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JACC: Cardiovascular Interventions
Percutaneous Circulatory Assist Devices for High-Risk Coronary Intervention
Author + information
- Received July 8, 2014
- Accepted July 17, 2014
- Published online February 1, 2015.
Author Information
- Aung Myat, MBBS∗,
- Niket Patel, MBBS†,
- Shana Tehrani, MD‡,
- Adrian P. Banning, MD, PhD†,
- Simon R. Redwood, MD∗ and
- Deepak L. Bhatt, MD, MPH§∗ (dlbhattmd{at}post.harvard.edu)
- ∗King's College London BHF Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St. Thomas' Hospital, London, United Kingdom
- †Department of Cardiology, Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- ‡Hatter Cardiovascular Institute, University College London, London, United Kingdom
- §Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
- ↵∗Reprint requests and correspondence:
Dr. Deepak L. Bhatt, Brigham and Women's Hospital Heart & Vascular Center, 75 Francis Street, Boston, Massachusetts 02115.
A unifying definition of what constitutes high-risk percutaneous coronary intervention remains elusive. This reflects the existence of several recognized patient, anatomic, and procedural characteristics that, when combined, can contribute to elevating risk. The relative inability to withstand the adverse hemodynamic sequelae of dysrhythmia, transient episodes of ischemia-reperfusion injury, or distal embolization of atherogenic material associated with coronary intervention serve as a common thread to tie this patient cohort together. This enhanced susceptibility to catastrophic hemodynamic collapse has triggered the development of percutaneous cardiac assist devices such as the intra-aortic balloon pump, Impella (Abiomed Inc., Danvers, Massachusetts), TandemHeart (CardiacAssist, Inc., Pittsburgh, Pennsylvania), and extracorporeal membranous oxygenation to provide adjunctive mechanical circulatory support. In this state-of-the-art review, we discuss the physiology underpinning their application. Thereafter, we examine the results of several randomized multicenter trials investigating their use in high-risk coronary intervention to determine which patients would benefit most from their implantation and whether there is a signal to delineate whether they should be used in an elective pre-procedure, standby, rescue, or routine post-procedure fashion.
- diastolic augmentation
- extracorporeal membrane oxygenation
- high-risk PCI
- intra-aortic balloon pump
- mechanical circulatory support
The evolution of percutaneous coronary intervention (PCI) has witnessed unprecedented advances in the past 2 decades. In the wake of such progress, interventional cardiologists are now attempting revascularization of more complex coronary anatomy in patients often declined for surgical intervention. Yet with greater complexity comes greater risk, hence the development of percutaneous mechanical circulatory support (MCS) devices. Borne from a sound physiological platform, in theory they serve to maintain coronary perfusion pressure and reduce myocardial workload, allowing the operator sufficient time to optimally complete the procedure. In this review, we highlight the criteria that elevate PCI to the high-risk category. Thereafter, we compare and contrast the physiology and evidence base underpinning MCS use to determine where these devices sit in the wider context of high-risk PCI.
What Defines High-Risk PCI?
A universally accepted definition of high-risk PCI remains elusive. This reflects the myriad adverse clinical, anatomic, and hemodynamic factors that, if taken in isolation, are potentially surmountable but when combined, will significantly increase the chance of periprocedural, subacute, medium- and long-term major adverse cardiac and cerebrovascular events occurring.
High-Risk Criteria used in the Current Evidence Base
The diversity of criteria adopted by investigators to study the performance of percutaneous circulatory assist devices (PCADs) (Table 1, Online Appendix) would suggest a lack of consensus on what defines high-risk PCI. This makes robust intertrial comparison speculative at best and standardization problematic, especially when patient characteristics, procedural adjuncts, timing of hemodynamic support, and metrics of risk are largely heterogeneous (1,2). To this end, the definition of high-risk PCI becomes somewhat arbitrary, reflecting a need to pigeonhole the population under investigation to satisfy inclusion criteria rather than corresponding to universally accepted parameters. This also limits our ability to recommend one model of risk stratification over another. Moreover, risk scores may identify who might benefit from MCS, but they do not, as yet, inform the operator as to which PCAD to use or whether it should be used in an elective pre-procedure, standby, rescue, or routine post-procedure fashion. Despite these inconsistencies, there is a common thread. It is the relative inability of the high-risk patient to withstand the deleterious hemodynamic consequences of dysrhythmia, transient intervals of ischemia-reperfusion injury, or the distal embolization of atherogenic material (i.e., the no-reflow phenomenon) associated with PCI. A high-risk patient may have significantly attenuated cardiovascular reserve and be increasingly susceptible to post-ischemic stunning. The onus falls on the heart team to recognize this patient subset, anticipate potential difficulties that may occur during the procedure, and decide whether MCS is an appropriate intervention. Otherwise, a chain of deleterious events may ensue, leading to further reduction in cardiac output (CO) and an amplification of ischemia, culminating in cardiogenic shock (CS) or malignant ventricular arrhythmia. Conversely, the patient may already be in CS on presentation, a diagnosis based on evidence of hypotension (systolic blood pressure <90 mm Hg), end-organ hypoperfusion (cool extremities and urine output <30 ml/h), a cardiac index (CI) of ≤2.2 l/min/m2, and a pulmonary capillary wedge pressure of ≥15 mm Hg (3). A mixed venous blood oxygen saturation <65% may also be incorporated (4).
Key Fundamentals of Mechanical Circulatory Support
Once Kantrowitz et al. (5) had performed the first-in-human intra-aortic balloon pump (IABP) implantation in 1968, the following 4 basic characteristics for an MCS device to have a therapeutic impact on CS management had already been proposed: effective insertion with minimal surgical application; simplicity of initiation and maintenance for widespread use by minimally trained professional personnel; capability for aiding the coronary and peripheral circulation intermittently or continuously for hours or days; significant support for the ischemic myocardium by reducing its work (Figures 1 and 2⇓⇓).
Maintenance of End-Organ Perfusion
The landmark SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial demonstrated a mid- to long-term survival advantage for early revascularization versus medical stabilization for managing acute myocardial infarction (AMI) complicated by CS (3,6,7). Although not primarily a trial of IABP, ≥86% of participants in each trial arm received a balloon pump, reflecting both the severity of the clinical setting and it being the recognized mainstay of adjunctive MCS at the time. Moreover, IABP was recommended in the study design for those patients randomized to medical stabilization. Post-hoc analysis of the parallel SHOCK trial registry also confirmed the benefit of IABP for lowering in-hospital mortality (8,9). The SHOCK investigators introduced the concept of cardiac power output (in W = mean arterial pressure [MAP] × CO/451) and cardiac power index (in W/m2 = cardiac power output/body surface area) as novel hemodynamic parameters for the assessment and subsequent management of CS. Although seldom performed now, cardiac power output (p = 0.002) and cardiac power index (p = 0.004) were shown to be the strongest independent predictors of in-hospital mortality (10). A core function, therefore, of any PCAD should be to augment MAP and CO to maintain end-organ perfusion, thereby avoiding (or rationalizing) the use of supplementary vasopressor or inotrope therapy.
Optimization of Myocardial Perfusion
When the epicardial coronary arteries are patent, myocardial tissue perfusion is almost universally determined by an inverse correlation with microvascular resistance and the pressure gradient between the driving aortic force (proximal to the subtended myocardium) and coronary sinus/right atrial pressure (the distal vascular bed). During AMI, the microvascular resistance is high as a result of vasoconstriction, plugging related to microemboli, and ischemia-reperfusion injury. In CS, this is compounded by a decrease in driving pressure and an increase in right atrial pressure (11). Mechanical support devices should ideally facilitate myocardial perfusion by increasing the MAP and reducing right atrial pressure to overcome the higher resistance encountered in the infarct-related territory.
During systole, ventricular contraction exerts a compressive force on the microvasculature, and during ventricular relaxation in diastole, a large suction effect. As such, coronary blood flow (CBF) occurs predominantly in diastole (12). The ideal PCAD should lower left ventricular (LV) end-diastolic pressure. This, in turn, diminishes microvascular resistance and increases the perfusion pressure, subsequently increasing CBF and hence myocardial oxygen delivery.
Intra-Aortic Balloon Counterpulsation
The benefit of the IABP is underpinned by the concept of diastolic augmentation (13,14). Theoretically, this gives rise to greater myocardial perfusion by increasing the coronary pressure gradient from the aorta to the epicardial coronary circulation at a time when the aortic valve is closed (15). Active deflation immediately before the onset of systole and precisely at the beginning of isovolumic contraction creates a dead space in the thoracic aorta, which reduces afterload and promotes forward flow from the LV. This stimulates a reduction in LV end-diastolic pressure, volume, wall tension, and work (leading to a lowering of myocardial oxygen demand) along with preservation of or an increase in stroke volume, ejection fraction and overall CO (15). The magnitude of the hemodynamic effect is dependent on the balloon size in proportion to the aorta. The larger the balloon is, the greater the volume of blood displaced (Figure 1) (15). The blood volume displaced toward the aortic root has been calculated at 6.4% (during 1:1 inflation) and 10.0% (with 1:2 support) of the nominal balloon volume (16). The remainder is stored in the compliant aortic wall during balloon inflation or distributed among the branches along the arch. Although this percentage appears small, it represents a significant fraction of baseline coronary flow (16).
An increase in aortic compliance (or reduction in systemic vascular resistance), however, will result in diminution of the IABP effect. Moreover, as heart rate increases to maintain CO, LV and aortic diastolic filling times decrease, resulting in less balloon augmentation per unit of time elapsed. There is conflicting evidence on the degree of post-stenotic CBF augmentation achieved despite the increase in perfusion pressure. Some reports demonstrate no increase in CBF distal to a critical stenosis (17–19), whereas others have revealed an enhancement of distal flow, regardless of the presence or absence of obstruction (20,21). As such, the predominant benefit of IABP on high-risk patients with severe coronary stenosis may relate to a reduction in oxygen demand through LV systolic unloading over and above that stimulated by diastolic augmentation of CBF (19).
Observational and registry data
A recent U.S. CathPCI Registry analysis revealed that IABP use was limited to just 10.5% of all high-risk PCI procedures (22). This could partly reflect a lack of interoperator and interhospital consensus on what is deemed high risk. Indeed, the criteria used to define high-risk were superimposed retrospectively by the authors of the analysis and were not labeled as such by the operators at individual hospitals inputting the raw data (22). This should negate any selection bias at the source but could amplify any disconnect between what the operator or specific hospital protocol would recognize as high risk and what the registry analysis deems to be high risk. Furthermore, the registry analysis did not provide any information on the timing of MCS. Notably, after multivariate adjustment, neither in-hospital mortality nor complication rate varied between hospitals categorized by their frequency of IABP implantation. We must also accept how difficult it is to quantify the expertise, familiarity, and confidence that an individual operator has with the "kit" and what effect this, and the overriding protocol of the center, has on their decision to use a mechanical adjunct.
Similarly, a EuroHeart Survey PCI Registry of those patients revascularized for CS as a complication of AMI revealed that the IABP was only used in 24.8% of cases (23). Interhospital differences in the definition of CS may have led to significant selection bias. Again IABP use did not confer an overall survival advantage in this patient cohort (n = 653), lending credence to the decision not to use the device routinely (23).
Ultimately, current data from registries and retrospective analyses cannot be used to confidently support the IABP in high-risk PCI despite its being a low-risk therapeutic option. Some studies have shown a significant benefit of IABP in terms of in-hospital mortality (24) and freedom from catheterization laboratory events (25,26), whereas others have demonstrated no benefit (22,27–30) or even a trend toward harm (23,31).
Randomized trial data
Early ST-segment elevation myocardial infarction (STEMI) trials have shown benefit when IABP was implanted post-procedure for 36 to 48 h (4,32,33). Extrapolation to modern-day PCI, however, is difficult because patients were treated primarily by balloon angioplasty. The IABP has also been associated with reduced mortality when combined with thrombolysis for AMI (8,31). Latter-day single-center, randomized controlled trials (RCTs) have been underpowered to provide meaningful answers; trial participants and metrics of risk are heterogeneous, timing of MCS initiation varies, and their findings conflict (Online Appendix).
The BCIS-1 trial
The BCIS-1 (Balloon Pump-Assisted Coronary Intervention Study-1) was the first prospective, open, multicenter RCT designed to determine whether elective IABP insertion before high-risk single-vessel or multivessel PCI was able to reduce major adverse cardiac and cerebrovascular events at 28 days (34). Metrics of high risk included a modification of the Duke Jeopardy score. There was, however, no protocol-mandated assessment of coronary disease complexity or requirement for complete revascularization of all amenable lesions. Bailout IABP was permitted in the no-planned IABP group if clinical circumstances justified the intervention. There were similar rates of the primary endpoint of major adverse cardiac and cerebrovascular events in both treatment arms (15.2% elective IABP vs. 16.0% no planned IABP, p = 0.85). There was no significant difference in the secondary endpoint of 6-month mortality or overall rates of bleeding. When broken down, there were significantly more minor bleeds in the elective IABP arm (15.9% elective IABP vs. 7.3% no-planned IABP arm, p = 0.02). Conversely, periprocedural complications occurred more frequently in the no-planned IABP arm, predominantly due to procedural hypotension (1.3% vs. 10.7% in favor of elective IABP, p < 0.001), which might explain the need for rescue/bailout IABP in 18 patients (12%).
Overall, the study did not support the use of prophylactic IABP insertion before high-risk PCI. Given the rate of crossover, an initial strategy of standby IABP for PCI in those patients with compromised myocardial reserve and extensive coronary artery disease could attenuate the delay in gaining arterial access, and would therefore seem a sensible strategy. Interestingly, those patients requiring rescue IABP in the no-planned IABP group had a significantly higher BCIS-1 Jeopardy score (Jeopardy score 11.2 vs. 10.2, p = 0.02), further emphasizing the need for standby MCS in those at the extreme end of the risk spectrum.
Five-year all-cause mortality data from the BCIS-1 study are now available with complete capture of all trial participants using a central national database (35). The Kaplan-Meier curves demonstrated a significant survival advantage in favor of elective IABP (hazard ratio: 0.66, 95% confidence interval: 0.44 to 0.98, p = 0.039), which appear to be diverging further still at the 5-year mark. Analysis by treatment received also confirmed a mortality benefit in those 18 patients who had crossed over. No systematic differences were found between groups at baseline or regarding the extent of revascularization; both are potential confounders (35,36). The etiology of death, however, is unknown, hampering any efforts to mechanistically understand the reduced mortality seen in the elective IABP arm and limiting the ability to make any robust cause-and-effect associations. Since the trial was not originally designed to investigate all-cause mortality, inferences made can only be hypothesis generating. Nevertheless, the results should stimulate future studies to be powered adequately for all-cause mortality and to incorporate long-term surveillance so that differences not immediately apparent may be detected later.
The CRISP-AMI trial
The CRISP AMI (Counterpulsation to Reduce Infarct Size Pre-PCI Acute Myocardial Infarction) trial was a prospective, open, multicenter RCT undertaken to determine whether prophylactic IABP insertion within 6 h of pain onset and planned primary PCI (PPCI) for anterior STEMI (without CS) could reduce the mean infarct size, as measured by cardiac magnetic resonance imaging between 3 and 5 days post-intervention (37). IABP insertion in the PPCI alone group was at the operator's discretion for indications such as persistent hypotension, overt CS, malignant arrhythmias, and AMI complications. Of note, 15 patients (8.5%) initially receiving standard care crossed over to IABP. This again highlights the susceptibility of these high-risk patients to hemodynamic collapse, which in turn further supports the argument for standby MCS.
The primary efficacy endpoint was not significantly different between the 2 groups. Secondary cardiac magnetic resonance imaging measures such as mean LV ejection fraction and LV systolic volume were also similar. There were no significant differences in major bleeding/transfusion or major vascular complications at 30 days. By 6 months, mortality rates along with the composite endpoint of death, recurrent MI, or new or worsening heart failure had not diverged. There was a significant difference in the exploratory composite endpoint of time to death, shock, or new or worsening heart failure in favor of PPCI plus IABP (5.0% vs. 12.0%, p = 0.03). Like BCIS-1, longer term follow-up is planned for the CRISP-AMI population, which may uncover further trends as events accrue. For now, the investigators postulate that mean ischemic times (time between symptom onset to first device application) of longer than 3 h may have been outside a therapeutic window in which significant myocardial salvage could have occurred (37–39). This explanation contradicts an RCT in which LV infarct size was significantly reduced by mechanical reperfusion in AMI patients presenting 12 to 48 h after symptom onset (40). Overall, the trial was underpowered for the evaluation of clinical outcomes after IABP implantation. Moreover, the cohort studied was not that sick. Couple that with early reperfusion from PPCI having such a dominant effect on myocardial salvage and hence mortality, it could be argued that any further adjunctive measures would add very little to the net clinical benefit. A strategy of routine prophylactic IABP implantation in PPCI of STEMI without CS cannot therefore be advocated.
The IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial
The trial enrolled 600 patients with CS complicating AMI proceeding to early revascularization (almost double that of the landmark SHOCK trial), who were then randomized in an open-label manner to IABP or no IABP (3,41). Importantly, the timing of MCS was at the discretion of the operator and could be applied before PCI (n = 37, 13.4%) or immediately post-procedure (n = 240, 86.6%). The trial did not achieve its primary endpoint of 30-day all-cause mortality (IABP group 39.7% vs. control group 41.3%; p = 0.69). Indeed, the mortality rate itself appears relatively low compared with the original SHOCK trial (30-day mortality rate of 46.7% in the early revascularization arm), although trends in hospital outcomes associated with CS do confirm declining short-term death rates over time (42.0% case fatality rate in 2005) (3,42). As such IABP-SHOCK II may well have been underpowered to detect a difference in mortality. The "low" mortality rate also calls into question the definition of CS used by the investigators. There was an absence of mixed venous saturation, wedge pressure, and CI parameters used to satisfy a CS diagnosis (3,4). Moreover, there were a significant proportion of patients (IABP group 42.2% vs. control group 47.8%) who required resuscitation before randomization. Given that resuscitation for more than 30 min was an exclusion criteria, we can only assume that these patients required resuscitation for 30 min or longer, during which time their hemodynamic indices may have transiently satisfied a protocol-driven CS diagnosis. Furthermore, ∼80% of patients in each arm also required mechanical ventilation for a median of 3 days and spent a median of 6 days in the intensive care unit. The lower-than-expected mortality could thus be attributed to superior critical care management. Although entirely speculative, it does reinforce the notion that the population under investigation was not entirely representative of true CS.
There was also no significant difference in mortality between either MCS strategy (pre-PCI 36.4% vs. post-PCI 36.8%; p = 0.96). That patients received an IABP post-procedure would suggest that their perceived hemodynamic instability at randomization was not severe enough to warrant prophylactic support. On the contrary, had there been a protocol stipulation for prophylactic counterpulsation only, we might have observed greater benefit because susceptibility to circulatory collapse is heightened during PCI in this cohort. There was also a liberal use of catecholamines in almost 90% of patients in both arms at randomization. Given that a standout advantage of using MCS is to obviate the need to continue pharmacological circulatory support, it would seem to defeat the purpose of investigating IABP effects if these agents were so widely used. Catecholamines were continued for a median of 3 days in each trial arm. At 1 year, mortality remained similar in both arms (IABP group 52% vs. control group 51%; p = 0.91). IABP insertion did no excess harm, with no significant differences between either group in terms of stroke, bleeding, sepsis, or peripheral ischemic complications requiring intervention (41).
Are we expecting too much from a device that can only augment systemic blood flow by <500 ml/min/m2? Bear in mind the pathophysiology of CS is not only a compromise in cardiac contractile function but also encompasses a multiorgan dysfunction syndrome secondary to peripheral hypoperfusion along with microcirculatory dysfunction, often complicated by a systemic inflammatory response syndrome and sepsis (11,43). In light of these equivocal results, the use of IABP in CS complicating AMI has been downgraded from a previous Class I indication to a Class IIa and Class IIb recommendation in the most recent U.S. and European STEMI guidelines, respectively (Table 2) (44,45).
The Impella (Abiomed Inc., Danvers, Massachsetts) is positioned across the aortic valve under radiographic or echocardiographic guidance. It aspirates blood from the left ventricle into the ascending aorta. Impella-mediated LV unloading reduces end-diastolic wall stress, improves diastolic compliance, increases aortic and intracoronary pressure and coronary flow velocity reserve, and stimulates a decrease in coronary microvascular resistance (46,47). This may allow for recovery of hibernating or stunned myocardium. The pigtail conformation promotes stable positioning in the left ventricle and prevents adherence to the endocardium. The mode of deployment underscores the importance of ruling out pre-existing aortic valve disease or LV mural thrombus before implantation.
The Impella 5.0 requires surgical cutdown of the femoral or axillary artery and so is not truly percutaneous. The Impella 2.5 received U.S. Food and Drug Administration approval in June 2008 and can provide antegrade flow up to 2.5 l/min (Figure 1). The newly introduced Impella CP (known as cVAD in Europe) received U.S. Food and Drug Administration approval in September 2012 and is based on the same 2.5 platform but can provide flow up to 4.0 l/min. The IMPRESS in Severe Shock (IMPella versus IABP REduces mortality in STEMI patients treated with primary PCI IN SEVERE and deep cardiogenic SHOCK) trial (NTR3450) will compare the Impella cVAD with IABP in patients with CS complicating AMI awaiting PPCI. Current guideline recommendations for the Impella are shown in Table 2 (44,45,48–51).
The use of the Impella in high-risk PCI including CS is feasible according to registries and small single-center studies, with demonstrable improvements in CI and myocardial performance (Online Appendix). However, the increase in vascular access–related issues and the propensity for hemolysis due to the high rotational speed of the axial flow pump do not appear to be outweighed by any significant gains in survival. The EUROSHOCK registry reported a 30-day mortality of 64.2% in patients presenting with CS complicating AMI, a figure compounded by access site complications occurring in 24.2% of the study cohort (52). Potentially, the excess mortality here could have been secondary to a selection bias isolating the very sickest patients with a poor hemodynamic profile and imminent risk of death. Indeed, Impella support was only instituted once CS had become refractory to high-dose inotropes and IABP (52).
The ISAR-SHOCK (Efficacy Study of LV Assist Device to Treat Patients With Cardiogenic Shock) study randomized 25 patients with AMI complicated by CS to IABP (n = 13) or the Impella LP 2.5 (n = 12) implanted post-revascularization (53). The Impella achieved significantly greater augmentation of CI, but this did not result in improved 30-day mortality. There were nonsignificant trends toward greater requirements for packed red blood cells and fresh frozen plasma for the Impella group, further emphasizing the issues associated with higher-profile devices.
The PROTECT II (Prospective Randomized Clinical Trial of Hemodynamic Support with Impella 2.5 versus Intra-Aortic Balloon Pump in Paitents Undergoing High-Risk Percutaneous Coronary Intervention) study is the largest randomized comparison of the Impella and IABP to support nonemergent high-risk PCI to date (54). It did not meet its target recruitment of 654 patients because the trial was terminated early for reasons of futility. The primary composite endpoint of major adverse events at hospital discharge or 30 days (whichever came sooner) in the intention-to-treat population (n = 448) was similar in both arms (Impella 35.1% vs. IABP 40.1%; p = 0.277). At 90 days, there was a nonsignificant trend toward a lower major adverse event rate for the Impella (p = 0.066). At 90 days in the per-protocol population (n = 427), that trend became significant (p = 0.023), suggesting that the Impella may hold promise over the longer term. The patient cohort studied in PROTECT II was similar to that of BCIS-1 (34). Given that the BCIS-1 study did not support the use of elective IABP insertion before high-risk PCI, it would seem intuitive to expect that the superior hemodynamic support provided by the Impella would offer no supplementary impact on adverse outcomes.
The TandemHeart (CardiacAssist, Inc., Pittsburgh, Pennsylvania) is inserted via the femoral vein and right atrium into the left atrium via a transseptal puncture. The outflow cannula is inserted in either femoral artery and positioned at the level of the aortic bifurcation, providing left heart bypass at a flow rate of ∼4 l/min into the lower abdominal aorta or iliac arteries (Figure 1). Studies of the TandemHeart in severe refractory CS have shown the device to improve CI, MAP, and reduce pulmonary capillary wedge pressure, pulmonary artery pressure, and central venous pressure, leading to decreased filling pressures in both ventricles (55–58). This culminates in an amelioration of myocardial workload and oxygen demand.
The TandemHeart is a high-profile system; thus, critical limb ischemia, bleeding, and vascular complications are a major concern. This was borne out in a randomized comparison of IABP (n = 20) with the TandemHeart (n = 21) in patients revascularized for AMI complicated by CS (59). Although the device improved hemodynamic and metabolic variables more effectively, this did not result in a survival advantage. Furthermore, severe bleeding and limb ischemia occurred more frequently with the TandemHeart. Single-center series have demonstrated the device to be hemodynamically effective and straightforward to deploy in expert hands (Online Appendix). However, the arrival of the Impella CP, which promises to maintain an equivalent flow rate based on a lower-profile cannula system, may impede the widespread dissemination of the TandemHeart in the high-risk PCI arena.
Extracorporeal Membrane Oxygenation
Venoarterial extracorporeal membrane oxygenation (ECMO) is effectively a modified cardiopulmonary bypass circuit that provides a continuous, nonpulsatile CO that can be applied percutaneously via cannulation of the femoral artery and vein (Figure 2) (60,61). ECMO removes carbon dioxide from and adds oxygen to venous blood via an artificial membrane, thereby bypassing the pulmonary circulation (62). As such, it is the only PCAD that also oxygenates the blood. ECMO can provide significant hemodynamic support but has a propensity to increase LV afterload and wall stress, which in turn can increase myocardial oxygen demand and therefore limit any cardioprotective benefit.
The implantation procedure requires considerable technical skill and full collaboration between the cardiologist, surgeon, catheterization laboratory staff, anesthesiologist, and perfusionist. The system is composed of a venous reservoir, external centrifugal blood pump, membrane oxygenator, and a rewarming heparin-coated circuit. The technology has become smaller and more portable. Systemic anticoagulation with heparin is required to achieve an activated clotting time of 150 to 180 s (63). Contraindications to ECMO include significant aortic valve incompetence, severe peripheral arterial disease, bleeding diathesis, recent stroke or head trauma, and uncontrolled sepsis (62).
A retrospective analysis of prophylactic versus standby cardiopulmonary support revealed significantly greater procedural morbidity (e.g., femoral access site complications) in the former (41% vs. 9.4%, p < 0.01) but higher procedural mortality in the latter (4.8% vs. 18.8%, p < 0.05) (64). The investigators suggested that standby CPS was preferable in the majority although patients with LVEF <20% may benefit from a prophylactic strategy. Early institution of ECMO for STEMI complicated by profound CS has been shown to significantly reduce 30-day mortality when compared with an historical cohort of patients not receiving cardiopulmonary support (65). Monocentric observational studies and individual case reports constitute the remainder of the evidence base on ECMO-assisted high-risk PCI (60,61,66–73). All confirm the feasibility and efficacy of ECMO, but vascular complications remain a notable problem. A reduction in platelet count, hemolysis, and a consumptive coagulopathy along with systemic heparinization can further increase the hemorrhagic risk. Intrathoracic, abdominal, or retroperitoneal hemorrhage not related to the access site may also occur as a result. Since no RCT or meta-analysis data are available for ECMO, current guidelines can only be based on expert consensus (Table 2).
Can Meta-Analyses Shed Light on the Matter?
The majority of meta-analyses have studied outcomes for IABP versus control in high-risk PCI (74–78). All echo what we already know. In the PPCI era, IABP does not confer a 30-day survival advantage when used for AMI without CS (74–78). At 6 months or longer, however, there appears to be a mortality benefit signal with an associated reduction in re-ischemia and heart failure events (77). When the analysis was limited to those with STEMI complicated by CS, a significantly improved in-hospital outcome was noted in favor of IABP support, although much of this benefit emanated from the thrombolysis era (74,75). This must be taken with a note of caution because thrombolysed patients in those studies tended to be younger and male, and were more likely to undergo subsequent revascularization (74). A single meta-analysis compared the Impella and TandemHeart with IABP (79). Ventricular assist devices delivered superior hemodynamic support, although use of all 3 resulted in similar 30-day mortality rates. There were also similar rates of limb ischemia, but bleeding occurred more often with the TandemHeart and hemolysis with the Impella. The conclusions here remain tenuous because the analysis was based on just 100 patients (80) (Table 3).
Despite a sound physiological platform, the modest uptake of PCADs to support high-risk PCI (22,23) reflects the equivocal results and mixed messages emanating from the current evidence base and latent uncertainty as to what constitutes high risk outside of CS. From a clinical standpoint, the IABP, Impella, TandemHeart, and ECMO should have a place in high-risk PCI, although they cannot be advocated as standard of care for every procedure. It is up to the heart team to assess, on a case-by-case basis, which patient may benefit from a particular device and thereafter ensure MCS availability as a standby adjunct in the catheterization laboratory. This can only come from shared expertise, familiarity with and confidence in using all 4 adjuncts, supported by an experienced multidisciplinary team (Figures 3 and 4⇓⇓, Case Vignettes #1 and #2). The onus should also be on device companies to foster educational relationships with centers undertaking high-risk PCI and to encourage proctoring of operators keen to learn and gain proficiency.
Moving forward, we must level the playing field. Akin to the consensus definitions proposed for stent thrombosis, bleeding, and trials of transcatheter aortic valve implantation (81–83), there must be a willingness to establish standardized criteria to define what high-risk PCI is. Thus far, only the American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography and Interventions guideline writing committee has documented these features (Table 2) (48). It is a fundamental first step in benchmarking a degree of uniformity between future trials of high-risk PCI to allow researchers, policymakers, and clinicians alike to compare outcomes of a specific intervention with a degree of scientific and statistical equipoise. Only then can we be more proscriptive as to which combination of lesion complexity and LV ejection fraction, for instance, would indicate the use of a particular PCAD. The same applies for trials of CS. The definition from the outset should incorporate right heart catheterization parameters and mixed venous saturations to ensure that the population under study truly reflects a CS sample, although we do accept the impracticalities of conducting the former in critically ill patients (3,4).
In the end, we return full circle to the days of Harken, Kantrowitz, and Moulupoulos and the essential features for a viable PCAD. We believe that the IABP, Impella, TandemHeart, and ECMO fulfill each criterion to some degree. It should no longer be a case of determining which device is superior. There should be a shift in emphasis moving forward to identify the patient, anatomic, hemodynamic, and procedural characteristics that signal adjunctive MCS may be necessary, to prepare the subject and catheterization laboratory accordingly, and then to perform the PCI with the knowledge that a stepwise increment in hemodynamic support can be facilitated.
For supplemental tables, references, and a figure, please see the online version of this article.
Dr. Myat is supported by the Department of Health via the National Institute for Health Research (NIHR) Comprehensive Biomedical Research Centre award to Guy's & St. Thomas' NHS Foundation Trust in partnership with King's College London and King's College Hospital NHS Foundation Trust; and also receives financial support from the British Heart Foundation via a Clinical Research Training Fellowship (grant no. FS/11/70/28917). Dr. Banning is partially funded by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre. Dr. Redwood has received unrestricted grant support for the BCIS-1 Trial; and travel support from Maquet. Dr. Bhatt is on the advisory board of Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; is on the Board of Directors of Boston VA Research Institute and the Society of Cardiovascular Patient Care; is Chair of the American Heart Association Get With the Guidelines Steering Committee; is on Data Monitoring Committees of Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, and Population Health Research Institute; has received honoraria from the American College of Cardiology (Editor of Clinical Trials and Cardiosource), Belvoir Publications (Editor-in-Chief of the Harvard Heart Letter), HMP Communications (Editor-in-Chief, Journal of Invasive Cardiology), and Slack Publications (Chief Medical Editor, Cardiology Today's Intervention); is Associate Editor of Clinical Cardiology; is Section Editor of Journal of the American College of Cardiology; is on the clinical trial steering committees of Duke Clinical Research Institute, Harvard Clinical Research Institute, and Population Health Research Institute; is on the CME steering committee of WebMD; and has received research grants from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Roche, Sanofi, and The Medicines Company. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- acute myocardial infarction
- coronary blood flow
- cardiac index
- cardiac output
- cardiogenic shock
- extracorporeal membrane oxygenation
- intra-aortic balloon pump
- left ventricular
- mean arterial pressure
- mechanical circulatory support
- percutaneous circulatory assist device
- percutaneous coronary intervention
- primary percutaneous coronary intervention
- randomized controlled trial
- ST-segment elevation myocardial infarction
- Received July 8, 2014.
- Accepted July 17, 2014.
- American College of Cardiology Foundation
- ↵
- Peterson E.D.,
- Dai D.,
- DeLong E.R.,
- et al.
- Brennan J.M.,
- Curtis J.P.,
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- et al.
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- et al.
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- et al.
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- et al.
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- Bhatt D.L.,
- et al.
- Kappetein A.P.,
- Head S.J.,
- Généreux P.,
- et al.
Citation Manager Formats
Article Outline
- Top
- Abstract
- What Defines High-Risk PCI?
- High-Risk Criteria used in the Current Evidence Base
- Key Fundamentals of Mechanical Circulatory Support
- Maintenance of End-Organ Perfusion
- Optimization of Myocardial Perfusion
- Intra-Aortic Balloon Counterpulsation
- Impella
- Tandemheart
- Extracorporeal Membrane Oxygenation
- Can Meta-Analyses Shed Light on the Matter?
- Discussion
- Appendix
- Appendix
- Footnotes
- References


text:
i want a brutally rate lol
Most Helpful Guy
8/10 till I saw the duckface
2/10 because of the duckface61|50|1
Most Helpful Girl
ahh you're back!
I was wondering where you went. You didn't ask this question in ONE WHOLE day!62|40|0
i want a brutally rate lol
8/10 till I saw the duckface
2/10 because of the duckface
ahh you're back!
I was wondering where you went. You didn't ask this question in ONE WHOLE day!
Have an opinion?
@TheBraveLion I always have spare bags of attention, don't worry 8)
😂 😂 😂
That duck face ruined the attractiveness. 6.5/10
You're very pretty but why do you ask this question so often?
Your kind of a bit cross eye and look a little plastic like a barbie doll. Noes is ok just something a bit off about it. Everything else is fine.
I'll give you 5/10.
You look like someone who is 42 but had work done to make them look 22.
@ThisDudeHere Looks like more unwanted attention needs to be emptied out of the trash can dude 😂 😂 😂 😂
Lighten up on the eye liner but other wise really pretty
I think very attractive
Not my type at all but some guys here like
Average or so
I think your very attractive
Especially the eyes
You also have cute lips
However if you want 100% brutal honesty I'd recommend not getting those highlights
For me personally , I don't like them on you
You're attractive, but points off for duck face. You don't need it!
Only if we want to yeah?
I think you could easily be a model, especially if you are tall enough.
Please don't come and hunt me at night
You look like an ex g/f of mine. You have some french in you? Honestly, can't give a brutal rate if there is no body in the shot. Your face is sexy though. At least a 9 as long as your not hiding behind make up magic.
You look like my celebrity crush ❤
What else can I say...
Goosebumps 😶
You are a very attractive girl
Having beautiful eyes.
Your look is very mature, you'll be an amazing older woman.
obviously, all the guys are going to say you're hot and all because they want to get laid… :)
very pretty. however, you should try smiling a little it will lighten up your face and eyes so much more.
You are pretty.
again with the the god dam duck face
You are very attractive.
you're beautiful
You've got a LOOOONG nose.
Look fine to me :)
Looking good.
You are very pretty
Ok I can't.
This is like the 20th time you ask the same damn question
You HAVE NOT CHANGED since the last time.
People always say you're attractive. Are you blind? Are you retarded?
My husband says:
You're hot, but the lipstick should go all the way up to the top of your lips.
He is a detail person.
So you want me to be honest?
Ok, I think you're wearing way too much make-up, like make up to the point where it looks a bit like a drag queen (not like that is bad but it's just.. Very intense lol) ~ from what I can see I think you're really pretty enough to chill on the make-up. That's all :)
9 you're very pretty :)
*sigh* You again...
YAY!!! Here we go again for the 100th time!!! 💁
You're gorgeous!
You look good
you look a lot older then 17 o_o
and you're pretty!
You look a lot older than 17. Not ugly but not pretty to me. I'm sure people are attracted to you though.

subset: commoncrawl


text:
Trey Burke
Strengths: Strong, physical guard, Very good drive and kick guard, Nice shooter off the dribble, Has some range on his jumper, Sees the floor really well
Weaknesses: Can lack aggression at time, Needs to improve his defensive intensity
The Future Gets Even Brighter: Trey Burke
A Picture is Worth a Thousand Words
The picture below tells you everything you need to know when you think about the qualities that Mr. Trey Burke possesses: Clutch, NBA range, fearless, leader, and champion. This picture was taken during the 2013 Elite Eight game between the Michigan Wolverines and Kansas Jayhawks. The Kansas Jayhawks held a lead of 74-66 with 1:22 remaining in the 2nd half. From that point on, all Trey Burke did was make two three pointers and a lay-up, including the three pointer in the picture below from way behind the three point line that tied it up with 5 seconds left. It was clutch, deep, and well contested. Incredible poise if you ask me. If you can say that about anyone else in the draft, I would love to know. Trey Burke is amazing, and he has the demeanor of a champion. Add him to a group of unbelievably talented players, and the sky is the limit. A combination of Trey Burke and Kyrie Irving on the floor at the same time would be an absolute nightmare for opposing coaches, emphasis on absolute. All this praise for Trey Burke is coming from a die-hard Buckeye fan, so I am not being a homer Michigan fan or anything. I truly believe this kid will be a star in this league, and if we pick him it will go down as one of the best picks in Cleveland Cavaliers history!
Defense isn't an Issue
Trey Burke is known as an offensive guard. As of right now, his defense isn't the reason he is the best player in the draft. But that doesn't mean that his defense is a liability. In fact, with some work, his defense could be amazing. Just look at the athleticism and instincts possessed by this young man. On the big stage, the National Championship, he times up the jump perfectly and meets the ball ABOVE the rim. His height is not an issue when you can jump like that. With some help from Mike Brown and the staff, we can turn him into one of the best two way guards in the NBA. I get excited just thinking about what this team can become.
I don't need any outside sources at this point to know what is best for this team. Trey Burke is the man for the Cleveland Cavaliers. Let's go through all the other candidates.
Nerlens Noel- Ultra talented big man with great defensive instincts. Very poor offensive game and too thin to handle the more physical bigs in the NBA. He also has a torn ACL. Not worth a #1 pick.
Ben McElmore- Good shooting guard. He definitely can shoot at the NBA level, but doesn't shoot enough to make a difference. If we needed a 2 guard, then I would consider it, but he is not good enough for the #1 overall pick.
Otto Porter Jr.- I am strongly against Otto Porter Jr. becoming a member of the Cleveland Cavaliers. His game against FGCU was bad, real bad. He couldn't get his team to beat a 15 seed. It wasn't his teammates fault, he was supposed to be the best player of Georgetown and he didn't step up when the time came. He is not a leader. He is a rotation player in this league, and with the #1 overall pick, rotation players just don't cut it.
With all that being said, it is obvious that Trey Burke is the guy for the Cleveland Cavaliers. With the 1st overall pick, we must take a difference maker, and Trey Burke is far and away the biggest difference maker in this draft class. We can NOT take Porter Jr. just because we lack at the 3 position. We have been blessed with unbelievable luck, and we must take advantage. Every ounce of me trusts Chris Grant and his decisions making. He has been 4 for 4 on his draft decisions the past two years and I expect that to continue, with the decisions of Trey Burke.
All I want to hear on June 27 when David Stern steps to the stage is: With the 1st pick in the 2013 NBA Draft, the Cleveland Cavaliers select Trey Burke, PG, University of Michigan. Make it happen Chris Grant.


text:
I'm in need of a Auto-responder for exchange. Specifically every email message sent to our any of our company's email addresses must have a legal dislaimer type message sent back in reply.
Does anyone know of an autoresponder that works with Exchange that meets this simple need?
(We are a medical company and send back an email to tell people to see their GP or call 000 if it is an emergency).
We did come up with one (Exclaimer: http://www.exclaimer.com/exclaimerstore.aspx?u=pricing&lang=en-us&p=mu ) but they want an arm and a leg per user + yearly support amount as it has a whole lot of other function that we don't need.
3 Replies
May 14, 2009 at 5:58 UTC
Please don't take this wrong, but sending a auto-response for every email that comes in with your disclaimer? That's just SPAM. Please don't do it.
You can have Exchange add disclaimers to every email thats sent OUT though: http://support.microsoft.com/kb/317680
Also, take a look at your anti-spam program, they often have disclaimer, or footer functionality built right in.
May 14, 2009 at 10:30 UTC
I've never heard of a legal disclaimer sent back in reply...Martin's right, that's just not something that anyone should recommend doing. I'm sure I could make my Sonicwall Email Security do that with the rules it has, but that would just not be something you'd want to do. Imagine all of the people who would get spam back in their inbox because of spoofing spam, not to mention the headache for outside users who email you often.
But Martin's suggestion on the disclaimer addition will work, though if you have a spam device usually they can do it MUCH easier than the built-in Exchange method.
May 14, 2009 at 7:55 UTC
To put this in to context, the company is a group of Cardiologist. Blelive it or not, on the odd occasion we get an email from one of our patients or a new patient describing serious life threatening heart problems. They should be going straight to the emergency department of the hospital - not emailing us. Also because of the nature of our workers, email is read straight away. So we have a response sent to people that email in to the company outling what should be obvious but isn't for all of our patients for the patients' own good and to cover ourselves legally (as emails are considered by law to be delivered on the other party sending). As you can see this ISN'T spam. The catch is currently this is done with all mail going to a pop account and the autoresponder working from there however for obvious reasons we want mail going directly to our Exchange server.
This is our current auto response:
This is an AUTOMATED REPLY.
If your email requires URGENT attention please call us immediately on (xx) xxxx-xxxx.
If you require URGENT medical assistance outside of business hours, you should
1. Phone the Ambulance on 000 (if appropriate)
2. Visit your General practitioner or
3. Proceed to your nearest Hospital Emergency Room.
The email we have received from you be will processed but this may take a number of business days.
Remember that email is not a secure or confidential form of communication. If you need to communicate private information please do not use email.
This discussion has been inactive for over a year.
You may get a better answer to your question by starting a new discussion.


text:
spongebob cotton eye joe MP3
spongebob and patrickstar great vid.
Spongebob cotton eyed joe MP3
spongebob rocks this summer vacation!! song cotton eyed joe by Rednex.
Spongebob Schwammkopf Cotton Eye Joe MP3
spongebob singt Cotton eye joe.
Cotton eye joe chipmunk version MP3
Rednex - Cotton Eye Joe - Lyrics MP3
NOTE: I do not own this song. No copyright infringement intended. All rights reserved to the rightful owner. This video is intended for entertainment purposes ...
Just Dance "Cotton Eye Joe" MP3
By: Rednex Difficulty: 1/3 All Rights To Rednex And UBI Soft. =============================== LINK TO JUST DANCE 2014! DANCE FROM SONGS ...
Spongebob cotton eye joe MP3
Spongebob Sings Timber MP3
Okay all my lovely fans. Since I ALMOST have 2000 subscribers (I have 1995), I'm deciding to give all my Spongebob fans their gift early. One Direction and ...
Cotton-Eye Joe Lyrics MP3
Lyrics to Cotton Eyed Joe. You have to dance when you hear this.
Cotton Eye Joe by Rednex [1 Hour] Infinite Jukebox MP3
Cotton Eyed Joe MP3
Rednex-Cotton Eye Joe-Lyrics MP3
Cotton Eye Joe by Rednex (Lyrics on Screen)
Cotton Eye Joe Snoopy MP3
Cotton Eyed Joe MP3
music video to Cotton Eye Joe by Rednex follow us on twitter https://twitter.com/Dangibbo16.
REDNEX COTTON EYE JOE (en live) MP3
REDNEX COTTON EYE JOE un tube incontournable dans les bals country.
Cotton-Eye Joe - Rednex MP3
Visits Steve Morse Gibson guitar blog:http://buygibson.com/ James Hetfield (Metallica) Rhythm Lesson for free and 35 free online Guitar Lesson.
Bugs Bunny - Cotton Eye Joe MP3
Music: Cotton Eye Joe Artist: Rednex Animation: Bugs Bunny A little thing I made while I was bored.
Rednex - Cotton Eye Joe (Lyrics) MP3
This is the 2nd lyrics video that I've ever made, which I wanted to make because "Cotton Eye Joe" is my favorite song for group dancing. There are multiple ...


text:
LaLa Vazquez
July 12, 2010 by Post Team
LaLa Vazquez:It's (finally) official? After a five-year-old actress and MTV VJ LaLa Vasquez and NBA star Carmelo Anthony were married in New York on Saturday night.
Adorably, her 3-year-old Kiyana, accompanied them to the altar.
About 320 people, including friends Kim Kardashian and Ciara, LaLa were present to see walk down the aisle in a Vera Wang gown, adorned with flowers.
Carmelo proposed in 2005 with an eight-carat diamond cushion cut, but then added two carats 1/2-more matching with two wedding bands, worth $ 200,000.
"They are ready to party!" Kevin Osbourne, who led the band playing during dinner, he said. "A lot of soul and R & B. Michael Jackson to Stevie Wonder."
DJ Clue, was scheduled to spin.
In the period before the big day, LaLa Vasquez joked that the wedding planning carried out, despite planner Mindy Weiss was giving the details.
"I'm seeing an increase in tension before the wedding … The guest list was from this to that which indicates [major]. I'm trying to control it. It's, like, up now!"
I'm glad I solved. Congratulations to the happy couple!
Please feel free to send if you have any questions regarding this post , you can contact on
Disclaimer: The views expressed on this site are that of the authors and not necessarily that of U.S.S.POST.


text:
Auto Repair Services
Good reliable mechanic with with honest work I get the job done right for an affordable price! I do brakes, wheel bearings and suspension work such as struts stabilizer links tie-rods ball joints and more. Also engine maintenance such as starters alternators water pumps etc is needed give me a call!


text:
This page contains New Super Mario Bros. 2 Video Walkthroughs for 3DS called "Walkthrough Part 18 Final Boss(All Star Coins)" and has been posted or updated on Oct 19, 2013 by SuperBrosTv.
- Developer: Nintendo
- Publisher: Nintendo
- Genre: Action Platformer
- Release: Aug 19, 2012
- ESRB: Everyone
Walkthrough Part 18 Final Boss(All Star Coins)
Watch this step-by-step Video Walkthrough, which may help and guide you through each and every level part of this game.
Please Submit a Problem for any incomplete, non-working or fake cheat listed above.
If you know other secrets, hints, glitches or level guides, then please Submit your Cheats and share your insights with other players.
From: Kiki
From: Raccoon mario
From: Primaritzaayala
From: Venudactyl
From: Starr
From: Sean
Stuck in this game? Set a specific, clearly defined question and let other gamers answer your question or view answers to previously asked questions. If you think you are an expert then please try to help others with their questions.
New Super Mario Bros. 2 - Let's Play! Gameplay
- Added on: Aug 21, 2014
New Super Mario Bros. 2 - Unboxing and Gameplay Video
- Added on: Mar 7, 2015
New Super Mario Bros. 2 - Secrets & Hidden Things Gameplay Video
- Added on: Mar 7, 2015
New Super Mario Bros. 2 - Level 1-1 Gameplay Video
- Added on: Mar 7, 2015
- Dragon Quest 2: Akuryou No Kamigami, (3DS)
- Dragon Quest, (3DS)
- Chou 2 Talk, (3DS)
- VoxelMaker, (3DS)
- Inch Worm Animation 2: Butterfly, (3DS)
- Crystareino, (3DS)
- Hey! Pikmin, (3DS)
- Swipe, (3DS)
- Sumikko Gurashi: Koko, Dokona Nodesu?, (3DS)
- Team Kirby Clash Deluxe, (3DS)
- New Style Boutique 2 - Fashion Forward, (3DS)
- Sekaiju To Fushigi No Dungeon 2, (3DS)
- Ice Station Z, (3DS)
- Disney Magical World, (3DS)
- Dragon Sinker, (3DS)
- Tomodachi Life, (3DS)
- Ever Oasis, (3DS)
- Vacation Adventures: Park Ranger, (3DS)
- Beyblade Burst God, (3DS)


text:
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Masters Project Report 1
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|Page (1) of 1 - 01/20/12
|email article
|print page
Police witnesses called in fake 'Rockefeller' caseWitness called in fake 'Rockefeller' case testifies he lent defendant a chain saw
Page: 1
Related Keywords:Rockefeller Mystery, Legal proceedings, Crime, Law and order, General news, Violent crime
Source:Copyright 2012 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.. All Rights Reserved


text:
Many landlords are content with renting out a single property to keep things simple, but if you're more interested in expanding your investment portfolio, you may be ready to look for a new property. If you're going to make this type of commitment, remember the main rule of real estate: Location is key. Fortunately, you can easily research several aspects of a community to see if it's right for you.
1. High-Ranked Schools
Local schools are one of the main things renters look for in a community. Families with children want to know that their young ones will get a good education in a safe environment.
Fortunately, U.S. News & World Report ranks the nation's top schools each year, so it's easy to see where great schools are located. Try your best to purchase a property that's in a strong school district to attract great families. Because property values are often higher in these areas, you can expect a better return on investment.
2. Great Amenities
No matter where your rental unit is located, you can be sure that prospective tenants will be paying attention to the amenities a community offers.
Individuals looking at more expensive neighborhoods may wonder how close they are to a golf club, but those living in low-cost areas may simply want to be close to a community center or local park. Amenities vary by neighborhood, but you'll want to try to get the most bang for your buck in the area.
3. Low Crime Rates
Try to invest in property in an area with low crime rates. The Crime Reports website will show you all crime reports in any given area, and they even include addresses of registered sex offenders. A low crime rate is an ideal feature of a community, and researching area statistics is important because potential tenants are also checking these websites.
You could find an absolutely amazing property with a great price, but if people don't feel as if they'd be safe there, you're simply not going to rent it out. When you do find a great area with a low crime rate, it's in your best interest to do online background checks on all prospective tenants to ensure that it stays that way.
4. Local Government Services
The services that the local government provides are also important features of any community. Is citywide trash pickup available? What about public transit? Will tenants be able to get around the area easily?
There are other features, such as libraries and community parks, that local governments provide. While tenants might not always look into these before the move, it's better to be safe than sorry. The more services available in your neighborhood, the more appealing your property will be.
5. Nearby Businesses
If you're seeking out a property in a secluded area that's away from the hustle and bustle of the city, people may appreciate having to drive 20 minutes to the nearest fast food restaurant. Most renters, however, prefer to avoid a long commute to go grocery shopping, visit their bank, or grab a quick bite to eat. This means that finding a property with nearby businesses is usually ideal.
There are countless community amenities that will draw in new renters, and it's your job to seek out areas that provide the best of these features. By doing so, you'll greatly increase the likelihood that you'll see a quick return on investment. If you find appealing properties with these characteristics in mind, it can turn into a very profitable asset.
Comprehensive credit & criminal screening.
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Darlene S. My connection to the Divine is discerned as an inner presence... creation whispers and awakens in me. There is a fire that fuels me with passion for being... assuring me of my connection to the One eternal flame.
 There are flowing waters originating from beyond, yet actively present and moving through me. The movement impels me to know and to release the essence of my being. Living waters stirring me to remember... to reveal... and to relax into the flow.
 I sense the heartbeat of creation animating and connecting me to all life... to Infinite Presence and Mind. The life I AM is a bridge between heaven and earth... the seen and the unseen... spirit and substance. I AM inspiration... I am expression... I am being... I AM... singing and dancing in me.

 Darlene S.
 Lawrence, Kansas
 2006


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February 18, 2014
Showtime announced today that Shameless has been renewed for a fifth season. The cable network has ordered 12 new episodes of critically-acclaimed drama for 2015.
The show is currently at the halfway point of Season 4, with the season finale set to air in April.
(Source: Showtime)


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- Pitbull:
- A quick scouting unit with a similar role as the humvee and wolverine units of Tiberian Dawn and Tiberian Sun, respectively. The pitbull is an all-terrain jeep with an anti-vehicle/anti-air missile launcher. They are quick, but are lacking in armor and firepower. (Compared with Nod's Attack Bikes, Pitbulls are slower and less powerful, but better armored.)
Pitbulls can be upgraded with mortars to grant them better range to complement their fast speed, though Mortars cannot be used whilst the Pitbull is in motion.
- The APC is GDI's armored personnel carrier. Each APC is equipped with a machinegun that's strong against infantry and aircraft and can transport a single squad of infantry. Infantry squads that are garrisoned within the APC can still fire at enemy units outside of the APC, all while being protected by the APC's durable armor.
The APC can also lay a small minefield for 500. The mines are stealthed, and will either kill or severely damage infantry, deal heavy damage to light vehicles, and deal moderate damage to heavier vehicles. With so many mines being laid per use, tanks that cross over a minefield risk being destroyed before they could even get to do battle.
In Kane's Wrath, the APC can be upgraded with armor piercing bullets for more firepower.
- Mobile Repair Transport: (Kane's Wrath, Steel Talons only)
- A Steel Talons exclusive APC with a repair arm instead of a machinegun. The arm does nothing, but the drone following the vehicle will repair any units in range of the MRT. Other than that, the MRT can perform any of the standard APC's other functions, including the ability to lay mines, and allowing garrisoned infantry to fire at enemies from within the MRT.
- Wolverine: (Kane's Wrath, Steel Talons only)
- A well-armored walker that is absolutely devastating towards infantry (and can also deal low-moderate damage towards vehicles and structures). It made its first appearance in Tiberian Sun and returns to the battlefield once more for Kane's Wrath, under the exclusive service of the Steel Talons subfaction.
The Wolverine can be upgraded with armor piercing bullets to bolster its firepower.
An AP upgraded Wolverine can take on a standard Seeker. This means that AP Wolverines can be used against all of Scrin's basic units.
- Predator tank:
- GDI's mainstay armored vehicle and a multi-purpose delivery platform. Predator tanks are armed with a single, powerful anti-vehicle and anti-structural cannon. Predators can be upgraded with railguns from the Tech Center for added firepower.
Compared to the Nod Scorpion tank and the Scrin Seeker, the Predator has greater firepower and armor. A Predator can defeat a Scorpion tank with more than half it's health left, and have even greater effect faced against Seekers. However, it is the most expensive at 1100 compared to the 800 price tag of its rivals.
Predators can receive Railgun from the Tech Center.
- Titan: (Kane's Wrath, Steel Talons only)
- The Steel Talons' replacement of the Predator Tank. Though it has equal armor and firepower compared to the Predator, and has only slightly longer range. The Titan can stomp over several Predators, Scorpions or Seekers before it is defeated, making it potentially the most powerful early game unit. It can also flatten Harvesters.
The Titans can be upgraded with Railguns for even more firepower. They can also be upgraded with the ability to use adaptive armor to both increase their armor and make them immune to EMP attacks, though at the cost of decreased rate of fire, but overall the armor boost is greater than the potential firepower lost, making in nearly always necessary to have it engaged during battle
- Rig: (Requires Command Post)
- A versatile multi-purpose platform that can be deployed on any position on the map. When deployed the Rig serves as a repair bay for GDI's vehicles that can be packed up should the Rig be needed elsewhere. A deployed Rig can also serve as a mobile defense platform, since it's armed with a couple of anti-vehicle Guardian Cannons and a surface-to-air missile battery.
In Kane's Wrath, the Rig's Guardian Cannons can be upgraded with railguns to give them a bigger punch. They can also move faster.
- Slingshot: (Kane's Wrath, Requires Command Post)
- The Slingshot is a dedicated anti-air vehicle that uses quad cannons to take out enemy aircraft with devastating effectiveness. The slingshot is equipped with hover technology, which allows it move faster but at the cost of armor. (Oddly enough, unlike hovercraft in Tiberian Sun, hovercraft in C&C3 can't traverse through water.) The Slingshot cannot attack any ground-based units, though it can crush light infantry with devastating effectiveness and a glitch (only know on Xbox 360 version) allows it to force attack the ground when selected with other ground attacking units.
- Shatterer: (Kane's Wrath, Requires Command Post, Vanilla GDI only)
- The Shatterer is a light armored vehicle that fires a sonic beam (that's reminiscient of the Disrupter Tanks from Tiberian Sun). The Shatterer also has hover technology which makes it faster but lighter in armor. Shatterers can not fire while moving, but can inflict damage upon multiple units in a line, making the Shatterer very useful against large armies.
- Zone Shatterer: (Kane's Wrath, Requires Command Post, ZOCOM only)
- The Zone Shatterer is ZOCOM's version of the basic Shatterer. In addition to having all of the abilities of the standard Shatterer, Zone Shatterers also have the ability Overload Beam, which fires an even more powerful sonic wave, but disables the Zone Shatterer for a few seconds. Though it looks more heavily armored than the standard Shatterer, it is in fact not. It also cost 100 more than the standard.
- Mammoth tank: (Requires Tech Center)
- After being absent from Tiberian Sun, Mammoth Tanks return to the fray once more. These heavily armored units come equipped with dual cannons that are highly effective against vehicles and structures, as well as dual rocket pods that are equally effective against infantry and aircraft alike. Moreover, Mammoth Tanks can crush smaller vehicles, including tanks, by merely rolling over them (though it's slow speed makes it difficult to do so). As if that wasn't enough, Mammoth Tanks can be upgraded with railguns for even more firepower.
Additionally, the Steel Talons' version of the Mammoth Tanks can be upgraded with the adaptive armor ability, which, when activated, increases the Mammoth Tanks' armor and makes them immune to EMP attacks, but at the cost of rate of fire.
- Juggernaut: (Requires Tech Center)
- GDI's heavy artillery walker was first seen in Tiberian Sun's expansion pack Firestorm. While the Juggernaut has since undergone several changes (including not having to be manually deployed to fire), what hasn't changed is the fact that the Juggernaut is a mobile artillery unit that can lay waste to infantry, vehicles, and structures from afar.
An additional improvement over the Firestorm version is the ability for the Juggernauts to fire at any point on the map provided that a Sniper Team is near the target and is stationary (so that the spotter can paint targets for the Juggernauts to bombard from anywhere on the map).
Note: Like Nod's Avatars and the Scrin's Annihilator Tripods, once this unit is destroyed, it leaves a husk that can be captured by any faction's Engineers, Saboteurs, or Assimilators. Once captured, the unit recovers some HP, and is under the control of the faction that captured the husk.
- Behemoth: (Kane's Wrath, Requires Tech Center, Steel Talons only)
- The Steel Talons' variant of the Juggernaut in Kane's Wrath. A bunker that can store a single infantry squad was jury-rigged onto their hulls to allow them to survive in close-combat situations better. In all other cases, they behave similarly to the Juggernauts, and leave a husk when destroyed.
Unfortunately, unlike the Juggernaut, the Behemoth is unable to strike anywhere on the map, even with the help of an allied/acquired Sniper team.
- Harvester: (Vanilla GDI only)
- Used for the collection of Tiberium. GDI harvesters are better armored than Nod and Scrin Harvesters and are armed with an anti-personnel machinegun for self-defense.
- Heavy Harvester: (Kane's Wrath, Steel Talons only)
- The Heavy Harvester replaces the standard GDI Harvester's machinegun for a bunker that can provide cover for a single squad of infantry, who, in turn, provide the harvester with additional defense. Otherwise, it's identical to the standard GDI Harvester.
- Rocket Harvester: (Kane's Wrath, ZOCOM Only)
- The Rocket harvester replaces the standard GDI Harvester's machinegun with a rocket pack that allows it to defend itself against vehicles and aircraft more effectively. Otherwise, it's identical to the standard GDI Harvester.
- Surveyer:
- Like Nod's Emissaries and the Scrin's Explorers, the Surveyer can move to distant parts of the map, and deploy into an outpost to expand ground control to remote spots. Surveyors, as with all expansion vehicles, take 30 seconds to finish deploying.
- The MCV can be unpacked into a Construction Yard to allow for the production of other structures. The Construction Yard also expands ground control to a greater radius than the Surveyer, and can be packed up into an MCV again so that it could be moved to another location.
The Construction Yard is extremely vital to your infrastructure. Without it, structures and base defenses cannot be built, so it's imperative that you protect it at all costs. (Well, almost all costs.)
- MARV (Kane's Wrath, Requires Reclamation Hub)
- The Mammoth Armored Reclamation Vehicle (or MARV) is GDI's Epic Unit. The MARV is armed with a tri-barreled sonic cannon that deals splash damage over several units at a time. The MARV is also equipped with an onboard refinery and can process any Tiberium that it drives over, turning it into extra credits that can be used to finance the player's war efforts.
The MARV comes with four garrison slots, which can be permanently garrisoned (meaning that the garrisoned infantry can't leave the vehicle, but rather, become a permanent part of the vehicle instead). The MARV becomes the most powerful unit on land once it is fully equipped. The following infantry can garrison the MARV:
Rifleman Squad - provides an anti-infantry machinegun.
Missile Squad - provides anti-armor and anti-aircraft rockets.
Engineer or Combat Engineer - grants the MARV the ability to gradually heal. Garrisoning additional Engineers (or Combat Engineers) increases the healing rate.
Grenadier Squad - provides garrison-clearing grenades.
Sniper Team - provides a sniper nest, which is extremely effective against infantry.
Zone Troopers - provides railguns that are very effective against vehicles and structures.
Zone Raiders - provides sonic grenades that deal splash damage.
- Hovercraft: (Unplayable)
- The GDI hovercraft provides the player with reinforcements by transporting them across water.
- Attack bike:
- A fast recon and hit-and-run vehicle of the Brotherhood of Nod. It is armed with two anti-air missile launchers equal in power to a Rocket squad and can move across terrain very rapidly. It is the fastest land unit in the game. It is typically used in the early game to destoy Harvesters and to scout.
- Raider buggy:
- A quick scouting unit with a similar basic function as its previous incarnations in Command & Conquer: Tiberian Dawn and Command & Conquer: Tiberian Sun, the raider buggy comes equipped with a light machine gun effective against infantry. It can be upgraded to wield a laser as its weapon making it more powerful and more accurate (if you watch closely when it fires regular bullets, the gunner sometimes misses), and can additionally be outfitted with an electromagnetic pulse blast which will disable nearby enemy vehicles. Black Hand Raider buggies have stealth-detecting properties.
- Scorpion tank:
- Nod's light-to-medium tank, these vehicles can be upgraded to be mounted with a heavy laser turret, and additionally can be outfitted with a so-called 'dozer blade' which will allow it to run over heavily armored infantry such as GDI's zone troopers. This also allows it to crush hordes of Disintegrators without taking damage from explosions, and run through mine fields.
- Flame tank:
- The flame tank returns to its original function as seen in Command & Conquer: Tiberian Dawn. The unit will unleash a massive torrent of flame which is highly effective against infantry, as well as potent in the damaging of structures. Flame tanks are to be one of the most effective units in the game for clearing out buildings that are being garrisoned by squads of enemy infantry. When upgraded with Purifying flames (Black Hand) it's power is boosted to the extent that it now has greater anti-armor capabilities than a Scorpion tank, not to mention against infantry and structures. It can even be used to destroy tiberium fields that enemies may be using, depriving them of resources.
- Stealth tank:
- The stealth tank is a high-tech scouting and assault vehicle which is capable of remaining invisible to enemy units whenever it is not actively engaging them or being engaged by them. It also comes equipped with missiles which are capable of damaging buildings, vehicles and air units alike. In Kane's Wrath, Tiberium Core Missiles upgrade more than make up for its new, almost double price tag 1800.
- Mantis (Kane's Wrath):
- The Mantis is an anti-aircraft droid that is only available for the Black Hand sub-faction. It is equipped with anti-aircraft rockets, and is designed to replace the role of the Stealth tank in fighting off aircraft.
- Beam cannon artillery:
- The artillery unit of the Brotherhood of Nod, beam artillery is capable of outranging static base defenses and can additionally combine with each other's firepower for increased damage output on a single target. These units can also be combined with the Venom scout aircraft and the Obelisk of Light defensive structure, which will increase both its target range and its offensive power. They have weak armor and are relatively slow-moving, making them an easy target for Orcas and other such aircraft.
- Purifier (Kane's Wrath):
- The Purifier is the predecessor to the Avatar, which is available only to the Black Hand sub-faction. It comes equipped with a flamethrower and a laser cannon, but unlike the Avatar it cannot commandeer technology. However, it can be upgraded with purifying flames which allow it to raze an entire base in a few seconds, provided that it can get inside without being attacked.
- Avatar warmech:
- Nod's main battle walker. In comparison to its rivals (the GDI Mammoth tank and the Scrin Annihilator tripod), it is weak, though its laser is powerful, and has decent range. It's commandeer ability can be used on Nod Vehicles to snatch one of their features; Attack bike's stealth detector, Flame tank's flamethrower, Beam cannon's laser (not identical to the Beam cannon's weapon but rather to the Avatar's own laser) and Stealth tank's Stealth generator, which provides stealth when not moving. Because of the weakness toward its rivals and it's ability to snatch the weapon off certain Nod vehicles, it can be used against another Nod player to power up the Avatar for free (no one ever said you had to use your own units).
- Harvester:
- Nod's version of the standard Tiberium harvester, it is able to cloak itself whenever outside of its refinery. It's only defense upon detection is to crush offending infantry, or simply flee the scene.
- Nod Emissary:
- The Nod Emissary can be move to other parts of the map, allowing for the construction of outposts and expanding the base to new areas.
- The mobile construction vehicles can be moved to any point on the map and be deployed into a construction yard. An extra MCV provides a extra building tab, which enables the player to build more than one structure at a time.
- Specter artillery (Kane's Wrath):
- The Specter artillery is a stealth cannon artillery that remains cloaked until it fires. They can fire clear over defenses and cause massive splash damage, then disappear and retreat. By practicing this process, Specters can become extremely efficient. Some people use Specters to force attack an area outside their base, providing a deterrent and damaging all that come near. The Shadow Team can place a stealthed beacon on the map to allow the artillery to fire within the radius of the beacon, and thus Specters can be used to destroy the enemies' Tiberium. Note: the location of the Specter will be revealed if it cannot be seen in the opponents sight radius.
- Reckoner (Kane's Wrath):
- The Reckoner is an unarmed heavy transportation unit that can garrison 2 units inside, though they cannot fire out initially. The Reckoner can deploy into a attack bunker, which allows the infantry inside to fire out of it and gives a third infantry slot. Upon deploying the Reckoner cannot become mobile again. Reckoners can be stealthed via Cloaking Field to easily sneak units such as Commandos and Engineers behind enemy lines.It can be upgraded with dozer blades to smash heavily armored infantry.
- Redeemer (Kane's Wrath):
- The Redeemer is Nod's Epic unit which is armed with an obelisk-derived tri-part laser, and dual shoulder-mounted weapon customization slots. When Militant Rifle Squad, Confessor Cabal, or Awakened enter the slot the redeemer is armed with a anti-infantry machinegun. If rocket squads enter, then it is armed with anti air and vehicle rockets. If a saboteur enters, then it can heal faster. If a Black Hand enters, it will gain flamethrowers and be effective against infantry and buildings. If a tiberium trooper enters it will be effective against vehicles and infantry. The Redeemer also has a Rage Generator which causes all ground units without a target to go berserk and attack everything nearby. (When playing against the AI, your units will attack each other regardless).
- Seeker
- The seeker is an hover tank armed with sensors to detect stealth, and plasma discs that are anti-air and anti-vehicle. The seeker cannot crush infantry, and is the weakest of its rivals. In Kane's Wrath, all Scrin sub-factions except the Traveler-59 faction can upgrade forcefields on their seekers, but all three sub-factions can purchase the Shard launchers upgrade.
- Gun Walker
- The gun walker is a vehicle armed with energy weapons which are anti-air and anti-infantry. It is the only basic anti-infantry vehicle that can crush infantry. In Kane's Wrath, it can be upgraded with forcefields.
- Shard Walker (Kane's Wrath)
- The shard walker is a more powerful, slightly faster moving version of the Gun walker. It can also be upgraded with Blue shards to make it more powerful.
- Harvester
- The harvester absorbs tiberium for the Scrin. It can regenerate health if Tiberium is present and the harvester can generate an ion storm if it is destroyed (not in Kane's wrath). It has absolutely no forms of self-defense.
- Shielded Harvester (Kane's Wrath)
- The shielded harvester absorbs tiberium for the Scrin, and is available exclusively for the Reaper-17 sub-faction. It can regenerate health if Tiberium is present, and has a force field that allows the harvester to take more damage.
- Devourer tank
- The devourer tank is armed with a proton laser cannon which is effective against infantry and vehicles. The tank can consume Tiberium to super charge its cannon to power up the main cannon for a certain number of shots. In the Kane's Wrath expansion, Reaper-17 faction can upgrade it with conversion reserves to keep firing green conversion beams longer. Ichor seed may be used near the Devourer for easy access to a conversion site. (Conversion does NOT use up Tiberium).
- Corruptor
- The corruptor sprays a corrosive Tiberium spray to attack. This spray proves effective in healing allied Scrin units and clearing garrisoned structures. It is fairly powerful against infantry, so-so against structures and not so good against armor. Sometimes, enemy infantry may be transformed into Visceroids, who attack all units around them. The spray heals Visceroids so the Corrupter will have to crush them if it is alone. Most people use them to follow the Eradicator Hexapod, healing it as it goes. The Eradicator does a fair job defending the Corruptors in turn.
- Mechapede (Kane's Wrath)
- The mechapede is a multi-segmented unit that can be upgraded with eight segments. It starts with the head segment, which is armed with an anti-armor laser similar to the one of the Disintegrator. The mechapede can be upgraded with segments for $100. The possible segments are Shard segments which fires Tiberium shards at infantry units, Toxin segments which can melt buildings and clear garrison structures, Disc segments for anti armor and anti aircraft, and Disintegrator segments for anti-vehicle laser. Many people favour a full set of Disintegrator segments because they destroy structures and vehicles as fast as Disintegrators themselves, with increased range and easily replaceable segments. Mechapedes tend to take up several command points, probably because it would not be fair if they could be built in huge numbers because of their power.
- Annihilator Tripod
- The annihilator is a walker armed with three long range beam weapons on its tentacles, capable of engaging several targets at once. It is able to crush small vehicles and destroy most ground vehicles and structure. A shield upgrade is also available for this unit (not for Traveler-59). The Tripod also has a short range EMP blast which can shut units and buildings offline for a short time, but can be used again as soon as it wears off. For this reason, an Annihilator Tripod may single-handedly defeat an epic unit. For EMP to be used, the tripod must be close to the target, at which point the player must manually command the Tripod to attack the unit. The Tripod can defeat a Mammoth tank but even the assistance of a riflemen squad would completely change the outcome, signifying that it is a small difference between the two's capabilities.
- Reaper Tripod (Kane's Wrath)
- The Reaper Tripod is the Reaper-17 version of the Annihilator Tripod. It is similar to the Annihilator except for its Conversion ability, which when in use makes it more powerful than its counterpart. It can be upgraded with Conversion reserves. Forcefields cost only 2/5 as much as Annihilator shields because it doesn't need to be applied to Devastators or Planetary Assault Carriers.
- Explorer
- The explorer is used for base expansion for the Scrin.
- The Eradicator Hexapod
- The Eradicator Hexapod is the epic unit for the Scrin. It has a Lifeform Recycling System which gives the player cash if an enemy unit is destroyed within the large radius of a Hexapod. The Hexapod is capable of assimilating three units. If it assimilates a Prodigy or Mastermind, it gains the ability to teleport across the map. If a Disintegrator is assimilated it gains a anti vehicle laser. If a Assimilator is assimilated it gains persistent healing and the rate will increase with each additional assimilator. Assimilated Shock Trooper will provide anti-vehicle and anti-air disc launchers. A Ravager will provide anti infantry and anti vehicle tiberium shards


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See what we see
Forced From Home is an interactive, outdoor educational exhibition presented by Doctors Without Borders to raise public awareness about the experience of the world's more than 65 million refugees and internally displaced people. With an experienced aid worker as your guide, learn about the many challenges people on the move encounter and the work Doctors Without Borders does to address their basic medical needs in a host of settings.Continue Reading
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Join Forced From Home at Seattle's SLU Discovery Center.
Refugees in Greece: The Inescapable Shadow of Syria
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| The following page is a proposal.
It has not been ratified and is therefore not currently part of the associated timeline. You are welcome to correct any errors and/or comment on the talk page. If you add this template to an article, please don't forget to mention this proposal on the main discussion page.
|"God Save the Queen"
|Largest city
|French, Russian
|Prime Minister
|James Carrey
|875,161 km²
|Ontarian dollar
The Dominion of Ontario was formed from the remnants of British Canada. It was to function as a buffer state between the French colony in New France and the Empire of Alaska.
Ontario has strong democratic traditions upehld through a parliamentary government within the construct of constitutional monarchy, the monarchy of Ontario being the foundation of the executive, legislative, and judicial branches and its authority stemming from the Canadian populace. The sovereign is Queen Elizabeth II who resides predominantly in the Kingdom of Oceania. As such, the Queen's representative, the Governor General of Ontario (presently Stephen Lewis), carries out most of the royal duties in Canada.
The direct participation of the royal and viceroyal figures in any of these areas of governance is limited, though; in practice, their use of the executive powers is directed by the Cabinet, a committee of ministers of the Crown responsible to the elected House of Commons and headed by the Prime Minister of Ontario (presently James Carrey), the head of government. To ensure the stability of government, the governor general will usually appoint as prime minister the person who is the current leader of the political party that can obtain the confidence of a plurality in the House of Commons and the prime minister chooses the Cabinet. The Prime Minister's Office (PMO) is thus one of the most powerful institutions in government, initiating most legislation for parliamentary approval and selecting for appointment by the Crown, besides the aforementioned, the governor general, lieutenant governors, senators, federal court judges, and heads of crown corporations and government agencies. The leader of the party with the second-most seats usually becomes the Leader of Her Majesty's Loyal Opposition (presently Tim Hudak) and is part of an adversarial parliamentary system intended to keep the government in check.
Each Member of Parliament in the House of Commons is elected by simple majority in an electoral district or riding. General elections must be called by the governor general, on the advice of the prime minister, within four years of the previous election, or may be triggered by the government losing a confidence vote in the House. Members of the Senate, whose seats are apportioned on a regional basis, serve until age 75. Four parties had representatives elected to the federal parliament in the 2008 elections: the New Democratic Party (governing party), the Liberal Party of Ontario (the Official Opposition), the Conservative Party of Ontario (CPO). The list of historical parties with elected representation is substantial.
Ontario's federal structure divides government responsibilities between the federal government and the ten provinces. Provincial legislatures are unicameral and operate in parliamentary fashion similar to the House of Commons.
An abundance of natural resources, excellent transportation links to the American heartland and the inland Great Lakes making ocean access possible via container ships, have all contributed to making manufacturing the principal industry, found mainly in the Golden Horseshoe region, which is the largest industrialized area in Canada, the southern end of the region being part of the North American Rust Belt. Important products include motor vehicles, iron, steel, food, electrical appliances, machinery, chemicals, and paper. Ontario surpassed Michigan in car production, assembling 2.696 million vehicles in 2004. In 2005 the Ontarians nationalized the various automobile plants in the nation, and the Ontarian Automobile Company was born.
Banking & Information Technology
Toronto, the capital of Ontario, is the centre of Canada's financial services and banking industry. Neighbouring cities in the Greater Toronto Area like Brampton, Mississauga and Vaughan are large product distribution and IT centres, in addition to having various manufacturing industries. The information technology sector is also important, particularly in the Silicon Valley North section of Ottawa, as well as the province of Waterloo. Government is the single largest employer in the province of York employing hundreds of thousands. Hamilton is the largest steel manufacturing city in Canada, and Sarnia is the centre for petrochemical production. Construction employs at least 7% of the work force, this sector has slowed down somewhat after a ten year plus boom.
Mining & Tourism
Mining and the forest products industry, notably pulp and paper, are vital to the economy of Northern Ontario. More than any other region, tourism contributes heavily to the economy of Central Ontario, peaking during the summer months owing to the abundance of fresh water recreation and wilderness found there in reasonable proximity to the major urban centres. At other times of the year, hunting, skiing and snowmobiling are popular. This region has some of the most vibrant fall colour displays anywhere on the continent, and tours directed at overseas visitors are organized to see them. Tourism also plays a key role in border cities with large casinos, among them Windsor, Cornwall, Sarnia and Niagara Falls, which attract many U.S. visitors. Sudbury has been dubbed "Ontario's Sin City" due to its many casinos.
Once the dominant industry, agriculture occupies a small percentage of the population but still a large part of Southern Ontario's land area. The number of farms has decreased from 68,633 in 1991 to 59,728 in 2001, but farms have increased in average size, and many are becoming more mechanized. Cattle, small grains and dairy were the common types of farms in the 2001 census. The fruit, grape and vegetable growing industry is located primarily on the Niagara Peninsula and along Lake Erie, where tobacco farms are also situated. The Corn Belt covers much of the southwestern area of the province extending as far north as close to Goderich. Apple orchards are a common sight along the southern shore of Georgian Bay near Collingwood and along the northern shore of Lake Ontario near Cobourg. Tobacco production, centred in Norfolk County has decreased leading to an increase in some other new crop alternatives gaining popularity, such as hazelnuts and ginseng. The Ontarian origins of Massey Ferguson, once one of the largest farm implement manufacturers in the world, indicate the importance agriculture once had to the Ontarian economy.


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October. Still a good three months before the Alps open for business and the snowboarding season begins. What to do when you want something active and lying by a pool reading books doesn't quite appeal? It seems too decadent as stock markets crash and the world as we know it collapses anyway.....
.......why not surfing? Actually, the two sports appear to have much in common. The love of outdoors, the strange coded language (are you goofy or regular?) and the often ridiculous clothing. So why not surf in Lanzagrotty?. How hard can it be to stand on a 10-ft plank for a minute or so? The first few hours of surfing school will teach you to jump on giant hard-foam training boards and paddle for imaginary waves. Don't worry if you swallow half the Atlantic on the first go, everyone does.....
By mid-way through the day you'll be giving the Vaya Cono Dios speech and calling your mate Bodhi – (his name's Ron) and more importantly will be hooked both on surfing and Lanzarote – which, by the way, is far from grotty.
A wicked pad can be found at Fincamalvasia.com, and surfing lessons booked at surfschoollanzarote.com. Flights with Monarch won't break the bank either. Radical Dude!
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