text:
How many patients fulfil the surface electrocardiogram criteria for subcutaneous implantable cardioverter-defibrillator implantation?
Aims To determine the number of patients with a primary or secondary prevention implantable cardioverter-defibrillator (ICD) indication who are eligible for subcutaneous ICD (S-ICD) implantation according to the S-ICD manufacturer's surface electrocardiogram (ECG) screening template.
Methods and results One hundred and ninety-six ICD patients with a non-paced ventricle were assessed using erect and supine ECG limb lead recordings to simulate the three S-ICD sensing vectors. Each ECG lead was scrutinized by two independent observers. Subcutaneous ICD eligibility required two or more leads to satisfy the S-ICD screening template in both erect and supine positions. Overall, 85.2% of patients [95% confidence interval (CI): 80.2–90.2%] fulfilled surface ECG screening criteria. The proportion of patients with 3, 2, 1, and 0 qualifying leads were 37.2% (95% CI: 30.4–44.0%), 48.0% (95% CI: 41.0–55.0%), 11.2% (95% CI: 6.8–15.6%), and 3.6% (95% CI: 1.0–6.2%). The S-ICD screening template was satisfied more often by Lead III (primary vector, 83.7%, 95% CI: 78.5–88.9%) and Lead II (secondary vector, 82.7%, 95% CI: 77.4–88.0%) compared with Lead I (alternate vector, 52.6%, 95% CI: 45.6–59.6%). A prolonged QRS duration was the only baseline characteristic independently associated with ineligibility for S-ICD implantation. There was 92.9% agreement between the two independent observers in assessment of eligibility using the S-ICD screening template.
Conclusion About 85.2% of patients with an indication for a primary or secondary prevention ICD have a surface ECG that is suitable for S-ICD implantation when assessed with an S-ICD screening template. There is minor inter-observer variation in assessment of eligibility using the S-ICD screening template.
- Subcutaneous implantable cardioverter-defibrillator
- Electrocardiogram
What's new?
About 85.2% of patients with a primary or secondary prevention implantable cardioverter-defibrillator (ICD) were eligible for subcutaneous ICD (S-ICD) implantation according to the manufacturer's surface electrocardiogram (ECG) screening template.
The surface ECG screening template was simple to use and there was 92.9% agreement between observers with regard to S-ICD eligibility.
Prolonged QRS duration was the only baseline characteristic independently associated with S-ICD ineligibility according to the surface ECG screening template.
Implantable cardioverter-defibrillators (ICDs) reduce the risk of sudden death in individuals at high risk of ventricular arrhythmias.1,2 Conventional ICD systems use a transvenous lead for sensing of ventricular arrhythmias and delivery of ICD therapy. Transvenous ICD leads are associated with complications such as lead fracture, infection, and venous obstruction.3–5 Removal of failed or infected transvenous leads is associated with considerable morbidity and mortality.6 An entirely subcutaneous ICD (S-ICD, Cameron Health) was recently approved by the US Food and Drug Administration agency and is now commercially available.7 The S-ICD comprises the SQ-RX pulse generator, positioned over the left sixth rib between the mid and anterior axillary lines, connected to the Q-TRAK subcutaneous lead which consists of a left parasternal coil electrode flanked by distal and proximal sensing electrodes at the level of the manubriosternal junction and xiphoid process.
Subcutaneous ICD utilize one of three subcutaneous electrograms recorded between two sensing electrodes and the pulse generator for ventricular sensing (Figure 1). In certain patients, subcutaneous electrograms are inadequate for sensing. During early experience, S-ICD implantation was occasionally aborted mid-procedure due to inadequate R-wave amplitude for sensing. In real-world patients with S-ICD systems, T-wave oversensing is a frequent cause of inappropriate shocks.8–10 To avoid S-ICD implantation in patients who are likely to experience sensing problems, the manufacturer has developed a pre-implant surface electrocardiogram (ECG) screening template to identify patients that are likely to have unsuitable subcutaneous ECG. Surface and subcutaneous ECG are highly correlated with similar R-wave amplitudes and signal-to-noise ratios.11–13 However, surface ECG exhibit postural and beat-to-beat variations in depolarization and repolarization amplitudes relating to changes in cardiac axis and autonomic tone.13,14 As such, erect and supine surface ECG must be assessed with the screening template. It is uncertain how many patients with an ICD indication are eligible for S-ICD according to this surface ECG screening template.
In this study, we assessed an unselected series of patients with a conventional ICD to determine the number of patients that fulfil surface ECG screening criteria for S-ICD implantation, to compare the three available subcutaneous electrogram vectors, and to examine predictors of eligibility for S-ICD use.
Study population
Liverpool Heart and Chest Hospital is a tertiary centre serving a population of 2.2 million people. All patients with a single-chamber or dual-chamber transvenous ICD that attended routine follow-up at ICD clinic between February 2012 and October 2012 were screened for inclusion. An ECG was performed at ICD clinic. We excluded patients with an S-ICD, patients with a paced QRS complex, and patients who were unable to stand for the time required to record an erect ECG. Use of routinely collected anonymous data was approved by the local ethics committee and deemed not to require formal patient consent.
Electrocardiogram collection
Additional ECG recordings were obtained using limb lead electrodes to simulate the S-ICD sensing vectors (Figure 1). The left arm (LA) and right arm electrodes were positioned 1 cm lateral to the left sternal border, and, respectively, 1 cm above the xiphoid process and no more than 14 cm superior to the LA electrode. The left leg electrode was positioned in the fifth intercostal space on the mid-axillary line, and the neutral electrode on the lower torso to ensure other lead positions were undisturbed. The resulting augmented leads (Leads I, II, and III) correspond to the alternate, secondary, and primary vectors of the S-ICD, respectively. Two page rhythm strips were recorded using these three leads, at two gains (5 and 10 mm/mV) both erect and supine with a further 20 mm/mV recording made in each posture if the smallest R-wave amplitude seen in any channel of the supine 10 mm/mV recording did not reach 0.5 mV.
Electrocardiogram analysis
Use of the surface ECG screening template is described in Figure 2. The template consists of six coloured shapes that correspond to the six S-ICD automatic gain settings. Each shape has two constant threshold periods and a subsequent exponential decay curve. The screening template was placed over a single QRS-T complex. The horizontal line on the template was aligned with the isoelectric line and the left edge of the template was aligned with the onset of the QRS complex. To satisfy the template, no part of the QRS-T complex may lie outside coloured shape and the maximum amplitude of the QRS complex must cross the dashed line. To be eligible for S-ICD implantation, at least two ECG leads (I, II, or III) must satisfy the template (at any gain) in both erect and supine postures. All ECG were analysed by two independent blinded observers and their assessment of S-ICD eligibility was compared. When there was disagreement, ECG for that patient were adjudicated by a third independent observer. All three observers received brief training before using the surface ECG screening template.
Sample size estimation
The sample size was calculated using the standard confidence interval (CI) approach to a proportion. Prior observations suggested over 90% of patients matched the template.15 We conservatively estimated the true population proportion to be 85%. A sample size of 196 patients is required to provide 95% confidence that the true population proportion lies within the range 85 ± 5% (α = 0.05).
Statistical analysis
The proportion of patients fulfilling ECG criteria are presented as percentages with 95%CI.16 Baseline characteristics are reported as means with standard deviations for continuous variables and by frequencies and percents for categorical variables. The data were assessed for normality using the Shapiro–Wilk's test. The characteristics of patients fulfilling or failing the ECG criteria were examined. Means were compared using the Wilcoxon rank sum test or Student's t-test (with Levene's test for equality of variances) depending on the distribution of the data. Proportions were compared using the χ2 test or Fisher's exact test when the observed frequencies were <5. Logistic regression was used to examine the effect of baseline characteristics on S-ICD eligibility according to the surface ECG screening template.17 A two-tailed P value of <0.05 was considered statistically significant. Statistical analyses were performed using SAS for Windows Version 9.2 (SAS Institute).
Study population
A total of 196 patients with a single-chamber or dual-chamber satisfied the inclusion and exclusion criteria. The population was predominantly male (80.1%) with a mean age of 66 years. The indication for ICD implantation was primary prevention in 40.3% and secondary prevention in 59.7% of patients. Baseline characteristics are presented in Table 1.
|All patients
(n = 196)
(n = 167)
(n = 29)
|P value
|Male (%)
|157 (80.1)
|130 (77.8)
|27 (93.1)
|Age (years)
|66 ± 12
|65 ± 12
|67 ± 13
|Height (cm)
|172.1 ± 8.4
|172 ± 8.5
|172.8 ± 7.6
|Weight (kg)
|85.9 ± 17
|86.4 ± 17.5
|83.3 ± 14.1
|Body mass index (kg/m2)
|29 ± 5.3
|29.2 ± 5.4
|27.9 ± 4.6
|79 (40.3)
|68 (40.7)
|11 (37.9)
|117 (59.7)
|99 (59.3)
|18 (62.1)
|Ischaemic heart disease
|115 (58.7)
|95 (56.9)
|20 (69.0)
|Arrhythmogenic right ventricular cardiomyopathy
|12 (6.1)
|12 (7.2)
|0 (0.0)
|Long QT syndrome
|4 (2.0)
|3 (1.8)
|1 (3.4)
|Dilated cardiomyopathy
|25 (12.8)
|21 (12.6)
|4 (13.8)
|Hypertrophic cardiomyopathy
|25 (12.8)
|22 (13.2)
|3 (10.3)
|Brugada syndrome
|3 (1.5)
|3 (1.8)
|0 (0.0)
|Tetralogy of Fallot
|3 (1.5)
|1 (0.6)
|2 (6.9)
|Medical history and previous intervention
|Left ventricular systolic dysfunction
|39 (19.9)
|32 (19.2)
|7 (24.1)
|27 (13.8)
|21 (12.6)
|6 (20.7)
|40 (20.4)
|36 (21.6)
|4 (13.8)
|90 (45.6)
|78 (46.7)
|12 (41.8)
|Myocardial infarction
|108 (55.1)
|93 (55.7)
|15 (51.7)
|Atrial fibrillation
|37 (18.9)
|33 (19.8)
|4 (13.8)
|Diabetes mellitus
|34 (17.3)
|33 (19.8)
|1 (3.4)
|23 (11.7)
|17 (10.2)
|6 (20.7)
|External defibrillation
|112 (57.1)
|95 (56.9)
|17 (58.6)
|Ventricular tachycardia ablation
|9 (4.6)
|8 (4.8)
|1 (3.4)
|Device/lead extraction
|17 (8.7)
|15 (9.0)
|2 (6.9)
|Device therapy—ATP
|48 (24.4)
|41 (24.6)
|7 (24.1)
|Device therapy—shock
|51 (26.0)
|44 (26.3)
|7 (24.1)
|164 (83.7)
|139 (83.2)
|25 (86.2)
|43 (22.0)
|37 (22.2)
|6 (20.7)
|1 (0.5)
|1 (0.6)
|0 (0)
|Device location and type
|183 (93.3)
|157 (94.0)
|26 (89.7)
|13 (6.6)
|10 (6.0)
|3 (10.3)
|Single chamber
|98 (50.0)
|81 (48.5)
|17 (58.6)
|Dual chamber
|98 (50.0)
|86 (51.5)
|12 (41.4)
|Baseline ECG characteristics
|QRS duration (ms)
|114.9 ± 26.8
|112.3 ± 24.6
|130 ± 34
|<120 ms
|123 (62.8)
|112 (67.1)
|11 (37.9)
|120–149 ms
|47 (24.0)
|38 (22.8)
|9 (31.0)
|>149 ms
|26 (13.3)
|17 (10.2)
|9 (31.0)
|QRS morphology
|132 (67.3)
|119 (71.3)
|13 (44.8)
|Left bundle branch block
|27 (13.8)
|20 (10.2)
|7 (24.1)
|Right bundle branch block
|20 (10.2)
|14 (8.4)
|6 (20.7)
|Intra-ventricular conduction delay
|17 (8.7)
|14 (8.4)
|3 (10.3)
|Corrected QT interval (ms)
|442.1 ± 33.8
|441 ± 32.1
|447 ± 43
Continuous variables given as mean ± standard deviation; categorical variables given as number (percentage).
COPD, chronic obstructive pulmonary disease; ATP, anti-tachycardia pacing.
How many patients are eligible for subcutaneous implantable cardioverter-defibrillator according to the surface electrocardiogram screening template?
The number of patients with zero, one, two, or three ECG leads that satisfied the surface ECG screening template is summarized in Figure 3. For a patient to be eligible for an S-ICD, at least two ECG leads had to satisfy the screening template. Overall, 167 (85.2%, 95% CI: 80.2–90.2%) patients were eligible for S-ICD implantation. The eligible group comprised 73 (37.2%, 95% CI: 30.4–44.0%) patients with three qualifying ECG leads and 94 (48.0%, 95% CI: 41.0–55.0%) patients with two qualifying ECG leads. Conversely, 29 (14.8%, 95% CI: 9.8–19.8%) patients were ineligible for S-ICD implantation. The ineligible group comprised 22 (11.2%, 95% CI: 6.8–15.6%) patients with only one qualifying ECG lead and 7 (3.6%, 95% CI: 1.0–6.2%) patients with no qualifying ECG leads.
How frequently does each surface electrocardiogram lead satisfy the screening template?
The number of times that each lead satisfied the surface ECG screening template is described in Table 2. In order for a lead to qualify, that lead had to satisfy the screening template (at any gain) in both the erect and supine position. Lead III (primary vector) had an overall qualification rate of 83.7% (95% CI: 78.5–88.9%). Lead II (secondary vector) had an overall qualification rate of 82.7% (95% CI: 77.4–88.0%). Lead I (alternate vector) had an overall qualification rate of 52.6% (95% CI: 45.6–59.6%). The overall qualification rate for Leads III and II were significantly greater than Lead I (P < 0.05).
S-ICD vector
|Lead I
S-ICD 'Alternate'
|Lead II
S-ICD 'Secondary'
|Lead III
S-ICD 'Primary'
|5 mm/mV
|58 (29.6%)2,3
|121 (61.7%)1
|136 (69.4%)1
|10 mm/mV
|108 (55.4%)
|111 (56.6%)
|89 (45.4%)
|20 mm/mVa
|29 (14.7%)3
|23 (11.7%)
|14 (7.1%)1
|5 mm/mV
|38 (19.4%)2,3
|118 (60.2%)1
|132 (67.3%)1
|10 mm/mV
|93 (47.4%)
|110 (56.1%)
|110 (56.1%)
|20 mm/mVa
|30 (15.3%)
|22 (11.2%)
|19 (9.7%)
|Lead eligibility
|103 (52.6%)2,3
|162 (82.7%)1
|164 (83.7%)1
1P < 0.05 vs. Lead I, 2P < 0.05 vs. Lead II, 3P < 0.05 vs. Lead III, using Bonferroni's correction.
aOnly 69 of the 196 patients were screened at the 20 mm/mV gain setting as described in the Methods section. These percentages were still calculated from the total sample size as enough information was derived from the compulsory gain settings in the remaining 127 patients to formulate an outcome and allow comparison.
There were minor differences in lead qualification rate between the erect and supine positions. For Lead I (alternate vector) at 5 mm/mV, the qualification rate was higher in the supine position, compared with the erect position (P = 0.02). For Lead III (primary vector) at 10 mm/mV, the qualification rate was higher in the erect position, compared with the supine position (P = 0.01). For all other leads at all other gains, there was no significant difference in qualification rate between erect and supine postures. The colour template satisfied by each lead is described in the Supplementary material online, Table.
Inter-observer agreement and adjudication
Agreement between the two independent blinded observers is summarized in Table 3. Both observers agreed on the overall eligibility for S-ICD implantation in 182 (92.9%) of patients and disagreed on 14 (7.1%) of patients. Where the two observers disagreed, ECG were adjudicated by a third independent observer. After adjudication, 12 patients were deemed eligible and 2 patients were deemed ineligible. In addition to the overall eligibility for S-ICD implantation, the two observers disagreed about the number of qualifying leads in 32 patients, but these disagreements did not alter the overall eligibility. Finally, the two observers frequently disagreed with regard to the colour template that was satisfied by a lead, but once more, these disagreements did not alter the overall eligibility.
|Observer 2
|Observer 1
Baseline characteristics associated with the eligibility for subcutaneous implantable cardioverter-defibrillator implantation
All baseline characteristics, stratified by S-ICD eligibility, are described in Table 1. There were no differences in demographics, ICD indication, underlying aetiology, and co-morbidities between patients who were eligible for S-ICD implantation and patients who were ineligible for S-ICD implantation. However, patients who were ineligible for S-ICD implantation had a significantly longer QRS duration compared with patients who were eligible for S-ICD implantation (P = 0.008). This difference was particularly marked for those with severe QRS prolongation (>149 ms), of whom only 65% were eligible for S-ICD implantation. Correspondingly, a greater proportion of patients who were eligible for S-ICD implantation had normal QRS morphology, compared with those patients who were ineligible for S-ICD implantation (P = 0.005).
Predictors of eligibility
All baseline characteristics were assessed in a multivariable logistic regression model to identify independent predictors of eligibility. The only baseline characteristic that was associated with eligibility for S-ICD implantation was QRS duration. When QRS duration was analysed as a continuous variable, the odds ratio was 0.977 (95% CI: 0.964–0.991) and the area under the receiver-operating curve (ROC) was 0.66. When QRS duration was analysed as a categorical variable (>149 ms), the odds ratio was 0.25 (95% CI: 0.1–0.63) and the area under the ROC was 0.61.
This is the first study to describe the proportion of patients with an ICD that would be eligible for S-ICD implantation according to surface ECG screening criteria. In a series of unselected patients with an indication for a primary or secondary prevention ICD, 85.2% (95% CI: 80.2–90.2%) of patients had a surface ECG that satisfied the pre-implantation screening template in at least two leads (vectors) and these patients would therefore be eligible for S-ICD implantation. Our results are similar to unpublished observations of a single German centre, who screened 58 patients using an identical screening tool, and reported that 88% of patients had a satisfactory surface ECG for S-ICD implantation.15
We found that the primary vector (Lead III) and the secondary vector (Lead II) satisfied the surface ECG screening template more frequently than the alternate vector (Lead I). The S-ICD automatically selects the optimal sensing vector during implantation, although the operator may select a different vector if desired.18 Previous studies have not described which sensing vector is selected by the S-ICD.8,9,19–21 In theory, the primary or secondary sensing vectors are most attractive as they encompass the heart within the sensing field between the sensing electrode on the lead and the generator. The sensing field of the alternate vector is between two sensing electrodes on the parasternal portion of the QTRAK subcutaneous lead. Interestingly, there is a case report of a patient in which it was desirable to select the alternate vector and exclude the generator from the sensing field when it had been positioned more inferiorly than usually recommended.22
Previous studies have reported significant differences in R-wave amplitude between erect and supine postures.14 There is consequent concern that postural changes may result in oversensing or undersensing by S-ICD systems. In the present study, we did not see any significant difference between erect and supine ECG in terms of the overall eligibility according to the surface ECG screening template. The only difference in lead qualification rates between erect and supine posture was for the alternate vector (Lead I) at the 5 mm/mV gain setting and primary vector (Lead III) at the 10 mm/mV gain setting. There was no difference at higher gain settings for either lead. As such, it would appear that postural changes in R-wave or T-wave amplitude that might have an adverse effect on S-ICD sensing are likely to be accommodated by the ability of the S-ICD to automatically adjust gain.
Use of the pre-implantation screening template was straightforward with minimal requirement for training. All three observers were able to use the template on an independent basis after 5min of tuition. We demonstrated 92.9% agreement between two independent observers when using the surface ECG screening template to determine the overall eligibility for S-ICD implantation. This observation suggests that use of the surface ECG screening template is relatively reproducible and should be useful in daily clinical practice. During subsequent discussion between the three observers, it appeared that most discrepancies in lead qualification according to the screening template were the result of minor beat-to-beat variation in the isoelectric baseline and R-wave amplitude.
Finally, our study has demonstrated that eligibility or ineligibility for S-ICD implantation according to the surface ECG screening template was not associated with age, gender, height, weight, primary or secondary prevention indication, or underlying aetiology of heart disease. The only baseline characteristic associated with ineligibility for S-ICD implantation was an abnormal QRS complex on the baseline ECG, such as left or right bundle branch block. Although S-ICD ineligibility was more frequent in patients with severe prolongation of the QRS complex (>149 ms), 65% of these patients remained eligible for S-ICD implantation and an area under the ROC of 0.61 implies that QRS prolongation is not a useful predictor of eligibility in clinical practice. In addition, it is uncertain whether QRS abnormalities limit real-world use of S-ICD systems. Irrespective of surface ECG eligibility, severe QRS prolongation would frequently lead to selection of a transvenous device rather than an S-ICD, either for delivery of cardiac resynchronization therapy or bradycardia pacing.
First, the external validity of our study is limited to the included patient group. Due to the organization of cardiac services in our region, we did not include any patients aged <19 years and only 1.5% of patients included had adult congenital heart disease. These patient groups are important potential S-ICD recipients. Secondly, our study only determined S-ICD eligibility according to the surface ECG screening template. We did not examine other reasons why a patient might be ineligible for an S-ICD. In a Dutch study of 463 patients with a transvenous ICD, 45% of patients would have become 'ineligible' for S-ICD over 5 years of follow-up because of an indication for atrial or ventricular pacing, delivery of successful anti-tachycardia pacing without a subsequent shock, or upgrade to cardiac resynchronization therapy.23 Finally, an even larger sample size might have provided greater insight into the influence of other baseline characteristics on S-ICD eligibility.
About 85.2% of patients with an indication for a primary or secondary prevention ICD had a surface ECG that was suitable for S-ICD implantation when assessed with a surface ECG screening template. The screening template was simple to use, with 92.9% inter-observer agreement. No baseline characteristics other than QRS duration predicted eligibility, suggesting that the S-ICD may have broad clinical applicability.
Supplementary material
Supplementary material is available at Europace online.
Conflict of interest: none declared.
- Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2013. For permissions please email: firstname.lastname@example.com.


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Cardinal Hill Rehabilitation Hospital
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argonaut17 November 24, 2012
I visited this facility
Staff: The nursing aides and physical therapists were all very nice and seemed very involved with patient care. The nurses seemed a little understaffed, but were still pleasant to work with. Amenities: The rooms were large and open, with windows and appropriate furniture and a big bathroom. There seemed to be a wide variety of activities that the residents could participate in. Facilities: Public restrooms, hallways, and nurses stations were all very clean and attractive. The center itself is very beautiful and very big. The cafeteria had a good selection of food that the patients seemed to enjoy. All of the patients I interacted with seemed to enjoy the center, though most were only there for a few weeks to recover from surgery. Overall I was very pleased with the facility and staff. I think the only recommendation would be to add more nurses to the staff so that they did not seem so stressed out over paperwork all day.
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Where Shall OOoCon 2011 Meet?
The annual OpenOffice conference takes place this year the end of September in Budapest. The project is also looking for suggestions for 2011.
There is no definite time of year when the annual conference should take place, although the OpenOffice project has always leaned toward the fall. Proposals for venues can be submitted until Sunday, February 21, 2010. It should describe the location of the conference hall, possible travel limitations to the country in which it will be located, and the approximate cost of accommodations.
The proposal this year for Budapest is a good example. The OpenOffice.org project requests sending new proposals for 2011 to email@example.com.
Issue 27: Raspberry Pi Adventures/Special Editions
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For all that we hear about the flotilla being a humanitarian mission, they refused the request of Gilad Shalit's father to even ask to see Gilad, who has not been visited by the Red Cross or any other humanitarian group in three years. Some people don't like it when the Palestinians are compared to the Nazis. In fact, in this respect they are worse than the Nazis.
Hitler agreed to allow Red Cross visitation to Terensiensadt. Hamas -- whose stated intention is to eradicate the Jewish State, which means potential genocide -- won't even do what Hitler did, agree to any Red Cross or humanitarian visits to Shalit. Everybody talks about how Hitler hoodwinked the Red Cross, but at least Hitler was forced -- for one of the only times in the Holocaust -- to think twice, to be defensive, to have his concentration camp guards and officials prepare for the visit, distracting and delaying the Nazis for even a few weeks from their murderous work. Once the Red Cross was in the camp, the fault was theirs for being naive. But Hitler did allow them in, and the Palestinians won't.
In this respect, Hitler was incontrovertibly better than Hamas. And for most of the 1930s, until the Final Solution fully kicked in, Hitler actually released many Jews from the concentration camps after a few weeks or months. That is more than Hamas will do with Shalit or what Hezbollah did with Goldwasser and Regev, the captives who were only returned to their families in a casket, and Ron Arad after decades will not even have his body returned. There is no question that when it comes to the treatment of prisoners, prior to the Final Solution, anyway, Hitler and the Palestinians are in the same conversation. And the "humanitarians" of the flotilla are partners with those who are keeping Shalit in his one-man Dachau.
It's a funny thing about the Jewish left. They can compare the Arizona immigration law to the Nazis but they can't say the same about Hamas. I'd bet Shalit would give anything to be an illegal Mexican in Arizona.
That American Jews -- and the American government -- are not speaking up louder, demanding humanitarian visits to Shalit is ugly, nothing less. If Gild Shalit was your son or daughter, you'd agree.
Another point -- Oslo. Everyone wants Israel to agree to a peace process. Oslo was that, According to Oslo, Israel has the right to patrol the waters off Gaza. Now Israel does that, and where are all the peace advocates to back Israel up?
A third point -- The anti-Israel fifth column within the Jewish people has been working overtime in recent weeks, demeaning AIPAC, demeaning the Conference of Presidents, demeaning Israel's Ambassador Michael Oren, and rarely bringing up the crimes of Hamas or Fatah, if ever, and then only fleetingly. That so many Jews accept the enemy's propaganda regarding this off-shore battle reveals the extent that Israel and the pro-Israel lobby has been weakened in the hearts and minds of too many American Jews. Notice that the initial instinct of so many Jews is to blame Israel first. Notice how many organizations, such as J Street, don't even mention that Shalit is in Gaza, or that Israel sends hundreds of tons of humanitarian aid into Gaza each month.
In this respect, the Palestinians have it better than Hitler. Hitler did his own propaganda, he didn't outsource it, other than to the German-American Bund here in the States. The German-American Bund waved the swastika, there was no doubt whose side they were on. Hamas and Fatah have the American far-left intellectuals and neo-Jews doing so much of their propaganda for them. But the anti-Israel left claims to be pro-Israel, wanting to help Israel, which makes their propaganda only more insidious.
Now that Israel needs a solid and energetic defense, there are students at Brandeis and readers of The New York Review of Books, and numerous others places who are primed to dismiss the defense of Israel that is being attempted by the pro-Israel activists.
In wartime there is a line between honest dissent and treason -- giving aid and comfort to the enemy -- that we can start discussing. I'm not certain we're there yet, but there must be some line, somewhere, between dissent and treason. What would it take to say that this line has been crossed by some American Jews? It was Rabbi Lookstein who said the attempt to silence Oren. and deligitimize Israel, was not dissent but "evil."
Like Rabbi Lookstein, the pro-Israel grassroots has to start hitting back -- hard. At least as hard as the anti-Israel camp is working every single day. Make the bad guys start playing defense for a change. Make them start answering questions about themseves.
Here's a good starting point -- Daniel Gordis on why he's saddened but not apologetic. Also check out some good talking points here and here.
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Leah Graham
Leah Graham info
Leah Graham filmography
Here you can learn about the movies Leah Graham acted in. You can see the names of the movies, their budget, years of release and the money gained from the screening of the certain movie. It is always interesting to know.
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A firm favourite with the A-list denim fans, Current/Elliott was launched in 2008 by stylists Emily Current and Merritt Elliott. Channelling the pair's combined passion for denim, the brand was created to offer fashionistas a fearless alternative to classic jeans.
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Last month a group of RAF Benevolent Fund trustees travelled to RAF Valley as part of their programme to visit stations nationwide, to gain a fuller understanding of the needs of serving personnel in an ever changing environment.
Be in with a chance of winning a cash prize by playing our weekly lottery. It costs just £1 to play and is easy to join. Draw prizes range from £5 to our jackpot prize of £10,000!
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We were there for former RAF serviceman Duncan Slater after he was seriously injured by an IED in Afghanistan.
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Boll hopes for more game films
Hollywood movie director Uwe Boll has announced that he is not planning sequels for Far Cry, Alone in the Dark or House of the Dead, regardless of the fact that he still holds the licences for the games-turned-films. Sci Fi Wire does however report that the much maligned director is planning a BloodRayne 2, or would at least like to work on a sequel. "I have the right to a sequel for BloodRayne, and there are many possibilities," he told the Sci Fi Wire. "I'd love to see her wash up on the shore 100 years later and end up in the Wild West, and then later go to World War II or something like that." Wonderful.
Of forthcoming sequel House of the Dead 2: Dead Aim, Boll stated that he had nothing to do with the project, which he described as 'more expansive' than his own concept for the sequel. The director's work on the original House of the Dead was arguably his most badly-received project, though Alone in the Dark proved particularly unpopular with the critics too. "Last year we only had Resident Evil 2 come out as a videogame movie, and this year there are a lot of them, but these movies will only become more mainstream, have better plots and have better actors," Boll commented, highlighting the growing significance of games-turned-films in the movie industry.
Gaming films are certainly becoming increasingly notable, this week alone an animated feature based on Rare's forthcoming Xbox 360 RPG Kameo was announced, whilst a third Resident Evil film has also been confirmed titled 'Afterlife'.
More as we get it.
Source: Eurogamer.net
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I can't take pictures because I have no camera. I'll explain the best I can.
My (18mo) DS has an EvenFlo Titan Elite (I believe that's what it's called). He's 27lbs and just about to be too tall to be in this seat, but I have him rear facing.
After I installed it, whenever I would make a left turn his seat would flip or turn over and he would freak out (obviously) because he's on his side. I tried everything I could think of: used the belt locking clip, got a seat protector/cover-thing, moved the seat from the center to the driver's side and still it would turn.
Now, I used the LATCH belt that is at the top of the car seat back and attached that to the LATCH loop thing that is on the door side, in the vehicle's seat. (Does that make sense? ...I hope so...) His seat hasn't flipped or turned since, it's been 2 days (I kept forgetting to post the question). But, I don't know if it's safe! And, I don't know what else to do!


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Indocyanine green
|IUPAC name
sodium 4-[2-[(1E,3E,5E,7Z)-7-[1,1-dimethyl-3-(4-sulfonatobutyl)benzo[e]indol-2-ylidene]hepta-1,3,5-trienyl]-1,1-dimethylbenzo[e]indol-3-ium-3-yl]butane-1-sulfonate
|Other names
Cardiogreen; Foxgreen; Cardio-Green; Fox Green; IC Green
|ECHA InfoCard
|Jmol 3D model
|Interactive image
|Molar mass
|774.96 g/mol
|Main hazards
Except where otherwise noted, data are given for materials in their standard state (at 25 °C [77 °F], 100 kPa).
|verify (what is ?)
|Infobox references
Indocyanine green (ICG) is a cyanine dye used in medical diagnostics. It is used for determining cardiac output, hepatic function, and liver blood flow, and for ophthalmic angiography.[2] It has a peak spectral absorption at about 800 nm.[3] These infrared frequencies penetrate retinal layers, allowing ICG angiography to image deeper patterns of circulation than fluorescein angiography.[4] ICG binds tightly to plasma proteins and becomes confined to the vascular system.[2] ICG has a half-life of 150 to 180 seconds and is removed from circulation exclusively by the liver to bile juice.[2]
ICG is a fluorescent dye which is used in medicine as an indicator substance (e.g. for photometric hepatic function diagnostics and fluorescence angiography) in cardiac, circulatory, hepatic and ophthalmic conditions.[5] It is administered intravenously and, depending on liver performance, is eliminated from the body with a half life of approx. 3–4 minutes.[6] ICG sodium salt is normally available in powder form and can be dissolved in various solvents; 5% (<5% depending on batch) sodium iodide is usually added to ensure better solubility.[7] The sterile lyophilisate of a water-ICG solution is approved in many European countries and the United States under the names ICG-Pulsion and IC-Green as a diagnostic for intravenous use.
- 1 History
- 2 Optical properties
- 3 Toxicity and side-effects
- 4 Uses
- 4.1 Angiography in ophthalmology
- 4.2 Diagnostics for the non-invasive monitoring of liver or splanchnic perfusion
- 4.3 Perfusion diagnostics of tissues and organs
- 4.4 ICG-supported navigation for sentinel lymph node biopsy with tumors
- 4.5 Diagnosis of rheumatic diseases
- 4.6 Selectively over-heating cells (especially cancer)
- 5 References
- 6 External links
ICG was developed in the Second World War as a dye in photography and tested in 1957 at the Mayo Clinic for use in human medicine. After being granted FDA approval in 1959, ICG was initially used primarily in hepatic function diagnostics and later in cardiology. In 1964, S. Schilling was able to determine renal blood flow using ICG. From 1969, ICG was also used in the research and diagnosis of subretinal processes in the eye (in the choroid). In the years since 1980, the development of new types of cameras and better film material or new photometric measuring devices has cleared away many technical difficulties. In the mean time, the use of ICG in medicine (and especially in fluorescent angiography in ophthalmology) has become established as standard. A distinction is therefore also made, when describing fluorescent angiography, between NA fluorescent angiography and ICGA / ICG fluorescent angiography. Around 3,000 scientific papers on ICG have now been published worldwide.[8]
Optical properties[edit]
The absorption and fluorescence spectrum of ICG is in the near infrared region. Both depend largely on the solvent used and the concentration.[9] ICG absorbs mainly between 600 nm and 900 nm and emits fluorescence between 750 nm and 950 nm. The large overlapping of the absorption and fluorescence spectra leads to a marked reabsorption of the fluorescence by ICG itself. The fluorescence spectrum is very wide. Its maximum values are approx. 810 nm in water and approx. 830 nm in blood. For medical applications based on absorption, the maximum absorption at approx. 800 nm (in blood plasma at low concentrations) is important. In combination with fluorescence detection, lasers with a wavelength of around 780 nm are used. At this wavelength, it is still possible to detect the fluorescence of ICG by filtering out scattered light from the excitation beam.[10]
Toxicity and side-effects[edit]
ICG is metabolized microsomally in the liver and only excreted via the liver and bile ducts; since it is not absorbed by the intestinal mucous membrane, the toxicity can be classified as low. Administration is not without risks during pregnancy. It has been known since September 2007 that ICG decomposes into toxic waste materials under the influence of UV light, creating a number of still unknown substances. A study published in February 2008, however, shows that ICG (the substance without UV effect) is basically, as such, of only minor toxicity. The intravenous LD50 values measured in animals are 60 mg/kg in mice[11] and 87 mg/kg in rats. Occasionally – in one out of 42,000 cases – slight side-effects occur in humans such as sore throats and hot flushes. Effects such as anaphylactic shock, hypotension, tachycardia, dyspnea and urticaria only occurred in individual cases; the risk of severe side-effects rises in patients with chronic kidney impairment.[12] The frequencies of mild, moderate and severe side-effects were only 0.15%, 0.2% and 0.05%; the rate of deaths is 1:333,333. For the competitor substance fluorescein, the proportion of people with side-effects is 4.8% and the death rate is 1:222,222.
Angiography in ophthalmology[edit]
Because the preparation contains sodium iodide, a test must be carried out for iodine intolerance. Because around 5% of iodide is added, the iodine content of a 25 mg ampoule is 0.93 mg. In comparison, preparations for a bone marrow CT (140 ml) contain 300 mg/ml and for a corona angiography (200 ml) 350 mg/ml of iodine. ICG has the ability to bind 98% to plasma proteins – 80% to globulins and 20% to alpha-lipoprotein and albumin[6] – and thus, in comparison with fluorescein as a marker, has a lower leakage (slower emergence of dye from the vessels, extravasally).[13] Because of the plasma protein binding, ICG stays for up to 20–30 minutes in the vessels (intravasally). When the eye is examined, it thus stays for a long time in tissues with a higher blood flow, such as the choroid and the blood vessels of the retina.[6] In ophthalmology, the ICG angiography is used for an angiography of the ocular fundus in the following cases:[citation needed]
- If there is a suspicion of retinal damage with poorly defined edges and if there is bleeding
- In basic diagnostics, if there is a suspicion of a particular form of AMD
- If there is a suspicion of choroidal neovascularisation (CNV)
- If there is a suspicion of polypoidal choroidal vasculopathy (PCV)
- If there is a suspicion of retinal angiomatous proliferation (RAP)
- If there is a suspicion of choroidal melanoma
- If there is a suspicion of choroidal hemangioma
- If there is a suspicion of choroidal metastases
- In individual cases for extended diagnostics or documentation (differential diagnostics)
Diagnostics for the non-invasive monitoring of liver or splanchnic perfusion[edit]
Because of the high binding rate of ICG to plasma proteins, the substance allows liver / splanchnic perfusion to be measured by monitoring the changes in the ICG plasma disappearance rate (ICG-PDR). This method is therefore suitable as a parameter for predicting the probability of survival of intensive-care surgical patients. Since reduced PDR values can be measured in about two thirds of intensive-care surgical patients in whom expanded haemodynamic monitoring is indicated, it is clear that there is a significantly increased mortality rate here. Regular monitoring of the ICG-PDR (generally twice a day) helps to reveal restrictions in liver / splanchnic perfusion at an early stage. After intravenous ICG administration, the plasma disappearance rate is measured using an external monitoring device.the role of ICG for detection of liver reserve before liver resection in management of HCC.[citation needed]
Perfusion diagnostics of tissues and organs[edit]
ICG is used as a marker in the assessment of the perfusion of tissues and organs in many areas of medicine. The light needed for the excitation of the fluorescence is generated by a near infrared light source which is attached directly to a camera. A digital video camera allows the absorption of the ICG fluorescence to be recorded in real time, which means that perfusion can be assessed and documented. This is used in the following cases:[citation needed]
- Plastic surgery: skin and muscle transplants; determination of amputation level
- Abdominal surgery: gastrointestinal anastomosis
- General surgery: wound healing and ulcers
- Internal medicine: diabetic extremities
- Heart surgery: aortocoronary bypasses
In addition, ICG can also be used as a tracer in cerebral perfusion diagnostics. In the case of stroke patients, monitoring in the recovery phase seems to be achievable by measurement of both the ICG absorption and the fluorescence in everyday clinical conditions.[14][15][16][citation needed]
Sentinel lymph node biopsy (SLB or SLN biopsy) allows selective, minimally invasive access for assessment of the regional lymph node status with malignant tumours. The first draining lymph note, the "sentinel", represents an existing or non-existing tumour of an entire lymph node region. The method has been validated using radionuclides and/or blue dye for breast cancer, malignant melanoma and also gastrointestinal tumours and gives a good detection rate and sensitivity. For the SLB, a reduced mortality has been observed in comparison with complete lymph node dissection, but the methods have disadvantages with regard to availability, application and disposal of the radionuclide and the risk of anaphylaxis (up to 1%) for the blue dye. ICG, because of its near-infrared fluorescence and previous toxicity investigations, was evaluated in this investigation as a new, alternative method for SLB with regard to the clinical application of the transcutaneous navigation and lymph vessel visualisation and SLN detection. This technique is sometimes referred as fluorescence image-guided surgery (FIGS). ICG fluorescence navigation achieves high rates of detection and sensitivity in comparison with the conventional methods. Taking into account the learning curve required, the new, alternative method offers a combination of lymphography and SLB and the possibility of carrying out an SLB without the need for radioactive substances for solitary tumours[17][18][19]
Diagnosis of rheumatic diseases[edit]
The Physikalisch-Technische Bundesanstalt and mivenion GmbH developed an imaging process, known as "Rheumascan", for the diagnosis of microcirculatory problems in the hands. This imaging process can be used with arthritic and rheumatoid diseases. ICG is used as the marker for the microcirculatory disorder. Rheumascan was presented for the first time in 2009 at the European Congress of Radiology.[citation needed]
Research in the area of ICG has by no means been completed at the current time. In particular, it seems that, under certain circumstances, such as the right laser strength and particular wavelengths, ICG may have the capacity to trigger a photodynamic reaction. ICG could thus also be used in the medium term as a PDT therapy. On the other hand, ICG can be used very universally in the area of (perfusion) diagnostics, and further research is therefore also being carried out here.[citation needed]
Selectively over-heating cells (especially cancer)[edit]
ICG absorbs near infra-red, especially light with a wavelength of about 805 nanometers. A laser of that wavelength can penetrate tissue.[20] That means, dying tissue with injected ICG allows an 800 nm-810 nm laser to heat or overheat the dyed tissue without harming the surrounding tissue.[21][22] Although overheating is the main mechanism for it to kill cells, a small amount of the laser energy absorbed by the ICG releases free radicals such as singlet oxygen that also damage target cells.
That works particularly well on cancer tumors, because tumors naturally absorb more ICG than other tissue. When ICG is injected near tumors, tumors react to the laser 2.5 times as much as the surrounding tissue does.[23] It's also possible to target specific cells by conjugating the ICG to antibodies such as daclizumab (Dac), trastuzumab (Tra), or panitumumab (Pan).[24]
Studies have been done,[22] and are currently being done, on using this method to destroy cancer tumors without surgery. Early experiments on mice managed to slow tumor growth with a single laser treatment, but the tumor later recurred and metastasized.[22] Other studies also showed significant reduction in mouse tumor growth.[20]
Studies are currently examining the combination of ICG laser therapy with a triggered immune response for tumor destruction. This method is similar to cancer vaccine).,[25] where the immune system is trained to target future recurrences of cancer. Glycated Chitosan is currently undrgoing trails for this purpose.[citation needed]
ICG and laser therapy has been shown to kill human pancreatic cancer cells (MIA PaCa-2, PANC-1, and BxPC-3) in vitro.[26]
ICG and an infrared laser have also been used the same way to treat acne vulgaris.[27][28]
And they have been used to specifically target and kill P. gingivalis 381 and A. actinomycetemcomitans 67 bacterial infections in the jaw.[29]
- ^ Cardiogreen at Sigma-Aldrich
- ^ a b c Definition of indocyanine green, National Cancer Institute
- ^ Optical Absorption of Indocyanine Green (ICG), Oregon Medical Laser Center
- ^ Ophthalmic Diagnostic Photography; Indocyanine Green (ICG) Angiography University of Iowa Health Care
- ^ "Indocyanine green solution". NIH. National Cancer Institute. Retrieved 1 December 2012.
- ^ a b c Wipper, Sabine Helena (2006). Validierung der Fluoreszenzangiographie zur intraoperativen Beurteilung und Quantifizierung der Myokardperfusion [Validation of fluorescence angiography for intraoperative assessment and quantification of myocardial perfusion] (Dissertation) (in German). LMU München: Faculty of Medicine. pp. 18–23. OCLC 723710136.
- ^ Augustin, A.J., Krieglstein, G.K.,: Augenheilkunde, 2001, Springer-Verlag, ISBN 3-540-65947-1[page needed]
- ^ Alander, Jarmo T.; Kaartinen, Ilkka; Laakso, Aki; Pätilä, Tommi; Spillmann, Thomas; Tuchin, Valery V.; Venermo, Maarit; Välisuo, Petri. "A Review of Indocyanine Green Fluorescent Imaging in Surgery". International Journal of Biomedical Imaging. 2012: 940585. doi:10.1155/2012/940585.
- ^ Optical Optical Properties of ICG (English)[page needed]
- ^ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512618/
- ^ Laperche, Yannick; Oudea, Marie-Claire; Lostanlen, Danielle (1977). "Toxic effects of indocyanine green on rat liver mitochondria". Toxicology and Applied Pharmacology. 41 (2): 377–87. doi:10.1016/0041-008X(77)90039-4. PMID 19859.
- ^ Cardiogreen at Sigma-Aldrich[page needed]
- ^ Ophthalmic Diagnostic Photography; Indocyanine Green (ICG) Angiography University of Iowa Health Care[page needed]
- ^ Steinkellner, Oliver; Gruber, Clemens; Wabnitz, Heidrun; Jelzow, Alexander; Steinbrink, Jens; Fiebach, Jochen B.; Macdonald, Rainer; Obrig, Hellmuth (1 January 2010). "Optical bedside monitoring of cerebral perfusion: technological and methodological advances applied in a study on acute ischemic stroke". Journal of Biomedical Optics. 15 (6): 061708. doi:10.1117/1.3505009. PMID 21198156.
- ^ Milej D, Gerega A, Zołek N, Weigl W, Kacprzak M, Sawosz P, Mączewska J, Fronczewska K, Mayzner-Zawadzka E, Królicki L, Maniewski R, Liebert A (21 October 2012). "Time-resolved detection of fluorescent light during inflow of ICG to the brain—a methodological study". Physics in Medicine and Biology. 57 (20): 6725–6742. doi:10.1088/0031-9155/57/20/6725. PMID 23032301.
- ^ Weigl, W.; Milej, D.; Gerega, A.; Toczylowska, B.; Kacprzak, M.; Sawosz, P.; Botwicz, M.; Maniewski, R.; Mayzner-Zawadzka, E.; Liebert, A. (30 June 2013). "Assessment of cerebral perfusion in post-traumatic brain injury patients with the use of ICG-bolus tracking method". NeuroImage. 85: 555–65. doi:10.1016/j.neuroimage.2013.06.065. PMID 23831529.
- ^ Hirche, C.; Hünerbein, M. "Forschungsgruppe 'Fluoreszenzfarbstoff-gestützte Navigation zur Sentinel-Lymphknoten-Biopsie und real-time Lymphographie bei solitären Tumoren'" [Research Group 'fluorescent dye-based navigation for sentinel lymph node biopsy and real-time lymphography with solitary tumors'] (in German). Berufsgenossenschaftliche Unfallklinik Ludwigshafen (BG Klinik).
- ^ Hirche, Christoph; Murawa, Dawid; Mohr, Zarah; Kneif, Soeren; Hünerbein, Michael (2010). "ICG fluorescence-guided sentinel node biopsy for axillary nodal staging in breast cancer". Breast Cancer Research and Treatment. 121 (2): 373–8. doi:10.1007/s10549-010-0760-z. PMID 20140704.
- ^ Hirche, C.; Dresel, S.; Krempien, R.; Hünerbein, M. (2010). "Sentinel Node Biopsy by Indocyanine Green Retention Fluorescence Detection for Inguinal Lymph Node Staging of Anal Cancer: Preliminary Experience". Annals of Surgical Oncology. 17 (9): 2357–62. doi:10.1245/s10434-010-1010-7. PMID 20217256.
- ^ a b Shafirstein, Gal; Bäumler, Wolfgang; Hennings, Leah J.; Siegel, Eric R.; Friedman, Ran; Moreno, Mauricio A.; Webber, Jessica; Jackson, Cassie; Griffin, Robert J. (2012). "Indocyanine green enhanced near-infrared laser treatment of murine mammary carcinoma". International Journal of Cancer. 130 (5): 1208–15. doi:10.1002/ijc.26126. PMC 3190070. PMID 21484791.
- ^ Chen, Wei R.; Adams, Robert L.; Heaton, Sean; Dickey, D.Thomas; Bartels, Kenneth E.; Nordquist, Robert E. (1995). "Chromophore-enhanced laser-tumor tissue photothermal interaction using an 808-nm diode laser". Cancer Letters. 88 (1): 15–9. doi:10.1016/0304-3835(94)03609-M. PMID 7850768.
- ^ a b c Chen, Wei R.; Adams, Robert L.; Higgins, Aaron K.; Bartels, Kenneth E.; Nordquist, Robert E. (1996). "Photothermal effects on murine mammary tumors using indocyanine green and an 808-nm diode laser: An in vivo efficacy study". Cancer Letters. 98 (2): 169–73. doi:10.1016/S0304-3835(06)80028-5. PMID 8556705.
- ^ Li, Xingde; Beauvoit, Bertrand; White, Renita; Nioka, Shoko; Chance, Britton; Yodh, Arjun G. (1995). Chance, Britton; Alfano, Robert R, eds. "Tumor localization using fluorescence of indocyanine green (ICG) in rat models". Proc. SPIE Vol. 2389. Optical Tomography, Photon Migration, and Spectroscopy of Tissue and Model Media: Theory, Human Studies, and Instrumentation. 2389: 789–97. Bibcode:1995SPIE.2389..789L. doi:10.1117/12.210021.
- ^ Ogawa, Mikako; Kosaka, Nobuyuki; Choyke, Peter L.; Kobayashi, Hisataka (2009). "In vivo Molecular Imaging of Cancer with a Quenching Near-Infrared Fluorescent Probe Using Conjugates of Monoclonal Antibodies and Indocyanine Green". Cancer Research. 69 (4): 1268–72. doi:10.1158/0008-5472.CAN-08-3116. PMC 2788996. PMID 19176373.
- ^ Bromwell, Logan (November 2012). "Innovative Laser Therapy Offers New Hope for Breast Cancer Patients". Life Extension.
- ^ Tseng, William W.; Saxton, Romaine E.; Deganutti, Adriana; Liu, Carson D. (2003). "Infrared Laser Activation of Indocyanine Green Inhibits Growth in Human Pancreatic Cancer". Pancreas. 27 (3): e42–5. doi:10.1097/00006676-200310000-00018. PMID 14508139.
- ^ Genina, Elina A.; Bashkatov, Alexey N.; Simonenko, Georgy V.; Tuchin, Valery V.; Yaroslavsky, Ilya V.; Altshuler, Gregory B. (2005). "Indocyanine green-laser thermolysis of acne vulgaris". In Van Den Bergh, Hubert; Vogel, Alfred. Therapeutic Laser Applications and Laser-Tissue Interactions II. 5863. pp. 74–80. Bibcode:2005SPIE.5863...74G. doi:10.1117/12.633088.
- ^ Genina, Elina A.; Bashkatov, Alexey N.; Simonenko, Georgy V.; Odoevskaya, Olga D.; Tuchin, Valery V.; Altshuler, Gregory B. (2004). "Low-intensity indocyanine-green laser phototherapy of acne vulgaris: Pilot study". Journal of Biomedical Optics. 9 (4): 828–34. Bibcode:2004JBO.....9..828G. doi:10.1117/1.1756596. PMID 15250771.
- ^ Boehm, TK; Ciancio, SG (2011). "Diode laser activated indocyanine green selectively kills bacteria". Journal of the International Academy of Periodontology. 13 (2): 58–63. PMID 21913603.
External links[edit]
- Stanga, Paulo E.; Lim, Jennifer I.; Hamilton, Peter (2003). "Indocyanine green angiography in chorioretinal diseases: Indications and interpretation: An evidence-based update". Ophthalmology. 110 (1): 15–21; quiz 22–3. doi:10.1016/S0161-6420(02)01563-4. PMID 12511340.
- Optical Absorption of Indocyanine Green (ICG


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St. Mark's Thrivent chapter distributes checks
The Ohio, West Virginia and Pennsylvania Thrivent Chapter No. 30763 of St. Mark Lutheran Church, 133 Lovers Lane, Steubenville, presented four $650 checks on Dec. 18 to the Salvation Army of Jefferson County, Urban Mission Ministries, American Red Cross Jefferson County Chapter and the Jefferson County Fourth Street Health Center.
The checks were distributed by St. Mark members Sonny and Jean Reitter and Charles and Charlene Pearce.
Thrivent has a group at St. Mark called the "Holy Rollers" that makes fruit, nut and poppy seed rolls during the holidays and also from June to October for sale at the Farmers Market in downtown Steubenville.
This enables the group to support local charities.


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The Premier's Reading Challenge is an annual statewide initiative for state and non-state schools and home-educated students up to Year 9, as well as children (aged up to five years) enrolled in an early childhood centre, and individual home readers.
The Premier's Reading Challenge is not a competition but aims to improve literacy and encourage children to engage in reading for pleasure and learning.
Congratulations to all the readers who took part in the 2016 Premier's Reading Challenge!
The reading period has now finished and Certificates of Achievement will be mailed for the Premier's Reading Challenge Celebration Weeks to be held from 7 - 18 November 2016.
For further information please contact the Premier's Reading Challenge program manager.
The 2016 Premier's Reading Challenge is proudly supported by:
This page was last reviewed on 30 Sep 2016
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© The State of Queensland (Department of Education and Training) 2016.


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Allen West: Sun Tzu, Drones and the 21st Century Battlefield
Posted on 09 Feb 2013 @ 14:27 by Brent Parrish
About Brent ParrishAuthor, blogger, editor, researcher, graphic artist, software engineer, carpenter, woodworker, guitar shredder and a strict constitutionalist. Member of the Watcher's Council and the Qatar Awareness Campaign. I believe in individual rights, limited government, fiscal responsibility and a strong defense. ONE WORD: FREEDOM!
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Media Molecule Developer Rex Crowle Previews Tearaway On PS Vita
Tearaway stars Iota, a messenger from a paper dimension whose envelope head contains an urgent message to deliver…to you! It's a very special message, and one that's unique for each and every player. In order to read yours, you'll need to take up the role of co-star and, together with Iota, journey through the vibrant papery landscape - two buddies going on an epic adventure. You and iota will travel afar, taking on enemies and helping those in need. You'll conquer adversity and discover magical papery surprises. But, with this game, you the player are holding more than just a PS Vita in your hands; you're holding the paper world itself. Using the god-like powers inherent to someone who can hold an entire world in their giant hands, you can make your presence felt using a whole range of godly powers that take advantage of all of the PS Vita's bells and whistles - some subtle and some epic. You can shake things up or turn them upside down. A gentle breath from you is a gusty storm. You can even poke your fingers into the back of the PS Vita to tear through into the world and help Iota complete this very special delivery. Media Molecule developer Rex Crowle previews the game in this exclusive video interview below.


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"AMBS" - Most Undervalued Micro Cap BioTech
Recently signed a development deal with Becton Dickinson for a diagnostic test to diagnose early stage Alzheimer's. Potential $500,000,000 in annual revenues.
Due diligence.
P.s. Stock is currently trading under a nickle. Noted bio-tech analyst Jason Napadano values the company at .25 currently. Google his Seeking Alpha articles about the company and its patented MANF technology.
Read yesterday's mid year update from the company's C.E.O.
Substantial upside.
The DTC chill order was lifted today.
Get in under a nickle. 1,000% upside within six months.
1,000% upside before the end of the year is possible.
Major news on the way.
If Becton Dickinson is successful in developing the company's Lympro test that alone would value the company at $1.00/share.
The company's patented MANF technology could be worth many times that amount.
Starting to take off.
Great percentage play at the current price.
Risk/reward favors buying a few shares if your time frame for holding is more than a week.
Dr. Joseph Rubinfeld, one of the co-founders of Amgen, is on the company's scientific advisory board.
The Becton Dickinson deal to develop "Lympro" could be worth $1.00/share or more.


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Elba Pacheco, MD
Ratings based on 5 reviews
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Reviews (5)
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Dr Pacheco listens and takes time to create a plan for your total rejuvenation ....working within your budget and time constraints.
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Blepharoplasty & Injectables - Baltimore, MD
My last visit to her office December 2013 she brought in an observer to watch her give filler and botox injections. Her attention was on the new doctor who wanted to know how to make his fortune doing injections. I was not asked If I had a problem being used in a teaching environment. I was not offered a reduced payment for being used in a teaching environment. The result of this appointment was 2 black eyes - one was immediate before I left the office. The bottom lip left side is still noticeably larger after 2 months and only the right side of my forehead received botox. The wait times for appointments are extreme. I was forgotten in an office for 2.5 hours once and at a follow up visit for the one in office laser treatment to correct my uneven eye lift performed by an assistant I was left 2 hours waiting for her, only to be told when I finally walked out that she wasn't even in the building. I would give zero stars for wait times if it was possible. do not recommend this doctor.
There is no recent activity.


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TYR Patriot Silicone Swim Cap - 2016
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"Black Don't Crack"
Paul Mooney is as much a yarn-spinner as he is a comic. Attend one of his live shows and you'll understand: it feels more like sitting around the living room with a ridiculously funny father-figure than a traditional stand-up set with lead-ins and punchlines. Mooney doesn't need all of those formalities; he's earned the right to go freestyle. He created the time-enduring prose for Richard Pryer, Eddie Murphy, and Redd Foxx and was head writer for In Living Color's first season. (Remember Homey The Clown? All Mooney, baby.) Even with the longevity in the comedic writing circuit, Mooney might have gone relatively unknown to the next generation of comedy-goers had it not been for Dave Chapelle's Mooney-centric sketch "Ask a Black Dude," where Paul drops wisdom bombs that detonate in a multiracial question/answer confetti explosion. (Side note of advice: If you're pressed for time, maybe check out the early show. If you can't get enough of Mooney's awesomness, go for the later adventure. Last time he performed in Austin he stayed on stage for nearly two hours.) Paul Mooney keeps it real this Thursday, February 9 through Sunday, February 12 at the Addison Improv. Tickets cost $20. Get them at http://www.symfonee.com/improv/addison/home/index.aspx.
Feb. 9-12, 2012
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With spring training just around the corner as pitchers and catchers report by Feb. 13, baseball's offseason talk moves from transactions and the Hall of Fame to the new season ahead.
Along with that transition comes the discussion of who will make teams' rosters out of spring training, and while that sometimes can be almost set before a baseball is thrown, it's rarely the case.
For the Philadelphia Phillies, that possibility is probably more true than false, although there are still some openings to be determined. The bullpen is still shaky, the rotation's fourth member has yet to be officially named and third base remains a tossup.
While there are incumbents at each of those positions who could handle the starting duties, surprise runs of dominance in spring training could change each incumbent's status.
On Jan. 8, Matt Gelb of Philly.com reported that Phillies top prospects Maikel Franco and Jesse Biddle would be invited to big league camp, which is generally a sign that those players will surface in the majors at some point in 2014. The only question is when that will happen during the season. If they play their cards right, like some of the Phillies' other top prospects, they stand a better chance at defying the odds and cracking the Opening Day roster.
However, this slideshow only covers those prospects who have a legitimate shot at making the Phillies' roster to start the season. Prospects at levels such as Single-A will not be considered. In addition, in includes those prospects who have yet to make their major league debuts, meaning that players such as Ethan Martin and Cesar Hernandez will be excluded.
Here are the Phillies' top prospects' odds of doing just that.
*All prospect rankings courtesy of Baseball America's 2014 Top 10 Phillies Prospects list.


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I googled helicopter used to find deer and came up with this link. http://www.fieldandstream.com/photos/gallery/hunting/deer-hunting/finding-deer-hunt/2009/10/ohio-crossbow-hunter-rents-helicopter-?photo=2#node-1001339432
Apparently it was an Ohio crossbow hunter trying to recover a 20 point deer he shot. Interesting to think about this...we give guys heck about not exerting enough effort to find game, but will we also give guys heck for exerting too much effort? Something to think about.


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McLane Food Service's proposal to build a massive 168,000-square-foot warehouse near Thruway Exit 25A could be actively pursued again, but only if Princetown renews a special-use permit set to expire at the end of the month. The food distributor that supplies fast-food companies such as Pizza Hut, Taco Bell and Long John Silver's is again exploring options to build a warehouse on property that it has the right to purchase. Right now, the company's main ...
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realmagick.com The shrine of knowledge.
Agusan Del Norte Political
A selection of articles related to agusan del norte political.
Original articles from our library related to the Agusan Del Norte Political. See Table of Contents for further available material (downloadable resources) on Agusan Del Norte Political.
- Survivalists' Guide for the New Millennium: Chapter 5
- WHERE I LAY MY HEAD IS HOME A foot and light-hearted I take to the open road, Healthy, free, and the world before me, The long brown path before me leading Wherever I choose. Henceforth I ask not for good fortune, I myself am good fortune, Henceforth I...
Philosophy >> Survivalists Guide for the New Millennium
- Manifesting World Enlightenment: Part 2
- When thoughts are replaced by silence in the mind, perception arises. It is a part of the modern condition wherein the mind of humanity is constantly overwhelmed, by a million considerations and thoughts. In acquiring silence, the mind is enabled to get out...
Mind >> World Mind
- Manifesting World Enlightenment: Part 4
- There can be no doubt that the world situation today is grave. It is becoming increasingly apparent that the institutions, governments, and traditional methods of society, have little effectiveness in solving a collective crisis of global proportions. In this...
Mind >> World Mind
- History of the Egyptian Religion, part I: Early Dynastic Period
- I - Predynastic - Early Dynastic Period. The temples were in essence the *Home of the God* and thus a place where only Pharaoh as the Son of God and those he appointed as his deputies, could meet with the god. This goes all the way back to Archaic and...
Religions >> Egyptian
- The Perpetual Raising: Part 3
- (Part 3 of 5) The body is an instrument through which we interact with the physical plane, as souls or conscious beings. As we refine this instrument through meditation, and ideally with pure foods and sufficient exercise, the body becomes, "a spiritual...
Mind >> World Mind
- The Pagan Roots of Democracy
- I stepped into the voting booth with civic pride and religious inspiration. The pastors urged the congregation to renew America and vote for a good Christian man, Ronald Reagan. I voted a straight Republican ticket. Those godless Democrats were no better than...
Saga of Times Past >> History & Anthropology
Agusan Del Norte Political is described in multiple online sources, as addition to our editors' articles, see section below for printable documents, Agusan Del Norte Political books and related discussion.
Suggested News Resources
- Agusan del Norte mayors back Duterte's presidential bid
- BUTUAN CITY, Philippines – All of Agusan del Norte's mayors broke party lines and threw their all-out support behind the presidential bid of Partido Demokratiko Pilipino-Lakas ng Bayan (PDP-Laban) standard-bearer Rodrigo Duterte.
- Philippine court shakes up election race by allowing Poe to run
- Edmund Tayao, a political science professor at Catholic-run University of Santo Tomas, said the court ruling could boost Poe's numbers by at least 10 points, boosting her chances of winning the May vote.
- Campaign Trail: March 11
- Liberal Party standard-bearer Manuel "Mar" Roxas was in Agusan del Norte. With him was the eldest daughter of ... However, he said he was not fazed and denied the accusations, saying these were politically motivated.
- Campaign Trail: Where candidates are, March 7-13
- Poe was in Butuan and Bayugan in Agusan del Sur, and in Cabadbaran in Agusan del Norte. At 11 am, Duterte paid a courtesy call to Governor Jun Ynares at the provincial capitol of Rizal. Roxas and running mate Robredo attended an International Women's ...
Great care has been taken to prepare the information on this page. Elements of the content come from factual and lexical knowledge databases, realmagick.com library and third-party sources. We appreciate your suggestions and comments on further improvements of the site.
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[Intro: Kanye West]
You a bad girl, and your friend's bad too (ooh)
We got the swag sauce, she dripping swagu
You a bad girl and your friends bad too, ooh
You got the swag sauce, she dripping swagu (ooh)
[Verse 1: Beyonce]
I may be young, but I'm ready
To give you all my love
I told my girls you can get it
Don't slow it down, just let it go
"Party" is a song recorded by American singer Beyoncé Knowles for her fourth studio album, 4 (2011). It features guest vocals from American rapper André 3000.
The song was written by Kanye West, Jeff Bhasker, Knowles, Dexter Mills, Douglas Davis and Ricky Walters and produced by Knowles and West and co-produced by Bhasker.
A midtempo R&B song, "Party" exhibits elements of the 1980s funk and soul music, and samples the 1985 song "La Di Da Di". It recalls the work of New Edition and Prince, among others.
Built on a 808-retro beat, multi-tracked harmonies, and a smooth groove, the song's instrumentation includes slow-bouncing synthesizers, keyboard tones, and drums.
"Party" was nominated for Best Rap/Sung Collaboration at the 54th Grammy Awards.


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Contributed by Stephen Coles
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Contributed by Stephen Coles
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1. Night Clubs
The K Bar is a relatively new restaurant and bar in downtown Sacramento. It is part of the Paragary group of at least nine restaurants that is owned by three local partners. It is located at the old...more
2. Live Music
The Sac memorial auditorium was built in 1927 and was dedicated to all the Sacramento citizens who died in war. Though it is elegant in appearance, it is very warm and welcoming...to Sacramento...more
3. Dancing
This club has lots of parking space, compared to clubs in midtown or downtown. The age group is 18-35 yrs. old, and they play different kinds of music each day. The cover charge is between $5-$10, and...more
4. Eating / Drinking
Although Midtown (see tips on that), the mixed commercial/residential portion of the old central core Sacramento just east of downtown, has long dominated nightlife, with nightclubs, bars, eateries,...more
5. Sleep Train Arena: Kings: Going, Going, Staying, May 2013
Attending an NBA game featuring the Sacramento Kings has been for years a great sporting event to witness locally. Despite their generally poor records, folks...more
6. Second Saturday: Second Saturday Arts Walk
Second Saturday is an arts and music walk that happens on the second Saturday of every month in midtown Sacramento. It started as an arts walk a couple of years...more
7. Crest Theatre: Gracefully Restored Downtown Sacramento
The Crest Theater has been a symbol of downtown Sacramento long before we moved to Sacramento. Its elegant marquee reaches above the building and at night the...more
8. Various Clubs & Eateries: Midtown Sacramento
Midtown Sacramento is actually the most hip and lively part of the city actually. This is the old heavily residential, but mixed residential/office/commercial...more
9. Tower Theatre: Sacramento's Other Art Cinema
In addition to the Crest, Sacramento has another venerable old art cinema. Since 1938, this theatre has been showing movies--making it the longest...more
10. Esquire IMAX Theatre: Sacramento's IMAX Theatre
Any major city today has at least one IMAX theatre, and Sacramento is no exception. This one is downtown, near the Crest Theatre. So you can take in a show at...more
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Technique and condition
The image is painted in watercolour applied over a pencil underdrawing on cream wove paper. The work is in good condition although it has suffered creasing, abrasion and discolouration from its mount and from being backed onto a paper support with animal glue.
Shulla Jaques
On acquisition the work was removed from its mount prior to being pressed, inlaid and mounted onto white museum board.
Shulla Jaques
November 1997


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This review is from: Acer Laptop Aspire TimelineX AS4820T-7633 Intel Core i3 370M (2.40 GHz) 4 GB Memory 320 GB HDD Intel HD Graphics 14.0" Windows 7 Home Premium 64-bit
Pros: Excellent performance for the money, sturdy construction (better than expected from the reviews I read before purchase), thin and light enough to be carried around comfortably for long period of time, above average battery life, and lastly, very quiet and doesn't run hot when CPU intensifies.
Cons: Flimsy and shallow USB ports! This is my biggest grip with this machine, the ports are so shallow that 1/3 of the plug is extended outward, slight touch will cause the connector to fall out. This brings to my second complaint, 3 USB ports out of 4 are aligned on the right side, exactly where the right hand/wrist movement will cause the connectors to become loose.
LCD is good for watching movies due to slight warm red hue tint, but bad for photo editing. I calibrated it and it's better now but it still has warmer hue than my other laptops.
Other Thoughts: I didn't buy this laptop from newegg since I have $100 coupon to use with another merchant. Overall, it is a very good notebook for the price, I only paid $500 for it so for that price it is a 5-star machine. i3 packs enough power for daily business use and is decent enough when some entertainment is required. I don't play games, so no thoughts on that aspect. And it is a slim build for a 14-inch, probably the best looking one in its price range.READ FULL REVIEW
This review is from: Logitech K740 Illuminated USB Keyboard
Pros: excellent typing feedback and build quality. makes you want to type more, I find myself writing longer emails after getting this KB.
Cons: contextual key needs to be activated via FN key because it is shared with print screen function next to the insert key. I prefer the normal layout of this key because I'm a KB guru in MS Excel so not having direct access is a quite a deal breaker.
Other Thoughts: a real pleasure to use. the multimedia keys are pretty useless since logitech's setpoint software is pretty limited in customization. would be perfect if contextual key was placed where it should be (next to the right alt key).READ FULL REVIEW
This review is from: ASUS Laptop F8 Series F8Sp-X1 Intel Core 2 Duo T5750 (2.00 GHz) 3 GB Memory 250 GB HDD ATI Mobility Radeon HD 3650 14.0" Windows Vista Home Premium
Pros: fast and sturdy.
Cons: Fn key in place of ctrl, very annoying, I keep looking at the keyboard which I almost never do with other PC/Laptop.
screen is good but has somewhat limited view angle.
keyboard doesn't have enough reflex.
Hcontrol utility which controls multimedia key (including volume adj) sucks. if you don't care about the hotkeys next to the indicator lights, get rid of it then.
Other Thoughts: overall, very nice for $900, little annoyances here and there but nothing deal breaking.READ FULL REVIEW


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Oh Xmas Tree
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Oh Xmas Tree is an irregular episode of Happy Tree Friends .
Cuddles, Giggles, Toothy, and Lumpy arrive at the door. They all sing the Christmas carol "Oh, Christmas Tree". When they finish singing, the door closes with a message saying Happy Holidays! from Happy Tree Friends. Afterwards, five presents appear on screen, each containing a link leading to a kringle:
- Toothy has normal buckteeth.
- It would have been impossible for Lumpy to put on the hat he is wearing, considering his antlers.
- It should be possible to see some of Lumpy's leg from where he is standing.
- Cuddles is not holding his candle correctly.
- No one dies in this episode. This is one of the few episodes to feature no deaths and no pain, the other three being Deck the Halls, Intimate Spotlight, and We Wish You. Other episodes featuring pain but no deaths include Nuttin' but the Tooth and Out on a Limb.
- This is the fourth time that Cuddles, Giggles, Toothy, and Lumpy have gone Christmas caroling (after Deck the Halls, Kringle Karols, and We Wish You), indicating that they do it each year.
- About 18 seconds into the video, Giggles messes up the song. This was done for humor.
- This song is briefly heard in No Time Like the Present.