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Patent application title: Method and Apparatus for External Stabilization of the Heart Valves and Myocardium
Jaishankar Raman (Chicago, IL, US)
Jaishankar Raman (Chicago, IL, US)
P. Srirama Rao (San Diego, CA, US)
IPC8 Class: AA61F224FI
USPC Class:
623 236
Class name: Prosthesis (i.e., artificial body members), parts thereof, or aids and accessories therefor heart valve annuloplasty device
Publication date: 2009-01-22
Patent application number: 20090024213
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Patent application title: Method and Apparatus for External Stabilization of the Heart Valves and Myocardium
P. Srirama Rao
JaiShankar RAMAN
Mardil, Inc.
Origin: ALEXANDRIA, VA US
IPC8 Class: AA61F224FI
USPC Class:
623 236
The present disclosure is directed to an external cardiac basal
annuloplasty system (ECBAS or BACE-System: basal annuloplasty of the
cardia externally) and methods for treatment of regurgitation of mitral
and tricuspid valves. The BACE-System provides the ability to correct
leakage of regurgitation of the valves with or without the use of
cardiopulmonary bypass, particularly when the condition is related to
dilation of the base of the heart. This ECBAS invention can be applied to
the base of the heart epicardially, either to prevent further dilation or
to actively reduce the size of the base of the heart. Such devices also
include an extension thereto for the treatment of localized myocardial
defects, scars and damage.
1. A device for use as an external heart stabilizer to provide both
valvular stabilization and myocardial reinforcement, wherein the heart
has a base and an apex, comprising:(a) a strip of biocompatible,
implantable material having a predetermined width adapted to encompass
the base of the heart and not the apex of the heart to prevent basal
dilation during all cardiac cycle phases; and(b) an extension comprising
a biocompatible, implantable material to provide mechanical myocardial
reinforcement, wherein the extension is operably connected to the strip.
2. The device of claim 1, wherein in the biocompatible material facilitates cell ingrowth.
3. The device of claim 2, wherein the cells are stem cells or skeletal myoblast cells.
4. The device of claim 1, further comprising growth factors associated with the biocompatible material.
5. The device of claim 1, wherein the extension comprises a different material than the strip.
6. The device of claim 1, wherein the extension extends from the base of the heart towards the apex of the heart.
7. The device of claim 1, wherein the extension extends from the base of the heart, but does not reach the apex of the heart.
8. The device of claim 1, wherein the strip is a band that encircles the heart.
9. The device of claim 1, wherein substantially all parts of the strip are in continuous contact with heart tissue.
10. The device of claim 1, wherein the strip is constrictive during all parts of the cardiac cycle.
11. The device of claim 1, wherein the extension comprises a material that is more rigid relative to the strip.
12. The device of claim 1, wherein the strip and/or extension further comprises an inflatable bladder.
13. The device of claim 1, wherein the strip comprises a top edge, a bottom edge and a center portion, and wherein the extension is attached to the bottom edge.
14. The device of claim 13, wherein the extension is contiguous with the strip.
15. The device of claim 13, wherein the extension is narrower than the length of the strip.
16. The device of claim 13, wherein the distance from the top edge to the bottom edge is about 2 cm to 5 cm.
17. A method of treating a heart disease or disorder resulting in mitral and/or tricuspid valve regurgitation, comprising implanting a device of claim 1 in a subject afflicted with the disease or disorder, such that the device is located at the atrio-ventricular junction.
18. A method, comprising:implanting the device of claim 1 along the atrio-ventricular junction of a subject, wherein the device reduces or eliminates mitral and/or tricuspid valve regurgitation in the subject.
19. A method of treating mitral and/or tricuspid valve regurgitation, comprising constricting the base of the heart at about the atrio-ventricular junction with a device located on the surface of the heart.
20. The method of claim 19, wherein the device comprises a biocompatible, implantable strip having a width of about 2 cm to 5 cm.
21. The method of claim 19, wherein the device is a band that encircles the heart.
[0001]This application is a continuation-in-part of U.S. Ser. No. 10/796,580 filed on Mar. 8, 2004, pending, which is a continuation application of U.S. Ser. No. 10/236,640 filed on Sep. 6, 2002, which issued as U.S. Pat. No. 6,716,158 on Apr. 6, 2004, and which claims priority of U.S. Provisional application 60/318,172, filed on Sep. 7, 2001.
[0002]The invention relates to devices and methods for treating dilatation of the valves at the base of the heart by external stabilization of the base of the heart, which subtend the atrio-ventricular valves of the heart. Such devices also include an extension thereto for the treatment of localized myocardial defects, scars and damage.
[0003]Dilatation of the base of the heart occurs with various diseases of the heart and often is a causative mechanism of heart failure. In some instances, depending on the cause, the dilatation may be localized to one portion of the base of the heart (e.g., mitral insufficiency as a consequence of a heart attack affecting the inferior and basal wall of the left ventricle of the heart), thereby affecting the valve in that region. In other cases, such as cardiomyopathy, the condition may be global affecting more of the heart and its base, causing leakage of particularly the mitral and tricuspid valves. Other conditions exist where the mitral valve structure is abnormal, predisposing to leakage and progressive dilatation of the valve annulus (area of valve attachment to the heart). This reduces the amount of blood being pumped out by the ventricles of the heart, thereby impairing cardiac function further.
[0004]In patients with heart failure and severe mitral insufficiency, good results have been achieved by aggressively repairing mitral and/or tricuspid valves directly, which requires open-heart surgery (Boiling, et al). The mitral valve annulus is reinforced internally by a variety of prosthetic rings (Duran Ring, Medtronic Inc) or bands (Cosgrove-Edwards Annuloplasty Band, Edwards Lifesciences Inc). The present paradigm of mitral valve reconstruction is therefore repair from inside the heart, with the annulus being buttressed or reinforced by the implantation of a prosthetic band or ring. Since this is major open-heart surgery with intra-cavitary reconstruction, there is the attendant risk of complications and death associated with mitral valve surgery. Another approach has been to replace the mitral valve, which while addressing the problem, also requires open-heart surgery and involves implantation of a bulky artificial, prosthetic valve with all its consequences. Because every decision to perform major surgery requires some risk vs. benefit consideration, patients get referred for risky surgery only when they are significantly symptomatic or their mitral valve is leaking severely.
[0005]In contrast to the more invasive approaches discussed above, in specific instances of inferior left ventricular wall scarring causing mitral regurgitation, Liel-Cohen and co-workers have suggested localized pressure or support of the bulging scar of the inferior wall of the heart from the outside (Liel-Cohen. N. et al. (2000) "Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: insights from 3-dimensional echocardiography". Circulation 101 (23):2756-2763).
[0006]Another less invasive approach to preventing global heart dilation is ventricular containment with a custom made polyester mesh, or cardiac support device (U.S. Pat. Nos. 6,077,218 and 6,123,662). These devices are designed to provide a passive constraint around both ventricles of the heart, and constrain diastolic expansion of the heart. Other devices include ventricular assist devices that provide cardiac assistance during systole and dynamic ventricular reduction devices that actively reduce the size of the heart. However, this technique does not specifically address valve leakage using a device that reinforces the base of the heart in all phases of the cardiac cycle.
[0007]Accordingly, there is a need to provide a less invasive, simple technique of repairing, reinforcing, reducing or stabilizing the base of the heart and its underlying valves (mitral and tricuspid valves) from the outside. In one embodiment, such devices circumvent the atrio-ventricular junction to provide for basal ventricular stabilization. When the device also includes at least one extension thereto, it is capable of simultaneously providing myocardial reinforcement/restraint.
[0008]The invention addresses the problems discussed above by providing a device for the treatment of certain heart disorders, in particular mitral and/or tricuspid valve insufficiency. The device aims to reduce the size of the base of the heart that contains these valvular structures. In addition, the invention can be used to address progressive dilatation of any localized area of the heart, such as the atrial or ventricular myocardium, or the cardiac base. It does so by providing external re-enforcement or remodeling of the cardiac base. As used herein, the surgical procedure for implanting the device is referred to as ibasal annuloplasty of the cardia externally ("BACE") and the device is referred to as the external cardiac basal annuloplasty system ("ECBAS") or BASE System.
[0009]The invention also provides a BACE device with an extension thereto ("BACE-PLUS") for treating valvular regurgitation and simultaneously reinforcing the myocardium.
[0010]In one embodiment, a customized or specially constructed biocompatible strip is implanted along the base of the heart at the level of the atrio-ventricular groove. In one aspect, the strip encircles the heart. The strip or mesh is between 2 and 5 cms wide and can be secured by 2 rows of clips or sutures, one on the atrial side and the other on the ventricular side of the atrio-ventricular groove. Specific care is taken to avoid injury to the circumflex and right coronary arteries and the coronary sinus. This procedure may be performed either as a stand-alone procedure or as an adjunct to other cardiac surgery. Additionally, it may be performed with or without the aid of cardiopulmonary bypass.
[0011]Another embodiment of this approach is a device or strip, which once implanted at a certain size, can be tightened over time either by inflation of an attached chamber or programmed to return to a pre-formed size (based on elasticity or pre-existing memory) of the material used.
[0012]Another embodiment of this device, while externally stabilizing the base of the heart, also provides a localized increase in contraction along any segment of the base to improve contractile function. This may be accomplished by the aid of contractile metal, biomaterial or modified muscle or other cells.
[0013]Variations of the device include a complete stabilization of the base of the heart, or a partial stabilization around the expansile portions of the mitral and tricuspid valves by a biocompatible strip.
[0014]Another variation uses ports along the device that will facilitate delivery of specialized drugs, gene therapeutic agents, growth factors, etc.
[0015]A specific variation incorporates the use of epicardial bi-ventricular pacing electrodes implanted along with the BACE-System, where multi-site pacing might be indicated.
[0016]The invention also provides a method of implantation, which may be through a conventional full median sternotomy with the strip being secured by sutures, or a minimally invasive approach whereby the device/strip may be implanted by a specialized implantation system using adhesives, self-firing clips, sutures, etc.
[0017]Another modification of this technique is the local application of prosthetic material to stabilize scars of the heart to prevent their expansion (local ventricular stabilization).
[0018]In an alternate embodiment, the device incorporates additional strips to be used in concert or as an extension to provide localized support to areas of ventricular reconstruction or areas of fresh infarction or old scar.
[0019]FIG. 1 depicts a cross-section of the heart, showing the approximate location of a representative embodiment of the device of the invention by dashed lines.
[0020]FIG. 2 depicts a cross-section of the base of the heart between the dotted lines depicted in FIG. 1.
[0021]FIG. 3 depicts a cross-sectional schematic diagram of the base of the heart. As depicted therein, PV=pulmonary valve, MV=mitral valve, AV=aortic valve and TV=tricuspid valve.
[0022]FIG. 4 depicts a traditional method of repairing MV and TV with bands inside the heart.
[0023]FIG. 5 depicts basal angioplasty of the cardia externally.
[0024]FIG. 6 depicts a representative embodiment of the device of the invention.
[0025]FIG. 7 depicts a schematic drawing of a heart with a representative BACE device in place.
[0026]FIG. 8 depicts a schematic drawing of a heart with a representative BACE-PLUS device in place.
[0027]The invention is directed to and external support device for the base of the heart. The support functions to decrease, and/or prevent increases in, the dimensions of the base, and in particular the atrio-ventricular junction, beyond a pre-determined size. The device is designed to reduce the size of the cardiac base in a manner similar to an internal annuloplasty band or ring.
[0028]This invention is particularly suited for use in regurgitation of the mitral and tricuspid valves. The device may also be used prophylactically in heart failure surgery to prevent further cardiac basal dilation or expansion even if the underlying mitral and tricuspid valves are competent. The device may be used in moderate or advanced heart failure to prevent progression of basal dilation or reduce the size of the dilated base.
[0029]As used herein, "cardiac base" refers to the junction between the atrial and ventricular chambers of the heart, also known as the atrio-ventricular junction marked externally by the atrio-ventricular groove. This is easily identified in the change of appearance of the cardiac muscle and also the presence of arteries and veins.
[0030]The heart is enclosed within a double walled sac known as the pericardium. The inner layer of the pericardial sac is the visceral pericardium or epicardium. The outer layer of the pericardial sac is the parietal pericardium. The term "endocardial surface" refers to the inner walls of the heart. The term "epicardial surface" refers to the outer walls of the heart.
[0031]The mitral and tricuspid valves sit at the base of the heart and prevent blood from leaking back into the atria or collecting chambers. See FIG. 1. Mitral regurgitation is a condition whereby blood leaks back through the mitral valve into the left atrium. Over time, this creates a damming of blood in the lungs causing symptoms of shortness of breath. The left heart particularly the left ventricle has to pump a greater volume of blood as a result causing greater strain on this chamber.
[0032]Dilatation of the mitral annulus occurs maximally in the posterior portion of the annulus, which is not supported by the cardiac fibro-skeleton. FIG. 2 is an anatomic diagram of the base of the heart, showing the valves and the structures in contact with them. FIG. 3 is a schematic representation of the valves at the cardiac base.
[0033]Mitral valve repair or replacement at present is always performed from inside the heart with the aid of cardiopulmonary bypass. Rings are implanted along the inner surfaces of the entire or expansile portions of the mitral and tricuspid annuli (FIG. 4). Alternatively, when mitral valve malfunction is severe, replacement of the valve with a prosthetic valve may be indicated.
[0034]The basal ventricular stabilization of the invention works by using a prosthetic material such as polyester mesh anchored or sutured to the base of the heart at the level of the atrio-ventricular groove. This serves to stabilize the mitral and tricuspid annuli from the outside (FIG. 5). This technique reduces the complexity of the procedure and minimizes the invasive nature and complications from work on the valve. This technique is of particular benefit in patients that have morphologically normal valves with annular dilatation. The device can be applied and anchored to the cardiac base, with the heart beating, without the aid of cardiopulmonary bypass.
[0035]Many patients with moderate degrees of mitral regurgitation are not treated surgically, because the risks of surgery outweigh the potential benefits in this group of patients. However, patients with conditions such as chronic heart failure tend to get very symptomatic even with moderate degrees of mitral regurgitation. These groups of patients would benefit from the less invasive procedures, which are the subject of the invention. Thus, the potential of this technique in treating mitral regurgitation as a minimally invasive procedure has great appeal as the population ages and more patients manifest with symptoms of heart failure. It also can be applied en passant in patients undergoing coronary artery surgery without the aid of a heart-lung machine.
Device Parameters
[0036]The device of the invention can be constructed of any suitable implantable material. Examples of such materials are well known in the art and include, e.g., synthetic polymers such as polyester, polytetrafluoroethylene, polypropylene, Teflon felt, etc., as well as metallic materials such as stainless steel, mitinol and the like. Such metals may provide "memory", such that they return to a specific shape after deformation, and in this manner provide an element of dynamic contraction. In yet another embodiment, the device may be constructed either partially or completely by natural materials, such as polyglycolic acid or compressed and/or crosslinked collagen, which may or may not be reinforced with synthetic polymers or other means. Any material is suitable that is biocompatible, implantable, and has a compliance that is lower than the heart wall. Other variations include incorporation of elastic material or elastin ingrowth into the biomaterial.
[0037]As shown in FIG. 6, the preferred device is in a "strip" configuration and comprised of two edge members and a center portion, each of which may be constructed by the same or different material. In one embodiment (not shown), there is no distinction between the edge members and the center portion and the device is completely uniform from top to bottom. If the device strip is laid flat or if the device band is cut and laid flat the device is substantially planar.
[0038]The center portion of the device may be in the form of a solid single or multi-layer sheet, but is preferably of an open mesh, porous or woven design, such that the exterior of the heart is not completely covered and therefore remains exposed to the surrounding tissue. The size of the openings in the mesh can vary, for example from 2 mm to 2 cm, and can take any shape, such as circular, square, octagonal, triangular, or irregular. In a preferred embodiment, the center portion of the device is a mesh as depicted in FIG. 6.
[0039]The center portion may also be adapted for the delivery of various therapeutic agents, such as growth factors or plasma proteins. In addition, it may be adapted to facilitate cellular growth, which in turn may facilitate anchorage of the device.
[0040]The device may be designed to completely circle the base of the heart, or it may be a "C" shape, in which case it is specifically designed and implanted so as to not impede blood flow through the aorta and pulmonary artery.
[0041]The biomaterial from which the device is constructed may also be radiolucent, radio-opaque or have radio-opaque markers at present intervals to monitor the movement of the cardiac base in real-time using fluoroscopy and to facilitate implantation.
[0042]The device may be completely rigid prior to implantation, or may have regions of varying rigidity. However, it is important that the device is sufficiently flexible to move with the expansion and contraction of the heart without impairing its function. It should, however, be designed to prevent expansion of the cardiac base during diastolic filling of the heart to a predetermined size. Since the size expansion parameters of a beating heart are well known, this can be accomplished by testing the device in vitro by applying forces that mimic heart expansion.
[0043]The edges of the device, which are depicted in FIG. 6 having securing eyelets attached thereto, may be constructed of a more rigid material, such as carbon fiber tubing. In addition, means of making the device, or portions thereof, such as one or both edges and/or the center portion, more or less rigid post-implantation are also within the invention. For example, the center portion may be constructed of a partially biodegradable material and may become more flexible after implantation when the biodegradable material is hydrolyzed by the surrounding tissues and fluids. Alternatively, the edges may be provided with means for making them more rigid or flaccid prior to implantation, such as by inflating/deflating closed chambers. Many alternate means for adjusting the rigidity/flexibility of the device, or portions thereof, would be easily adapted from other mechanisms known in the surgical arts.
Device Extensions
[0044]In one embodiment, a limited extension of the BACE device may be applied to reinforce an area of myocardium that is in need thereof. This treatment may serve as an alternative to surgical reconstruction of the myocardium.
[0045]These areas may be akinethic or dyskinetic and may contribute to worsening cardiac function and mitral regurgitation. Such a dual-purpose device is referred to herein as a BACE-PLUS device.
[0046]The extension consists of biocompatible patch material that is made of the same material or a material similar to, but not necessarily identical to, the BACE device, such as biopolymers, mitinol and other materials described above for the BACE. The shape of the extension or patch is, for example, oval or circular to cover/encompass the whole region of the affected ventricle. In one embodiment, the extension has some degree of stiffness and additional reinforcement to prevent the "give" of a progressively enlarging heart. Such an embodiment would synergistically diminish heart enlargement while at the same time providing myocardial support.
[0047]The structure of the extension may be porous, cross-linked, woven, etc., as with any other relatively flat implantable material. The configuration of the materials provide a platform for impregnation of biomolecules such as growth factors, and also promote the propagation and growth of new myocardial repair cells along specific patterns that would optimize cardiac contraction.
[0048]The extension may be secured to the heart with sutures, specially designed staples or clips. Alternatively, the extension is secured with transmural neo-chords or non-reacting tensioning chords, akin to guide ropes of a sail or parachute. Finally, the extension may incorporate special Velcro type fastening material on one side that facilitates anti-slip and firm adhesion to the epicardial surface of the ventricles.
[0049]The BACE-PLUS device is adapted for administration to a patient population that has not undergone surgical myocardial reconstruction (i.e. surgical removal of the aneurism or scar). Indeed, the BACE-PLUS device may function by cellular or mechanical reconstruction of the myocardium as an alternative.
Device Attachment
[0050]The device may be attached to the outside of the base of the heart by any known method. For example, attachment may be biological, chemical or mechanical. Biological attachment may be brought about by the interaction of the device with the surrounding tissues and cells, and can be promoted by providing appropriate enhancers of tissue growth. Alternatively, chemical attachment may be provided by supplying a mechanism for chemical attachment of the device, or portions thereof, to the external surface of the heart. In yet another embodiment, the rigidity and tightness of the device around the heart may provide for sufficient mechanical attachment due to the forces of the heart against the device without the need for other means of attachment. In a preferred embodiment, however, as depicted in FIG. 6, the device further comprises attachment members, such as the eyelets shown therein. Specific anchor points or loops made of any biocompatible and implantable material may be attached to the edges or to the center portion or both to facilitate anchoring. Suitable materials include, inter alia, polyester, polypropylene or complex polymers. Alternative attachment members may comprise suture materials, protrusions that serve as sites for suturing or stapling, as well as other structural members that facilitate attachment to the surface of the heart.
Device Size
[0051]Although the size of the device depends on the purpose for which it is being implanted, it is contemplated that the device will be wide enough (measured from the outside of the first or top edge, i.e. the base edge, to the outside of the second or bottom edge, i.e. the apex edge) to provide efficient support to the atrio-ventricular grove. Accordingly, in one embodiment, the device is between 2 and 5 centimeters wide. In other embodiments, the device may be adapted to provide support over a larger area of the heart. This would provide specifically for reinforcement of areas of scar or muscular weakness as in dyskinetic infracted areas of the myocardium.
[0052]As shown in FIG. 1, the distance between the base and the bottom of the apex of the heart can be expressed as distance "X". Because the focus of the device of the invention is base stabilization, it is generally preferred that the width of the device be less than or equal to 1/2 X, and be adapted for placement around the top half of the distance X, i.e. closer to the base than the bottom of the apex.
[0054]The ECBAS or BASE system may be implanted through a conventional midline total sternotomy, sub maximal sternotomy or partial upper or lower sternotomy. Alternatively, the device may be implanted through a thoracotomy incision, or a Video Assisted Thoracoscopic (VAT) approach using small incisions. The BASE system can also be implanted by a sub-costal incision as in the Sub-Costal Hand-Assisted Cardiac Surgery (SHACS). Additionally, the BASE system may be implanted with sutures onto epicardium or clips, staples, or adhesive material that can secure the device on the heart accurately. The device may also be implanted using robotic placement of the device along the posterior aspects of the base of the heart.
[0055]The method of implantation and the adequacy of the external annuloplasty can be dynamically assessed by intra-operative trans-esophageal echocardiography, epicardial echocardiography or trans-thoracic echocardiography. The size of the device is assessed based on external circumference measurements of the cardiac base in the fully loaded beating heart state.
Versions of the BACE Systems
[0056]a. Complete Versus Partial BACE
[0057]The ECBAS may completely encircle the cardiac base or just partially support the mitral and tricuspid valve portion of the cardiac base.
[0058]b. BACE with Extensions
[0059]In one embodiment, a limited extension of the ECBAS or an extension member may be applied to reinforce an area of myocardium. For example, the extension can served to support an area of the myocardium that has been reconstructed to exclude an aneurysm or scar. The extension typically extends from the bottom edge of the ECBAS. The extension can extend from the base of the heart towards the apex but does not need to reach the apex of the heart. The extension may be contiguous with the ECBAS material or may be a separate and/or different biocompatible material.
[0060]c. BACE with Pace
[0061]In another embodiment, the ECBAS has attached close to, or within it, epicardial steroid eluting pacing wires that can facilitate multi-site ventricular pacing for heart failure.
[0062]d. Dynamic BACE
[0063]In this embodiment, the device has fluid filled chambers that may be inflated gradually over time, to gradually reduce the size of the cardiac base. These chambers may also effect passive transfer of energy to facilitate diastolic and systolic support with a closed pericardium
[0064]e. Smart & Dynamic BACE
[0065]In this embodiment, the bio-material would have the capability to shrink to a pre-formed size over a period of time, based on the memory of the material or some other programmable characteristic. This would achieve controlled reduction over a period of time of the base of the heart.
[0066]f. Cellular BACE
[0067]In this embodiment, the bio-material uses available matrix technology, and seeding of appropriate cells to provide dynamic reduction and assistance to the cardiac base.
[0068]1. Pai R G, Silvet H, Amin J, Padmanabhan S: Prognostic importance of mitral regurgitation at all levels of LV systolic function: Results from a cohort of 8931 patients. Circulation 2000; 102(18) Suppl. II: 369. [0069]2. Boiling S F, Pagani F D, Deeb G M, Bach D S: Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg 1998; 115:381-8. [0070]3. Timek T A, Dagum P, Lai D T, Liang D H, Daughters G T, Ingels N B, Miller D C: Pathogenesis of mitral regurgitation in tachycardia induced cardiomyopathy (TIC). Circulation 2000; 102(18) Suppl. II:420. [0071]4. Liel-Cohen N, Guerrero J L, Otsuji Y, Handschumacher M, Rudski L, Hunziker P R, Tanabe H, Scherrer-Crosbie M, Sullivan S, Levine R A: Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: insights from 3-dimensional echocardiography. Circulation 2000; 101 (23):2756-63. [0072]5. Lamas G A, et al: Poor survival in patients with mild to moderate mitral regurgitation. Circulation 1997; 96:827.
Example 1
BACE Procedure
[0073]Over a 12 month period, ten patients underwent Basal Annuloplasty of the Cardia Externally (BACE), to correct moderate mitral regurgitation. This technique involves securing a specially constructed polyester mesh like device to the epicardial surface of the cardiac base, at the level of the atrio-ventricular groove. These procedures were performed in conjunction with coronary artery surgery in all patients. All patients demonstrated a dramatic improvement in functional status, quality of life, mitral regurgitation and function of the heart. BACE can be performed safely with expectation of a good clinical outcome as an adjunct to conventional heart surgery.
Clinical Approach and Experience:
[0074]Careful pre-operative screening included radionuclide ventriculography to document left ventricular ejection fraction, a detailed trans-thoracic echocardiogram, a coronary angiogram, and in most cases a stress thallium and/or a Positron Emission Tomographic Scan looking for myocardial viability. The functional status of the patients were carefully documented by a heart failure cardiologist and nurse.
[0075]Ten patients who were undergoing conventional cardiac surgery, usually in the setting of poor cardiac function with moderate mitral regurgitation, were enrolled. All of these patients had coronary artery bypass surgery. All of them had at least moderate mitral regurgitation pre-operatively and intra-operatively (confirmed by trans-esophageal echocardiography). All of these patients had the Basal Annuloplasty of the Cardia Externally (BACE) performed with a polyester mesh constructed intra-operatively, based on the measured circumference of the cardiac base.
Surgical Technique:
[0076]The circumference of the base of the heart at the level of the atrio-ventricular groove was measured before the patient was connected to cardiopulmonary bypass (CPB). Based on these measurements, a strip of polyester mesh measuring 2.5 to 3 cm in width was cut to size and fashioned, such that its length would be less than the basal circumference by about 2.5 to 4.5 cms. Once the patient was connected to cardiopulmonary bypass, the coronary artery bypass grafts were performed. Left ventricular reconstruction was performed when indicated.
[0077]The constructed BACE mesh was anchored posteriorly at the level of the atrio-ventricular groove, on atrial and ventricular sides with combination of 4/0 Ticron® sutures and hernia staples, which were placed about 1.5 to 2 cm apart. The mesh was secured laterally as well. Final assessment of the tension and the securing of the BACE system was performed with the patient weaned off cardiopulmonary bypass with the heart filled to pre CPB levels. The mesh was then tightened and secured just as the mitral regurgitation was abolished on trans-esophageal echocardiographic monitoring.
Post-Operative Course:
[0078]All these patients had trivial to mild mitral regurgitation at the completion of the procedure. At follow-up, 3, 6 and 12 months post-operatively, all of these patients demonstrated improved cardiac function (as measured by left ventricular ejection fraction), improved functional status and quality of life, and were able to maintain their improvement in the degree of mitral regurgitation. Radionuclide ventriculography was used to determine the left ventricular ejection fraction pre- and post-operatively. Compared to a preoperative value of 25±3.1% (n=8), the ejection fractions improved to 40.+-0.14.2% and 39.3±5.7% after 3 and 6 months post-operatively, respectively (p<5). Likewise, the New York Heart Association (NYHA) classification was used as an index of functional heart status. Compared to a pre-operative value of 3.11±0.33 (n-8), the NYHA improved to 1.17±0.41 after 3 months post-operatively (p<5). Mitral regurgitation (graded 1 to 4) was also observed to improve dramatically from 3.01 pre-operatively to 0.1 post-operatively after 6 months (p<5). In addition, there was improvement in tricuspid regurgitation as well.
[0079]Dilatation of the cardiac base often accompanies heart failure. This may be a secondary development due to volume overload and increased left ventricular wall stress. In cases of mitral or tricuspid valvular heart disease, annular dilatation occurs along with decompensation of the regurgitant lesions. Severe annular dilatation accompanies severe regurgitation. However, significant basal dilatation may co-exist with moderate or moderately severe atrioventricular valve regurgitation. Since repair of these conditions requires intra-cavitary repair of the affected annulus, the majority of surgeons tend to leave moderate and moderately severe mitral and/or tricuspid regurgitation alone. Using the methods and apparatuses of the invention, these conditions can be corrected from the outside of the heart. Furthermore, the correction can be tailored under trans-esophageal echocardiographic guidance. This avoids intra-cavitary manipulation. In selected cases, this procedure could be performed with heart beating also and without using the heart-lung machine, making it an "off-pump" procedure.
Example 2
Comparative and Long Range Studies Using BACE Procedure
[0080]Twelve patients were treated with the BACE procedure as described in Example 1. All of the patients had pre- and post-operative studies at 3, 6, 12 and 18 months, including echocardiography and radionuclide ventriculography to look at cardiac function, amount of mitral regurgitation and the size of the hearts. All twelve patients were very symptomatic, with the majority in New York Heart Association (NYHA) class III status. The mean left ventricular ejection fraction (LVEF) was 25% preoperatively and all patients had moderate mitral regurgitation.
[0081]The BACE procedure was performed on cardiopulmonary bypass with the heart decompressed. The procedure took approximately 15 minutes of extra bypass time and about 5 minutes of extra cross-clamp time.
[0082]The results are shown below in Table 1. As shown, the BACE procedure dramatically improved cardiac function and was at least equivalent to mitral valve repair eighteen months post-operatively.
TABLE-US-00001 TABLE 1 BACE Procedure Results Pre-OP 6 months 12 Months 18 months NYHA 3.11 1.14 1.2 -- Functional Status Left 25.0 39.3 43.1 44.5 Ventricular Ejection Fraction (%) Degree of Mitral 2.8 -- -- 3 Regurgitation - BACE Patients Degree of Mitral 3.7 .7 Regurgitation - Mitral Valve Replacement Patients
[0083]All publications and patents mentioned in the above specification are herein incorporated by reference. Various modifications and variations of the described method and system of the invention will be apparent to those skilled in the art without departing from the scope and spirit of the invention. Although the invention has been described in connection with specific preferred embodiments, it should be understood that the invention as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the invention which are obvious to those skilled in hematology, surgical science, transfusion medicine, transplantation, or any related fields are intended to be within the scope of the following claims.
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Executers know how to execute. Take a look at which retailers did well in a tricky part of the season with the "wrong" weather. The retailers with the good comp numbers are the same ones we have come to expect to do well, the guys who get it and have the right merchandise at the right price points in an attractive setting.
For example, TJX Corp. (TJX) once again delivered that level of consistency that we have come to admire so much, despite its big presence in Europe. Costco (TJX) has the best eye of the group, fantastic merchandise, a treasure-hunt experience, rock-bottom prices -- unlike Target (TGT) -- so it shoots the lights out. No surprise. And Target is truly in Costco's crosshairs.
Ross Stores (ROST) -- when will people believe in these guys? Another 52-week-high on a terrific beat. Macy's (M) has become a delivery machine. They just seem to execute and execute regardless of the weather, and they aren't so apparel-heavy as to be caught (as Kohl's (KSS) obviously was). Pier One (PIR) is not up despite the guide-up, in part because it has run so much. I would take advantage of that one and scoop it up, as this is a major transformation that has multiple years ahead of it.
Limited (LTD) keeps its record of returning money to shareholders with a terrific $2 special dividend as Les Wexner -- no longer spry but certainly my guy -- quietly churns out some terrific profits, led by Victoria's Secret. Nordstrom (JWN) has managed to keep the high end alive as a theme in a time when Tiffany (TIF) has stumbled. The stock motors higher.
The only real surprise of the "surprises" came from Saks (SKS), which has become maddeningly inconsistent and very difficult to game.
The losers ? Lululemon (LULU) seems to have hit a wall, at least when it comes to guidance. It's perceived as still one more overvalued high-growth name when people want lower growth and lower valuation. Kohl's has become a total conundrum. They have the wrong merchandise at the wrong time. Gap (GPS) and JCPenney (JCP) don't deliver, but given their compressed expectations, people brush it off as a chance to snap up stocks that seem to have put in a bottom.
Target? No reason to own it. No momentum. The object of so much competition. Just too easily copied at lower prices. Target was once the darling. Now it is just another retailer in a market where the others are just doing better, period.

subset: commoncrawl


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Get the Best Priced Dodge D350 Bug Shield
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COPping the heat (and the procrastination) in Durban
The beachside city of Durban is packed, with 10,000 people from 194 countries in town for the 17th Conference of the Parties (COP17) to negotiate the next step in the process of the United Nations Convention on Climate Change (UNFCCC).
It's also the 7th meeting of the parties to the Kyoto Protocol (CMP7), the mechanism through which the Protocol is implemented, and the central subject of this meeting, as nations wrestle with what arrangements can be put in place to replace or extend the agreements under the Protocol which expires in 2012.
But Australian officials need to do a better job both here in Durban and at home to create a compelling narrative for strong climate action. There are many 'frames' through which climate action can be positively viewed i.e. benefits to health, risk management, and low carbon market opportunities - all of which are real, and available right now.
While many of the negotiations here are taking place behind closed doors, there is a vital role for observers in tracking progress and spreading the word on how the talks progress.
This happens to be our 100th post.
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Talking points
Our editors will be looking ahead today to these developing stories...
Thai 'red shirts' face trial
Leaders of Thailand's "red shirt" protest movement are expected to go on trial on charges of terrorism, in connection with deadly street protests in 2010. The "red shirts" - most of them supporters of ousted prime minister Thaksin Shinawatra - brought chaos to Bangkok in days of rallies in which civilians and police were killed. The trial may spark off more unrest, especially as it comes days after royalist "yellow shirts" protested to demand the removal of Thaksin's sister, Prime Minister Yingluck Shinawatra.
October retail sales figures due
Hong Kong's retail sales figures for October are released, shedding light on the city's performance in the crucial "golden week" national holiday at the start of that month. Retail sales rose more strongly than expected in September. But there were signs of a slowdown in some segments, with the luxury sector particularly hard-hit.
British media ethics inquiry reports
Britain's biggest media ethics inquiry releases its findings - a report that could lead to fundamental changes in the way the country's newspapers are regulated. Lord Justice Brian Leveson has heard from 474 witnesses since the inquiry began a year ago. It was set up in the wake of the phone-hacking scandal that led to the demise of Rupert Murdoch's News of the World tabloid.
Appeal verdict in Air France crash case
A court in Versaille delivers its verdict on an appeal by the parties found guilty of manslaughter in the crash of an Air France Concorde jet. Continental Airlines and one of its mechanics were convicted of manslaughter in 2010 after debris from one of the former airline's planes caused the crash in 2000 of Flight 4590, killing 113 people. The previous trial ruled that titanium debris dropped by a Continental DC-10 on to the runway at Charles de Gaulle airport in Paris was to blame.
UN to vote on Palestinian statehood
The UN General Assembly is set to vote on recognising the Palestinian Authority as a state - a proposal likely to pass despite the fierce opposition of the United States and Israel. France has indicated it will support the proposal to make Palestine a non-member observer state at the United Nations, and other European nations are also considering backing it. Unlike the Security Council, there is no veto for larger states in the assembly.
Zheng hopes for 'player of the year' title
The Asian Football Confederation names the continent's player of the year at an awards ceremony in Kuala Lumpur. Guangzhou Evergrande's Zheng Zhi is one of three names on the shortlist after he helped his side retain their Chinese Super League title. The former Celtic and Charlton Athletic star faces competition from Iran's Ali Karimi and Lee Keun-ho of South Korea.
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For Fashion Week, Five Foods Just as Hard to Eat as Those Clothes are to Wear
It's Fashion Week, which means lots of impractical clothes clothes on impractically shaped people.
But designers aren't alone in their ability to turn something as functional as clothes into high art. Chefs often do the same with food, as demonstrated by the above dish -- a salad from Abacus -- and the four that follow.
This amuse bouche from Craft. Or, for most of the models participating in Fashion Week: dinner.
Matt McCallister
Chef Matt McCallister, soon of Oak Cliff's Campo built this garden, which we imagine tastes as fabulous as it looks.
Tei An Uni
Tea An's sea urchin. How are ya', little fella?
Sergei Arola
This little rum ball is a creation from Chef Sergei Arola in Spain, who dabbles in molecular gastronomy. Could you tell?
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Day 63
Skin improvement today but I wanted to post a photo to show how horribly flaky my skin is. I can't do anything about it, when I put sunscreen or BB cream it stays as dry! Any help or tips would be appreciated!! : (
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Jeezy Joins Roc Nation
Rapper Young Jeezy is joining forces with Jay Z and his company Roc Nation.
Jeezy has inked a deal with Roc Nation's artist management branch. A photo of Jeezy and Jay Z toasting to the partnership was posted on Jay's RocNation.com.
Roc Nation also took the opportunity to plug Jeezy's upcoming mixtape, It's Tha World 2, which is slated to arrive on November 27th.


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Rome, GA At the inaugural dual round of World Superbike/AMA Superbike races at Miller Motorsports Park in Tooele, Utah, Pirelli entertained fans who helped raise $5,000 for two powerful charities: Racing 2 Save Lives and the Roadracing World Action Fund. Pirelli would like to thank these fans for their support of these two charities.
To support these funds Pirelli sold spectators numerous sporting items such as books, hats and T-shirts, donating 100% of the proceeds to these two well known and proactive funds. Racing 2 Save Lives raises funds for children's charities while the Roadracing World Action Fund is dedicated to protecting the safety of racers.
Sharon Foxworthy, President of Racing 2 Save Lives, said, "We're delighted with this unexpected donation from Pirelli and racing fans to our foundation, and our volunteers had a great time working this event with the Pirelli people. Since our fund was created in 2004, this latest donation has pushed our total raised for various children's charities to over $200,000. This event nicely complements our regular fundraising activities of hosting track days around the country at tracks like Miller Motorsports Park and Virginia International Raceway." To learn more about attending the July 3 6 event at Miller, or the August 11 16 event at VIR, please visit: www.racing2savelives.com.
Roadracing World Action Fund's Vice President, Trudy Ulrich, commented, "This fund has served racers since 2001, and this great gift takes our new total of funds raised to over $600,000. The use of soft barriers has saved lives and reduced injuries more than any other option for absorbing impact. Our fund helps educate the public and increase race track safety by purchasing soft barriers and deploying and demonstrating their use at various race tracks throughout the United States, and by providing motorcycle racing safety education at our website. Since the fund was created many tracks and racing organizations have bought soft barriers on their own, significantly increasing racer's safety throughout America." To learn more about making racers safer or to make a donation, go to: ~http://actionfund.roadracingworld.com~.
Pirelli Tire North America specializes in the manufacture and marketing of high-performance tires for passenger vehicles, motorcycles and motorsports. An industry leader in technology and quality, Pirelli operates its highly advanced Modular Integrated Robotized System (MIRS) in Rome, Georgia, to better serve the North American OEM and Replacement markets. For more information please visit: www.us.pirelli.com.


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Italian greyhound.(5 Posts)
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Tony Blackburn On Showbiz
- over 8 years ago
It's not so much about how corny the joke is, it's the wait with the full knowledge that it's going to be terrible. Wonderful!
- over 8 years ago
Hi Tony - I have just completed the alpha of an audioboo toolkit at http://falling-night-28.heroku.com (that's a sneak preview, domain will be boobase.com in a few days). Allows you to filter, refine and harness the true power of audioboo in a way that is currently not offered by the site. Check it out!
- over 8 years ago
Great to hear you on here.. not so sure about this last joke but i am all up for giving you the benefit of the doubt.. ;)


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'I've done absolutely nothing wrong,' insists Redknapp
Portsmouth manager Harry Redknapp maintains he has done 'absolutely nothing wrong' following the BBC's screening of their Panorama investigation into alleged corruption in football.
The programme aimed to expose a `bung culture' within the game, a topical prelude to the publication of Lord Stevens' report on the 300-plus player transfers involving Premiership clubs over the past two years.
Redknapp, 59, is accused in the programme of `tapping up' Blackburn defender Andy Todd in discussions held in the canteen at Portsmouth's training ground.
Redknapp tells agent Peter Harrison: 'I like Toddy, don't I? No I'd take him. I would take him. I would take him without a doubt. I like him.'
The Portsmouth boss is renowned for his record in the transfer market, and a number of shrewd signings during the summer have helped Pompey top the Premiership after five matches.
Redknapp vehemently denies he has any case to answer after Panorama's broadcast.
'I haven't seen it (the programme) but I'm looking forward to going home and having a nice cup of tea and a slice of toast and watching it because I've done absolutely nothing wrong,' said Redknapp.
'There's nothing on there that I would have to consult my lawyer about. As far as I'm concerned there's not a single thing to worry about and I've said that from day one.
'If you haven't done anything wrong then you haven't got anything to worry about have you? Simple as that.'
Redknapp does not want to let the Panorama claims overshadow the work he is doing this season with the south-coast club.
Last night saw Pompey win 2-1 at Mansfield in the Carling Cup, thanks to goals from loan signing Manuel Fernandes and Matthew Taylor.
'It's not been a difficult weekend for me but the hassle has been difficult because it's distracted from the fantastic team performances that we've turned in,' Redknapp added.
'I really want to start focusing now on how well my team is doing. What a start to the season we've had, top of the Premier League - Pompey. Harry, you are different class.'


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|Thread Tools
Anyone have one?do you like it?what are seat darts?
I'm really thinking about getting one but I contacted BH and they said the body is 16"wide.My baby has really short legs so I am concerned. We have a WAHM MT and it's 14.5 wide.Not sure what to do...
I have one! Very comfortable carrier! My DS is just growing into it (20lbs, 28 inches, almost 8 months). It IS wider than say, the Ergo. But, it's taller too, so there is a lot more support. The waist belt is very comfy too. Very adjustable all the way around, really
Seat darts are just sort of seams in the fabric, that make the seat form-fit the baby. I'm not remembering if the Oh Snap has seat darts. My Kanga doesn't, and it helps keep them snug up against you, so not sure if they're really necessary. Depends on the carrier style.
If your baby is smaller, it would be very easy to roll up a receiving blanket to put under baby's bum. This would accomplish two things. First, it would get baby up higher in the body of the carrier. Second, it would help put baby's legs in a more comfortable position.
I would highly recommend it! Oh, and I think there is a really cute Oh Snap on the BabyWearer site, in the for sale or trade section. It had brown straps with an owl print. I was coveting it, but really can't justify having two! :P
Good luck!
thanks!I asked about darts because I contacted BH and they said the OhSnap had them.I would check TBW but I'm having technical issues with the site!
I was ready to return it or sell it when I first got it because of that but now it is no longer an issue as his legs are longer and don't seem to be rubbing. Apart from that it seems a good carrier, I just think that was a flaw in design considering the child's comfort as those clips/buckles are right where the legs are. It is a well made carrier otherwise.
The BHOS is a great carrier, for a toddler. It is not a suitable carrier for a small baby. I know people who have used it at about 6 months with really big babies, but even that is really pushing it. It really shines after 12-18 months.
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The Hays Police Department is set to conduct Special Situation Response Team Training on Thursday afternoon and evening.
Their work will be done at 1010 Reservatoin Rd. Lot J15.
Police officers will be training with special tactical equipment. This training is being done with great care and safety.
Police are advising that local resident may see law enforcement officers in training activities but there is no need to be alarmed. The officers are merely conducting a realistic training exercise and there is no danger to the community.


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May 11 2013
Stroud makes second ace of week
Chris Stroud make a hole-in-one at the 13th hole on Saturday.
By Helen Ross, PGATOUR.COM
PONTE VEDRA BEACH, Fla. -- Chris Stroud made the week's second hole-in-one on Saturday during the third round of THE PLAYERS Championship.
Stroud used a 6-iron for the ace on the 13th hole, which was playing 186 yards. On Thursday, Michael Thompson aced the eighth hole with a 3-iron.
The aces were the 25th and 26th on the Stadium Course at TPC Sawgrass -- and the first since 2008. Prior to Thompson's hole-in-one, the last seven aces during THE PLAYERS had come at the 13th hole.
The ace was Stroud's first on the PGA TOUR but the seventh he's made in his career.
"The wind didn't touch it, came down just short of the ridge and we saw it disappear toward the hole off the hill," Stroud said. "And then we had all of our friends and family here, and they started going crazy, so we knew it was going to be pretty good.
"They were walking toward the green, and we could see them start standing up and they went crazy. It was a good feeling. It was a good feeling."


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UPDATE: The rumors were wrong. See the GoPro Hero 3+ announcement for details.
Normally we don't report on rumors, but this one is especially interesting. It's been around for a few months, but considering we're nearing GoPro's normal release window and yesterday's iPhone 5C camera spec announcements, we think it's worth a look.
Based on the specs of the A9 4K Ultra HD Camera SoC(pdf), some are speculating that since the GoPro Hero 3 uses the A7 - Hybrid DV/DSC 1080p60 Camera SoC, that the next logical step for GoPro is upgrading to the new A9. Doing so would mean the GoPro could capture 4k video at 30fps, which, frankly, would be a very big deal. There are no consumer-level camcorders capable of doing that today.
Even more exciting, from our perspective, is that the A9 is capable of capturing 1080p footage at 120fps and 720p footage at 240fps. Anyone who's ever shot action videos knows the value in high frame-rate footage, as it allows for stunning, glass-smooth slow motion.
Is there any truth to the rumors? It's tough to say, but we're skeptical. The A9 4K Ultra HD Camera SoC was announced back in January, so the timing may work out for the next GoPro release, but what about the other factors? A chip upgrade may mean a significant increase in price for the GoPro. Additionally, form factor may be an issue, though form factor changes are nothing new for GoPro. Finally, we imagine there would have to be some significant bitrate sacrifices in order to keep the size, cost, and SD card requirements down. The A9 spec sheet says "Low bit-rate/high quality recording" which sounds like marketing speak to us.
What do you think? Should we expect to see usable 4k and 1080p high-speed footage from the GoPro Hero 4? If you ask us, we'd be happy with better battery life, but 4k would be nice as well.


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Low Carb, No-Bread Sandwich Ideas
Low-Carb Sandwich Alternatives For When You're on the Go
Low-Carb Sandwich Alternatives For When You're on the Go
Whether you're going back to school or just trying to be healthier and save money, bringing your lunch with you when you're on the go is a good idea for many reasons. This is especially so if you're following a diet — you won't have to search for a place to eat that follows your rules, and you know just what is in your food. But sometimes it can be hard to come up with healthy lunch ideas that'll keep you from being bored or ditching your brought lunch for the nearest pizzeria. On a low-carb diet and can't give into those sandwich cravings? Here are some low-carb sandwich options for you!
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Artist Ann Gumpper is fiddling with stage design in TH
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And so it begins...Although months away from opening night, volunteers led by director Paul Deaner and stage designer Ann Gumpper began bringing the village of Anatevka to life for Lake Superior Community Theater's production of Fiddler on the Roof. The beloved musical will be staged at Two Harbors High School in April. Gumpper, well known in arts circles, has created stage designs for dozens of regional theater, dance and opera productions. Working with local artists and cast members from the play, paint, plywood, yards of fabric and elbow grease will be transformed into the small Russian community where the play takes place. Photos by Dick Bohrer.


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With the yearly ABC Kids Spring Show comes even more new baby gear announcements! And it's no surprise that a lot of these gear items are coming in one particular color – grey is everywhere in 2016, and given that grey is such a popular color for cars, and Britax is one of the top names in car seats, it's no surprise ... Read More »
Search Results for: grey
NEW Stokke nursery furniture in grey and: how to decorate with grey!
SEE STOKKE AT DROOL BABY EXPO APRIL 7, 2016, 3PM-9PM GET TICKETS NOW Stokke is a brand that likes to give you choices: as we've said again and again in this blog, their products adapt and transform to fit with your parenting lifestyle and your child's ages and stages, with a simple and elegant design philosophy that blends smoothly with ... Read More »
We're mad for mélange! New Bugaboo Grey Mélange fabrics
Here at Magic Beans, we have seen the value of Bugaboo as a brand: these strollers really stand the test of time. And their latest color theme is a timeless neutral that we just can't stop talking about: not completely grey, subtle and sophisticated, Grey Mélange. Mélange: a French word meaning a mixture, a medley. Isn't that what life is, in ... Read More »
New Stokke Tripp Trapp colors! Hazy Grey, Soft Pink, and Wheat Yellow plus new accessories
Come see Stokke at Drool Baby Expo on April 7! Get your tickets here! There are few products that reflect our vision as a company as fully as the Stokke Tripp Trapp High Chair, in both form and function. Our gear experts are always happy to talk about how this high chair does so much to make your life easier, with style: It ... Read More »
ABC Kids Expo 2016: New UPPAbaby Vista & UPPAbaby Cruz, now with real leather!
UPDATED 4/20/2017: UPPAbaby Vista 2017 UPPAbaby Cruz 2017 The UPPAbaby Vista Stroller and UPPAbaby Cruz Stroller are two perennial Magic Beans favorites, and we're thrilled to hear about their 2017 updates – both practical and chic! The biggest news from UPPA this year is REAL leather accents: you'll find REACH compliant leather on the handlebars and bumper bars of ... Read More »
ABC Kids Expo 2016: new UPPAbaby Mesa with fire-retardant free fabrics!
Order the UPPAbaby Mesa 2017 here! We know that today's parent is extra-conscious about the risks of toxic chemicals in the products that you buy, so we make an extra effort to stock items that are as safe and "green" as possible. This isn't always easy, because there are always more studies unveiling new potential risks, and obviously we ... Read More »
Celebrate classic design with the Stokke Limited Edition Anniversary Collection High Chair!
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I will be the first to admit that my history is not as sharp or as extensive as I would like it to be, but I am reasonably sure neither the French nor the Native Americans knew martial arts in the 18th century. Mind you, I could be wrong, but I'm quite sure I'm not.
The above statement aside, Brotherhood of the Wolf is quite an unexpected movie. I went into this film expecting it to be one thing but it turns out to be another entirely. Even after having seen its trailer quite a few times, I thought I had the movie figured out pretty well. After all, how many trailers have kept the "mystery" of a movie hidden, especially in the last few years, where "more" seems to be, well, more? Such is the state of movie trailers nowadays. That aside, Brotherhood is quite a good movie, although there were directorial choices by filmmaker Christophe Gans, the movie's director, which is open to complaint.
Brotherhood starts off with a farm girl being mauled by an unseen creature in the French countryside. As previously stated, with my knowledge of French history and French geography being what it is (that is to say, almost nonexistent), I can't tell you where the movie takes place, or is supposed to. Suffice it to say, we're somewhere in the French countryside, where the agent of the French King has just arrived with his companion, a Native American name Mani (Mark Dacascos). How this Frenchman, Fronsac (Samuel Le Bihan) came to meet and befriend the Indian (Mani's the last Mohawk of his tribe) is a mystery that is delved into as the movie progresses.
Fronsac claims to be "the King's gardener" but he proves to be an excellent embalmer, a philosopher, as well as a hunter. Mani, on the other hand, doesn't talk much and seems to be able to communicate with nature (How many Native American characters have you seen in the 20th century that can't communicate with nature? It's one of the more annoying stereotypes that seems to keep being repeated because filmmakers think it "honors" Native Americans.)
The two men are immediately thrust into the mystery of the countryside. A beast, an unseen creature (the locals believe it's a wolf) is killing people left and right, and the local army is helpless to stop them. Fronsac himself is skeptical about the existence of such a creature. In fact, Fronsac seems more concerned with getting into the corset of the local royalty's daughter than he is hunting a creature he doesn't believe exists. The beast, it seems, has been making the King look very bad, and books are being published and stories told about the King's inability to kill the beast. It isn't long before Fronsac begins to sniff cover-ups all around him, from the King as well as from the locals. I won't give away the movie's plot-twist, but suffice it to say, the movie's hunt for the "beast creature" is only a minor diversion, and there are other — as Sherlock Holmes like to say — mischief afoot.
Brotherhood of the Wolf is supposed to be based on a true story about a creature in the French countryside that murdered hundreds of locals before the King sent men to kill it. The movie's first half is suppose to follow the tale very closely, until the beast is "killed," at which point the movie begins its JFK-like fable: that is, its plots are no longer based on the creature legend, but is the "true and untold story about what really happened back then." (For those not in the know, that means the writers are making up this part. Oliver Stone would be proud.) Telling more about the movie would spoil its surprise, so I'll stop right here.
Direction by Christophe Gans, whose last work was "Crying Freeman" in 1995 (that movie, incidentally, starred Mark Dacascos as an assassin), is quite impressive most of the times. The French countryside has never looked better, even when it's pouring rain or being assaulted by a large beast. That brings us to my problems with the movie. The beast, when we finally see it in action halfway into the movie, comes across like just what it is: a poorly done cgi "monster creature." There is absolutely no realism to the creature as it jumps from cliff to cliff and splinters woods of all kinds like a raging rhino. This is a major problem with the movie, but fortunately for the film as a whole, the beast is only a minor character, and there are bigger fishes for Fronsac to fry.
Another problem I have with the movie is Gans' insistence on using computer tricks to slow down and speed up the action at different intervals. Guy Ritchie did it quite often in his movies, but Gans seems so in love with the trick that he uses it on even the most absurd situations. Thankfully, Gans seems to fall out of love with the trick, only to come back to it in small spurts during the final fight. Other than that, Gans has shown tremendous growth since Crying Freeman and looks to be a director to watch in the future.
Acting is competent all around, although Vincent Cassel, as Jean-Francois, comes across as too cartoonish and ridiculous toward the end. Mark Dacascos is terrific as the silent but deadly Mani, and although his character is second fiddle to Bihan's Fronsac, Dacascos makes the movie's first half worth watching. Frankly, it's almost absurd to see the movie focus so much on Fronsac's courting of Marianne (Emilie Dequenne) while Mani is left to fight off soldiers, hunters, and the beast creature.
As Fronsac, Bihan is perfectly cast. He comes across as a waspy Frenchman in the beginning, leaving all the grunt work to Mani, and for a long time (most of the movie's first half) we think he's nothing but a dandy bureaucrat who visits brothels when he can't get into Marianne's corset fast enough. That is, until his transformation in the second half, when Bihan becomes unrecognizable from his first half self. (To understand the comment, pay attention to the movie's title. "Brotherhood" means more than you think, and "wolf" has a lot to do with Mani.)
Of the supporting cast, the only standout is Monica Bellucci ("Malena") as Sylvia, the high-priced hooker who works in the town brothel, who charms Fronsacs and is much more than she seems. Bellucci is mysterious, sexy, and is the only female character worth a mention. As Marianne, Emilie Dequenne is nothing special. She is supposed to be Fronsac's love interest and the object of many men's desires, but she comes across as jailbait — and one without much personality or any desirability. In fact, compared to Sylvia, Marianne is a royal bore.
Brotherhood of the Wolf is a good movie, with a well-plotted story and some finely filmed action. Although it could have been much better, what there is is still pretty good.
Christophe Gans (director) / Christophe Gans, St'phane Cabel (screenplay)
CAST: Samuel Le Bihan …. Gr'goire
Vincent Cassel …. Jean-François
Emilie Dequenne …. Marianne
Monica Bellucci …. Sylvia
J'r'mie R'nier …. Thomas d'Apcher
Mark Dacascos …. Mani


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need to change a key on my keyboard
If say when you press "a" on your keyboard "b" is echoed to your screen, but only when X is loaded, is there an easier way than xmodmap to try to tell the Xserver to echo the correct key.
Is this a bug with XFree86 4.3.0 and the "be" keyboard map ? I'm using Window Maker, but I don't think that has anything to do with the problem. Plus didn't have this problem with Slack 8.2 either.
|All times are GMT -5. The time now is 08:53 PM.


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QBS Awards Program
Every year, ACEC and NSPE partner to create the QBS Awards Program. The purpose of the QBS Awards Program is to recognize public and private entities that make exemplary use of the QBS selection process at the state and local levels. In turn, the QBS Award winners provide examples of how well the QBS process works, and helps ACEC and NSPE promote the practice of QBS in states that are not currently using QBS for the selection of engineering services. ACEC and NSPE present a grand QBS award each year in each of two categories. The categories are the Non-Governmental Sector and the Governmental Sector.
Non-Government entities include private corporations, privately-funded research labs, private utility companies, design professionals, construction contractors, developers and any non-government entity that uses design professional services on a regular basis.
Government entities include states, municipalities, local governments, departments or agencies of government, school districts, university systems, public utility systems, research laboratories (if publicly funded), special purpose districts, and the like.
A call for award nominations is usually sent out to the ACEC Member Organizations in December. Following review of the nominations and selection of the winners, the winners are then invited to receive an engraved trophy and will be honored at an awards ceremony at either the ACEC or NSPE Annual Conference.
In addition to the two QBS Awards, the QBS Awards program will designate up to four Merit Award winners, who will be presented a plaque locally, at an event coordinated by the PEPP State Chair and the ACEC Member President.
The 2013 QBS Award Nomination Form. Deadline for nominations is March 15, 2013.


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TENNIS: Gordon Lee claims victory over Ridgeland
The Gordon Lee Trojans and Lady Trojans tennis teams finally got in the win column on Wednesday with a pair of victories at county neighbor Ridgeland.
The Trojans won 3-1 in the boys' match. Joseph Looney beat Sam Snyder, 6-0, 6-1, at No. 1 singles, and Jonathan Bettis stopped Dakota Phillipps, 6-3, 6-1, at No. 2 singles. The Panthers got a point at No. 3 singles as Lief Atchley beat Chandler Steele, 6-3, 6-4.
Gordon Lee's team of Logan Davis and Kalen Bradley won by forfeit at No. 1 doubles, while there was a double forfeit at No. 2 doubles.
On the girls' side, the Lady Trojans earned a 5-0 sweep.
Madison Hilley beat Tiffany Culpepper at No. 1 singles, 6-2, 6-0. Katie Barger defeated Erica Taylor at No. 2 singles by the same score, and at No. 3 singles Bonnie Hankins outlasted Megan Hise, 7-8, 6-3, 1-0.
Gordon Lee swept the doubles matches with identical 6-0, 6-0 scores. Sara Clayton and Katherine Chambers beat Brittany Gravitte and Megan Barns, while Tori McElhaney and Sara Holcomb teamed up for a win over Somi Kim and Courtney Green.
Both Gordon Lee teams are now 1-4 on the season.
Gordon Lee is scheduled for a home match at noon on Saturday against Dalton, while Ridgeland will take the court again on April 2 at LaFayette.


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During her interview with Oprah Winfrey on Sunday, Lindsay Lohan said she's "present and clear-headed and focused," but it appears TV viewers were focused on watching something else.
The just-released ratings of the first airing of Lohan's episode of "Oprah's Next Chapter," show that only 892,000 people tuned in to hear the headline-making actress talk about her troubles.
In comparison, Oprah's interview with disgraced cyclist Lance Armstrong pulled in 3.2 million viewers during its first airing in Janurary.
PHOTOS: Lindsay Lohan Over The Years
Lohan's OWN interview – where she vowed to turn her life around and admitted to using cocaine "no more than 15 times" – was aired a again following the initial 9 PM Sunday showing and again on Monday. The combined total for both of Sunday's telecasts (at 9 PM and 10 PM) was 1.8 million.
Average total viewership for "Oprah's Next Chapter" is 837,000. The 9 PM interview with Lindsay (892,000 total viewers) was up 7 percent in total viewers and up 6 percent in women aged 25-54 versus the show's Sunday season average.


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And, of course, the fine print:
Get free shipping on your next order when you spend over $100. The discount will be automatically applied to your purchase; no promo code required. The subtotal of your purchase must be $100.01 or greater after any promotional discounts have been applied. Additional fees such as tax or shipping and handling do not apply toward your minimum subtotal requirement of $100.01. Offer applies to standard shipping only. Certain items that require additional shipping and handling are excluded from this promotion and do not apply towards your $100.01 subtotal minimum. Offer subject to change.
Featuring two organic ovals, one nested in the other, this hand hammered sterling silver necklace dangles on a delicate chain for a minimalist look. The low shine and and slight texture makes this oval necklace an elegant and beautifully understated choice for any occasion. It's easy to wear, and you'll reach for it often, especially on those oh-no-so-late mornings.
- Sterling silver
- Pendant measures 1.75''
- Chain measures 16"
This product ships from the maker within 12 days, via USPS
If you're not happy with this item for any reason, you may return it for a full refund within 14 days.


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Barbara Walters To Retire In 2014?
It's hard to remember a time when Barbara Walters wasn't on television. But the media maven is reportedly looking to hang up her proverbial mic.
According to The Hollywood Reporter's sources, the 84-year-old media maven plans to announce that she's retiring in 2014.
A mainstay on ABC News and The View, Walters has earned a rep as a hard-hitting interviewer with the power to make subjects tear up. ABC is expected to celebrate her legacy with a few on-air tributes.
The news comes as The View is on the brink of switching up its line-up, with Joy Behar and Elisabeth Hasselbeck reportedly on the way out.
Photo Credit: INF


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|By: Robert
1.Red Lake (upper, lower) - Beltrami County in the upper part of the state is the largest lake in Minnesota with 288,800 acres. Red Lake is the second largest lake in the United States that is entirely inside the U.S. borders. Red lake is separated by two sections by a peninsula causing it to be known as Upper Red Lake and Lower Red Lake.
2.Mille Lacs Lake - Minnesota's second largest lake spans 132,516 acres or a little more than 200 miles. Beautiful lake that is barely deeper than 40'. You can catch Walleye, Northern Pike, Muskie, Jumbo Perch, Small Mouth Bass and Tullibee is Minnesota's most famous fishing lake. The primary county that this lake is in is Mille Lac.
3.Leech Lake - Leech Lake is the heart of the Chippewa National Forest. You can find walleye, northern pike, bass, and muskie in the great lake. The Chippewa Forest as the highest concentration of bald eagles anywhere in the continental U.S.--almost 200 pairs. The town of Walker is located on the shores of Leech Lake. 111,527 acres makes Leech Lake Minnesota's third largest inland lake.
4.Lake Winnibigoshish - With 58,544 prime fishing water, Lake Winni is Minnesota's fourth largest lake inland lake. The deepest point of the lake is 78'. All sorts of game fishing in this big lake. Located in the Chippewa National Forest Lake Winni is surrounded by 95% of undeveloped shoreline. This is a one of a kind lake.
5.Lake Vermilion - 40,557 acres of water, 365 islands and 1200 miles of shoreline makes Lake Vermilion one of the top 10 most scenic lakes in the United States. St. Louis is the primary county for Lake Vermilion.
Have a great time while you explore the top 5 lakes that make up beautiful Minnesota.
|Travel and Leisure


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28 Ffrydan Road, Bala, Gwynedd, LL23 7RY
Price FromView Rooms
- Excellent
- 2 guest reviews
"Very nice B&B in a gorgeous listed building, in walking distance to Bala main street with its restaurants and pubs...."
"Wonderful b & b, had a fantastic peaceful sleep in the cosy bed, best breakfast ever - will definitely book again..."
About the hotel
Bodiwan is located in Bala a short walk from local shops, restaurants and the lake. This grade II listed historic building is run by Mark and Sarah as a modern, friendly, family bed and breakfast.
Facilities Show/hide
- Main
- Cots available, Tea/Coffee making facilities in each room, Hairdryer in each room, Wake Up Call Available, Ground floor bedrooms
- Parking
- Car parking available onsite
- Business
- Wi-Fi Available, Meeting Facilities, In-room Broadband, In-room Modem Hook up, Wi-Fi Available In Public Areas, Wi-Fi Available In Rooms, Business Centre, Private dining services
- Leisure
- Steam Rooms, Massage, Beauty Salon/Manicure, Jacuzzi, Mountain Bike Hire, Clay Pigeon Shooting, Sailing, Games Console, [Channels] News, [Channels] Movies (Free), [Channels] Childrens
- In Room Entertainment
- TV, Satellite TV, Radio
- Dining
- Breakfast to go
Useful Info Show/hide
- Between 00:00 and 22:00
- By 00:00 hours
- Up to 12 years old
- The price shown is based on the occupancy and dates you have searched for. Prices and availability are subject to change based on the arrival date, number of nights and occupancy searched for. All prices are inclusive of all local taxes.
- Pets are not allowed
Customer Reviews
Our reviews are from genuine LateRooms.com customers. We verify that the customer has stayed before leaving a review.
100% would recommend it to a friend
Customer service
Food quality
Room quality
Very nice B&B
Very nice B&B in a gorgeous listed building, in walking distance to Bala main street with its restaurants and pubs....
Excellent in all respects
Wonderful b & b, had a fantastic peaceful sleep in the cosy bed, best breakfast ever - will definitely book again...


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The Headwear Association Announces 2016 Headwear Hall of Fame Inductees
Inductees are John Wayne, Usher, Justin Timberlake, Christina Aguilera, Kate Hudson and Hedy Lamarr
(New York, NY) The Headwear Association (THA) has announced the inductees for the 2016 Headwear Hall of Fame, and this year's honors go to John Wayne, Usher, Justin Timberlake, Christina Aguilera, Kate Hudson and Hedy Lamarr.
"This is the eighth annual Headwear Hall of Fame Induction. Every year, The Headwear Association recognizes individuals known for their signature style, which of course includes wearing a wide variety of hats," said THA President, Charles Rand. "We are excited to welcome this year's inductees to the Headwear Hall of Fame, which now totals 48 members."
For more information on the 2016 THA Headwear Hall of Fame, visit the THA Facebook Page.
Members of The Headwear Association nominated more than 50 legendary hat wearers, living and deceased. The Headwear Association board of directors voted and approved the final six honorees who will be formally inducted into The Headwear Hall of Fame at the 108th annual THA Gala event at The Central Park Boathouse on April 14, 2016.
John Wayne, almost never seen without his Stetson hat, is the epitome of rugged Western American style.
Usher is regularly spotted in beanies, caps and even the occasional fur trapper. But he is best known for his dapper modern take on classic suits and fedoras.
Justin Timberlake brought sexy back, and he did it in a wardrobe of hats. His go-to styles are fedoras, the stingy brim trilby and ivy caps on the golf course.
Kate Hudson is known for her SoCal cool, boho style. Whether it is a felt floppy at a music festival, a summer straw hat in Malibu or a fur trapper in Aspen, Kate's hats are a signature wardrobe staple.
Christina Aguilera has evolved her unique style from a teen Genie in a Bottle to a chic, modern fashionista. When she is performing on stage, coaching on The Voice, recording in the studio or just hitting the market — her vibrant, sexy style includes a variety of hats.
Hedy Lamarr personifies the iconic glamourous style of the original Hollywood screen sirens. The hats she wore were magnificent creations, and she was breathtakingly stunning in them. Just Google "Hedy Lamarr Hat," and get lost in exquisite millinery and beauty.
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TRESemme Smooth & Silky No Frizz Shine Spray Reviews
greasy roots :Sthis is great @ making my hair shiny and smooth. but when i use it to reduce the frizz on my roots, they become greasy and chunky. I used one spritz and rubbed it in my hands so I'm pretty sure that i didn't use too much product. — 8 years, 1 month agouknowwho90 | 39 reviews
Works good!This works great, and best of all it doesnt make your hair greasy or weigh it down! It has a fresh clean smell. — 8 years, 1 month agomelissaBmomof3 | 17 reviews
This review is: Helpful | Not helpful | Inappropriate | 1 of 1 people said helpful
Not for meI am a fan of Tresemme products, and had to try this one when it saw the words "no frizz" on the label. I really didn't like this very much. Sure it made my hair shiny and sometimes silky. Mostly it just seemed to weigh down my hair. It also made me feel like my hair was oily. Which I did not enjoy. Didn't help much with frizz either. — 8 years, 5 months agozomb | 6 reviews
does half the jobmmkay so i bought this in the winter cuz dats when my hairr is the frizziest and dryest! i bought this for the anti frizz part but i dont see it reducing the frizz in my hair! i still get them BUT!!!! it makes my hair VERY nice and shiny!!! and pretty Soft! so i might try another antifrizz product next summer! =] — 8 years, 7 months agoilylikenotherx3 | 18 reviews
leaves my hair shiny and softi have been using this for some time, and i love the fact that it is in a spray form. i love more that my hair is always super soft after using it! i like to spray it on before and after i heat style, and it works great at keeping the frizz away! it's not greasy ever and it's priced very well-- this will always be my go-to shine product! — 8 years, 9 months agobeauty_girl_musings | 136 reviews
Meh...not the worst not the bestI have to believe that somewhere out there there's a product that actually reduces frizz and increases shine for thin slightly dried out hair and this one isn't it. It wasn't expensive, so I wasn't angry that I bought it, but this stuff barely did anythng. I noticed my hair wasn't frizzy, but also slightly limp. — 9 years agoProductAddict | 12 reviews
Perfect!I wish I had found this product sooner cause it really is everything the description says it is; no frizz at all, even when I apply it on wet hair, and my hair is super-thick! It has a very nice, sweet smell to it and leaves just a little shine without feeling thick or greasy. It's like a miracle for my hair! — 9 years, 2 months agomusicmodel | 4 reviews
made my hair super soft and shinysprayed this on damp hair before I blow dried and notice my hair was a bit shinier and softer, then sprayed all over my hair before I flat ironed it. Super soft and shiny, I really like this and it's not greasy feeling in my hair! — 9 years, 2 months agoFindingmyzen | 27 reviews
Beat the Fizzies and ShineI have short naturally wavy hair and have fallen in love with TreSemme No-Frizz Spray! It keeps the frizzies away while adding shine! The high humiditiy here in Kansas City can make it hard- but I keep No-Frizz right on top of my dressing table and finish off with it before leaving the house at any time! It doesn't weigh my hair down and doens't feel sticky at all! It is so reasonable- found at the discount stores. — 9 years, 3 months agobeverlylittle | 6 reviews
This review is: Helpful | Not helpful | Inappropriate | 3 of 3 people said helpful
good stuff!smells good, and leaves my hair nice and shiney without being greasy — 9 years, 4 months agoarareseed | 14 reviews
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My Reasons for Reporting This


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189-3 Flight Operations Inspector (from CAA/DGCA) (Prospective Post)
Qualifications Requirements:
1. Management or supervisory experience in a substantial airline or with a government department of civil aviation, directly associated with the preparation and responsibility for implementation of rules, regulations, operating manuals and flight and ground procedures deemed necessary for flight safety, inspection and certification.
2. Knowledge of legal responsibilities and administrative procedures for the issuance of documents under state of registry approval relating to supervision of flight operations.
3. Holds or have held an airline transport pilot license with one or more type ratings, preferably on Airbus A-300 or higher categories, B-737 or higher categories, MD different categories or business aviation and helicopter aircraft.
4. Extensive experience as a government flight operations inspector dealing with flight operations inspection, accident investigation and prevention and safe transportation of goods by air.
5. Knowledge of the requirements for personnel licensing, training, and maintenance of competency of flight crews concerned with flight operations.
6. Experience in the preparation, approval and use of flight operations manuals and other flight documentation.
7. Experience in the preparation and approval of flight training and checking programmes, and development of training plans for inspectors and managers in the field of flight operations.
8. Sound knowledge of related ICAO annexes, recommended practices and related documentation.
9. A good command of oral and written English, French or Spanish is essential.
1. Judgment/decision–making: Proven ability to take ownership of all responsibilities and to honour commitments, to exercise mature judgment, to recognize key issues and analyze relevant information, to make feasible recommendations and to take sound decisions.
2. Communication: Ability to write clearly and concisely and to present articulate verbal reports.
3. Teamwork: Ability to work with colleagues to achieve the project goals and maintain harmonious working relationships in a multinational environment.
4. Leadership, vision and management of performance: Demonstrated ability to plan and guide the work of a technical team in a multinational environment, to identified priorities and adjust them as required.
5. Client Orientation: Ability to establish and maintain partnerships with external collaborators, to work and advocate effectively in a consensus-based system and to successfully manage and resolve conflict.
6. Commitment to continuous learning: Willingness to keep abreast of new developments in professional field.
7. Technological awareness: Ability to use contemporary office automation equipment, software, databases.
1. Review existing civil aviation legislation and flight operations regulations and revise them to conform to ICAO annexes, to be applied to all operations.
2. Assist with conducting workshops and providing on-the-job training to flight operations inspectors to qualify them in the full range of tasks related to airline flight operations inspection.
3. Advise on and assist national inspectors with performing flight operations certification functions, including certification of airmen and approval of operations manuals, crew training and checking programmes, minimum equipment lists and the issuance of operating certificates and/or specifications.
4. Assist with the development and execution of an annual flight operations surveillance programme.
5. During certification and inspection missions, provide guidance and on-the-job training to national flight operations inspectors.
6. Advise on and assist with supervising the review, revision and approval of operations manuals, aircraft operating manuals, minimum equipment lists, flight crew and cabin attendant training programmes, etc.
7. Perform other related duties as may be required.
In accordance with the ICAO Technical Co-operation Bureau (TCB) grading system.


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ALBUQUERQUE, N.M. — The Lobos face 24th-ranked Boise State on Saturday at University Stadium in a game that will say a lot about how much last week's victory over New Mexico State really means. Join Journal staffer Rick Wright right here at 11 a.m. on Thursday to chat about the big game.
If you want to be at the head of the line of questions, just post them below right now.
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