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|Aortic valve supporting device
|Reimold et al.
|Bioprosthetic heart valve with absorbable stent
|Biodegradable drug delivery vascular stent
|Buscemi et al.
|Medical devices fabricated from homopolymers and copolymers having recurring carbonate units
|Tang et al.
|Valveless conduit with sigmoid valve annuloplasty ring
|Rapid assembly, concentric mating stent, tissue heart valve with enhanced clamping and tissue alignment
|Love et al.
|Absorbable stent
|Stack et al.
|Sigmoid valve annuloplasty ring
|Mitral and tricuspid annuloplasty rings
|Wright et al.
|Biodegradable stent
|Goldberg et al.
|Flexible cardiac valvular support prosthesis
|Carpentier et al.
|Multi-segmented annuloplasty ring prosthesis
|Carpentier et al.
|Biomaterial implants which resist calcification
|Langer et al.
|Adjustable ringprosthesis
|Ahmadi et al.
|Stent for a cardiac valve
|Ross et al.
|Adjustable annular prosthesis for cardiac surgery
|Support for a natural human heart valve
|Carpentier et al.
|Valvuloplasty ring and prosthetic method
|Edwards et al.
|Schmitt et al.
|Prosthetic device for the surgical correction of tricuspid insufficiency.
|Bioabsorbable foam pledgets.
This is a continuation of application Ser. No. 08/551,352, filed Nov. 1, 1995, now abandoned.
This invention relates to biocompatible annuloplasty prostheses that are resorbed by the patient following implantation.
Human heart valves comprise leaflets or cusps that open and close to control the flow of blood to a particular region of the heart. The mitral and tricuspid valves are located in the atrioventricular opening of the heart and function to prevent backflow of blood from the ventricle into the atrium when the ventricle contracts. The aortic valve is located between the left ventricle and the ascending aorta and functions to prevent backflow of blood into the left ventricle.
The mitral valve is located in the left atrioventricular opening of the heart. It includes two leaflets or cusps and is encircled by a dense fibrous ring known as the annulus. The anterior leaflet is located next to the aortic valve and is also known as the anterior medial leaflet. The posterior leaflet has a wider attachment to the annulus and is also known as the posterior lateral leaflet. The leaflets are held in place by chordae tendineae and papillary muscles. The commissure is the point at which the annular attachment of the leaflets meet and fuse. Coaptation refers to valve closure and the meeting of the free edges of the leaflets.
The tricuspid valve is located in the right atrioventricular opening and comprises three leaflets, sometimes referred to as the anterior, posterior and septal cusps (leaflets). These leaflets are roughly triangular in shape and, like the mitral valve leaflets, are attached to a fibrous ring, or annulus.
The aortic valve is composed of three segments, each of which is termed a semilunar cusp. The valve is closed during ventricular diastole and is open during systole.
The most common defect leading to mitral dysfunction is a dilation or elongation of the posterior two-thirds of the annulus, the section corresponding to the posterior leaflet. The anterior section of the annulus is anchored to the aortic root and is therefore not as subject to elongation. However, not infrequently in cases of mitral valve dysfunction, the anterior leaflet is displaced away from the center of the valve and is slightly thickened and shortened. Thus, in repairing a mitral valve, it is sometimes necessary to reduce the annulus to its physiological dimensions by repairing the dilated portion of the valve, to ensure coaptation. It may also be necessary to restore the commissure to its normal curvature and to reposition and reshape the anterior leaflet. Similar concepts apply to correction of tricuspid valve defects.
Mitral valve repair has been performed successfully since the late 1950's. Its appeal with cardiac surgeons, however, was not immediate. Only in more recent years, as surgeons have had appropriate devices to use and have increasingly realized the advantages of repair, has the proportion of mitral valves repaired increased. The clinical advantages of mitral valve repair as compared to replacement are attributed to better left ventricular function and the lack of need for long-term anticoagulation therapy. Better left ventricular function has led to a lower incidence of mitral valve stenosis and regurgitation for repair as compared to replacement procedures. The incidences of thromboembolism, hemorrhagic complications and infective endocarditis have been shown to be lower after mitral valve repair than after replacement. Actuarial survival after repair is also greater than that after valve replacement. Akins et al., Ann. Thora. Surgery 58: 668-76 (1994).
Annuloplasty, or annulus repair, has become an intermediate measure between non-invasive management of valvular heart disease and replacement of an entire heart valve with a prosthetic implant. Annuloplasty prostheses, for example ring-shaped devices, are used in the procedures and represent the standard method of repair. As clinical results increasingly show that annuloplasty prostheses better preserve left ventricular function, surgeons have become more enthusiastic about annuloplasty repair over valve replacement whenever feasible.
Annuloplasty prostheses differ from prosthetic heart valves in that the prostheses are designed to support diseased or damaged natural heart valves rather than replace them. An annuloplasty prosthesis is a device implanted around or in association with the mitral, tricuspid or aortic valve for reconstructive repair of valvular insufficiency. The indications for repair using annuloplasty prostheses include correction of annular dilatation, increases in leaflet coaptation, reinforcement of annular suture lines and prevention of future dilatation.
Annuloplasty prostheses are relatively new medical devices. The first annuloplasty prosthesis, designed by cardiovascular surgeon Dr. Alain Carpentier, was introduced in the early 1980's. Several other designs, including one by Professor Carlos Duran, followed shortly thereafter. Annuloplasty prostheses consist of three types: rigid, semi-flexible and flexible. Currently available rigid or flexible prostheses may be entirely composed of a biocompatible fabric (classified as flexible) such as polyester. Alternatively, a prosthesis may constitute a multiple component system composed of a more rigid core such as titanium, polyethylene or silicone, which is then covered by a fabric (classified as rigid or flexible depending on the core material). Some of the prostheses are made radiopaque through use of metal or by impregnating polymers with barium sulfate (BaSO4).
The Carpentier-Edwards® ring (see, e.g. U.S. Pat. No. 5,061,277) is classified as rigid. This prosthesis is kidney shaped with one long curved segment corresponding to the posterior annulus; the ring is open in the portion corresponding to the anterior leaflet. It is constructed of a titanium alloy core with a sewing ring margin that consists of silicone rubber covered with polyester knit fabric. The Medtronic-Duran ring (Duran et al., Circulation (Suppl. I) 78:91-96 (1989)) is classified as flexible and, like the Carpentier ring, is not adjustable after implantation. It is constructed of a radiopaque core of silicone elastomer impregnated with (BaSO4), and covered by polyester. It is claimed that this prosthesis can adapt to change in the mitral annulus, permitting optimal hemodynamics in diastole while maintaining coaptation and valve integrity in systole. The Puig-Massana Ring (see, e.g. U.S. Pat. No. 4,290,151) is a flexible and adjustable prosthesis that is also constructed of a core of silicone elastomer impregnated with (BaSO4). The adjustability feature is not fully functional since the ring slips under the suture line resulting in equalization of tension around the entire ring. The Carpentier-Edwards Physio™ Annuloplasty Ring (see, e.g., U.S. Pat. No. 5,104,407) is a semi-rigid prosthesis that combines support for valve repair, yet has flexible properties allowing dynamic movement throughout the cardiac cycle. Other prostheses include partial rings (e.g., Cosgrove-EdwardS™, U.S. Pat. No. 5,290,300) which are constructed of polyester and are intended to be used only in the posterior mitral annular segment.
The ability of the valve to change shape during the cardiac cycle influences hemodynamic performance. It has been reported that the mitral annulus dilates 20% to 50% during diastole. Ormiston et al., Circulation 64:113-120 (1981). The hemodynamics seen with flexible prostheses 2 to 3 months following implantation have been reported to be better than that seen for rigid prostheses. However, by one year post-implantation the hemodynamics are the same for both groups. This may be due to tissue encapsulation of the prosthesis, thereby affecting its flexibility. However, the data do indicate that there may be less post-surgical morbidity and mortality with flexible prostheses than that seen with rigid prostheses. David, Ann. Thorac. Surg. 47:524-528 (1989). Rigid prostheses can prevent the ventricle from working efficiently by restricting annulus motion. In addition, rigid prostheses are more likely to dehisce than flexible devices. Dehiscence is due to the normal movement of the mitral valve annulus during systole and diastole and the resultant tension on the suture lines. Cohn, Ann. Thorac. Surg., 45:284-290 (1988). Rigid prostheses also have a higher incidence of systolic anterior motion (SAM) of the mitral valve that can cause subaortic stenosis.
Suturing techniques for annuloplasty prostheses may vary depending on the design or the physician's preference. The suture may be placed around the prosthesis or passed through a portion of the prosthesis. Surgeons generally use either interrupted single or mattress sutures, or a continuous running suture similar to that used in prosthetic valve replacement.
An important drawback of all the currently available annuloplasty prostheses is that they are constructed of nonbiodegradable materials which, as discussed above, eventually are encapsulated by tissue and become rigid. This may lead to a stenotic valve that has suboptimal hemodynamics. Ideally, a bioresorbable annuloplasty prosthesis allows a natural, physiologically functional annulus to be reformed.
The invention relates to an annuloplasty prosthesis for use in remodeling a diseased annulus of a natural heart valve, comprising a biocompatible, resorbable member that is sized and shaped to extend about at least a substantial portion of the circumference of the annulus. Following surgical implantation, the member is resorbed at a rate allowing regeneration of reinforcing tissue in the annulus. The member can be adapted to function at the tricuspid, mitral or aortic valve positions of the heart. In one embodiment, the member may be sized and shaped to extend about less than the whole of the circumference of an annulus. Such an "open" or "non-continuous" member has opposed, spaced apart ends, the annular arcuate spacing between the ends being not less than about 1% and not more than about 50% of the whole of the circumference.
The member may comprise a biocompatible, resorbable polymer. The polymer can be composed of, without limitation, dextran, hydroxyethyl starch, gelatin, derivatives of gelatin, polyvinylpyrolidone, polyvinyl alcohol, poly[N-(2-hydroxypropyl)methacrylamide], polyglycols, polyesters, poly (orthoesters), poly (esteramides) and polyanhydrides. The polyesters can include, without limitation, poly (hydroxy acids) and copolymers thereof, poly ([epsilon]-caprolactone), poly (dimethyl glycolic acid) and poly (hydroxy butyrate). In a preferred embodiment, the polymer is selected from the group consisting of D,L-polylactic acid, L-polylactic acid, glycolic acid and copolymers of D,L-polylactic acid, L-polylactic acid, and glycolic acid.
The member may be manufactured to be of non-uniform rigidity. Preferably, the polymer of the member is invested with one or more biological response modifiers, including without limitation cell adhesion molecules, growth factors and differentiation factors.
The invention also includes a method for treating a patient having a diseased or defective tricuspid valve, comprising providing a resorbable annuloplasty prosthesis adapted for functioning at any one of the tricuspid, mitral or aortic valve positions of the heart, and surgically implanting the prosthesis in the heart of a patient.
FIG. 1 depicts a "closed" or "continuous" embodiment of the bioresorbable annuloplasty prosthesis of the present invention.
FIG. 2 depicts an "open" or "non-continuous" embodiment of the bioresorbable annuloplasty prosthesis of the present invention.
FIG. 3 depicts a ring-like annuloplasty prosthesis contoured and adapted for use in aortic valve repair.
FIG. 4 depicts a ring-like annuloplasty prothesis contoured and adapted for use in aortic valve repair including a collar.
The invention relates to annuloplasty prostheses used to correct tricuspid, mitral and aortic valve insufficiencies. The resorbable annuloplasty prosthesis of the present invention will allow reinforcement of the annular tissue for the time period necessary to achieve optimal regeneration of a natural annular structure. The regenerated tissue will completely replace the resorbable prosthesis, thereby leaving the recipient with a completely biological and functional annular structure that supports leaflet coaptation and optimal hemodynamics.
A bioresorbable annuloplasty prosthesis generally may be circular in cross section. The annuloplasty prosthesis may be continuous, or may be non-continuous. The shape of the prosthesis generally mimics the shape of the native annulus. The prosthesis can be designed to mimic the structural and functional properties of a healthy annulus. Specifically, the resorbable annuloplasty prosthesis has the following properties:
1. The bioresorbable prosthesis possesses sufficient mechanical properties to maintain coaptation and valve competence, but sufficient flexibility to permit good hemodynamics during diastole. The structural or functional properties may vary along the prosthesis to mimic the natural annular structure.
2. Prostheses may be manufactured in various sizes and shapes to accommodate the wide variation in annular morphologies.
3. The bioresorbable prosthesis degrades at a rate that allows substantially complete regeneration of the host annular structure. The resulting time period to resorption may be on the order of 4 to 6 months.
4. Tissue integration may be encouraged with the incorporation of biological response modifiers into the prosthesis. These substances include but are not limited to cell adhesion molecules, growth factors, differentiation factors and cytokines. In addition, heparin or other anticoagulants can be added to the prosthesis if blood compatibility is an issue. X-ray detectable substances can be incorporated into the prosthesis if desired.
5. An open cell structure (see below) allows rapid clot stabilization within the prosthesis, facilitating tissue ingrowth. A stable clot facilitates adhesion of the prosthesis to the host tissue and prevents peri-valvular leakage.
The main advantage of the bioresorbable annuloplasty prosthesis is that it encourages reinforcement of a diseased annulus with natural tissue rather than with foreign materials. The "naturally" remodeled tissue annulus has advantageous hemodynamic properties during diastole and allows sufficient leaflet coaptation during systole. Endocarditis that could occur during the remodeling phase may be minimized with the use of poly(α-hydroxy) acid bioresorbable polymers due to their ability to induce inflammatory leukocytes' bactericidal function. Devereux, D. F. et al., J. of Surgery, 162:243-246, 1991. Even in the situation in which the surgical implantation must be redone, there is no pre-existing implant to remove. The resorbable annuloplasty prosthesis is as easy to use and implant as other non-resorbable annuloplasty prostheses. Usually, the prosthesis is not manufactured to have an adjustable circumference, although such adjustability is not excluded from the prosthesis of the present invention.
The concept of a bioresorbable annuloplasty prosthesis that is substantially or completely replaced by functional annular tissue is new. All other annuloplasty prostheses are composed of non-resorbable materials that cause varying degrees of foreign body response long term, and which eventually become encapsulated by fibrous tissue. Such encapsulation can adversely affect function.
The resorbable annuloplasty prosthesis has mechanical properties sufficient to support the valve during implantation and during the post-implant healing period, while allowing the function of the adjacent structures, for example, the aorta, to be retained. Preferably the prosthesis is of sufficient flexibility such that the native compliance of the adjacent host structures (e.g., chordae tendineae, papillary muscles, aorta) and of the valve commissures is not significantly reduced.
Preferably, the bioresorbable material of the prosthesis resorbs, post implantation, at a rate that allows good tissue incorporation, but that also results in sufficient resorption within the normal post-operative period, approximately 4 to 6 months. A variety of resorbable, biocompatible materials, for example polymers, may be employed for manufacture of the prosthesis of the present invention. Homopolymers and copolymers such as those disclosed in U.S. Pat. No. 5,412,068, incorporated herein by reference, are appropriate for the resorbable prostheses of the present invention. Other polymers include without limitation dextran, hydroxyethyl starch, gelatin, derivatives of gelatin, polyvinylpyrolidone, polyvinyl alcohol, poly[N-(2-hydroxypropyl)methacrylamide], polyglycols, polyesters, poly (orthoesters), poly (esteramides) and polyanhydrides. Preferably the resorbable annuloplasty prostheses of the present invention are fashioned from polyesters such as poly (hydroxy acids) and copolymers thereof, poly (ε-caprolactone), poly (dimethyl glycolic acid), or poly (hydroxy butyrate).
Most preferably the prostheses are manufactured of polymers of D,L-polylactic acid, L-polylactic acid, or glycolic acid, or copolymers of D,L-polylactic acid, L-polylactic acid, and glycolic acid. Such polymers may be manufactured as disclosed, for example, in U.S. Pat. No. 5,133,755, incorporated by reference herein.
It will be apparent to the ordinary skilled artisan that particular bioresorbable materials may be chosen to fit particular patient needs. For example, polymers may be chosen to be resorbed within the normal 4-6-month interval referenced above, but other polymers may be chosen to be resorbed within shorter or longer intervals. Variations in selected times to resorption may depend on, for example, the over-all health of the patient, variations in anticipated immune reactions of the patient to the implant, the site of implantation, and other clinical indicia apparent to the skilled artisan.
Preferably the fabricated resorbable prosthesis has an open, interconnected porosity allowing rapid clot stabilization and subsequent tissue ingrowth. The porous resorbable prosthesis may be fabricated using any of a variety of processes known to those of ordinary skill in the art, including a "replamineform" process, a positive replication process or common textile processes.
The replamineform process involves infiltrating a porous, inorganic structure (typically, calcium carbonate) with wax, dissolving the calcium carbonate, adding the appropriate monomer or mixture of monomers, polymerizing the monomers, and finally increasing the temperature to withdraw the wax. See, for example, Hiratzka et al., Arch. Surgery 114: 698-702 (1979), incorporated herein by reference. This process yields a positive copy of the porous, inorganic structure. Negative copies or casts of the porous inorganic structure may be made by filling the pores with a selected polymer, then dissolving the inorganic matrix (e.g., calcium carbonate) as a final step. What remains following completion of either the positive- or negative-cast steps of the replamineform process is a polymer with defined porosity.
A positive replication process is disclosed in, for example, Jamshidi et al., Resorbable Structured Porous Materials in the Healing Process of Hard Tissue Defects, ASAIO 34: 755-60 (1988), incorporated herein by reference. In principle, a positive replication process is very similar to the replamineform process.
In a further alternative embodiment, porosity can also be introduced into the prosthesis by mixing the polymer with particles of a specific size range (e.g., 20 to 300 micron diameters), then dissolving those particles during a final stage of the fabrication process. For example, sodium chloride crystals may be incorporated into a polymer or copolymer by adding crystals of the salt to a solution of dissolved polymer. After evaporating the solvent, annealing the polymer or copolymer by heating, and cooling at controlled rates, the sodium chloride crystals may be leached out. This leaves a porous polymer matrix. Porosity and pore size may be controlled by varying the concentration and size of the crystals. See, for example, Hubbell and Langer, Chem. & Engineering News, Mar. 13, 1995, pages 47-50, incorporated herein by reference.
The open porosity of the above-described resorbable prostheses provides a scaffold for cellular ingrowth. To facilitate ingrowth of host or other cells after implantation, a variety of biological response modifiers may be incorporated into the structure of the resorbable prosthesis. Biological response modifier molecules may be covalently or non-covalently coupled to the various internal and external surfaces defining the porosity of the resorbable prosthesis, or may be incorporated directly into the resorbable material during, for example, the polymerization process. In the latter case, the biological response modifier is slowly released as the prosthesis is resorbed.
Appropriate biological response modifiers may include, for example, cell adhesion molecules, cytokines including growth factors, and differentiation factors. Cell adhesion molecules (CAM) may be incorporated into the resorbable prosthesis in order to stimulate cell attachment, which is critical for normal cell function. Various CAM useful for incorporation include without limitation fibronectin, vitronectin, fibrinogen, collagen and laminin. See, e.g., Beck et al., J. FASEB 4: 148-160 (1990); Ruoslahti et al., Science 238: 491-97 (1987). The cell attachment activity has been isolated to specific amino acids sequences (expressed herein with standard singleletter code), for example RGD in the case of fibronectin, fibrinogen, collagen, osteopontin and others, REDV from fibronectin and YIGSR from laminin. Hubbell et al., Bio/Technology 9: 586-72 (1991); Humphries et al., J. Cell Biol. 103: 2637-47 (1986); Graf et al., Cell 48: 989-96 (1987). Other examples of cell attachment domains include the heparin-binding domains of fibronectin, KQAGDV and GPRP-containing peptides of fibrinogen and EILDV-containing peptides of fibronectin. Hynes et al., Cell 69: 11-25 (1992); Loike et al., Proc. Natl. Acad. Sci. USA 88: 1044-48 (1991). Thus, any cell attachment peptide-containing molecules functional as CAM for the cells seeded onto or migrating into the resorbable prosthesis may be incorporated into the prosthesis structure during or after fabrication.
Cellular ingrowth may be further facilitated through use of growth factors, including without limitation the fibroblast growth factors including acidic (FGF 1), basic (FGF 2) and FGF 3 through 9, platelet-derived growth factors including PDGF, PDGF-AA, PDGF-BB and PDGF-AB, transforming growth factors (β1-β5), epidermal growth factors including heparin-binding EGF, transforming growth factor α and other members of the epidermal growth factor family, the insulinlike growth factors I and II, platelet-derived endothelial cell growth factor and vascular endothelial growth factor. These factors have been shown to stimulate cellular migration (useful for attracting the appropriate cell population(s) into the prosthesis), proliferation (cell replication) and protein synthesis (required for production of extracellular matrix as the newly indwelling cells remodel the resorbing structure of the prosthesis). Albumin may be added to a particular growth factor to increase its effectiveness. Murray et al., Cancer Drug Delivery 1: 119 (1984).
Other biological response modifiers that may be incorporated into the resorbable annuloplasty prosthesis of the present invention include without limitation polysaccharides, mucopolysaccharides, glycoproteins, and glycosaminoglycans such as hyaluronic acid, chondroitin, chondroitin 4-sulfate, dermatan sulfate, keratan sulfate, heparin, heparan sulfate, alginate, poly-D-lysine, laminin and collagen types I, III and IV. It will be apparent to the ordinary skilled artisan that variations in individual biological response modifiers or combinations of biological response modifiers may be employed to suit the requirements of particular cell types, prosthesis materials, prosthesis configurations, sites of implantation and patient needs.
As described above, the bioresorbable prosthesis may be fabricated to have a structure conducive to formation of a stabilized blood clot after implantation. Such prostheses may have relatively high porosity, i.e., relatively high internal surface area (see above). Alternatively, the stabilized clot may be induced to form by inclusion of chemicals, e.g., coagulants, into the prosthesis structure as described above. Inducing a stabilized clot layer to form on the surface upon implantation facilitates cell ingrowth and healing, with the clot layer potentially functioning as a provisional matrix for healing, comparable to that occurring during normal vessel repair. Van Der Lei et al., Int. Angiol. 10: 202-08 (1991), for example, reported on the poor healing of expanded polytetrafluoroethylene prostheses in general, but also reported success in encouraging complete healing by inducing a clot layer to form on the graft surface upon implantation.
Referring now to the Figures, a resorbable annuloplasty prosthesis may be fashioned to have a generally oval shape similar to that of the native tissue annulus. For example, the prosthesis depicted in FIG. 1 is designed to conform to the shape of the base of the mitral valve, and has substantially the shape of a closed, continuous ring 2. Closed ring 2 may be circular, oval or, as shown, slightly straightened at 4 over a length of its periphery. Substantially straight portion 4 corresponds to the curvature of the anterior leaflet, and the opposite, complementary zone 6 corresponds to the curvature of the posterior leaflet. The prosthesis has in its plane an axis of symmetry, with its largest dimensions, along this axis and along a perpendicular axis, being generally between about 15 and 30 mm and about 15 and 40 mm respectively. Any given portion of the prosthesis may be generally circular in cross section, or may be oval or flattened in cross section.
In an alternative embodiment as depicted in FIG. 2, the prosthesis may be in the form of an open, non-continuous ring 8 that is slightly straightened over a length of the periphery. A non-continuous design may be desired for hemodynamic performance and implant considerations. This part-annular-shaped prosthesis is open over a length generally between about 1% and 50 of the total annular shape. The free ends 10 and 12 of the open ring 8 are rounded or otherwise shaped so as not to damage the tissue in which they are disposed after implantation.
It will be appreciated by the ordinary skilled artisan that the prosthesis of the present invention can be sized and shaped to any useful configuration appropriate to the mitral, tricuspid or aortic valve of an individual patient. For example, the prosthesis may be shaped generally as depicted in FIG. 3 so as to follow the contours of the commissures of the aortic valve, i.e., to be adapted to the trifoliate form of the aortic valvular orifice. In an alternative embodiment, an aortic valve annuloplasty prosthesis can be manufactured to include a sleeve or collar extending upward (with respect to the orientation depicted in FIG. 3), from along all or a substantial portion of the contour length. Referring to FIG. 4, in this orientation, the sleeve or collar 100 extends upward from the contoured ring-like prosthesis 102 into the aortic root or complex. The sleeve or collar 100 thereby facilitates attachment to and additional remodeling of the aortic complex above the commissures.
The resorbable material of the annuloplasty prosthesis preferably is flexible, with the flexibility selected and manufactured to approximate that of the native annulus and its supporting structure. As desired, the rigidity of the prosthesis (reflective of flexibility) may vary from one point to another on the prosthesis, i.e., the prosthesis may be of non-uniform rigidity. For example, more flexibility may be desired in the posterior part of the mitral valve annulus than the anterior part. This can be accomplished by controlling porosity of the matrix. In this manner, rigidity of the resorbable polymeric prosthesis material may be made to vary continuously from one region of the prosthesis to another region, or may vary in multiple step-wise increments from one region to another.
Any sutures used for attachment of the resorbable annuloplasty prosthesis to a patient may be bioresorbable. Preferably the resorption rate of the sutures is similar to that of the prosthesis.
A resorbable annuloplasty prosthesis of the present invention is implantable with a variety of surgical techniques appropriate to the configuration of the valvular tissue (e.g., annulus) and prosthesis and to the site of implantation. These surgical procedures will be apparent to the ordinary skilled artisan, and may include without limitation techniques such as disclosed in U.S. Pat. Nos. 3,656,185 and 4,042,979, incorporated herein by reference. Annuloplasty surgical procedures such as may be used with the annuloplasty prostheses of the present invention are also disclosed in Murphy et al., Ann. Thorac. Surg. 43: 52-8 (1987) and in Gorton et al., Ann. Thorac. Surg. 55: 860-3 (1993). Generally, a series of interrupted or continuous sutures is placed around the tissue annulus. The annuloplasty prosthesis is then parachuted down the sutures and tied in place. Following this, the cardiovascular incision (e.g., aortotomy) is then closed and the heart restarted.
With the resorbable annuloplasty prosthesis of the present invention, cross-clamp times for implantation will approximate those required with present annuloplasty rings, in which the prosthesis consists of non-resorbable materials.
The foregoing detailed description has been provided for a better understanding of the invention only and no unnecessary limitation should be understood therefrom as some modifications will be apparent to those skilled in the art without deviating from the spirit and scope of the appended claims.


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I grew up on a solid Southern USA diet, where nearly all the meat was batter fried. Funny how I ended up working in a Chinese restaurant as a first job, and I've been hooked ever since on hot sour soup, spring rolls, wontons, pork fried rice, and moo goo gai pan (chicken and mushrooms). Forget those sugar-coated fried biscuits…Those are strictly an American thing. lol
One of my visitors this evening writes about Asian food. OMGosh! I think I am in love – with the food peeps, with the food! It is Taiwanese, which is the Asian food I learned to cook so many yeaers ago, and I stuck with my favorites. 🙂 Healthy soups, plenty of vegetables, and spicy — I love spicy dishes, and I am totally digging into the recipes provided here once my fast is over…or maybe sooner. They sure look delicious! 🙂
I had leftover napa cabbage and bean sprout (from Shanghai Style Stir-Fried Rice Cake) in the fridge, and I wanted to make a hot soup to go with the Sichuan Cold Noodle. Taiwanese Vegetable Thick Soup was the result. Traditionally thick soup is made with pork or/and squid wrapped in fish paste. This vegetarian/vegan version is easy… just leave out the meat.
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Hundreds from the Newtown community gathered on the day that marked one week since the tragedy in Sandy Hook Elementary school, where 20 children and six adults were gunned down.
As the names of the victims were read out loud, candles were lit in memory of the children, teachers, and school officials who lost their lives in the classroom last Friday.
"We're a close knit community. And when something like this happens with children in our community, it's like our own children. So we just want to come out and support everyone," said parent Jenel Siebern.
Under a chilly and leaden sky, students and families paid a minute of silence for the victims that were laid to rest this week.
"I think it's important to acknowledge the light that each one of us bears. And that light has not been extinguished and that it's gathering more strength as we gather together and we support the community. And just to affirm the positive and the goodness in each person and in our country and the goodness of humanity in general and support one another in our grief," said Alice Unschuld, a resident of Connecticut.
The gunman, identified by law enforcement officials as Adam Lanza, killed his mother Nancy on Friday, then drove to the school where he gunned down another 26 people before taking his own life in one of the deadliest mass shootings in US history.
Source: Reuters


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Bent's RV Blog
- 0 0Published on Feb 20, 2017
Where to camp for Mardi Gras
Mardi Gras festivities attract nearly 1.2 million people to the city of New Orleans every year. That's almost 3x the population!!! And every year, those million people flock to the downtown and French Quarter areas to take part in the parades, Fat Tuesday celebration and much, much more. So where do you put 1.2 million people overnight? Nearby hotels, motels, bed and breakfasts, even Airbnb sets people up. But, what about the people that come to camp for the week? There happens to be quite a few campgrounds and RV parks in or near the city. We've got your list of best places to camp for Mardi Gras in 2017.
- Mardi Gras RV Park and Motel- The Red Carpet Inn and Suites, located at 6050 Chef Manteur Highway, New Orleans. This place has the best of both with a motel and RV park in one. Just 5 miles from the downtown area, Mardi Gras RV Park and Motel has 100 paved and grassy RV sites along with a motel for guests to stay. The sites offer 30/50 amps with full hookups, free shower and laundry facilities, a fitness facility, pool, dump station and convenience store. Free Wi-Fi is available and pets are allowed. To check availability you can email email@example.com or call 800-290-0085
- KOA- There is 4 KOA campgrounds in Louisiana but the closest to New Orleans is the New Orleans KOA. Located at 11129 Jefferson Highway, River Ridge, LA, this KOA has full hookups and can accommodate any size RV. They have paved or grassy campsites with 30/50 amp hookups, free cable and Wi-Fi, shower and laundry facilities, and pets are allowed. The New Orleans KOA offers a free shuttle to the downtown and French Quarter area so you don't have to worry about driving. For availability you can call 800-562-5110.
- Jude Travel Park- Conveniently located off the main highway just 5 minutes from downtown New Orleans, Jude Travel Park is a full service RV Park. Their facility is gated to offer the utmost safety and privacy; they have 30/50 amp hookups, shower and laundry facilities, a saltwater pool, and free cable and Wi-Fi. Jude also has a shuttle service to the downtown and French Quarter areas. Although a smaller RV park, their facility is well-maintained and the staff friendly. Call 800-523-2196 for availability.
- Ponchartrain RV Park and Marina- Located at 6001 France Rd, New Orleans, this RV park is another best of both. This is a top rated RV Park in the city and offers full RV park services as well as a marina for your boating activities. Ponchartrain RV park is another gated park for your safety and security. They offer not only RV accommodations but villas as well if you need a break from your RV for a night. On-site is a full restaurant and bar and convenience store. There is free Wi-Fi, showers and laundry facilities, pool and hot tub, and has waterfront RV sites for your viewing pleasure. There is a free shuttle here as well with service both day and night to the downtown area. For availability call, 877-376-7850.
There are other RV sites further outside the city if you prefer to be away from the hustle and bustle of the downtown area. With it being so close to the start of the week-long festivities, availability close to the area may be scarce anyway. Wherever you stay, be safe and enjoy the celebration!


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|Top Online Data Backup Rankings
IRVINE, CA and ARMONK, N.Y. – 25 Jan 2016 — /BackupReview.info/ — Western Digital (NASDAQ: WDC) today announced that it has acquired more than 100 patent assets from IBM (NYSE: IBM). The parties also entered into a patent cross-license agreement. Terms of the transaction were not disclosed.
Patents acquired by Western Digital are in distributed storage, object storage, and emerging non-volatile memory. Western Digital expects the IP to further strengthen its technology leadership position and drive value creation for the company and its customers. The patents will augment Western Digital's existing portfolio of more than 10,000 patents and patent applications.
"This agreement reflects our continued focus on innovation and sets the stage for even more rapid advancement and commercialization of new data storage solutions," said Mike Cordano, president and chief operating officer, Western Digital. "We are building on Western Digital and IBM's long-standing relationship and look forward to future collaborations and business opportunities."
"This agreement with Western Digital illustrates the value of patented IBM inventions and demonstrates our leadership in licensing access to our broad patent portfolio. We look forward to a productive relationship with Western Digital," said William LaFontaine, general manager, intellectual property for IBM.
IBM has led the annual list of U.S. patent recipients for 23 consecutive years. More information about IBM's patent leadership is available at: http://ibm.co/1hLSj8W
About Western Digital
For more information, please visit www.hgst.com and www.wd.com
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Source: IBM
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Happy Utah Pioneer Day Quotes Wishes Salt Lake Valley Images Pics 2016 : Pioneer Day is a state occasion in Utah in the United States. It is commended on July 24 every year to honor the passage of Brigham Young and the main gathering of Mormon pioneersinto Utah's Salt Lake Valley in 1847.
Notwithstanding being an official occasion in Utah, Pioneer Day is viewed as a unique event by numerous individuals from The Church of Jesus Christ of Latter-day Saints (LDS Church). On Pioneer Day, some Latter-day Saints walk parts of the Mormon Trail or reenact entering the Salt Lake Valley byhandcart. Contemporary Saints all through the United States and around the globe may observe July 24 in recognition of the LDS Church's pioneer time, with melodies, moves, potlucks, and pioneer related exercises.
Pioneer Day exercises incorporate firecrackers, parades, picnics, rodeos and different merriments all through the state. A few people say that this day is commended in Utah with more enthusiasm and pride than major occasions, for example, Christmas. Kids partake in exposition challenges and tasks about pioneers, while families appreciate the day with shows and celebrations. For the parades, a few people may wear ensembles that look like garments worn amid the nineteenth century when Salt Lake Valley was established.
Pioneer Day is likewise celebrated in numerous parts of Idaho, where it is usually known as Celebration Day. Family get-togethers are famous close by July 24.
Happy Pioneer Day Quotes Wishes
To me, Arnold was a pioneer in the spirit of Thomas Edison or Benjamin Franklin, while Tiger is a pioneer in the spirit of Bill Gates.
To me, Arnold was a pioneer in the spirit of Thomas Edison or Benjamin Franklin, while Tiger is a pioneer in the spirit of Bill Gates.
I come from pioneer stock, developers of the West, people who went out into the wilderness and set up home with nothing but a pair of oxen.
In a word I was a pioneer, and therefore had to blaze my own trail.
As it stands, motherhood is a sort of wilderness through which each woman hacks her way, part martyr, part pioneer; a turn of events from which some women derive feelings of heroism, while others experience a sense of exile from the world they knew.
Renewable energy also creates more jobs than other sources of energy – most of these will be created in the struggling manufacturing sector, which will pioneer the new energy future by investment that allows manufacturers to retool and adopt new technologies and methods.
It is not easy to be a pioneer – but oh, it is fascinating! I would not trade one moment, even the worst moment, for all the riches in the world.
I'm the kind of person who, if I were living in another time, if I had to pick any time, I would probably be a pioneer. I just love the simplicity of what it means to work hard with your hands – to eat and survive.
Happy Pioneer Day Images Pictures
If you really like this article on Happy Utah Pioneer Day Quotes Wishes Salt Lake Valley Images Pics 2016 then please do not forget to share it on social networking sites such as facebook, whatsapp, hike, bbm, wechat, instagram, line, viber, pinterest, stumble upon, twitter etc. you can also provide us with your feedback below the article in the commenting section. Stay connected with us to get more updates on upcoming festival and many more.


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Episode 440 - Character tropes VS characterisation
Aug 19, 2019
Today we compare and contrast two ways of making characters: starting with a pure archetype and building it with tropes, or creating a character organically through circumstance and interaction with other characters.
Topics and Show Notes
Quackcast 440 has the full crew of Ozoneocean, Banes, Pitface and Tantz! Our description of the two types of characterisation are are probably artificial extremes but it helps to see the advantages and disadvantages of both.
Some advantages to starting with archetypes and building traits with pre-defined tropes are that it's very quick, very easy and you can create something you know for sure your audience will understand and resonate with! Disadvantages are that you risk making stale characters: either by creating a cliché or by sticking too closely to your archetype (as you're always tempted to do when you make a character this way), and not allowing the character to evolve, change out of it and escape it. You generally want to return them to "true".
A good use for this approach are quickly made side characters who won't be around long, characters in a short-form or one-off story, or sitcom characters where you have to quickly get the audience to like them.
building a character organically over the course of a story through interaction and circumstance is harder and takes longer, but give you a changeable character that grows with your audience and who your audience grows to love! …if they can invest the time. The disadvantage here is that often you can't afford that time. This is better for long-form stories, dramas and novels.
In reality most of the time you'll use a mixture of the two approaches, often starting out with a reasonably defined character with a few traits in place, who grows as the story progresses and is changed by what happens to them and around them. That's a good, balanced way to do things, though short stories and side characters benefit from tropes.
This week Gunwallace has given us the theme to Ice Massacre: A quiet, contemplative meditation on the vastness of space and time. Gentle ripples of sound lap against and wash over you… building slowly and then receding back into the ocean of time. Percussive tinkles glitter within the flow, like unusual seashells or sparkling pieces of colourful coral. For a moment they catch your eye, only to disappear again forever in the wash of sound.
Topics and shownotes
Featured comic:
The Mystic from Wanzerbe - https://www.theduckwebcomics.com/news/2019/aug/13/featured-comic-the-mystic-from-wanzerbe/
Featured music:
Ice Massacre - - https://www.theduckwebcomics.com/Ice_Massacre/, by Icemassacre, rated T.
Special thanks to:
Gunwallace - http://www.virtuallycomics.com
Pitface - https://www.theduckwebcomics.com/user/PIT_FACE/
Ozoneocean - https://www.theduckwebcomics.com/user/ozoneocean
Banes - https://www.theduckwebcomics.com/user/Banes
kawaiidaigakusei - https://www.theduckwebcomics.com/user/kawaiidaigakusei/
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Become a subscriber on the $5 level and up to see our weekly Patreon video and get our advertising perks!
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Even at $1 you get your name with a link on the front page and a mention in the weekend newsposts!
Episode 439 - weather flavour enhancer!
Aug 12, 2019
Tantz's clever idea was that the weather isn't just a backdrop… it's an important prop in it's own right. Weather can be used to drive a plot: the wind snatches a hat and makes a person chase it, which causes them to meet another character. It can be an antagonist: people fighting a storm for example or running form a tornado. It can signal and enhance emotions: rain for a sad funeral or sun for happy for a happy event. Growing shadows can signal an ominous turn of events, wind billowing out a cloak signals a dramatic character! You can just use it for fancy visual effects if you like, snow and rain are great fun to draw, and stormy skies are the best! We chat about all things weather and give examples of how we've used it ourselves.
Episode 438 - You just don't get it
Aug 5, 2019
Sometimes your audience just doesn't pick up on the clever symbolism, the hints, the metaphor, the underlying themes and all the artistic cleverness in writing and art that you've filled your work up with!
Episode 437 - Old Warhorse
Jul 29, 2019
Today we cover the interesting trope of the "old warrior". This was based upon a newspost Banes came up with last week. He was thinking of Captain Picard in the latest Star Trek series and he also brought up Luke Skywalker from the latest Star Wars movie. The "Old Warrior" makes a really cool protagonist, in this Quackcast we try and discover why that is…
Episode 436 - Master of none?
Jul 22, 2019
To become truly successful at one thing you need to focus on that alone. Is it worth it? There are MANY calls on our time with all the side things we like to do, ESPECIALLY webcomics. One of the few ways to become a really successful superstar at any one thing is to start dropping all the other things that call on your time and devote all your energy to that one thing! Then you can push past all limitations and devote the effort and time needed to properly succeed.
Episode 435 - Spinoffs!
Jul 15, 2019
We're discussing spin-offs in this one. Why do them? There are many very different reasons for doing a spin-off as opposed to a sequel, prequel or a totally new story:
Episode 434 - Where do your characters exist?
Jul 8, 2019
This time we're chatting about settings and where your characters exist in space… where does all the action happen in your comics and WHY does it happen there? Bane's had the really novel idea of thinking of story settings as action playsets, which are toy settings made based on a TV show or movie where you can play with action figures and act out key moments FROM the TV show or movie: Unlike a dollhouse they only have the key sets where the important things happen.
Episode 433 - everyone is a beginner
Jul 1, 2019
Today we chat about a furore on Twitter focussing on a artist who made a tutorial about the differences between the line work of beginners and advanced artists. Many people identified their art style with the work described as "beginner" and took extreme offence at that characterisation. It's the contention of Tantz that "beginner" is not a dirty word. We're all beginners at something. We can all stand to learn things.


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Holiday Heroes - Meet Chris
Meet Chris
Chris is the man behind www.newdad.io where he writes about the challenges of being a forty-something new father, cruise journeys with a baby and reviews baby products from a dad's point of view. He shared his holiday planning tips with us…
Q: How seriously do you take holiday planning?
A: Pretty seriously, but not religiously - we're not like control freaks. It all depends on the holiday we're going on and whether we've been before. If there's anything in particular we consider a "must do" we will always plan, and usually book online if available.
Q: Why do you do it?
A: The way we see it is that those two weeks away are meant to be relaxing so we've always found that the more planning you do before you go, means that the holiday is likely to run like clockwork, making it a proper chill-out. Also, because we do chill-out so much, it's easy to miss or forget things.
Q: What form does your planning take?
A: For Canada, we did a road trip from Calgary to Vancouver. We used spreadsheets to list the B&Bs we were staying at along the way, and we pre-booked some activities such as whitewater rafting, walking with wolves, and zip lining in Whistler. We added the activities to the spreadsheet just so we knew what was coming up and to help keep any necessary clothes towards the top of our suitcases. No point in having jeans and shirt at the top if you plan on bobbing down a river in Clearwater.
Also we usually check out restaurants on TripAdvisor before we go and again, if possible, we'll book a table online. It's always easier to cancel a table.
Q: Do you budget for your holiday? And do you generally stick to it?
A: We usually pay for a lot of activities up front by booking them online. As for the rest of the budget we don't usually have one in mind but are careful whenever we're away. We don't usually buy tat, purely due to limitations on baggage more than anything. We tend to spend our money on making memories whether that be exploring ourselves or hiring a local guide.
Q: How far in advance of a holiday do you start to plan it?
A: It depends on work and location. Planning a trip on a research boat to Antarctica took a long time to make sure we had all the correct flights and the correct clothing and equipment. A road trip in Canada also required a lot of planning. However, a cruise in the western Med takes far less. We've sometimes booked on a whim with only weeks before departure so not much planning takes place.
Q: Do you share your plans and tips with other people? (if you're going on holiday with them, or if they're going to a place you've been to)
A: We prefer to holiday alone as it's our time. We've been lucky to travel to a lot of destinations and have shared info with others, whether it be via TripAdvisor reviews or things like Wunderlist where we created a list of the best Speakeasy Bars to visit.
Q: Does your planning help you to make the most of your holiday time?
A: Absolutely.
Q: Can you share your top three holiday planning tips?
- For a road trip, Google Maps is an essential piece of planning. It's also handy as you can list all details and phone numbers of your accommodation.
- Take photos of any reservations or things you really want to do. It's then easy to find without remembering everything and it saves you paying any roaming charges.
- Take a 4way plug extension with you. That way you only need 1 plug adapter and can still charge all the mobile phones, iPads etc.
You might also like these Holiday Heroes tools to help you get organised.


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The third edition of Nation Dates: Events that have shaped the nation of New Zealand was published in October 2017.
To purchase a copy, please see here.
Authors: Wendy McGuinness
Editor: Alexandra Hollis and Ella Reilly
Cover Designer: Ashley Brown
About this cover design
The cover for this edition was designed by Institute's in-house designer Ashley Brown. The illustration was inspired by the Māori Poutama pattern, which is often featured on the woven panels of meeting houses. The Poutama, a series of steps leading upwards to the sky, can be seen as representing levels of learning and personal development, the metaphorical climb towards greater understanding that we undertake every day. For some iwi, the Poutama also symbolises the journey Tāne undertook when he climbed through the twelve realms to obtain ngā kete o te wananga (the baskets of knowledge) for human kind.
Different iwi have varying interpretations of ngā kete. Kete aronui can generally be understood as the basket of love, peace, and arts and crafts, and is sometimes also known as the basket of the humanities — ritual, literature and philosophy. Kete tuatea can be known as the basket of the unknown, dark arts, evil and war, as well as agriculture, wood work, stone work and earth works. Kete tuauri can be seen as the basket of sacred knowledge of the ancestors relating to the creation of the world. It holds the knowledge of ritual, memory and karakia and is generally known as the basket of light. (Adapted from Tangaere, 1997, with input from Anna-Marei Kurei).
About the Editors
Alexandra Hollis joined the Institute in November 2016 to work alongside Wendy editing the third edition. She has a BA in English Literature and a MA in Creative Writing from Victoria University.
Ella Reilly joined the Institute in February 2016 and recently completed her MA(Dist) in English Literature at Victoria University. She holds a BA(Hons) in English and a BA in English and History from the University of Auckland.
References to the third edition
Comprehensive table of references A–M (with links) can be found here.
Comprehensive table of references N–Z (with links) can be found here.
Previous editions
For information on the first edition of Nation Dates, please see here.
For information on the second edition of Nation Dates, please see here.
Fourth edition
While we have only recently published the third edition of Nation Dates, we are already thinking about events to include in the fourth edition, to be published in 2019. We welcome public feedback and suggestions, which can be made here or by emailing email@example.com.


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Just a few weeks ago we urged our readers to help bring Christmas cheer to people who were struggling to afford to eat.
Your response was amazing. It helped foodbanks across our region collect tonnes of food which will give thousands of families and individuals a happier and less stressful festive season.
Johnston Press newspapers - including the Peterborough Telegraph – in Suffolk, Cambridgeshire, Lincolnshire and south Norfolk joined the Feed our Families campaign.
We called on readers to donate food and Christmas treats to the foodbanks in their own towns.
One foodbank organiser said the generosity of people this year had been overwhelming.
Another said he could not overestimate the value of the campaign.
n Simon Bysshe, chair of the Peterborough Foodbank Project, said: "As far as the appeal is concerned this is building on long-standing support. It's a reminder of how generous people are.
"They've provided Christmas things like advent calendars and other things which is great and helps make people's Christmases."
He added: "There can be so many reasons people can fall into crisis with uncertainty in the labour market and changes to benefits.
"Our job is not to comment on the politics, but we are interested in providing very critical support for people at real times of need.
"This then means that because we are working so closely with other agencies which are helping, we can sometimes provide that little bit of extra support that makes a big difference.
"It helps them to bridge that gap, and what we want to do particularly is then make sure that people are signposted to other help that's available."
Peterborough Foodbank received over 5.5 tonnes of food during December for Christmas.
This was from regular donors such as churches, agencies and individuals, as well as new individuals and companies such as Excel Displays, Cummins, BT Group, Dalmark Grain, Elliott UK and Peterborough City Council,
The foodbank also had volunteer teams from Thomas Cook and Home Group come and help with sorting the donated food.
The foodbank itself supported charity Hope into Action (which tackles homelessness) with food parcels for their tenants, and the Family Nurse Partnership with donated food and toiletries making hampers for their clients.
In Newmarket staff at two of the town's racing stables responded to our call for help by organising their own food collections.
"Godolphin and Darley stables have done big collections for us prompted by the Journal's appeal," said John Durrant who manages the foodbank run by the Open Door charity.
The stable staff's donations have given a welcome festive boost to the steady stream of food flowing in from other sources.
"We greatly appreciate people's generosity, and I'd like to say a big thank-you to all those people out there who donate to us.
He added that publicity could also make people less reluctant to come forward and ask for help.
"It gives them some sense of what the foodbank is, and could help make people less averse to using it," he said.
n Donations have been pouring into Haverhill's foodbank, leaving its volunteers overwhelmed at people's generosity.
"So far this month we have taken in over 2 tonnes," said Ann Merrigan, operations manager of REACH Community Projects which runs the foodbank,
A special three day collection in early December at Haverhill Tesco alone brought in 1.9 tonnes.
"We are so very grateful to everyone who donates," said Ann. This year again, it's been overwhelming."
Last week the gifts were still coming. "We have just weighed in donations from a local Children's Centre who had a 'giving tree' where the families they support were able to donate Christmas items to us.
"It always amazes us as to how people in our community are so generous and we just want to say a vey big thank you to everyone."
n Wide-ranging support has been given to the Boston Food Bank in the run-up to Christmas.
Ian Evans, project manager, said: "People have been very generous. People have been donating both as groups and individuals and people have been contributing also through the static collections points at Asda and Tesco."
In addition to items of food, people have been donating money to the organisation.
Pupils at Haven High Academy, in Boston, have raised £2,000 for the cause - a sum Mr Evans described as 'incredible'.
The Lincolnshire Co-operative has also donated more than £800 to the food bank through its Community Champions scheme, which sees every one of the society's 250,000 members linked to a good cause close to where they live.
Of the support, Mr Evans said: "It will make a terrific difference. I just want to thank everybody for their generous support."


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Mark Feldman, MD; Alexander T. McMahon, MBA
Note added in proof: The equal efficacy of celecoxib and naproxen in rheumatoid arthritis, with fewer endoscopic ulcers in the celecoxib groups, was reported in a recent paper (Simon LS, Weaver AL, Graham DY, Kivitz AJ, Lipsky PE, Hubbard RC, et al. Anti-inflammatory and upper gastrointestinal efects of celecoxib in rheumatoid arthritis: a randomized, controlled trial. JAMA. 1999; 282:1921-8).
Disclaimer: Dr. Feldman performed clinical studies of rofecoxib for Merck and Co., Inc., before the drug received FDA approval. He currently has no consulting or financial arrangements with any company that manufactures NSAIDs or COX-1-COX-2 inhibitors. Mr. McMahon and Salix Pharmaceuticals, Inc., have no current financial interest in the use of NSAIDs or COX-1-COX-2 inhibitors for the treatment of arthritis or other conditions and are not now involved in the manufacture of any related drugs or products.
Acknowledgments: The authors thank Drs. Byron Cryer, Ping Hsu, Lorin Johnson, and Salahuddin Kazi for their useful comments and Vicky Robertson for helping prepare the manuscript.
Grant Support: By the Veterans' Administration (Merit Award to Dr. Feldman).
Requests for Reprints: Mark Feldman, MD, Medical Service (111), Dallas Veterans Affairs Medical Center, 4500 South Lancaster Road, Dallas, TX 75216; e-mail, email@example.com. For reprint orders in quantities exceeding 100, please contact the Reprints Coordinator; phone, 215-351-2657; e-mail, firstname.lastname@example.com.
Current Author Addresses: Dr. Feldman: Medical Service (111), Dallas Veterans Affairs Medical Center, 4500 South Lancaster Road, Dallas, TX 75216.
Mr. McMahon: Oncology Therapeutics Network, 345 Oyster Point Boulevard, Suite 405, South San Francisco, CA 94080.
Two forms of cyclooxygenase, cyclooxygenase-1 (COX-1) and cyclooxygenase 2 (COX-2), act as rate-limiting enzymes in prostaglandin and thromboxane synthesis. Discovery of these compounds led to the development of drugs that selectively or specifically inhibit the COX-2 isoform. Although the COX-1 isoform is expressed at fairly constant levels in cells, including the gastrointestinal mucosa and platelets, expression of COX-2 varies greatly. In many cells, low expression of COX-2 can be upregulated by various stimuli, including inflammatory cytokines, bacterial toxins, and growth factors; this suggests that COX-2 plays a role in inflammation, infection, and cellular proliferation.
It was thought that newly developed drugs designed to block COX-2 but not COX-1 would have anti-inflammatory properties and would avoid inhibiting the synthesis of gastrointestinal prostaglandins (thereby avoiding ulcers) and platelet thromboxane (thereby avoiding bleeding). Gastrointestinal ulcers and bleeding are side effects of traditional nonsteroidal anti-inflammatory drugs (NSAIDs) that block COX-1 and COX-2. Meloxicam and nimesulide, selective COX-2 inhibitors available outside the United States, are as effective as traditional NSAIDs but have similar gastrointestinal side effects. Celecoxib (Celebrex, G.D. Searle and Co., Chicago, Illinois) and rofecoxib (Vioxx, Merck and Co., Inc., West Point, Pennsylvania), selective COX-2 inhibitors approved in the United States in the past year, are also as effective as traditional NSAIDs. However, celecoxib and rofecoxib have no antiplatelet activity and lead to fewer endoscopically detected gastric and duodenal ulcers than traditional NSAIDs, such as ibuprofen or naproxen.
Preliminary analyses of data pooled from several trials suggest that celecoxib and rofecoxib are associated with fewer clinically symptomatic ulcers and ulcer complications than traditional NSAIDs are. Postmarketing surveillance should help clarify the actual risk for serious ulcer complications with these new COX-2 inhibitors and reveal other potential nongastrointestinal toxic reactions that can result from their use.
Feldman M, McMahon AT. Do Cyclooxygenase-2 Inhibitors Provide Benefits Similar to Those of Traditional Nonsteroidal Anti-Inflammatory Drugs, with Less Gastrointestinal Toxicity?. Ann Intern Med. 2000;132:134–143. doi: https://doi.org/10.7326/0003-4819-132-2-200001180-00008
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© 2019
Published: Ann Intern Med. 2000;132(2):134-143.
Emergency Medicine, Gastroenterology/Hepatology.
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on stage
- eskimo by marcos simões © marcos simões
- eskimo by marcos simões > wtp#01 > dec 2010 brigittines © tine declerck
- eskimo by marcos simões >wtp#01 > dec 2010 brigittines © tine declerck
MARCOS SIMÕESLast updated : 12/06/2011PRINT THIS PAGE
Eskimo (known before as (Laughing)Insults) is a new step in Marcos Simões' research of the laughing body. Last autumn, he performed a previous part called Laughingame at Amperdans4.
Insult as a mask.
Insult as a perspective, a way of feeling, an emotional reaction.
Insult as a result of the impossibility to express the inexpressible.
Insult as a carnival, a ritual of initiation.
Insult as a transitional moment.
Eskimo is an insult.
Eskimo is a game of embodiment of insults. A relational event,
in which the performers are mocking themselves and the others.
A relation that generates thought and language.
An infancy state that plays within and without the law,
generating a field of possibilities.
- concept: Marcos Simões
- performance: Sara Manente, Varinia Canto Vila, Michiel Reynaert, Ondine Cloez & Christophe Albertijn
- video: Marcelo Mardones
- costumes: Patricia Fernández
- production: Monty, Detheatermaker & workspacebrussels
- with the support of: Bains Connective & the members of EVE vzw
WSB Connected artists
Other productions
EsKImo started from the idea of using the insults as the motor to generate a creation. Trough the embodiment of the insults, what kind of bodies would appear? What kind of relation would these bodies have? What kind of sounds, movements, and language would these bodies generate? And how we do look at this things? These where some of the questions that I was interested in instigate.
When the insults are towards something that we cannot reach, this insults become a field of possibilities. The insults becomes the carnival, folklore, etc
The insults as a mask.
During the process the performers in a constant embodiment of the insults, where the mockery (the mockery towards oneself and the other) was the insult more present, where playing a game of recognition, associations and becoming, through watching oneself and the other in this embodiment process, what kind of associations you could make towards you where doing, what kind of relation events you could recognize? Eskimo is a community event, to defend their territory from bad feelings. Eskimo is a renewal process. Eskimo is a game of liberation, where the bodies moves in a space of transitions, within and without the law. Eskimo as a state of exception.


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Autumn Buchanan Scarf
- By Johnstons/Scotland.
Autumn Buchanan Scarf
- By Johnstons/Scotland.
Autumn Buchanan tartan in pure cashmere.
Centuries old – now rediscovered.
Centuries ago, the famous Buchanan Clan wore particularly vibrant colours. They were so cleverly composed that they appeared much more elegant than most other tartans – even when signs of fading and wear started to show after years of wind and weather exposure. This scarf is new. Yet it is still a genuine tartan classic with its vintage appearance in vivid autumn colours that still look soft and gentle.
By Johnstons/Scotland.
For more than 220 years only high-quality cashmere has been processed in this traditional weaving mill in Scotland. All this experience can be seen and felt – particularly after many years. Woven in a generous size from the finest Mongolian cashmere.
Size without fringes approx. 25 x 180cm (9.8ʺ x 70.8ʺ). 100% cashmere. Dry clean only.


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A new corporate management team structure that will help ensure South Ayrshire Council is fit for purpose and can embed best value throughout the organisation was approved by Councillors today (Thursday 15 May 2014).
[Pictured: Eileen Howat, Chief Executive of South Ayrshire Council.]
The new structure – which will introduce changes at Executive Director and Head of Service levels – takes account of significant revisions to the Council's operational responsibilities, such as the transfer of social work services to the new Health and Social Care Partnership and the creation of the Ayrshire Roads Alliance.
The approved changes will mean the removal of the Council's Care, Learning and Wellbeing directorate and Executive Director post, the introduction of a new Director for Educational Services and the deletion of a number of Heads of Service posts.
These are Head of Children's Services; Head of Community Care and Housing; Head of Education; Head of Policy, Community Planning and Public Affairs; and Head of Property and Facility Services.
As a result, the following new Head of Service posts will be established:
• Head of Finance and ICT, with responsibility for the administration of the financial affairs of the Council, as well as revenues and benefits
• Head of Policy and Performance, with responsibility for best value, the Single Outcome Agreement, Council Plan, oversight of Service and Improvement Plans, performance and public affairs.
• Head of Communities, bringing together the various strands of work with communities across South Ayrshire.
• Head of Housing and Facilities, with responsibility for housing, facilities management and property maintenance.
In addition, the equivalent of one Head of Service post will transfer to the Shadow Integration Board for health and social care, and there will also be minor changes to other Heads of Service remits and titles.
Eileen Howat, Chief Executive of South Ayrshire Council, said: "The changes approved by members today are wholly designed to ensure we are a fit for purpose organisation. They will ensure we are structured in a sensible way that allows us to work efficiently and effectively, while continuing to deliver both high-quality services and best value for our communities.
"That will remain our focus at all times, and I am confident our new structure, which will be implemented as quickly as possible, provides the right basis for us to move the organisation forward to where we want to be."
Changes to personnel within the new structure will be managed in line with the Council's Managing Change Policy.
Full details of the proposed changes and the new structure chart can be found in the Council paper, which is available on the Council website, www.south-ayrshire.gov.uk
South Ayrshire Council is a Founder Member of the Elite Ayrshire Business Circle.


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Building your dream home? We offer construction loans suitable for building a brand new home, remodeling, expanding, or overhauling a house from top to bottom. With options for short fixed rate terms to work within your construction schedule and flexible payment options, your dream home can be yours.
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Woman Has Grandmother As Bridesmaid
(Photo credit: Sweetwater Portraits)
When Christine Quinn was thinking about who her bridesmaids would be, she knew instantly that her "Nana" was going to be one of them. Nana Betty was worried that she wasn't as "young and pretty" as the other bridesmaids and declined the offer. It took some convincing on the bride-to-be's part, but Nana finally agreed to be in the wedding. She's become an internet sensation! Doesn't she look lovely? See more photos of the wedding here.
Jack & Erin
Listen to The Jack Show every weekday afternoon, 3pm - 7pm!
Listen to The Jack Show every weekday afternoon, 3pm - 7pm!


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/ Romance / Romance Novel's Rejected CEO
Romance 1 Chapter 1,491 Views
Author: immensely_earnest
Not enough ratings
Low EQ? Cold and distant CEO? Dysfunctional family who wants to covet his riches?
You got it all wrong.
Samuel Ciao is the sole heir to the Ciao family business. Growing up he had it all. Loving parents, supportive sister, luxurious life. These led to him being unruly and wild!
"CEO? What CEO? I want to be a homicide detective! It's fun looking at corpses." Samuel's sole dream of becoming a homicide detective really troubled his parents, but they supported him and watched him grow into the best detective in Z City.
Everything was going smooth and sailing well until the rumor of a deadly pale girl dressed in black started to spread.
With a series of murders happening, will Samuel look for the girl in black whom everyone suspects?
Orion Song. The keeper of the constellations and the best shooter in the world. Because of her human body, she couldn't inherit every bit of the hunter Orion's power, but she still had superpowers like speed, magnified sight and extraordinary hearing.
Originally, she resided in the stars, she didn't have to do much, just her staying alive protected the stars. But something pulled her into this planet she watched over. Something or someone who pulls her towards him every time their eyes meet.
Is it just a first encounter? Or do they have more that goes beyond this world of love and friendship? What is it that makes Orion protect him every time and what is it that makes Samuel's head hurt and hands tremble every time he stares at the night sky?
Author's words- This is not a meaningless CEO smut for fan service. So, if you're looking for a cold and distant CEO who falls for a cute beauty and together they faceslap everyone, this is not for you.
However, if you're looking for actual true love, friendship and loyalty without Low IQ characterless villains who get faceslapped by the leads for drooling over them, this is for you. Thank you.
Please switch to the pop-up to complete the payment.
Complete the daily and EXP missions, as well as every week's reading missions to obtain EXP and SS as rewards.Learn more about the rules 1. You can obtain the corresponding EXP and Bonus SS as rewards by completing daily missions and EXP missions, as well as weekly reading missions. 2. The obtained EXP can raise your user level. 3. Bonus SS can be used to unlock chapters, gift authors, etc. They are effective for 30 days. 4. Daily Tasks and corresponding rewards renew daily at 00:00 UTC+8. Don't forget to claim your rewards in time. 5. Weekly Reading Missions refer to the time you spend reading novels and comics on Webnovel every week. 6. The weekly reading time is calculated while your device is connected to the Internet. This might result in a delay of several minutes.
Read on the app and claim your rewards!
Read anywhere, anytime


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Questions? Call Mod Experts at 714-582-3330 Mon-Fri: 8am - 6pm / Sat: 8am - 5pm
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Evolution RaceWerks Charge Pipe E60 535i N54 prevents boost leaks and improves performance.
Please note, this product no longer includes 3" charge-pipe-to-intercooler silicone coupler.
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text:
This Week at Physics
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Event Number 2242
Thursday, November 17th, 2011
- R. G. Herb Condensed Matter Seminar
- Resonant Passage of Spin States in a Triple Quantum Dot
- Time: 10:00 am
- Place: 5310 Chamberlin
- Speaker: Xuedong Hu, University of Buffalo
- Abstract: Experimental and theoretical research on spin qubits in quantum dots are progressing toward systems with multiple spins in multiple dots. Among the many quantum information processing tasks that can be accomplished by such a multi-qubit system is the coherent transfer of quantum states on chip, which is an essential capability of a practical quantum computer. In this talk I will discuss our recent work on the physics of adiabatic quantum teleportation in a triple dot system. In particular, we show that a teleportation process over a three-spin chain can be mapped exactly onto two parallel and coherent adiabatic passages, one for each spin orientation. When the time evolution is not adiabatic, we find that the fidelity of information transfer displays a strong oscillatory behavior, and it is possible to have high fidelity when the switching frequency of the qubit interactions is a subharmonic of the characteristic energy splitting of the three-spin system. This resonant operation of an adiabatic passage protocol of spin states is both fast and robust, and points to a new way to perform other quantum gates.
- Host: Coppersmith
- Add this event to your calendar
- Resonant Passage of Spin States in a Triple Quantum Dot


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Friday, September 3, 2010
Friday's Featured Fluff Addict is....MommieV!
Tell us a little about yourself, where you are located, how many kids you have,little ones in cloth, etc.- I am a single mother of a beautiful little girl. I live in Southern Indiana and I am a college professor. My daughter is 16 months old, and we have been using cloth diapers full-time since she was about 2 months old. On my Blog, My Little Slice of Mommie Heaven I go by MommieV!
What made you decide to give cloth diapers a try? I like the idea of reusable diapers because I don't like the thought of disposable diapers sitting in a landfill somewhere. I thought they would be better for my daughter, I thought I could save some money, and I thought I could save the planet, all by using cloth.
What were your friends and family's reaction when seeing the "new" cloth diapers and have they been supportive or skeptical of your choice to use cloth diapers? Everyone that has seen them has thought they were really neat. My mom was the one I was most worried about, but she was very supportive of my choice to use cloth diapers. One advantage to being a single mom is that you don't have to convince a husband or partner to use cloth!
What was your very first cloth diaper? I tried everything at first! The very first one I ever put on her was a custom-made preemie sized AIO I bought from a woman on Hyenacart. I had ordered it from a laptop while on bedrest in the hospital, when I found out she would be early - and small! I ordered it custom to match her "going home" outfit. When we started cloth diapering full-time we were using prefolds and covers primarily, but I also had some fitteds. When she started daycare at 9 months old, they wanted to use a "one piece" diaper, so that gave me an excuse to buy more pockets!
What type of diapers does your stash primarily consist of; pockets, aio, onesize, prefolds, flats, hybrids, etc.? We started with a stash that was mostly prefolds and covers. I still have a good stash of prefolds and covers that we sometimes use on the weekends, and I have a stash of fitteds that I use under woolies in the winter. But right now the majority of my stash is pockets.
What is your favorite Knickernappies product or which Knickernappies product are you dying to try and why? I'm divided here. I started with the Knickernappies sized pockets in size M when she was just getting to that size. She is very petite, so it is likely that she will potty learn out of this size. The sized pockets are just so trim and look great on her. However, I like the OS pockets also. I like that if she does get alot bigger that one diaper will accommodate different sizes. But I guess if I had to pick, I would say our sized Knickernappies pockets.
Do you have a favorite place to hang out and talk or learn about cloth ; a blog, message board, facebook page, etc.? I talk about cloth diapers all the time on my blog - My Little Slice of Mommie Heaven. I have a series of posts called Cloth Diapering 101 where I try to introduce mamas interested in cloth into the basic ideas about cloth diapers and some of the things that I have learned firsthand. But I also have done A Day in Cloth, and sometimes I just write about different things related to using cloth diapers. I have also posted photos of my daughter's naked behind when she takes her diapers off - she will hate me for that when she is older! In the past I have hung out on the Diaperswappers forums alot, but I haven't had as much time to do that recently.
What cloth diapering item, besides diapers, do you consider to be a must-have accessory? Wet bag. Definitely. I dunk-and-swish, so I've never had a diaper sprayer, and it's never been missed.
If you could share just one tip with someone who is just starting out with cloth or considering using cloth, what would be your best piece of advice to them? Think about why you are interested in cloth diapering, or what you expect to get out of it. Your expectations will help you to decide what kind of diapers to look into. If you want to spend minimal money and be really frugal, you will probably shop for different diapers than if you want all organic fabrics for your baby. So knowing what your goals and expectations are will help you to navigate all the different choices.
*We'd like to thank MommieV for contributing and sharing her story! Please stop by and visit her over at her Blog My Little Slice of Mommie Heaven, she's got some really informative posts. Are you interested in being our next Featured Fluff Addict? Visit our FaceBook Page and check the Discussions Tab for more info.
Posted by Julie at 12:01 AM
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A Dream Come True – Exposures International Fine Art Gallery
My new Family in Sedona, AZ
It is truly a dream to be among such prestigious artists, my idol from a young age; JD Challenger, Bill Wardell, Rebecca Tobey…. the list goes on. These are the artist I looked up to as a child, saw in magazines, admired there styles and masterpieces for some time.
To visit, the 20,000-foot gallery was an experience in its self. You could be there for hours and not see everything. One amazing artist and piece after another. So much to take in, from the fine jewelry in the cases to the sculptural pieces, the whole large sculpture garden out front, the paintings, and everything in between is a spectacular showing, to say the least.
Then to be accepted among all of this, simply amazing, humbling and such a dream.
Marty and all the crew at Exposures are my new family. I felt such love from them all.
In case you are not able to visit Sedona Arizona, here are some of the pictures I took while I was there. Yet, it truly is something to be seen for yourself and well worth the trip.


text: Rick who blogs at Invest In 2012 is honored to be featured here as a guest blogger!As media has shown us, the rich don't necessarily live happier than the poor. I like to think of it like this. "Someone who's rich might not live happily, but someone who's poor definitely won't live happily." Hence, it is wise to live an in between, modest lifestyle; neither as an ascetic … [Read more...]


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by Bill Nugent
Article #11
One of the things that shows the uniqueness of the Bible and proves its divine wisdom is the Sabbath. One ancient Roman writer lamented that "The Hebrews waste one-seventh of their lives." Better minds now know that rest is not waste! The whole world now follows a seven day week and businesses all around the world (with he exception of retailers!) close either on Saturday or Sunday or both.
The importance of the Sabbath in the Bible is clear. The command to rest on the Sabbath is the fourth commandment. "Remember the sabbath day, to keep it holy" (Exodus 20:8.) The Sabbath is the seventh day of the week. By Hebrew biblical reckoning the day begins at sundown and ends the following sundown. Hence the Sabbath begins on Friday evening at sundown and ends on Saturday evening at sundown. Orthodox Jews observe the Sabbath 20 minutes before sundown on Friday to 20 minutes after sundown on Saturday. The extra 20 minutes on each end of the Sabbath is like a buffer to ensure that the entire Sabbath day is observed.
Down through the centuries there has been much discussion and much dispute among Christians as to whether or not to observe the literal seventh day Sabbath. Most mainstream Christians believe that the Sabbath has been moved from Saturday to Sunday. They say this because Jesus was raised from the dead on the first day of the week which is Sunday. So there is a dispute not only about whether the Old Testament Sabbath laws apply to Christians today but also what day we are to observe, if any.
Personally I see nothing in the Bible that states or even infers that the Sabbath has been moved from the seventh day to the first day of the week. I also see that the Bible clearly teaches that literal Sabbath observance, that is the actual cessation from work on the Sabbath, is not required of the Christian. "Let no man therefore judge you . . . in respect of . . . the sabbath days" (Colossians 2:16). "One man esteemeth one day above another: another esteemeth every day alike. Let every man be fully persuaded in his own mind (Romans 14:5).
The passage from Romans 14:5 quoted above is particularly intriguing. Here we see Paul, the apostle, writing to the church under the inspiration of the Holy Spirit and telling them that Sabbath observance is optional. Just observe the Sabbath or refrain from observing it according to how you are persuaded in your own mind. Think of it. Paul is writing about the fourth commandment! He writes as if it is totally optional. Paul was raised as a Pharisee which is a very strict sect of Judaism. He didn't say "Jewish believers must observe the Sabbath but you Gentiles believers can regard every day the same." He made a general statement that infers that all Christians, whether of Jewish or Gentile heritage, can observe or not observe the Sabbath at will.
The Sabbath law is a clear example of how we are not under law but are under grace. Romans 14:5 is also a very clear example of the Christian concept of individual rights and individual autonomy. Paul didn't use his authority as an apostle to simply command all Christians to rest on the Sabbath. God lets each person "be fully persuaded in his own mind." That is radical stuff. That is freedom. This and many other verses in the Bible formed the basis for the western concept of individual rights and liberties. The founding fathers of the United States quoted from the Bible far more than any other book in their political writings.
So what then of the Sabbath? Should we just ignore it? Should we observe it in a loose way and just take it easy on Saturday or Sunday? I think the answer is found in Jeremiah 31:33 which is part of an Old Testament predictive prophetic passage written around 600 BC in which God was speaking about the future new covenant that would be implemented at the coming of Christ. In Jeremiah 31:33 God says through Jeremiah that He will write the law on our hearts. "I will put my law in their inward parts, and write it in their hearts" (Jer. 31:33).
All of the Old Testament commands are written on our hearts. Under the New Covenant we think and move from the heart. Under the Old Testament people were expected to think and move more from the mind. Under the Old Testament law everything was spelled out. Clear commands were given such as rest on the seventh day, give 10% of your income, abstain from shellfish and if you need guidance cast lots.
In the New Testament the last time the apostles cast lots was in Acts 1:15-26 and that was immediately before the Holy Spirit was poured out mightily upon them in Acts chapter two. The contrast is clear. The Old Testament walk was by external law, by rote, by formula and everything was spelled out. The New Testament walk is much more intuitive, much more from a personal relationship with God and hearing from God as an individual.
Most Christians simply ignore the fourth commandment. Most of us just rush through life and work every hour of every day. Mark Twain once said that "Most men live lives of quiet desperation." Most Christians live lives of quiet (and some not so quiet) desperation.
Hebrews 4:9 says "There remaineth therefore a rest to the people of God." That rest is not a literal Sabbath observance of cessation of physical labor every seventh day. This New Testament rest is a rest that fills all seven days per week. The fulfillment of Sabbath rest is a freedom from anxiety, turmoil and worry. As we take the yoke of Christ upon us we find rest unto our souls (Matthew 11:28-29).
So there is a fulfilled Sabbath under the New Covenant. The Old Testament law of enforced rest every seventh day was a prophetic picture, a mere parable that foreshadowed the fulfilled New Testament rest that fills all seven days. Can I explain it or can I give you a three step process to get to this rest? Let me try. Yield your self to the Lord. Lay your life down before him and take up your cross daily and follow Him. Draw close to God and He will draw close to you (James 4:8). To rest in Christ and to fulfill the Sabbath we must walk in a constant state of trust and yieldedness. So we must keep the fulfillment of the Sabbath every day. Remember, if you are anxious or worried you are breaking the Sabbath!


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A man who stole several hundred dollars of charitable donations from a Boca Raton church has been arrested, according to police.
Boca Raton Police have identified the man who took a little more than 20 minutes to break into the church's charitable locker as 46-year-old Michael Quick.
Employees at St. Joan of Arc Church reported the burglary Saturday after reviewing surveillance footage that shows Quick waiting until the only other person in the church left and going into the back room to break into the locker.
Detectives received a tip Thursday from a man who saw the video and recognized him. The tipster works at a nearby Valero gas station and recognized him from there, police said.
After speaking with some of Quick's neighbors, detectives located him and charged him with grand theft. Quick told police he needed the money for food, officials said.


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"Quality of Living, for the purposes Mercer's survey, analysis, and city rankings, differs from"quality of life." Quality of life may involve a subjective assessment or opinion about one's personal state and circumstances in a given city, but Mercer's criteria for Quality of Living are objective, neutral and unbiased. Our objective system measures the quality of living for expatriates based on 39 criteria grouped into 10 key categories. We weigh each category to reflect its importance for overall quality of living. We assess the degree to which expatriates enjoy the standard of living in each host location, factoring in the interaction of political, socio-economic and environmental factors in the host location.
For Mercer's Quality of Living rankings, New York serves as the base city. All other cities are ranked in relation to it.
This table shows the categories and criteria that Mercer quantifies for each city:
" Source : www.mercer.com
Tuesday, 18 September 2012
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