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Accompanying this issue of CHEST, readers will find the supplement containing the Executive Summary,1 Introduction,2 and Methodology3 articles from the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (AT9). These broad articles, as well as those that address specific content areas covered by the latest guidelines, can also be accessed at http://chestjournal.chestpubs.org. There have been several noteworthy advances in the methodology used to produce these guidelines since the last edition was published in 2008.4 Additionally, AT9 marks the initial step of a transition in the American College of Chest Physicians (ACCP) process for guideline updating and publication.
A limitation to the recommendations on drug treatment made in asthma guidelines is that these are based on clinical studies performed in selected groups of patients.1 For example, in many trials, only 5% of adults with asthma fulfill the entry criteria; current smokers or former heavy smokers are usually excluded.2 The lack of information on the best approach to manage smokers is of considerable importance, given the high prevalence rates of active smoking in asthma and the poor levels of asthma control in this group.3 In developed countries, one-fifth to one-third of adults with asthma are smokers, and in some areas of the world, such as southeast Asia, almost one-half are smokers. Smokers experience increased morbidity from asthma compared with nonsmokers, including more severe symptoms, increased rates of admission to hospital with acute asthma, and accelerated rates of decline in lung function.3,4 Clinical trials are urgently required that will provide evidence on which drugs and treatment strategies are most appropriate for this group.
Let us begin with the premise that endobronchial ultrasound (EBUS) is the single most useful pulmonary procedure introduced in decades and should be available to all patients with thoracic adenopathy requiring evaluation. The question then becomes when and where rather than whether it should be offered. In this issue of CHEST (see page 506), Pastis and colleagues1 report an encouraging analysis showing positive downstream revenue resulting from their introduction of EBUS to their institution. The authors are based at an academic institution, but their results may be extrapolated to other settings. The authors do present the ideal: a quick, safe, efficient, and cost-effective procedure that benefits patients while financially benefiting the institution. It will be telling whether this encouraging information will be used to offer patients the best application of this outstanding technology.
The quote "It is better to be alone than in bad company," by George Washington (1732-1799), can be applied to many situations but is particularly true for atrial fibrillation (AF). AF is the most common sustained arrhythmia in the adult population, and it is well known that its occurrence is linked to a series of risk factors, such as advanced age, hypertension, valvular or ischemic heart disease, heart failure, diabetes, and hyperthyroidism.1,2 The term "lone AF" was introduced by Evans and Swann in 19543 and is also used currently to describe the condition wherein AF develops in a young patient (<60 years of age) in whom clinical and laboratory assessment and testing exclude the presence of an overt structural cardiac disease or of other comorbidities (including systemic hypertension) known to facilitate the development of AF.4 Patients affected by lone or idiopathic AF have been traditionally identified as subjects with a favorable prognosis with regard to thromboembolic events and mortality.4
Patients with atrial fibrillation (AF) face an annual stroke risk of about 5%. Evidence that anticoagulants reduce the risk of stroke has evolved over the 20th century. The American College of Chest Physicians (ACCP) has played a critical role in presenting guidelines for stroke prevention in AF. This commentary highlights the role that the ACCP guidelines have played, from their inception to the ninth edition. The first ACCP Conference on Antithrombotic and Thrombolytic Therapy in 1986 developed evidence-based guidelines for the indications, dosage, and monitoring of antithrombotic therapy. The conference recommended that anticoagulants be monitored by the international normalized ratio, and the appropriate dosage was to increase the international normalized ratio to two to three times control. This recommendation was widely accepted. Anticoagulants were recommended for AF with mitral valve disease and for nonvalvular AF with a history of embolism. No recommendations were made for nonvalvular AF without a history of embolism. These recommendations stimulated numerous randomized controlled trials (RCTs). By the third ACCP conference in 1992, RCTs had demonstrated a dramatic 69% stroke reduction in patients with nonvalvular AF. The third ACCP conference was the first to strongly recommend anticoagulation for primary and secondary stroke prevention in nonvalvular AF. ACCP conferences since 1992 have refined recommendations for nonvalvular AF on the basis of associated risk factors. The most recent conference, in 2011, recommended a direct thrombin inhibitor, dabigatran, rather than warfarin as the anticoagulant of choice. These ACCP guidelines have played a critical role in changing physicians' practice patterns. In 1980 only 7% of patients with AF in the United States received OA; by 2007, this had increased to 57%.
Performance measures (PMs) are specified metrics by which a health-care provider's care can be compared with national benchmarks. The use of PMs is a key component of efforts to improve the quality and value of health care. The National Quality Forum (NQF) is the federally recognized endorser of PMs. From 2006 to 2009, the Quality Improvement Committee (QIC) of the American College of Chest Physicians engaged in the review of proposed PMs as a member of the NQF. This article provides a review of the QIC's experience with PMs and NQF membership and the lessons learned, an overview of the enhancements made to the NQF endorsement process in 2010 and 2011, and a discussion of the next steps that would further strengthen the measure development and endorsement processes and increase the likelihood of measurement leading to better patient outcomes.
Postthrombotic syndrome (PTS) is a frequent, chronic complication of DVT. The effectiveness and safety of available treatments are unknown. The objective of this study was to systematically review the literature to assess whether pharmacologic and compression therapies are effective and safe for the treatment of PTS.
We sought to identify randomized controlled trials (RCTs) via a search of PubMed, studies referenced in included publications, and studies that cited relevant literature.
A total of 121 titles were reviewed, 12 full-text publications were assessed for inclusion, and seven RCTs, including 703 patients, were selected for inclusion. Four trials assessed the effectiveness of drugs, including rutosides, hidrosmin, and defibrotide, and four trials assessed compression therapies for treatment of PTS. Systems for the diagnosis and classification of PTS severity varied across studies. Three of four drug therapy trials reported moderate improvement in selected PTS symptoms, minor changes in calf and ankle circumference, and some effects on ulcer healing. Two studies of compression stockings did not report benefit. Two studies that assessed compression devices reported improvement in PTS symptoms scores; one of these reported an improvement in quality-of-life score.
There is limited and low-quality evidence for the effectiveness of rutosides, hidrosmin, defibrotide, and compression stockings, but moderate-quality evidence that supports the use of intermittent compression to provide at least short-term relief from PTS. More rigorous studies are needed to assess the short- and long-term effectiveness and safety of PTS therapies.
According to the Comparison of Arixtra in Lower Limb Superficial Vein Thrombosis with Placebo (CALISTO) study, a recent randomized, controlled trial, prophylactic fondaparinux can prevent thrombotic complications following superficial vein thrombosis (SVT). The cost-effectiveness of this treatment remains to be determined.
We developed a decision-tree model comparing fondaparinux 2.5 mg daily for 45 days vs no treatment of SVT. It included all clinical events associated with SVT, its treatment, its complications, and all respective quality-adjustment factors. Data were mainly derived from the CALISTO study and the published literature. Measured outcomes comprised clinical events (VTE, major hemorrhage, death), quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). The analysis was conducted using a lifetime time horizon from a health-care system perspective. We performed one-way and probabilistic sensitivity analyses to evaluate parameter uncertainty.
In 10,000 patients, we estimated that fondaparinux would prevent 123 VTE events and two deaths. On a per-patient basis, the incremental QALY compared with no treatment was 0.04 (1 day) at an incremental cost of $1,734, resulting in an ICER of $500,000 per QALY. This result remained robust in the one-way sensitivity analyses, with an ICER remaining > $100,000 per QALY throughout all ranges. Based on probabilistic sensitivity analyses, the probability that fondaparinux was cost-effective was 1% at a willingness-to-pay of $100,000 per QALY.
Fondaparinux for 45 days does not appear to be cost-effective when treating patients with isolated SVT of the legs. A better value for money could be obtained in subgroups of patients with a higher incidence of VTE after SVT. Shorter durations of treatment should be further evaluated in future clinical studies.
Smoking induces airway inflammation and relative resistance to inhaled steroids. The objective of this study was to evaluate the effects on airway hyperresponsiveness of adding salmeterol to fluticasone vs doubling the dose of fluticasone in patients with asthma who smoked and patients with asthma who did not smoke.
Sixteen patients with mild to moderate persistent asthma who did not smoke and 15 such patients who smoked completed a double-blind, randomized, placebo-controlled crossover study. They received either a fluticasone/salmeterol combination (FP/SM) (125/25 μg) two puffs bid (plus fluticasone placebo), or active fluticasone (250 μg) two puffs bid (plus FP/SM placebo), for 2 weeks each, with baselines after 1-week to 2-week run-in and washout periods. The primary outcome was the change from baseline in the provocative concentration of methacholine required to produce a 20% fall in FEV1 (PC20).
In the patients who did not smoke, there were similar improvements in the methacholine PC20 with the use of fluticasone and FP/SM. The patients who smoked gained a benefit from FP/SM but not fluticasone, amounting to a PC20 difference of 1.6 doubling dilutions (95% CI, 1.0-2.2), P < .01. The provocative dose of mannitol required to produce a 15% fall in FEV1 (PD15) showed greater improvements with FP/SM than fluticasone in both patients who smoked and did not smoke. Similar differences in airway caliber between those who smoked and did not smoke were observed in FEV1 and airway resistance.
FP/SM confers greater improvements in airway hyperresponsiveness and airway caliber in patients with asthma who smoke compared with double the dose of fluticasone. We hypothesize that in the presence of relative steroid resistance, the smooth muscle stabilization conferred by salmeterol is of greater clinical importance in patients who smoke than in those who do not smoke.
Trial registry:
ClinicalTrials.gov: No.: NCT00830505; URL: www.clinicaltrials.gov
Lone atrial fibrillation (AF) has been suggested to have a favorable long-term prognosis. Significant interest has been directed at factors predicting arrhythmia progression, and the HATCH score (hypertension, age ≥ 75 years, transient ischemic attack or stroke [2 points], COPD, and heart failure [2 points]) recently has been proposed as a predictive score for AF progression. We investigated long-term outcomes in a large cohort of newly diagnosed lone AF and whether progression from paroxysmal to permanent AF confers an adverse impact on outcomes, including stroke and thromboembolism.
The study was an observational cohort of 346 patients with newly diagnosed lone AF with a mean follow-up of 12.1 ± 7.3 years.
Baseline paroxysmal AF was confirmed in 242 patients, and of these, 65 (26.9%) subsequently experienced progression to permanent AF. Older age and development of congestive heart failure during follow-up were the multivariate predictors of AF progression (both P < .01), which was documented in 19.8% of patients with a HATCH score of 0 vs 63.2% with a score of 2 (P < .001), although the predictive validity of the HATCH score per se was modest (C statistic, 0.6). The annual rate of thromboembolism and heart failure during follow-up were low (0.4% each), and five patients (1.4%) died. AF progression, development of cardiac diseases, and older age were multivariate predictors of adverse outcomes, including thromboembolism (all P < .05). Baseline CHADS2 (congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, prior stroke or transient ischemic attack) score was not predictive for thromboembolism (C statistic, 0.50; 95% CI, 0.31-0.69).
This 12-year follow-up study provides confirmatory evidence of a generally favorable prognosis of lone AF, but adverse outcomes (including stroke and thromboembolism) are significantly influenced by age and the (new) development of underlying heart disease. Arrhythmia progression in lone AF is a marker of increased risk for adverse cardiovascular events.
Animal and human studies suggest that selective serotonin reuptake inhibitors (SSRIs) might be useful for the prevention or treatment of pulmonary arterial hypertension.
We conducted a population-based, nested case-control study to explore the hypothesis that SSRIs might reduce the risk of pulmonary arterial hypertension. Cases were individuals who developed pulmonary arterial hypertension requiring pharmacologic treatment. For each case, we selected up to 10 matched control subjects. Exposure to SSRIs and non-SSRI antidepressants was ascertained using administrative data. The outcome of pulmonary arterial hypertension requiring pharmacologic therapy was defined as the receipt of a drug specific for the treatment of pulmonary arterial hypertension.
In contrast to our hypothesis, and likely because of residual confounding, we found a positive association between SSRI use and pulmonary arterial hypertension (adjusted OR, 1.55; 95% CI, 1.13-2.13).
At conventional doses, SSRIs are not associated with a reduced risk of pulmonary arterial hypertension.
In pulmonary arterial hypertension (PAH), survival predictions can be important for optimization of therapeutic strategies. The present study aimed to validate a quantitative algorithm for predicting survival derived from the Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL Registry) and develop a simplified calculator for everyday clinical use.
Prospectively collected data from patients with newly diagnosed (< 3 months) World Health Organization group I pulmonary hypertension enrolled in the REVEAL Registry were used to validate a predictive algorithm for 1-year survival. Model calibration was evaluated by comparing algorithm-predicted survival with observed Kaplan-Meier estimates for the overall validation cohort and for five risk groups. Similarly, the risk discriminators for the simplified calculator were compared with those of the quantitative algorithm.
The validation cohort comprised 504 individuals with mean ± SD 6-min walk distance 308 ± 128 m, and 61.5% were functional class III. The proportion of patients surviving 1 year fell within the range predicted by the model (95.1%, 91.5%, 84.6%, 76.3%, and 58.2%, respectively) among patients in the low (predicted survival ≥ 95%), average (90% to < 95%), moderate (85% to < 90%), high (70% to < 85%), and very high (< 70%) risk strata. Predicted and observed 1-year survival were similar across risk stratum, and the c-index indicated good discrimination for both the full equation (0.726) and the simplified risk calculator (0.724).
The REVEAL Registry predictive algorithm and simplified risk score calculator are well calibrated and demonstrate good discriminatory ability in patients with newly or previously diagnosed PAH.
Trial registry:
ClinicalTrials.gov; No.: NCT00370214; URL: www.clinicaltrials.gov
Pulmonary arterial hypertension (PAH) is a life-threatening disease that affects more women than men. The reasons for the female preponderance are unclear, and there are limited data available for men with PAH.
Data from the Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL Registry) were analyzed to explore sex differences among patients with PAH with regard to 2-year survival from enrollment and 5-year survival from time of diagnosis.
The data set included 2,318 women and 651 men. More women had PAH associated with connective tissue disease (P < .001), and more men had portopulmonary hypertension (P < .001) and HIV-associated PAH (P < .001). More women had congenital heart disease-associated PAH (P = .017), thyroid disease (P < .001), and depression reported (P ≤ .001). At diagnosis, men had higher mean pulmonary artery pressure (53 ± 14 vs 51 ± 14.3 mm Hg; P = .013) and mean right atrial pressure (10 ± 6 vs 9 ± 6 mm Hg; P = .031). Women had better survival estimates for 2 years from enrollment and for 5 years from diagnosis. Stratifying by age showed that survival from enrollment was similar between men and women aged < 60 years at enrollment, whereas men aged ≥ 60 years have lower survival rates compared with women aged ≥ 60 years.
Our findings highlight similarities and differences between men and women with PAH, raising questions for future exploration regarding the role of hormones and sex in causation and survival in PAH.
A prolonged QRS duration ( ≥ 120 milliseconds) predicts outcomes in patients with left-sided heart failure, but the impact in idiopathic pulmonary arterial hypertension (IPAH) and right-sided heart failure is unknown. We assessed the prognostic value of a prolonged ECG QRS duration in patients with IPAH in China.
We retrospectively analyzed the initial 12-lead ECG for QRS duration in 212 consecutive patients with IPAH seen at our center between 2007 and 2009. Patients were divided according to QRS duration < 120 milliseconds or ≥ 120 milliseconds. The baseline characteristics and survival of the two groups were compared.
Thirty-five patients with IPAH (16.5%) had a QRS duration ≥ 120 milliseconds, including 21 (9.9%) with right bundle-branch block and 14 (6.6%) with nonspecific intraventricular conduction delay. Prolongation of the QRS duration was associated with a worse World Health Organization functional class and 6-min walk test distance and higher serum uric acid when compared with patients with normal QRS duration (P < .05). Prolonged QRS duration was an independent predictor of mortality and was associated with a 2.5-fold increased risk of death (P = .024).
Prolongation of the QRS duration is associated with clinical severity in patients with IPAH. In addition, QRS prolongation has an independent association with cardiopulmonary mortality and could be a new predictor of adverse outcome in patients with IPAH.
Planar ventilation/perfusion (V˙/Q˙ ) lung scintigraphy is a validated tool for the diagnosis of pulmonary embolism (PE). Nevertheless, given the high rate of nonconclusive V˙/Q˙ , further investigation is often necessary. V˙/Q˙ single-photon emission CT (SPECT) scan could improve V˙/Q˙ performance, but sparse data are available on its accuracy. This study assessed the diagnostic performance of V˙/Q˙ SPECT scan in a cohort of consecutive patients with suspected PE.
Three hundred twenty-one consecutive patients with a clinical suspicion of PE were prospectively included. Patients suspected of having PE were managed according to a reference diagnostic strategy validated by a 3-month follow-up. In addition to the reference strategy, patients had a V˙/Q˙ SPECT scan, the results of which were compared with the initial work-up results.
Prevalence of PE was 0 of 41 (0%; 95% CI, 0%-9%), six of 134 (4%; 95% CI, 2%-9%), 15 of 36 (42%; 95% CI, 27%-58%), and 28 of 32 (88%; 95% CI, 72%-95%) in the normal, low, intermediate, and high V˙/Q˙ SPECT scan probability groups, respectively. The combination of V˙/Q˙ SPECT scan with clinical probability was diagnostic in 88% of patients.
V˙/Q˙ SPECT scan results show satisfactory accuracy for PE diagnosis. Validation of dedicated interpretation criteria is required, followed by outcome studies that use V˙/Q˙ SPECT scan as part of a diagnostic strategy to rule out PE.
Trial registry:
ClinicalTrials.gov; No.: NCT01183026; URL: www.clinicaltrials.gov
The relationship between obesity and right ventricular (RV) morphology is not well studied. We aimed to determine the association between obesity and RV structure and function in a large multiethnic population-based cohort.
The MESA-Right Ventricle Study measured RV mass and volumes by cardiac MRI in participants aged 45 to 84 years without clinical cardiovascular disease in the Multi-Ethnic Study of Atherosclerosis (MESA). Participants were divided into three categories based on BMI: lean ( ≤ 24.9 kg/m2), overweight (25-29.9 kg/m2), and obese ( ≥ 30 kg/m2).
The study sample included 4,127 participants. After adjustment for demographics, height, education, and cardiovascular risk factors, overweight and obese participants had greater RV mass (6% and 9% greater, respectively), larger RV end-diastolic volume (8% and 18% greater, respectively), larger RV stroke volume (7% and 16% greater, respectively), and lower RV ejection fraction ( ≥ 1% lower) than lean participants (all P < .001). These findings persisted after adjusting for the respective left ventricular (LV) parameters.
Overweight and obesity were independently associated with differences in RV morphology even after adjustment for the respective LV measure. This association could be explained by increased RV afterload, increased blood volume, hormonal effects, or direct obesity-related myocardial effects.
Exacerbations of COPD (ECOPD) remain a major cause of mortality and morbidity. Despite advances in the understanding of their pathophysiology, their assessment relies primarily on clinical presentation, which can be variable and difficult to predict. A large number of biomarkers already have been assessed in this context, and some appear to be promising.
An online search for articles published until December 2010 was conducted using three terms for ECOPD, five terms for biomarkers, and five terms for the sampling method. Biomarkers were evaluated for their potential role in the establishment and confirmation of the diagnosis of ECOPD, the evaluation of etiology and severity, the prediction of prognosis, and the guidance of treatment decisions.
Several systemic biomarkers have been measured in the context of ECOPD, and most have been found to increase at ECOPD onset and to subside during the course of exacerbations. Correlations have been reported among these biomarkers, but direct associations with clinical variables have been more difficult to establish. Although there are several limitations yet to be addressed, some of the biomarkers, most notably C-reactive protein for the identification of an ECOPD and procalcitonin for antibiotic guidance, may provide clinically relevant information.
So far, no single biomarker has been able to gain wide acceptance, but some provide clinically useful information. The evaluation of such biomarkers in large decision-making studies is expected to become an area of intense investigation in the near future.
The aims of this study were to determine which tests of exercise capacity relate to average daily energy expenditure (DEE) and to quantify aerobic reserve during daily life in people with COPD.
A cross-sectional study was undertaken in 26 people with COPD (16 men; FEV1, 50% ± 16%). Six-min walk distance (6MWD) and incremental shuttle walk distance (ISWD) measures were collected, and peak oxygen uptake (V˙ o2 peak) was measured during a symptom-limited ramp cycle ergometry test. The SenseWear Armband was worn during the waking hours for 4.4 ± 1.1 days to measure DEE. The intensity at which activities of daily living were undertaken was expressed as a percentage of V˙ o2 peak.
DEE was associated with 6MWD (r = 0.40, P = .046) and ISWD (r = 0.52, P = .007) but not V˙ o2 peak (mL/kg per min) (r = 0.07, P = .74). Stronger associations were observed between DEE and the body weight-walking distance product for the 6MWD (r = 0.73, P < .001) and ISWD (r = 0.75, P < .001). The average intensity of daily activity was equivalent to 58% ± 11% of V˙ o2 peak, leaving an average aerobic reserve of 42%.
Both 6MWD and ISWD, but not V˙ o2 peak, were related to DEE. Because activities of daily living were performed at a high percentage of V˙ o2 peak, it may be more realistic to optimize habitual DEE in COPD by increasing the frequency or duration rather than the intensity of physical activity.
Walking is frequently used in the exercise rehabilitation of patients with COPD. Walking ability can be characterized by the two-parameter hyperbolic relationship between endurance and speed. One parameter, critical walk speed (s_critical), represents the maximum speed that can be endured indefinitely. The purpose of this study was to: (1) determine the effect of pulmonary rehabilitation on the critical speed and (2) compare the critical speed with the speed chosen during self-paced walking.
We estimated critical speed in patients with COPD before and after rehabilitation. Patients completed four high-intensity constant-speed walk tests to intolerance on a 30-m course. The parameters of the hyperbolic relationship were determined using nonlinear regression of endurance on speed. Participants also completed self-paced walks: (1) for as long as they could, (2) at their "usual" and "fast" speeds, and (3) as a 6-min walk test.
Twelve participants (FEV1 [SD], 41 [16] % predicted; FEV1/FVC, 41 [12]) completed the study. At baseline, the critical speed (65 [12] m/min) was not significantly different from the self-paced, usual, or 6-min walk speeds (65 [12], 67 [14], and 63 [15] m/min, respectively). There was a significant increase in critical speed (6 [1-10] m/min) and 6-min speed (16 [10-21] m/min) after rehabilitation, without changes in the self-paced, usual, or fast speeds.
Patients with COPD increase their critical walk speed after pulmonary rehabilitation. The pace chosen during common walk tasks is closely related to critical speed; this relationship is altered after rehabilitation.
Trial registry:
ClinicalTrials.gov; No.: NCT00781183; URL: www.clinicaltrials.gov
Thyroid transcription factor 1 (TTF-1) positivity correlates with a higher prevalence of epidermal growth factor receptor (EGFR) mutation in lung adenocarcinoma. It is unknown whether TTF-1 expression affects the clinical outcome of patients with advanced lung adenocarcinoma, who have received EGFR tyrosine kinase inhibitors (TKIs) during the treatment course.
This study enrolled patients with advanced lung adenocarcinoma who had results of EGFR mutation analysis and TTF-1 immunostaining. The impact of TTF-1 expression on overall survival (OS) and progression-free survival (PFS) under EGFR TKI treatment was evaluated. Multivariate analyses were done to examine the independent predictors of OS and PFS.
Of 496 patients with advanced lung adenocarcinoma, 443 had TTF-1-positive adenocarcinoma. Patients with TTF-1-positive lung adenocarcinoma had longer OS than did those with TTF-1-negative lung adenocarcinoma (median survival, 27.4 vs 11.8 months, P = .001). In patients with EGFR TKI treatment, those with TTF-1-positive lung adenocarcinoma and mutant EGFR had longer OS. In patients with EGFR mutation, those with TTF-1-positive lung adenocarcinoma had longer PFS than did those with TTF-1-negative lung adenocarcinoma (median survival, 8.7 vs 5.7 months, P = .043). Multivariate analysis showed that negative TTF-1 expression is a predictor for shorter OS, and a predictor for shorter PFS under EGFR TKI treatment.
TTF-1 shows independent prognostic significance in advanced lung adenocarcinoma. Patients with TTF-1-negative lung adenocarcinoma have not only shorter OS, but also shorter PFS under EGFR TKI treatment, despite the existence of mutant EGFR. Further studies are needed to investigate the optimal treatment of patients with TTF-1-negative lung adenocarcinoma.
The objective of this study was to compare the safety, use, and cost profiles of open thoracotomy vs video-assisted thoracoscopic surgery (VATS) for wedge resection in lung cancer performed by thoracic surgeons in the United States.
The Premier database, which contains complete patient billing, hospital cost, and coding histories from > 25 million inpatient discharges and > 175 million hospital outpatient visits, was used for this analysis. Eligible patients were those who underwent wedge resection by a thoracic surgeon for cancer diagnosis or treatment through open thoracotomy or VATS in 2007 or 2008. Multivariable logistic regression analyses were run for binary outcomes, and ordinary least squares regressions were used for continuous outcomes. All models were adjusted for patient demographics, comorbid conditions, and hospital characteristics.
Of 8,228 eligible procedures, 2,051 patients underwent wedge resections by a thoracic surgeon using the open technique (n = 999) or VATS (n = 1,052). Hospital costs remained significantly higher for open wedge resections than for VATS ($17,377 vs $14,795, P = .000). Surgery time was significantly longer for open resections vs VATS (3.16 vs 2.82 h). Length of stay was 6.34 days for open vs 4.44 days for VATS. Adverse events were significant in the multivariable analysis, with an OR of 1.57 (95% CI, 1.29-1.91) in favor of VATS.
Although this retrospective database analysis could not address the issue of oncologic outcome equivalence, a clear advantage of VATS over open wedge lung cancer resection was found for both acute clinical outcomes and hospital costs.
Unrecognized obstructive sleep apnea (OSA) is associated with unfavorable perio-perative outcomes among patients undergoing noncardiac surgery (NCS).
The study population was chosen from 39,771 patients who underwent internal medicine preoperative assessment between January 2002 and December 2006. Patients undergoing NCS within 3 years of polysomnography (PSG) were considered for the study, whereas those < 18 years of age, with a history of upper airway surgery, or who had had minor surgery under local or regional anesthesia were excluded. Patients with an apnea-hypopnea index (AHI) ≥ 5 were defined as OSA and those with an AHI < 5 as control subjects. For adjusting baseline differences in age, sex, race, BMI, type of anesthesia, American Society of Anesthesiology class, and medical comorbidities, the patients were classified into five quintiles according to a propensity score.
Out of a total of 1,759 patients who underwent both PSG and NCS, 471 met the study criteria. Of these, 282 patients had OSA, and the remaining 189 served as control subjects. The presence of OSA was associated with a higher incidence of postoperative hypoxemia (OR, 7.9; P = .009), overall complications (OR, 6.9; P = .003), and ICU transfer (OR, 4.43; P = .069), and a longer hospital length of stay (LOS), (OR, 1.65; P = .049). Neither an AHI nor use of continuous positive airway pressure at home before surgery was associated with postoperative complications (P = .3 and P = .75, respectively) or LOS (P = .97 and P = .21, respectively).
Patients with OSA are at higher risk of postoperative hypoxemia, ICU transfers, and longer hospital stay.
Most reports addressing pulmonary complications (PCs) in hematopoietic stem cell transplant (HSCT) recipients have focused on allogeneics. This study describes the PCs, their risk factors, and the impact on mortality in autologous recipients.
We reviewed the medical records of 1,243 adult autologous HSCT recipients. We collected pretransplant and posttransplant data and data on PC after transplant and long-term mortality.
Four hundred eighty-seven PC developed in 343 patients (27.6%): 173 infectious (13.9%), 127 noninfectious (10.2%), and 43 both infectious and noninfectious (3.5%). Bacterial, fungal, and viral pneumonias were the most common infectious complications. The main noninfectious complications were acute pulmonary edema (APE) (59 [4.7%]), diffuse alveolar hemorrhage (DAH) (26 [2.1%]), peri-engraftment respiratory distress syndrome (PERDS) (31 [2.5%]), and idiopathic pneumonia syndrome (IPS) (12 [1.0%]). Independent factors associated with PC included diffusing capacity of lung for carbon monoxide and indications for transplant. Factors associated with mortality included sex, history of pulmonary disease, disease status at the time of transplant, FVC, Karnofsky score, and underlying diagnosis. A Cox proportional hazards regression model with separate time-dependent predictors for the first 1 month, 1 to 2 months, 2 to 6 months, and 6 or more months showed an association with mortality at hazard ratios (HRs) of 32.39, 10.13, 4.29, and 0.98, respectively, compared with persons without PC.
More than 25% of autologous HSCT recipients develop PCs within 1 year of transplant. Most of the complications are infections. The most common noninfectious complications are APE, DAH, PERDS, and IPS. PCs increase the risk of death, with HR as high as 32.
Size mismatch between donor lungs and a recipient thorax could affect the major determinants of maximal expiratory airflow: airway resistance, propensity of airways to collapse, and lung elastic recoil.
A retrospective review of 159 adults who received bilateral lung transplants was performed. The predicted total lung capacity (pTLC) for donors and recipients was calculated based on sex and height. Size matching was represented using the following formula: pTLC ratio = donor pTLC / recipient pTLC. Patients were grouped according to those with a pTLC ratio > 1.0 (oversized) or those with a pTLC ratio ≤ 1.0 (undersized). Allograft function was analyzed in relation to the pTLC ratio and to recipient and donor predicted function.
The 96 patients in the oversized cohort had a mean pTLC ratio of 1.16 ± 0.13 vs 0.89 ± 0.09 in the 63 patients of the undersized group. At 1 to 6 months posttransplant, the patients in the oversized cohort had higher FEV1/FVC ratios (0.895 ± 0.13 vs 0.821 ± 0.13, P < .01) and lower time constant estimates of lung emptying (0.38 ± 0.2 vs 0.64 ± 0.4, P < .01) than patients in the undersized cohort. Although the FVCs expressed as % predicted for the recipient were not different between cohorts, the FVCs expressed as % predicted for the donor organ were lower in the oversized cohort compared with the undersized cohort (at 1-6 months, 52.4% ± 17.1% vs 65.3% ± 18.3%, P < .001). Kaplan-Meier estimates for the occurrence of bronchiolitis obliterans syndrome (BOS) showed that patients in the oversized cohort had a lower probability of BOS (P < .001).
A pTLC ratio > 1.0, suggestive of an oversized allograft, is associated with higher expiratory airflow capacity and a less frequent occurrence of BOS.
The aim of this study is to evaluate the efficacy and safety of medium-dose formoterol-budesonide combined inhaled treatment in a single inhaler compared with high-dose budesonide treatment in patients with non-cystic fibrosis (non-CF) bronchiectasis.
This is a 12-month randomized, double-blind, parallel-groups clinical trial, to run in 40 patients with non-CF bronchiectasis diagnosed by high-resolution CT scan of the chest, receiving formoterol-budesonide combined treatment (18/640 μg daily) or budesonide treatment (1,600 μg daily). Variables concerning clinical condition, health-related quality of life (HRQL), lung function, β2-adrenergic agonist use, potentially pathogenic microorganism (PPM) isolates, and medication side effects were analyzed by intention-to-treat analysis.
The study group receiving a formoterol-budesonide combined treatment showed a significant improvement, both clinically and statistically, of symptoms (dyspnea, number of coughs, and rescue β2-adrenergic agonist-free days). Furthermore, we observed an HRQL improvement, with no changes in functional parameters or in PPM isolates, together with an important reduction in overall side effects, especially for those related to inhaled steroids, compared with the high-dose budesonide treatment group.
Inhaled medium-dose formoterol-budesonide combined treatment in a single inhaler is more effective and safe compared with high-dose budesonide treatment in patients with non-CF bronchiectasis.
Trial registry:
ClinicalTrials.gov; No.: NCT00728715; URL: www.clinicaltrials.gov
Current bilevel positive-pressure ventilators for home noninvasive ventilation (NIV) provide physicians with software that records items important for patient monitoring, such as compliance, tidal volume (Vt), and leaks. However, to our knowledge, the validity of this information has not yet been independently assessed.
Testing was done for seven home ventilators on a bench model adapted to simulate NIV and generate unintentional leaks (ie, other than of the mask exhalation valve). Five levels of leaks were simulated using a computer-driven solenoid valve (0-60 L/min) at different levels of inspiratory pressure (15 and 25 cm H2O) and at a fixed expiratory pressure (5 cm H2O), for a total of 10 conditions. Bench data were compared with results retrieved from ventilator software for leaks and Vt.
For assessing leaks, three of the devices tested were highly reliable, with a small bias (0.3-0.9 L/min), narrow limits of agreement (LA), and high correlations (R2, 0.993-0.997) when comparing ventilator software and bench results; conversely, for four ventilators, bias ranged from −6.0 L/min to −25.9 L/min, exceeding −10 L/min for two devices, with wide LA and lower correlations (R2, 0.70-0.98). Bias for leaks increased markedly with the importance of leaks in three devices. Vt was underestimated by all devices, and bias (range, 66-236 mL) increased with higher insufflation pressures. Only two devices had a bias < 100 mL, with all testing conditions considered.
Physicians monitoring patients who use home ventilation must be aware of differences in the estimation of leaks and Vt by ventilator software. Also, leaks are reported in different ways according to the device used.
Soluble mesothelin (SM) and megakaryocyte potentiating factor (MPF) are serum biomarkers of mesothelioma. This study examined the effect of clinical covariates on biomarkers levels and their diagnostic and prognostic value.
Five hundred ninety-four participants were enrolled in a multicenter study, including 106 patients with mesothelioma and 488 control subjects. Multiple linear regression analyses were used to identify which covariates were independently associated with SM and MPF levels. The effect of these covariates on the diagnostic accuracy was evaluated with receiver operating characteristics curve analysis. In patients with mesothelioma, survival analysis was performed with Cox regression.
SM and MPF levels were independently associated with age, glomerular filtration rate (GFR), and BMI in control subjects and with GFR and tumor stage in patients with mesothelioma. The diagnostic accuracy of SM and MPF was significantly affected by the distribution of these covariates in the study population. The patients with mesothelioma were best discriminated from the control subjects with either the youngest age, the highest GFR, or the largest BMI. Furthermore, the control subjects were significantly better differentiated from stage II to IV than from stage I mesothelioma. MPF, not SM, was an independent negative prognostic factor, but only if adjusted for the biomarker-associated covariates.
SM and MPF levels were affected by the same clinical covariates, which also had a significant impact on their diagnostic and prognostic value. To improve the interpretation of biomarker results, age, GFR, and BMI should be routinely recorded. Approaches to account for these covariates require further validation, as does the prognostic value of SM and MPF.
Pulmonary exacerbations (PEx) are responsible for much of the morbidity and mortality associated with cystic fibrosis (CF). However, there is a paucity of data on outcomes in CF PEx and factors influencing outcomes.
We reviewed all PEx in patients infected with Pseudomonas aeruginosa treated with parenteral antibiotics over 4 years at our center. Treatment failures were categorized a priori as those PEx requiring antibiotic regimen change, prolongation of therapy > 20 days because of failure to respond, an early recurrent event within < 45 days, or failure to recover lung function to > 90% of baseline FEV1.
A total of 101 patients were followed for 452 PEx. Treatment failures were observed in 125 (28%) of PEx; antibiotic regimen change was observed in 27 (6%), prolongation of therapy in 29 (6%), early recurrent events in 63 (14%), and failure to recover lung function to > 90% of baseline FEV1 in 66 (15%). Demographic factors associated with one or more treatment failures per year included advanced airways disease, use of enteric feeds, CF-related diabetes, and CF liver disease but did not include female sex or F508del homozygosity. Increased treatment failure risk was associated with lower admission FEV1 and increased markers of inflammation. At therapeutic completion, increased inflammatory markers correlated with treatment failure. Failure rates decreased with increasing number of active antimicrobial agents used based on in vitro susceptibility (zero, 28/65 [43%]; one, 38/140 [27%]; two, 59/245 [24%]; three, 0/2 [0%]; P = .02).
One-fourth of PEx fail to respond adequately to initial management. Patient demographic and episode-specific clinical information can be used to identify individuals at increased risk of initial management failure.
The OX40 receptor is preferentially expressed by T cells, and its cognate ligand OX40L is primarily expressed by antigen-presenting cells such as dendritic cells following activation by thymic stromal lymphopoietin (TSLP). TSLP is released by the bronchial epithelium, airway smooth muscle, and some inflammatory cells in response to numerous insults such as allergens, viruses, and physical damage. OX40L is a costimulatory molecule that plays a sentinel role in the adaptive immune response by promoting T helper (Th) 2 polarization of naive T cells within the lymph node. These polarized T cells produce Th2 cytokines such as IL-4, IL-5, and IL-13, which have been implicated particularly in allergic eosinophilic asthma. Animal models have positioned both TSLP and OX40/OX40L as critical in the development of airway inflammation and hyperreactivity. In human disease, there is good evidence that TSLP is upregulated in asthma, but there are limited data to demonstrate overexpression of OX40 or OX40L in disease. Targeting the OX40/OX40L axis or TSLP presents a novel therapeutic strategy that has the potential of modifying the disease process and, therefore, impacting on its natural history. Whether this approach can demonstrate efficacy in established disease rather than at disease onset is unknown. Biologic therapies directed toward OX40/OX40L are in early phases of development, and results from these studies are eagerly awaited.
Over the past 50 years, we have seen dramatic changes in cardiovascular science and clinical care, accompanied by marked declines in the morbidity and mortality. Nonetheless, cardiovascular disease remains the leading cause of death and disability in the world, and its nature is changing as Americans become older, fatter, and ethnically more diverse. Instead of young or middle-aged men with ST-segment elevation myocardial infarction, the "typical" cardiac patient now presents with acute coronary syndrome or with complications related to chronic hypertension or ischemic heart disease, including heart failure, sudden death, and atrial fibrillation. Analogously, structural heart disease is now dominated by degenerative valve or congenital disease, far more common than rheumatic disease. The changing clinical scene presents cardiovascular scientists with a number of opportunities and challenges, including taking advantage of high-throughput technologies to elucidate complex disease mechanisms, accelerating development and implementation of evidence-based strategies, assessing evolving technologies of unclear value, addressing a global epidemic of cardiovascular disease, and maintaining high levels of innovation in a time of budgetary constraint and economic turmoil.
Over the last decade, endobronchial ultrasound (EBUS) evolved into a validated and powerful diagnostic tool. Although it is integral to medical care in some health-care systems, others struggle to justify its purchase based on diminishing reimbursement. In analyzing its value to a health-care system, looking at procedural reimbursement alone will grossly underestimate its economic impact. Downstream revenue has been defined by administrators as revenue captured after patients use one hospital service and then use others. By analyzing consecutive EBUS cases and taking downstream revenue into account, $2.4 million in collections was attributed to 97 patients who were newly referred for this procedure.
Mucinous bronchioloalveolar carcinoma (BAC) can be associated with significant bronchorrhea. A 46-year-old man presented with BAC with 2,000 mL of sputum production on a daily basis, which prevented him from being extubated. As this condition is rare, there are only case reports outlining the therapy for the associated bronchorrhea. We used azithromycin, scopolamine, and inhaled fluticasone with moderate success. The initiation of an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, gefitinib, resulted in dramatic improvement in the volume of pulmonary secretions produced. The patient's EGFR mutation status was subsequently found to be negative, which supports the hypothesis that the mechanism of reduction of bronchorrhea is independent of the antiproliferative effect of the drug.
The polymyxins (polymyxin B and E) are bactericidal polypeptide antibiotics first discovered in 1947 and used for the treatment of gram-negative bacterial infections. Renal and neurologic toxicities coupled with the increasing availability of effective alternatives led to declining use in the 1960s. The emergence of multidrug-resistant organisms in the past decade has resulted in a resurgence in the use of polymyxins in critically ill patients, yet the side effects are not well known. We report two cases of respiratory arrest likely due to polymyxin B infusions in the context of a 10-fold increase in the use of polymyxin B in our institution over the past 10 years.
Plain chest roentgenogram remains the most commonly ordered screening test for pulmonary disorders. Its lower sensitivity demands greater accuracy in interpretation. This greater accuracy can be achieved by adhering to an optimal and organized approach to interpretation. It is important for clinicians not to misread an abnormal chest radiograph (CXR) as normal. Clinicians can only acquire the confidence in making this determination if they read hundreds of normal CXRs. An individual should follow the same systematic approach to reading CXRs each time. All clinicians must make a concerted effort to read plain CXRs themselves first without reading the radiologist report and then discuss the findings with their radiology colleagues. Looking at the lateral CXR may shed light on 15% of the lung that is hidden from view on the posteroanterior film. Comparing prior films with the recent films is mandatory, when available, to confirm and/or extend differential diagnosis. This article outlines one of the many systematic approaches to interpreting CXRs and highlights the lesions that are commonly missed. A brief description of the limitations of CXR is also included.
Correspondence to: Suhail Raoof, MD, FCCP, Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, 506 Sixth St, Brooklyn, NY 11215; e-mail: email@example.com
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).
Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Sung was the principal investigator for Broncus Technologies 2007 to 2009. Drs Suhail Raoof, Feigin, Sabiha Raoof, Irugulpati, and Rosenow have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Part 2 of this review of ICU scoring systems examines how scoring system data should be used to assess ICU performance. There often are two different consumers of these data: lCU clinicians and quality leaders who seek to identify opportunities to improve quality of care and operational efficiency, and regulators, payors, and consumers who want to compare performance across facilities. The former need to know how to garner maximal insight into their care practices; this includes understanding how length of stay (LOS) relates to quality, analyzing the behavior of different subpopulations, and following trends over time. Segregating patients into low-, medium-, and high-risk populations is especially helpful, because care issues and outcomes may differ across this severity continuum. Also, LOS behaves paradoxically in high-risk patients (survivors often have longer LOS than nonsurvivors); failure to examine this subgroup separately can penalize ICUs with superior outcomes. Consumers of benchmarking data often focus on a single score, the standardized mortality ratio (SMR). However, simple SMRs are disproportionately affected by outcomes in high-risk patients, and differences in population composition, even when performance is otherwise identical, can result in different SMRs. Future benchmarking must incorporate strategies to adjust for differences in population composition and report performance separately for low-, medium- and high-acuity patients. Moreover, because many ICUs lack the resources to care for high-acuity patients (predicted mortality >50%), decisions about where patients should receive care must consider both ICU performance scores and their capacity to care for different types of patients.
There is a strong association between sleep-related problems and neurologic diseases. Neurologic diseases of the CNS can directly cause sleep problems when sleep-wake mechanisms associated with the ascending reticular activating system are involved. The major sleep disorders associated with neurologic problems are outlined in the International Classification of Sleep Disorders, 2nd edition, as hypersomnias of central origin, sleep-related breathing disorders, the insomnias, circadian rhythm sleep disorders, sleep-related movement disorders, parasomnias, and sleep-related epilepsy. In a patient with CNS disease and excessive sleepiness, sleep-related breathing disorders should be a first concern, given the known association between obstructive sleep apnea (OSA) and cerebrovascular disease and the potential confounding effects that OSA might have on an otherwise compromised ischemic CNS penumbra. A basic knowledge of the anatomy and physiology of the sleep-wake mechanisms provides a rationale for pharmacologic intervention. Nonpharmacologic treatments are also important, especially when sleep-related breathing disorders are a concern. In addition, as patients with neurologic diseases are often prone to the adverse effects of many medications, the specific treatment regimen for any given individual should always include good sleep hygiene practices that use cognitive behavioral therapy.
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text:
Lions, Tigers, and Monkeys...Oh my!
Trip Start Aug 27, 2011
10Trip End Aug 31, 2012
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Shanghai Zoo
For our field trip we went to the Shanghai Zoo. Like previous field trips, it was a bit of a mess because most of the time no one knew what was going on. I was assigned to Aston and we were going to spend most of the day at the zoo and then go back for nap time. I was really excited for the kids because they made a zoo the day before with pictures on a collage. We talked about our favorite animals but it wasn't the same as seeing the animals in real life.
After the exciting bus ride where we pointed out cars and trucks...my kid's favorite thing...we waited around for what seemed like an eternity with my class for the tickets. Without direction of what to do next, I took the parents and children forward only to be turned around by Morgan to head the opposite way. We spent a long time looking at the monkeys. Each monkey was a new adventure to see what they were doing
Other animals we saw at the zoo were elephants, zebras, giraffes, a lion, a tiger, and many more. We couldn't see all of the animals but every animal we saw the children were amazed.
The day after the zoo we sang a song in my class.
"We went to the zoo, we went to the zoo
Hi-ho the derry oh! We went to the zoo.
We saw a monkey and we saw Valentina too."
The kids are so funny because they would add in new animals and their names to the song.
The pictures are what makes this blog and not the story. It was a great experience and 2 weeks later the children are still talking about it.
This blog also has pictures from my neighborhood as I walked to the gym as well as pictures from the English class I teach after school on Wednesdays.
My students also decorated eggs for Easter the day after the zoo and they were amazed at how they could roll the egg and it would change colors. The little things we miss as kids.
Post your own travel photos for friends and family More Pictures & Videos

subset: commoncrawl


text:
Jul 8, 2013|
Don Cherry joined the show to discuss the Bruins trade of Tyler Seguin. Grapes thinks the Bruins acted too quickly and that they will regret the trade down the line.
Transcript - Not for consumer use. Robot overlords only. Will not be accurate.
-- back Dennis and -- little -- radio stuff -- and hand -- real hook up with a pal -- in the 36 years I -- covering sports in -- -- Only three coaches getting fired may be sad. Pete Carroll -- -- a lot yeah. Walpole Joseph Morgan when the Red Sox got rid of him body count. And -- not Bobby Valentine. Don share he has -- small -- cap on Hockey Night in Canada on grape cherry joins us on the AT&T hotline AT&T forgy LTE good morning mr. Jerry how -- -- my -- I'm glad dug out of Europe. Sorry I was that I don't think Kerry was to. Did you think of Perry asked are very good back flip for about a week and a half on. Perry was at that time we were not very good enemies -- -- it was a couple of cartoons in the paper and had become an aristocracy in and every bit and that -- is definitely got a Don -- on elected. They've got that lifetime contract. There was another or great whether cartoon. And it I would I would block and a way of blue without regard to the other regular -- great site to our -- a little helper Harry. Brent now you you patch it up. Yeah we -- up at the last Barack. We cut it up but let's face -- your estimation dog did Peter to rally the Bruins give up on Tyler Sagan to quickly Gloria. -- you know the kids sentiment thirteen. And other people what happened there I'm a little upset that they you know they targeted -- the -- It's 41 years old I mean I would be a part myself. And I don't understand that one day that's the way I think fear would happen and you got currency. And you got Bergeron better and the kids and natural -- -- -- right wing here before got thirty gold. Is going along pretty good and and they bring in yarder. Yarder in the playoffs I used to watch the power play would play about a minute and three quarters -- this played out obviously to but it went exactly two minutes. He got the last -- being second of every power play. I mean I can you end up. You know and Eric and I -- -- -- occupant of the big get a good occupier but that's -- -- and got twelve goals he then got sixteen. Ericsson not a good club but you know minus nine the damage you can believe it -- 22 yeah. And Eric had eight minutes of penalties though you know where he's coming from again at 20/20. Two minutes the appellate got what I continue to that something must happen there. You get rid of a -- like I'm sure he's gonna Iguodala and got to play better and look out I'm -- -- this kid. Is that as is one step away from being a superstar you're seeing -- but as he's gotten about books somehow in. You know I have to watch you have to watch the Bruins have a real. Damage. A billion pop right off the play against that's the -- and unity in the nineteen Canadians on the club. And every one of them are are are rough rough guys who votes start to lose it to go down with. The thing. Chicago had 23 Canadian partners in their organization. LA who won the championship the year before -- 27 inning and I shouldn't be in the not a US. Network but the fact they're back. -- they have to watch that date they don't lose that little grip because most people are afraid to go and play about yeah. But -- do you -- and did you buy into the idea you his story and herald last week that. There's security guard at a hotel and all make -- get away from his house skeptics -- wouldn't allow I mean I understand guys crawl was some martian does a lot of guys do. Is a -- idea that -- gotten so lot of control was taken note there was no going back. Well I bureau brawl at the hotel -- but I understood there both of them -- at the hotel anyhow. And I think that the what happened once when you know the word commode Canada you know a big deal. Big deal here especially around Toronto because we know on so well that we heard but stuff we I was shocked and let the guys. I'm 41 years old. I'm all by myself delivered by myself and after the game -- regular -- Michael Goldman not strictly. I know I'm gonna have a few different and I'm sure you guys would do. And -- what happened -- -- -- had two Beers. And I'd like I don't know what happened but I just say that I know I it will abide by with 21 years old after game might -- what our record toolbar to I don't like the idea that you would -- open it minute let's let's go to a -- that he did do what he did whatever they're saying he did. One of the people thought well equipped sort of what the percentages David you don't. I don't doubt that they'll get a -- -- Well maybe it's to stem the criticism for those people who think Tyler Sagan is a superstar in making NN and the Bruins organization once people are now well there's a reason we didn't just give away there's a reason it was a problem child here and so don't. Don't criticize us we had to do we have to do I guess that's the big idea -- What with the way. -- a guy can get these thirty big. Gold on the right wing and he's a natural better and he's a little problem the I would rather have -- I wouldn't mind that I try to fill out over the little right but I think what happened was when it got to. That they said that what the heck was that these. This is all I Norton wasn't as if we didn't trade him because of his on -- abilities. Well I mean now. You open up what city do like you know what what the heck did he do some like well IA unit and the broker in the final that -- pretty good though. Throw him out we don't have the right but -- -- -- in my opinion I would have never given up 122 year old. Is that a reported thirty gold the year before playing in the wrong position. Our behavior aside guys mature and develop and blossom at different times. And -- -- -- it's brought to my attention that Rick Middleton the number fourteen pick overall by the Rangers and 73. Played two years and didn't do much the Rangers came to Boston is 73 and developed into nifty. -- before he -- He. He -- with BI knew of him when he was in Providence civic and I thought that the lucky enough here at first big step into a perfect compliment and -- you don't -- it sure wouldn't mind -- saying that they got rid of them because of that reason and the reason this story was that both -- -- the story -- he told me that he -- -- one time that he had a little problem with John Ferguson. He said well look I'm gonna go in the basement. And I'll go up to my room migrate as he -- He got an abatement in the hotel. Got up at the door opened in the lobby -- -- who vetted John Hurt as. He who'd gone the next day and we got them and I saw my with the way he I would go to team Canada I can back there -- with -- in the practice I come back I mean this guy look like Porky Pig he was told about. It's if he he would get on I know you're gonna say what does he didn't have good he is here with known well I thought I'm. The October 20 -- because he's -- got a haircut -- -- -- not having to do with it but I'll tell you one thing I have played through them on the bench they get a -- recover the point he'll tell -- preacher turned into technical score a lot of thing is -- don't give up on that point three year old -- just because he has extracurricular. -- that -- activity because they give up on him and he turned into a goal scorer and by the -- get over 400 gold should be in the hockey -- Well -- -- got the long answer but that's my answer. This idea though Don with say can you hear hear all the time he just wasn't tough enough to play in Julian system he just. That he had twenty minute penalty that 48 him but. I -- you got it -- you're not gonna get a guy Rick you go to and he was hit I think hit it -- I think he was doctorate ladies and we've had a team that was. Monsters their beer and everybody was afraid of if you can't have everybody. -- of the world bank and you gotta have both nights I admit I thought he had it he had a little lead -- all the time. Hey -- short offseason for the Boston Bruins those who didn't make the playoffs get an extra six weeks what does that mean when training camp resumes and five minutes. Well when you don't win that pretty tough but I know what you're talking about and always -- -- -- -- -- get off to a bad start in the I don't know they did it and it is a war let's -- as you go for two months. But that here at the end -- -- he was -- that -- dollar bank unit -- and I mean that you're either basis they're. -- as a -- and both of them got cold there that I mean we did it every other night and he -- weird thought as well. It really does they can pull in and it pixel or I would get a cranked up again you can see every year nobody ever went back to back. Does that -- holes. Claude Julien to manage charged minutes a little differently next year you've got a couple two or three young defensemen coming up to take some load. Would it help him at the end of thought if he didn't play quite as much as you play during the regular season. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- Get a Paul DuPont in the globe. In the last week after the trade described Ericsson as Patrice Bergeron with a greater scoring touch is that accurate. Com law and could be he he he can talk. Bergeron burger on the -- the ultimate hockey player if you wanna occupy -- just talk to -- about what I can't say enough for both backed I mean. You've got caught in all right I don't think Derek have would play with a broken rib and punctured lung and -- separated shoulder all he's got a pretty good touch I have to admit they got a good guys back men knocking them but. Please Bergeron that this guy is the -- bowl he's he's their leader he is the god I can't say enough of. Regarding your estimation is Tuukka Rask a world class goaltender I've -- top three top. Or one group I don't want you to be in the MVP for sure and you know he kept them in their allotted enveloped earlier in the two goals he didn't. Nickel gold. Didn't -- it and what bowling with. He would beat tiger when he put it and -- Not knowing he would visit guys were -- maybe that I would do the best goaltender in hockey. -- was a good move firfer for the money. All the you had no choice. I think it was indicative offer anything -- had to give -- human -- -- He was the guy I mean look at I -- he is it about goaltender and occupied by a third. A -- or let you go and I know there's no such thing is replacing blue but did you get another dog. But did I got another would never the same that never liked it never did that they've been. Do everything that they had a good -- but not the light blue Honda and I have I ever on -- coach's corner I always cover on the opening and I get better because Betsy Stark. This year did does -- the new one -- on your lap and drink Budweiser of the camp. If -- this dog never. I had the lap the last pitcher we had taken with a broad we had we've been derelict bigger bullet forget which one. And that he pitcher there was blue implement lap he -- -- growing at area and all the guys collapsed at the headlines good group going to the -- Don cherry Hockey Night in Canada always a pleasure talking populated that I I a couple of I thought Jerry would Dennis -- on the AT&T hotline AT&T forgy LTE quick time out we'll go from what energy guide to another Stephen A Smith next with -- and Kirk.


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20 Feb
Posted by Gadgets as Audio/Video Gadgets, General Cool Stuffs, PC Hardware
Look no further than the SP/ Silicon Marvel M60, for experiencing the ultimate high speed USB 3.0 flash drive! Leading memory storage brand SP/Silicon Power today introduces its highest read/write speed USB 3.0 flash drive to date, the Marvel M60. The product hits a new milestone among SP USB 3.0 flash drive series by giving a read capability of up to 100/MB/sec. Encased in a uniquely designed, metallic exterior, the Marvel M60 is the consumer's choice, both inside and out!
Sans any ostentatious packaging, it seems like the flash drive wants its performance to do all the talking. Wrapped in a simple package, the device confidently shows off its stylish form factor through the transparent plastic on the front side while its features are jotted down on the flip side. Well, that's about it. Not that we were expecting anything more in the packet but an accompanying USB cable would do no harm. Now what sits in our hands comfortably is the sturdy Marvel M60 USB 3.0 flash drive of capacity 32GB.
Silicon Power was kind enough to provide me a sample of the Marvel M60 32GB USB3 flash drive for this review. The Marvel M60 series comes in two capacities, 32GB and 64GB. So now it's time to start this review.
The LED indicator on the front side of the device flashes blue light as soon as we connect it to a system. The drive measuring 73mm x 22mm x 9mm tips the scale at 15 grams. While these measurements leave no doubts about the portability of the device, its packet confidently announces the lifetime warranty which takes care of all questions regarding the durability. As it sports a pull-out design, all possibilities of losing the cap are eliminated and its slider seems sturdy enough to last long. To add to it, the drive meets all guidelines laid down by RoHS and is CE FC certified.
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From Our Friends
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Jenny just wrote about a delicious sounding citrus pulled pork that's cooked in a crock pot: http://food52.com/recipes...
I'm certainly not an expert on pulled pork, but an Army drill sergeant I know makes the BEST pulled pork ever. He hunts wild hogs, so wild, sweet meat is part of his secret. The other part is cooking the meat in a CrockPot on low heat, bathed in 3 parts apple cider vinegar and one part water, till it falls apart. I wish that I had his sauce recipe, too, but I don't.
Use a pork butt, brown it on a grill then put it in a crock pot with 1 can of cola, 1 onion sliced thin, any other spices or seasonings you so desire and just barely cover with water. Cook time will be a few hours (3-6) depending on the size of your pork and the temp of you pot, but just cook it till it pulls apart easily. Mix in your favorite BBQ sauce at the end, I usually just make a quick sweet sauce for mine. Ciabatta rolls work great as a bun.
Get the recipes and features that have us talking, plus first dibs on events and limited-batch products.
(Oh, and $10 off your order of $50 or more in the Food52 Shop, too.)


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Article Preview
Stokes to Be Married to Lettice Lee Sands; He Divorced Rose Pastor Last October
J.G. Phelps Stokes, millionaire Socialist, who divorced Mrs. Rose Pastor Stokes, storm centre of many Socialist and Communist troubles, is to be married tomorrow to Miss Lettice Lee Sands at the home of his sister, Mrs. Ransom Spafard Hooker, 173 East Seventy-first Street.
March 12, 1926
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Consumer Deception and a Potential Health Hazard
In 2004 the Food and Drug Administration (FDA) allowed the use of carbon monoxide in consumer-ready fresh meat packaging. The use of carbon monoxide in fresh meat causes a chemical reaction that creates a substance that makes the meat look red and fresh beyond the time it is safe to eat. Because consumers use appearance as the principal indicator of freshness, this is a serious issue of deception and food safety.
A petition was filed with the FDA on November 15, 2005 asking the federal agency to withdraw its allowance of this practice.
No action has been taken on the petition thus far and carbon monoxide treated meat remains available in some supermarkets.
The GRAS ("Generally Recognized as Safe") notices that were accepted by the FDA, thereby allowing the use of carbon monoxide in fresh meat packaging, are available here.
We will continue to update this website as new information becomes available. You can get more general carbon monoxide information, advice about carbon monoxide alarms and detector placement available here
Please see the links above for relevant documents.
For additional information please contact: firstname.lastname@example.com


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What is Academic integrity?
It is the moral code or ethical policy of academia. This includes values such as avoidance of cheating or plagiarism; maintenance of academic standards; honesty and rigor in research and academic publishing. (Wikipedia.com)
What is plagiarism?
According to the Undergraduate Catalog of William Paterson University, it defines plagiarism as "the copying from a book, article, notebook, video, or other source material, whether published or unpublished, without proper credit through the use of quotation marks, footnotes, and other customary means of identifying sources, or passing off as one's own the ideas, words, writings, programs, and experiments of another, whether or not such actions are intentional or unintentional."
It further describes that "plagiarism will also include submitting, without the consent of the professor, an assignment already tendered for academic credit in another course." (Undergraduate Catalog, William Paterson University, 2002)
How to Recognize Plagiarism?: Examples
How to Avoid Plagiarism?: Avoiding Plagiarism
William Paterson University Academic Integrity Policy: Policy Policy for students


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The Best Teas For Your Health
Tea is the second most popular drink in the world besides water, but unlike water, tea comes in a wide variety of flavours and can even be infused into other types of food and drink.
But with such a wide selection of teas to choose from, the problem can be finding the right brew for you. Picking the perfect tea can involve a lot of factors, including taste, sensitivity to caffeine and desire for a particular physical or mental effect.
According to Toronto-based health and nutrition expert Rosanna Lee, regular brewed tea makes for a great, low-calorie, mid-day treat — plus it keeps you hydrated. But drinking tea isn't just a good option for weight control. Different teas can also have different effects on your gut, brain and muscles, thanks to their ingredients.
While the caffeine in coffee, for example, gets praise for reducing the risk of a stroke, some teas can contain up to 70 mg of caffeine per cup, slightly less than a cup of joe, according to the Mayo Clinic, meaning they'll have the same effect.
Meanwhile, stimulants like peppermint are also known to help relax stomach muscles, allowing for gas to pass and bloating to decrease.
Of course, if you're loading up your cuppa with cream, sugar, honey or milk, you might be counteracting any benefits in your brew. Lee suggests limiting sweeteners and opting for skim milk or low-fat dairy alternatives in place of full fat milk.
Take a look at six types of tea she suggests for the most health benefits per cup:
Ginger on its own has long been touted as a natural medicine due to its anti-inflammatory properties, its ability to reduce nausea and relive settle an upset stomach. Instead of eating ginger, reap the benefits by whipping up a cup or pot of homemade ginger tea.
Just like ginger, peppermint has been known to tame tummy troubles. But the herb does a lot more than that, including easing headaches, curbing cravings and clearing a stuffy nose. Tap into the power of peppermint by pouring out yourself a cup of peppermint tea the next time you feel bloated or tired.
Green tea in general contains powerful antioxidants that can help protect against cellular damage, says nutrition expert Rosanna Lee. This tea has been found to increase alertness and help improve concentration, helping you with mental and physical performance. To get more concentrated antioxidants out of your tea, steep the tea longer and opt for matcha tea instead of a green tea bag. Matcha powder is made from whole tea leaves and it is regularly consumed in its entirety when prepared.
You've probably heard about the benefits of drinking lemon water, but you might not realize drinking lemon tea is practically the same thing. Adding real lemon juice to make lemon tea can also provide you with vitamin C, an antioxidant that can help protect your body's cells from free radical damage. Vitamin C is also essential in helping your body undergo its daily repair and maintenance of skin, blood vessels, cartilage and tendons, says Lee.
Chamomile is known to be effective in reducing swelling, while fighting bacteria. Other studies have pointed to its ability to alleviate stomach cramps. If you are allergic to flowers, pollen or ragweed, you should avoid chamomile, as pollen found in some chamomile tea varieties can cause allergic reactions. Chamomile may also interfere with blood thinner (anti-coagulant) medications, says Lee.
Those that are pregnant, lactating or have chronic conditions that require medications should always consult a certified health practitioner for the best advice when trying new teas, warns Lee. Through teas are normally not concentrated enough to cause any major harm, excess consumption can cause complications.


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Protecting the starter on a sbc
Got a quick question for you guys.
I have an issue with the starter on my s10. Due to how the headers are routed, the starter gets alot of heat.
That heat makes it almost impossible to crank after the motor has been running for awhile. I first thought it was a timing issue but adjusting the timing makes no difference. I have also replaced all the wiring to the starter and bought a battery with higher cranking amps.
The only constant has been the starter and I still have the same issue.
I plan on getting a new starter in the extremely near future and wanted to know what you guys would suggest as far as sheilding it from all that heat.
Wrapping the header isn't really an option.
So, should I try and wrap the starter itself?
Did any SBCs come with a heat shield for the starter?
Protecting the starter on a sbc
Moroso make bolt on heat shields for regular and mini size starters and Thermotec makes thermal wrap,use whatever is easier would be my suggestion.I have a Moroso shield on on mine and it works fine.
Add grounds, one from the frame to the block, another from the block to the battery, another from the firewall to the block. It worked for me.
1 Attachment(s)
I had the same problem on my 86 cutlass. I used a ford solenoid from a late 80's crown vic. I've attached a picture on how to wire it. But instead of using a piece of wire as the short I used a piece of copper pipe for plumbing. I cleaned it very well then flattened it with a hammer. You have to bend a kink in it, you should be able to see what I mean by looking at the solenoid. Then all you have to do is drill a couple of holes and mount and wire it. I never had a problem after that even on hot summer days. There are kits out there but I say DIY. Hope it helps.
Doc here, :pimp:
My opinion is use a heat shield..Logically , anything that can hold heat OUT (heat wrap) Can also hold it IN...
GM actually has a PN For the shield, (I haven't a clue what it is though..) so you should be able to find one just about anywhere.
Doc :pimp:
I haven't actually seen before exactly what the shield looks like. How far does it stick out from the starter?
Listen to RippiRon. I had the same problem with my Olds. Chased the problem for a while. New wires, larger battery cables, checked all grounds, checked and rechecked timing, 2 types of starter shields and so on. Finally, I gave in and put a remote solenoid on the car, and no more problem. The battery doesn't bog down anymore and the car starts without hesitation now, whether hot or cold.
Had the same prob with my S-15/350 swap. Tried all of the above and finally went to a mini starter that I could rotate away from the hedders, that was the final fix. My 99 Silverado has a heat shield on it from the factory, so if you see one in a junkyard you could pull it off of one of them, it just pushes on.
Here's an article that may be informative http://www.chevyhiperformance.com/te.../148_0312_hot/
A starter heat shield is a good idea, providing you can get it in. On my engine, one header tube (Hooker headers) is about .010 away from the solonoid. I even had the speed shop (Lopers here in Phoenix) bend the headers as far as they could and it still had hot start problems. Many years ago I installed the Ford solonoid and its been flawless every since. That was an actual Chevy "fix" many years ago. It came out as a TSB for certain large delivery vans with "no start" problems when hot.
It may also be that the starter is going bad.I have an 85 S10 with a 350 running Patriot headers,using a stock starter and have not had any problems so far. I did wrap the starter motor and solenoid with reflective duct tape used in HVAC before installing.Hope this might also help.
Thanks for all the ideas guys. I really appreciate the input.
I looked at wrapping the starter and don't think it will work.
I have also been checking out different heat shields to see how well that would work.
I think I may go with the "remote" solenoid idea....especially since I have a barnd new one wasting away on that cougar I can't seem to sell.
I'll probably try a couple of different things before settling on one fix.
I'll make sure to post here again and let everyone know what worked.
for my 400 in my elky it has stock manifolds but has a small leak and it was also not liking to turn over when it got hot. I picked up a heat shield from my local autozone in that section of "help" parts. If I recall it was under 5 and was just a piece of metal that covered the solenoid and left a small air gap around it for cooling. So far no troubles since but once I get my headers installed that could change :)
All great ideas. The remote solenoid works.
Heat shields can be made easily from aluminum that comes in rolls for roof shingle flashing, etc.
Make a shield on the header itself and install with hose clamps,
Make another for the starter installed with a big hose clamp,
Cool air can pass between them and around the starter for decent cooling.
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text: I've got a 2005 GMC Yukon XL 4x4 w/ about 70,000 miles. Yesterday I drove from Dallas TX to Austin TX and upon reaching Austin, noticed the truck starting to shift slightly erratically (hopping between 3rd and 4th on hills where it shouldnt be). Several hours later I drove the truck around town and had no trouble. Today, I headed back to Dallas and made it as far as Waco. Right as I reached Waco, I lost overdrive, then within a couple of minutes the truck wouldnt stay in third on the highway. I exited and let the truck sit for several minutes. It was a bit low on transmission fluid (not critically so, but low enough that I added a quart). I let the truck sit for about an hour then tried it back up. I can get into second gear but as soon as I rev it far enough to jump into third, it crashes back into first. I left it in Waco and will have it towed to the closest stealership tomorrow when I drive another car back down to it (hopefully it'll be fine where I left it). I cannot believe that the transmission would be toast at 70,000 miles, but with how it was acting I have trouble believing its anything else. Anyone have an ideas on how bad this is going to be? $$$


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Liz Jones Makeup Artist Makeup Artist
LukaPhotoPhotographer Male Portland, Oregon, US
My Website: LukaPhotoMy MM URL: http://www.modelmayhem.com/lukaphoto
Mayhem # 690738
About Me
welcome to the model mayhem portfolio of lucas balzer. my top 20 portraits live here, on occasional rotation as a new stellar piece knocks off one that i've grown tired of having on display.
if you are in portland metro and are interested in shooting, you should contact me. if you're looking to do tfp, please also be willing to come with some ideas of your own -- i want to collaborate, to work with someone who will commit some thought to the project and is interested making art.
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Modern apartment near Les Halles (Tiquetonne)
숙박 가능인원6
침실 수2
면적55 m²
Floor No.(with elevator)
- 가족 / 아이들과 친근함
- 부엌
- 세탁기 / 건조기
- 엘레베이터
- 인터넷
Accommodation summary
Lively area with its multiple traditional shops (butchery, cheese dairy, bakery, grocery, fish shop ...).
Numerous touristic places nearby :
- In less than 10 minutes walking is the "Place de la République" with stores (famous for clothes), night clubs, coffee shops and restaurants. And the "Canal Saint-Martin".
- Less than 10 minutes to the Louvre Museum, the Palais Royal and the Tuileries Garden.
- Less than 15 minutes to the Seine River, the "Ile Saint-Louis" and the "Ile de la Cité" with its Notre Dame cathedral of Paris.
- Less than 20 minutes to the "Place des Vosges" with its art galleries and the Square Louis XIII.
- Less than 25 minutes to the "Place de la Bastille" with its coffee shops, restaurants, clubs, fashionable clothes shops…
And many other places to discover…
Two covered parkings are accessible by walking from the flat : located on "rue Saint-Denis" (3 minutes) and on "rue Dussoubs" (4 minutes).
The nearest metro stations are : "Etienne Marcel" station (2 minutes), "Les Halles" station and "Sentier" station (5 minutes).
This bright flat offers a total surface of 55 sqm.
It consists of 2 levels.
- 1st level : a living room, an open fully equipped kitchen, a bathroom with toilet, a bedroom.
- 2nd level (mezzanine) : a bedroom.
Please notice that the flat is "ready to live".
It was renovated in November 2013.
There is a large bed of 140 x 200 cm (2 persons) in the 1st level bedroom, a large bed of 140 x 200 cm (2 persons) in the 2nd level bedroom, a sofa bed in the living room (1 person) and an extra mattress (1 person).
A baby cot can be provided on request (10 Euros per day).
A Service Pack (including one set of linen, one cleaning on arrival and some cleaning supplies) of 60 € is to be added for this flat.
Attention : fees apply to payments by PayPal and to transfers resulting from outside the Euro countries. It will be added to your balance.
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The flat was in good condition, it was clean and we were provided with sheets, pillows, towels, cutlery, etc.
The bed was ok but the sofa bed was very noisy and uncomfortable, the toilet wasnt that great either but we survived, and the bathroom would have been fine if it wasnt for the mold on the ceiling.
The area is really good, with loads of bars and cafes, it seems like a young area with many transport links, Notre Dame and the Cemetery were only a few minutes walk, so it was convenient.
Overall it was good accomodation for the price that we paid.
Apartment is located near to the top of Montmartre which has its own special charms. However, the apartment is located above a busy restaurant, the neighbors are noisy and a number of things in the apartment need repair . Not really value for money.
Apartament has very good location near by the main centre of Paris- Arc the Triomphe and near bus station to airport . It is safe place , at nigt we walked aroud to admire city . The equipment was sufficient for couple of days - we were preparing dinner.The apartament is worth its price .In future I am going to rent it
The property was nice, location of the property was very good. Lost of shop, bars and very comfortable to reach city center by walk or metro. 10 -15 min walk to Notre Dame Cathedral.
Due to fact that in August you can park your car in some streets for free we got parking next to the flat.
Bed was very comfortable, but sofa-bed was very uncomfortable.
I tried Wimdu.co.uk first time, but now I can say that not the last time. Thank you very much for nice place in Paris:)
A studiot for up to 4 people. Close to metro, supermarket, restaurants and much more.
The apartment was not clean. The bathroom is full of mold it was really dirty. The faucet in the kitchen was almost disattached kitchen sink .
Thank you for three wonderful days in Paris. Everything was so simple with the flat - picking up the key, finding the flat, leaving the flat - a brilliant system :-) And the flat is really beautiful, with a nice view over the roofes of Paris and the Eiffeltower... We had everything we needed! There is a supermarket on the opposite side of the street and a bakery on the corner. We walked to Sacre Coeur (about 25min). The next Metro station is about 5min walk - so a really great location :-)
Very good location, near the station and clean.
We had a wonderful stay in Paris and the flat was perfect for us! It is bright and lovely decorated and also close to metro, supermarkets and (very good) boulangeries.
Very good location, but small, and warm. For the price, though, an excellent value.
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