA patients [13,16], and both trials showed that magnesium had not improved neurologic outcomes at hospital discharge compared with placebo.
Amiodarone versus lidocaine
Two studies compared the effects of amiodarone and lidocaine during CPR (Table 1) [19,20]. Dorian and colleagues [19] performed a randomized study conducted under the auspices of the Toronto EMS system, and 247 patients were enrolled. OHCA patients with VF/pulseless VT refractory to defibrillation shocks were included, and the CPR was performed based on the 2000 AHA guidelines. Amiodarone (5 mg/kg) or lidocaine (1.5 mg/kg) was administered in a randomized, double-blinded manner. If VF persisted after a further shock, a second dose was given (1.5 mg/kg lidocaine; 2.5 mg/kg amiodarone), and resuscitation was continued. The rate of survival to admission was significantly higher in the amiodarone group compared with the lidocaine group (RR, 1.90; 95% CI, 1.16 to 3.11), however, no significant difference was found in the survival to discharge between the two groups (RR, 1.67; 95% CI, 0.57 to 4.88). Rea and colleagues [20] retrospectively reviewed the data of IHCA (pulseless VT/VF) from three large academic medical centers. Cardiac arrest was caused by circulatory or respiratory diseases. All CPR treatments and drug doses were according to 2000 AHA guidelines. The results showed that no difference was found in the proportion of patients alive 24 hours after arrest and at discharge between the two groups, the survival to ICU admission was reported. However, amiodarone was administered 8 minutes later on average, compared with lidocaine.
In Dorian et al. [19], adequate allocation concealment and binding was considered, according to the article, but no information about randomized-sequence generation was reported, so unclear risk of selection bias was considered. For the retrospective study [20], high risk of selection, performing, and detection bias was considered. Details are shown in Table 2.
Both of the two studies reported survival to discharge and survival to admission. The pooled results showed that no significant differences in survival to discharge (χ2 = 1.18; P = 0.28; I2 = 15%; RR, 1.01; 95% CI, 0.65 to 1.55) and also survival to admission (Figure 5).
Figure 5. Comparison of the effects of amiodarone versus lidocaine. (A) Survival to hospital admission/24 hours. (B) Survival to hospital discharge.
Nifekalant versus amiodarone/lidocaine
In our review, we attempted to study the use of new potassium-channel blockers during CPR, and only four trials that studied the effects of nifekalant were identified (Table 1) [21-24]. Amino and colleagues [21] compared nifekalant versus amiodarone for OHCA patients (shock-resistant VF) who were transferred to the EMS of Tokai University [21]. Thirty patients were enrolled, and the study drugs were given randomly; amiodarone was shown to be superior to nifekalant in all outcomes (Figure 6). Shiga and colleagues [22] conducted a prospective observational study to compare the effects of nifekalant versus lidocaine for IHCA (shock-resistant VF/VT) [22]. Tahara and colleagues [23] performed a retrospective, historical controlled study that enrolled OHCA patients with shock-resistant VF. Both studies showed that nifekalant significantly improved ROSC compared with lidocaine but not the live discharge. Additionally, Igarashi and colleagues [24] conducted a controlled study with only 22 patients to compare nifekalant and lidocaine for OHCA patients with VF. Nifekalant (0.2 to 0.4 ml/kg) or lidocaine (1 to 2 mg/kg) was given respectively after arrival at the ED and confirmation of VF. All patients died before discharge, but nifekalant was shown to improve the return of sinus rhythms compared with lidocaine.
Figure 6. Comparison of nifekalant with amiodarone. (A) ROSC. (B) Survival to hospital admission/24 hours. (C) Survival to hospital discharge. ROSC, return of spontaneous circulation.
In the assessments of methodologic qualities (Table 2), unclear risk of selection bias was considered for the randomized trial, but high risk of selection and performing bias was considered for the other two observational studies [21-23]. In the case of Igarashi et al., because no detailed information about study design was found in the text, a high risk of bias was considered for this study [24]. The overall pooled results showed that nifekalant significantly improved initial resuscitation compared with lidocaine (Figure 7), but no significant difference was found in the live discharge between the two groups (χ2 = 0.59; P = 0.44; I2 = 0; RR, 1.40; 95% CI, 0.88 to 2.25).
Figure 7. Comparison of nifekalant versus lidocaine. (A) ROSC. (B) Survival to hospital admission/24 hours. (C) Survival to hospital discharge. ROSC: return of spontaneous circulation.
One randomized trial enrolled 91 out-of-hospital patients with VF refractory to four countershocks and compared the effect of bretylium with lidocaine [25]. Bretylium was not shown to have better effect than lidocaine on survival to hospital admission (RR, 1.01; 95% CI, 0.48 to 2.15) and survival to hospital discharge (RR, 0.45; 95% CI, 0.09 to 2.18). Another randomized double-blinded trial compared the effect of bretylium with placebo [26]. Bretylium was not shown to improve the proportion of patients who survived to leave the ED (RR, 4.28; 95% CI, 0.60 to 30.26).
In a randomized double-blinded trial of sotalol versus lignocaine in out-of-hospital VF patients [27], 129 patients with VF refractory to four shocks were enrolled, and the results showed that sotalol was not superior to lignocaine for improving survival to hospital admission (RR, 0.60; 95% CI, 0.33 to 1.10), survival to hospital discharge (RR, 0.33; 95% CI, 0.07 to 1.52), and neurologic outcome (RR, 0.13; 95% CI, 0.01 to 2.32).
Subgroup analysis
In the comparison of magnesium with placebo and amiodarone with lidocaine, both OHCA and patients were included, so we performed subgroup analysis of OHCA and IHCA patients.
In the comparison of magnesium with placebo, three double-blind, randomized controlled trials enrolled 281 OHCA patients, and magnesium was not shown to improve survival to hospital discharge (RR, 1.57; 95% CI, 0.41 to 6.05), ROSC (RR, 1.16; 95% CI, 0.71 to 1.89), and survival to ICU admission (RR, 0.92; 95% CI, 0.68 to 1.24) [13-15]. One double-blind, randomized controlled trial enrolled 67 IHCA patients, and the results showed that magnesium had not improve survival to hospital discharge (RR, 0.99; 95% CI, 0.54 to 1.82), ROSC (RR, 0.90; 95% CI, 0.68 to 1.18), or survival to 24 hours (RR, 1.16; 95% CI, 0.32 to 4.26) [16].
In the comparison of amiodarone with lidocaine, one double-blind, randomized controlled trial with 347 patients showed that amiodarone improved the survival to ICU admission (RR, 1.90; 95% CI, 1.16 to 3.11) in OHCA patients compared with lidocaine [19]. However, in IHCA patients, the other retrospective study that enrolled 118 patients, showed no significant difference in survival to 24 hours between the two treatments (RR, 0.91; 95% CI, 0.69 to 1.18) [20]. No significant difference was found between the effects of amiodarone and lidocaine on survival to hospital discharge (RR, 0.99; 95% CI, 0.54 to 1.82) in both OHCA and IHCA patients [19,20].
Sensitivity analysis
In the comparisons of amiodarone with placebo and amiodarone with lidocaine, only one trial could be identified if the other trials with high risk of bias were excluded [11,19]. In the comparison of amiodarone with placebo, amiodarone was shown to improve ROSC rate and survival to admission (RR, 1.27; 95% CI, 1.02 to 1.59) compared with placebo; however, the survival to discharge did not differ significantly in the two groups (RR, 1.02; 95% CI, 0.65 to 1.59) [11]. These results were consistent with those synthesized before exclusion of the retrospective designed study, which was considered to be with high risk of bias.
In the comparison of amiodarone with lidocaine, when the retrospective designed study with high risk of bias was excluded, only one randomized blinded trial was included, and no significant difference was found in the survival to discharge between the two groups (RR, 1.67; 95% CI, 0.57 to 4.88), but the survival to admission was significantly better in the amiodarone group compared with the lidocaine group (RR, 1.90; 95% CI, 1.16 to 3.11) [19]. This was not consistent with the totally pooled results. This result might come from the design of two studies. In the retrospective designed study, no randomization and blinding were performed, so high risk of selection bias and detection bias were considered. However, statistical heterogeneity (I2 = 88%) and clinical heterogeneity (the retrospective designed study enrolled IHCA patients) were found.
In our review, we included all adult nontraumatic patients. The included studies were all conducted in urban or suburban settings, and the medical treatment was performed by European/American/Asian EMS systems or EDs, respectively. The CPR treatment during ALS was according to AHA or ERC guidelines published in 2000 or before. The majority of participants' rhythms were presented as VF/VT.
In the comparison of magnesium versus placebo, four studies with good methodologic quality were included [13-16], and no significant differences could be found in ROSC, survival to admission, and survival to hospital discharge between the two treatments. In subgroups of OHCA and IHCA patients, no significant differences were found in all outcomes. Although two trials included few patients with other rhythms, we did not perform subgroup analysis for these rhythms because of such small sample size [15,16]. Thus, our results demonstrate that magnesium has no significant benefits when used for CPR, for either OHCA or IHCA.
In the assessments of the effects of amiodarone, no improvement of survival to admission was found in ROSC, survival to admission, and survival to hospital discharge when treated with amiodarone according to the pooled results. But when excluding a retrospective observational study, one randomized trial that had enrolled 504 patients and was considered to have good quality showed that amiodarone had improved the survival to admission but not the survival to discharge, compared with placebo [11]. All high statistical (I2 = 86%), methodologic, and clinical heterogeneity was concerned between the two studies included in the synthesis. The heterogeneity derived from the retrospective study with high risk of bias [12], and in this study, the prehospital condition was more severe in the amiodarone group [20]. So the pooled results of survival to admission must be interpreted with caution. According to the high-quality study [11], amiodarone is still likely to be beneficial to initial resuscitation, although the effect size is rather small (RR, 1.27; 95% CI, 1.02 to 1.59).
We also identified two studies that had compared amiodarone with lidocaine. The pooled results showed that no significant differences could be found in the survival to hospital discharge and survival to admission/24 hours between the two study groups. However, one good-quality study indicated that amiodarone was superior to lidocaine in initial resuscitation (evaluated by the survival to admission) [19]. This was inconsistent with the results reported from the other retrospective designed study and also the pooled result [20]. According to sensitivity analysis, the pooled results did not seem to be robust. However, the retrospective observational study included IHCA patients, whereas the RCT included OHCA patients, and it was considered to be with high risk of bias. Moreover, in the observational study, amiodarone was administered later than lidocaine, and it was not administered with the recommended doses to all the patients. So it is suggested that the reduced demonstrated effects of amiodarone on survival to 24 hours in this study is due to such clinical heterogeneity. Significant statistical heterogeneity (I2 = 88%) was also considered between these two studies. Thus, in the comparison of amiodarone with lidocaine, the pooled result of the survival to admission still must be interpreted with caution. We generally suggest the use of amiodarone instead of lidocaine, according to the findings of the randomized trial.
Two studies with high risk of bias compared lidocaine with placebo [17,18], and showed that no significant differences were found in those alive at discharge between the two groups. Although it is indicated that lidocaine has the potential to improve initial resuscitation compared with placebo, the quality of evidence is low, and we suggest that the replacement of lidocaine with amiodarone in clinical use seems to be appropriate.
Moreover, we suggest that the new potassium-channel blockers might have the potential to be used during CPR. However, after our literature search, no more trials were identified, except for four trials that focused on the effects of nifekalant, and they were all conducted in Japan [21-24]. The pooled results of three low-quality trials indicated that nifekalant was superior to lidocaine in initial resuscitation but not in the survival outcomes [22-24]. By contrast, a randomized trial with small sample size showed that nifekalant was inferior to amiodarone in either initial resuscitation or survival outcomes [21]. Thus, no present evidence can support the use of such potassium-channel blocker instead of amiodarone. Although nifekalant may be superior to lidocaine in initial resuscitation, considering the low quality of evidence, it is still hard to suggest the use of nifekalant.
Some studies focused on the use of bretylium and sotalol, but the very limited data showed no benefits of the two drugs.
Above all, all antiarrhythmic drugs were not shown to be significantly beneficial for cardiac arrest. However, because many variables might affect the practice of resuscitation, such as the cause of arrest, the response interval of the EMS system, the chest-compression fraction, the quality of CPR, and postresuscitation treatment. Thus, regarding these issues, the retrospective design of a study might bring high risk of overall bias through the study, including allocation, performing, and detection bias. All of these might have the potential to affect the demonstration of treatment effect. Therefore, according to the high-quality studies [11,19], it is suggested that amiodarone still seems to be superior to placebo (RR, 1.27; 95% CI, 1.02 to 1.59) and lidocaine (RR, 1.90; 95% CI, 1.16 to 3.11) for improving initial resuscitation assessed by the survival to admission, although the effect sizes are not big.
For the lack of data, we only performed subgroup analysis according to OHCA and IHCA in the comparison of magnesium with placebo and amiodarone with lidocaine. Similar results were found in both subgroups in the comparison of magnesium with placebo for all outcomes. Although in the comparison of amiodarone with lidocaine, the results were not consistent in the two subgroups in the analysis of initial resuscitation, this inconsistence might derive from the nonrandomization of the observational study.
Limitations in our review include that little evidence can be found after searching the literature. In the subgroups of amiodarone versus placebo, amiodarone versus lidocaine, and nifekalant versus amiodarone, only one or two controlled trials could be found. In total, 433 patients were included in the pooled results of the subgroup of magnesium versus placebo. Therefore, the results derived from present literature were rather underpowered to appraise certain ideas according to the sample sizes.
The second limitation is related to the methodologic quality of individual evidence. Many of the included studies were observational cohort studies, and especially, retrospective design. We suggest that adequate randomization and blinding of the rescuers is important to reduce the allocation, performing, and detection bias in clinical practice of CPR; thus, high risk of bias might be considered for these individual observational studies.
The third limitation is related to the heterogeneity, especially clinical heterogeneity, which is an inherent problem in data synthesis. The emergency settings in the rescuing from cardiac arrest bring particular difficulties of access to the expected homogeneity in clinical studies. The reviewed studies included patients with varied baseline characteristics (such as the settings of collapse, basic diagnosis, bystander CPR, CPR protocols performed by professional rescuers, and different regimens of antiarrhythmics and postresuscitation care, such as hypothermia). Although no significant difference was found in baseline characters between the study groups, all these variables lead to clinical heterogeneity. Significant statistical heterogeneity was found according to the χ2 test and I2 statistic in subgroups. These encouraged us to use a random-effect model.
So according to these issues, the pooled results of the data from current evidence still need to be interpreted with caution. We assessed the data according to subgroups of OHCA and IHCA, but conversely, the sample size is rather weakened.
Our review provides some implications. To our knowledge, lack of evidence focused on medications during CPR can be found. No antiarrhythmia agents have been demonstrated to improve the survival of cardiac-arrest patients. According to studies of high quality, only amiodarone seems to be beneficial in the improvement of initial resuscitation, although the strength of existing evidence is not robust enough, according to the sample size. Our review supports the summarization of the effects of antiarrhythmics and the recommendation of medication strategies in the AHA 2010 guidelines [5,6], and we suggest the use of amiodarone in patients with refractory VF/pulseless VT. A previous review provided a similar implication. Compared with the review, we performed a more up-to-date literature search; we also used an optimized tool to assess the quality of evidence, and we synthesized data by meta-analysis.
According to the review, a major issue of research in resuscitation drugs is the lack of clinical data. It is important to develop randomized prospective studies with large sample sizes to assess the effects of antiarrhythmia agents during CPR. According to our review, nonrandomization and nonblinding design seem to bring a high risk of selection bias and performing bias, which might affect the study results. Larabee et al. [28] suggested that developing prospective regional/national systems for analysis of cardiac arrest outcomes would be help to capture an appropriate sample size to examine the medications and intended outcomes.
We suggest that it is important for the articles to report details about the randomization or blinding methods (such as allocation concealment) in resuscitation studies, because in the research into resuscitation, the details of randomization and blinding are important in the assessment of the quality of evidence. Additionally, no new drugs seem to be valuable in resuscitation currently. Studies have not applied new antiarrhythmics to resuscitation, such as other potassium-channel blockers, but it is possible that these agents (such as ibutilide, dofetilide) may have the potential to be used during CPR, according to the pharmacologic mechanisms. Further studies focusing on these agents might also be expected.
In summary, no current drugs have been shown to improve the survival in cardiac-arrest patients. Only amiodarone may improve initial resuscitation, and no new drugs can be recommended currently. A major issue in resuscitation research is that relevant studies focused on resuscitation drugs are very limited, especially high-quality studies.
Key messages
● An up-to-date systemic review and meta-analysis have found that according to present literature, only limited data about the use of antiarrhythmic drugs for cardiac arrest can be found, and the quality of evidence is rather low. No antiarrhythmic drugs have been shown to improve the survival of cardiac-arrest patients, and only amiodarone is suggested to be used for improving initial resuscitation by our review.
● More clinical studies focused on resuscitation drugs are expected and warranted, especially studies with good quality and focused on new types of antiarrhythmic drugs.
ACLS: Advanced cardiac life support; AHA: American Heart Association; CI: Confidence interval; CPC: Cerebral performance category; EMS: Emergency medical service; IHCA: In-hospital cardiac arrest; ILCOR: International Liaison Committee on Resuscitation; OHCA: Out-of-hospital cardiac arrest; RCT: Randomized controlled trial; ROSC: Return of spontaneous circulation; RR: Risk ratio; SCA: Sudden cardiac arrest; VF: Ventricular fibrillation; VT: Ventricular tachycardia.
Competing interests
We received funding support from National Natural Science Foundation of China (NSFC) 81071539. The authors declare that they have no competing interests.
Authors' contributions
YH and QH were responsible for study concept and design. YH acquired the data. YH, MY, LZ, and QH analyzed and interpreted the data. YH and QH performed statistical analysis. YH drafted the manuscript. QH was responsible for the revision of the manuscript for important intellectual content. QH supervised the study. YH, MY, LZ, and QH read and approved the manuscript for submission.
Authors' information
Yu Huang and Qing He are co-first authors.
Thom T, Haase N, Rosamond W, Howard VJ, Rumsfeld J, Manolio T, Zheng ZJ, Flegal K, O'Donnell C, Kittner S, Lloyd-Jones D, Goff DC Jr, Hong Y, Adams R, Friday G, Furie K, Gorelick P, Kissela B, Marler J, Meigs J, Roger V, Sidney S, Sorlie P, Steinberger J, Wasserthiel-Smoller S, Wilson M, Wolf P, American Heart Association Statistics Committee and Stroke Statistics Subcommittee: Heart disease and stroke statistics 2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
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Camm AJ, Lip GY, Caterina DR, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, et al.: 2012 focused update of the ESC Guidelines for the management of atrial fibrillation.
Eur Heart J 2012, 33:2623-2630. PubMed Abstract | Publisher Full Text
Katoh T, Mitamura H, Matsuda N, Takano T, Ogawa S, Kasanuki H: Emergency treatment with nifekalant, a novel class III anti-arrhythmic agent, for life-threatening refractory ventricular tachyarrhythmias post-marketing special investigation.
Circ J 2005, 69:1237-1243. PubMed Abstract | Publisher Full Text
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Circ J 2009, 73:2021-2028. PubMed Abstract | Publisher Full Text
Higgins JPT, Altman DG, Sterne JAC: Assessing risk of bias in included studies. In Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). Edited by Higgins JPT, Green S. The Cochrane Collaboration; 2011.
Available from http://www.cochrane-handbook.org webcite
Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T: Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation.
N Engl J Med 1999, 341:871-878. PubMed Abstract | Publisher Full Text
Skrifvars MB, Kuisma M, Boyd J, Määttä T, Repo J, Rosenberg PH, Castren M: The use of undiluted amiodarone in the management of out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2004, 48:582-587. PubMed Abstract | Publisher Full Text
Hassan TB, Jagger C, Barnett DB: A randomised trial to investigate the efficacy of magnesium sulphate for refractory ventricular fibrillation.
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Allegra J, Lavery R, Cody R, Birnbaum G, Brennan J, Hartman A, Horowitz M, Nashed A, Yablonski M: Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting.
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Rea RS, Kane-Gill SL, Rudis MI, Seybert AL, Oyen LJ, Ou NN: Comparing intravenous amiodarone or lidocaine, or both, outcomes for inpatients with pulseless ventricular arrhythmias.
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Amino M, Yoshioka K, Opthof T, Morita S, Uemura S, Tamura K, Fukushima T, Higami S, Otsuka H, Akieda K, Shima M, Fujibayashi D, Hashida T, Inokuchi S, Kodama I, Tanabe T: Comparative study of nifekalant versus amiodarone for shock-resistant ventricular fibrillation in out-of-hospital cardiopulmonary arrest patients.
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Igarashi M, Fujino T, Toyoda M, Sugino K, Sasao K, Sasamoto S, Otsuka T, Kobayashi K, Okano Y, Yosiwara K, Koyama N: Defibrillation effects of intravenous nifekalant in patients with out-of-hospital ventricular fibrillation.
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text:
Canada Goose Camp Down Coat
|Shell Fabric
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|Lining Fabric
62 gsm, 40D 100% recycled Polyester down proof, plain weave treated with a DWR finish.
750 fill power Hutterite white duck down
Where to Buy
sponsored links
Manufacturer's Description
Visit Canada Goose's Camp Down Coat page.
Retailers' Descriptions
Here's what other sites are saying:
Free Shipping. Canada Goose Women's Camp Down Coat FEATURES of the Canada Goose Women's Camp Down Coat Windproof by construction Long-thigh length provides maximum protection Down filled collar adjusts with a drawcord to seal out drafts Centre front YKK 2-way locking reversed coil zipper, with Canada Goose logo zipper pull Insulated centre front storm flap that extends over centre front zipper Brushed tricot at chin for comfort Canada Goose logo ribbon runs along centre Two hand pockets secured with YKK reverse coil zippers and zipper pulls Brushed tricot at the back of the neck for increased warmth Access to single-handed adjustable hem using pocket access to seal out cold and wind Internal stretch mesh pocket Lycra stretch cuffs for comfort and warmth SPECIFICATIONS of the Canada Goose Women's Camp Down Coat Centre Back Length: 37.5in. / 95.25 cm Fill Power: 750 Fill Power Hutte Rite White Duck Down Fit: Slim Insulated This product can only be shipped within the United States. Please don't hate us.
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subset: commoncrawl


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Catherine McKenzie Press Releases
By GingerNewYork TV Show
Cat McKenzie, Board Member for MS Hope for a Cure, Will Join Founder EJ Levy in a Discussion about their Charity and Upcoming Fundraiser, The 10th Annual WABC-TV & Friends vs. MS Benefit. Join the TV Studio Audience. February 15th, 2pm EST
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From our buddies at This Is Fly .Sad news for all American salt water fishing fans… The famous José Wejebe , Cuban born master of the Spanish Fly TV show on the Outdoor Channel (ESPN), died in a plane crash in the Everglades. He was known to be one of the most passionate fisherman ever.
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Jose, may the Eternal Fishing Grounds be your haven of peace.


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1998 Chevrolet Cavalier • 4 cylinder FWD Automatic • 131,000 miles
I have a 1998 Chevy cavalier with 130K miles on it. We replaced the thermostat because it went bad an overheated on us. We also replaced the radiator, fan relay and water pump to avoid future "surprises". It's still overheating (even in idle)and the fan is coming on like it should. From what I'm reading, we should bleed the cooling system. Ok, so how do we bleed the cooling system?
February 20, 2011.
February 20, 2011.
I know the thermostat is in correctly. I know that the fan is running like it should. I know that the hoses are not clogged and are all connected. I know that there is not a leak from the new radiator. Boyfriend is a mechnic, on large trucks and tanks and things like that, this is a different animal. He did a compression test on it and the head gasket has not been compromised. We just got this car 2 weeks ago and don't know it yet.
Feb 20, 2011.
Feb 20, 2011.
Bleed the cooling system by removing the top cap, that lets the air out, and you can add coolant to the radiator, and bleed it out in that fashion. If you need to bleed your cooling system as a unit, that's an entirely different procedure. That outline is going to be given to your owner's manual, and that depends on where the highest point in the cooling system is, as to what the bleeding procedure is, but for a radiator, as long as the cap is the highest point of the radiator, that's how you'll bleed a radiator. If there's a higher point on there, that can trap air in it, you're going to have to put a bleed valve on there, to let the air out, or the system isn't going to bleed correctly, so if you have to bleed a cooling system, what you're going to need to find, is that bleed valve, and that just depends on whether there's a point in the cooling system, that exceeds the height in the cap of the radiator. Wherever the highest point in the cooling system is, that's where it's going to trap the air, and that's where a required bleed point is going to be, but for most vehicles, a radiator, and a radiator cap, is the highest point in the cooling system, and so the radiators can be bled, just simply by removing that cap, and allowing the system to fill up, until all the air is gone. You need to remember also, that there's a thermostat in the system, and when that's sealed, or in the cold or closed position, it can trap air into the bottom side of the engine, so you want to make sure, anytime you're trying to bleed the system, after you've bled it, you've run the engine for at least fifteen, twenty minutes, make sure it's thoroughly warmed up, and the cooling system has cycled several times, and then recheck it after it's cooled, and re-top as necessary, to remove any additional air, that might have been trapped in the engine, so that's how you bleed a radiator, and/or cooling system."
Feb 25, 2011.
Feb 25, 2011.
Engine Cooling problem 2003 Oldsmobile Intrigue 6 cyl Two Wheel Drive Automatic 150,00 miles A replacement engine was installed in this vehicle. The engine runs perfectly as long ...
1 answer • 2003 Oldsmobile Intrigue
Engine Cooling problem 2000 Lincoln Town Car V8 Two Wheel Drive Automatic 206000 miles How do i get the air out of the cooling system is there some bleed off valves and where are ...
1 answer • 2000 Lincoln Town Car
Engine Cooling problem 2003 Toyota Corolla 4 cyl Front Wheel Drive Automatic 93000 miles Hi, I am having a problem with the cooling system and am trying to pinpoint what's wrong...
3 answers • 2003 Toyota Corolla


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Listen: The Knife "Lets Talk About Gender Baby Lets Talk About You & Me" (Planningtorock rework)
Swedish sibling duo The Knife have just announced a new single "Let's Talk About Gender Baby, Let's Talk About You And Me".
It's not really a brand new track though – The Knife have invited English electronic producer Planningtorock to rework their track "Full of Fire", the first single off their 2013 album 'Shaking the Habitual'. Take a listen, it's a real treat!
'Shaking the Habitual' is out now on Pod
Buy online
Posted in News on September 19th, 2013 - By Leo / Tags: Electronic, Pod, The Knife, Video


text: Description Suggest an Edit The discovery of anthracite coal in the Tremont area of Pennsylvania shaped commerce and development well into the 1800s. The Union Canal was constructed in the 1820s to connect the Schuylkill and Susquehanna rivers and improve transport of anthracite coal. A branch canal was constructed from Lebanon to Pine Grove through what is now Swatara State Park. The flood of 1862 destroyed the branch. By then because the Lebanon–Tremont Branch of the Reading Railroad on the opposite bank of Swatara Creek served all transport needs, the canal was never repaired. The Swatara Rail-Trail stretches 10 miles along the western side of Swatara Creek, from Pine Grove almost to Lickdale, revealing remnants of both the canal and the railroad along the way. A new bridge, several hundred feet long, crosses the creek and provides a connection to Bear Hole Trail on the other side. Together, the trails provide a 20-mile loop of riding along the waterway. Both trails are primarily surfaced with crushed limestone, but the rail-trail includes a short paved section along an unused road at its southern end at Waterville Bridge for the Appalachian Trail crossing. There is then about two miles of as yet unimproved but passable trail from the bridge to the Lickdale trailhead. Note that there is also an unimproved section on the rail-trail's northeastern end, between Suedberg and the Pine Grove Interchange, that is closed as of July 2013.Swatara State Park covers more than 3,500 acres of land, offering lush forest surroundings that create a sense of remoteness perfect for the adventure lover. Although the rail-trail starts and ends outside the park's boundaries, the majority is within it. Several new trailheads with parking and informational kiosks offer a choice of where to begin your explorations. Paddling and fishing are allowed in Swatara Creek and access to the water is provided at the Lickdale and Swopes Valley trailheads. From the State Park Lane trailhead, you can also access six single-track, natural-surface trails for mountain biking. Each one is roughly 1.5 miles long with twists and hills through the woods.Nearby, a few miles north of the park, the Stony Valley Railroad Grade offers another backcountry treat; an extended day or weekend excursion on both trails may be in order. The trail also connects to the Appalachian Trail near Inwood. Click to read more Parking and Trail Access There are several places with parking and informational kiosks along the Swatara Rail-Trail, as listed below from south to north. - Lickdale Trailhead: located on the southern tip of the trail on Monroe Valley Road; includes spaces for horse and boat trailers - Trout Run Trailhead: located on Route 72; a new restroom facility is planned for this trailhead - State Park Lane Trailhead; a good choice for accessing the park's mountain biking trails- Sand Siding Road parking lot: located mid-trail along Swatara Creek, south of State Route 443- Swopes Valley Trailhead: located on the northeastern end of the trail, across from Wagner's Pond Click to read more Reviews Continual improvement August, 2015 by youker The state park system has continued to improve the trails in Swatara State Park. The new Mill Creek bridge in Suedberg is in with access from Swopes Valley road and opens up more yards of trail. The trail in the other direction to Pine Grove Interchange ...read more Good ride on the Swatara-Bear Hole Trails August, 2015 by dan reynolds I had a good ride on the Swatara-Bear Hole Trails today with a close friend. I'm 56 and he's 53 (and in better shape) so keep that in mind. The day was heavily overcast (but, no rain while on the trail) with a temp. about 70°. Some points: 1) If you ...read more Nice Trail July, 2015 by fujiguy Had trouble finding the parking lot in Lickdale so I drove to Pine Grove and parked at the Swopes Valley Trailhead parking lot. Nice size and not many people there on this Saturday morning. Rode Bear Hole trail down to the Waterville bridge which joins ...read more


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Act I©2004 Robert Reynolds Photo
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NOTE: The quoted costs are subject to change. Final costs will be set when a contract is requested.
* Does not include board operators or follow spots
View Scenery Technical Drawings
**Does NOT include space for storage of scenery between acts.
Duke of Mantua (Francesco Demuro) and Countess Ceprano (Carissa Castaldo)Act I© Rozarii Lynch Photo
Rigoletto (Marco Vratogna) Act I© Rozarii Lynch Photo
Duke of Mantua (Francesco Demuro) and Gilda (Nadine Sierra)Act I© Rozarii Lynch Photo
Duke of Mantua (Francesco Demuro), Marullo (Barry Johnson) and Chorus Act II© Rozarii Lynch Photo
Gilda (Nadine Sierra) and Rigoletto (Marco Vratogna)Act II© Rozarii Lynch Photo
Rigoletto (Marco Vratogna), Gilda (Nadine SIerra), Duke of Mantua (Francesco Demuro), and Maddalena (Sarah Larsen) Act III© Rozarii Lynch Photo
Rigoletto (Marco Vratogna) and Sparafucile (Andrea Silvestrelli) Act III© Rozarii Lynch Photos
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Dancer Women (5 costumes)5) Party guests
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Super Women (7.5 costumes)7) Party guests0.5) Party guests outdoor wear
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9th Annual Sedona Marathon
by: Christy on 8/23/2013
It's never too early to start training for the 9th Annual Sedona Marathon! On February 1, 2014, runners from around the globe will be gathering in Sedona to run through beautiful red rock country to complete either the full marathon, half marathon, 5k, or 10k. As a proud sponsor of the Sedona Marathon, the BEST WESTERN PLUS Arroyo Roble Hotel & Creekside Villas would like to extend a special discount* to runners on Standard Red Rock or Town View Guestrooms during the week of the race! For additional information and a complete list of terms and conditions, please visit http://bestwesternsedona.com/package/sedona-marathon/


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Town Square
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COMMENTS ON STORIESAlamo concerned over lack of police at nighttime
Residents expressed concerns about lack of police response amid the ongoing county cutbacks, reporting at a recent meeting...Original post made on Jul. 23, 2009
Last comment by Askidoo, on Aug 9, 2009 at 10:15 pm | 33 comments | 2298 Views
CRIMES & INCIDENTSSheriff's deputies continue probe in Fuchs killing
Investigators with the Contra Costa Sheriff's Department continue to work on making arrests in the January murder of Danville...Original post made on Aug. 19, 2009
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AROUND TOWNJogger leaps out of roadway, still gets struck in hit-and-run
A man jogging eastbound at 6:30 a.m. Saturday in the bike lane on Crow Canyon Road near Barbados Drive was struck by a vehicle...Original post made on Dec. 22, 2009
Last comment by Bud, on Jan 12, 2010 at 9:38 pm | 33 comments | 1766 Views
SCHOOLS & KIDSAcceptance-related activities in local high schools?
My daughters attended MV and SRV high schools, and one of many reasons I'm proud of them is that both were involved with...Original post made by Tom Cushing on Oct. 2, 2010
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AROUND TOWNPatrick David's offers solution to gift card complaints
People who bought Patrick David's gift cards at Costco can't use them at the restaurant, but at least they can get their...Original post made on Oct. 27, 2010
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CRIMES & INCIDENTSLast player in St. Isidore embezzlement case sentenced
An Alamo resident and former volunteer at St. Isidore's Catholic Church has been sentenced in an embezzlement case. Evelyn...Original post made on Dec. 9, 2011
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COMMENTS ON STORIESThieves rush Livermore Outlets store, steal thousands of dollars worth of designer jeans
In a brazen daytime robbery, as many as 10 suspects rushed a Livermore outlet store and stole thousands of dollars worth...Original post made on May. 28, 2013
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COMMENTS ON STORIESDirty politics
Emotions are running high in the Alamo incorporation election, but that is no reason to start playing dirty. Read the full...Original post made on Feb. 20, 2009
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CRIMES & INCIDENTSDanville man among slain Oakland officers
Ervin Romans of Danville was one of the three Oakland police officers shot and killed yesterday by a man on parole. Romans,...Original post made on Mar. 22, 2009
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COMMENTS ON STORIESTwo shot in Alamo in attempted jewelry store robbery
Two people were shot last night in Alamo, reported San Ramon Valley Fire Protection District Chief Richard Price. The shooting...Original post made on Dec. 4, 2009
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SCHOOLS & KIDSSchool Dress Code- Do you think kids dress appropriately?
School starts in less than a month, and along with warm weather go styles that are more appropriate for the beach instead...Original post made by Lili L. on Jul. 26, 2010
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SCHOOLS & KIDSSRVUSD gets aggressive with bullies
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AROUND TOWNMayor highlights projects, fiscal responsibility in State of the Town speech
Mayor Candace Andersen delivered the annual State of the Town address Thursday afternoon, which highlighted the town's fiscal...Original post made on Mar. 22, 2012
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COMMENTS ON STORIESJudge: Rail authority's funding plan violated law
The California High-Speed Rail Authority violated state law and "abused its discretion" in proceeding with the controversial...Original post made on Aug. 20, 2013
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COMMENTS ON STORIESACA call center preps to enroll Californians in health exchange
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COMMENTS ON STORIESPlaying games
The GOP rallied against Social Security in the 1930s, Medicare in the '60s and now ObamaCare, Tom Cushing writes in this...Original post made on Oct. 9, 2013
Last comment by C. R. Mudgeon, on Oct 16, 2013 at 10:47 am | 32 comments | 1716 Views
COMMENTS ON STORIESState attorney general appeals concealed weapons ruling
California Attorney General Kamala Harris on Thursday asked the 9th U.S. Circuit Court of Appeals to review and reverse a...Original post made on Mar. 5, 2014
Last comment by Peter Kluget, on Mar 18, 2014 at 9:51 am | 32 comments | 1845 Views
COMMENTS ON STORIESAlgae blooms, new water source blamed for bad-tasting water
Some San Ramon Valley residents may have noticed a strange taste or bad smell in their water in recent weeks. Read the...Original post made on Sep. 28, 2015
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COMMENTS ON STORIESStatewide funding measures defeated
The state of California's ongoing budget mess got no help Tuesday from voters, who turned down several ballot measures aimed...Original post made on May. 20, 2009
Last comment by Rick, on May 27, 2009 at 10:53 am | 31 comments | 2279 Views
AROUND TOWNDon't Give Up On Health Care Reform
The recent headlines regarding Anthem's decision to raise rates up to 39% for individual policy holders is yet another...Original post made by jrm on Feb. 9, 2010
Last comment by jrm, on Feb 22, 2010 at 12:44 pm | 31 comments | 1724 Views
Thanksgiving Dinner
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Happy Thanksgiving
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adorable Chesaberian female puppy
We will have a new litter of Chesaberian pups . New pups due late Nov 2015. These dogs make very good pet companion dogs, will retrieve, swim and also can be excellent fast sled sled dogs, making them good to use for dog mushing, our state sport. pups will be vaccinated and tattooed for I.D. Dewormed. Contract required. The pup in our picture is a Chesaberian .Deposit to save one for ...
Nov 4 -
Tok - Dogs & puppies
Widwood kennels Siberian Husky pups.Georgous loving companions
Akwildwood Siberian Huskies. We have gorgeous red sable as well as some red with blue eyes, black and white as well as silver .Deposit required to hold a puppy for you. Pups must be 8 weeks old before they are sold. Priced $1000.00 to $1500.00.Shipping available to Fairbanks and Anchorage.
Bloodlines are from working sled dog parents. We have healthy, beautiful puppies with good ...
Beautiful Siberian Husky pups
Gorgeous,, Siberian Husky pups From Working sled dog parents. Beautiful loving companions.
We have Siberian pups due November 2015. Colors are black and white .Silver and red and white, rare red sable . Many with blue eyes. Deposits are required to hold a puppy of your choice. Pups from $1000.00 . Contracts are required . Shipping available to Fairbanks and Anchorage. Call us at 907-883 ...
AKC Saint Bernard puppy for sale !
Akc registered, champion blood lines, dry mouth, very smart,super sweet temperament and bueitiful puppies. Good whit kids and another animals.Puppies dewclaws front and back,dewormed evry 2 weeks .Mom feed puppies 8 weeks age, we feed extra after 4 weeks old w puppy food.Puppies very healthy and happy. Website :saintbernardpups.com 907-987-0024
Nov 3 -
Fairbanks - Dogs & puppies
AKC Champ.line Saint Bernard puppies for sale !
Akc register puppy, champion blood lines, dry mouth, very smart and beautiful,very sweet, love kids and good whit another animals, puppies front and back dewclaws, dewormed and have shots,website ;saintbernardpups.com contact 907-987-0024 or 907-616-1500
Oct 15 -
Delta Junction - Dogs & puppies
Chesapeake retrievers, AKC pups ,Dual Ch. Bloodlines
Chesapeake Pups Double Line Bred On Duel (field and show Champion ) Coots Gypsy Clipper MH. Two Males One Female 12 Weeks Old. Will Make Excellent Family And Gun Dogs. Vaccinated Tattooed And Dewormed. Forever Homes Only Contract Required. AKC Breeder Of Merit, Breeding Since 1963. Home(907)883-5866 Cell(907)505-0651. Please Visit Our Website At www.akwildwoodchesapeakeretrievers.com
Oct 11 -
Tok - Dogs & puppies


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Title: Web Programming with SAP's Internet Communication Framework
Location: MadLab
Description: With web-scale integration becoming increasingly important in the SAP and enterprise software world, understanding the framework that underpins SAP's offerings in this area is crucial, whether you want to extend your end-to-end integration process knowledge, embrace and adopt existing web offerings from SAP, or roll your own HTTP services.
Start Time: 10:00
Date: 2011-09-05
End Time: 17:30
Sign up: Book your place
SAP's Internet Communication Framework (ICF) is the platform that underpins the majority of SAP's offerings in this space, even SAP NetWeaver Gateway. This 2-day course will help you gain a detailed understanding of the framework, harness its power, and unleash your own resource orientated web service masterpieces!
Get that Competitive Edge
Why is this course important? Well, if you've already read this far, you probably have an inkling that the web is where it's at, and more specifically, in the SAP universe, HTTP is where it's at from an interfacing and platform extension perspective. Want to get involved in building mobile apps and be the backend SAP guru for all forms of modern web-based integration? Do you have a desire to upskill to the next level of SAP integration? Sharpen your competitive edge in an increasingly commoditised industry.
What you need to be familiar with
To benefit from this course, you need to have a basic understanding of SAP and web services, basic knowledge of HTTP, and some ABAP programming experience.
We will be using an SAP NetWeaver 7 system, which has all the components we need for the course. We'll be using SAPGUI to connect, which can be downloaded from the SAP Service Marketplace or from the SAP Developer Network (SDN). We highly recommend that you become a member of the SAP Community Network (of which SDN is a part) if you aren't already.
Equipment you'll need
You'll need to bring your own wifi-capable laptop, with SAPGUI installed. If you are members of SDN we can make the SAPGUI Windows and Java versions available to you on the day too, but we recommend you bring your laptop with SAPGUI pre-installed.
Suggested preparatory work
Familiarise yourself with the SAP Help topics on the ICF, and keep an eye on the SDN weblog posts pertaining to web services, Gateway and the ICF.
Learning Outcomes
You will gain a detailed understanding of SAP's underlying mechanisms for HTTP communications.
You'll have the knowledge and confidence to build, debug and deploy HTTP orientated interfaces into and out of SAP enterprise systems.
You'll also have some exposure to tips, tricks and tools outside of SAP to help in debugging and testing.
About the tutor
DJ Adams is an O'Reilly author, SAP Mentor and a 24-year veteran of SAP technologies. He started out extending SAP R/2 modules in S/370 assembler and after integrating SAP and non-SAP systems with web programming since the mid 1990′s is now recognised as a thought leader in this space.
If you are interested in the course head over to Omniversity
To sign up to Web Programming with SAP's Internet Communication Framework Course


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Well, I'm back after disappearing for a second time this summer. I have not laced up my shoes and ran in 9 DAYS!!!! Im pretty sure I'm on my way out of Funkville, but I had a major setback this past week. I'm not talking about an ankle sprain, knee injury, or even really bad shin splints. Oh no...I'm talking about THE FLU!!!! It started the day after a 3-mile rain run with cold symptoms and really bad neck pain. I started freaking out around day 5, believing I had meningitis (despite being vaccinated for it already. NEVER Google your symptoms). I also made the stupid decision to go through my illness "straight-edged", or without any meds (I was honestly too tired to go buy any). So, I'm feeling fine right now, and if everything goes well, I'll be back to running tomorrow. Good to be back.
It's not running, it's aggressive power-walking!!!!!
5k PR- 28:xx
Get well soon. You probably don't agree right now, but I'd take the flu over a running injury any day.
Good Better Soon. Yeah, Googling your symptoms is never a good idea.
I've said this to other people.......getting sick in the summer is terrible. Get well.
Run on everyone.....................Steve
Summer flu sucks. Get well soon!
Don't stop believing


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Apparently there is another Dir En gray gig on the 2nd of november they are not headlining and its gonna be a bunch of bands.
This is gonna be held in sheperds bush london (which is like 10 min walk away from me so im syked)
Or so the guy who works in Sai Sai says?
Any news?


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Bronx, NY (Sports Network) - Robinson Cano and Lyle Overbay each drove in two
runs and spurred a seventh-inning rally that lifted the New York Yankees to a
4-3 triumph over the Seattle Mariners in the opener of a three-game series.
Cano delivered a game-tying two-RBI double in the seventh and later scored the
go-ahead run as part of a 2-for-3 performance. Chris Nelson also came through
with a pair of hits and a run scored to help the Yankees post their seventh
win in eight outings.
The comeback prevented Felix Hernandez from winning a fifth consecutive start
after the star righty outdueled CC Sabathia in a clash of aces. Hernandez held
New York to one run and five hits while striking out eight before exiting
after six innings.
Charlie Furbush (0-2) was hung with the loss after permitting two runs and
recording just one out in the seventh.
Sabathia racked up a season-best 10 strikeouts, but was reached for three runs
-- two earned -- on 10 hits over 6 1/3 innings. Two of those runs came on a
homer by former Yankee Raul Ibanez that put Seattle up 3-0 in the sixth.
Ex-Mariner Shawn Kelley (2-0) received the victory after retiring both men he
faced in relief of Sabathia, with Mariano Rivera firing a 1-2-3 ninth to notch
his 16th save in as many chances this season.
Ibanez finished 2-for-4 for the Mariners, with Kyle Seager contributing an RBI
double in the setback.
Curtis Granderson returned to the New York lineup from a fractured right
forearm sustained in late February, but went 0-for-3 with a walk and run
scored in his season debut.
The Sports Network


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One of these was Maison Albert Bichot, and Simon wrote: "Since the late 1990s, Bichot has emerged from the doldrums in startling fashion. 2004 saw Bichot elected Winemaker of the Year by magazines in both England and France, and the wines go from strength to strength."
I recently had the opportunity to spend some time visiting the various properties of Albert Bichot. Current head of the company, Albéric Bichot, is the sixth generation to be involved in the business, and he has expanded all areas of the operation whilst upping quality throughout. Although a large volume of generic and village Burgundy appears under the Bichot label, there are also some fine individual estates within the Bichot portfolio, including Domaine Long-Depaquit in Chablis, Domaine du Pavillon in Pommard and Domaine du Clos Frantin in Vosne-Romanée.
Albert Bichot Bourgogne Rouge Vieilles Vignes 2005
Bichot's generic Bourgogne rouge comes from old vines in the Côte d'Or and Côte Chalonnaise. It has a pale crimson colour, and a nicely expressive, perfumed nose with delicate floral and rose-hip nuances to redcurrant and cranberry fruit. On the palate there's a suggestion of creaminess from some small barrel aging, but this is a forward, brightly-focused, very nicely poised style of fruity Burgundy, with more of that summer fruit character and nicely ripe tannins adding a silky but grippy edge. Acidity is very good too, in an impressive generic Burgundy. 88/100. £8.99, Harrison Vintners, Grapevine.
Albert Bichot Gevrey-Chambertin Les Corvées 2004
Les Corvées is a Lieux-dits just south of the village of Gevrey. Around 40 - 45% of new oak is used in the maturation of this wine. The colour is a medium ruby, and the nose offers exquisitely expressive aromas of truffle and spice-edged raspberry and cherry fruit. There's a touch of game, but this is a charmingly fruity and quite delicate aromatic profile. On the palate there is more weight and depth than I would have anticipated, with little liquorice nuances to quite sinewy, fleshy, deep plum and cherry fruit. The tannins are brisk and positive, and a good core of acidity keeps this very fresh. Quite a solid, powerful wine, with richness of oak supporting the finish. Impressive village Gevrey-Chambertin. 91/100. £21.00, Soho Wine Supplies, Harrison Vintners.
|The Château of Long-Depaquit is without doubt one of the most imposing in Chablis.
Long-Depaquit is a substantial vineyard owner, with more than 65 hectares (160 acres) of vines including the Monopole Grand Cru 'La Moutonne', a superb amphitheatre of vines that straddles the Grands Crus boundaries of Preuses and Vaudésirs. This is classic Kimmeridgian rock, planted densely and managed in a near organic regime. In fact, 10% of Long-Depaquit's holdings are Grands Crus, with vineyards in Les Clos, Preuses, Vaudésirs, Blanchots and Bougros. For these and their six Premières Crus sites, all picking is by hand, with fruit sorted both in the vineyard and back at the state of the art winery in the village of Chablis.
|Domaine du Pavillon lies in the village of Pommard, with 17 hectares of vines spread around the villages of Meursault, Volnay, Pommard, Beaune and Aloxe Corton.
The vineyards include two monopoles owned solely by Albert Bichot, the walled Clos des Ursulines in Pommard and the Clos des Maréchaudes, composed of 50 ares of Grand Cru Corton and 1.5 hectare of Aloxe Corton Premier Cru.
Here, as in all the Bichot estates, Albéric Bichot has understood that whilst preserving a very Burgundian approach to winemaking, much more concentration has to be placed on the vineyards.
|Domaine du Clos Frantin has been in the Bichot family since 1969, though a lack of space means wine-making has moved from Vosne-Romanée to a large facility in Nuits St-Georges. Thirteen hectares of vineyards
encompass Flagey-Echezeaux, Gevrey- Chambertin, Vosne-Romanée and Vougeot.
Bichot is not afraid to use new oak, but is careful to adjust the percentage according to the qualities of the vintage.
Only red Burgundy is made here, with a second sorting of the grapes on arrival, before they are moved by gravity to the open-topped fermenters.


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The operator of the wrecked Fukushima nuclear power plant says it is struggling with its latest efforts to stop contaminated underground water leaks from running into the sea. / Issei Kato, AP
TOKYO (AP) - Japan's government says it will step in to tackle contaminated water leaks at the country's crippled nuclear plant, and is considering funding a multibillion-dollar project to fix the problem.
Government officials said Wednesday about 300 tons of contaminated water has been leaking into the sea daily since early in the crisis, which was caused by the 2011 earthquake and tsunami. On Tuesday, the operator of the Fukushima plant said some of the water is seeping over or around an underground barrier it created by injecting chemicals into the soil that solidified into a wall.
Prime Minister Shinzo Abe said Wednesday the government would intervene to tackle the problem.
Government officials said they're considering funding a multibillion-dollar project to surround the reactor buildings with a wall to block underground water.
Copyright 2015 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
Read the original story: Japan to help stop radioactive water leaks


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Monday through Friday, 7:30 AM to 9 PM
Saturday and Sunday, 8:30 AM to 9 PM
(212) 746-4230
The Gift Shop is located behind the Information Desk. It offers a wide selection of items, including flowers, toiletries, newspapers, magazines, cards, snacks, beverages, gifts, and Mylar balloons.
Search Komansky Center | Find a Physician


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Last Saturday evening Bob and I were at home in our matching tracksuits watching the History Channel. Anomie was out doing her regular Saturday teenage capitalist ritual of hanging out at New Look and Clares Accessories (well brainwash the anarchist lifestyle into her one day), saving us from having to apply factually correct leftist interpretations of historical events for her benefit.
In the middle of a documentary on Cubas jailing and executing of its undesirables, Bob leapt off the sofa and turned the TV off. Normally this is the cue for us to hold an informal symposium on the MSMs propagandist output, and test Anomie on her recall of famous bearded anarchists. But with our cousin out at the shopping centre, clearly he was in the mood for something different.
I just cant lounge about like a mental midget, watching TV and wearing a tracksuit! I'm anarchic as hell, and I'm not going to take this anymore!"
My chronic fatigue was playing up, so this funny turn of Bobs concerned me slightly. Normally hes able to take out his antisocial impulses and societal frustrations in his role as PE teacher by kicking the fat kids into the showers after games. Clearly, this wasnt going to be an option at the weekend.
Were anarchists, sis! We gotta do somefing to bring on Revolution!
But what, Bob? You know I had to wind down my law studio because of the CFS.
I danno. Youre supposed to be the brain! Thats why youre a proven lawyer and Im a PE teacher!
We could have a sit-in, I suppose.
Thats the bleedin chronic fatigue talkin! Whats anarchic about that? Would any true Iranian get a CFS diagnosis! We need action! Direct action! I'm anarchic as hell, and I'm not going to take this anymore!"
Ok, bruv. How about we...
Cancel the TV license direct debit!
Cancel the TV licence direct debit?
Yeah, stick it to those muggy propagandist cunts at the BBC! How anarchic is that, eh!
But, Bob. Nonpayment of the TV licence is an offence which could lead to prosecution and a fine of up to £1,000 (plus legal costs), not to mention the embarrassment and hassle of a court appearance And you know it was the hassle of all those court appearances that led to me having to take a career break from the law.
Cmon, sis! Youre supposed to be a proven lawyer! Youd be able to get me off. And whats bunce compared to anarchy and revolution!
But... we need the MSM! I know we critique it all the time, but wed be lost without it! What would we do if we couldnt sit here feeling smug and sanctimonious at being able to see through all the Establishments conspiracies and propaganda!
Suppose youre right, sis. Plus Id really miss my post-midnight dose of Goldie Hawn!
Yes, sis.
Seeing as Anomie is out... well, we could always...
Ah, go on then. I know we both have wanted to do it for a long time... I cant suppress my feelings any more... Lets do it! Lets watch ITV!


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Middlebury British pianist Paul Lewis will perform the last three piano sonatas written by Franz Schubert on Friday, Oct. 26. at Middlebury College's Mahaney Center for the Arts. The non-profit concert setting is a finale to his run of five concerts featuring all of Schubert's mature piano works from the Wandererfantasie onwards. Lewis is internationally recognized as one of the leading pianists of his generation.
Lewis began his Schubert project in 2011, and Middlebury was thrilled to be among fewer than 15 venues worldwide to present the entire cycle. This fifth and final concert features a tremendous program: Schubert's D. 958, 959, and 960. Lewis has already garnered significant critical acclaim for his Schubert performances.
This is not the first time Lewis has undertaken an epic series approach to his music work. Between 2005 and 2007, he performed the complete series of Beethoven piano sonatas at venues throughout Europe and North America to great critical acclaim, and his recordings of the cycle for Harmonia Mundi have received unanimous praise throughout the world. In the summer of 2010, Lewis became the first pianist in the history of the BBC Proms to play all five Beethoven piano concertos in a single season.
He has recently completed recordings of the three Schubert song cycles with tenor Mark Padmore. Many of these recent recordings will be made available for purchase at the concert venue in Middlebury.
Concert attendees will be offered an additional treat on October 26. In conjunction with the concert, a special pre-performance meal "Dinner and Conversation with Friends," will be offered at 6:30 p.m. in the lower lobby of the Mahaney Center. Tickets for the dinner are $25.
The Mahaney Center is located at 72 Porter Field Rd. in Middlebury, off Route 30 south. Concert admission is $25 for the general public; $20 for Middlebury College faculty, staff, alumni, emeriti, and parents; and $6 for Middlebury College students.
For tickets of information, call (802) 443-MIDD (6433) or go to http://go.middlebury.edu/tickets.
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Endogenous is a word that means "from within." Psychiatrists and researchers once theorized that it was important to differentiate between endogenous (primarily biological and genetic in nature) and exogenous (reactive to stressful life events) types of depression.
They believed that treatments would necessarily vary depending upon that distinction.
However, early research into antidepressant medications failed to reveal the differences and the term "endogenous" largely has been absorbed into psychiatric literature to describe the melancholic features associated with major depressive disorder (MDD).
New Studies
Studies from the 1980s and 90s found no statistical correlation between the effectiveness of antidepressants on depressions that were either biological in nature or caused by adverse life events. However, more recent research shows there are distinct differences between the two subtypes.
A report published in Molecular Psychiatry in 2012 found that "endogenous depression and chronic stress response are regulated by independent molecular pathways." This led researchers to suspect that people who are more susceptible to stress may develop subtypes of depression that are distinct from endogenous ones. They suggest that it may be beneficial to develop new and novel treatments to help these patients. Research is ongoing.
Differences Between Endogenous and Exogenous Depression
For individuals with endogenous depression, symptoms often appear "out of nowhere" and for seemingly no reason. Endogenous depression is characterized by feelings of guilt and worthlessness and anhedonia. Anhedonia is the inability to derive pleasure from once pleasurable activities such as exercise, hobbies, or sex.
Although there is a significant amount of overlap between the two types of depression, the exogenous form is usually triggered by a highly stressful situation. It most often lacks physical symptoms such as changes in sleeping or eating habits. Although stressful events often precipitate both types of depression, people with the endogenous form are more likely to relapse than those whose depression is more reactive in nature.
One British study done in the 1990s found that, for those incurring a second depression, 70 percent with reactive depression had encountered severe stress shortly before their ?relapse. And only one third of those in the endogenous group had.
Symptoms of Endogenous Depression
As is the case with major depressive disorder, individuals with endogenous depression often experience anhedonia along with feelings of hopelessness, helplessness, worthlessness, guilt, or self-hate. Other symptoms that may accompany endogenous depression include:
- fatigue or lack of energy
- irritability and difficulty concentrating
- social isolation
- insomnia or hypersomnia (excessive sleeping)
- changes in appetite with corresponding weight gain or loss
- suicidal thoughts or behaviors
In more severe cases, patients may also experience psychotic symptoms such as hallucinations or delusions.
Diagnosis and Treatment
Because endogenous depression is a form of major depressive disorder, diagnosis and treatment is the same. A clinician or mental health professional will ask the patient a series of questions about their symptoms, medical history, and any substance abuse issues. Lab tests also are usually performed to rule out underlying physical causes such as a hormone imbalance.
The first line of treatment for endogenous forms of depression is usually medication—typically, a selective serotonin re-uptake inhibitor (SSRI)-type antidepressant. Additional treatments often consist of some form of talk therapy, such as cognitive behavioral therapy.
In more serious cases, antipsychotic drugs or electroconvulsive therapy (ECT) may be employed.
More on SSRIs
Contrary to what many people believe, SSRIs don't increase serotonin levels in the brain.
Instead, they act by blocking serotonin re-uptake into the presynaptic cell. This allows additional serotonin to "slosh around" in the synaptic cleft, making it more available to bind to other receptors. Thomas A.M. Kramer, MD compares the misunderstandings regarding SSRIs to a boat sinking in the ocean. It's like saying the boat "needs to have reduced water levels" without acknowledging that there's water all around. Instead, he says, SSRIs "plug the holes" in the boat.
Research has shown, however, that SSRIs are generally no more effective than a placebo for mild to moderate forms of depression. But they are highly effective for more severe forms of depression, including MDD.
Suicide Risk
If you're having thoughts of harming yourself or others, or if you're a caregiver of such a person, call 9-1-1 or proceed to a hospital emergency room immediately.
You also may contact the National Suicide Prevention Lifeline 24 hours a day, seven days a week at 1-800-273-TALK (1-800-273-8255).


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- Telstra Road to Discovery
I got an email two days ago letting me know that I'm one of 6 Melbourne singer-songwriters who will be performing in the Telstra Road to Discovery!
Now, I'm not a big fan of music competitions in general. But I think this competition is something different. It focuses on original music, and there are alot of opportunities along the way for skill developement and networking with big wigs in the industry.
The first heat is on Wednesday the 8th of October. I'll be sharing the stage with Ella Hooper from Killing Heidi! Fun!
- Supporting Dave Graney
I'm very stoked to announce that I will be opening for the legendary Dave Graney at the Northcote Social Club on September 14th.
He's been a pillar of the Australian music scene for decades, playing in bands like The Moodists and Coral Snakes. He presents a radio program on RRR, Banana Lounge Radio, and has been kind enough to play my new single quite a lot over the last couple of months.
Dave Graney is playing around a bit at the moment to promote his new solo album Fearful Wiggings. This will be a good one. Get your tickets here:
- Mmmm, Brisbane...
Winter is truly here in Melbourne.
Tis the season of soup and hot water bottles.
Here's a photo from the tour in January. This shot was taken in Brisbane by Tim Roberts. It was 45 degrees that day. I was melting. Mmmmm, melting.
- Yes, I am alive!
Phew, that was close. I have just emerged from Study-Land, a place so all-consuming that there were times when I wondered if it was even possible to leave.
But here I am, pale and dishevelled, thesis handed in and ready to play some MUSIC!
Right now I'm booking a tour to Brisbane, as well as a very exciting launch show for the new single, Meet Me.
Cannot wait to share that one with y'all!
Anna x
- Darling, will you meet me?
The single "Meet Me" has been printed and pressed and is ready to go! I'm busy booking some launch shows right now. But you can get your hot little hands on a copy of the song in advance if you're on the band mailing list. I swear I hardly ever send chain mail or requests to put a million dollars in your bank account.


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Home / Accessories / Misc. Accessories
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Misc. Accessories by Acoustic Revive
Manufacturer's Description:Newly developed vibration protect pin for output terminals. IP-2FIP-2F is made from hybrid structure of brass and 2017 Duralumin which is the same structure as SIP-8F and BSIP-2F. By the its hybrid and complete non-magnetism structure, just inserting the IP-2F to a vacant RCA output terminal will have a great vibration control effect. Also the sound position and S/N ratio will improve further. The vibration control characteristic has further improved by the attached sheet.
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Vanilla is a product of Lussumo:
Documentation and Support.
The Cthulhu Mythos is a shared fictional universe, based on the work of American horror writer H. P. Lovecraft. The term was first coined by August Derleth, a contemporary correspondent of Lovecraft, who used the name of the creature Cthulhu – a central figure in Lovecraft literature[1] and the focus of Lovecraft's famous short story The Call of Cthulhu (first published in pulp magazine Weird Tales in 1928) – to identify the system of lore employed by Lovecraft and his literary successors.