text:
Valerie A. Lawrence, MD; John E. Cornell, PhD; Gerald W. Smetana, MD
Disclosure: Members of the American Society of Anesthesiologists also reviewed the manuscript. Their review implies neither agreement with nor endorsement of this document.
Acknowledgments: The authors gratefully acknowledge the tremendous contribution of medical librarian Martha R. Harris, MA, for her time and expertise in searching the medical literature and managing the resulting project database. They also thank the Department of Anesthesiology, especially Christopher Jankowski, MD, of the Mayo Clinic, Rochester, Minnesota, for assistance in interpreting the anesthesiology literature.
Grant Support: By the Veterans Evidence-based Research, Dissemination, and Implementation Center (VERDICT) (Veterans Affairs Health Services Research and Development, HFP 98-002).
Potential Financial Conflicts of Interest: Stock ownership or options (other than mutual funds): G.W. Smetana (SafeMed Harvard Imaging); Other: G.W. Smetana (Novartis Pharma Schweiz).
Requests for Single Reprints: Valerie A. Lawrence, MD, Medicine/General Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX 78229-3900; e-mail, email@example.com.
Current Author Addresses: Drs. Lawrence and Cornell: Medicine/General Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX 78229-3900.
Dr. Smetana: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Lawrence VA, Cornell JE, Smetana GW. Strategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery: Systematic Review for the American College of Physicians. Ann Intern Med. 2006;144:596-608. doi: 10.7326/0003-4819-144-8-200604180-00011
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Published: Ann Intern Med. 2006;144(8):596-608.
Postoperative pulmonary complications are as frequent and clinically important as cardiac complications in terms of morbidity, mortality, and length of stay. However, there has been much less research and no previous systematic reviews of the evidence of interventions to prevent pulmonary complications.
To systematically review the literature on interventions to prevent postoperative pulmonary complications after noncardiothoracic surgery.
MEDLINE English-language literature search, 1 January 1980 through 30 June 2005, plus bibliographies of retrieved publications.
Randomized, controlled trials (RCTs); systematic reviews; or meta-analyses that met predefined inclusion criteria.
Using standardized forms, the authors abstracted data on study methods, quality, intervention and control groups, patient characteristics, surgery, postoperative pulmonary complications, and adverse events.
The authors qualitatively synthesized, without meta-analysis, evidence from eligible studies. Good evidence (2 systematic reviews, 5 additional RCTs) indicates that lung expansion interventions (for example, incentive spirometry, deep breathing exercises, and continuous positive airway pressure) reduce pulmonary risk. Fair evidence suggests that selective, rather than routine, use of nasogastric tubes after abdominal surgery (2 meta-analyses) and short-acting rather than long-acting intraoperative neuromuscular blocking agents (1 RCT) reduce risk. The evidence is conflicting or insufficient for preoperative smoking cessation (1 RCT), epidural anesthesia (2 meta-analyses), epidural analgesia (6 RCTs, 1 meta-analysis), and laparoscopic (vs. open) operations (1 systematic review, 1 meta-analysis, 2 additional RCTs), although laparoscopic operations reduce pain and pulmonary compromise as measured by spirometry. While malnutrition is associated with increased pulmonary risk, routine total enteral or parenteral nutrition does not reduce risk (1 meta-analysis, 3 additional RCTs). Enteral formulations designed to improve immune status (immunonutrition) may prevent postoperative pneumonia (1 meta-analysis, 1 additional RCT).
The overall quality of the literature was fair: Ten of 20 RCTs and 6 of 11 systematic reviews were good quality.
Few interventions have been shown to clearly or possibly reduce postoperative pulmonary complications.
Postoperative pulmonary complications are as common as cardiac complications for patients undergoing noncardiothoracic surgery (1-6). Further, these complications have similar mortality rates and length of stay after elective abdominal surgery or hip fracture repair (1, 2). In an accompanying systematic review (7), we identify patient, procedure, and laboratory risk factors for postoperative pulmonary complications. Our current systematic review synthesizes the evidence on preventive strategies and focuses on atelectasis, pneumonia, and respiratory failure. While we have written the review primarily for internists, this field crosses specialty disciplines.
We performed a systematic MEDLINE English-language literature search from 1 January 1980 to 30 June 2005. The search strategy and inclusion and exclusion criteria are described in the accompanying review of risk factors and in further detail in its Appendix (7). The search strategy used 1) the Medical Subject Heading (MeSH) terms preoperative care, intraoperative care, postoperative care, intraoperative complications, and postoperative complications as a focus of the article; 2) the MeSH text term perioperative complications as a text term in the title or abstract; and 3) additional MeSH and text terms for pulmonary, respiratory, or cardiopulmonary conditions, complications, or care. In addition, we performed additional focused searches for preoperative chest radiography and spirometry, laparoscopic versus open major abdominal operations, general versus spinal or epidural anesthesia, intraoperative neuromuscular blockade, postoperative pain management, and postoperative lung expansion techniques. Eligible studies were randomized, controlled trials; systematic reviews; or meta-analyses. We excluded studies with less than 25 participants per group; studies from developing countries (because of potential differences in respiratory and intensive care technology); studies that used physiologic (for example, lung volumes and flow, oximetry) rather than clinical outcome measures; studies of gastric pH manipulation; studies of complications that are unique to the surgery (for example, upper airway obstruction after uvulectomy); studies of cardiopulmonary, pediatric, or organ transplantation surgery (because of profoundly immunosuppressive drugs); and studies that used only administrative data to identify postoperative complications (for example, International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes) because of recent evidence that administrative data have poor validity for postoperative complications (8, 9).
We used the Quality of Reporting of Meta-analyses (QUOROM) statement for reporting meta-analyses and the U.S. Preventive Services Task Force criteria for hierarchy of research design to assess internal validity and study quality (good, fair, or poor) and to make conclusions about strength of the evidence (10, 11).
We used simple means and chi-square tests to calculate CIs and P values when they were not provided in publications. We did not perform quantitative pooling because multiple meta-analyses were beyond the scope of a broad review of multiple potential interventions. We report pooled results from previous meta-analyses when applicable.
The Veterans Evidence-based Research, Dissemination, and Implementation Center (VERDICT) (Veterans Affairs Health Services Research and Development, HFP 98-002) provided the research librarian and administrative support for the study. The funding source had no role in the design, conduct, or reporting of the study or in the decision to submit the manuscript for publication.
The search and inclusion criteria identified 20 randomized clinical trials and 11 systematic reviews or meta-analyses (12-42). Figure 1 in the accompanying review (7) of risk factors for postoperative pulmonary complications details the search results. Appendix Tables 1 through 7 provide detailed characteristics of the eligible randomized trials and systematic reviews.
In the only trial of preoperative smoking cessation (12), 108 older, relatively healthy men undergoing hip or knee replacement were randomly assigned to usual care or weekly meetings with a nurse for advice about smoking cessation and nicotine withdrawal plus individualized nicotine replacement for 6 to 8 weeks before surgery until 10 days after surgery. The mean age of the men was 65 years, and 95% were American Society of Anesthesiologists (ASA) physical status class I or II. Of 56 patients in the intervention group, 36 stopped smoking and 14 reduced smoking before surgery. Overall complications rates were lower in the intervention group (18% vs. 52%; P < 0.001), primarily due to fewer wound complications and urinary tract infections. The only pulmonary outcome, postoperative ventilator support, occurred in 1 patient in each group. Non–statistically significant trends favored shorter mean hospital stay (11 days vs. 13 days; P = 0.41) and fewer cardiac complications (0% vs. 10%; P = 0.08) in the intervention group.
Although the trial was of good quality, several factors limit its ability to demonstrate decreased risk for postoperative pulmonary complications. Pulmonary risk is inherently low with hip and knee replacement. Furthermore, the timing of smoking cessation seems important. A previous cohort study showed paradoxically higher postoperative pulmonary complication rates for smokers who stopped or reduced smoking within 2 months before noncardiothoracic surgery (43). Smoking cessation may increase short-term risk because of transiently increased mucus production due to improved mucociliary activity and reduced coughing due to less bronchial irritation.
Anesthetics disrupt central regulation of breathing and result in uncoordinated neural messaging. Due to resulting hypoventilation plus positional dependence, regional atelectasis occurs shortly after induction. It persists postoperatively and is compounded by ongoing disruption of respiratory muscles, limited respiratory excursion due to pain, and disruption of neurally mediated diaphragmatic functions after manipulation of abdominal viscera (43).
One good-quality trial found no difference in rates of postoperative pulmonary complications between intermediate-acting (atracurium, vecuronium) and long-acting (pancuronium) neuromuscular blocking agents among 691 patients undergoing elective abdominal, gynecologic, or orthopedic surgery (13). However, the incidence of residual neuromuscular block was higher among patients receiving pancuronium (26% vs. 5%; P < 0.001). Patients with residual blockade after pancuronium were 3 times more likely to develop postoperative pulmonary complications than those without residual block (17% vs. 5%; P < 0.02). In contrast, among patients receiving intermediate-acting agents, postoperative pulmonary complication rates did not differ between those with (4%) and without (5%) prolonged blockade. Therefore, pancuronium may directly lead to higher rates of prolonged neuromuscular blockade and indirectly to increased pulmonary risk compared with shorter-acting agents.
Neuraxial blockade (either spinal or epidural anesthesia) blocks a constellation of stress responses to surgery (neuroendocrine, cytokine, and pain threshold) and may improve recovery and prevent complications (44). Postoperative epidural analgesia may reduce respiratory muscle dysfunction and pain-related hypoventilation. The epidural approach involves either a single injection or an infusion and can be used for both intraoperative anesthesia and postoperative analgesia. Spinal anesthesia has a faster onset (5 to 10 minutes vs. 15 to 20 minutes), produces denser sensory and motor block, and is technically easier than epidural anesthesia. However, spinal anesthesia is administered only as a single injection because of practical constraints of indwelling intrathecal catheters. The possible benefit of neuraxial blockade has generated studies of general versus neuraxial blockade anesthesia, followed by trials comparing epidural analgesia to other modes of analgesic delivery (for example, oral, intramuscular, intravenous, patient-controlled analgesia) and, more recently, trials of combined epidural intraoperative anesthesia and epidural postoperative analgesia.
A recent good-quality meta-analysis combined 141 trials (n = 9559) comparing general anesthesia and neuraxial blockade in patients undergoing a variety of operations (32). The authors compared patients receiving neuraxial blockade (with or without concomitant general anesthesia) with those receiving only general anesthesia. Neuraxial blockade reduced overall mortality (2% vs. 3%; odds ratio, 0.70 [95% CI, 0.54 to 0.90]), pneumonia (3% vs. 5%; odds ratio, 0.61 [CI, 0.48 to 0.76]), and respiratory failure (0.5% vs. 0.8%; odds ratio, 0.41 [CI, 0.23 to 0.73]). In a subgroup analysis of trials of neuraxial blockade alone versus general anesthesia alone, results were similar (odds ratio, 0.63 [CI, 0.46 to 0.87] for pneumonia; odds ratio, 0.37 [CI, 0.11 to 1.21] for respiratory failure).
Potential sources of bias in the meta-analysis include 1) clinically heterogeneous studies; 2) unusually high mortality rates in several trials; 3) older literature (82% of included studies were published before 1990); 4) small studies (81% of included studies had ≤ 50 patients); and 5) statistically significant benefit only for orthopedic surgery in subgroup analyses (45-47).
A smaller good-quality systematic review identified 15 randomized or quasi-randomized trials of 2162 patients undergoing hip fracture repair (33). Postoperative pneumonia rates were almost identical: 5.1% of 529 patients having neuraxial blockade and 5.5% of 567 patients having general anesthesia (odds ratio, 0.92 [CI, 0.53 to 1.59]). Twelve of the 15 trials were also included in the larger meta-analysis (32), which included 44 trials of orthopedic surgery (n = 3617). Why the results for pneumonia differ between the 2 meta-analyses is not clear, but important variables may include type or duration of procedure (hip fracture repair is inherently low risk for postoperative pulmonary complications), intraoperative fluids, and postoperative pain and rehabilitative management.
Table 1 summarizes 6 eligible trials that compared various regimens of intraoperative anesthesia and postoperative analgesia. In a double-blind, good-quality efficacy trial of patients undergoing abdominal aortic surgery (14), investigators randomly assigned patients to 1 of 4 combined anesthetic and analgesic protocols. The trial standardized the entire episode of anesthesia and pain management to optimize efficacy in all 4 groups. The primary outcome measure was length of stay; secondary outcomes included postoperative pulmonary complications. Sample sizes were small (37, 38, 39, and 46 participants, respectively), and median length of stay (7 to 8 days for all groups) or postoperative pulmonary complication rates did not differ among the groups.
Table 1.
Strengths of the trial include the double-blind design and equally highly standardized protocols for both anesthesia and analgesia (48, 49). Unequally optimized regimens can introduce bias that systematically favors one type of intervention. Potential weaknesses, regarding prevention of postoperative pulmonary complication, include length of stay as the primary outcome measure and small sample size (50-52).
In a subsequent fair-quality effectiveness trial (15), 915 patients undergoing major abdominal surgery were randomly assigned to general anesthesia and 1) postoperative intravenous opioid or 2) intraoperative epidural local anesthetic plus postoperative epidural analgesia. Overall infections did not differ, and the authors did not report results for pneumonia. Statistically significantly less pain and respiratory failure occurred with epidural anesthesia, but only 225 of 447 patients in the epidural group completed the protocol.
In a subgroup analysis of high-risk patients (respiratory insufficiency by arterial blood gas analysis, severe obstructive or restrictive lung disease, acute respiratory failure within the past 2 years, or morbid obesity), rates of pneumonia (11% vs. 12%; P = 0.71) or mechanical ventilation for more than 24 hours (8% for both groups) did not differ. Respiratory failure (ventilation > 24 hours, reintubation, Pao2 ≥ 50 mm Hg, or Paco2 ≥ 50 mm Hg on room air) occurred significantly less often with epidural (45% vs. 29%; odds ratio, 0.5 [CI, 0.29 to 0.88]) (53).
In a large fair-quality trial (16), 1021 patients undergoing abdominal surgery were randomly assigned to general anesthesia and 1) postoperative systemic opioid or 2) intraoperative epidural anesthesia plus postoperative epidural morphine. Mortality rates did not differ, and non–statistically significant trends favored the epidural approach for pneumonia and respiratory failure.
In 1 fair-quality trial (17), 217 patients undergoing elective abdominal aortic surgery were randomly assigned to general anesthesia alone or general anesthesia plus intraoperative epidural opioid. Both groups received the same postoperative pain management. A non–statistically significant trend favored intraoperative epidural for overall postoperative pulmonary complications. Rates of individual types of postoperative pulmonary complications did not differ, but statistical power was low.
In a smaller poor-quality trial (18), 70 elderly patients undergoing major abdominal surgery were randomly assigned to general anesthesia and 1) postoperative patient-controlled morphine or 2) intraoperative neuraxial blockade plus postoperative patient-controlled epidural analgesia. Rates of atelectasis or major pulmonary complications did not differ. In an additional, small poor-quality trial (19), 75 patients undergoing elective cholecystectomy were randomly assigned to general anesthesia and 1) postoperative intramuscular morphine, 2) continuous intravenous morphine, or 3) intraoperative epidural local anesthesia plus postoperative epidural local anesthetic for 12 hours. Postoperative pneumonia occurred less often with epidural (4%) than with either intramuscular morphine (24%; P = 0.05) or intravenous morphine (20%; P = 0.11).
A fair-quality meta-analysis examined the evidence for 3 epidural techniques: intercostal nerve block, systemic opioids, and wound infiltration with local anesthetic (34). The number of trials that compared any 2 strategies varied from 2 to 11. Compared with systemic opioids, epidural opioids reduced atelectasis (relative risk, 0.53 [CI, 0.33 to 0.85]; 11 studies) but not pneumonia (relative risk, 0.53 [CI, 0.18 to 1.53]; 5 studies). Compared with systemic opioids, epidural local anesthetic reduced "pulmonary infection" (relative risk, 0.36 [CI, 0.21 to 0.65]; 5 studies) but not atelectasis (relative risk, 0.74 [CI, 0.50 to 1.11]; 4 studies). However, the authors pooled studies of both on-demand (that is, as requested) and patient-controlled intravenous analgesia, which could bias the results of the meta-analysis in favor of epidural analgesia.
In contrast, a good-quality meta-analysis identified 32 trials (n = 1029) of patient-controlled opioid analgesia versus the same drug given intravenously, intramuscularly, or subcutaneously (35). Opioid consumption, pain scores, length of stay, or adverse effects did not differ. In the 2 trials reporting postoperative pulmonary complications, fewer complications occurred in the patient-controlled analgesia group (odds ratio, 0.93 [CI, 0.86 to 0.99]; number needed to treat, 15 [CI, 8 to 98]).
Evidence from 1 good-quality trial suggests that shorter-acting neuromuscular blocking drugs may prevent postoperative pulmonary complications. Intraoperative neuraxial blockade, either alone or in combination with general anesthesia, may prevent postoperative pulmonary complications, but the evidence is conflicting. Several meta-analyses (which included small unblinded studies) suggest that epidural anesthesia may reduce pulmonary risk, but recent large randomized trials do not confirm benefit. Randomized trials of combined intraoperative and postoperative anesthetic or analgesic regimens do not clearly indicate that a combined epidural approach prevents postoperative pulmonary complications. Two meta-analyses of postoperative analgesic regimens suggest that part of the variability may be due to on-demand analgesia (intravenous, intramuscular, or subcutaneous) versus patient-controlled analgesia (intravenous or epidural). Postoperative epidural and patient-controlled intravenous analgesia both seem superior to on-demand delivery of opioids in preventing postoperative pulmonary complications. Epidural analgesia may further reduce postoperative pulmonary complications. More good-quality efficacy trials with standardized optimal regimens for all groups and sufficient size to examine pulmonary complication rates are needed (14). The risk for epidural bleeding due to postoperative epidural catheters in patients receiving heparin (especially low-molecular-weight heparin) makes timing of catheter placement important and may influence decisions about modalities for pain control and thromboembolism prophylaxis (54-56).
Our search identified many trials comparing laparoscopic and open procedures, but few reported postoperative pulmonary complication rates. Those that did focused on cholecystectomy and colorectal surgery. Downs and colleagues (36) performed a good-quality systematic review through March 1995 of open and laparoscopic cholecystectomy. They identified 18 trials (n = 1645) that were published with sufficient detail to judge methodologic quality. Twelve trials had at least 40 patients per study group, and the largest study had 150 participants per group. Since the authors did not quantitatively pool data because of clinical heterogeneity and methodologic problems, we examined the studies individually. None met the criteria for inclusion in our review (<25 participants per group [8 studies] or no clinical postoperative pulmonary complications reported [10 studies]).
Among the 4 highest-quality trials reporting spirometric outcomes, unblinded outcome assessment found statistically significantly greater compromise in FVC and FEV1 at 24 hours and 48 hours postoperatively with open cholecystectomy. In 1 study that followed patients until pulmonary function recovered to within 10% to 15% of preoperative levels, pulmonary function recovered 4 to 10 days earlier with laparoscopic cholecystectomy. Only 1 very small (n = 40) blinded trial assessed whether reduced pulmonary dysfunction translated into clinically important differences in postoperative pulmonary complication rates. On postoperative chest radiography, atelectasis occurred significantly less often with laparoscopic operations (40% vs. 90%; P = 0.001).
We identified 1 subsequent, poor-quality trial of laparoscopic versus open cholecystectomy (20). Among 82 patients, the frequency and severity of atelectasis, assessed by radiologists who were blinded to type of procedure, were significantly less among patients randomly assigned to laparoscopic cholecystectomy (frequency, 29% vs. 63% [P < 0.05]; severity, chi-square for trend P < 0.05). However, the analysis was not intention-to-treat: Patients who converted from laparoscopic to open operations were excluded from analysis.
Table 2 summarizes the results of a good-quality meta-analysis of laparoscopic versus open resection of colorectal cancer (37). Overall mortality did not differ. Risk was consistently less with laparoscopic operations for several complications but was not statistically significantly less with the more conservative statistical approach of random-effects modeling. The reduced risk for overall complications was primarily due to fewer wound complications, especially wound infection. Regarding pulmonary complications, a non–statistically significant trend favored laparoscopic resection. Three studies that evaluated postoperative pulmonary complications reported that respiratory recovery (defined by spirometry) was statistically significantly faster. Nine studies reporting data confirmed shorter length of hospital stay (mean, 21% shorter [range, 14% to 38%]) after laparoscopic operations (37).
Table 2.
We identified 1 additional good-quality trial of laparoscopic versus open colorectal resection in 384 patients; 269 were in an earlier publication that was included in the previous meta-analysis discussed (21). Again, a nonsignificant trend favored lower rates of pneumonia after laparoscopic operations (3 of 190 [1.8%] patients and 6 of 194 [3.5%] patients; P = 0.52) (21).
Two large retrospective cohort studies highlight the problems with using designs other than a randomized trial and ICD-9-CM codes to identify postoperative pulmonary complications to compare open and laparoscopic operations (57, 58). Atelectasis (the only postoperative pulmonary complication studied) occurred significantly less often with laparoscopic (n = 19 662) compared with open (n = 23 771) cholecystectomy (4% vs. 2%; P < 0.001) (57). Overall postoperative pulmonary complications were significantly less frequent after laparoscopic (n = 709) compared with open (n = 17 735) sigmoid resection (2.5% vs. 6%; P < 0.001) (58). The results of these 2 studies may be unreliable because of lack of systematic prospective surveillance. Clinicians may have been biased to order more postoperative chest radiographs (and therefore identify more atelectasis) after open procedures. Furthermore, in a recent study comparing discharge ICD-9-CM codes and systematic chart review for complications (8), specificity of ICD-9 codes was high but sensitivity was low: 35% (CI, 30% to 41%) for all complications and 32% (CI, 19% to 45%) for all infectious complications.
In summary, while supported by spirometric, postoperative pain, and length of stay data, whether laparoscopic procedures reduce the risk for clinically important pulmonary complications is not clear. The literature did not systematically assess or report pulmonary complications, and most studies did not have sufficient statistical power to detect differences in postoperative pulmonary complication rates.
Selective use of nasogastric decompression, or tubes, refers to use only for postoperative nausea or vomiting, inability to tolerate oral intake, or symptomatic abdominal distension. Routine decompression (that is, standard use until bowel function returns) has been thought to speed bowel recovery and decrease risk for aspiration. We identified 2 meta-analyses of studies of routine versus selective nasogastric decompression (38, 39, 59). One or both meta-analyses included all the trials that we identified.
The first meta-analysis was of good methodologic quality up to quantitative analyses, which pooled data from randomized trials, nonrandomized trials, "uncontrolled" trials, and case–control studies (38). For the overall group of 26 studies (which comprised 15 RCTs, 3 nonrandomized trials, and 8 case–control studies [n = 3964]), patients receiving selective decompression had significantly lower rates of pneumonia (odds ratio, 0.49; P < 0.001) and atelectasis (odds ratio, 0.46; P = 0.001) and shorter time to oral intake (3.5 days vs. 4.6 days; P = 0.04). Aspiration rates (odds ratio, 0.61; P = 0.88) did not differ. Selective decompression did not statistically significantly increase nausea, vomiting, or abdominal distension. For 20 higher-quality studies (15 trials and 5 case–control studies), patients receiving selective decompression also had lower rates of pneumonia (odds ratio, 0.59; P = 0.01) and atelectasis (odds ratio, 0.52; P = 0.002), a trend toward shorter time to oral intake (3.5 days vs. 4.5 days; P = 0.07), no difference in aspiration rates, and significantly higher rates of vomiting (odds ratio, 1.45; P = 0.005) and abdominal distension (odds ratio, 1.34; P = 0.02)
The recent meta-analysis was of good quality, and it identified 28 eligible trials (n = 4194) of routine versus selective nasogastric decompression after open laparotomy (39, 59). It included 15 of the 17 RCTs in the previous meta-analysis. Of 19 trials (n = 2892) reporting postoperative pulmonary complication, 18 included only elective operations (39, 59). Patients who were randomly assigned to selective decompression had fewer postoperative pulmonary complications, and the benefit approached statistical significance (relative benefit increase, 1.35 [CI, 0.98 to 1.86]; P = 0.07; calculated relative risk reduction, 0.74 [CI, 0.54 to 1.02]). Selective decompression also resulted in earlier bowel recovery (8 studies; n = 862; 0.46 day [CI, 0.28 day to 0.64 day]; P < 0.001).
In summary, the evidence suggests that selective nasogastric decompression (that is, for specific indications rather than routine decompression) improves return of bowel function and may reduce the incidence of postoperative pulmonary complications after elective abdominal operations.
Decreased lung volumes and atelectasis due to surgery-related shallow breathing, bed rest, diaphragmatic dysfunction, pain, and impaired mucociliary clearance may be the first events in a cascade leading to postoperative pulmonary complication. However, the evidence on prophylactic lung expansion is limited by variable techniques, inconsistent definitions of postoperative pulmonary complications, and poor-quality trials. Techniques include incentive spirometry, deep breathing exercises, chest physical therapy (which may include variable combinations of deep breathing, cough, postural drainage, percussion and vibration, suctioning, and ambulation), intermittent positive-pressure breathing, and continuous positive airway pressure. Table 3 summarizes the evidence.
Table 3.
The first of 2 poor-quality systematic reviews focused on upper abdominal surgery and identified 14 randomized trials (sample size, 17 to 200 participants) (40). Across all lung expansion modalities, a trend favored fewer postoperative pulmonary complications compared with controls (odds ratio, 0.85 [CI, 0.59 to 1.2)], but heterogeneity was statistically significant. In 2 studies, postoperative pulmonary complications occurred less often in patients receiving incentive spirometry compared with control (odds ratio, 0.44 [CI, 0.18 to 0.99]). In 4 studies, postoperative pulmonary complications occurred less often in patients who were randomly assigned to deep breathing exercises (odds ratio, 0.43 [CI, 0.27 to 0.63]), but heterogeneity was again statistically significant. Across other studies, no single modality was clearly superior. The second systematic review identified 4 randomized trials of patients undergoing abdominal surgery (41). The authors did not report raw or pooled postoperative pulmonary complication rates. In the only trial in our systematic review that met our sample size criteria, incentive spirometry, deep breathing exercises, and intermittent positive-pressure breathing equally prevented postoperative pulmonary complications compared with no intervention.
We identified 5 other trials in patients undergoing major abdominal surgery. The first 4 trials were of poor quality. Two trials compared chest physiotherapy with no prophylaxis (22, 23). In the first study, patients who were randomly assigned to chest expansion, maximum inspiration exercises, cough, and early ambulation had fewer abnormalities on postoperative chest radiography and a non–statistically significant trend toward fewer postoperative pulmonary complications (22). In the second trial, patients who were randomly assigned to cough and deep breathing exercises had significantly lower rates of pneumonia (0.6% vs. 7%; P < 0.05) (23).
The third trial compared "conventional chest physiotherapy" with incentive spirometry in 876 patients undergoing abdominal surgery and found no difference in rates of overall postoperative pulmonary complication, abnormal postoperative chest radiography, or Pao2 less than 60 mm Hg (24). The fourth poor-quality study compared 1) incentive spirometry and deep breathing exercises in 155 low-risk patients and 2) incentive spirometry versus incentive spirometry plus chest physiotherapy in 301 high-risk patients (ASA class > I or age ≥ 60 years) undergoing abdominal surgery (25). Among high- or low-risk patients, postoperative pulmonary complication rates did not differ with any intervention.
In the fifth and only good-quality trial (26), 204 patients undergoing intra-abdominal vascular surgery were randomly assigned to supplemental oxygen to maintain arterial oxygen saturation greater than 95% or to nasal continuous positive airway pressure for 12 hours after surgery. Severe hypoxemia (Pao2 < 70 mm Hg at fraction of inspired oxygen ≥ 0.70%) occurred statistically significantly less often (5% vs. 16%; P = 0.01), and non–statistically significant trends favored less pneumonia and reintubation with continuous positive airway pressure.
For patients having abdominal surgery, the evidence suggests that any type of lung expansion intervention is better than no prophylaxis. No modality seems superior, and combined modalities do not seem to provide additional risk reduction. Incentive spirometry may be the least labor-intensive, while continuous positive airway pressure may be particularly beneficial for patients who cannot participate in incentive spirometry or deep breathing exercises.
A fair-quality meta-analysis of 14 randomized or quasi-randomized trials of total parenteral nutrition (TPN) versus no TPN through August 1986 concluded that routine TPN in major surgery was not beneficial, except perhaps for severe malnutrition or for extended periods (10 days to 14 days) of inadequate enteral nutrition (60). The meta-analysis did not report results specific to pulmonary complications and was therefore ineligible for our review.
Subsequently, a good-quality multisite trial randomly assigned 395 patients undergoing laparotomy or noncardiac thoracotomy to perioperative TPN or no TPN (27). Overall rates of major complications (26% vs. 25%) and 90-day mortality (13% vs. 11%) were similar between the groups. Total parenteral nutrition was associated with non–statistically significant trends toward higher rates of pneumonia and empyema but significantly lower rates of noninfectious complications (5.3% vs. 42.9%; P = 0.03).
We identified 1 poor-quality meta-analysis (230 patients) and 2 additional, good-quality trials of TPN versus total enteral nutrition (TEN) (28, 29, 42). In the meta-analysis, infections were twice as common among patients receiving TPN (35% vs. 16%; P = 0.01) even after excluding patients with catheter sepsis from analysis (29% vs. 16%; P = 0.03) (42). There was a nonstatistically significant trend toward more frequent pneumonia in patients receiving TPN. In a trial of 241 patients, there was a non–statistically significant trend toward more postoperative pulmonary complications with TEN (7% vs. 13%; P = 0.12) (28). In a second, larger trial, 317 malnourished patients (>10% weight loss in previous 6 months) were randomly assigned to TPN or TEN (29). Rates of overall complications and infectious complications were statistically significantly lower with TEN, but rates of pneumonia (9 of 159 patients vs. 14 of 158 patients; P = 0.39) or the combined outcome of pneumonia and respiratory failure (13 of 159 patients vs. 20 of 158 patients; P = 0.27) did not differ.
Immunonutrition refers to enteral feedings with additional ingredients (variable combinations of arginine, Ω-3 fatty acids, or ribonucleic acids) to enhance the immune system and to possibly prevent infection. A good-quality meta-analysis of trials found that for patients undergoing elective surgery, enteral immunonutrition had no mortality benefit but resulted in significantly fewer overall infectious complications (relative risk, 0.53 [CI, 0.42 to 0.68]) (61). The authors did not report results for respiratory infections; therefore, the study was not eligible for our review.
In a subsequent good-quality trial of enteral immunonutrition (30), 305 patients undergoing elective resection of gastrointestinal cancer were randomly assigned to an enteral solution enriched with arginine, Ω-3 fatty acids, and ribonucleic acids preoperatively (5 days before surgery; n = 102) or perioperatively (5 days before surgery plus jejunal tube feeding begun within 12 hours of surgery and continued until oral intake was resumed; n = 101) or to a control group (n = 102) of postoperative intravenous glucose and electrolytes. Overall infection rates were significantly lower with immunonutrition (14% and 16% vs. 30%; P = 0.006 and 0.02, respectively), but rates of pneumonia (3 of 102 patients and 6 of 101 patients vs. 8 of 102 patients) did not differ (30).
In summary, while hypoalbuminemia and malnutrition increase postoperative complications, including pneumonia, routine TPN has no benefit over either TEN or no hyperalimentation, except perhaps for patients with severe malnutrition or for long periods of inadequate oral nutrition. More research is needed on enteral formulations that may enhance immune status. Prompt resumption of oral intake after surgery is important because atrophy of intestinal villi occurs quickly with inadequate intake and increases the risk for bacterial translocation across gut mucosa and subsequent sepsis (62).
After observational data suggested higher rates of respiratory failure and pneumonia in patients receiving right- heart catheterization for noncardiac surgery (63), Sandham and colleagues (31) performed a good-quality RCT. High-risk patients (n = 1994; age ≥ 60 years; ASA class III or IV) undergoing urgent or elective major noncardiac operations were randomly assigned to usual care or treatment guided by perioperative pulmonary artery catheter. Pulmonary artery catheterization did not reduce the primary outcome of in-hospital all-cause mortality (7.8% vs. 7.7%) or the rate of postoperative pneumonia, a secondary outcome (6.7% vs. 7.3%; P = 0.70).
Recent evidence has shown that postoperative pulmonary and cardiac complications are equally prevalent and clinically important in morbidity, mortality, and length of stay. However, compared with postoperative cardiac complications, much less research on prevention of pulmonary complications has been published. Table 4 summarizes the strength of available evidence, based on our systematic review, on interventions to reduce the risk for postoperative pulmonary complications.
Table 4.
Good evidence suggests that lung expansion therapy (for example, incentive spirometry, deep breathing exercises, and continuous positive airway pressure) reduces postoperative pulmonary risk after abdominal surgery. Well-designed trials are needed to clarify the magnitude of benefit and the comparative effectiveness of different modalities.
Fair evidence suggests that selective nasogastric tube decompression after abdominal surgery reduces risk. Fair evidence also suggests that short-acting neuromuscular blocking agents result in lower rates of residual neuromuscular blockade and may reduce risk for pulmonary complications.
Laparoscopic, compared with open, abdominal operations reduce pain and pulmonary compromise as measured by spirometry and oxygenation. However, the evidence is insufficient to determine whether laparoscopic operations prevent clinically important pulmonary complications. Given the benefits of laparoscopic procedures in pain control and length of stay, future trials to adequately assess clinical pulmonary outcomes are unlikely.
Evidence is insufficient to judge the potential benefit of preoperative smoking cessation in reducing risk. Risk may actually increase transiently after stopping or reducing smoking within 2 months of surgery due to increased secretions. We need trials of preoperative smoking cessation before higher-risk surgeries that adequately address optimal duration of cessation.
Evidence on intraoperative epidural anesthesia and postoperative epidural analgesia is insufficient. More good-quality efficacy trials of sufficient size (in which all groups receive equally standardized and optimized regimens) are needed to accurately examine complication rates.
Although malnutrition is associated with increased risk for postoperative pulmonary complications, good evidence indicates that routine total parenteral or enteral hyperalimentation nutrition does not reduce risk, except perhaps for patients with severe malnutrition or for those undergoing long periods with inadequate oral intake. Enteral formulations that are tailored to enhance immune status and reduce postoperative infections may be promising.
Evidence from 1 well-done randomized trial indicates that invasive perioperative monitoring with pulmonary artery catheterization does not reduce risk of pulmonary complications.
A limitation of our review is the overall quality of the literature. Only 10 of 20 RCTs and 6 of 11 systematic reviews or meta-analyses were of good quality.
Future studies of interventions to reduce postoperative pulmonary complications should be randomized trials that are designed to overcome methodologic problems in earlier literature. Cohort studies using secondary analyses of administrative databases should use measures for pulmonary complications that are proven valid and reliable by direct clinical assessment or medical chart audit. Studies should be large enough to adjust for known potential risk factors and confounding variables (as synthesized in the accompanying systematic review of preoperative risk stratification [7]) and should go beyond surrogate or intermediate physiologic or spirometric outcomes to detect clinically meaningful differences in clinical pulmonary complications. This is important for 2 reasons: to base patient care on clinically meaningful evidence and to determine when it is appropriate to substitute intermediate outcomes to shorten study timelines and reduce study cost. Researchers should define postoperative pulmonary complications a priori according to explicit criteria and, whenever possible, use outcome assessment that is masked, or blinded, to intervention assignment.
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Gonzalo Tornero-Campello
Department of Anesthesiology and Reanimation. Hospital General Universitario de Elche (Spain)
April 22, 2006
Strategies to Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery
Dr. Lawrence and colleagues (1) write that "Evidence on intraoperative epidural anesthesia and postoperative epidural analgesia is insufficient". However, they affirm that "Good evidence suggests that lung expansion therapy reduces postoperative pulmonary risk after abdominal surgery".
The use of postoperative lung expansion therapy (incentive spirometry, deep breathing exercises, and continuous positive airway pressure) may be very difficult because of pain. Epidural analgesia has been shown to reduce postoperative pain, improve gastrointestinal function and reduce the incidence of serious complications (2,3).
The authors state that the risk for epidural bleeding due to postoperative epidural catheters may influence decisions about modalities for pain control and thromboembolism prophylaxis. They don't consider that epidural analgesia permits early mobilization programmes, avoiding immobility.
In our hospital anesthesiologists provide critical care for surgical patients; the use of epidural analgesia provides them safe analgesia, avoiding opioids which are known to produce ileus and ease development of hyperalgesia (4).
If the authors haven't found evidence that epidural analgesia reduces postoperative pulmonary complications, they must admit that epidural analgesia does reduce pain, allowing lung expansion therapies and early mobilization programmes which have shown to reduce length of hospital stay (5).
1. Lawrence VA, Cornell JE, Smetana GW. Strategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery: Systematic Review for the American College of Physicians. Ann Intern Med. 2006;144:596-608. [PMID:16618957]
2. Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health- related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 2002;97:540""549. [PMID:12218518]
3. Rodgers A, Walker N, Schug S,McKee A, KehletH, van Zundert A et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:1493. [PMID: 11118174]
4. Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104:570-87. [PMID:16508405]
5. Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg. 2003;90:1497-504. [PMID:14648727]
None declared
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Privacy Policy
Conditions of Use
This PDF is available to Subscribers Only


text:
American Made
High-Quality Men's Hats Made in the USA
If you're looking for the best selection of high-quality American-made hats, you'll find it at Hats in the Belfry. We're not only devoted to preserving long-standing hat-making traditions that often get lost when jobs are outsourced, but also to supporting and boosting the American economy by creating jobs. Hats in the Belfry offers tons of American-made men's hats., including fedora hats, U.S.-made ivy caps, newsboy caps and so much more. Our very own Belfry Hats line includes plenty of dapper made-in-USA hats for men, and these stylish options are affordable enough for any hat shopper on a budget.
Our selection of fedora hats made in the U.S.A. includes hats by Stetson, Biltmore and our own Belfry brand. Although many of these styles feature imported materials such as genuine Panama straw or lambskin leather, they are constructed and/or hand-blocked in the U.S. for exceptional quality and care. All of these hats are designed with age-old hat-making techniques right here in America, so you can expect them to last throughout all of your greatest adventures. When you shop at Hats in the Belfry for American hats, you automatically get personalized, reliable customer service with every order. Stock up on all of your favorite made-in-USA hats for sale at Hats in the Belfry and get free shipping when you spend $100 or more.
There are no products matching the selection.

subset: commoncrawl


text: Cooper is 3 weeks and feedings during the day are getting worse. He has gone from crying while eqating to pulling off and not wanting to eat at all, but he will have 2 or 3 good feedings during the night. He pulls off the breast as if he is in pain. I have stopped dairy in case that's it but it seems to affect him only after a few swallows, not after the feeding which most websites seems to say is thw way allergies will cause a reaction. Went to an LC who over the phone thought it might be a let-down problem but she checked my latch and said it was fine. Does anyone else have a similar problem?


text:
Learning Center Search Results
Showing 1-9 of 9 results
What can you learn from a census record? Watch this video to find out how to read a 1930 U.S. Census record and learn how this record can help you discover more on Ancestry.com.
Finding your Ancestors in Vital Records
Learn why, where, and when vital records were created in the United States and how to find them.
This class will help you to find information to identify the ancestor in the records of his hometown. The Mexico-United States border crossing information and their content is analyzed during this class.
Discover records which will assist you with pre-1850 United States research.
We will learn why we should use church records, how to find them, types of church records and information found in them, and ways to determine an ancestor's religion
Learn how these often overlooked records can assist with making family connections and fleshing out a family history
United States Naturalization Records
Learn about the process by which a native or citizen of one country becomes a citizen of a different country.
We will discuss probate basics and process, probate records and how to locate them.
Vital records overview and content, jurisdictions, and regional differences.


text:
I am nursing my almost 9 month old and am having a lot of pain on just the left side. He latches on great for the right but it feels like his teeth are digging in on the left. I loaned out my book that talks about helping a baby to latch and can't find any diagrams here.
Can anyone remind me of where the chin and nose should be? And is there a way I can position him that will help? His belly is turned towards me and he doesn't pull away while latched on....it's just as he's sucking that his top teeth seem to be digging in. I'm nervous about him biting if I try to latch him on properly over and over so I'd like to get it right the first time...or at least bareable!
Also, does this just happen when they get new teeth and will go away eventually?
Thanks for any help and suggestions!


text:
MRP: Rs. 576 for 1 packet(s) (500 ML scrub each)
Report Error
Composition for WOKADINEPovidone Iodine(7.5%)
food interaction for WOKADINE
alcohol interaction for WOKADINE
pregnancy interaction for WOKADINE
lactation interaction for WOKADINE
It can be taken with or without food, but it is better to take it at a fixed time.
Interaction with alcohol is unknown. Please consult your doctor.
It may be unsafe to use during pregnancy.
Animal studies have shown adverse effects on the foetus, however, there are limited human studies. The potential benefits may outweigh the risks. Please consult your doctor.
Animal studies have shown adverse effects on the foetus, however, there are limited human studies. The potential benefits may outweigh the risks. Please consult your doctor.
It is probably unsafe to use during breastfeeding. Please consult your doctor.
SALT INFORMATION for WOKADINE
Povidone Iodine(7.5%)
It is used to to treat and prevent and treat infection in wounds and as an antiseptic and first aid for minor cuts, grazes, burns, abrasions and blisters.
How it works
Wokadine 7.5% scrub is broad spectrum antiseptic for topical use. Wokadine 7.5% scrub liberates iodine in contact with the skin causing antiseptic action.
Common side effects
Skin discolouration, Increased sodium level in blood, Renal impairment, Metabolic acidosis, Increased level of thyroid hormones, Decreased level of thyroid hormones in neonates, Deep tissue toxicity, Mucous membrane toxicity, Superficial punctuate keratitis
SUBSTITUTES for WOKADINE
6 Substitutes
Sorted By
- BETADINE 7.5% SURGICAL SCRUB(50 ML scrub in packet)Win-Medicare Pvt LtdRs. 2.58/ML of scrubRs. 129pay 124% more per ML of scrub
- WOKADINE 7.5% SCRUB(50 ML scrub in packet)Wockhardt LtdRs. 1.66/ML of scrubRs. 83pay 44% more per ML of scrub
- CIPLADINE 7.5% SCRUB(500 ML scrub in packet)Cipla LtdRs. 0.13/ML of scrubRs. 65.57save 89% more per ML of scrub
- POVI 10 7.5% SCRUB(500 ML scrub in packet)Nemus Pharmaceuticals Pvt LtdRs. 0.86/ML of scrubRs. 428.57save 26% more per ML of scrub
- POVI 10 7.5% SCRUB(60 ML scrub in packet)Nemus Pharmaceuticals Pvt LtdRs. 1.35/ML of scrubRs. 81pay 17% more per ML of scrub
Top Ophthalmologists
- Dr. Sanjay VermaMBBS, MS
- Dr. Varun GogiaMBBS, MD
- Dr. Vandana SarohaMBBS, MS, Fellowship
- Dr. Ajay SharmaMBBS, MS
- Dr. Reema DasMBBS, Diploma, MS
Expert advice for WOKADINE
- Apply a small amount of povidone iodine solution to the affected area after cleaning it properly.
- The affected area can be left uncovered or covered with a sterile bandage.
- If you experience a skin rash, hives, or itching, or any other unusual reaction after using this product, discontinue use and contact your doctor as soon as possible.
- Povidone iodine cutaneous spray powder is meant for external application and should not be instilled in eyes, nose, or mouth.
- Do not use the povidone iodine solution on large parts of the body for more than a week unless advised by your doctor.
- Seek doctor's advice before use if injuries are deep or puncture wounds or serious burns.
Frequently asked questions for WOKADINE
Povidone Iodine
Q. Is povidone iodine the same as betadine?
Yes. Betadine is the brand (proprietary) name of povidone iodine.
Q. Is povidone iodine the same as iodine or iodine tincture?
No. Povidone iodine is the stable chemical complex of povidone (polyvinylpyrrolidone i.e. PVP) and elemental iodine. Iodine tincture has iodine and potassium iodide dissolved in ethanol and water. Both the formulations show antiseptic action.
Q. Does povidone iodine kill yeast, bacteria or fungus?
Yes. Povidone iodine being disinfectant and antiseptic inhibits the growth and development of microorganisms.
Q. Does povidone iodine burn, stain, sting or hurt?
Topical application of povidone iodine may cause slight irritation. Temporary staining of affected area is also possible. However, it is not a matter of concern and gets resolved quickly.
Q. Is povidone iodine safe?
Povidone iodine is safe when used at prescribed dose and duration as directed by doctor.
Q. Does povidone iodine contain alcohol?
No. Povidone iodine is stable chemical complex of povidone (polyvinylpyrrolidone i.e. PVP) and elemental iodine.
Q. Does povidone iodine stain teeth?
Povidone iodine should be used externally. It should not be used on teeth.


text: I have a 2 week old baby girl and my milk seems less than adequate. I am nursing for about 20 minutes on each side because she's such a slow eater. I've been supplementing w/ formula if needed, but I'd like to have enough milk to strictly BF. I only get about an ounce from both breasts when I pump. I've been reading about teas, and other things to increase milk supply. What tea? Where do I get it? What else can I do? I need all the advice I can get.


text:
What is in this article?:
- Why is it so difficult to delay weed resistance?
- Some deny the problem
- Key to survival?
- One of the hindrances to resistance management is economics.
- Acreage has expanded and people don't cultivate anymore, so to go backwards is a hard pill to swallow.
- There's also denial about having or ever getting the problem.
More About:
We know why weed resistance occurs, and we know it is happening now, so why aren't we doing a better job of delaying it?
That's the question asked by University of Georgia Extension Weed Scientist Eric Prostko during the recent Beltwide Cotton Conferences in Atlanta.
"We know we get weed resistance due to the repeated application of herbicides with the same mode of action. This occurs more in annual weeds that have high populations or are highly distributed and are prolific seed producers, such as Palmer amaranth pigweed," he says.
Everyone at the Beltwide and at other conferences and meetings is talking about resistance, but it's not a new phenomenon, says Prostko. "It has been happening since 1968. My point is we know why it happens, and we know that it does happen, but it's not getting any better. So why can't we do a better job of delaying it? We can't prevent it because we can't prevent what Mother Nature is going to do," he says.
One of the hindrances to resistance management is economics, he says.
"A lot of growers aren't thinking long-term, they can't. They're thinking about how they'll make it to next year and pay the banker," says Prostko.
Another hindrance has been reluctance to change, he adds. "Think about what has happened from about 1997 to 2004. Weed control became very easy and very cheap or at least relatively cheap. Now we're talking about going back to some things we used to do, and that's significant. We've expanded acres and people don't cultivate anymore, so to go backwards is a hard pill to swallow."


text:
If you pump, you'll be fine. I've known a few Mom's to go on week long trips and their LO's picked right up where they left off.
They also pumped and dumped so they could "partake in the festivities". They had a great time, they reconnected with their DH's and their LO's did fine as well. Go for it! Maui will be INCREDIBLE!!


text:
How can I run a safe simulation of downloading and executing a virus, and confirm that my Norman antivirus protection is performing as expected?
There is a special file called Eicar. This is a file that doesn't have any harmful content whatsoever, but is detected as the Eicar-virus by consensus from all antivirus companies. (For advanced users: this is the only 'false positive' that is kept in the definition files on purpose.)
Downloading and running Eicar is exactly the same as downloading and running a virus, except of course that there is absolutely no danger involved. If the Eicar file is intercepted/detected, the scanner is active and functional.
For more information, visit www.eicar.org.
You can download different versions of the Eicar executable from Eicar's web site.
When executing this test through a remote session, you will not see the popup about a detected virus. In that case, just check whether the Eicar file is still where you put it after downloading and/or running it. If not, it was successfully removed by Norman.


text:
Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results - A Long Term Evaluation (LEADER®)
This study has been completed.
Novo Nordisk A/S
Information provided by (Responsible Party):
Novo Nordisk A/S
ClinicalTrials.gov Identifier:
First received: August 6, 2010
Last updated: August 31, 2016
Last verified: August 2016
|Tracking Information
|First Received Date ICMJE
|August 6, 2010
|Last Updated Date
|August 31, 2016
|Start Date ICMJE
|August 2010
|Primary Completion Date
|December 2015 (final data collection date for primary outcome measure)
|Current Primary Outcome Measures ICMJE
|Time from randomisation to first occurrence of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke (a composite cardiovascular outcome) [ Time Frame: from randomisation up to 60 months ] [ Designated as safety issue: No ]
|Original Primary Outcome Measures ICMJE
|Same as current
|Change History
|Complete list of historical versions of study NCT01179048 on ClinicalTrials.gov Archive Site
|Current Secondary Outcome Measures ICMJE
|Original Secondary Outcome Measures ICMJE
|Current Other Outcome Measures ICMJE
|Not Provided
|Original Other Outcome Measures ICMJE
|Not Provided
|Descriptive Information
|Brief Title ICMJE
|Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results - A Long Term Evaluation
|Official Title ICMJE
|A Long-term, Multi-centre, International, Randomised Double-blind, Placebo-controlled Trial to Determine Liraglutide Effects on Cardiovascular Events
|Brief Summary
|This trial is conducted in Africa, Asia, Europe, and North and South America. The aim of this trial is to determine the long term effect of liraglutide on cardiovascular events in subjects with type 2 diabetes.
|Detailed Description
|Not Provided
|Study Type ICMJE
|Study Phase
|Phase 3
|Study Design ICMJE
|Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Double Blind (Subject, Investigator)
Primary Purpose: Treatment
|Condition ICMJE
|Intervention ICMJE
|Study Arm (s)
|Publications *
* Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
|Recruitment Information
|Recruitment Status ICMJE
|Enrollment ICMJE
|Completion Date
|December 2015
|Primary Completion Date
|December 2015 (final data collection date for primary outcome measure)
|Eligibility Criteria ICMJE
Inclusion Criteria:
Exclusion Criteria:
|50 Years and older (Adult, Senior)
|Accepts Healthy Volunteers
|Contacts ICMJE
|Contact information is only displayed when the study is recruiting subjects
|Listed Location Countries ICMJE
|United States, Australia, Austria, Belgium, Brazil, Canada, China, Czech Republic, Denmark, Finland, France, Germany, Greece, India, Ireland, Israel, Italy, Korea, Republic of, Mexico, Netherlands, Norway, Poland, Puerto Rico, Romania, Russian Federation, Serbia, South Africa, Spain, Sweden, Taiwan, Turkey, United Arab Emirates, United Kingdom
|Removed Location Countries
|Administrative Information
|NCT Number ICMJE
|Other Study ID Numbers ICMJE
|Has Data Monitoring Committee
|Plan to Share Data
|Not Provided
|IPD Description
|Not Provided
|Responsible Party
|Novo Nordisk A/S
|Study Sponsor ICMJE
|Novo Nordisk A/S
|Collaborators ICMJE
|Not Provided
|Investigators ICMJE
|Information Provided By
|Novo Nordisk A/S
|Verification Date
|August 2016
ICMJE Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP


text:
Welcome to the CRG Discussion Forum!Forum registration problems: Make sure you enter your email correctly and you check your spam box first. *Then* email KurtS2@gmail for help.
Reminds me of the cap (3908372) used on the left rear shock only on all 1st gen camaro's. No one ever talks about them but they do exist.


text:
Preliminary OK given for Courthouse McDonald's
MARTINSBURG – Plans for a new McDonald's at Old Courthouse Square shopping center received preliminary approval from the Martinsburg Planning Commission Wednesday, but not without members expressing concerns about traffic trying to get in and out of the proposed fast-food restaurant.
The restaurant would go on about a one-acre lot in the shopping center's parking lot across from the Summit Community Bank. The entrance and exit to the restaurant would be from Courthouse Drive off Edwin Miller Boulevard.
Planning Commission member Jeff Molenda said there could be potential issues with cars backing up on Edwin Miller Boulevard trying to turn onto Courthouse Drive to get to the restaurant, as well as with cars leaving the restaurant stacking up as they try to get onto Courthouse Drive.
"There's not any easy way out of the parking lot now, especially in the morning and evening," he said.
Planning Commission member Reenie Raines pointed out that there is no traffic light at that intersection.
"It's hard to get out – it's something we should think about," she said.
Mike Nestor, project engineer for Thrasher Engineering Inc. of Clarksburg, W.Va., said there are four points of access to the shopping center's parking lot and that drivers would use other entrances and exits if the one at the proposed restaurant is busy.
Nestor was requesting a change to the shopping center's concept plan to allow for the restaurant. The shopping center is a planned urban development and is zoned planned business.
The zoning would not change. The request was for a change of use within the PUD.
A public hearing was held on the request, but no one commented.
Planning Commission members unanimously voted to recommend to Martinsburg City Council the revisions to the original concept plan that would allow for the restaurant. City Council has the final say on such changes.
Carmen DiDiano, of McIlvried, DiDiano and Mox LLC in Great Falls, Va., presented the sketch site plan, or preliminary plans, to the Planning Commission.
He explained that the McDonald's Corp. wants to build the restaurant to replace the existing McDonald's on Eagle School Road. He called it a relocation.
The franchisee for the McDonald's on Eagle School Road is Susan Erwin. She also is the franchisee for the McDonald's on Apple Harvest Drive, which recently underwent a complete rebuild.
The 4,350-square-foot restaurant would seat about 85, DiDiano said. It would have a double drive-through, he said.
He added that landscaping around the restaurant would replace about 3,000 square feet of pavement, which would help with storm water management.
Planning Commission members gave unanimous approval for the project to move onto the final site plan, which they hope will take into account their concerns about the traffic.
Also at Wednesday's meeting, Planning Commission members unanimously approved recommending to City Council a change in zoning of a 17,600-square-foot parcel at 605 Baltimore St. from urban residential class A to service business. The applicant was R&D Investments LLC of Glengary, which was represented by Steve Cunningham.
– Staff writer John McVey can be reached at 304-263-3381, ext. 128, or firstname.lastname@example.com.


text:
Wordsmith Talk
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#172712 - 01/21/08 11:58 AM tone color and color tone
Carpal Tunnel
Registered: 06/23/06
Posts: 5295
Loc: Netherlands, the Hague
Quoted from O.Sack's Musicophila:
"The ability to maintain a sense of timbre constancy is a multileveled and extremely complex process in the auditory brain that may have some analogies with color constancy--
indeed, the language of color is often applied to timbre, which is sometimes referred to as "sound color" or "tone color".
Funny, that when you turn "tone color" around to "color tone", you find yourself in the field of visual arts concepts; "color tone " is 'the grey- the tone value' of a color.
In both art forms they affect "timbre" and "shade", though seing and hearing are located in different parts of the brain.
I don't know exactly what to make of this,(I know not much more about the brain than that like most people I got one), but when you add "shades of meaning " to it (from today's AWAD context), they are all three together: music, visual arts and language.
Edited by BranShea (01/21/08 02:36 PM)
#172723 - 01/21/08 02:01 PM Re: tone color and color tone [Re: BranShea]
Carpal Tunnel
Registered: 06/24/02
Posts: 7210
Loc: Vermont
isn't that what he is saying?
btw, I just finished Musicophilia, and was underwhelmed.
#172725 - 01/21/08 02:30 PM Re: tone color and color tone [Re: Buffalo Shrdlu]
Carpal Tunnel
Registered: 06/23/06
Posts: 5295
Loc: Netherlands, the Hague
That's what he is saying , but what I'm trying to say (I think ) is that "tone color" and "color tone" are definitely two different things, although somehow related. (that's aside from the book)
I'm halfway now and just like in this "The Man who took....etc",
he's fluttering from one case history to the next, sometimes a bit incoherently. I find the various phenomena and symptoms quite interesting. Only I'd rather not have known all the problems one can get with one's hearing. I'm very fond of music and sounds.
#172729 - 01/21/08 03:41 PM Re: tone color and color tone [Re: BranShea]
Carpal Tunnel
Registered: 06/24/02
Posts: 7210
Loc: Vermont
yes, fluttering, that's a good way to put it. what surprised me (and had I read any of his other books, perhaps I wouldn't have been surprised) is that he doesn't draw any conclusions from all this stuff. maybe that's being a good doctor/scientist, but give me some grist! speculate! go out on a limb! frankly, it was a pretty boring read, but I got through it. though I should have read it with a pencil in hand. I'll need to read it again (ugh!) and take notes. (pun only slightly intended)_________________________
formerly known as etaoin...
#172731 - 01/21/08 03:58 PM Re: tone color and color tone [Re: Buffalo Shrdlu]
Carpal Tunnel
Registered: 06/23/06
Posts: 5295
Loc: Netherlands, the Hague
Right, it's what you call a rather flat read (pun only slightly intended), but the conclusion I draw for myself afer each case history is , mind your head.
Never go bashing or bumping it, if you care to keep your sound sound.
(He does take amusing side steps; the entomologist with absolute pitch, who can distinguish the sound pitch of insects in flight, the wind whisteling in D).It's not exciting, but I'm not bored.
Edited by BranShea (01/21/08 05:09 PM)
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text:
Người tiêu dùng
Các doanh nghiệp
1 of 1 photos
CE Tech 1000 ft. Riser Cable packaging
CE Tech 1,000 ft. Riser Cable
The riser cable does not meet fire resistance standards for riser cable, posing a fire hazard.
Home Depot at (800) 394-7519 from 8 a.m. to 5 p.m. ET Monday through Friday or online at www.homedepot.com and click on Product Recalls for more information.
About 11,300
This recall involves 1,000 ft. CE Tech riser cable sold in boxes of 1,000 ft. lengths. It is intended to run between floors of a building as data cable. This type of cable must self-extinguish in a fire. The cable is gray and marked (UL) E316395. The cable's box is blue and black and is marked CE Tech 1,000 ft. riser cable, Cat 6 23-4.
None reported
Consumers should remove the recalled cable and return it to Home Depot for a full refund.
Home Depot stores nationwide from January 2013 through February 2013 for about $100.
Home Depot U.S.A. Inc., of Atlanta, Ga.
The U.S. Consumer Product Safety Commission is charged with protecting the public from unreasonable risks of serious injury or death from thousands of types of consumer products under the agency's jurisdiction. The CPSC is committed to protecting consumers and families from products that pose a fire, electrical, chemical, or mechanical hazard. The CPSC's work to ensure the safety of consumer products - such as toys, cribs, power tools, cigarette lighters, and household chemicals - contributed significantly to the decline in the rate of deaths and injuries associated with consumer products over the past 30 years.
To report a dangerous product or a product-related injury, call CPSC's Hotline at 800-638-2772 or CPSC's teletypewriter at 301-595-7054. To join a CPSC e-mail subscription list, please go to http://www.cpsc.gov/Newsroom/Subscribe/ (http://www.cpsc.gov/Newsroom/Subscribe/). Consumers can obtain recall and general safety information by logging on to CPSC's Web site at www.cpsc.gov (http://www.cpsc.gov).
Times: 8 a.m. - 5:30 p.m. ET; Messages can be left anytime
Call to get product safety and other agency information and to report unsafe products.
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text:
Saint Honore
Curvy Bootcut Jean
Style: 570097885
Out of Stock
Dark boot leg jean lightly faded in all the right places. Undulating pink stitching graces the back pockets.
- Our curvy fit. Curvy through the hip and thigh and sits just below the waist.
- Bootcut leg.
- Dark wash.
- Contrast stitching. Shank button and zip fly; belt loops. Inside waistband inscribed with "Feel beautiful". Metal logo bar at back pocket.
- 73% cotton, 14% rayon, 11% polyester, 2% spandex. Machine wash. Imported.
- Inseams: regular 33.5", short 32", long, 35.5".
Read more… Read less…


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A 79-year-old Waterloo man was flown to the hospital and arrested after a crash on Saturday afternoon, according to the Dane County Sheriff's Office.
Deputies were called to State Highway 73 at Clarkson Road in the town of York at 5:45 p.m. for a report of a single-vehicle crash.
Investigators said the driver, Gerald E. Turley, was traveling south on Highway 73 when he failed to negotiate a curve. His 2003 Mercury Marauder left the roadway and struck a tree. Turley was unresponsive and needed to be extricated. He was flown to University of Wisconsin Hospital with life-threatening injuries. His condition improved by Monday morning.
His passenger, Karen L. Turley, 70, of Waterloo, also needed to be extricated from the vehicle and was taken to UW Hospital by ambulance with serious but non-life-threatening injuries, according to deputies.
Gerald Turley was arrested f on suspicion of operating while intoxicated causing injury. He was cited on suspicion of failure to maintain control.


text:
TravelCenters of America Restaurant Cashier - Full Time or Part Time job in Ogallala, NE
- Company
- TravelCenters of America
- Job Title
- Restaurant Cashier - Full Time or Part Time
- Job Type
- Part-time, Summer
- Pay Type
- Hourly
- Location
- 103 Prospector Drive
Ogallala, NE 69153
Restaurant Cashier - Full Time or Part Time
TravelCenters of America is the nation's largest full-service travel center network. We offer a variety of positions with great advancement opportunities as well as the ability for individuals to try different aspects of our business. Each site has a full-service restaurant, a large convenience store, several fast food concepts, and a service repair shop. We offer a great manager training program for those that wish to advance their career.
As a Restaurant Cashier, you will provide quality service to each guest in a courteous and efficient manner while always displaying a pleasant and enthusiastic attitude. Your duties will include processing guest checks and receiving payment by utilizing a point of sale register and keeping your area neat and clean. This position requires good communication skills, good personal grooming habits, and accurate money handling skills. Physical requirements include standing up to 8 hours during a shift and able to lift up to 50 pounds.
If you are interested in a career with TravelCenters, click "Apply Now" and start your application process today!


text:
What is in this article?:
- Agricultural research continues funding scramble
- Waiting for magic
- The new reality for university agricultural researchers and administrators is a near-constant scramble to find ways to keep research programs afloat. The March 1 sequester further jeopardizes the gains made in research programs.
More About:
In recent years, university agricultural research funding has too often been short. The new reality for researchers and administrators is a near-constant scramble to find ways to keep research programs afloat.
The March 1 sequester, says Michael Mazourek, further jeopardizes the gains made in research programs. Mazourek,an assistant professor in Cornell University's Department of Plant Breeding and Genetics, tells a story that he insists could be told by agriculture professors and researchers across the country.
"I'm a vegetable breeder and have new varieties that end up in seed catalogs. We also do the initial 'rough draft' of germ plasm that goes to the seed companies and they take that to the finished cultivar. In addition, we do a lot of genome metabolite nutrition research.
"All that requires a lot of trials on grower farms to ensure that the things we develop actually works in the field. If it doesn't work on the farm, it just wastes everyone's time."
Unfortunately, in terms of public perceptions, agricultural research has a high hill to climb.
"Many people have the image of a faculty member, a professor, sitting in a big chair, reading dusty books from the library while smoking a pipe with heels up. Of course, that's not what we're doing.
"To get everything done, I've invested a lot in recruiting a dedicated staff. They're key to everything we do. So, I spend a lot of time trying to make payroll, keep enough grants coming in to fund the research and keep momentum going."
Developing a new vegetable is often a multi-year process. That requires a team that's in it for the long haul and funding to keep it in place.
"Getting a grant is very tough. Often, you're looking at a 1 or 2 percent success rate. That means instead of sitting with pipe in hand and my feet up, I spend time writing grant application after grant application, bringing the best arguments I can trying to persuade someone to fund us. Every once in a while we're lucky enough to get that funding."
One grant the Cornell team is part of is being led by Oregon State University. "It's one of the big OREI (Organic Agriculture Research and Extension Initiative) USDA grants that involved farmers, getting new varieties. We have a lot that's almost ready to release – we just need to increase seed.
"That grant was set to renew this year and, right now, I should be writing the renewal request. And actually, the budget category for the grant was increased because the whole program has been so successful for the USDA. But with the sequestration, as far as I can tell, we have a big budget but there's no money allocated. That means they're not accepting renewal applications."
Will Mazourek be forced to furlough team members?
"In our case, we were lucky enough to have a rainy day fund. However, we've been dipping into it so much there's not much left. We can see the bottom of the barrel.
"I hear the same thing from other researchers, regardless of region."
Agricultural research, Mazourek points out, provides stability to the markets. It's also the place where people are trained in agricultural disciplines, the place where the next generation of specialists and consultants come from.
And it's very hard to absorb the lack of funding.
If you are enjoying reading this article, please check out Southwest Farm Press Daily and receive the latest news right to your inbox.
"Others have it worse than I do, though. The potato breeders are in a special bind. Every year they plant tubers in the ground, which will last only a year if they aren't regenerated. Without proper funding to plant those and, at a minimum, harvest them to storage for next year, all their work will be for naught. Decades and decades of progress could just end.
"Think about the research on vineyards and orchards. You can't just stop hiring someone to irrigate the crops.
"The situation for vegetable breeders like me is a bit milder. We can put seeds in the fridge and, hopefully, weather the storm."


text:
(60) Customer Reviews
Price Range: USD $146.99 to $324.99
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From there, General Tire engineers developed four key technologies, which provide a synergy of comfort, durability, and performance.The Grabber HTS combines the synergy of style, durability and performance for a tire that exhibits excellent road manners and a long life.
DURAGEN: Ultra high strength steel belts, micro-fiber casing reinforcements, and a broad contour result in a strong, durable tire that provides even treadwear for longer mileage and confidence in challenging driving conditions.ADAPTIVE PERFORMANCE: Response Grooves, Stabilink Bars and three kinds of siping result in an excellent all-season tire that promotes enhanced steering response and provides reliable performance when braking, accelerating and cornering.COMFORT/BALANCE: An all-new tread cushioning system and noise-capturing pockets which provide a quieter, more comfortable ride without sacrificing responsiveness.ECO RIDE: This latest-generation tread compound significantly improves fuel economy by reducing rolling resistance, and is designed to minimize CO2 emissions to support a cleaner, greener planet.
These are the original equipment tires and at 14000 miles they are more than half worn out.
Size: 245/70R17
made this review on 7/14/2016 and is a
Aggressive Driver (Hard Cornering)
Have had these tires on 3 vehicles in the last 6 years. Great tire in dry, wet, snow and icy conditions.
made this review on 2/27/2016 and is a
Confident, Experienced Driver
These tires came on 2011 Chevy Traverse and they are complete garbage GM change the tires twice for me at free of charge I do not recommend these tires to anyone
Vehicle: 2011 Chevrolet Traverse 4 Dr Sport Utility LS with 35 KM of Tire Wear
made this review on 1/7/2016 and is a
Confident, Experienced Driver
Have rotated tires religiously and they are still noisy, beginning at about 50% tread life remaining.
Size: 235/70R16
Vehicle: 2007 Mercury Mariner 4 Dr Sport Utility Premier with 24135 KM of Tire Wear
made this review on 12/23/2015 and is a
Confident, Experienced Driver
Best all season tire for snow I've ever used. From slushy ice to deep (2.5-2 ft) snow they work with the Traverse AWD system to pull through in a straight line. Just drove out my 1/4 mile long drive w/ over 1.5 feet of snow pushing the air dam like a plow. My neighbor waiting for me on his tractor was amazed the AWD Traverse made it. Nice on 80MPH SD interstate runs too. Works OK in mud and fine on our rural gravel roads. Sometimes a bit noisy on groved concrete pavement. Never a problem. Just bought 2nd set @ 70K miles so wear is good.
made this review on 11/21/2015 and is a
Confident, Experienced Driver
To see all 60 reviews on tire reviews page
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text:
DS #2 was born on Dec. 1st at 35 weeks 2 days. After a one week stay in the NICU where we were not allowed to breastfeed we are now home. I'm currently exclusively pumping for him. He refuses the breast each time that I offer - actually can barely get my nipple in his tiny mouth with or w/out the nipple shield. I'm a 42H right now with huge nipples and aerolas. (sp?)
He is now two weeks old, we've been home for one week and seen a lactation consultant. He refuses the recommended bottle nipple the LC mentioned (second nature) so we're using evenflo bottles (closest to the nicu bottles)
He's currently taking in 2.5 - 3 ounces of breastmilk (with added neosure) every 3.5-4 hours and I'm waking him to nurse in between feedings around every two hours (except at night) I've tried offering the breast before, during and after the bottle feeds as well with little success.
I don't have any supply issues. I'm pumping approx every 3 hours during the day... at night I pump for the midnight feeding, skip the middle of the night feeding and pump again first thing in the morning. I'm getting 6 ounces at every session, 9 ounces in the morning session.
I breastfed my first for 2.5 years and I want to be able to do the same for my second.


text:
tagline: From openSUSE
Welcome to the Distribution Portal edit
The openSUSE distribution is a stable, easy to use and complete multi-purpose distribution.
It is aimed towards users and developers working on the desktop or server. It is great for beginners, experienced users and ultra geeks alike, in short, it is perfect for everybody! The latest release, openSUSE Leap 42.2, features new and massively improved versions of all useful server and desktop applications. It comes with more than 1,000 open source applications.
openSUSE is also the base for SUSE's award-winning SUSE Linux Enterprise products.
What features does openSUSE offer you? edit
Full desktop operating system
openSUSE has everything you need to do your work and play. Browse the web, send email, be online in social, write documents, and much more; all (for) free.
Full office suite included
Use LibreOffice to create professional-looking documents, spreadsheets, presentations and more. With LibreOffice, you can work on office documents created with other office suites.
Enjoy your Internet experience, worry-free
Forget worrying about viruses and spyware. openSUSE has none, period. And the included Firefox web browser alerts you to known phishing websites, helping protect you from scams and identity thieves.
Have fun with media
Play your music, podcasts, and videos with Banshee and Amarok. Organize, edit, share, and fool around with your photos with F-Spot or DigiKam; make new photos of yourself and your friends with Cheese.
Live mobile
openSUSE works great on laptops and on personal handheld devices. So you don't have to be tied down to be working or having fun with openSUSE!
Simply change
Are you coming from another operating system and want to be free with Linux? There are tons of application equivalents.
We back you up
openSUSE products are backed with free software updates for 18 months after release. The openSUSE community is also helpful and ready if you have any questions or problems with openSUSE.
Full and accurate source code
openSUSE products allow developers to retrieve the exact source code of each distributed binary package. The complete sources for openSUSE products are available online, further information on how to get them is available.
Topics edit
Learn about your openSUSE computer
Access the documentation of openSUSE.
Get help with openSUSE.
Communicate with other openSUSE users.
View screenshots of openSUSE and access official artwork.
Learn more about the openSUSE Project and the people behind it.
In the news edit
In the news:
Releases edit
Current Releases:
- Tumbleweed - Rolling distribution
- openSUSE Leap 42.2
- More about derivatives
Maintained Previous Releases:
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text: You're looking at zazzle.co.uk's Monsters photo card page, where you can find a fantastic range of Monsters cards, ready for you to customise with your own family photos and text. Horizontal photo cards measure 20.32 cm by 10.2 cm and are printed on glossy, bright white, high quality card stock. Each card comes with a white envelope. To see some of the other products available on zazzle.co.uk, check out our main monsters page. No minimum order size and most photo cards are made within 24 hours.


text:
Nifty Needles Neighborhood Group meets
WEIRTON – The Nifty Needles Neighborhood Group of the American Sewing Guild met at the First Christian Church on Main Street.
Leader Nancy Sanders welcomed the nine in attendance, including guest Diane Smith.
Members were reminded of the Monroeville Sewing Expo Aug. 22-24.
During show-and-tell, Kay Nixon displayed three summer blouses, a patchwork purse and a knitted wool cardigan; Nancy Linn displayed an embroidered apron; Carol Village displayed a baby quilt and three cobbler's aprons; Dolly Grossman displayed a red-white-and-blue stars door hanging; Diane Smith displayed a reversible fabric purse and shadow quilt; and Susan Maze displayed a black-and-gold ruffled scarf and fleece baby blanket and pillow.
Dale Negle presented a program on self-tie scarves. All members received a pattern, instructions and their choice of a scarf made by Negle. Members watched a video on fashion scarf wear.
Negle won the door prize.
Grossman will present the program at the Aug. 6 meeting.
For information, contact Sanders at (304) 527-1405.


text:
Product Description
This sweet heart-shaped pin is made by Lynn Jenkins of Valle Crucis, NC.
Lynn started potting as a teenager in 1976, and clay has been a part of her life ever since. She works primarily with raku-fired pots. The word Raku means "enjoyment of freedom" and/or "peace." In pottery terms it refers to a firing process which dates back to the sixteenth century in Japan.
Raku is a fast firing process which takes approximately 1 hour. The pottery is glazed and then placed into a gas kiln where the temperature goes from 1500 to 1900 degrees F. The pin is then removed with tongs and placed in a drum of sawdust for about 30 minutes. During this process the pottery goes through a reduction and the unglazed clay turns black. The cracks form in the glaze because of the rapid cooling, and appear because the clay has turned black while the glaze was cracked open. The pins are removed from the sawdust and quenched in water, and then rubbed clean.
This is approximately 1 1/8 inches wide, and 1/8 inch thick. Each heart is a little different--expect variations!
Lynn hopes you enjoy the energy she passes to you with her pottery!
Artist statement and explanation of raku pottery included.


text:
Event: Sonam Kapoor, Abhishek Bachchan, Bipasha Basu and Neil Nitin Mukesh promote their film PLAYERS at JW Marriot hotel in Mumbai. Check it out.
Guest List: Sonam Kapoor, Sikander Kher, Neil Nitin Mukesh, Bipasha Basu, Abhishek Bachchan
Bollywood celebs Hrithik Roshan, Athiya Shetty, Kanika Kapoor among others were seen at Anandita De's blog launch.
Bollywood actress Shilpa Shetty Kundra was snapped at the inaugurationof jewellery showroom of Varti Jewells.
Bollywood celebs Deepika Padukone, Anushka Sharma, Yami Gautam, Sonam Kapoor, Arpita Khan Sharma, Vijay Krishna Acharya, Arjun Kapoor among others were seen at the special screening of BEFIKRE.
Bollywood celebs Irrfan Khan snapped at the launch of Johnston & Murphy store.
Bollywood celebs Sunny Deol and Madhurima Tuli were snapped at the airport.


text:
November 30, 2011 —
For decades the tiny hamlet of Parksville, some four miles north of the Village of Liberty, has been bisected by a four lane highway, Route 17. For the past 10 years or so, the only traffic light located on Route 17 in Sullivan County was right in the middle of Parksville.
In the 1960s, New York State bought land to move the highway out of town and up onto the side of a mountain. Now finally, the highway has been moved, the local roads are being reconfigured, and once drivers become accustomed to the new setup, the traffic light will be removed because of a lack of need.
For the past six years or so, a group of residents called the Parksville Priorities Committee has been meeting in an attempt to conjure up a future for the hamlet once the dramatic change had occurred.
Wes Illing, an engineer and a founding member of the group, has been promoting the idea of the creation of a planned community, but so far town officials have not been very receptive.
What is moving along, however, is a plan by a J.R. Baker, who lives in New York City and who has been involved in meetings of the committee, to turn an empty 8,000-square-foot building on Main Street into a digital production facility.
Illing turned out to a meeting of the Liberty Zoning Board on October 18 to seek a variance, which he received, to allow the project to move forward. Illing said, "That building used to be the old hardware store when I was a kid." Baker's plan is that about 90% of the building would be used for making films, commercials and video productions. "The other 10 percent would be for sleeping quarters so they could send staff up here, where they could stay for a week or two, do their work free of all the distractions at home or in the city, and go back with a finished product."
He said the general idea is not new, and is one that should be pursued more aggressively in Sullivan County. "Corporations are looking for places to send their think tanks, or creative people, someplace remote, without disturbances, to think outside the box."
He added, "Usually those jobs pay pretty good money, and they are typically college-educated people with good incomes; it's what we want, it's good for the community."
He said the price of real estate in Sullivan County, compared to the price in New York City, made the deal very attractive for the owner.


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Accused killer wants out of jail
Alleged murderer Mark F. Stevens recently passed a polygraph test in jail, denying any involvement in the 2008 murder of his Newport neighbor, according to his attorney.
While not admissible in court, the successful polygraph might be enough to get Stevens, 48, of 2385 Bells Run Road, out of jail while he awaits trial, said public defender Ray Smith.
"I filed a motion for a personal recognizance bond (Wednesday) on Mark Stevens," said Smith.
Stevens has been incarcerated since his Aug. 1 arrest, which came four years and a week after the shooting of 42-year-old Patrick Arnold at his 2410 Bells Run Road home.
At the time of his arrest, Washington County Sheriff's Office Detective Jeff Seevers said Stevens had been one of the initial suspects in the case, but there was no evidence linking him to the crime.
Details about the shooting that Stevens later gave to a wired confidential informant eventually led to his arrest, but the sheriff's office hasn't said exactly what information was gleaned from that recorded conversation.
Washington County Sheriff Larry Mincks declined to comment on the case this week, since it is ongoing.
However, Smith has long been convinced of Stevens' innocence, he said.
"I talked to (Mark) three years ago and I didn't think he committed this crime then," said Smith, who spoke with Stevens in 2009 after detectives first questioned him about the murder.
The attorney is not the only one who thinks detectives may have the wrong man. Members of Arnold's family, including cousins Patty Carpenter, Rose Grahame and Jonie Haught, have questioned Stevens' guilt.
All three women expressed support for Stevens during his last court appearance -a January hearing during which Stevens was found competent to stand trial.
During the polygraph exam, performed March 4 by a licensed polygraph examiner, Stevens was asked three questions which pertained to the case, according to a report the examiner made.
Stevens said he did not shoot Arnold, that he was not present at the time of the murder and that he had never been to Arnold's house prior to being taken there by an informant after the fact.
"It is the opinion of this examiner that the subject was truthful, to the best of his knowledge, concerning the information he supplied and in his denials of shooting Patrick Arnold," wrote examiner Dean Capehart, who was accredited by the American Polygraph Association in 1991.
Smith said he refrained from having Stevens asked further questions about his knowledge of the case because they did not want to risk him making conjectures based on what he "thought" was true.
"He's heard rumors so he may think he knows," said Smith.
If granted by acting Judge Julie Selmon of Monroe County, a personal recognizance bond would release Stevens on the promise that he would return for trial, which is scheduled for July 15.
Selmon did not return a call for comment Thursday.
It is possible some conditions would be attached to a recognizance bond, such as staying in Washington County, avoiding the victim's family and abstaining from drugs and alcohol, said Smith.
Bond is currently set at $500,000 in Stevens' case.
Washington County Prosecutor Jim Schneider said he would not comment on whether the results of Stevens' polygraph exam contradict the prosecution's information in the case.
Schneider did say that he does not trust the results of polygraph tests.
"The courts don't trust them. They don't acknowledge them," he said.
He thinks the current bond is appropriate because of the severity of the crime, Schneider said.
Stevens is facing an unscheduled felony charge of murder with a firearm specification and a third-degree felony count of tampering with evidence.
"I don't think the bond ought to be lowered in this case," said Schneider, who added that he plans to file a response asking that bond be continued.
He also cited the risk of Stevens fleeing and potential harm to Stevens or available witnesses as reasons bond should remain the same.
However, Smith argues that Stevens is not a flight risk.
"He has lived at that (Bells Run Road) address all of his life, and the family still owns that property," he wrote in the motion.
Smith added that he will likely be filing more motions before the trial.
The next hearing on pending motions in Stevens' case is set for April 17, said Schneider.