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New Research on NOACs: Which has More Bleeding Risk―Which is Safer?
Do you take the anticoagulant, Xarelto? Or one of the newer NOACs? Which is safest? Which has the least GI bleeding?
NOACs Research Study Results
A Mayo Clinic study indicated that the risk of gastrointestinal (GI) bleeding is higher for patients taking Xarelto than for other anticoagulants in its class.
The researchers compared the gastrointestinal (GI) safety profile of three rival oral anticoagulants: Xarelto (rivaroxaban), Pradaxa (dabigatran) and Eliquis (apixaban). All of the patients in the study had Atrial Fibrillation.
Bleeding occurrence: GI bleeding occurred more frequently in patients taking Xarelto compared to Pradaxa (approximately 20% increased risk), while Eliquis had the lowest GI bleeding risk.
Age factor: They also found that the risk of GI bleeds increased with age. In particular, patients over the age of 75 were at an increased risk.
Safety: Eliquis had the most favorable GI safety profile, even among very elderly patients, and Xarelto had the least favorable. … Continue reading this report…->
With A-Fib, Stroke is Not Your Only Risk
We hear it every day on TV, ads about 'living with Atrial Fibrillation'. In today's media, the message is about how to 'manage' your A-Fib. You're advised to 'just take our anticoagulant' and you'll live happily ever after.
But recent research (and common sense) indicates otherwise.
Mega Research Analysis of Your Additional Risks
Researchers at Oxford University, Oxford, UK and Massachusetts Institute of Technology (MIT), Cambridge, MA, USA, conducted a systematic review and analysis of 104 different studies involving nearly 10 million people, of which, over a half-million had A-Fib.
They found that Atrial Fibrillation is associated with not just stroke, but also with:
• Heart Disease
• Heart Failure
• Kidney Disease
• Sudden Death
• Death from All Causes
Heart failure: The strongest association was with heart failure, which was five times more likely in people with A-Fib. Because your heart isn't pumping properly, it's not surprising that A-Fib leads to heart disease, heart failure and sudden death.
Kidney disease: A surprising association is that A-Fib is tied to kidney disease and peripheral arterial disease, probably because of poor circulation due to A-Fib.
Death from all Causes: This isn't such a surprising finding as A-Fib affects the whole body. A-Fib damages your heart, brain and other organs. It reduces the heart's pumping capacity by about 15%-30% which may cause weakness, fatigue, dizziness, fainting spells, swelling of the legs, and shortness of breath.
Patients with A-Fib, even if they don't have a stroke or heart failure, are more likely to die from other causes compared with people in normal sinus rhythm (NSR).
Note: this study didn't examine the known link between dementia and A-Fib. See Leaving Patients in A-Fib Doubles Risk of Dementia—The Case for Catheter Ablation
Don't be Misled by Pharmaceutical Ads
For patients with A-Fib, it isn't enough to simply take an anticoagulant!
We need to worry not just about stroke, but also about the risks and potential damage of A-Fib to our overall health.
Contrary to today's media, your goal shouldn't be to just 'manage your A-Fib'. It's a Pollyanna fantasy to just 'Take a pill (anticoagulant) and live happily ever after'.
That misconceoption is propagated by drug manufacturers who want you to stay an A-Fib patient and thus a customer for life.
Don't Just Live with A-Fib
Don't Settle. Seek your A-Fib cure. Your goal should be to get your heart beating once again in normal sinus rhythm (NSR). We can't say it enough…
Do not settle for a lifetime on meds. Seek your A-Fib cure.
Do You 'Like' Your Doctor, Do You 'Connect'?…How it Affects Your Health
The more people like their doctors, the healthier they tend to be. This is what researchers at Massachusetts General Hospital found in a review study where they examined 13 research reports on this subject.
Being the "Best in the Field" Isn't Enough
Even if a doctor(s) is the best in their field and an expert in your condition, that may not help you if you don't communicate well with them and don't relate to them. If we don't like our doctors, we're less likely to listen to them.
Some doctors (particularly those from overseas) often communicate poorly, or talk in "medicalize" and are nearly incomprehensible. Other doctors come from a medical school with a tradition of aloofness and keeping a distance from patients (with women in particular).
Relationship-Based Strategies Improve Patients' Health
This mega-study review looked at doctors who were trained in "relationship-based strategies" such as making eye contact, listening well, and helping patients set goals. The results: these strategies significantly improved their patients' health compared to control groups. Their patients achieved lower blood pressure, increased their weight loss, reduced pain and improved glucose management.
If You Don't Like Your Doctor, Look For a New One!
It's intuitive, isn't it? But now a review of studies backs it up. If you like, trust and respect your doctor(s), you're more likely to accept and follow their advice. Developing a good relationship helps you feel comfortable asking questions and getting feedback in a give-and-take environment.
If you don't have this rapport with your current doctor(s), it's worth looking elsewhere for a new doctor―even if they are "the best" in their field.
In the article, Know When it's Time to Fire your Doctor, CNN.com Senior Medical Correspondent Elizabeth Cohen discusses five ways to know when it's time to think about leaving your doctor, and the best way to do it. The highlights are:
1. When your doctor doesn't like it when you ask questions
2. When your doctor doesn't listen to you
3. If your doctor can't explain your illness to you in terms you understand
4. If you feel bad when you leave your doctor's office
5. If you feel your doctor just doesn't like you — or if you don't like him or her
Don't Be Afraid to Fire Your Doctor
Changing doctors can be scary. According to Robin DiMatteo, a researcher at the University of California at Riverside who's studied doctor-patient communication. ""I really think it's a fear of the unknown. But if the doctor isn't supporting your healing or health, you should go."
To learn more, read our page: How to find the right doctor for you and your treatment goals.
Don't Delay—A-Fib is a Progressive Disease
The Longer You Have A-Fib, the Greater the Risk
A-Fib begets A-Fib. The longer you have A-Fib, the greater the risk of your A-Fib episodes becoming more frequent and longer, often leading to continuous (Chronic) A-Fib. (However, some people never progress to more serious A-Fib stages.)
Fibrosis makes the heart stiff, less flexible and weak, reduces pumping efficiency and leads to other heart problems. The abnormal rhythm in your atria causes electrical changes and enlarges your atria (called remodeling) making it work harder and harder over time.
Don't let your doctor leave you in A-Fib. Educate yourself. Any treatment plan for A-Fib must try to prevent or stop remodeling and fibrosis. And always aim for a Cure!
To learn more, read my editorial, Leaving the Patient in A-Fib—No! No! No!
Educate Yourself—and Always Aim for a Cure!
My Top 5 Articles About Warfarin Therapy, Associated Risks and Alternatives
Any treatment plan for Atrial Fibrillation must address the increased risk of clots and stroke. By far the most commonly used medicine for stroke prevention is the anticoagulant warfarin (brand name Coumadin).
But warfarin is a tough drug to take long term with monthly blood tests and possible side effects. These are my top 5 articles to help you understand warfarin therapy, the associated risks and some of the alternatives.
Review these articles to learn more about Warfarin therapy:
1. Clinical Trials Results: Watchman Better Than a Lifetime on Warfarin;
2. Arterial Calcification From Warfarin: Vitamin K May Reverse it;
3. "Is there a way to get off blood thinners all together? I hate taking Coumadin. I know I'm at risk of an A-Fib stroke.";
4. How to Avoid the Bleeding Risk of Anticoagulants;
5. If Sixty and Older: 99% Have Microbleeds—So Are Anticoagulants Risky?
Bonus: Video about Warfarin
Living with Warfarin: Patient Education
Excellent introduction to anticoagulant therapy with warfarin (Coumadin). Patients and medical professionals (clinical nurse, doctors, a pharmacist and clinical dietician) discuss the practical issues associated with taking warfarin. (16:22) Uploaded on Mar 7, 2011. Produced by Johns Hopkins Medicine.
An Alternative to Blood Thinners
Do you hate having to take Coumadin? Hate the monthly testing? Bothered by side effects? An alternative to taking blood thinners is closing off your Left Atrial Appendage (LAA) with the Watchman, an occlusion device. Learn more: The Watchman™ Device: The Alternative to Blood Thinners.
Can a Broken Heart Lead to Atrial Fibrillation? Yes!
by Patti J. Ryan, October 2016
Called 'Broken Heart Syndrome', a new study finds that the death of a partner is linked to a heightened risk of developing atrial fibrillation. The risk seems to be greatest among the under 60s and when the loss of the partner was least expected.
The researchers looked at a national registry in Denmark of 88,612 people who were diagnosed with atrial fibrillation and 886,120 healthy people matched for age and sex, and between 1995 and 2014. Other factors that might influence atrial fibrillation risk were included as well.
They found that people who had lost a partner were 41% more likely to develop atrial fibrillation in the first month after losing their partner. The risk seemed to be greatest 8 to 14 days following a death and gradually subsided during the following year.
More Evidence of Mind-Heart Link
Experts suspect acute stress may directly disrupt normal heart rhythms and prompt the production of chemicals involved in inflammation.
This study adds evidence to the growing knowledge that the mind-heart link is a powerful association.
What can be done about this risk? The answer requires more research but may focus on the way the body deals with stress.
Recommended Reading: The Anatomy of Hope: How People Prevail in the Face of Illness, by Jerome E. Groopman.
Written by an oncologist and citing actual patient cases (mostly cancer), Dr. Groopman explores the role of hope in fighting disease and healing. Top scientists are interviewed who study the biological link between emotion and biological responses; the most relevant studies are reviewed.
The author shows how hope, belief and expectations can alter the course of our lives, and even of our physical body. HOPE works! (For more read my review on Amazon.com.)
Dr. Groopman Interview: Listen to an audio interview with The Anatomy of Hope author, Dr. Groopman on NPR's Fresh Air program (recorded Sept. 2004; 20 min.)
MAM 2016: Fantastic 3-D Experience of the Heart or Why We Were Wearing 3-D glasses!
by Steve S. Ryan, PhD
In 1966, the wide-screen movie Fantastic Voyage took viewers inside the human body by injecting a miniaturized submarine, its crew and a surgical team into the carotid artery. Their mission was to break up a clot and save the VIP patient. Traveling through the heart to the brain, reveals a world of dazzling color, a floating wonderland with huge red corpuscles, whirling globules, platelets and particles.
I had that same amazing experience when Dr. Joris Ector presented his incredible 3-D vision of a real heart. Just like when watching the movie, there were involuntary gasps and shocks as you felt what it was like to move through the heart.
And yes, we had to wear 3-D glasses! That's got to be a first at an A-Fib conference.
Starting with the exterior of a beating heart, Dr. Ector, from the University of Leuven, Belgium, showed every possible 3-D angle.
Next, he peeled away the exterior to reveal the movement of the heart from the inside. Next, he whisked you inside the heart so fast that you almost got dizzy.
Particularly interesting was the trip through the left atrium into the Left Atrial Appendage (LAA) with its trabeculations (thick muscular tissue bands) which looked like columns in close-up.
In some ways, Dr. Ector's presentation felt more real and comprehensive than watching footage of an actual heart beating. It was an astounding experience (just like watching Fantastic Voyage in 1966). (I wish I had an interior of the 3-D heart to share with you.)
Image credit: Fantastic Voyage movie still from Foresight Institute
Return to Reports of A-Fib Medical Symposiums & Conferences
If you find any errors on this page, email us. ♥ Last updated: Friday, October 7, 2016
Heart Team/MAM 2016: Moving A-Fib Care to a New Level
Totally historic! The MAM 2016 symposium set important goals for shaping the future of A-Fib care and showed how the emphasis on a 'Heart Team' is moving the field of patient A-Fib care to a new level.
This first Multidisciplinary Arrhythmia Meeting (MAM) was held in Zurich, Switzerland Sept 15-16, 2016 and advocated for a team approach―EPs, Surgeons, and other healthcare professionals working together to better help the A-Fib patient.
Leading cardiologists and surgeons explained why they favored the hybrid surgery/ablation referred to by several terms: "hybrid simultaneous," or "hybrid staged," or "multidisciplinary sequential approaches".
Interactive Hands-On Workshops and Live Surgery
MAM 2016 featured interactive workshops with hands-on experiences in EP ablation, Surgical Ablation, and Mechanical Exclusion of the Left Atrial Appendage (LAA). Included were working examples of clinicians, electrophysiologists and surgeons teaming up to better help A-Fib patients.
Observing via a live video feed, attendees watched Dr. Stefano Benussi and his colleagues perform a surgery of an A-Fib patient showing both the left side and right side approaches. (The patient had a huge amount of fat which first had to be cut away before the pericardium sac could be reached and cut into in order to access the heart and pulmonary veins.)
MAM 2016 Program and Faculty
The Multidisciplinary Arrhythmia Meeting was the brain child of the Course Director Dr. Stefano Benussi of the University Hospital Zurich, Switzerland. Course Co-Directors were Harry Crijins of Maastricht, the Netherlands and Firat Duru of Zurich, Switzerland.
The Program Committee and Scientific Faculty making presentations included 54 distinguished doctors from around the world including the famed inventor of the original Cox Maze operation, James L. Cox of Denver, USA. (The Cox Maze operation was the first treatment to make patients A-Fib free.)
A partial list of MAM 2016 participating doctors and countries:
• Manuel Castella, Barcelona, Spain
• Paolo Della Bella, Alberto Pozzoli, Claudio Tondo, Milan, Italy
• Karl Heinz Kuck, Andreas Metzner, Hamburg, Germany
• Bart van Putte, Utrecht, The Netherlands
• Malcolm Dalrymple-Hay, Guy Haywood, Plymouth, UK
• Joris Ector, Mark La Meir, Laurent Pison, Brussels, Belgium
• Hans Kottkamp, Diana Reser and many more from Zurich, Switzerland
• Gunther Laufer, Vienna, Austria
• Randal Lee, Bing Liem, Steve S. Ryan, California, USA
• Ju Mei, Shanghai, China
• Peter Mueller, Dipen Shah, Geneva, Switzerland
• Amiran Revishvili, Moscow, Russia
• Timo Weimar, Stuttgart, Germany
• Michael Zembata, Zabrze, Poland
Additional presenting doctors will be identified along with summaries of their individual presentations.
My presentation summaries will follow.
Return to Reports of A-Fib Medical Symposiums & Conferences
If you find any errors on this page, email us. ♥ Last updated: Monday, October 3, 2016
How A-Fib Damages Your Heart, Brain and Other Organs
A-Fib reduces the amount of blood flowing to the rest of your body by about 15%–30% and can have damaging effects.
That's because the upper parts of your heart (the atria) aren't pumping enough blood into the lower chambers of your heart (the ventricles). At the same time, your heart is working progressively harder and harder.
Here's what can happen to your heart if you choose to just 'live with Atrial Fibrillation":
Don't Just Live With Your A-Fib
Don't listen to doctors who advise you to 'live with A-Fib' and who prescribe a lifetime on medication. Get a second opinion, or even a third! Educate yourself.
Seek your A-Fib cure!
Hybrid Surgery/Ablation Topic of the Multidisciplinary Arrhythmia Meeting (MAM)
Background: The Hybrid approach is an unusual team effort and is complementary in nature: the Surgeon works on the outside of the patient's heart and the Electrophysiologist on the inside of the same patient's heart.
Hybrid Surgery/Ablation is becoming an increasingly important and effective strategy for highly symptomatic patients with persistent atrial fibrillation or longstanding persistent atrial fibrillation who have failed one or two catheter ablations, and for the patient with a significantly enlarged left atrium. (Read more: Hybrid Surgery/Ablation.)
Multidisciplinary Arrhythmia Meeting (MAM)
The goal of MAM is to improve interaction between cardiologists and surgeons through multiple examples of cooperation in dealing with Atrial Fibrillation. [Note: In the past, it's been a rare occurrence for a surgeon to work with a cardiac electrophysiologist.]
Cardiologists and surgeons from leading institutions in Europe, the US and Asia will discuss their experiences with hybrid simultaneous, hybrid stages, and multidisciplinary sequential approaches, and report their results.
Reporting from Zurich in September: I've been invited to attend this first Multidisciplinary Arrhythmia Meeting (MAM) by the organizers. I'll be reporting on the key presentations and writing summary reports for our A-Fib.com readers.
Reduce Your Family's Risk of Arrhythmia: Don't Store Food in Plastic
The harmful chemical compound, BPA, may have been removed from many plastic bottles and food packaging, but "BPA-free" products may not be much safer.
The BPA chemical replacements, BPS and BPF, can also leach into food and beverages and may have the same impact on the human body (heart problems, as well as cancer, infertility and other health issues).
BPA Replacement Linked to Arrhythmias in Female Rats
A study published in the Journal Environmental Health Perspectives (Seltenrich) shows that the chemical compound BPS has nearly identical impacts on the cardiovascular system of rats as those previously reported for BPA. Researchers reported a link between BPS and irregular heartbeat. More research is needed.
What to Do: It Doesn't Hurt To Be Cautious
To reduce your risk of arrhythmia from BPS/BPF, decrease or eliminate your use of plastic storage containers for food or drink.
Drink from steel or glass containers, not plastic ones.
Don't microwave your food in plastic containers. The heat from the microwave can separate BPA-like compounds from plastic containers, making them easier to ingest. If you must use plastic containers, avoid the microwave.
Ideally, just store food in ceramic, glass or stainless steel containers in the first place.
To read more, see the April 2015 TIME magazine article by Justin Worland, Why 'BPA-Free' May Be Meaningless.
Conflicts of Interest—The Hidden Cost of Free Lunch for Doctors
by Steve S. Ryan, PhD, updated September 18, 2016
Few people in the U.S. today are shocked or scandalized that the Drug and Device Industry (DDI) basically bribes doctors and hospitals to prescribe their drugs or use their equipment. It's so commonly done that we take it for granted.
In the U.S., in general, it isn't considered unethical or immoral for doctors to accept payments or favors from the Drug and Device Industry (DDI). Nor is it illegal.
But soon U.S. patients will be able to simply type in our doctor's name in the Open Payments Database and see how much they are being paid by the DDI and what conflicts of interest they have.
Thanks to the Sunshine Act (a provision of the U.S. 2010 Patient Protection and Affordable Care Act), the DDI must report when they make a payment to a doctor for meals, promotional speaking or other activities.
This data is available at https://projects.propublica.org/docdollars/ Just type in your doctor's name. See also, OpenPaymentData.CMS.gov and the ProPublica Dollars for Docs project.
Influencing Doctors' Prescriptions for the Price of a Meal
In a recent JAMA Internal Medicine report (DeJong, C., June 2016), the authors compared meal payments to doctors with the drugs they prescribed to Medicare patients.
Even doctors who accepted only one free meal were more likely to prescribe the brand name drug.
Not surprisingly, they found that physicians who accept free meals from a drug company are more likely to prescribe that company's brand name drugs rather than cheaper (and usually more proven) generic drugs. This study only focused on physicians who received meals.
Even doctors who accepted only one free meal were more likely to prescribe the brand name drug. Doctors who accepted four or more meals were far more likely to prescribe brand name drugs than doctors who accepted no meals. Furthermore, doctors who accepted more expensive meals prescribed more brand name drugs.
In another related JAMA Internal Medicine report (Yeh, JS, June 2016), researchers found similar evidence that industry payments to physicians are associated with higher rates of prescribing brand-name statins.
Steer Clear of Conflicts of Interest
The publication, Bottom Line Personal, offered words of wisdom on this subject.
"Studies have found that when there is a conflict of interest, it is almost impossible for even well-meaning people to see things objectively."
Dr. Dan Ariely of Duke University described how, if a doctor must choose between two procedures, they are likely to pick the one that has the better outcome for their bottom line.
"That doesn't mean the doctor is unethical…it just means he is human. We truly seem to not realize how corrosive conflicts of interest are to honesty and objectivity."
He advocates that we steer clear of people and organizations with conflicts of interest "because it does not appear to be possible to overcome conflicts of interest."
Conflicts of Interest: Be Suspicious of Doctors
Doctors are only human. If a drug rep gets them great tickets to a sporting event, for example, of course they will be inclined to favor that rep's drug. Whenever you visit a health/heart website ask yourself: "Who owns this site?" and "What is their agenda?"
Whenever you visit a health/heart website ask yourself: "Who owns this site?" and "What is their agenda?"
But be suspicious if your doctor tells you:
• to take an expensive new drug
• to just "live with your A-Fib"
• insists that catheter ablation is too dangerous or unproven
• that A-Fib can't be cured
• that you have to take drugs for the rest of your life
If this happens to you, RUN and get a second opinion (and even a third opinion).
Conflicts of Interest: Be Suspicious of Health/Heart Websites
When I attend talks at most A-Fib conferences, the first slide a presenter shows is often a list of their Conflicts of Interest.
But this is not required of websites! Health/Heart websites are not required to be transparent and reveal their conflicts of interest.
Whenever you visit a health/heart website ask yourself: "Who owns this site?" and "What is their agenda?" (Hint: Check their list of "sponsors" and follow the money!)
Drug Industry Owns or Influences Most Heart/Health Web sites
The drug and device industry owns, operates or influences almost every health/heart related web site on the Internet!
The fact is most health/heart web sites are supported by drug companies who donate most of their funding.
For example, did you know that the drug company Ely Lilly partially owns and operates WebMD, the Heart.org, Medscape.com, eMedicine.com and many other health web sites?
The fact is that most health/heart web sites are supported by drug companies who donate most of their funding. Consider how that may affect the information they put on their web sites―they're not going to bite the hand that feeds them.
About A-Fib.com: Read A-Fib.com disclosures on our website and check
A-Fib.com's 990s at GuideStar.org.
Be Suspicious of A-Fib Info on the Internet
In our crazy world, you can't afford to trust anything you read on the Internet.
At one time I tried to keep track of all the mis-information found on various A-Fib web sites. When we'd find something wrong, we would write the site. I don't think we've ever received a reply. Finally, we gave up. (See my video: Buyer Beware of Misleading or Inaccurate A-Fib Information.)
Many web sites put out biased or mis-information. Be skeptical. You can tell if someone is trying to pull the wool over your eyes. Truth will out. If you feel uncomfortable or that something is wrong with a site, it probably is. When you find a good site, the truth will jump out at you.
In today's world, you have to do your own due diligence. You know what makes sense and what doesn't.
For more, see my article: EP's Million Dollar Club—Are Payments to Doctors Buying Influence?
Wearables in Healthcare: You can Help Develop A-Fib App
It's early days for wearables in healthcare, but there's a lot of potential.
In the near future, an Apple Watch or Android Wear could detect if the wearer is experiencing Atrial Fibrillation. A preliminary algorithm (app) to detect A-Fib has been developed by researchers at UCSF and engineers at Cardiogram, Inc.
The mRhythm Study: You Can Help Develop the Smart Watch App
The researchers need your help now. If you have an Apple Watch or Android Wear—regardless of whether you have A-Fib—you can contribute your data to help make the algorithm more accurate.
The mRhythm Study is being run with the UCSF Health eHeart Study, using Cardiogram to train a deep learning algorithm to detect atrial fibrillation.
To Participate in the Study: Visit the mRhythm Study website and scroll down the page and look for 'We Need Your Help.' At the bottom of the page, you can then read answers to 'Frequently Asked Questions'.
See How the System Works: To see the graphic displays of how the system works, go to Cardiogram, Inc. or see the Apple Watch graphics in particular.
What This Means for Patients
Each year, more than 100,000 strokes are caused by A-Fib. But all too often, their A-Fib is "silent" with no obvious or noticeable symptoms. In these cases, their A-Fib is undiagnosed until they have a stroke. Only then do they find out they have A-Fib (…if they survive). About 50% will have a disabling stroke.
Apple Watch owners—regardless of whether you have A-Fib—you can contribute your data to help develop this app.
If the Smart Watch algorithm app works as intended, anyone with an Apple Watch or Android Wear will be alerted if they are experiencing Atrial Fibrillation.
For the undiagnosed, their A-Fib will be 'visible' and no longer be "silent." They will know if they are at risk of an A-Fib stroke and can get the proper preventive treatment.
Today patients rely on an ECG in a doctor's office or the use of a Holter monitor to detect A-Fib. Instead, a Smart Watch with the A-Fib app can extend a patient's monitoring period to a year (between doctor's visits) or on an on-going basis.
Amazing! Think of all the lives saved and debilitating strokes avoided! The A-Fib Smart Watch app has the potential to revolutionize the field of A-Fib monitoring.
New Report: Is Your Stroke A-Fib-Related or Something Else?
Third in my series from the Ninth Annual Western Atrial Fibrillation Symposium held February 26-27, 2016 in Park City, UT. Read my other reports here.
If you have A-Fib, it's important to realize that not all strokes are 'A-Fib related'. You may be perfectly anticoagulated or have a Watchman Device installed and still experience a stroke.
Realize: an A-Fib patient can have a stroke that isn't caused by A-Fib.
Dr. Jennifer Majersik of the Stroke Center of the Un. of Utah described the case of a man with A-Fib who had an ischemic stroke even though his INR on warfarin was in the correct range.
An A-Fib patient can have a stroke that isn't caused by A-Fib. There are multiple mechanisms which can cause a stroke. Of the 690,000 strokes in the US/year nearly 1/3 are cryptogenic (of unknown cause) and of those 30% is caused by asymptomatic or Silent A-Fib.
Read my full report in which Dr. Majersik described five subtypes of artery occlusion strokes (as opposed to hemorrhagic [bleeding or vessel rupture] strokes.) <…continue reading…>
65 and Older: 99% Have Microbleeds—So Are Anticoagulants Risky?
In a recent study, 99% of subjects aged 65 or older had evidence of microbleeds; and closer examination of the cranial MRI images revealed an increased number of detectable microbleeds (i.e., the closer they looked, the more microbleeds they found).
Microbleeds in the brain are thought to be a precursor of hemorrhagic stroke.
Cerebral microbleeds (MBs) are small chronic brain hemorrhages of the small vessels of the brain.
If Microbleeds Cause Hemorrhagic Stroke, Should I be on a Blood Thinner?
The fact that almost everyone 65 or older has microbleeds is astonishing and worrisome, particularly if you have A-Fib and have to take anticoagulants. Anticoagulants cause bleeding. That's how they work.
In plain language, this study indicates that cerebral microbleeds lead to or cause hemorrhagic stroke. It's not surprising then that some doctors are reluctant to prescribe heavy-duty anticoagulants to older A-Fib patients.
Being older and already having microbleeds only makes taking anticoagulants all the more worrisome.
Risks of Taking Anticoagulants (Blood Thinners)
Taking almost any prescription medication has trade-offs. Older A-Fib patients find themselves between a rock and a hard place.
In the case of anticoagulants, on one hand you get protection from having an A-Fib stroke (which often leads to death or severe disability), but on the other hand you have an increased risk of bleeding.
For those over 65 who already have microbleeds, … Continue reading this report…->
Brush & Floss! Is Oral Hygiene Linked to A-Fib?
Warren Welsh, from Australia, answers 'Yes' to that oral hygiene question. He wrote me about how he developed bleeding gums and felt it contributed to his Atrial Fibrillation diagnosis. (A 2010 catheter ablation made him A-Fib free. Read Warren's story.)
Brush and floss regularly we were taught as kids, but who knew that oral hygiene is linked with A-Fib?
Dental Cleanings and New-Onset A-Fib
A study in Taiwan compared a group without A-Fib who received dental cleaning at least once a year to a similar group who didn't. Both groups were followed for five years. The regular dental cleanings group had a lower occurrence rate of new-onset A-Fib.
More frequent dental visits (2-3 times a year) further reduced the risk.
Good Oral Hygiene Reduces Inflammation
Studies have shown that inflammation is an independent risk factor both for the initiation of A-Fib and its continuation once you have it.
Good oral hygiene prevents A-Fib, probably by reducing the amount of inflammation of the gums and periodontitis (gum disease).
Take Away
Good oral hygiene reduces the risk of new-onset A-Fib and of sustaining it once you've got it.
For more about A-Fib and dental health, read my FAQ question about Local Anesthesia Used in Dentistry May Trigger Your A-Fib.
Blizzard of 2016 Increases Risk of A-Fib Stroke
We've all heard of someone dropping dead from a heart attack while shoveling snow. But along with record snowfall and subfreezing temperatures comes a warning for those with Atrial Fibrillation. Winter increases stroke risk in people with A-Fib.
Do You Live in a Cold Climate?
In a study from Taiwan, nearly 300,000 people with new-onset A-Fib were followed for eleven years. Almost 35,000 suffered an ischemic (A-Fib) stroke.
The risk for an ischemic stroke was nearly 20% higher in winter than in summer.
"When the average temperature was below 68⁰ F (20⁰C), the risk of ischemic stroke significantly increased compared to days with an average temperature of 86⁰F (30⁰C)."
Why More Ischemic Strokes During Winter?
Cold weather may make blood more prone to coagulate.
Cooler temperatures may produce greater plasm fibrinogen levels and factor VII clotting activity and may lead to "increased coagulability and plasma viscosity," according to the author of this study, Dr. Tze-Fan Chao.
Ischemic stroke was nearly 20% higher in winter than in summer.
What Patients Need To Know
The cold temperatures can put you more at risk for an A-Fib (Ischemic) stroke. So act accordingly. Bundle up during winter. Keep the thermostat set to keep you warm enough.
If you're on a blood thinner, discuss this research with your doctor. You need to keep your anticoagulant levels up during winter.
My 2015 Top Five List: Advancements in the Treatment of A-Fib
Looking back over 2015, I found five significant developments for those 'living' with A-Fib and those seeking their 'cure'. My 'Top Five List' focuses on the Watchman device, a Pradaxa antidote and research findings about lifestyle choices, and reducing fibrosis.
1. FDA Approves the Watchman Device
Anticoagulant Alternative: Because A-Fib patients are at high risk of stroke and clots, a blood thinner (anticoagulant) like warfarin is often prescribed. If you can't or don't want to be on blood thinners, you had few options.
That was until March 2015 when the US Food and Drug Administration (FDA) approved the Watchman device. There's now an option to blood thinners! The Watchman device (Boston Scientific) is inserted to close off the Left Atrial Appendage (LAA), the origin of 90%-95% of A-Fib clots.
To read my complete Top Five List…go to My 2015 Top Five List: A Review of Advancements in the Treatment of A-Fib->.
My 2015 Top Five List: A Review of Advancements in the Treatment of A-Fib
With the beginning of a new year, we often look back and measure how far we've come. In 2015, I found five significant advancements in the treatment of Atrial Fibrillation.
1. FDA Approves the Watchman Device
Anticoagulant Alternative: Because A-Fib patients are at high risk of stroke and clots, a blood thinner (anticoagulant) like warfarin is often prescribed. If you can't or don't want to be on blood thinners, you had few options.
That was until March 2015 when the US Food and Drug Administration (FDA) approved the Watchman device. There's now an option to blood thinners! The Watchman device (Boston Scientific) is inserted to close off the Left Atrial Appendage (LAA), the origin of 90%-95% of A-Fib clots.
It's not an absolute guarantee you will never have a stroke―but neither is taking warfarin or the newer anticoagulants. For more, see Watchman Device: An Alternative to Blood Thinners.
2. Research: Watchman Better Than a Lifetime on Warfarin
The Watchman device isn't simply an alternative to taking warfarin, clinical trials show it's actually better. Patients with the Watchman had fewer hemorrhagic strokes and less bleeding compared to patients on warfarin. (Warfarin and other anticoagulants work by causing bleeding and are inherently dangerous.)
It's too early to say the same about the newer anticoagulants like Pradaxa, Xarelto, Eliquis and Savaysa/Lixiana with their short history but one would expect the same general principles to apply. For more, see Watchman Better Than Warfarin.
3. Antidote for Pradaxa
Up to now, patients on Pradaxa have been bleeding to death in the emergency room while doctors were powerless to stop their bleeding and could only stand by and watch them die. See Stop Prescribing or Taking Pradaxa.
In October 2015, the FDA granted "accelerated approval" to Praxbind, the reversal agent (antidote) to Pradaxa (Boehringer Ingelheim). Praxbind (idarucizumab) is given intravenously to patients and reverses the anticoagulant effect of Pradaxa within minutes.
Note: The reversal agent, Andexanet Alfa, is on FDA fast track and is expected to be approved by mid-2016 as an antidote for Xarelto and Eliquis (Factor Xa inhibitors).
4. Life Style Changes Can Make Some People A-Fib Free
Weight Loss: A weight loss program and counseling in Australia has worked so well that some patients have become A-Fib free.
In his Adelaide clinic, Dr. Prashanthan Sanders convinces his overweight A-Fib patients to buy into the program, lose weight, and keep it off. This holistic approach to health has also been successfully applied to other A-Fib contributing factors such as diabetes, sleep apnea, hypertension, binge drinking and smoking. See Weight Loss Key to Reverse Atrial Fibrillation, Improve Ablation Success.
Exercise: But not everyone can lose weight and keep it off. And other risk factors like hypertension and diabetes are more difficult to permanently change.
The same Australian researchers found that exercise improves A-Fib (even obese A-Fib patients benefit from exercise). Supervised aerobic and strength exercises reduced A-Fib by 84%.
Combine for Best Results: Exercise and weight loss together produced the best results. An astounding 94% of obese patients who both lost weight and exercised regularly were A-Fib free after rhythm control therapy (i.e., antiarrhythmic drugs and/or catheter ablation).
Couch Potato Warning: If you don't exercise regularly, you're almost guaranteed to stay in A-Fib. Even with rhythm control (antiarrhythmic drugs and/or ablation), 83% of the low-fitness obese patients had A-Fib.
5. Research Studies: Preventing Fibrosis
A-Fib produces fibrosis, and up to now, was considered permanent and irreversible. Fibrosis is fiber-like scar tissue that stiffens and weakens the heart muscle which reduces pumping efficiency and leads to other heart problems. (See Fibrosis and A-Fib).
Dr. Jose Jalife's experimental studies with sheep found that a Gal-3 inhibitor (GM-CT-01) actually reduced or prevented fibrosis. Better yet, instead of having to wait years for possible FDA approval, a natural supplement, Pecta-Sol C (Modified Citrus Pectin) works like a Galectin-3 inhibitor.
For A-Fib patients, this may provide the means to avoid fibrosis or repair fibrotic heart tissue. (See Galectin-3 Inhibitor Prevents A-Fib).
A Personal Prediction
On a personal note, I'm excited about the great potential of the Watchman device to significantly reduce or eliminate the threat of strokes—especially in the elderly―even if they don't have A-Fib.
Imagine a world where stroke risk could be eliminated by a simple 20-30 minute procedure. The Watchman device (and other occlusion devices) may change the way elderly medicine is practiced.
If you find any errors on this page, email us. Y Last updated: Thursday, January 21, 2016
Report: FIRM Mapping System—Should Ablation Patients Avoid It?
The FIRM mapping system was a hot topic at the last annual AF Symposium. In his presentation Dr. Ravi Mandapati compared data from his study of FIRM ablations performed at UCLA Medical Center to the CONFIRM clinical trial data published by Dr. Sanjiv Narayan, one of the inventors of the FIRM mapping system.
Up to this point in time, everyone seemed to be jumping on the FIRM/Topera 'bandwagon' with very little critical analysis or understanding of how it worked.
As patients, we should now be skeptical of the FIRM system:
• It doesn't map nearly ½ of the left atrium
• The FIRM mapping algorithms finds stable rotors that other research finds are not stable, and electrophysical characteristics that other research doesn't confirm
• Results of ablating FIRM-identified rotor sites are relatively poor. (This is what should most concern us as patients.)
So, as an A-Fib patient, you may ask: "Should I now stay away from doctors or centers using the FIRM system?" Read my answer and my full 2015 AF Symposium report at Critical Analysis of the FIRM Mapping System.
For more background also see my 2014 AF Symposium report: ECGI vs. FIRM: Direct Comparison, Phase/Waveform Mapping.


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Wow, it's been a crazy week or so here at the office, or actually out of it as I was at the Exact Target user conference last week in Indianapolis. For three days all of my nerdy friends in the industry were all in one place discussing topics ranging from IPhone Apps, one to one email marketing communications, and even sms messages. (text messaging)
The plan is to come with with more exciting ways to make you aware of all of the great things happening here in Tampa Bay from an interactive standpoint in the form of email newsletters, text message offers and coupons. The conference was indeed filled with great sessions and speakers, highlighted by former Tampa Bay Buccaneers head coach Tony Dungy as he spoke about the importance of family and spoke about his new book, as well as the All Pro Dad organization.
I am back on the road this week in San Francisco for the E-Tourism Summit, to visit with more of my nerd friends in the industry as we discuss all of the trends in Travel & Tourism. This is the conference that is largely responsible for the post that you are reading as last year's focus was on blogging!
Looking forward to it though, so check back next week to see what I picked up while out there in San Fran!

subset: commoncrawl


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Dow professionals in Environment, Health & Safety (EH&S) and Sustainability have a shared commitment to protect people and the planet. Members of Dow's EH&S and Sustainability team work together to enable Dow's success by providing Product Safety Services for the company's more than 6,000 products while site EH&S Services provide support for Dow's operations at over 200 locations in 35 countries around the world.
Our EH&S and Sustainability team works with academia, government, environmental groups and other companies to minimize the impact of industry on the environment and to achieve new levels of corporate citizenship. Their efforts result in industry records at many Dow sites and extensive recognition from communities, governments, activists and the news media.
We offer many opportunities to develop expertise and leadership in these EH&S and Sustainability sub-functions:
EH&S Analytical Support
Provides analytical-based expertise such as consulting, sample collection and analysis, data interpretation and data reporting/submission to address EH&S needs. Areas of focus include issue management, process control and optimization, process safety and design, and regulatory compliance.
Emergency Services and Security
Our Emergency Services and Security professionals are industry leaders in Emergency and Security Preparedness and Response.
Environmental Regulatory Management
Provides regulatory expertise on EH&S, and implementation support to Dow sites and businesses. Advocates Dow positions with external stakeholders and develops external research organizations, including government and academia. In addition to consulting, the Epidemiology Expertise Center conducts studies to ensure company products are safe for customers, employees and communities.
Environmental Operations
Provides technical expertise on air emissions, wastewater management and waste management through permit implementation and reporting. Key areas of emphasis include managing and improving environmental compliance performance at Dow manufacturing sites.
Provides technical expertise and support to address health-related issues through consultation with business leaders and external research organizations, including government and academia. In addition to consulting, the Epidemiology Expertise Center conducts studies to ensure company products are safe for customers, employees and communities.
Industrial Hygiene
Provides technical expertise on exposure assessment to Dow businesses and their customers. In addition, provides consultation and guidelines on health-related issues like respiratory protection and ergonomics.
Life Cycle Assessment
Plays an integral part in Dow's externally recognized Sustainability program and helps promote life cycle thinking by creating Life Cycle Assessments (LCA) with our business leaders. Interacts with Dow businesses and with partners in the value chain and academia. Our sustainable chemistry concept is designed to promote life cycle thinking within Dow and considers social as well as environmental aspects in our assessments. LCA is a powerful tool, not only for Dow, but also for the value chain, consumers, and governments.
Occupational Health
Provides a comprehensive set of occupational health services as well as consulting to Dow leadership, businesses, and other functions such as Public Affairs & Government Affairs and Human Resources. Occupational Health staff members have a key role in driving the success of Dow's health strategy.
Product Sustainability
Involved in company-wide interactions to support the sustainable development, manufacturing, and sale of new and existing products. In addition to ensuring products are safe for people and the environment; Product Sustainability team members champion the development and implementation of product sustainability strategies for Dow's various businesses. Many members work with external stakeholders, such as the value chain partners and regulators, in order to improve risk characterization and management practices.
Provides specialty-specific expertise and advice to Dow business through the Toxicology Expertise Center and Research Laboratory. Conducts laboratory-based studies to understand and address human and environmental health, regulatory and product stewardship concerns.
The MBA Sustainability Leadership Internship Program at Dow provides a unique laboratory for catalyzed learning around real-world projects and challenges facing the industry. The objective of the program is to create an experience for exceptional MBA students who can bring new ideas and insights to the needs of a changing global marketplace while integrating sustainability directly into a Dow business. Ultimately, the program develops a powerful employment pipeline of future leaders with an appreciation for integrating sustainability into business development and management decisions.
Program Details
The 12-week summer internship is designed to:
Who We are Looking for
Dow is looking for candidates who have the passion and entrepreneurial spirit to grow sustainable business.
Applicants must:
Internship Assignments
The MBA Sustainability Leadership Internship Program identifies exciting business projects that integrate sustainability with business development. The program can open doors to many opportunities for professional growth. Upon completion of the program, employees position themselves well for full-time employment based on available jobs and the individual's area of preference and performance.
The program's project portfolio consists of a diverse set of opportunities such as:


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Tampa Bay Buccaneers
Tampa Bay Buccaneers news, rumors and injuries
Buccaneers | Three Bucs ERFAs receive offers
Mon, 27 Feb 2017 17:49:36 -0800
Tampa Bay Buccaneers exclusive rights free-agent DB Jude Adjei-Barimah, LB Adarius Glanton and WR Freddie Martino received one-year tender offers Monday, Feb. 27.
Comment () | Share: | Source: Tampa Bay Times - Greg Auman
Buccaneers | Adam Humphries receives offer
Mon, 27 Feb 2017 17:39:11 -0800
Tampa Bay Buccaneers exclusive rights free-agent WR Adam Humphries received a one-year tender offer Monday, Feb. 27.
Fantasy Tip: Humphries ranked third on the team with 622 yards in 2016 and received a solid amount of playing time because of the injuries at the position. The team probably will add at least one receiver this offseason, but Humphries could be a No. 3 receiver for the Buccaneers. Owners in most fantasy leagues probably can avoid him in their fantasy leagues.
Comment () | Share: | Source: Tampa Bay Times - Greg Auman
Buccaneers | Tampa Bay looking to add speed
Sun, 26 Feb 2017 17:44:43 -0800
Tampa Bay Buccaneers head coach Dirk Koetter said the offense needs to generate more explosive plays. "We need more speed, and when we say playmakers, playmakers and explosive plays are one and the same," Koetter said. "Guys that can catch a 10-yard pass, break one tackle and turn it into a 30-yard gain. Our run after the catch is not where it needs to be.''
Comment () | Share: | Source: Tampa Bay Times - Rick Stroud
Buccaneers | Alterraun Verner released Thursday
Thu, 23 Feb 2017 12:54:18 -0800
Tampa Bay Buccaneers CB Alterraun Verner is being released Thursday, Feb. 23.
Comment () | Share: | Source: NFL Network - Ian Rapoport
Buccaneers | Jameis Winston likes DeSean Jackson to TB
Wed, 22 Feb 2017 15:58:09 -0800
Tampa Bay Buccaneers QB Jameis Winston said he would love if the Buccaneers signed Washington Redskins impending free-agent WR DeSean Jackson this offseason.
Fantasy Tip: Jackson should receive interest from multiple teams if he hits the free-agent market and would make a solid tandem in Tampa Bay with Mike Evans. Jackson will have a solid role in an offense in 2017 and can be at least a No. 3 receiver in fantasy leagues.
Comment () | Share: | Source: Tampa Bay Times - Greg Auman
Buccaneers | DeSean Jackson could draw Bucs' interest
Tue, 21 Feb 2017 08:48:24 -0800
Washington Redskins impending free-agent WR DeSean Jackson could receive interest from the Tampa Bay Buccaneers, according to sources. Jackson has a rapport with QB Jameis Winston.
Fantasy Tip: Jackson would benefit from elite receiver Mike Evans anchoring one side. D-Jax just turned 30, and he is a better option in non-PPR formats. In such, he'd make a low-end WR3.
Comment () | Share: | Source: ESPN.com - Josina Anderson
Buccaneers | Vincent Jackson likely done in Tampa
Fri, 17 Feb 2017 20:50:17 -0800
Tampa Bay Buccaneers impending free-agent WR Vincent Jackson isn't likely to be back with the team in 2017 and could be finished in the NFL, according to beat writer Scott Reynolds.
Fantasy Tip: After topping 1,000 yards six times in seven years, Jackson has been limited to just 15 games and 716 yards over the last two years combined. If he plays in 2017, he isn't likely to have any fantasy value.
Comment () | Share: | Source: PewterReport.com - Scott Reynolds
Buccaneers | Doug Martin still in Bucs' plans?
Thu, 16 Feb 2017 10:23:54 -0800
Tampa Bay Buccaneers RB Doug Martin was expected to be released or traded before the 2017 NFL season, but the front office may be willing to keep Martin around and "play the situation out," according to Roy Cummings, of FloridaFootballInsiders.com. Martin is suspended the first three games of 2017 and will not cost the team any money if he is indeed released.
Fantasy Tip: Martin is coming off his worst season as a pro and has a lengthy injury history. Unless the draft or free agency bears a better option, he may stick around. Tampa could look to restructure his deal with incentives, as well. For fantasy purposes, assuming he is retained, Martin is a shaky RB3 in most setups.
Comment () | Share: | Source: Florida Football Insiders - Roy Cummings
Buccaneers | Bucs unlikely to use franchise tag
Wed, 15 Feb 2017 21:38:50 -0800
The Tampa Bay Buccaneers are unlikely to use the franchise tag in 2017, according to Rick Stroud, of the Tampa Bay Times. The Buccaneers have utilized the tag only four times in 24 eligible years.
Comment () | Share: | Source: Tampa Bay Times - Rick Stroud
Buccaneers | Record season for Cameron Brate
Sun, 12 Feb 2017 17:03:26 -0800
Tampa Bay Buccaneers TE Cameron Brate tied the single-season franchise record for touchdown receptions by a tight end with eight in 2016.
Fantasy Tip: Unless the Buccaneers add a tight end during the offseason, Brate looks like a low-end TE1 candidate heading into 2017.
Comment () | Share: | Source: Buccaneers.com
Buccaneers | Bucs make coaching changes
Fri, 10 Feb 2017 12:51:27 -0800
The Tampa Bay Buccaneers made some coaching adjustments Friday, Feb. 10, promoting Zack Grossi to offensive quality control coach, Anthony Perkins to assistant to the head coach, and Skyler Fulton to an offensive assistant. In addition, they named former NFL TE Alex E. Smith a pro scout.
Comment () | Share: | Source: Tampa Bay Times - Greg Auman
Buccaneers | Roberto Aguayo must have a great camp
Fri, 10 Feb 2017 12:01:19 -0800
Tampa Bay Buccaneers PK Roberto Aguayo is "not locked into" the team's roster, according to general manager Jason Licht, and "he needs to have a great camp" to solidify his spot. Licht added that "we will do everything we can to bring in the best competition at that position."
Fantasy Tip: Aguayo did not live up to the lofty expectations set for him as a rookie when he was drafted late in the second round -- very rare for a kicker -- as he went on to make just 22 of 31 field goal attempts, including going for 4-for-11 in kicks from 40 yards or more. Even if he makes the team, there should be plenty of other superior options at the end of drafts in standard leagues.
Comment () | Share: | Source: PewterReport.com - Scott Reynolds
Buccaneers | Skyler Fulton hired by Bucs
Fri, 10 Feb 2017 08:11:06 -0800
Former WR Skyler Fulton was hired by the Tampa Bay Buccaneers as an offensive assistant Friday, Feb. 10.
Comment () | Share: | Source: ESPN - Adam Caplan
Buccaneers | Ben Steele named Bucs TEs coach
Wed, 08 Feb 2017 14:25:00 -0800
Tampa Bay Buccaneers offensive quality control coach Ben Steele has been named the team's new tight ends coach.
Comment () | Share: | Source: PewterReport.com - Mark Cook
Buccaneers | Mike Glennon may be too expensive for Bucs
Wed, 01 Feb 2017 14:47:48 -0800
Tampa Bay Buccaneers general manager Jason Licht indicated the team would like to re-sign impending free-agent QB Mike Glennon but may be too expensive to sign since he likely will receive interest from teams looking for a starting quarterback.
Fantasy Tip: Glennon was a starting quarterback earlier in his career and probably will be able to find a starting job in free agency. Owners should keep an eye on the situation to see which team he joins, but he should only be considered a low-end No. 2 quarterback in deeper leagues at this point.
Comment () | Share: | Source: PewterReport.com - Scott Reynolds
KFFL: Sports Link of the Day
Tampa Bay Buccaneers Player News


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Different Referencing Styles
Finding the correct style guide for formatting references depends on the target institution or publication. Writers can choose from APA (American Psychological Association) style, Chicago Manual of Style rules and MLA (Modern Language Association) style. Specific subject areas may demand their own specialized style, such as CSE (Council of Science Editors) style for natural sciences and AMA (American Medical Association) for medical publications. Style guides may be subscriber only, but a college library may have manuals available.
American Psychological Association (APA)
The APA style guide is appropriate for psychology, business, anthropology, education, economics and other social science texts. Reference lists should be alphabetized and multiple works by the same author listed in order of publication. All major words of journal resources should be capitalized, but only the first letter of non-journal resources. Lines after the first line of the reference should be indented.
Modern Language Association (MLA)
The MLA style is used in literature and media research papers. The guide lists references in alphabetical order by author surname or by title of book. All major words in the resource should be capitalized. All lines except the first line of a reference should be indented. In-text citations use a system where the author and the relevant page numbers are included -- for example, (Spongebob 100-115).
Chicago Manual of Style
The Chicago Manual of Style has two different style systems. These are Author-Date and Notes and Bibliography. The most common style used in humanities publications is the Notes and Bibliography system and the Author-Date style is primarily used by the physical science communities. The major difference between the styles is that the Author-Date uses in-text citations using author's last name and date of publication, as opposed to entering more complete information in the text of the paper.
Council of Science Editors (CSE)
CSE style, formerly known as CBE style, has two separate ways of referencing material. These are the "Name-Year" system and the "Citation Sequence" system. The Name-Year system uses the format (Spongebob 1998) and the Citation Sequence uses superscripts for in-text citation. For reference lists, the Name-Year system alphabetizes the resources according to author surname; the Citation Sequence system lists resources in the order they were used in the paper.
American Medical Association (AMA)
The AMA style guide is used for medicine-related study publications. The guide covers Internet resources, books and journal articles. When following this guide, all references should be located at the end of the paper, and in the order they appeared. When referring a second time to a source, the reference number and page number of the information should be included. AMA requires that non-article resources have words with more than three letters capitalized. For article resources, only the first letter of a sentence should be capitalized.
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Adm. William Gortney was nominated in June to lead the U.S. Northern Command and the North American Aerospace Defense Command.
A Navy admiral nominated to head the joint command responsible for defending the U.S. homeland and aerospace acknowledged in his confirmation hearing that the country is lagging in its cyber-defense of critical infrastructure.
Adm. William Gortney, who was tapped last month by President Barack Obama to head the U.S. Northern Command and the North American Aerospace Defense Command, also told the Senate Armed Services Committee on July 10 that he was unaware of a formal coordinating mechanism between Northern Command and the Department of Homeland Security for responding to cyberattacks.
Northern Command does have a liaison officer in DHS's National Cybersecurity and Communications Integration Center, the department's 24/7 hub for monitoring and responding to cyber threats, a DHS official told FCW.
Northern Command would coordinate the military's response to any physical damage to infrastructure caused by cyberattacks, while DHS is the lead civilian agency in that response. The U.S. military set up Northern Command about a year after the Sept. 11, 2001, terrorist attacks as a cross-military-branch effort to protect the country.
Cybersecurity is not a primary area of focus of Northern Command, Adm. James Winnefeld, then head of the command, said in October 2010. U.S. Cyber Command takes the lead in the nation's cyber-defense, but Northern Command would coordinate with Cyber Command in the event of an attack, he said.
"If there were an attack that took down the electrical grid for a significant amount of time, it's going to be CYBERCOM who partners with DHS to help with the recovery from that attack," the Northern Command website quoted Winnefeld as saying. "My play in that is going to be how do we keep the trains running? How do we keep people fed? And we're exploring the linkage between those two things."
Nearly four years later, civilian and military agencies are still connecting the dots on how they would respond to an attack with cyber and physical dimensions.
"Who is responsible for the active defense of these facilities? Or is anybody responsible?" Sen. Jack Reed (D-R.I.) asked Gortney at his confirmation hearing last week, referring to infrastructure such as transit systems and financial institutions.
"For our civilian infrastructure, to be honest, sir, Homeland Security has that responsibility," the admiral replied. "And it is my professional opinion that we … as a nation are behind in our ability to defend that critical infrastructure."
"Do you have a coordination with Homeland Security? Again, if [they] are the ones responsible, there should be at least a joint planning effort, not just in response but in deterrence or prevention," Reed said.
While DHS is Northern Command's "closest inter-agency partner" in homeland defense, "I do not know if we have a formal coordinating, and if confirmed, I will make sure I understand that, sir," Gortney said.
The Senate Armed Services Committee has yet to vote on Gortney's nomination.
About the Author
Sean Lyngaas is an FCW staff writer covering defense, cybersecurity and intelligence issues. Prior to joining FCW, he was a reporter and editor at Smart Grid Today, where he covered everything from cyber vulnerabilities in the U.S. electric grid to the national energy policies of Britain and Mexico. His reporting on a range of global issues has appeared in publications such as The Atlantic, The Economist, The Washington Diplomat and The Washington Post.
Lyngaas is an active member of the National Press Club, where he served as chairman of the Young Members Committee. He earned his M.A. in international affairs from The Fletcher School of Law and Diplomacy at Tufts University, and his B.A. in public policy from Duke University.
Click here for previous articles by Lyngaas, or connect with him on Twitter: @snlyngaas.
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Save the date for 28th annual Federal 100 Awards Gala.
March 30, 2017
The Department of Commerce is revising its confidentiality agreement for statistical data survey respondents to reflect the fact that the Department of Homeland Security could see some of that data if it is captured by the Einstein system.
In a Feb. 17 memo, Defense Secretary Jim Mattis told senior leadership to establish teams to look for duplication across the armed services in business operations, including in IT and cybersecurity.
State election officials had more questions than answers after a Department of Homeland Security presentation on the designation of election systems as critical U.S. infrastructure.
The government desperately needs younger talent to replace an aging workforce, and experts say that a freeze on hiring doesn't help.
The Department of Veterans Affairs will test an internally developed scheduling module at primary care sites nationwide to see if it's ready to service the entire agency.
After missing in the last Congress, drafters of a bill to encourage cloud adoption are looking for a new plan.
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- Artist: Wild Honey
- Release Date: 06/19/2012
Best Buy is dedicated to always offering the best value to our customers. We will match the price, at the time of purchase, on a Price Match Guarantee product if you find the same item at a lower price at a Designated Major Online Retailer or at a local retail competitor's store.Here's how:
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Available ebook formats: epub html
Cheryl Anne Gardner is a hopeless dark romantic, lives in a haunted house, and often channels the spirits of Poe, Kafka, and de Sade. She prefers novellas and flash fiction to writing bios because she always seems to forget what point of view she is in. When she isn't writing, she likes to chase marbles on a glass floor, eat lint, play with sharp objects, and make taxidermy dioramas with dead flies. Her writing has been described as "beautifully grotesque," her characters "deliciously disturbed." Her short fiction has been published in dozens of journals including Dustbin, Hobo Pancakes, Carnage Conservatory, Pure Slush, Negative Suck, Danse Macabre, and at The Molotov Cocktail among others. She lives with her husband on the East Coast USA, and she is currently the head fiction editor at Apocrypha and Abstractions Literary Journal.
Review by:
Brandy Hunt
on Feb. 28, 2011 :
I really enjoyed this book. Once again it is something unique and different. But this time the characters are people I swear I knew in graduate school.
The characters in this particular novel are men and women trying to live their lives in spite of the expectations of family and society. It is a theme that I can understand and empathize with. Of course, the story is still dark and a bit bloody, so read only if you think you can handle it.
(reviewed long after purchase)


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String Noise at BerkleeBerk Recital Hall
Berklee's Composition Department, with assistance from the String Department, hosts violin duo String Noise.
As part of their residency at Berklee, String Noise performs a concert of newer works written for two violins by Bernhard Lang, Georg Friederich Haas, Derek Hurst, and others.
Santiago BarraganOliver Colvin Recital Hall
Guitar principal Santi Barragan and his modern jazz trio present original compositions featuring synth drums.
Great American Songbook: Tribute to Laurel CanyonBerklee Performance Center
From the mid-1960s to the early 1970s, some of the most memorable and iconic American popular music was written by residents of Laurel Canyon in the Hollywood Hills.
Georgeta Seserman: Let Me Entertain YouOliver Colvin Recital Hall
Join Georgeta and some friends/performers as she provides a night of musical theater numbers with the themes of love, sex, and life.
Music of Michael AbeneBerklee Performance Center
This concert features the music of composer/arranger/pianist and artist-in-residence Michael Abene, performed by a large ensemble of some of Berklee's finest soloists and ensemble players.
Beyoncé's Original All-Female Band: A 10-Year Anniversary ConcertBerklee Performance Center
Beyoncé's original all-female band celebrates its 10-year anniversary in a concert of Queen Bey's songs at Berklee, led by Tia Fuller, a professor in the Ensemble Department.
Kathleen Parks' Senior RecitalRed Room at Cafe 939
Kathleen Parks' senior recital will showcase her own compositions and songs, as well as arrangements featuring American roots, American Songbook, funk, and Harry Nilsson-esq pop.
Bridget's an Irish Tradition Presents Celtic Crossings: Phil Coulter and Andy CooneyBerklee Performance Center
Phil Coulter, from Derry, Northern Ireland, and Andy Cooney, from New York, once again join forces to present the masterful Celtic Crossings, weaving a tapestry of Irish warmth, spirit, and culture through music.
Gary Burton and Makoto Ozone: DuetsBerklee Performance Center
Multiple Grammy-winning vibraphonist, composer, and educator Gary Burton and prolific composer and arranger Makoto Ozone improvise on just about any kind of music, from traditional and contemporary jazz to tango and classical themes.
Guitar Night: Rock and PopBerklee Performance Center
The Berklee Guitar Department showcases pop and rock guitar students.
Words and Music Festival III
Berklee Performance Center
As part of its third annual Words and Music Festival, the Berklee Composition Department is sponsoring an evening of student Songwriting Competition winners in a variety of categories.
The Emperor's New Clothes
Berklee Performance Center
The Musical Theater for Young Audiences and Contemporary Musical Theater initiatives at Berklee present The Emperor's New Clothes, an original children's musical written by Rene Pfister, assistant professor of voice.
Maximilian Gerl: In Conclusion
Red Room at Cafe 939
Bassist Maximilian Gerl presents an hour of music that has impacted him throughout his four years at Berklee College of Music.
Xin Tian: Standard and Original
Berk Recital Hall
Electric bass player Xin Tian will present a concert featuring standards and original contemporary-style jazz music with a small-size band.
Julian Rodriguez's Senior Recital
Oliver Colvin Recital Hall
In his senior recital, bassist Julian Rodriguez, along with a dynamic and adventurous group of musicians, will play some of the most recognizable Grateful Dead tunes with unique twists and plenty of improvisation.
Chance Fuller's Senior Recital
Berk Recital Hall
Chance Fuller, a 22-year-old guitarist from Houston, Texas, will present a set of metal, rock, country, and jazz, including combinations of them all.
Maggie Koerner (of Galactic)
Red Room at Cafe 939
It's not uncommon to find Maggie Koerner performing on stage with a list of iconic acts including Widespread Panic, Gov't Mule, and Charles Bradley.
Rhythms and Frequencies: The Contemporary Writing and Production Department Concert
Berklee Performance Center
The Contemporary Writing and Production Department Student Concert features some of the department's best students and their dynamic songs and arrangements in an exciting mix of electrifying music.
Maddie Jay's Senior Recital
Red Room at Cafe 939
Bassist Maddie Jay presents her senior recital.
JP Goldman's Senior Recital
Berk Recital Hall
Join bassist/vocalist JP Goldman as he and some friends play his original songs and some unique arrangements of others.
Sergio Ramos: Fusion Confusion
Berk Recital Hall
Guitarist Sergio Ramos performs a variety of fusion/jazz/rock music for his senior recital, pushing his boundaries of genre and style.
The Magnetic Fields: 50 Song Memoir - Night One: Songs 1-25
Berklee Performance Center
In concert, 50 Song Memoir will be played and sung by seven performers in a stage set featuring 50 years of musical and decorative artifacts.
Jon McLaughlin / Katrina Woolverton
David Friend Recital Hall
Songwriter Jon McLaughlin was offered a role in the hit film Enchanted, performing a song that was later nominated for an Academy Award. Chart-topping singer-songwriter Katrina Woolverton will also perform.
The Magnetic Fields: 50 Song Memoir - Night Two: Songs 26-50
Berklee Performance Center
In concert, 50 Song Memoir will be played and sung by seven performers in a stage set featuring 50 years of musical and decotrative artifacts.
CANCELED: Free Improvisation Ensemble
David Friend Recital Hall
CANCELED: This event has been canceled.
The Strings Free Improvisation Ensemble performs new works of directed creation.
CANCELED: The Funkestra
David Friend Recital Hall
CANCELED: This event has been canceled.
This show will feature strings players performing covers of their funky favorites.
BGJI Concert Series and Jam Sessions
Zero Gravity Room
The Berklee Global Jazz Institute (BGJI) will feature an original repertoire as well as arranged standards in this concert.
Those Who Can Teach, Perform
David Friend Recital Hall
Students and faculty of the Music Education Department perform an eclectic program of music each semester.
The Big Finale with Andrew DeNicola
Red Room at Cafe 939
Over the past four years, saxophonist Andrew DeNicola has slowly been building his craft as not only a multi-instrumentalist, but also as a composer/arranger capable of doing many styles and varieties, all in the jazz tradition.
Beautiful Songs from Latin America
Berk Recital Hall
Beautiful Songs from Latin America is a recital featuring the Advanced Latin and Jazz Performance Workshop for Vocalists class, directed by faculty vocalist Mili Bermejo.


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11:56 am
November 25, 2008
haven´t been here for a while /blush.gif" style="vertical-align:middle" emoid=":blush:" border="0" alt="blush.gif" /> , but shot some photos last weekend, which I would like to share with you. One of my bigger tanks is waiting for a complete cleaning job, nothing inside except some wood, plants, snails, sand. I discovered some colonies of bell animalcules, and decided to photograph them:
I guess one can estimate their size: they are "sitting" on a single hair algue.
The picture above is a heavy cropped part of a photo made with a 60mm macro lens at 1:1 magnification. Since one can´t see very much details of these ciliates, I tried to get closer, without using a microscope. (I am actually looking for a good one.)
Here we can see them at about 6.3:1 (using extension tubes, bellows, macro lens and achromatic close-up lens)
On closer inspection you may notice Stentor on the upper left side and in the middle of the photo.
Below is even closer, maybe a little more than 10:1. That means less than 2mm real life length on the APS-C sensor of my Canon EOS 40D.
It is not as good as it could be photographed with a stereo microscope, but one can see some interesting details. Hope you like it, also if it is some unusual stuff for a fish board.
Best wishes,
12:47 pm
June 13, 2011
Stunning macro work Andreas the stalks of the individual 'bells' are clearly visible. Cool 'trumpets' in the second image too. /cool.gif" style="vertical-align:middle" emoid="B)" border="0" alt="cool.gif" /> Great to see you around again. /wink.gif" style="vertical-align:middle" emoid=";)" border="0" alt="wink.gif" />
1:23 pm
September 7, 2008
9:04 pm
November 25, 2008
Hi Matt and Lizz,
thanks for your comments!
Lizz, I wouldn´t talk about a job, they are just there - like we humans. They are widespread in freshwater and you will find them in almost every old aquarium filter sponge.
Here you can read some more about Vorticella, although I´m not sure whether this is the correct genus. There are even some movies.
10:50 pm
September 7, 2008
Trumpets, Matt? I thought they look like tiny bells.
Thanks, Andreas. I asked this because they looked familiar to something I have discovered in my tropical tank. At first (with the bare eye) I thought they were some kind of eggs. But they didn't hatch, they keep appearing, so I thought that there must be some sort of symbiosis between the bells and something in the tank. It was nice to read about the old stuff like cells and nucleaus again, I always loved biology.
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MICHAEL Michael Kors
'Devon - Large' Leather Satchel
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HideDetails & Care
Belted accents edge the curved silhouette of a modern satchel cast in sumptuous leather and topped with chain-detailed handles. A dangling logo medallion and a swishy tassel finish the street-chic style.
- Top magnetic-snap closure.
- Optional, adjustable shoulder strap.
- Exterior magnetic-snap and zip pockets.
- Interior zip, wall and cell-phone pockets; key clip.
- Logo-jacquard lining.
- Leather.
- By MICHAEL Michael Kors; imported.


text:
Listing information
- Status: Active
- Foreclosure: No
- Lot Size: 1320x3960
- Body of Water: Juncob Lake and Michigamme Rv
- Style: Business
- Stories: 0
- Total Square Footage: 10,000 ($84.50 per sq. foot)
- County: Marquette
- Year Built: 1930
- New Construction: No
- Lot Area: 104.80
- Neighborhood: Republic T
AIR CONDITIONING None
At Ski Resort No
BASEMENT Full
CABLE No
CONSTRUCTION Log
ELECTRIC Yes
Exclusions (Y/N) No
EXTERIOR Log
FINANCING OPTIONS None
Foreclosure (Y/N) No
FOUNDATION Block
HEAT Oil Hot Water
MISC. EXTERIOR Fireplace, Fixtures, Furniture, Inside Storage, Living Space, Onsite Parking, Recreation Facility, Restroom(s), Sauna-Interior
NATURAL GAS No
Other Body of Water - Juncob Lake and Michigamme Rv, Business Type - Resort Cabins, Est.Tot. Below Grade SQFT - 1500, Total # of Buildings - 13, Total Cold Storage SQFT - 2000, Total Liv. Quarters SQFT - 3051, Total Office SQFT - 500, Zoning - Mr
OUTBUILDINGS Barn, Garage, Gazebo/Screen House, Guest Cottage, Pole Building, Sauna, Shed
POSSESSION Negotiable
SEWER Septic
SHORELINE Cleared, Lawn, Sand, Wooded
SUPPLEMENTAL HEAT Wood
TELEPHONE Yes
Trailside No
WATER Drilled Well
Water View Lake
Waterfront Lake
WOODED Yes
Listing Courtesy of Bob Sullivan of Northern Michigan Land Brokers