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This guideline updates a previous version: Salem DN, O'Gara PT, Madias C, Pauker SG. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008 Jun;133(6 Suppl):593S-629S. [265 references]
Thromboembolism associated with valvular heart disease
Patients with valvular heart disease requiring treatment with antithrombotic therapy
Defining the Clinical Questions—Population, Intervention, Comparator, and Outcome
The thrombosis expert on the Executive Committee along with the deputy editors took primary responsibility for defining the scope of the clinical questions that each article would address. For each question, the topic editor and deputy editor defined the relevant population, alternative management strategies (intervention and comparator), and the outcomes (i.e., population, intervention, comparator, and outcome [PICO] format). Each clinical question provided the framework for formulating study inclusion and exclusion criteria and guided the search for relevant evidence (systematic reviews and original studies). Panels typically restricted included studies to randomized controlled trials (RCTs) for intervention questions but included observational studies when there was a paucity of RCT data addressing an intervention and for questions of risk assessment. Readers can find these PICO questions in the first table of each article. One or more recommendations could be formulated for each clinical question.
Identifying the Evidence
To identify the relevant evidence, a team of methodologists and medical librarians at the Oregon Health & Science University Evidence-based Practice Center conducted literature searches of Medline, the Cochrane Library, and the Database of Abstracts of Reviews of Effects. For each article, the team conducted a search for systematic reviews and another for original studies encompassing the main populations and interventions for that article. These searches included studies indexed from week 1, January 2005, forward because Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 8th Edition (AT8) searches were carried out up to that date (search strategies are available on request). Many articles supplemented these searches with more-focused searches addressing specific clinical questions. When clinical questions had not been covered in AT8, searches commenced at a date relevant to each intervention.
Titles and abstracts retrieved from bibliographic database searches generally were screened in duplicate, and full-text articles were retrieved for further review. Consensus on whether individual studies fulfilled inclusion criteria was achieved for each study between two reviewers. If consensus could not be achieved, the topic editor and other topic panelists were brought into the discussion. Deputy editors reviewed lists of included studies from the database searches in order to identify any potentially missed studies. Additional studies identified were then retrieved for further evaluation.
Topic panels also searched the same bibliographic databases for systematic reviews addressing each PICO question. The quality of reviews was assessed using principles embodied in prior instruments addressing methodologic quality of systematic reviews, and wherever possible, current high-quality systematic reviews were used as the source of summary estimates. Reviews were also used to identify additional studies to complement the database searches.
Not stated
Grading of Recommendations Assessment, Development and Evaluation (GRADE) Approach to Rating Quality of Evidence
Randomized Trial →
Risk of bias
-1 Serious
-2 Very serious
-1 Serious
-2 Very serious
-1 Serious
-2 Very serious
-1 Serious
-2 Very serious
Publication bias
-1 Likely
-2 Very likely
Large effect
+1 Large
+2 Very large
Dose response
+1 Evidence of a gradient
All plausible confounding
+1 Would produce a demonstrated effect or
+1 Would suggest a spurious effect when result show no effect
Observational Study →
Very Low
General Methods
Assessing Studies and Summarizing Evidence
Evaluating Risk of Bias in Individual Studies
The expert panel developed and applied uniform criteria for evaluating the risk of bias associated with individual randomized controlled trials (RCTs) based on the criteria recommended by the Cochrane Collaboration (Table 1 in the methodology companion [see the "Availability of Companion Documents" field]). Although all authors assessed risk of bias for individual studies, because of resource limitations, the panel summarized the results of the risk of bias for only a minority of the recommendations. Readers can find these assessments in the online data supplements. For most recommendations for which such tables were not developed, Evidence Profiles that typically provide information on the risk of bias in footnotes were developed.
The panel also developed specific criteria for assessing the risk of bias of observational studies (cohort studies with concurrent controls, cohort studies with historical controls, case-control studies, or case series). Again, these were based on the evidence-based domains recommended by the Cochrane Collaboration for observational studies.
Studies without internal comparisons were termed "cohort studies without internal controls" if they met the following criteria:
The panel labeled studies that did not meet these criteria as "case series." No distinction was made between prospective and retrospective studies because although prospective studies may on average be of higher quality, individual prospective studies may have a significant risk of bias and specific retrospective studies may not. For questions related to risk assessment, the panel evaluated the risk of bias of individual studies using the following criteria: valid outcome assessment, including blinding when appropriate; adjustment for between-group differences; and minimal loss to follow-up.
Evaluating Quality of Bodies of Evidence
The expert panel assessed evidence across studies on an outcome-by-outcome basis using criteria suggested by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. The expert panel defined quality of evidence as their confidence in the estimate of the effect to support a recommendation. RCTs start as high-quality evidence and observational studies as low-quality evidence. Additional factors that affect this rating of quality include the risk of bias; precision, consistency, and directness of results; likelihood of publication bias; and presence of very large effects. The American College of Chest Physicians (ACCP) adaptation of the GRADE system differs only in that the quality of a body of evidence can be high (A), moderate (B), or low (C); GRADE also provides a category for very-low-quality evidence. See the "Rating Scheme for the Strength of the Evidence" field.
Often, the panel found that the quality of the evidence differed across outcomes. For example, in assessing the quality of evidence for thienopyridines vs warfarin in patients undergoing percutaneous coronary interventions, the panel determined the evidence to be of moderate quality for mortality, nonfatal myocardial infarction, and revascularization but of low quality for major bleeding.
The panel then made a rating of the quality of the entire body of evidence bearing on the effect of alternative management strategies for each clinical question. In other words, the panel assessed the quality across outcomes, including both benefits and harms. Quality for each recommendation was the lowest quality rating of the outcomes judged as critical (as opposed to important, but not critical).
Most patient-important outcomes in this guideline are binary or yes-no outcomes (death, stroke, venous thromboembolism [VTE], myocardial infarction, bleeding). In general, relative effects are similar across subgroups of patients, including those with varying baseline risk. The evidence summaries (Evidence Profiles and Summary of Findings tables), therefore, include a presentation of relative effects (where possible as relative risks because they are easier to understand than odds ratios [ORs]) of intervention vs control management strategies.
Trading off desirable and undesirable consequences (e.g., thrombosis vs bleeding) requires, however, estimates of absolute effect. For example, in patients with atrial fibrillation, warfarin results in a 66% relative risk reduction in nonfatal stroke. This comes at a cost of inconvenience, lifestyle restrictions, and risk of bleeding. For patients with a CHADS (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke) score of ≥3, the 66% relative risk reduction translates into an absolute reduction of 6.3% (63 in 1,000) per year. Virtually all patients will consider this worthwhile. On the other hand, for patients with a CHADS score of 0, the 66% reduction translates into an absolute risk reduction of only 0.5% (5 in 1,000) per year. Many patients may consider this reduction not worth the undesirable consequences of warfarin use.
The panel calculated absolute effects by applying relative risks to estimates of control group risk. For instance, if control group risk of thrombosis is 4% and relative risk with an intervention is 50%, then the absolute difference between intervention and control is 4% of 50% or 2%, and the number needed to treat to prevent an episode of thrombosis is 100/2 or 50. In many cases, the Summary of Findings tables present effects as events prevented (or caused) per 1,000 patients. In this hypothetical example, the effect would be 20 events per 1,000 patients.
Whenever valid prognostic data were available from observational studies, they were used to estimate control group risks. When credible results from observational and prognostic studies were not available, risk estimates from control groups of RCTs were used.
Considering Subgroup-Specific Relative and Absolute Effects
Whenever the expert panel identified credible evidence that the relative effects vary across distinguishable subgroups of patients (i.e., interaction between the intervention and a patient characteristic), the respective relative effects were considered separately. The panel then calculated the associated absolute effects.
Even when the relative effect is the same, the absolute magnitude of treatment effects may differ in patients with varying levels of risk. For instance, although the relative risk reduction of warfarin vs aspirin in stroke prevention for patients with atrial fibrillation is likely close to 50% across risk groups, this translates into an absolute risk reduction of <1% per year in the lowest-risk groups and ~5% per year in the highest-risk groups.
The expert panel included control group risks and absolute-effect estimates for different groups in the summaries of effect when (and only when) two conditions were present. First, they required validated prognostic models or, at the very least, credible strategies for clinicians to easily identify higher- and lower-risk patients. Second, the panel identified varying risk groups only when recommendations differed in strength or direction between groups. Both conditions were met, for instance, in the atrial fibrillation recommendations in which strong recommendations in favor of anticoagulation were restricted to the higher-risk patients.
Conducting Meta-analyses
When pooled estimates of effects were not available from existing high-quality systematic reviews, the panel performed meta-analyses if the data were sufficiently homogeneous. When pooling two studies, they used a fixed-effects model. When three or more studies were available for generating a pooled estimate, they used a random-effects model as the primary analysis and a fixed-effects model as a secondary analysis. If there were discrepancies between the two, the panel considered the following reasons: If there was substantial heterogeneity leading to wider confidence intervals (CIs) with the random-effects model, the panel considered that model more trustworthy, and if the discrepancy was due to a single large dominant study with a result substantially different from smaller studies, they considered the fixed-effects model more trustworthy. The panel also assessed statistical heterogeneity using both a χ2 test and I2 as well as assessed possible explanations of heterogeneity considering a priori-generated hypotheses.
Summary Tables
When resources permitted, the expert panel used a standardized approach for summarizing the evidence and methodology of individual studies. These summaries appear in the online data supplements. Wherever possible, the expert panel reported nonfatal events (e.g., nonfatal stroke) so that there is no overlap with the number of fatal events reported.
For a large number of recommendations, the expert panel summarized the quality of the body of evidence (see the "Rating Scheme for the Strength of the Evidence" field) and estimates of relative and absolute effect of alternative management strategies using the methods of the GRADE Working Group. Evidence Profiles summarize the quality of the body of evidence and when evidence comes from randomized trials, generally include a presentation of reviewer assessment of risk of bias, precision, consistency, directness, and publication bias associated with each outcome. As specified in GRADE methodology, the overall quality of evidence represents the lowest quality of any critical outcome.
Evidence Profiles can be found in the online data supplement. The format for these tables was determined through a formal survey of panelists that evaluated the panelists' preferences for alternative presentations and the impact of these presentations on their understanding of the evidence. The text in the printed version of Antithrombotic Therapy and Prevention of Thrombosis, 9th ed (AT9) recommendations includes more succinct Summary of Findings tables, which include the overall quality assessment as well as the relative and absolute effect sizes for each outcome. Use of an associated computer program facilitated the production of the Evidence Profiles and Summary of Findings tables which are listed in the original guideline document.
Specific Methods for This Guideline
The value given to the harmful effect of an extracranial bleeding event (as compared with that of valve thrombosis, peripheral thromboembolism, or stroke) greatly impacts the balance of benefits and harms of a given therapy. There are limited data to guide us with respect to the relative value of these outcomes. For this article, the panel used the result of the preference-weighting exercise carried out by MacLean et al. as part of these guidelines, which attributes approximately three times the disutility (aversiveness, negative weight) to a stroke vs an extracranial bleeding event; a valve thrombosis carries slightly greater disutility than an extracranial bleeding event.
Composition and Selection of Topic Panel Members
The American College of Chest Physicians (ACCP) Antithrombotic Therapy and Prevention of Thrombosis, 9th ed (AT9) Executive Committee selected panel members for each article. A topic editor and a deputy editor led each of the AT9 panels issuing recommendations. The topic editor was the person primarily responsible for each article and was required to be a methodologist without serious financial or intellectual conflict of interest for any of the article's recommendations. In all but one case, the topic editor also was a clinician. The Executive Committee chose these individuals on the basis of their previous experience with guideline development and, in particular, their familiarity with methods developed by the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group. These topic editors and all panel members were approved by the ACCP Health and Science Policy (HSP) Committee after review of their conflict of interest disclosures.
Criteria for selection of the remainder of the panel members, including the deputy editor-thrombosis expert, were an established record in the relevant clinical or research area, international and gender representation, and an absence of financial conflicts of interest that were judged unacceptable. Some of the panelists had prior experience on ACCP guidelines in this area and represented the thrombosis community, but there was substantial turnover from the previous edition. After an international request for applications broadcast through multiple medical societies, the Executive Committee nominated individual topic editors and deputy editors and collaborated with them to identify and nominate other topic panel members.
The ACCP HSP Committee reviewed all nominees and approved all panel members after review of their curricula vitae and conflict of interest disclosures. Of 150 nominees, 137 were approved, 18 were approved with management of conflicts of interest (i.e., regular disclosures and review of ongoing conflicts as the process progressed), and 13 were disapproved as a result of the magnitude of financial conflicts of interest. Articles associated with recommendations included from seven to 14 panel members. Patients or representatives of specific stakeholder groups were not included on topic panels.
Each topic panel also included a frontline physician working in the relevant area who was neither an expert in thrombosis nor a methodologist or clinical investigator. These individuals were chosen in consultation with the topic editors and the ACCP HSP Committee. These clinicians were charged with the following: (1) proposing important real-world clinical questions on the prevention, diagnosis, and treatment of thrombosis that were not addressed in Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 8th Edition (AT8) and (2) reviewing the draft manuscripts and recommendations to assess the usability of the guidelines and the feasibility of implementation of AT9 recommendations.
To address issues of economic efficiency six health economist-physicians were included on the AT9 topic panels charged with making recommendations. These resource consultants were selected and approved through identical procedures to those for topic editors and panel members.
Ensuring Consistency Across Articles
A number of strategies were used to ensure consistency across articles, and one panel member participated extensively in the formulation of clinical questions for each article. To ensure consistency of judgments regarding bleeding, another panel member was responsible for standardizing the approach to bleeding outcomes and participated in multiple topic panels. Additionally, to ensure consistency in the trade-offs between thrombotic and bleeding events, all articles used the same ratings of values and preferences (described in more detail in the methodology companion [see the "Availability of Companion Documents" field]). Because some of the same evidence summaries were relevant to several articles, five individuals were chosen to participate in each of the articles addressing coronary artery disease, stroke, and peripheral arterial disease.
In AT9, prevention of venous thromboembolism (VTE) is addressed in three articles as opposed to a single article as was done in AT8. The prevention topic editors and deputy editors and those of the stroke article (which includes thromboprophylaxis recommendations) participated in multiple conference calls to develop and harmonize the approach to prevention and to ensure consistency among final recommendations. Topic editors consulted with one another when issues overlapped. For example, the decision regarding the use of a vitamin K antagonist, aspirin, and clopidogrel simultaneously in patients with atrial fibrillation, valvular disease, and intravascular stents is relevant for the atrial fibrillation, coronary, and peripheral arterial disease articles. Topic panels deferred to the Evidence-Based Management of Anticoagulant Therapy AT9 topic panel for recommendations related to the dosing and monitoring of anticoagulation therapies.
The AT9 Executive Committee met at least once a month and regularly issued statements of clarification of methods to topic editors and deputy editors (e.g., use of fixed- or random-effects models for meta-analysis), conflict of interest, preparation of tables, and issues of style and presentation. All these statements were communicated directly to the topic editors and deputy editors and made available in a central repository accessible to all AT9 panelists. The chair of the Executive Committee was available for resolving any challenging issues related to the aforementioned topics. Between September 2009 and September 2010, two members of the Executive Committee held regular (every 3 months), separate conference calls with each topic editor and deputy editor during which they addressed questions and concerns. Finally, the chair of the Executive Committee reviewed every article to ensure consistency of evidence presentation, evaluation, and writing style. Refer to the methodology companion for further information on the approach used to ensure consistent language in writing.
Formulating Recommendations
Following approaches recommended by the GRADE Working Group, the topic editor, in some cases aided by a panelist without conflicts, formulated the draft recommendations. The formulation of recommendations considered the balance between the desirable and undesirable consequences of an intervention; the quality of evidence; the variability in patient values and preferences; and, on occasion, resource use issues. The recommendations were graded as strong when desirable effects were much greater than undesirable effects or vice versa. Strong recommendations were worded as "The Expert Panel recommends" and labeled 1. Recommendations were graded as weak when desirable effects were not clearly greater or less great than undesirable effects. Weak recommendations were worded as "The Expert Panel suggests" and labeled 2. The rating of the quality of the evidence—high, A; moderate, B; or low, C—is provided with the strength of each recommendation.
Finalizing Recommendations
The topic panel members without primary conflicts discussed draft recommendations. Initial discussions generally led to a consensus at the article level on the quality of evidence and the direction and strength of recommendations. At least two members of the Executive Committee reviewed in detail drafts of articles, including recommendations. Written critiques were prepared and returned to the authors for revision. Articles were then made available to the entire AT9 panel.
Recommendations on which topic panels had difficulty coming to a consensus were discussed at a final conference in February 2011 attended by the topic editors and deputy editors and at least one other panel member from each article. Prior to the conference, all AT9 panelists updated their conflict of interest disclosures. The ACCP invited a number of clinical organizations with interest in the guideline topic to attend the final conference as observers.
At this final conference, a representative of each article presented potentially controversial issues in their article's recommendations. Following discussion, which included those present and those attending by video conference, all panelists without primary conflicts of interest voted on each recommendation. The voting process used a GRADE grid and required that for a strong recommendation, ≥80% of those voting had to agree that a strong recommendation was appropriate.
The AT9 Executive Committee members harmonized the articles and resolved remaining disagreements among them through facilitated discussion with topic editors and deputy editors without primary conflicts. All major correspondence and decisions at the final conference were recorded in written and audio formats and are available on request to email@example.com.
See the methodology companion (see the "Availability of Companion Documents" field) for information on accounting for patient values and preferences in recommendations.
Strength of the Recommendations Grading System
*The guideline developers use the wording recommend for strong (Grade 1) recommendations and suggest for weak (Grade 2) recommendations.
Resource Use Issues
In addressing resource use (cost) issues in Antithrombotic Therapy and Prevention of Thrombosis, 9th ed (AT9), the expert panel followed previously developed principles. In particular, the panel restricted economic evaluation to recommendations in which it was plausible that resource use considerations might change the direction or strength of the recommendation and in which high-quality economic evaluations were available. When this was not the case, the panel did not consider resource use in the recommendations.
Six clinicians with the requisite expertise in decision and economic analyses participated in the guideline development process; each article had the benefit of one of these experts as a full committee member. The following subsections present key points in the process of considering resource allocation issues in the recommendations.
Overview of the Process
Panelists, in consultation with resource use consultants, determined questions for which resource use might change the direction or strength of recommendations. For those questions, the panel sought high-quality economic analyses. If such analyses were available, the panel applied the evidence regarding resource use to the relevant recommendation. If net costs or marginal cost-effectiveness ratios were very high, panelists considered rating down the quality of evidence for an intervention from high to low or possibly changing the direction of the recommendation using guides described in the section "Criteria for Resource Allocation Issues to Affect Recommendations—Thresholds for Cost-Effectiveness" in the methodology companion (see the "Availability of Companion Documents" field).
Identifying the Literature
The Oregon Health & Science University Evidence-based Practice Center conducted thorough literature searches for economic analyses relevant to the different AT9 articles. The resource use experts supplemented these by searches focused on the specific questions of interest for each article. The searches were conducted in Medline and the Cochrane Central Register of Clinical Trials. On the basis that data from studies appreciably more than a decade old would not reflect the current situation, searches were restricted to published studies from 1999 forward. Thus, bibliographic database searches encompassed publications from January 1999 forward: The end date varied across articles and ranged between November 2009 and March 2010 when the searches were executed.
Evaluating the Evidence
A standardized data extraction form was used to ensure uniform evaluation of the quality of relevant economic analyses. Quality assessment was based on published criteria and included specification of perspective of analysis (e.g., societal, health system), appropriateness of time horizon (preferably lifetime), use of high-quality evidence for probabilities and rates, use of high-quality sources for costs (e.g., primary data, Medicare payments, claims data as proxies), use of appropriate methods for measurement of preferences, and performance of sensitivity analyses to explore uncertainty (both deterministic and probabilistic).
Criteria for Resource Allocation Issues to Affect Recommendations—Thresholds for Cost-Effectiveness
The results of economic analyses may either increase the strength of an otherwise weak recommendation or weaken the strength of a strong recommendation. If cost-effectiveness studies bolstered an already strong recommendation, no change to the recommendation was necessary. The panel chose the following thresholds for cost-effectiveness considerations affecting recommendations:
Extension of Economic Analyses to Low- and Middle-Income Countries
Although certain interventions may be cost-effective in high-income countries (e.g., <$20,000 per QALY gained), in poor countries, $20,000 gained per QALY may be prohibitive. The choice of a threshold will vary depending on who is making resource allocation decisions. To facilitate the use of already published cost-effectiveness analyses, the World Health Organization (WHO), through its WHO-CHOICE (Choosing Interventions that are Cost Effective) program has used criteria suggested by the Commission on Macroeconomics and Health. Interventions that cost <1 times the average per-capita income for a given country or region per QALY gained are considered very cost-effective. Interventions that cost up to three times the average per-capita income per QALY gained are still considered cost-effective, whereas those that exceed this level are not considered to be cost-effective. To facilitate this process, WHO has developed tables of such threshold values for different regions and countries around the world. Thus, the thresholds discussed in the previous section have been defined in terms of GDP per capita. Although referencing thresholds for cost-effectiveness to average per-capita income in middle- and low-income countries can help to extend results of economic analyses performed in high-income countries, such analyses may be less relevant in low-income countries because of significantly different material and labor costs and, thus, may be difficult to extrapolate. Furthermore, the comparator strategies may not be feasible or customary in these locales.
The American College of Chest Physicians (ACCP) Health and Science Policy (HSP) Committee established a process for the thorough review of all ACCP evidence-based clinical practice guidelines. After final review by the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed (AT9) Executive Committee, the guidelines underwent review by the Cardiovascular and Pulmonary Vascular NetWorks of the ACCP, the HSP Committee, and the ACCP Board of Regents. The latter two groups had the right of approval or disapproval but usually worked with the topic panelists and editors to make necessary revisions prior to final approval. Both the HSP Committee and the Board of Regents identified primary reviewers who read the full set of articles, and the remaining HSP Committee members were responsible for reviewing several articles each. The reviewers considered both content and methodology as well as whether there was balanced reporting and adherence to HSP Committee processes. All reviewers were vetted through the same conflict of interest disclosure and management process described in the "Description of Methods Used to Formulate the Recommendations" field. Finally, the Editor in Chief of CHEST read and forwarded the manuscripts for independent, external peer review prior to acceptance for publication. No recommendations or assessments of the quality of the evidence could be changed without the express approval of the topic panel members, AT9 Executive Committee, HSP Committee, and ACCP Board of Regents.
This guideline is endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the American Society of Health-System Pharmacists, the American Society of Hematology, and the International Society on Thrombosis and Haemostasis.
The grades of recommendation (1A, 1B, 1C, 2A, 2B, 2C) and the approach to rating the quality of evidence are defined at the end of the "Major Recommendations" field.
Rheumatic Mitral Valve Disease
In patients with rheumatic mitral valve disease and normal sinus rhythm with a left atrial diameter <55 mm the expert panel suggests not using antiplatelet or vitamin K antagonist (VKA) therapy (Grade 2C).
In patients with rheumatic mitral valve disease and normal sinus rhythm with a left atrial diameter >55 mm, the expert panel suggests VKA therapy (target international normalized ratio [INR], 2.5; range, 2.0-3.0) over no VKA therapy or antiplatelet (Grade 2C).
For patients with rheumatic mitral valve disease complicated by the presence of left atrial thrombus, the expert panel recommends VKA therapy (target INR, 2.5; range, 2.0-3.0) over no VKA therapy (Grade 1A).
For patients with rheumatic mitral valve disease complicated singly or in combination by the presence of atrial fibrillation or previous systemic embolism, the expert panel recommends VKA therapy (target INR, 2.5; range, 2.0-3.0) over no VKA therapy (Grade 1A).
Patients with Rheumatic Mitral Valve Disease Undergoing Percutaneous Mitral Balloon Valvotomy (PMBV)
For patients being considered for PMBV with preprocedural transesophageal echocardiography (TEE) showing left atrial thrombus, the expert panel recommends postponement of PMBV and that VKA therapy (target INR, 3.0; range, 2.5-3.5) be administered until thrombus resolution is documented by repeat TEE over no VKA therapy (Grade 1A).
For patients being considered for PMBV with preprocedural TEE showing left atrial thrombus, if the left atrial thrombus does not resolve with VKA therapy, the expert panel recommends that PMBV not be performed (Grade 1A).
Aortic Atheroma and Patent Foramen Ovale (PFO)
PFO and Atrial Septal Aneurysm
In patients with asymptomatic patent foramen ovale (PFO) or atrial septal aneurysm, the expert panel suggests against antithrombotic therapy (Grade 2C).
In patients with cryptogenic stroke and PFO or atrial septal aneurysm, the expert panel recommends aspirin (50-100 mg/d) over no aspirin (Grade 1A).
In patients with cryptogenic stroke and PFO or atrial septal aneurysm, who experience recurrent events despite aspirin therapy, the expert panel suggests treatment with VKA therapy (target INR, 2.5; range, 2.0-3.0) and consideration of device closure over aspirin therapy (Grade 2C).
In patients with cryptogenic stroke and PFO, with evidence of deep vein thrombosis (DVT), the expert panel recommends VKA therapy for 3 months (target INR, 2.5; range, 2.0-3.0) (Grade 1B) and consideration of device closure over no VKA therapy or aspirin therapy (Grade 2C).
Native Valve Endocarditis: Role of Anticoagulants and Antiplatelet Agents
In patients with infective endocarditis (IE), the expert panel recommends against routine anticoagulant therapy, unless a separate indication exists (Grade 1C).
In patients with IE, the expert panel recommends against routine antiplatelet therapy, unless a separate indication exists (Grade 1B).
Role of Anticoagulants in Prosthetic Valve Endocarditis
In patients on VKA for a prosthetic valve who develop IE, the expert panel suggests VKA be discontinued at the time of initial presentation until it is clear that invasive procedures will not be required and the patient has stabilized without signs of central nervous system (CNS) involvement. When the patient is deemed stable without contraindications or neurologic complications, the expert panel suggests reinstitution of VKA therapy (Grade 2C).
Nonbacterial Thrombotic Endocarditis
In patients with nonbacterial thrombotic endocarditis and systemic or pulmonary emboli, the expert panel suggests treatment with full-dose intravenous unfractionated heparin (IV UFH) or subcutaneous low molecular weight heparin (SC LMWH) over no anticoagulation (Grade 2C).
Bioprosthetic Heart Valves
Antithrombotic Therapy in the First 3 Months after Surgery
Aortic Bioprosthesis
In patients with aortic bioprosthetic valves, who are in sinus rhythm and have no other indication for VKA therapy, the expert panel suggests aspirin (50-100 mg/d) over VKA therapy in the first 3 months (Grade 2C).
Transcatheter Aortic Valve Bioprosthesis
In patients with transcatheter aortic bioprosthetic valves, the expert panel suggests aspirin (50-100 mg/d) and clopidogrel (75 mg/d) over VKA therapy and over no antiplatelet therapy in the first 3 months (Grade 2C).
Mitral Bioprosthesis
In patients with a bioprosthetic valve in the mitral position, the expert panel suggests VKA therapy (target INR, 2.5; range, 2.0-3.0) over no VKA therapy for the first 3 months after valve insertion (Grade 2C).
Long-term Antithrombotic Therapy for Bioprosthetic Valves
In patients with bioprosthetic valves in normal sinus rhythm, the expert panel suggests aspirin therapy over no aspirin therapy after 3 months postoperative (Grade 2C).
Mechanical Heart Valves
Early Postoperative Bridging to Intermediate/Long-term Therapy (Postoperative Day 0 to 5)
In patients with mechanical heart valves, the expert panel suggests bridging with UFH (prophylactic dose) or LMWH (prophylactic or therapeutic dose) over IV therapeutic UFH until stable on VKA therapy (Grade 2C).
Long-term Antithrombotic Therapy for Mechanical Valves
In patients with mechanical heart valves, the expert panel recommends VKA therapy over no VKA therapy for long-term management (Grade 1B).
Intensity of VKA Therapy for Mechanical Aortic Valve Prostheses
In patients with a mechanical aortic valve, the expert panel suggests VKA therapy with a target of 2.5 (range, 2.0-3.0) over lower targets (Grade 2C).
In patients with a mechanical aortic valve, the expert panel recommend VKA therapy with a target of 2.5 (range 2.0-3.0) over higher targets (Grade 1B).
Intensity of VKA Therapy for Mechanical Mitral Valve Prostheses
In patients with a mechanical mitral valve, the expert panel suggests VKA therapy with a target of 3.0 (range, 2.5-3.5) over lower INR targets (Grade 2C).
Intensity of VKA Therapy in Patients with Double Mechanical Valve or with Additional Risk Factors
In patients with mechanical heart valves in both the aortic and mitral position, the expert panel suggests target INR 3.0 (range 2.5-3.5) over target INR 2.5 (range 2.0-3.0) (Grade 2C).
Antiplatelet Agent in Addition to VKA Therapy for Mechanical Aortic or Mitral Valve Prostheses
In patients with a mechanical mitral or aortic valve at low risk of bleeding, the expert panel suggests adding over not adding an antiplatelet agent such as low-dose aspirin (50-100 mg/d) to the VKA therapy (Grade 1B).
Remarks: Caution should be used in patients at increased bleeding risk, such as history of gastrointestinal (GI) bleeding.
Antiplatelet Agent Therapy Instead of VKA Therapy
For patients with mechanical aortic or mitral valves the expert panel recommends VKA over antiplatelet agents (Grade 1B).
Heart Valve Repair
Antithrombotic Therapy after Mitral Valve Repair
In patients undergoing mitral valve repair with a prosthetic band in normal sinus rhythm, the expert panel suggests the use of antiplatelet therapy for the first 3 months over VKA therapy (Grade 2C).
Aortic Valve Repair
In patients undergoing aortic valve repair, the expert panel suggests aspirin at 50 to 100 mg/d over VKA therapy (Grade 2C).
Prosthetic Valve Thrombosis (PVT)
Right-Sided Prosthetic Valve Thrombosis
For patients with right-sided prosthetic valve thrombosis (PVT), in the absence of contraindications the expert panel suggests administration of fibrinolytic therapy over surgical intervention (Grade 2C).
Left-Sided Prosthetic Valve Thrombosis
For patients with left-sided PVT and large thrombus area (≥0.8 cm2), the expert panel suggests early surgery over fibrinolytic therapy (Grade 2C). If contraindications to surgery exist, the expert panel suggests the use of fibrinolytic therapy (Grade 2C).
For patients with left-sided PVT and small thrombus area (<0.8 cm2), the expert panel suggests administration of fibrinolytic therapy over surgery. For very small, nonobstructive thrombus the expert panel suggests IV UFH accompanied by serial Doppler echocardiography to document thrombus resolution or improvement over other alternatives (Grade 2C).
None provided
The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).
Appropriate monitoring and management of antithrombotic therapy in patients with valvular heart disease
An implementation strategy was not provided.
Not applicable: The guideline was not adapted from another source.
The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants were also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.
The sponsors played no role in the development of these guidelines. Sponsoring organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations.
American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel
Primary Authors: Richard P. Whitlock, MD; Jack C. Sun, MD; Stephen E. Fremes, MD, FCCP; Fraser D. Rubens, MD; and Kevin H. Teoh, MD
Executive Committee: Gordon H. Guyatt, MD, FCCP (Chair); Elie A. Akl, MD, MPH, PhD; Mark Crowther, MD; David D. Gutterman, MD, FCCP; Holger J. Schünemann, MD, PhD, FCCP; Sandra Zelman Lewis, PhD, ACCP; Joe Ornelas, DC
Panelists: Walter Ageno, MD; Pablo Alonso-Coello, MD, PhD; Sonia S. Anand, MD, PhD; Juan I. Arcelus, MD, PhD; Trevor P. Baglin, MBChB, PhD; Alex A. Balekian, MD, MSHS; Shannon M. Bates, MDCM; Sergio Bellmunt, MD; Neera Bhatnagar, MLIS; Robert Bona, MD; Henri Bounameaux, MD; Anthony K. C. Chan, MBBS; Clifford W. Colwell Jr, MD; Anthony J. Comerota, MD; Deborah J. Cook, MD, MSc(Epi); Michael H. Criqui, MD, MPH; Catherine Curley, MD; Mary Cushman, MD; Ola E. Dahl, MD; Antonio L. Dans, MD; Bruce L. Davidson, MD, MPH, FCCP; Francesco Dentali, MD; James D. Douketis, MD, FCCP; Andrew S. Dunn, MD; Shanil Ebrahim, MSc; Mark H. Eckman, MD; John W. Eikelboom, MBBS; Yngve Falck-Ytter, MD; Margaret C. Fang, MD, MPH; Jason Fish, MD, MSHS; Charles W. Francis, MD; Stephen E. Fremes, MD, FCCP; Alexander S. Gallus, MBBS; David A. Garcia, MD; Alan S. Go, MD; Neil A. Goldenberg, MD, PhD; Samuel Z. Goldhaber, MD, FCCP; Steven Goodacre, MBChB, PhD; Joel M. Gore, MD; Michael K. Gould, MD, FCCP; Ian A. Greer, MD, FCCP; Randolph Guzman, MD, RVT; Jonathan L. Halperin, MD; John A. Heit, MD; Jack Hirsh, MD, FCCP; Anne Holbrook, MD, PharmD; Patricia A. Howard, PharmD; Michael Hughes, PhD; Elaine M. Hylek, MD, MPH; Rebecca N. Ichord, MD; Roman Jaeschke, MD; Amir K. Jaffer, MD; Milosz Jankowski, MD, PhD; Norman A. Johanson, MD; Janna M. Journeycake, MD, MSCS; Susan R. Kahn, MD; Paul J. Karanicolas, MD, PhD; Clive Kearon, MD, PhD; Pooja Khatri, MD; Russell C. Klein, MD; Michael J. Kovacs, MD; Regina Kunz, MD, MSc(Epi); Deirdre A. Lane, PhD; Eddy S. Lang, MDCM; Maarten G. Lansberg, MD, PhD; Hoang Le, MD, FCCP; Wendy Lim, MD; A. Michael Lincoff, MD; Lori-Ann Linkins, MD; Gregory Y. H. Lip, MD; Samantha MacLean, MSc; Regina Makdissi, MD; Warren J. Manning, MD; Michael Mayr, MD; Marian S. McDonagh, PharmD; Shelley McLeod, MSc; Catherine McGorrian, MBBCh, BAO; Saskia Middeldorp, MD, PhD; Paul Monagle, MBBS, MD, FCCP; COL Lisa K. Moores, MC, USA, FCCP; Sohail Mulla, BHSc; M. Hassan Murad, MD, MPH; Michael E. Nelson, MD, FCCP; Mai N. Nguyen-Huynh, MD; Susan L. Norris, MD, MPH; Ulrike Nowak-Göttl, MD; Martin J. O'Donnell, MB, PhD; Thomas L. Ortel, MD, PhD; Gualtiero Palareti, MD; Stephen G. Pauker, MD; Anne-Marie Prabulos, MD; Paolo Prandoni, MD, PhD; Fraser D. Rubens, MD; Charles M. Samama, MD, PhD, FCCP; Meyer Michel Samama, MD; Sam Schulman, MD, PhD; Neil E. Schwartz, MD, PhD; Daniel E. Singer, MD; Frank A. Sonnenberg, MD; Frederick A. Spencer, MD; Alex C. Spyropoulos, MD, FCCP; Scott M. Stevens, MD; Matthew D. Stevenson, PhD; Jack Sun, MD; Peter J. Svensson, MD, PhD; Kevin H. Teoh, MD; Per Olav Vandvik, MD, PhD; David L. Veenstra, PharmD, PhD; Sara K. Vesely, PhD; Jeffrey I. Weitz, MD, FCCP; Philip S. Wells, MD; Richard P. Whitlock, MD; Daniel M. Witt, PharmD, FCCP; Ann Wittkowsky, PharmD, FCCP; Sherry M. Wren, MD; John J. You, MD
All panelists were required to disclose both financial conflicts of interest, such as receipt of funds for consulting with industry, and intellectual conflicts of interest, such as publication of original data bearing directly on a recommendation. Financial and intellectual conflicts of interest were classified as primary (more serious) or secondary (less serious). The operational definition of primary intellectual conflicts of interest included authorship of original studies and peer-reviewed grant funding (government, not-for-profit organizations) directly bearing on a recommendation. The operational definition of primary financial conflicts of interest included consultancies, advisory board membership, and the like from industry. Topic editors had no primary conflicts of interest, as noted. Some deputy editors, who were clinical experts in the topic of the article, had relevant primary conflicts of interest. The American College of Chest Physicians (ACCP) Health and Science Policy (HSP) Committee deemed some of these conflicts serious enough to require "management." Management involved more frequent updates of disclosures than required of the approved panelists without any conflicts and recusal from activities relevant to that conflict.
Topic panel members, including the deputy editor, with primary conflicts related to a particular recommendation did not participate in the final deliberations that led to the decision regarding the direction or strength of a recommendation, nor did they vote on recommendations for which they were primarily conflicted. Panelists with primary conflicts could, however, participate in discussions and offer their opinions on interpretations of the evidence. Readers will find a record of panelist conflicts of interest on a recommendation-by-recommendation basis in the online data supplement.
In summary, Dr Whitlock served on the advisory board for AstraZeneca in 2010 and served as a consultant for Boehringer Ingelheim for experimental anticoagulant study in mechanical valves; neither activity is related to the contents of this article. Dr Sun received funds from the University of Washington for research. Drs Freme, Rubens, and Teoh have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Guideline panel members, including the chair, and members of the Health & Science Policy Committee are blinded to the funding sources. Further details on the Conflict of Interest Policy are available online at http://chestnet.org .
Electronic copies: Available to subscribers of Chest - The Cardiopulmonary and Critical Care Journal .
Print copies: Available from the American College of Chest Physicians, Products and Registration Division, 3300 Dundee Road, Northbrook IL 60062-2348.
The following are available:
None available
This summary was completed by ECRI on July 30, 2001. The information was verified by the guideline developer on October 31, 2001. This NGC summary was updated by ECRI on December 8, 2004. The updated information was verified by the guideline developer on January 12, 2005. This summary was updated by ECRI on March 6, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on June 22, 2007 following the U.S. Food and Drug Administration (FDA) advisory on heparin sodium injection. This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin). This summary was updated by ECRI Institute on March 14, 2008 following the updated FDA advisory on heparin sodium injection. This NGC summary was updated by ECRI Institute on December 8, 2008. The updated information was verified by the guideline developer on January 7, 2009. This summary was updated by ECRI Institute on July 27, 2010 following the FDA drug safety communication on Heparin. This summary was updated by ECRI Institute on May 2, 2012. This summary was updated by ECRI Institute on March 10, 2014 following the U.S. Food and Drug Administration advisory on Low Molecular Weight Heparins.
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
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text:
Samrat and Co
3 Samrat and Co Articles
Will Rajeev Khandelwal make a good detective?2 years ago 0
No, the hunk isn't planning in changing his career. The actor will be stepping into a detective's shoes in an upcoming film Samrat and Co In 2014… Read Article ▶
Rajeev Khandelwal joins Twitter3 years ago 0
We've had Bollywood actors quit the micro-blogging site, however it hasn't stopped the new ones from entering the virtual world Anil Kapoor joined… Read Article ▶
Yogen Shah
Kavita Barjatya's Samrat and Co – definitely not Bollywood's first detective hero!3 years ago 0
Rajshri Productions latest character Samrat is being touted as Hindi cinema's first detective hero. Cineswami tells you otherwise... We received a… Read Article ▶

subset: commoncrawl


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Six children escape from house after sun refracting off perfume bottles causes fire
20:21 18 August 2013
Sunlight shining through a window and refracting off perfume bottles on the windowsill is believed to have caused a house fire.
A mother and six children left the terraced house on Hydeside Gardens, in Lower Edmonton before the fire brigade arrived, and no one was injured.
The blaze severely damaged the first floor of the property.
Edmonton fire station Watch Manager Adam Baker said: "The fire was just around the corner from the fire station so we were there in 30 seconds and managed to stop it spreading to the roof.
"Flames were shooting out of the bedroom window and melted the frame and the rest of the top floor was full of smoke when we arrived.
"The family all managed to get out quickly and they did the right thing by getting out and staying out.
"Try to avoid keeping mirrors and glass on windowsills as the magnification can cause the sun's rays to focus and set fire to things."
Four fire engines, two from Edmonton fire station and one each from Tottenham and Southgate fire stations went to the scene with 21 firefighters and officers.
The brigade was called at 8.06pm and the fire was under control by 8.47pm.
The fire on August 15 came a week after a mirror caused a house fire in Enfield while residents were on holiday. A smoke alarm in the home alerted a neighbour who rang the fire brigade.


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Blizzcon in a Box Contest winners have been PMed, please check your PMs so you don't miss out!
Patch 5.4.1 - RaF Changes, EU Connected Realms, Dampening Hotfix, Blue Posts, Comic
Inside the BlizzCon 2013 Goody Bag
[email protected] to discuss
The Sylvanas one from SDCC 2013 is made by the same company.
As for someone's comment about these selling for a ton on ebay and how you're going to recoup your travel expenses, think again. These retail for about $18 each, if that. The SDCC exclusive figure sold for $18 at the con and is going for about $30 on ebay as I'm posting this.. there was only about 2500 of them. There is going to be well over 25,000 sets of these little guys.
tldr; You'll find plenty of these little guys on ebay for a reasonable price if you wait around. Guessing about $30 give or take.


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William Carballo: When Carballo traveled to Spain in 1987 to learn both the language and the cuisine, he was instantly smitten with tapas, a local specialty. After working with two Spanish chefs in his native Chicago, he moved to Puerto Vallarta in 2000 to open his very successful restaurant.
Roberto Chávez: Internationally recognized in the Who's Who of Chefs in the United States, 33-year-old Chávez Oviedo found his calling while working at a hotel in Lima. After completing his studies, he accepted a position in Los Cabos, where he remained for the next five years.
Juan M. Castiglioni: Originally from Uruguay, 29-year-old Castiglioni has cooked on all five continents, countries including nearby Guatemala to exotic destinations such as New Zealand, Vietnam and Marrakech. He's been with Ginger Garden Lounge since its inception in August 2010.
Nacho Cadena: Nacho Cadena is a celebrity in Vallarta for his charismatic personality and active cultural and social life. He claims to follow the sun, and this is no flippant remark, but his inspired way of saying he lives the moment.
Eduardo Lugo: Eduardo Lugo did his studies as a photographer in Mexico City at AGFA institute, Kodak Mexicana and at the university center of cinematography studies where he had Doña Lola Álvarez Bravo as a teacher. He began his career as a photographer in 1982.
Marta Gilbert: Her body of work includes thousands of paintings—so many, she's lost track of the actual number—displayed in private homes and art galleries throughout Mexico, the United States and as far away as New Zealand and Thailand.
Miriam Pérez: Originally from Yucatán, Pérez grew up loving the outdoors and the sea. And rather than becoming an artist, she firmly states that she was born one.
Abelardo Favela: The multi-faceted artist was born in Mexicali in 1948 but moved to Guadalajara and eventually Mexico City, where he began painting in 1970. Alongside with his artistic pursuits, he was a TV producer for Channel 13, a cultural public television network, and subsequently opened and directed Grupo Match, his own advertising agency.
W. Douglas McLeod: was a native of Vancouver, Canada. In nineteen ninety-two he moved to Puerto Vallarta, Mexico, where he began to write for the local English language daily, Vallarta Today. For several years, as the paper's only reporter, Wayne wrote about everything under the sun.
Zina Sirutis: "My passion for painting and printmaking has always been a part of my life but it is only in recent years that my creative process has been solely focused on painting, drawing and printmaking."
Hugo Barajas: It's been a fine run for Bucerias-based visual artist, Hugo Barajas. Originally from Guadalajara, Barajas developed a keen artistic sense from his earliest memories. At age 14, he began an apprenticeship at El Palomar, a prestigious high-temperature ceramics stoneware workshop in Tlaquepaque, just outside of Guadalajara.
Alfonso Peña: Alfonso Peña is a Renaissance man. Equally at ease in front of an easel and canvas, an architectural floor plan, and even a microphone for an occasional stint at a local martini bar, the artist was born in Queretaro and raised in Monterrey, where he pursued his studies as an architect and visual artist.
Wednesday Evening Market Returns to Paradise Community Center: Featuring a new name, the International Food Fair & Market returns to Puerto Vallarta's Paradise Community Center in Colonia Emiliano Zapata, on Wednesday evenings, starting November 14, from 4 to 7:30 pm.
Eric Wichner: Talk about carving a successful niche for oneself! Burnt out from years of corporate fundraising in the US non-profit sector, Eric Wichner found himself vacationing with a friend in Mexico City in December 2010. Little did he know that a quick search for things to do on Trip Advisor would completely reshape his life in Puerto Vallarta, for the better.
Thierry Blouet: Those of us who enjoy a fine evening at a gourmet restaurant from time to time often rely on restaurant reviews to identify venues worth exploring. For chefs, on the other hand, there is no better way to hone their craft than putting their skills to the test in a competitive format.
Photo Essay: Los Muertos Pier, Construction in Progress: "How about giving us an update on the progress of the new pier," requested Vallarta Lifestyles Newsletter reader Jean Primm in a recent letter to the editor. We were happy to oblige. Read the rest of this entry to enjoy a photo essay of the current status of Los Muertos Pier, scheduled for completion by December of the current year.
Hike from Boca de Tomatlán to Las Ánimas: The small fishing village of Boca de Tomatlán is Puerto Vallarta's South Shore water taxi departure point, with small motor boats or "pangas" traveling regularly to some of the most secluded beaches in the bay, including Las Animas and Quimixto.
David Lyons: David Lyons can't remember if he banged himself on the head or fell off his chair when he learned in October 2010 that his latest novel, Ice Fire, was to be published by Emily Bestler Books, a division of Simon & Schuster.
Mark & Tracy: Originally conceived by Mark Rome and other associates as a hamburger pub, The Palm opened on Olas Altas street some 11 years ago. Somehow, however, the venue itself seemed to have its own ideas from the very beginning, becoming a centerpiece in this popular Puerto Vallarta neighborhood.
Melissa Castillo: Over the last couple of years, Melissa Castillo has gained recognition in the local cultural scene by actively collaborating in the organization of events that provide an opportunity for independent artists, local and foreign, to present their work in theater, dance and music in a suitable space, helping them generate their own income.


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Uncle Julio's Mexican Restaurant
On my first day in Chicago I asked the front desk clerk about the restaurants here. He advised me of the ones he liked and didn't. I asked him about Uncle Julio's across the street and he said it was just OK.
This morning I decided to get a second opinion and I asked the Shuttle Driver. She raved about it all the way to my training class. So I decided to check it out for dinner tonight.
I should have listened to the clerk from the first day. I was not impressed with their food. I got a two enchilada dish that came with rice and beans. The beans were super spicy, the rice was very dry and the salsa that was supposed to go with the chips kept its form after I took the lid off, I actually touched it to see if it was frozen and it wasn't, nor did it move.
The enchilada was very tough and tasted like it had been microwaved too long.
I can definitely say I will not be trying this place again before I leave.
Related Posts
- Coco Bolos by Ching | August 18, 2012
- A Week of Mexican Food by Ching | April 14, 2012
- My Carnitas Dinner at Raul & Theresa's by Ching | January 13, 2013
- Mom Felt Like Having a Margarita by Ching | July 21, 2013
- Dickey's Barbecue Pit by Ching | August 25, 2012
- Giordano's by Brian | August 26, 2012


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In Martial arts promote executive functioning success the idea of developing a stronger "executive function" through martial arts training was discussed. Studies have shown that traditional martial arts training can produce a significant positive impact on the executive function or decision-making skills of students. To understand how this might happen let's look at the self-defense training aspect of martial arts training.
Self-defense experts and military trainers have adopted the phrase "situational awareness" and the acronym O.O.D.A. to describe the decision-making process that leads to successful self-defense and combat. Martial arts pioneers like Bruce Lee taught us that we must always be aware of our surroundings,
"The best surprise against a surprise attack is not to be surprised." - Bruce Lee's Fighting Method: The Complete Edition.
When you dig deeper into these self-defense based teachings you will see executive functioning operating at a very high level. The stages of the O.O.D.A Cycle, for instance, very closely align with the "ISIS"; Initiate, Sustain, Inhibit, Shift, infrastructure used by Dr. Martha Denckla to describe key characteristics of executive functioning. The process of learning to be prepared for self-defense without becoming paranoid or overly cautious includes learning skills such as; interference control, flexible organization and strategic planning and preparedness to act. These are the same characteristics demonstrated daily by people with highly developed executive function.
Add to these self-defense skills the foundation of respect, courtesy, self-control and other life skills central to traditional martial arts teaching and you have a system well adapted to developing strong executive function at any age.


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Model, Rocket, Delta 3914, 1:15
This is a 1:15 scale model of the Delta 3914 rocket, one of many Delta rocket versions built by McDonnell Douglas for NASA. The three-stage, liquid-fuel rocket used a modified U.S. Air Force Thor intermediate-range ballistic missile for its first stage. Nine strap-on, solid-fuel rockets increased boost, five igniting at liftoff and four about a minute later. NASA launched Delta 3914s successfully 10 of 12 times from 1975 to 1987 to place in orbit three commercial communications satellites, one satellite for NATO, four for the National Oceanic and Atmospheric Administration, and two for the European Space Agency. McDonnell Douglas built this model and NASA's Goddard Space Flight Center transferred it to NASM in 1980.
Gift of NASA's Goddard Space Flight Center
- Country of Origin
- United States of America
- Manufacturer
- McDonnell Douglas Corporation
- Type
- MODELS-Missiles & Rockets
- Materials
- Plastic and metal.
- Dimensions
- Overall: 7 ft. 10 in. long x 1 ft. diameter (238.76 x 30.48cm) 1:15 scale.


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Coral Springs' Torgashev gets bronze medal in first trip to Figure Skating Junior Nationals; Chiera, Feigenbaum also post top-five finishes
Andrew Torgashev had never seen snow before traveling to Salt Lake City this week for the U.S. Figure Skating Championships. Nor had the 9-year-old from Coral Springs skated before in national competition.
His anxiety was evident as he warmed up for Saturday's finals of the juvenile boys division. He kept falling.
"He couldn't land his jumps in warmups. You could see he was very nervous," said Ilona Melnichenko, Torgashev's mother and Panthers Figure Skating Club coach. "He's just 9 years old, and he's telling me it's so much pressure. I just told him to go skate like in practice."
Torgashev overcame the jitters and skated like a seasoned veteran to earn the bronze medal in competition with skaters as much as three years older. His score of 49.85 was a personal best. He didn't attempt a double axel, which some of the older skaters featured, but his jumps were flawless and his spins superlative.
"I was really nervous; I had so much pressure on myself. My mom calmed me down," Torgashev said. "I'm really proud of myself. All the boys a lot older than me did what they can do, and I did what I can do.
"My dream is to get 50 points next year."
Torgashev's medal was another step in the PFSC's emergence as an elite program. The club had four skaters at junior nationals, and three of them recorded top-five finishes. It will have six at the U.S. Figure Skating Championships next month, including defending national champion pairs Caydee Denney and Jeremy Barrett.
Franchesca Chiera, 13, finished fifth Saturday in the intermediate women's division. Jackie Jablon was 13th. Vanessa Feigenbaum finished fifth late Saturday in the juvenile girls finals.
Lake Worth's Paolo Borromeo, of the Skating Club of Florida, finished seventh in juvenile boys Saturday after posting the second-highest score in Thursday's qualifying round. He improved from 16th last year.
"They all did a big improvement from regionals and from the whole season," Melnichenko said of the PFSC group. "We look at it as another competition for them, a learning experience. It's like they're climbing stairs. I want to say thank you to the parents. They all believe in what we're doing."
Melnichenko and husband Artem Torgashev, Andrew's dad, are former Soviet National Team skaters and part of an impressive coaching staff at the PFSC, based at Saveology Iceplex. Lisa Gold, Feigenbaum's primary coach, was a world-class skater for Great Britain. Silvia Fontana and John Zimmerman, who coach Denney and Barrett, are former Olympians, and there are others with impressive credentials.
Chiera, runner-up last year in the juvenile division at junior nationals, turned in a commendable performance in achieving a top-five finish in hew new age group after a two-week bout with an ear infection and head cold that forced her to cut back on training and hampered her in competition, particularly in Wednesday's qualifying round.
Because of that, she didn't attempt a triple jump, which all four of the skaters who placed higher landed.
"We decided to stay safe and do what she can do. Our decision was right because she ended up fifth in the whole nation. She did everything good that she can do today," Melnichenko said. "She knows what she needs to work on. We're going to go home and hit the triples."
Meanwhile, Andrew Torgashev had some more business to attend to in Utah. He was planning to celebrate his medal with a trip to the mountains Sunday for his first attempt at snowboarding.
"I think it's really fun seeing snow for first time, and tomorrow I'm going to play around with it," he said.
Complete results from Junior Nationals are at Icenetwork.com


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July 5, 2012
By Stacey Luke
By Stacey Luke
FRESNO, Calif. --- Lanie Madrazo, a senior agricultural business major and member of the Fresno State Equestrian team, leapt at the opportunity to travel with 14 other students to China where she would learn more about a future career in the agriculture industry from an international perspective.
During the trip, Madrazo visited Shanghai, Beijing, and Nanjing where she interacted with students and professors from local Universities and discussed global agricultural concerns.
Madrazo took time to sit down with GoBulldogs.com and discuss the highlights from a once in a lifetime experience.
GoBulldogs.com: What inspired you to pick China as a study abroad location?
Lanie Madrazo: Our department offers a trip where we get the chance to look at agriculture in China. It was an Ag based class we took so that's why I picked it because it's related to my major. It's also a new thing with agriculture, mixing with China.
GoBulldogs.com: Where did you study in China?
LM: We went to Shanghai, Beijing, and Nanjing. They are five hour high speed rail trips from each other. The trains go 200 miles per hour.
GoBulldogs.com: How many people did you go with?
LM: There were 14 people and two professors. They are all from the Jordan College of agriculture. Like enology, plant science and a bunch of Ag business majors.
GoBulldogs.com: How long did the program last and how long were you there?
LM: We were there for 16 days, left on a Monday and got back on a Wednesday. It was fun filled but definitely jam-packed.
GoBulldogs.com: What did you study?
LM: We focused on one class and gave presentations there. The Ag department is connected with some of the universities in China. We gave presentations about U.S. life and culture and some of the issues here in the U.S., like genetically modified organism and how it's becoming a world issue. We gave our opinion on it and presented it to some of the students and professors there. So that was the big part of our class. We were assigned topics and we worked with partners before we left. We also had to write a paper based off of an interview we did while we were about their life [in China] and how they liked it. We also wrote a paper at the end about an issue in China and how we felt about it.
GoBulldogs.com: Had you been to China before? Do you speak any Chinese?
LM: No, but I am taking Mandarin next semester. I've wanted to learn it in the past but now I really want to.
GoBulldogs.com: Was this your first travel abroad study or first time out of the country? If not, did you visit previously?
LM: This was my first study abroad for class credit but I've been out of the country before.
GoBulldogs.com: What was the most interesting thing about studying abroad?
LM: Probably the culture there, it is just so different from here. When you go, there are a lot of big buildings and it looks fancy but when you walk on the streets it still like a third world country.
GoBulldogs.com: How was the culture/school different from the U.S.?
LM: They have toilets there that you have to squat down on as there are no toilet seats. The hotels were nice but all public restrooms have them. We called them squatters. They have no toilet paper or soap or anything in the bathrooms, you have to bring everything. The food is also really different. What our tour guide ordered us to eat was pretty good but the things on the menu were crazy. We had a hotel that outside you could walk down the street and they would sell things like scorpions and snakes and whole sharks on a stick that they would fry up for you. Some of the guys ate the scorpions, you could try anything you wanted.
GoBulldogs.com: What is the most interesting thing you experienced during your stay in China?
LM: Going on the Great Wall of China was pretty awesome, definitely got to check that off my bucket list. It's interesting to see because it's really modernized so you can walk on it but if you walk to the end of that area you can see all the rubble and it was just kind of overgrown. It was really cool. Meeting the people there was also really cool, they are super friendly. If they go to school there they start learning English when they are six years old so they want to talk to you to practice their English since they don't have many opportunities to do that. It was cool to try and have conversations with them, it was hard sometimes but it was interesting to interact with them.
They all loved us and we were the best thing ever to them. They all wanted to take pictures with us, it was crazy. We were like celebrities, there were lines to take pictures with us sometimes, it was pretty fun to interact with them, especially when we went to the universities, we met a girl who is coming to Fresno to study in the Fall so it was awesome to meet her and know we will see her in August. She is going to live in the dorms and study plant science here for two years, so we were all excited to help her out when she gets here.
GoBulldogs.com: Anything additional that was interesting about your trip?
LM: I would definitely want to go back again, but maybe to some different parts in China. I want to go more inland and get a better look at the agriculture. We were more in the city and went inland in just a little bit - I want to go way inland.
We were also able to go to the U.S. Embassy and meet with our representatives there in China. I think I want to do something like that when I graduate. It was cool to talk to them and get contacts, definitely did a lot of networking.
We got to go to an organic tradeshow in Shanghai and we got to look at all the products they are developing and try a bunch of different things. It was really cool to see all the different new and upcoming products. There were people from the U.S. there selling their products trying to branch out and expand their market.
We went to an organic farm and a dairy farm, it was really interesting to see how they grew the different plants and commodities, we went to a lot of what we would call a farms market but they call them a wet market. They have everything you could imagine and so many people. There were rows and rows of people and everyone was selling the same thing. I'm not sure why but that's just how they do it.
All of the fruits and vegetables were imported so we saw a lot of stuff from California in China which was interesting. And they had raw meat, seafood and fish swimming in boxes of water. There were live chickens there too that they were killing in the back; you want a fresh chicken you can get it there. We were not allowed to eat anything from off the street or drink the water because we would have gotten sick. We drank all bottled water.
We ate at all restaurants, sometimes we ate at tourist restaurants and sometimes we went to more traditional on the street restaurants. In the U.S. we have a grading system like an A or a B in restaurants for food safety, but in China they had different smiley faces to represent the quality of the restaurant. A big smile meant it was good, a straight line meant it barely passed standards and a frown meant it was bad.
But I would definitely go back. I've been to Ireland and England but nothing like China. I think working with the U.S. Embassy or consulate office would be awesome and this trip definitely inspired me.
"Discover Fresno State Athletics" - Be sure to LIKE Fresno State Athletics on Facebook and follow your Bulldogs on Twitter (@FSAthletics).
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Some West Virginia History According To Wikipedia:
West Virginia is a state in the Appalachian, Upland South, and Mid-Atlantic regions of the United States, bordered by Virginia on the southeast, Kentucky on the southwest, Ohio on the northwest, and Pennsylvania and Maryland on the northeast. The capital and largest city is Charleston.
Historically the area now occupied by West Virginia was contested territory, mainly by Pennsylvania and Virginia. Some speculative land companies, such as the Vandalia Company, and later the Ohio Company and Indiana Company tried to legitimize their claims to land in parts of West Virginia and Kentucky but failed. With the settlement of the Pennsylvania and Virginia border dispute, which resulted in the creation of Kentucky, Kentuckians "were satisfied...and the inhabitants of a large part of West Virginia were grateful."
After the Wheeling Conventions, West Virginia broke away from Virginia during the American Civil War and was admitted to the Union as a separate state on June 20, 1863, and was a key Civil War border state. It is one of only two states formed during the American Civil War and is the only state to form by seceding from a Confederate state.
The Census Bureau considers West Virginia part of the South because most of the state is south of the Mason-Dixon Line. The northern panhandle, however, extends adjacent to Pennsylvania and Ohio with the West Virginia cities of Wheeling and Weirton being just across the border from the Pittsburgh metropolitan area, while Bluefield is less than seventy miles from North Carolina and Harper's Ferry is considered to be a part of the Washington D.C. metropolitan area. The unique position of West Virginia means that it is often included in a wide variety of geographical regions, including the Southeastern United States and even the Northeastern United States. Notably, it is the only state which entirely lies within the area served by the Appalachian Regional Commission, which is a common definition of "Appalachia".
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Larry Elder, a black conservative columnist and Tea Party speaker, has a piece out this week titled "Tea Party: Why the Left Doesn't Get It."
Setting aside the question of why any African-American would vote Republican (did any Jews vote for the Nazis?), Elder's column unintentionally reveals the intellectual inconsistency of the Tea Party.
For liberals the Ur question about the Tea Party concerns the timing of its origin: February 2009. Where, they ask, were these self-declared deficit hawks when Bush and his Republican Congress turned Clinton's budget surplus into record deficits? Where were these advocates of small government when Bush hired the biggest roster of federal employees in history and created a new federal department—the Department of Homeland Security—that became a national laughingstock due to its incompetence? Where were these Constitutional purists when Bush suspended habeas corpus, built concentration camps and signed off on torture?
"As to Bush's non-defense, non-homeland security domestic spending, [right-wing] people did complain—lots of them and frequently," Elder points out.
And he's right. There was grumbling. I remember.
But there weren't anti-Bush rallies, much less scary guys showing up at presidential appearances brandishing automatic weapons. Under Bush, of course, said scary guys would have been declared "enemy combatants" and tortured into psychosis like Jose Padilla.
"Better late than never," Elder lamely retorts.
Another right-wing columnist, Jonah Goldberg, goes so far as to call the Tea Party "a delayed Bush backlash."
But 57 percent of Tea Partiers say they like Bush. Huh.
On most of the policies Tea Partiers claim to deplore—deficit spending, expansive government, the bank bailouts—Obama is identical to Bush. The only difference between the two men is the color of their skin. Which makes lefties think anti-Obama racism is the Tea Party's true driving force.
As Paul Butler wrote in the New York Times: "No student of American history would be surprised to learn that when the United States elects its first non-white president, a strong anti-government movement rises up."
"Slanderous hogwash," Goldberg calls the charge that the Tea Party is motivated by racism.
If not racism, then what?
Stupidity. Or at least intellectual dishonesty.
Elder's qualifier that righties didn't like "Bush's non-defense, non-homeland security domestic spending" is revealing. Bush's two wars and tax cuts for the wealthy will account for a staggering 70 percent of the federal deficit over the next 10 years, according to the Center for Budget and Policy Priorities. (Obama's bailouts will cost five percent.)
Either you're against deficits, or you're not. Making an exception for optional military spending—neither the Afghan nor the Iraq war was necessary—is like saying you adore sharks except for all the sharp teeth.
My leftie friends find the Tea Party frustrating. They applaud Tea Partiers' distrust of government, their willingness to take to the streets to express their grievances. If only the Left had their energy!
Progressives also find much to like in Tea Partiers' calls for a return to core values embodied by the Constitution and the Bill of Rights. But only in theory.
The Tea Party's selective Chinese-menu style approach to constitutional purity and small government is appalling. They're loud and proud when it comes to the right to own guns, yet oppose or remain silent when it comes to the right of gays to sleep with whomever they want-and marry him. They decry government intrusion in the form of healthcare reform, but have nothing to say about the fact that the NSA is listening to their phone calls and reading their email. They complain about illegal immigrants but not about the corporations that hire them. And what should be more terrifying to opponents of big guvmint than reserving the right—as Bush did and Obama does—to assassinate American citizens just for fun? (The Tea Party is silent on this too.)
If the Tea Party is to emerge as a potent force in American politics, it will need to develop a coherent platform with broad appeal across class, party and racial lines. An appeal to fiscal sanity, constitutional freedoms and a government that keeps out of our bedrooms could form the foundation of a new majority. Otherwise, the Tea Party will be remembered as the latest incarnation of the nativist white wing of the GOP (c.f. "angry white males" circa 1995).
(Ted Rall is working on a radical political manifesto for publication this fall. His website is tedrall.com.)


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IEEE membership options for an individual and IEEE Xplore subscriptions for an organization offer the most affordable access to essential journal articles, conference papers, standards,
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The explosive growth of the Internet has brought many good things: electronic commerce, easy access to vast stores of reference material, collaborative computing, e-mail, and new avenues for advertising and information distribution, to name a few. As with most technological advances, there is also a dark side: criminal hackers. Governments, companies, and private citizens around the world are anxious to be a part of this revolution, but they are afraid that some hacker will break into their Web server and replace their logo with pornography, read their e-mail, steal their credit card number from an on-line shopping site, or implant software that will secretly transmit their organization's secrets to the open Internet. With these concerns and others, the ethical hacker can help. This paper describes ethical hackers: their skills, their attitudes, and how they go about helping their customers find and plug up security holes. The ethical hacking process is explained, along with many of the problems that the Global Security Analysis Lab has seen during its early years of ethical hacking for IBM clients.
Note: The Institute of Electrical and Electronics Engineers, Incorporated is distributing this Article with permission of the International Business Machines Corporation (IBM) who is the exclusive owner. The recipient of this Article may not assign, sublicense, lease, rent or otherwise transfer, reproduce, prepare derivative works, publicly display or perform, or distribute the Article.
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This single session class is for parents of infants from 4 weeks to crawling and is one of the most pleasant ways to "get in touch" with your infant. Infant massage has many benefits for baby too. It helps regulate digestive, respiratory, and circulatory systems, while influencing motor and memory development. Babies often sleep better, too! Small group classes are taught by a Certified Infant Massage Instructor at the hospital. Participants will receive a BabyBabyOhBaby: Infant Massage DVD to take home. The fee of $85 includes mother, her partner and the baby. If you are unable to attend your class, please call at least 48 hours in advance to reschedule or to receive a class refund. This will allow your seat to be made available to another participant.
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Please call Physician Referral at 312-926-8400 and one of our Health Consultants will assist you with referrals to Pediatricians.
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Phone: 1-877-926-4664
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One last night for Nevermind
- 11
Mon 5th Nov, 2012 in Local News
Oxford Street's gay hotspot Nevermind has shut its doors, with its new owner planning a hetero rebrand – but the Disgraceland crew will have one last hurrah this weekend.
"This Saturday night we're going to be re-opening the hallowed doors of the little club that could for one final night of partying just like it used to be," says Disgraceland's crew.
All the stars of the club's heyday have aligned – expect to see Courtney Act, who's travelled all the way from her new Hollywood home, dancer Daniel Garofali visiting from New York, plus Nevermind's former party promoter Tim Duggan (all the way from Darlinghurst) for this momentous occasion.
"Three and a half years ago we found a little nightclub on Oxford Street that we converted into the most happening party in Australia," says Duggan proudly.
"This Saturday night we're reassembling the original team to sprinkle a little bit of that magic over Nevermind for one last time. If you've ever partied with us, come along to make one last memory."
It'll be the last time the venue will be open as 'Nevermind'. Its new owner has signaled a complete revamp of the club, catering to a mainstream but gay-friendly crowd.
Through the years, Nevermind's celeb guests included Lady Gaga, The Spice Girls, Pusscycat Dolls, Amanda Lepore, Adam Lambert, pornstar Brent Corrigan and video crazy turned wannabe pornstar Chris Crocker.
The club's former resident drag diva Courtney Act will also present her live show at the nearby Slide nightclub this Friday – find details here.
DISGRACELAND: ONE NIGHT ONLY is on the Saturday November 10 from 10pm until late at Nevermind, level 1 at 163 Oxford Street, for $15.
See photos from some of Nevermind's big nights below, and video from when Lady Gaga visited in July 2011.
Courtney's Last Act!
July 8th, 2011
Luciana at Nevermind
June 8th, 2012
Saturday Night at Nevermind
December 3rd, 2011


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Artist: Matthew Barber
Album: Matthew Barber
Genre: Rock
I was at a party in my head
contemplating everything I said
But every time I tried to make a sound
the words they were nowhere to be found
Saw you in a thumbnail photograph
Wondered if you still knew how to laugh
I wish I could see
You'd probably be laughing back at me
Na na na na na na na na na
What were we like together?
Help me I can't remember
I wish I knew you better
Please don't be blue forever
I wonder who's been hanging 'round your door
Have you found what you've been looking for
You've been hurt so many times before
It only makes them want you more and more
More and more. More and more.
Na na na na na na na na na
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Homepage-- Programs and Services -- Contact Information
Thanksgiving dinners delivered to your home
If you are homebound, and not able to prepare a Thanksgiving dinner or will not be with family or friends this Thanksgiving Day, please contact one of the following organizations to order a traditional turkey dinner with all the fixings that will be home-delivered to you.
St. Johns Kitchen & Northern Berkshire United Way
Will deliver Thanksgiving meals to seniors and their caregivers age 55 and over in the following towns: North Adams, Adams, Williamstown, Cheshire, Clarksburg and Florida.
Call St. Johns Kitchen at 664-9656 no later than November 16.
First Congregational Church of Great Barrington
Will deliver Thanksgiving meals to seniors in the following areas: Great Barrington, Sheffield, Lenox, Lee, and most of Southern Berkshire. Call Grace Zbell at 528-0230 or the First Congregational Church, at 528-2740 before November 15.
Christian Center
Call them at 443-2828 for information on Thanksgiving meal delivery for the central Berkshires.


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April 18, 2014
FRESNO, Calif. - Now that the initial hiring process is over, new Fresno State women's basketball coach Jaime White can begin the process of settling in and getting organized as she takes over the Bulldog program.
Get to know a little bit about Fresno State's new women's basketball coach with this Q&A.
Q: What attracted you to Fresno State?
JW: "Being back in the Mountain West was something that I was excited about. Also I like California, can't go wrong there. I was born in Lancaster, Calif. and both of my parents were raised there. I've been in this area quite a bit, we've always recruited here and it just seemed like a nice transition from where we were at in Colorado."
Q: What are the values of your program at Northern Colorado and what you'll have here?
JW: "At Northern Colorado we really worked to have everything have meaning and we talk about building championships. Building championships in the classroom, on the court and in life and we really stuck to that to build a great culture at Northern Colorado and I plan on doing that here. They've had great tradition here and I really believe what we've done at Northern Colorado we can bring here and really make it better."
Q: What does a Jaime White coached team look like?
JW: "Disciplined, they are hard workers, they also put in a lot of extra time, not only on the court or in the weight room, but in the community. [The student-athletes] are great people to be around and want to be successful in their lives."
Q: You've got the job, now what process do you go through as you get started?
JW: "It's kind of a recruiting period. We need to touch base with the team and see where everybody is at as far as making sure people are getting into their workouts and just kind of get organized that way. We're going to go out into a recruiting period right now, we can bring juniors on campus and it's going to get going sooner than we know it. I think it's just important to be organized and have a plan set in place, not only for our players here, but hopefully for the players that are interested in Fresno State."
Q: Talk about your history in the Mountain West and some of your mentors along the way...
JW: "I'm so honored to have worked with a Hall of Famer Elaine Elliott at Utah. When I was a junior college coach she hired me and Utah was always the school to be at when you were in Utah. It was nice to be able to see how a championship team works. All of her hard work and effort that she put into that team, she's had a great history and I was very lucky and honored by that opportunity. From there I went to Wyoming with Joe Legerski, who was her assistant and there we kind of had to rebuild a team. We saw Wyoming go from I think it was 11 season ticket holders to 1,000 in the three years that I was there. I think the most important thing is that I am familiar with the teams we play, the Colorado State's, the Wyoming's, Air Force, San Diego State and the tradition that they've had. It's just nice to be a part of that and to know you have that expectancy of excellence around you."
"Catch the Wave" - ESPN2 790 AM is the home of the Fresno State women's basketball team.
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*picture is representative of product type, check specifications for details before ordering. Packaging also varies.
Lever-action. Designed for no-nonsense deer hunters. Tapped solid top receiver. Side ejection. Tubular magazine. Micro-Groove barrel. Hammer block safety. Walnut-finish hardwood stock w/pistol grip, cut-checkering, Mar-Shield finish Blued steel barrel band w/inegral swivel. Hard rubber buttpad. Ambidextrous offset hammer spur. Adjustable semi-buckhorn folding rear; ramp front sight w/brass bead & Wide-Scan hood. Deeply blued w/gold-plated steel trigger Wt.: 7 lbs. Includes: gun lock, padded sling.


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Three images from the test roll I took with my new Yashica Electro 35 GS. Shot without battery, which means a fixed time at 1/500, using sunny 16. Completely unedited; straight from the lab.
Love how they came out, sharp & creamy! As usual you can click the thumbs to go to my flickr where you can see them in larger sizes.