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Fact Sheet: The Companies Bill
As India prepares for the winter session of Parliament, here is the third of our fact sheets on key bills that lawmakers are likely to consider for approval. (Click here for more.)
Name: The Companies Bill, 2011
Aim: The bill seeks to update India's corporate laws to the realities of the 21st century, where social responsibility is a key area of a corporation's activities; fraud and money laundering have become more sophisticated and harder to monitor; and the accountability of executives and auditors have become a bigger priority.
Why it's important: It's a comprehensive piece of legislation that seeks to overhaul how corporations function– from how they raise funds, to how they set up subsidiaries, to how they register an enterprise in India.
Among the more-talked about provisions of this 372-page piece of legislation is a clause that would make it mandatory for companies to allocate at least 2% of their average annual profit to development initiatives.
The bill also aims to clamp down on money laundering by preventing companies from having more than two layers of investment subsidiaries.
If approved, it would give more powers to the Serious Fraud Investigation Office, a federal body, including the ability to arrest and submit investigation reports to courts. Currently, that's a power reserved to the police. It also includes provisions to set up special courts for corporate crimes.
The bill also allow shareholders of a company to file a class action lawsuit against the management.
What changes: The bill would replace the Companies Act, 1956. The biggest difference from the current law is that it would give more power to those responsible for investigating fraud and that it would make corporate social responsibility a legal obligation.
It would make it tougher for smaller companies to raise funds by accepting deposits from the public. The proposed law will only allow companies with a minimum net worth, an amount not specified in the bill, to raise deposits. Companies would be compelled to set aside assets equivalent to the value of the deposits, so that depositors may be paid their dues even if the company is in financial trouble.
Who it would affect: It would affect every company in India, including single-person outfits that have registered themselves as an enterprise. Within companies, the proposed law would affect the senior management, directors, auditors and shareholders of companies.
If implemented, it could boost community development projects across India, such as setting up schools, hospitals or improving drinking water supply to villages.
Reaction: The bill has elicited criticism from some corporations, tax advisers, lobby groups and management consultants. The Confederation of Indian Industry said it's "concerned" about the mandatory provision that 2% annual profit has to be set aside for community projects, saying this should be a voluntary activity and India would be the first country in the world to have such a provision.
But many industry leaders have welcomed aspects of the bill. "The new law would strengthen the concept of shareholders democracy and offer protection of the rights of minority stakeholders," said Chandrajit Banerjee, the director of the Confederation of Indian Industry, a lobby group. However, he said he was "concerned" about the requirement to set aside 2% of profits for community projects.
What's next? The bill is expected to be discussed in both houses of Parliament in the upcoming session. There hasn't much political opposition to the bill so far.
Follow India Real Time on Twitter @indiarealtime.


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You are sitting on your workstation, wondering if your skills are getting dated. You try to update your resume and are hit by the hard truth: "You haven't learnt anything
We have already discussed how you can identify your personal strengths in this other blog (link to Identifying Your Personal Strengths blog post). However, it is equally important to beThis post is part 5 of 3 in the series Job Hunting
It is that time of the year when a lot of us will be going through annual evaluations at our workplaces. There will possibly be some increments and some disappointments.This post is part 7 of 3 in the series Job Hunting
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In the modern world, relationships are more important but more complicated than ever. Social media means that we form relationships with people that we've never met. It means that we
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Under and by virtue of the Power of Sale contained in a Security Deed given by Donald Wesley Williams and Phyllis Williams to Mortgage Electronic Registration Systems, Inc, dated November 22, 2005, recorded on December 28, 2005 in Deed Book 411, Page 711-730, Appling County, Georgia Records, said Security Deed having been last sold, assigned, transferred and conveyed to Alliance Realty Capital, LLC, the secured creditor, by Assignment conveying the after-described property to secure a Note in the original principal amount of Eighty Thousand and 00/100 DOLLARS ($80,000.00), with interest thereon as set forth therein, the holder thereof pursuant to said Deed and Note thereby secured has declared the entire amount of said indebtedness due and payable and, pursuant to the power of sale contained in said Deed, will on January 2, 2013 during the legal hours of sale, before the Courthouse door in said County, sell at public outcry to the highest bidder for cash, the property described in said Deed, to-wit:
All that tract or parcel of land lying, being and situate in Land Lot 331 in the Second Land District of Applying County, Georgia, consisting of 0.75 acre, more or less, and being more particularly described as follows: Commencing at the Southwest original lot corner of said lot; thence East along the Southern lot line 856.61 feet to the Northwestern boundary of Patterson Road; thence Northeasterly 725.04 feet along the Northwestern boundary of Patterson Road to said point of beginning; thence North 41 degrees 0 minutes East 140.67 feet; thence North 31 degrees 0 minutes West 180 feet; thence South 41 degrees 0 minutes West 140.87 feet; thence South 30 degrees 50 minutes East 180 feet to said point of beginning. Bound now or formerly as follows: Northwesterly by lands of Bill Spell; Northeasterly by Steven Spell; Southeasterly by Patterson Road; and Southwesterly by and AT&T easement. This being a portion of the tract of land described on a survey and plat thereof by Allen T. Beach, dated November 20, 1978, recorded in Plat Book 9A, page 127, Appling County Records. This being the same property conveyed from Mildred Collett and Jeanne Spell to Jennifer Joiner Bass by deed dated July 26, 1999, recorded in Deed Book 327, page 661, Appling County Roads.
Said property is known as 548 Patterson Road, Baxley, GA 31513, together with all fixtures and personal property attached to and constituting a party of said property, if any.
Said property will be sold as the property of Donald Wesley Williams and Phyllis Williams, the property, to the best information, knowledge and belief of the undersigned, being presently in the possession of Donald Wesley Williams and Phyllis Williams or a tenant or tenants. Said property will be sold subject to any outstanding ad valorem taxes (including taxes which are a lien, but not yet due and payable), the right of redemption of any taxing authority, any matters which might be disclosed by an accurate survey and inspection of the property, any assessments, liens, encumbrances, zoning ordinances, restrictions, covenants, and matters of record superior to the Security Deed first set out above. The sale will be conducted subject (1) to confirmation that the sale is not prohibited under the U.S. Bankruptcy Code and (2) to final confirmation and audit of the status of the loan with the holder of the security deed.
Pursuant to O.C.G.A. Section 9-13-172.1, which allows for certain procedures regarding the rescission of judicial and non-judicial sales in the State of Georgia, the Deed Under Power and other foreclosure documents may not be provided until final confirmation of the audit of the status of the loan as provided immediately above.
The debt secured by said Security Deed has been and is hereby declared due because of, among other possible events of default, failure to pay the indebtedness as and when due and in the manner provided in the Note and Security Deed. The debt remaining in default, this sale will be made for the purpose of paying the same and all expenses of this sale, as provided in Security Deed and by law, including, without limitation, attorneys' fees. Notice has been given of intention to collect attorneys' fees and other charges in accordance with the terms of the Note secured by said Deed. The balance, if any, will be distributed as provided by law.
Pursuant to O.C.G.A. 44-14-162.2, the name, address and telephone number of the individual or entity who shall have the full authority to negotiate, amend, or modify all terms of the above-described mortgage on behalf of the secured creditor, Alliance Realty Capital, LLC, is as follows: FCI Lender Services, 8180 East Kaiser Blvd., Anaheim Hills, CA 92808, (714) 282-2424. The foregoing notwithstanding, nothing in O.G.C.A. 44-14-162.2 shall require the secured creditor to negotiate, amend or modify the terms of the mortgage instrument.
Alliance Realty Capital, LLC
as Attorney in Fact for
Donald Wesley Williams and Phyllis Williams
Morris|Hardwick|Schneider, LLC
1301 Hightower Trail, Suite 305
Sandy Springs, Georgia 30350
This is an attempt to collect a debt and any information obtained may be used for that purpose.
GAFC - Notice of Sale
gpn11 STATE OF GEORGIA COUNTY OF APPLING NOTICE OF SALE UNDER POWER
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A four part 'Faith Matters' lecture series takes place in Westminster Cathedral Hall on Tuesday evenings in Lent 2012.
The lectures examine some of the Catholic Church's key priorities identified by the Catholic Bishops' of England and Wales in their 2011 document 'A Vision for the Church in Our Land'.
The opening lecture, on Tuesday 28 February 2012, 'Faith of our Fathers: Legacies of English Catholic History', sets the scene for an exploration of how Catholics can be confident today through looking to the legacies of the past. John Morrill, Professor of British and Irish History at Cambridge University is a permanent deacon in the Diocese of East Anglia.
In his lecture he will seek show how English Catholicism, forged in the age of dungeon, fire and sword, and emerging confident and affirmed into modern times, has constantly been enriched by its ready acceptance of Irish, continental and post-colonial influences.
On Tuesday 6 March, in a joint lecture, Fr Paul O'Reilly SJ, a priest who works as a doctor, and Mr Martin Rainsford, Headteacher of Douay Martyrs School, Ickenham, will discuss the priority of 'Vocation in Church and World'. One of the teachings of the Second Vatican Council is that all have a vocation, be it to marriage and family, to be a priest or deacon, to the consecrated life, as a lay apostle.
On Tuesday 20 March, Faith Matters will explore the priority of deepening social engagement. Dr Anna Rowlands, Director of Studies at the Margaret Beaufort Institute of Theology, Cambridge, will speak on 'Catholic Social Teaching: Practising Visions of Hope'. Dr Rowlands will concentrate on the three elements of social teaching much to the fore in current political debate about social responsibility: the nature of the human person and their role in civil society, solidarity and the common good.
Finally, on Tuesday 27 March the focus will be on the contemporary challenge to proclaim and live the Gospel in a multifaith society. Archbishop Kevin McDonald, Chairman of the Catholic Bishops' Committee for Catholic-Jewish Relations and Office For Relations with Other Religions, will look at 'Sharing our spiritual riches: Interreligious Dialogue'.
'Faith Matters' is a collaborative project of the Agency for Evangelisation and the Mount St Jesuit Centre. Following each lecture, recorded video and text along with an online discussion forum will be posted on the Diocese of Westminster's website: www.rcdow.org.uk
'Faith Matters' are all public lectures to which all are welcome. All Lectures will start at 7.00pm and will be held at Westminster Cathedral Hall, Ambrosden Avenue, London SW1.


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Draw attention and attract visitors with outdoor signs! The wide variety of free standing, inflatable, and large-format signs are ideal for displaying your message or brand in a durable, weather-resistant format. Outdoor signs are easy to set up and are stable in all types of conditions.
Choose from rigid signage, banner stands, portable billboards, backpack flags and more to showcase your brand and message outdoors.
The Atlas Outdoor Sign Holder is designed to hold rigid signs or Zoom flags. Easy to setup and store, multiple Atlas Sign Holders can be used to showcase a large rigid graphic. The hollow plastic base can be filled with water or sand for additional counterweight.
Whirlwind is a heavy-duty double-sided wing sign for displaying indoor or outdoor graphics. The unit has a wheeled, compact moulded base that can be filled with water or sand. The snap frame poster holders make changing your message quick and easy.
Price starting at: $347.28
The Cafe Barrier is an indoor/outdoor modular display system includes heavy-duty stainless steel posts, base and 59" rails. This display system is a stylish way to define areas or direct traffic flow inside or outside restaurants, bars, retail establishments, airports, museums, casinos or at tradeshows. Unit kit, extension kit and individual compo...
Price starting at: $349.53
The Cafe Barrier Extension Kit includes one upright, one base, a top and bottom rail, and easily connects to existing Cafe Barrier systems for an extended display or area definition. This accessory kit is perfect for larger, high-traffic areas and can effectively direct traffic and define important areas in many different environments.
Price starting at: $242.95
The Contour Wave 1 with water base is a heavy-duty double-sided sign with sweeping lines that utilizes hook and loop connections to make graphic changes a breeze. The compact, molded water base features integrated wheels and a handle for easy transportation and can be filled with either water or sand for added stability.
Price starting at: $315.03
The Ace-2 Outdoor Sign is a sturdy, yet lightweight double-sided silver aluminum A-frame sign, perfect for storefronts, sidewalks, gas stations, car dealerships and so much more. The Ace-2 features snap frames on both sides for easy poster size graphic insertion and replacement. The Ace-2 sign fits rigid posters/graphics that are 24"w x 36"h. The...
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The Swing Outdoor Sign is a sleek and portable outdoor sign featuring an economy black steel tube frame, double ring mounting clips to keep graphic securely in place and wheeled, fillable base. The Swing Sign allows for easy graphic changes and replacements and comes with your choice of single or double-sided graphics printed on 6mm PVC board. The...
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The Stowaway 3 Large features a simplistic, lightweight and flexible frame with durable outdoor graphics. The Stowaway is ideal for advertising and messaging at sporting events, concerts, festivals or in front of any storefront.
Price starting at: $696.58
The Stowaway 3 Extra Large features a simplistic, lightweight and flexible frame with durable outdoor graphics. The Stowaway is ideal for advertising and messaging at sporting events, concerts, festivals or in front of any storefront.
Price starting at: $1,246.58
The Zoom™ Flex Outdoor Billboard is a strong, flexible outdoor billboard perfect for outdoor promotions and events. The Zoom™ Flex Outdoor Billboard features sturdy base plates on the inside of the unit, tube frame construction with flexible fiberglass poles at the top, which allows the display to move with the wind. Bags included to a...
Price starting at: $1,193.32
Monsoon Outdoor Sign Stand is a large format banner 'A' frame made from lightweight aluminum, ideal for use with eyelet banners. Monsoon is very easy to use, reusable and is the perfect graphics carrier for venues, events, exhibitions, promotions and indoor or outdoor shows.
Price starting at: $263.32
The Promotional Square Umbrella is an outdoor display that provides style and functionality. The umbrella features vibrant custom graphics that are water-resistant and long lasting. This durable umbrella provides shelter from outdoor weather elements, perfect for use in both commercial and residential environments.
Price starting at: $624.46
This double sided, plastic a-frame display is a great way to show your message in an indoor and outdoor environment. Sturdy, easy to use, and simple to store, Apex is a great solution for your display needs.
Price starting at: $195.92
The Wedge is a cost effective sign support that is simple to use. Quickly and easily create displays with the Wedge and a rigid or poster board graphic, and combine multiple units to create longer and taller displays. The Wedge sign stand is available in black and features a five year warranty.
The Cafe Barrier 1500 Rail is an a la carte 1500mm long rail for the Cafe Barrier banner system. Use as a replacement for a previous unit, or purchase with uprights and bases to create customized Cafe Barrier units. Rail measures 1500mm (59") long and is heavy-duty stainless steel.


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You can make it easy for users to find your Google services such as Gmail or Drive, or a web site you build with Google Sites, by customizing the web address (or URL) they type in their browser. That way, all they have to type is mail.yourdomain.com, or www.yourdomain.com, or just plain old yourdomain.com (using, of course, your organization's actual domain name).
Customize a Google service address
Create easy-to-remember shortcuts to users' services such as Gmail, Drive, and Calendar. With a custom web address, for example, users can type simply mail.yourdomain.com to access their Gmail account instead of the longer default address mail.google.com/a/yourdomain.com.
Customize a Google Site address
Customize an address to a web site you build in Google Sites so it doesn't include sites.google.com/a at the beginning of the address. This is how you create the address www.yourdomain.com for your organization's public web site.
Enable your "naked" domain address
Allow the public to also access your www.yourdomain.com web site by typing simply yourdomain.com—that is, the "naked" address without the w's.


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|Latin name
|Pomacanthus imperator - (Bloch, 1787)
|Common name
|Emperor Angelfish
|Pomacanthidae - Pomacanthus
|East Indian Ocean, West Indian Ocean, Australia, Japan
|Max length
|40.0 cm (15.7")
As aquarium fish
High water quality
This species demands a high water quality.
Amongst other things it means, that water must be properly oxygenated.
Can nibble at clams
This species sometimes nibbles at clams including Tridacna species.
Frequent feeding
This fish requires feeding several times a day, especially when newly added.
When the fish can find its natural food in the aquarium it requires less frequent feeding.
Well established aquarium with algae
These fish should be kept in a well run aquarium where they can "graze" algae from rocks and stones.
If there are insufficient algae on the rocks, it is important to feed more frequently and supplement with algae rich food e.g. Spirulina.
Acclimitises best as a juvenile
This species will better acclimatize to the aquarium`s condition if introduced, when young.
Very small individuals can be very delicate.
Requires a varied diet
This species must be fed with an appropriately varied diet.
Requires plenty of space for swimming.
This species revels in swimming and requires an aquarium with ample space.
This species can change gender from female to male.
When a male is needed, a female changes sex and takes on the role.
Initially shy
This species can be very shy when first introduced into a new aquarium.
More aggressive fish can be introduced after this species has acclimatized.
Hiding places
This species needs good hiding places, for example, between live rocks.
Can coexist as a pair
They can live as a pair provided they are introduced simultaneously.
Grunting sounds
This species can make a grunting sound when it feels threatened for example.
Refuses to eat at first
This species can refuse to eat when newly introduced.
Normally however, they begin to eat within about a week, but it's advantageous if they can find their own food in the aquarium.
Tips for keeping Angelfish
It is possible to keep various different sizes of Angelfish in the same aquarium, but it means that one must choose species with care and that the conditions in the tank are optimum.
Here are some suggestions to increase the chances of success:
Choice of species
It is important not to choose species that are too similar, the greater the variance, the larger the chance of success. It is also advantageous to choose fish of different sizes. Two young Angelfish of the same same size and pattern for example are a bad idea. One should of course avoid the most aggressive species.
Order of introduction
It is a good idea to make a wishlist and choosing the order so, that the least aggressive are introduced first. When adding similar sized Ange fish it works best if they are introduced simultaneously.
There should be enough space in the aquarium, but it is difficult to give specific advice. Of course there are exceptions to the table below as to just how big a tank should be in order to stand a good chance of success. Space itself is not enough, there should also be sufficient hiding places so the fish do not have to fight over these.
100 gal (400 liters): Several small Angelfish (<15cm) can live together.
240 gal (900 liters): Several medium Angelfish (< 20cm) can live together.
400 gal (1500 liters): Several large Angelfish (<25cm) can live together.
Food and water quality
It is always helpful to give the fish a varied diet, so they can withstand the occasional stress situation when for example new fish are introduced. Water quality must also be very high, so that the fish do not get stressed for that reason either.
Corals suitable for an aquarium with Angelfish
It can be a challenge to keep corals together with Angelfish, since the latter eat most soft corals and LPS. Especially Zoathus are swiftly eaten by the larger species.
It is however possible to build up a mixed coral aquarium with Angelfish. If some of the following corals are choosen there is a good chance the Angelfish will leave them alone; Hammer corals, Bubble corals, Star polyps, Disc anemones and others.
Most of the SPS corals can be kept with Angelfish.
Can be aggressive
This species can be aggressive when kept together with fish that are very similar, or if they are not provided with adequate space.
When young these fish are black with white and blue markings.
Genus description (Pomacanthus)
The Pomacanthus genus of Angelfish, is extremely impressive with their beauty of colours and patterns. They live mostly on most sponges, but also soft corals, tunicates and macroalgae found naturally.
There is typically rather a large difference in the appearance between juvenile and adult.
When properly fed, these fish can grow fast and become very large. In captivity, it can take well over a week for these fish to start feeding. This, because they are not used to catching their own food in the aquarium. It is best to feed them little and often, 4/5 times daily.
As the feeding indications suggest, these fish are not reef safe, but if one chooses the corals with care, it is possible to keep them together in a aquarium.
One may obtain a species specific preparation containing sponges to meet nutritional needs of some species. Thier diet should include algae based foods, i.e. nori seaweed, spirulina, or similar.
Pomacanthus species can be very aggressive, but not to the same degree as the Holacanthus. Thus in a tank with shyer species it is best to add a Pomacanthus last.
They must also not be kept together with Lionfish, Seahorses, Scorpionfish or similar, as they might be nibbled.
Family description (Pomacanthidae)
Angelfish (Pomacanthidae) are known as some of the most colourful and impressive fish on the reef.
Many species are not reef safe, as they especially target the soft corals and LPS. But by choosing your corals carefully, or by getting specific species of Angelfish, they can be kept in coral aquariums.
There are Angelfish suitable for most aquarium sizes, from Dwarf Angelfish which are well suited to smaller aquaria, to the larger of the species which can be impressively displayed in a larger aquarium.
The demands of the individual species can vary widely. Some are food specialists and require therefore special food, while for others can be difficult to acclimatize, as they live in deep water in the wild. It is recommended that one has a reasonably good knowledge of the different types of food and of treatments of illnesses, if one wishes to keep the larger species.
|Aquarium trade
|Indo-Pacific: Red Sea and East Africa to the Hawaiian, Line and Tuamoto islands, north to southern Japan and the Ogasawara Islands, south to the Great Barrier Reef, New Caledonia, and the Austral Islands (Ref. 33390). Not found in Easter Island, Rapa an
|English common names
|Imperial angelfish, Emperor angelfish
|Danish common names
|Ægte kejserfisk
|German common names
|French common names
|Poisson-ange empereur, Poisson ange impérial
References and further reading
Niels K. 2014. Private conversation - saltvandsforum.dk - (Danish)
Scott W. Michael. 2004. Angelfishes and Butterflyfishes (Reef Fishes Series Book 3) TFH Publications / Microcosm Ltd. - (English)
Bob Fenner. Marine Angelfishes, Family Pomacanthidae - Wet Web Media - (English)
Bob Fenner. The Best Angelfishes For Marine Aquarium Use - Wet Web Media - (English)
Bob Fenner. The Ultimate Angelfish Aquarium; An amazing and challenging collection of marine angelfishes - Wet Web Media - (English)
Collection of links to additional information - Wet Web Media - (English)
Reef Central. 2009. Keeping more than one emperor angelfish together - (English)
Froese, R. and D. Pauly. Editors. 2014. FishBase. World Wide Web electronic publication. www.fishbase.org, version (08/2014).
|hermaphroditic, herbivore, algae eater, docile shy, pair couple, eats tridacna, angel, tag_kejser


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Bellahouston Park (map )
Where: Bellahouston Park
When: Sat 6th June 2020
Difficulty Level: Beginners & Improvers
Status: Must wear pads & helmet
Private lessons available at Bellahouston Park or Glasgow Green and are weather dependent. (Indoor beginner lessons available.)
Need more information contact TrySkating or text 07733 276 902. Lesson costs.


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Imaging to Stratify Coronary Artery Disease Risk in Asymptomatic Patients with Diabetes
MaanMalahfji, MD; John J. Mahmarian, M.D.Houston Methodist Hospital, Houston, Texas
Coronary artery disease (CAD) is the leading cause of morbidity and mortality in patients with diabetes mellitus. Patients with diabetes have a higher prevalence of CAD and a larger magnitude of ischemia, and they are more likely to have silent myocardial ischemia and myocardial infarction. However, recent large cohort studies demonstrate that diabetic patients are not a homogenous group with similar high risk for cardiac events. In fact, more than 30% of asymptomatic diabetic patients do not have evidence of coronary atherosclerosis and have a very low annual cardiac event rate. Accordingly, there has been a recent paradigm shift as to whether the detection of subclinical coronary atherosclerosis through imaging can best guide therapeutic decision making. This review discusses the role of various cardiac imaging techniques for stratifying cardiovascular risk and optimizing therapy in asymptomatic diabetic patients.
Coronary artery disease (CAD) is the leading cause of morbidity and mortality in patients with diabetes mellitus. These patients have a higher prevalence of CAD and are more likely to have silent myocardial ischemia and myocardial infarction (MI) than nondiabetics.1,2 The goals for screening asymptomatic diabetic patients should be to (1) stratify risk beyond that estimated by clinical risk factors alone, (2) identify subclinical coronary atherosclerosis, (3) identify patients with significant obstructive CAD who have silent myocardial ischemia and are at higher short-term risk for events, and (4) guide patient management to improve long-term outcomes. Another important objective is to identify low-risk patients who may not require statin and aspirin pharmacotherapy and/or further diagnostic testing. Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend high-dose statin therapy for all patients with diabetes.3 Yet large cohort studies demonstrate that asymptomatic patients with diabetes are not a homogenous group, with > 30% having no evidence of coronary atherosclerosis let alone obstructive CAD. The following review discusses the role of cardiac imaging in risk-stratifying asymptomatic diabetic patients and guiding therapeutic decision making.
The coronary artery calcium score (CACS) is a well-established noninvasive test for identifying patients with coronary atherosclerosis; it requires no patient preparation, is easily interpretable, and can be performed within seconds with very low radiation exposure (Figure 1). In a general asymptomatic population without prior CAD, a CACS reclassifies risk beyond clinical risk models alone and, unlike functional testing, identifies the entire spectrum of subclinical coronary atherosclerosis.4,5 A CACS of 0 predicts a very low annual risk for major adverse cardiac events (MACE) in both men and women.5-7 This is paramount because approximately 60% of patients screened will have a CACS = 0 (more so women than men at any given age). Such low-risk patients are unlikely to benefit from further cardiac testing or statin therapy.8,9 Conversely, an abnormal CACS identifies patients at increased risk for having myocardial ischemia10-12 and subsequent cardiac events, particularly when atherosclerosis is severe. A recent meta-analysis of 20 studies showed a 23.6% prevalence of ischemia on single photon emission computed tomography myocardial perfusion imaging in patients with a CACS > 400.13 Furthermore, CACS testing influences both patient and physician behavior regarding statin and aspirin use and is a strong motivator for reducing cardiac risk factors and decreasing unnecessary downstream testing.14-16
A recent meta-analysis of eight studies covering 6,521 patients reported a CACS < 10 in 29% of patients with diabetes18 who then had an annual hard cardiac event rate (death/non-fatal MI) of 0.35%, a 6.8-fold reduction from the predicted 2.4% rate. The MESA investigators reported CACS = 0 in 45% of patients with metabolic syndrome and 38% of patients with diabetes, with a low overall annual MACE in both groups.19 A longer follow-up analysis showed similar results but with MACE rates increasing as CACS severity increased in those with metabolic syndrome and particularly diabetes. The addition of a CACS to clinical risk factors significantly improved net risk reclassification in both diabetic and nondiabetic patients and in those with metabolic syndrome.23
Although a CACS of 0 appears reassuring, other reports indicate that it may not confer the same low mortality risk in the long term.24 An observational study of 9,715 asymptomatic subjects undergoing a CACS and 15-year follow-up found that diabetic patients with a CACS = 0 had a 2.5-fold higher hazard ratio for all-cause mortality compared to nondiabetics, although the annual mortality rates were still relatively low. Of interest, a significant increase in mortality within the diabetic cohort began > 5 years after the baseline normal CACS, suggesting that the "warranty period" for a CACS of 0 may be shorter for diabetic patients. Two studies in the general population have shown conversion from 0 to non-0 CACS in 16% of patients over 2.4 years and 25% over 5 years.25,26 In the latter study, the mean time of conversion was 4.1 + 0.9 years, suggesting that a repeat CACS at 4- to 5-year intervals may be prudent in patients with an initial CACS = 0.26
Data from the MESA investigators indicate that diabetic patients with a preexisting abnormal baseline CACS showed greater annual CACS progression compared with nondiabetic patients, regardless of sex.27 Poor glycemic control was a predictor of both conversion and progression. An increase in cardiac events mirrored the degree of change in CACS, with continued low event rates in nonprogressors but the highest event rates in patients at the highest tertile of progression and especially among those with metabolic syndrome or diabetes. This may explain the higher event rates seen at all levels of CACS > 0 in other studies comparing diabetic and nondiabetic patients. In further support of this finding, patients with diabetes/metabolic syndrome have a higher frequency of stress-induced myocardial ischemia compared to nondiabetic patients who have a severe or moderate CACS.28 Because myocardial ischemia predicts cardiac events, progression to even moderate CACS may be more worrisome in diabetic patients. These data support optimal glycemic control in all patients with diabetes and management of other cardiac risk factors to prevent plaque progression. Currently, CACS is considered an appropriate test in asymptomatic patients who are at intermediate or high clinical risk for CAD, a subgroup that includes the diabetic population.29
Computed tomography coronary angiography (CTA) is highly accurate for diagnosing CAD,30,31 detecting ischemia,32-34 and predicting patient outcome based on the presence, extent, and severity of CAD.35-37 In the SCOT-HEART trial, CTA was significantly better than exercise treadmill testing (ETT) at reclassifying CAD diagnosis, leading to more aggressive treatment with statins and other therapies; also, patients undergoing CTA had better outcomes than those assessed by ETT alone.38 This is consistent with a recent observational study showing that statin therapy significantly improved outcomes in patients undergoing CTA who had extensive nonobstructive plaque.39
Although CTA has a potential advantage for detecting the entire spectrum of atherosclerotic plaque in asymptomatic diabetic patients, there are no data to suggest that it would perform better than a much simpler CACS. This is based on numerous studies in low-to-intermediate-risk patients with suspected CAD, wherein < 1.0% of patients had significant stenosis on CTA if the CACS was 0. At this juncture, CTA is not considered an appropriate test in asymptomatic patients.29
Exercise treadmill testing predicts mortality in asymptomatic patients based on the presence of stress-induced ischemia, peak exercise capacity,40,41 post-exercise heart rate recovery,42 and the Duke Treadmill score (a composite of exercise duration, symptomatic status during exercise, and presence/extent of ischemia).43,44 Exercise capacity is one of the strongest predictors of survival in both asymptomatic men and women.40,41 In a recent study of 5,638 asymptomatic women, the Duke Treadmill score predicted total and cardiac mortality, but outcome was primarily driven by exercise capacity.45 Currently, ETT is considered "maybe appropriate" for asymptomatic patients at intermediate risk and "appropriate" for those at high global risk, providing that the baseline electrocardiogram is normal and the patient can exercise.29 Despite these recommendations, a normal ETT has a limited warranty period, suboptimal sensitivity and specificity for CAD detection, and does not identify subclinical coronary atherosclerosis.5,38
A recent observational study of approximately 1,000 generally asymptomatic patients compared the relative values of ETT and CACS for long-term risk stratification and determined that CACS severity best predicted risk5; it also improved risk prediction in the 85% to 90% of patients who had low-risk/normal ETT results, with subsequent event rates driven primarily by CACS severity. The results suggest that use of ETT in the general asymptomatic patient population has limited value. However, because of its low cost, it may serve some value in diabetics with multiple other risk factors (i.e., the high-risk group) in situations where CACS is not available.
Stress myocardial perfusion imaging, stress echocardiography, and stress cardiac magnetic resonance imaging have all been shown to detect ischemia and predict outcome in patents with known or suspected coronary artery disease but are of limited clinical value in asymptomatic patients due to the low prevalence of a positive test result.12,13,46-58 Furthermore, they are inferior to CACS for predicting long-term risk due to their inability to detect subclinical coronary artery atherosclerosis and may therefore lead to a false sense of security if the test result is normal.12,13 However, targeted stress myocardial perfusion imaging is helpful in refining risk stratification in patients with a moderate (101-400) or severe (> 400) CACS because 25% to 40% will have significant silent myocardial ischemia.12,13,29
There is limited direct evidence showing improvement in patient outcomes through cardiac screening of asymptomatic patients, diabetic or otherwise. This is likely due to multiple issues including relatively short patient follow-up, low cardiac event rates, lack of structured protocol-directed treatment algorithms defined by imaging results, and the inability of most techniques to detect early coronary atherosclerosis. Most asymptomatic patients will have normal functional tests, but over half will have subclinical coronary atherosclerosis that will ultimately lead to a poor outcome.
Primary and secondary prevention trials have demonstrated significant reductions in cardiac event rates with statin therapy.59 In the JUPITER trial, 17,802 asymptomatic patients with elevated C-reactive protein as a marker of high risk were randomized to rosuvastatin or placebo. There was a 63% reduction in cardiac event rates in the treated population, primarily when low-density lipoprotein level was reduced to < 50 mg/dL.60,61 This was true irrespective of sex, age, body mass index, Framingham Risk Score, or presence of metabolic syndrome. Recently, the MESA investigators matched their patients to those in JUPITER and six other randomized primary prevention statin trials and demonstrated indirect evidence of benefit.9 Of the patients who would qualify for statin therapy based on clinical evidence, 44% had a CACS of 0. The annual event rates in patients with a CACS of 0 were only 0.39% for total atherosclerotic disease events and 0.17% for coronary heart disease events. In this analysis, 197 patients with a CACS of 0 would need statin treatment for 10 years to prevent one coronary heart disease event. However, the number of patients decreases to 56 for a CACS of 1 through 100 and only 28 for a CACS > 100. The CACS is the only noninvasive technique that detects early coronary atherosclerosis (other than CTA), effectively redefines risk, and can better discern which patients warrant statin therapy. This has been shown even within clinical groups recommended for statin therapy in the most recent ACC/AHA guidelines.8 The CACS appears to be an optimal initial screening test for defining the presence and extent of coronary atherosclerosis in asymptomatic diabetic patients and thereby guides patient management. In patients with a CACS of 0, statin therapy could be avoided with aggressive risk factor modification and repeat CACS testing at 3- to 4-year intervals. In patients with a CACS > 0, statin and aspirin therapy should be added to aggressive risk-factor modification, with functional testing reserved for those with silent myocardial ischemia who have a moderate to severe CACS score. Future large randomized trials should focus on how refining targeted treatment of patients with an abnormal CACS can lead to prevention of cardiac events.
- The coronary artery calcium score (CACS) is currently the preferred noninvasive imaging test for stratifying risk and guiding therapeutic decision making in asymptomatic men and women, particularly those with diabetes.
- Patients with a CACS of 0 have an exceedingly low annual event rate and can avoid statin therapy. Repeat CACS imaging is recommended at 3- to 4-year intervals.
- Patients with a CACS > 0 should undergo aggressive risk factor modification that includes aspirin and statin therapy. Repeat CACS testing in such patients is not currently recommended.
- Stress testing has limited value in asymptomatic patients with diabetes since it cannot detect subclinical coronary atherosclerosis, and a normal test result has only a 2- to 3-year warranty period. However, functional testing is recommended in the high-risk subset of patients with moderate (100-400) and severe (> 400) CACS to detect silent myocardial ischemia.
Emerging Risk Factors Collaboration et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet (London, England) 2010;375:2215–22.
- Morales DCV, Bhavnani SP, Ahlberg AW, et al. Coronary risk equivalence of diabetes assessed by SPECT-MPI. J Nucl Cardiol. 2017 Dec 6.
- Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jul 1;63(25 Pt B):2889-934.
- Erbel R, Möhlenkamp S, Moebus S, et al. Coronary Risk Stratification, Discrimination, and Reclassification Improvement Based on Quantification of Subclinical Coronary Atherosclerosis. J Am Coll Cardiol. 2010 Oct 19;56(17):1397-406.
- Chang SM, Nabi F, Xu J, et al. Value of CACS compared with ETT and myocardial perfusion imaging for predicting long-term cardiac outcome in asymptomatic and symptomatic patients at low risk for coronary disease: clinical implications in a multimodality imaging world. JACC Cardiovasc Imaging. 2015 Feb;8(2):134-44.
- Detrano R, Guerci AD, Carr JJ, et al. Coronary Calcium as a Predictor of Coronary Events in Four Racial or Ethnic Groups. N Engl J Med. Mar 27;358(13):1336-45.
- Blaha M, Budoff MJ, Shaw LJ, et al. Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging. 2009 Jun;2(6):692-700.
- Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. 2015 Oct 13;66(15):1657-68.
- Mortensen MB, Falk E, Li D, et al. Statin Trials, Cardiovascular Events, and Coronary Artery Calcification: Implications for a Trial-Based Approach to Statin Therapy in MESA. JACC Cardiovasc Imaging. 2018 Feb 1;11(2):221-30.
- Berman DS, Wong ND, Gransar H, et al. Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol. 2004 Aug 18;44(4):923-30.
- He ZX, Hedrick TD, Pratt CM, et al. Severity of coronary artery calcification by electron beam computed tomography predicts silent myocardial ischemia. Circulation. 2000 Jan 25;101(3):244-51.
- Chang SM, Nabi F, Xu J, et al. The coronary artery calcium score and stress myocardial perfusion imaging provide independent and complementary prediction of cardiac risk. J Am Coll Cardiol. 2009 Nov 10;54(20):1872-82.
- Bavishi C, Argulian E, Chatterjee S, Rozanski A. CACS and the Frequency of Stress-Induced Myocardial Ischemia during MPI: A Meta-Analysis. JACC Cardiovasc Imaging. 2016 May;9(5):580-9.
- Wong ND, Detrano RC, Diamond G, et al. Does coronary artery screening by electron beam computed tomography motivate potentially beneficial lifestyle behaviors? Am J Cardiol. 1996 Dec 1;78(11):1220-3.
- Taylor AJ, Bindeman J, Feuerstein I, et al. Community-based provision of statin and aspirin after the detection of coronary artery calcium within a community-based screening cohort. J Am Coll Cardiol. 2008 Apr 8;51(14):1337-41.
- Rozanski A, Gransar H, Shaw LJ, et al. Impact of coronary artery calcium scanning on coronary risk factors and downstream testing the EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) prospective randomized trial. J Am Coll Cardiol. 2011 Apr 12;57(15):1622-32.
- Raggi P, Shaw LJ, Berman, DS, Callister TQ. Prognostic value of coronary artery calcium screening in subjects with and without diabetes. J Am Coll Cardiol. 2004 May 5;43(9):1663-9.
- Kramer CK, Zinman B, Gross JL, et al. Coronary artery calcium score prediction of all cause mortality and cardiovascular events in people with type 2 diabetes: systematic review and meta-analysis. BMJ. 2013 Mar 25;346:f1654.
- Malik S, Budoff MJ, Katz R, et al. Impact of Subclinical Atherosclerosis on Cardiovascular Disease Events in Individuals with Metabolic Syndrome and Diabetes. The multi-ethnic study of atherosclerosis. Diabetes Care. 2011 Oct;34(10):2285-90.
- Agarwal, S. Cox AJ, Herrington DM, et al. Coronary calcium score predicts cardiovascular mortality in diabetes: diabetes heart study. Diabetes Care. 2013 Apr;36(4):972-7.
- Dabelea, D. Kinney G, Snell-Bergeon JK, et al. Effect of type 1 diabetes on the gender difference in coronary artery calcification: a role for insulin resistance? The Coronary Artery Calcification in Type 1 Diabetes (CACTI) Study. Diabetes. 2003 Nov;52(11):2833-9.
- Hoff JA, Quinn L, Sevrukov A, et al. The prevalence of coronary artery calcium among diabetic individuals without known coronary artery disease. J Am Coll Cardiol. 2003 Mar 19;41(6):1008-12.
- Malik S, Zhao Y, Budoff M, et al. Coronary Artery Calcium Score for Long-term Risk Classification in Individuals with Type 2 Diabetes and Metabolic Syndrome from the Multi-Ethnic Study of Atherosclerosis. JAMA Cardiol. 2017 Dec 1;2(12):1332-40.
- Valenti V, Hartaigh BÓ, Cho I, et al. Absence of Coronary Artery Calcium Identifies Asymptomatic Diabetic Individuals at Low Near-Term But Not Long-Term Risk of Mortality: A 15-Year Follow-Up Study of 9715 Patients. Circ Cardiovasc Imaging. 2016 Feb;9(2):e003528.
- Kronmal RA, McClelland RL, Detrano R, et al. Risk Factors for the Progression of Coronary Artery Calcification in Asymptomatic Subjects Results From the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2007 May 29;115(21):2722-30.
- Min JK, Lin FY, Gidseg DS, et al. Determinants of coronary calcium conversion among patients with a normal coronary calcium scan: what is the "warranty period" for remaining normal? J Am Coll Cardiol. 2010 Mar 16;55(11):1110-7.
- Wong ND, Nelson JC, Granston T, et al. Metabolic syndrome, diabetes, and incidence and progression of coronary calcium: the Multiethnic Study of Atherosclerosis study. JACC Cardiovasc Imaging. 2012 Apr;5(4):358-66.
- Wong ND, Sciammarella MG, Polk D, et al. The metabolic syndrome, diabetes, and subclinical atherosclerosis assessed by coronary calcium. J Am Coll Cardiol. 2003 May 7;41(9):1547-53.
- Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT /SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014 Feb 4;63(4):380-406.
- Yang L, Zhou T, Zhang R, et al. Meta-analysis: diagnostic accuracy of coronary CT angiography with prospective ECG gating based on step-and-shoot, Flash and volume modes for detection of coronary artery disease. Eur Radiol. 2014 Oct;24(10):2345-52.
- Opolski MP, Staruch AD, Jakubczyk M, et al. CT Angiography for the Detection of Coronary Artery Stenoses in Patients Referred for Cardiac Valve Surgery Systematic Review and Meta-Analysis. JACC CV Imaging. 2016 Sep;9(9):1059-70.
- Nørgaard BL, Leipsic J, Gaur S, et al. Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). J Am Coll Cardiol. 2014 Apr 1;63(12):1145-55.
- Min JK, Leipsic J, Pencina MJ, et al. Diagnostic accuracy of fractional flow reserve from anatomic CT angiography. JAMA. 2012 Sep 26;308(12):1237-45.
- Nørgaard BL, Hjort J, Gaur S, et al. Clinical Use of Coronary CTA-Derived FFR for Decision-Making in Stable CAD. JACC Cardiovasc Imaging. 2017 May 10(5):541-50.
- Min JK, Dunning A, Lin FY, et al. Age- and Sex-Related Differences in All-Cause Mortality Risk Based on Coronary Computed Tomography Angiography Findings Results From the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 Patients Without Known Coronary Artery Disease. JACC. 2011 Aug 16;58(8):849-60.
- Hulten EA, Carbonaro S, Petrillo SP, Mitchell JD, Villines TC. Prognostic value of cardiac computed tomography angiography: a systematic review and meta-analysis. J Am Coll Cardiol. 2011 Mar 8;57(10):1237-47.
- Hadamitzky M, Achenbach S, Al-Mallah M, et al.; CONFIRM Investigators. Optimized prognostic score for coronary computed tomographic angiography: results from the CONFIRM registry (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry). J Am Coll Cardiol. 2013 Jul 30;62(5):468-76.
- SCOT-HEART investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet. 2015 Jun 13;385(9985):2383-91.
- Hulten E, Bittencourt MS, Singh A, et al. Coronary artery disease detected by coronary computed tomographic angiography is associated with intensification of preventive medical therapy and lower low-density lipoprotein cholesterol. Circ Cardiovasc Imaging. 2014 Jul;7(4):629-38.
- Blair SN, Kohl HW 3rd, Paffenbarger RS Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA. 1989 Nov 3;262(17):2395-401.
- Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005 Feb 8;111(5):682-96.
- Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS. Heart-rate recovery immediately after exercise as a predictor of mortality. N Engl J Med. 1999 Oct 28;341(18):1351-7.
- Shaw LJ, Peterson ED, Shaw LK, et al. Use of a Prognostic Treadmill Score in Identifying Diagnostic Coronary Disease Subgroups. Circulation. 1998 Oct 20;98(16):1622-30.
- Alexander KP, Shaw LJ, Shaw LK, Delong ER, Mark DB, Peterson ED. Value of exercise treadmill testing in women. J Am Coll Cardiol. 1998 Nov 15;32(6):1657-64.
- Gulati M, Amsdorf MF, Shaw LJ, et al. Prognostic Value of the Duke Treadmill Score in Asymptomatic Women. Am J Cardiol. 2005 Aug 1;96(3):369-75.
- Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol. 2004 Mar-Apr;11(2):171-85.
- Nabi F, Chang SM, Xu J, Gigliotti E, Mahmarian JJ. Assessing risk in acute chest pain: The value of stress myocardial perfusion imaging in patients admitted through the emergency department. J Nucl Cardiol. 2012 Apr;19(2):233-43.
- Mahmarian JJ, Shaw LJ, Filipchuk NG, et al. A Multinational Study to Establish the Value of Early Adenosine Technetium-99m Sestamibi Myocardial Perfusion Imaging in Identifying a Low-Risk Group for Early Hospital Discharge After Acute Myocardial Infarction. J Am Coll Cardiol. 2006;48:2448-57.
- Giri S, Shaw LJ, Murthy DR, et al. Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease. Circulation. 2002 Jan 1;105(1):32-40.
- Acampa W, Cantoni V, Green R, et al. Prognostic value of normal stress myocardial perfusion imaging in diabetic patients: A meta-analysis. J Nucl Cardiol. 2014 Oct;21(5):893-902.
- Marwick TH, Case C, Sawada S, Vasey C, Short L, Lauer M. Use of stress echocardiography to predict mortality in patients with diabetes and known or suspected coronary artery disease. Diabetes Care. 2002 Jun;25(6):1042-8.
- van der Sijde JN, Boiten HJ, Sozzi FB, Elhendy A, van Domburg RT, Schinkel AFL. Long-Term Prognostic Value of Dobutamine Stress Echocardiography in Diabetic Patients With Limited Exercise Capability: A 13-year follow-up study. Diabetes Care. 2012 Mar;35(3):634-9.
- Greenwood JP, Maredia N, Younger JF, et al. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet. 2012 Feb 4;379(9814):453-60.
- Liu A, Wijesurendra RS, Liu JM, et al. Diagnosis of Microvascular Angina Using Cardiac Magnetic Resonance. J Am Coll Cardiol. 2018 Mar 6;71(9):969-79.
- Greenwood JP, Herzog BA, Brown JM, et al. Prognostic Value of Cardiovascular Magnetic Resonance and Single-Photon Emission Computed Tomography in Suspected Coronary Heart Disease: Long-Term Followup of a Prospective, Diagnostic Accuracy Cohort Study. Ann Intern Med. 2016 May 10;165:1-9.
- Zellweger MJ, Hachamovitch R, Kang X, et al. Threshold, incidence, and predictors of prognostically high-risk silent ischemia in asymptomatic patients without prior diagnosis of coronary artery disease. J Nucl Cardiol. 2009 Mar-Apr;16(2):193-200.
- Blumenthal RS, Becker DM, Moy TF, Coresh J, Wilder LB, Becker LC. Exercise thallium tomography predicts future clinically manifest coronary heart disease in a high-risk asymptomatic population. Circulation. 1996 Mar 1;93(5):915-23.
- Young LH, Wackers FJT, Chyun DA, et al. Cardiac Outcomes after Screening for Asymptomatic Coronary Artery Disease in Patients with Type 2 Diabetes: the DIAD study: a randomized controlled trial. JAMA. 2009 Apr 15;301(15):1547-55.
- O'Keefe JH Jr, Cordain L, Harris WH, Moe RM, Vogel R. Optimal low-density lipoprotein is 50 to 70 mg/dL: lower is better and physiologically normal. J Am Coll Cardiol. 2004 Jun 2;43(11):2142-6.
- Hsia J, MacFadyen JG, Monyak J, Ridker PM. Cardiovascular event reduction and adverse events among subjects attaining low-density lipoprotein cholesterol < 50 mg/dL with rosuvastatin. The JUPITER trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin). J Am Coll Cardiol. 2011 Apr 19;57(16):1666-75.
- Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008 Nov 20;359(21):2195-207.


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RPin wrote:Woohoo! I was the first to vote!
Krug wrote:I guess webscomicspace sounds rather... unambitious? Comicgen does have a more hip factor.
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Posted by Editor on 03/22/99
Happy Birthday To...
National Road Team member Sylvain Beauchamp.
Report From Italy
(courtesy Paul Kelly)
Howdy all, here is Sunday's race report:
Marini Victorious at the 39th G.P. San Giuseppe
Sunday March 21, 1999. Montecassiano (PE), Italy
Mirko Marini, a 24 year old rider of the L'Edile Rosa OK BABY Gaverina squad, took Sunday's 39th G.P. San Giuseppe with commanding style in an aggressive hilltop sprint, ahead of 3 breakaway companions. Their 45 km. break held strong on the wind battered and hilly Montecassiano circuit, fueled by the support of thousands of spectators who turned up to watch the classic. At a maximum gap of 50 seconds, the lead group concluded the fast UCI 1.6 International event 7 seconds ahead of Espoir World Champion Ivan Basso and the decimated field of 23 riders.
159 competitors started the event, but a selective climb and little room for recovery rang up a heavy toll for those less prepared for the furious pace. Nine laps of various loops over Montecassiano whittled away the weak - for the most part, the delegations of stranieri (non-Italian national and trade team athletes) who had come in hope of collecting a few UCI points. Looking for the reason behind the domestic charge of the top twenty, one had to look no further than the lead car - sitting shotgun was Giancarlo Montedori, part of the Italian Cycling Federation's team selection committee.
(I completed 5 grueling laps before being dropped for good - as was the case in last year's race. And here I thought that the new UCI/IOC drug regulations would slow things down a little bit! )
ELITA's Kim Langton sprints to victory in Sea Otter Sprinters Competition
(courtesy Dave Cathcart of Team Elita)
A weekend of challenging racing in the Monterey peninsula has ended and a new star on Team ELITA is born. Known more for her tactical savvy than blazing speed, Team ELITA's captain Kim Langton proved at the SRAM Sea Otter Classic that she is more than just a good team leader. Matched against an unbelievable Saturn powerhouse, Langton managed to wrestle away the coveted Green Jersey from Lyne Bessette and Anna Wilson with the support of her Team ELITA mates.
The Sea Otter's first stage, an 8km prologue, would define the shape of the race. Fresh back from a World Cup win in Sydney, Saturn's Anna Wilson would be the class of the field. One of the first starters, Wilson's time would never be matched and catapulted her into the leader's jersey for stage two. Team ELITA's best finish was a promising 11th from Cybil DiGuistini.
The highlight of the SRAM Sea Otter Classic was certainly the road race held on the roads of neighbouring Fort Ord. Its gut wrenching climbs and twisty descents would test the mettle of the world's best. Proof of this were the riders sliding out the back of the field on the first long climb - Linda Jackson of Timex and Jeannie Longo of France!! The pace of the first lap was kept high by a Saturn contingent that didn'' want to see anything get away. The only thing to get by them briefly was ELITA's Langton as she blazed around them to pick up the first sprinters points at the top of the longest climb. Kim managed to repeat this feat on the second and third laps before Saturn moved to the front to prepare for a bunch sprint. Saturn's train led out for the last 2 kilometres but obviously the rigours of the circuit had diminished them as three riders snuck by them for the sprint win - Karen Dunne of Voler, Marie Holjer of Lemond and Liz Emery of Celestial Seasonings. Team ELITA's contingent finished in the pack.
On the final day, Laguna Seca's famous F1 race track was the hurdle as the field tackled its many climbs 12 times. What's more, on alternating laps the field had to contest points sprints and time bonus sprints. Team ELITA would have their work cut out for them! At the bell for the first sprint, Team ELITA's red freight train was set up beautifully and Langton scooped the sprint ahead of Bessette and Wilson. The next sprint lap it was ELITA's Melanie Dorion who assisted Langton in thwarting the Saturn effort. On the third sprint it was Langton again, followed by Dorion. But the laps were taking their toll. Now that the jersey was locked up, we turned to survival mode for the finish. Fortunately, the sprints ended with 5 laps to go and the field cruised in behind an amazing Anna Wilson who took her second stage of the classic.
Jake Watson Memorial Page
With the help of Steve Fleury of Mountain Cycle, MTB Review has created a memorial web page for Jake Watson. It includes a poem written by Jake's Mom about this great loss. The page also allows visitors to post their condolences and sentiments which will all be forwarded to the Watson family.
Since we put this page up 2 days ago, over 70 people have posted their condolences on this page. I think this really captures the bond that exists between our fellow mountain bikers. We invite you to visit and celebrate the life of Jake Watson:
Setmana Catalana, Spain
Stage 1 - Lloret de Mar, 172 km
1. Marcel Wust (Ger) Festina-Lotus 4:31:57
2. Erik Zabel (Ger) Telekom at 0:20
3. Gian Matteo Fagnini (Ita) Saeco-Cannondale
4. Biagio Conte (Ita) Liquigas
5. Angel Edo (Esp) Kelme-Costa Blanca all s.t.
Paris to Ancaster Registration
Just a reminder that the Paris to Ancaster enduro is approaching, so you should get your registrations in. Go Here to register online.
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Coffee house at historical society Friday
The question being asked by the Westport Historical Society this week is: "How does an evening of wine, women and song (plus one brilliant young man) sound?"
Just lovely, said Westport singer-songwriter-guitarist Suzanne Sheridan and poet Drew Lamm, of Norwalk, who will entertain at "Coffee House at the Wheeler's" Friday, June 14.
The event will take place in the Westport Historical Society's Sheffer Gallery within the historic Wheeler House.
Joining the women on stage will be 16-year-old Cole Smith, of Wilton, who plays jazz/classical violin "like an angel," said Sheridan, a Clio Award-winner for her vocal work on the "Join the Pepsi People" advertising campaign of the 1970s.
On the program are vocal compositions by Sheridan, Joni Mitchell and Leonard Cohen. Wine and other refreshments will be served.
Sheridan, who also is a professional portrait photographer, said she will mix her own compositions with songs from her CD, "Suzanne Sheridan Sings Joni Mitchell and Leonard Cohen."
The CD, which includes Mitchell's "Chelsea Morning" and "Big Yellow Taxi," and Cohen's "Hallelujah," was recorded live at the Westport Unitarian Church's Voice Cafe.
The entertainer described her songs as "powerfully poetic" and sung with "passion and intensity."
More InformationCoffee House at the Wheeler's
Westport Historical Society, 25 Avery Place, Westport. Friday, June 14, 6 p.m. Reservations required. $10 donation at the door. 203-222-1424, www.westporthistory.org.
Sheridan, a Bronx, N.Y., native who has lived in Westport for about 20 years, said she is an avid supporter of the Westport Historical Society, for which she has photographed several of its annual garden tours.
She recently approached the society with the coffeehouse idea. The first was such a success that a total of four are planned at the moment.
This is the second concert in the series, with others slated for Oct. 11 and Nov. 22.
"I really love doing this and being connected with the historical society," Sheridan said.
Lamm will read from her poem series, "To Taste Life Twice," which takes its name from author Anais Nin, who wrote: "We write to taste life twice, in the moment and in retrospect."
"My poems are about ... discovering the `aha' in everyday life," Lamm writes. "They ... usually have a twist or a surprise. ... I write to have windows swing open, to see new views."
An educator and book author, Lamm also gives writing workshops, titled "Women Who Run with Pens."
"It's so civilized," said Sheridan, laughing, about the coffeehouse. "Really, it's wonderful. People come to listen to the music," to enjoy the experience of an evening out.
"The timing is great, too, so that the audience can go to dinner afterward. What I enjoy most is being together with the audience. An event like this is a great community-builder."


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Would a diabetes drug also protect against breast cancer?
One of the most commonly used medications to control diabetes may also have positive effects against cancer cell proliferation, as show in research done at the Center for Research and Advanced Studies (CINVESTAV) in Mexico.
The study led by José Eduardo Pérez Salazar examines the protective effects of metformin in the role of growth and migration of cancer cells in the body (metastasis), especially those related to breast cancer.
Research in the Department of Cell Biology also analyzes the effects of oleic and linoleic acids (found in edible oils) as a kind of catalyst for the cancer cells to spread in the body.
According to Perez Salazar, it was found that cancer cells get "addicted to insulin", so in the case of overweight women with diabetes who have no control over the disease, the risk of developing breast cancer and metastasis increases.
"High insulin levels in the body are related indirectly to the formation of malignant breast tumors, but only in the case of women, in the case of men this cancer develops primarily by heredity "said the expert from the National System of Researchers.
He also explained that in Mexico there is a higher prevalence of the disease characterized by insulin resistance than for the lack of production of this hormone by the organism, meaning that the prevalence of breast cancer in women living with diabetes is higher.
However, it has been seen that women who take metformin to control insulin levels have a protective factor against breast cancer. "The drug prevents insulin resistance in the body, so that it is properly metabolized and cannot be acquired by cancer cells, which then spread across the body" said Perez Salazar.
"In people with insulin resistance, their body produces more of this hormone, which is not used and brings consequences due to the high levels of it. Metformin is what makes the receivers work better, avoiding the high levels of the hormone and this is what protecting against cancer," said the researcher.
The work done so far is based on laboratory tests using cellular tissue, but the research group at Cinvestav joined with the Juarez Hospital of Mexico City, plans to conduct tests with human tissue obtained by biopsies, therefore having greater certainty about the results.


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∅ 57 x H 74 cm
Beautiful natural materials adorning refined iron frames: that is the new collection of bistro and side tables. Tops in Italian marble or Terrazzo are the perfect canvas for these new eyecatchers in the range. The tops are available in various sizes and combined according to own taste.
In 1987, brothers Axel and Serge Van den Bossche decided to take over their mother's business under the name of Serax.


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Nick Paterson-Jones necesitaba un nuevo diseño de botón o icono y lanzó un concurso de diseño en 99designs.
Un ganador ha sido elegido entre 69 diseños de 14 diseñadores freelance.
We are developing a series of consumer products which contain a unique antimicrobial formula that cleans and disinfect better than any existing products on the market.
It's effective to the very highest level; kills 99.9999% of germs, and is also proven to kill viruses and superbugs including MRSA, E.coli, Norovirus, Salmonella, Bird flu, Swine flu and more.
‣ Fast acting; eliminates bacteria within 30 seconds
‣ Long lasting; remains effective for upto 6 months
‣ Environmentally friendly, non-bleach, non-irritant, non-taint, non-flammable, non-toxic, skin safe formula
‣ Flexible formula; can be used across many applications of household cleaner and can be combined with fragrances, insect repellants, silver nano etc.
The brand will be called HyGenie.
All the products will be aimed at women, and will be positioned alongside all the traditional cleaning products - for the kitchen, around the house and for personal hygiene.
Potential branded products include...
‣ Surface spray
‣ Surface wipes
‣ Air freshener
‣ Floor cleaner
‣ Bath cleaner
‣ Fabric freshener
‣ Fabric conditioner
‣ Fabric detergent
‣ Carpet cleaner
‣ Dishwasher tablets
‣ Hand sanitiser
‣ Travel towels
‣ Pen spray
‣ Cleansing soap
‣ Anti-viral tissues
‣ Anti-viral kitchen roll
‣ Anti-viral toilet roll
‣ Pet deodoriser
‣ Pet blankets
We have trademarked the name HyGenie and have attached some reference files. However, we now want to develop a Genie character (or a family of Genies) as a visual icon to represent a short cut for the brand, and to help recognition across different languages.
We've attached a pdf with reference for the brand and some of the key consumer messages. We've also provided reference of characters that provide inspiration.
Further reference is available on request to email@example.com


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I'm twice born, once in 7-something
Once as the resurrection of honorable function
Been shoveling coal as the engine's doctor
Long enough to see my silhouette acquire a permanent kink in the posture
The maintenance of icicle spirit by the warmth of true endearment
Was, is, and forever will be a luxury
I'm a sovereignty columnist fathering doom doc*ment
Curséd version of a certain Virgin Mary womb occupant
[Interlude (spoken):]
(Oh my Lord, what have I gotten myself into?
Seems like I woke up in yesterday again
Another day, another dream…)
[Verse One:]
I know swamp rats who never suckled oxygen purification
Sure as blurry mayhem had 'em spent (Zen freeze)
Stuck until my friend leaves, puppet for the plummet committee
Sputtering bum, numb enough to stomach the city
Who's that hugging the silhouetted willows where the hill's crest pan out?
Barter candy-coated crab apples and sugar-dipped death hand outs
I got a plan, I'll tourniquet my quest
Then feed a needle in the bad ending to mute the mess
When patience gallops with absentee ballots, I shove in the button
Strutting to exhibit mankind's hostility function with a (heave)
Paling in comparison to Matthias, Goliath
Lies the rickety frame of the wicked silence
I died the day my nameless creator and I bumped eyelids
Swear to Christ we saw the same thing for a second (What's that?)
The grand mosaic depicting historical glory of the legend
Nursed me through the time stick-and-stone mixers hexed my fertile crescent
Now all's well, I'm laughing on the inside I swear
Just trying to keep my head above red tide despair
My imperfections pair off with buddy system symmetrics morbidly
So every second of discontent's logged accordingly
Now let's turn mummy subtle perfection to preserve glory condition
And pray for the day a starchild tugs the ribbon
Better land a two-hand grip on that spoonful-of-sugar medical chaser
Credible crazer antidote's terrible, taste her
Barter with a Stolen Soul Peddler, pigeon backed feather pen
Never said a grin implied health
Consider me a mobile advertisement for that hybrid blend of fabrics I deemed practical
Now is you is or is you ain't compatible?
I feel the wind in my opinions
Plus hyper clutched to crush one's gingerbread tenement awful
It's like the day the great oak met the sawmill
A lifeline of spectacular expansion meets the reaper at the hand of one man's tantrums
My friend's got a book about dreams. I look and laugh
I dreamed a book about my friends and still can't decipher the half
Chatterbox. Now let a soothsayer major cater to a kinked breed
Battered on the brink of disease
(Well) I am (skin and bones), I am (sin and poems), I am (tin and chrome)
Grin and groans, f*ck it, I'm tinted quinacridone
Blow the petals off a dandelion trying to make my little gypsy blush
And felt as if I'd actually accomplished something
Fortify the bullies, let a joke soak in the treatment
Sit and watch the percentages teeter on the evening
Caught a ghost up in the fuselage seconds before the cog dropped to the sticks
And stared him down until he fixed it
Oh, fashion? It's cool and all, but what about God?
(Oh God? well he's the man, but I mean, what about reading?)
What like novels? Man, that don't hold my attention. How about television?
(Television hurts my brain. How about walking in the rain?)
Oh I hate walking. It's boring. How about some old-fashioned gone fishin'?
(Yeah, fishing's great, but I just hate hooking the bait. Let's dance)
Nah, I got two left feet plus motion sickness. How about breakfast?
(Man I'm hungry, but that means I'mma have to borrow some money)
Let's fly a kite. (Let's burn the generals). Let's sell lemonade. (Let's drink)
Let's poke a hole inside the tugboat, ease on back, and watch it sink
(Nah, let's fail a pupil once a year at random to shake the academy)
Casually note the blossom of phantom alignment. (Strategy)
[Verse Two]
Well, I'll make a waterfall out of water and autumn
Sorta caught 'em when their guards mimicked the vintage knuckle drag sagged in the coffin
I affiliate my rag dummy appearance with a most cohesive spirit
Cried a river yesterday, ain't shed a tear since
'Gimmie gimmie', crooned the Old Yeller community cartoon
The carousel ballooned extravagant. Aware
Inviting, yet I'm sworn to adamant manner and saddle in worn head, thorax, and abdomen
To primitive horseback galloping
My index finger's dressed in my talisman
Branded up in the jackal skin, I spy mark of the product
Well, one must pardon ye old common sheep detour weaving graceful through the prime directive column
Pray the virus retreats to allotted phylum
Beanstalk with a fiend walk and my name is mud
But that's got a ring to it, so my soil welcomes the flood
I walk as God's practical joke on man, practically broke
And if they raise my rent again, I'll spend my nights practically soaked
Who spit silk dimension through the noose looped by the rafters?
After lack of reasoning, dead 'em. (It's like "three, two, one, bedlam")
Ooh, I'm hung. I clung to hope, but see you in hell
I'll be that clear blue icicle that simply refused to melt
Sturdy iron grillage, tin can skeleton
Skull of a thousand dilapidated dream remnants
Here to convict based on a tin bucket of evidence
That stairway to heaven's merely a legend so the peasants dream well
(Blesséd peasants, blesséd peasant dream well
Every blesséd peasant's just trying to dream well…)


text:
When you've got the back of the recliner in the resting position, its a huge hassle to adjust back to the sitting position for watching TV. Now you can save your neck and maintain a perfect viewing angle for TV or reading with this power headrest recliner. The same gentle power motion that lets you customize the position of your back and legrest allows you to adjust the headrest angle to better cradle your body.
Sitting up and getting out of the chair is easier with the ability to put the footrest away with the simple press of a button instead of having to slam it shut. Sit far back to completely recline or stop at any point before then to get the most comfortable position for your body with power motion.
Gently rock back and forth from the comfort of your reclining chair with a rocker base. The base allows you to gently move as you sit and watch your favorite TV programs or as you read a book after a long day. Add a rocker to your nursery as a comfortable place to rock your baby and cherish those precious moments with your little one while sitting comfortably.
Since you need to plug in your power recliner anyway, it just makes sense that they are now available with built-in USB charging ports for powering up your phones and devices. The USB port is located on the arm right next to the power activation button, so it's easy to reach when you're relaxing and want to power up your phone or stream video on your tablet.
BioH Polyols are made from soybeans, a renewable resource. They replace a portion of the petroleum in your cushions, reducing waste making a positive impact on the environment. You will not notice a difference in the way your cushions feel, but you will feel good making a more sustainable decision.
You can bring the ultimate lounging experience into your own home with this recliner. While casual in design, you'll notice these pillow arms are much more understated than you typically see in similar pieces, making it the perfect recliner for those who prefer more contemporary elements in their home. The Complete Comfort Control feature adds a home button, memory setting, and Bluetooth app, making it easier than ever to reach utmost relaxation in your home. Additionally, the built-in USB port lets you charge and use your devices without the additional, obnoxiously long chords laying around your living room.
The Nola Casual Power Rocking Recliner with Power Headrest/Lumbar and USB Port by Klaussner at Find Your Furniture in the area. Product availability may vary. Contact us for the most current availability on this product.
You've sat in them each time you're at a furniture store, you know how comfortable they are, and you know how much you would love to have one in your home. It's time to treat yourself with an ultra-comfortable recliner, you deserve it. A more subtle look with the slopped pillow arms makes this piece perfect for someone that tends to favor contemporary design but still wants an exceptional piece of furniture for relaxation. With top-of-the-line features and fabric options available, kicking-back in style has never been easier.
The Nola collection is a great option if you are looking for Casual furniture in the area.
Browse other items in the Nola collection from Find Your Furniture in the area.
This item has been tagged as: Recliner, Reclining Chair, Glider Rocker Recliner, Rocking Recliner, High Leg Reclining Chair, Lift Recliner, Pop - Up Recliner, Reclining Chair and Ottoman, Motion Recliner, Standard Recliner, No - Rock Recliners, Wall Recliners, Easy Chair, Living Room Chair, Living Room Furniture, TV Chair, Chair Recliner, Massage Chair, Massage Recliner, Swivel Rocker Recliner, Massaging Recliner
Nothing on this page may be copied or reproduced without explicit permission.


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"All-Glass Look" Frames
Fits 2007+ Models
28% Dark Gray Glass
No Layout Required, Use OEM Stampings for Cut Line
The all-new Sprinter now has CRL "All Glass
Look" Sprinter Van Windows to complement this great design. Our windows are
configured to fit within the OEM stampings and provide a customized OEM look.
This great feature eliminates the time consuming efforts of laying out where the
window will be installed. Just line it up to cut, starting on the upper inner
dimple and follow along the OEM stamping.
Outside Frame Dimensions: 25-15/16 in x 23-5/16
in (659 x 5929 mm)
Cut Out Dimensions:
24-11/16 in x 22-1/16 in (627 x 560 mm)
Clamp Ring:
1/8 in (3.2 mm)


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Despite Lawsuit and Numerous Glitches, New Jersey Voted, but It Wasn't Pretty
Email in-boxes filled up and sent back bounces. There was at least one lawsuit. And the whole thing still hasn't finished because election officials in several counties were overwhelmed. But New Jersey Gov. Chris Christie says he is "satisfied" with how Tuesday's impromptu experiment in email voting went.
"Given the amount of time we had to deal with what we had to deal with I'm really satisfied with how it went," Christie said at a press conference today, which was covered by the Bergen Record. He said the problems that were reported were "scattered and anecdotal."
County voting offices have until Friday to process all the electronic voting requests they've received, and then voters will have until 8 pm Friday to get their final ballots in. All the late ballots probably won't be counted and properly recorded until sometime next week.
In the end it will make very little difference. New Jersey wasn't exactly competitive in the presidential race — President Obama carried it by a 58-41 margin and easily salted away its 14 electoral votes. And none of its congressional races were any closer than seven or eight percentage points. Several local elections, like one in Morris County where the margin was only four with more than 20,000 mail-in ballots yet to count, were too close to call.
It is from those that there will likely arise some recounts and lawsuits. Last night I talked with Robert Brownstone, a lawyer at Fenwick & West in San Francisco who specializes in technology and electronic discovery issues. He says the way New Jersey rushed into all this without any time to prepare for concerns like data security and privacy, or even having email in-boxes with enough storage capacity to handle the increased load, are going to be grounds for numerous complaints. "I heard of at least one local election official who told people to send requests to his personal Hotmail account," Brownstone told me.
New Jersey officials were trying to make the rules as flexible as possible in the wake of Hurricane Sandy. "On the other hand, the more desirable approach would be to tell people to fill out provisional paper ballots anywhere in the state," Brownstone said. Electronic votes are too easy to copy and send over and over, he said. "I think they're going to end up with a lot of extra votes that they wouldn't have otherwise had." And while some of those extra votes may have been intentional and therefore fraudulent, most of them, he said, will be the result of mistakes.
So while all the national races are settled, lots of the local races will probably have long, drawn-out recount processes — followed by lawsuits.


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This office prank—probably created by Satan himself—is so evil that it would make me punch the screen. Heck, even the Dalai Lama would get a hammer and destroy his computer, foaming at the mouth. Watch how to do it.
See what I mean? SEE? Can you imagine the face of your victim? I can. And that's why I'm grinning. [Acidcow]


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LibreOffice 3.5 was released few days back with loads of features and improvements. Most bragged about feature should be capability to read visio diagrams. You can read the full list of features here. And here are some interesting features:
- Better UI for header/footer handling. Easily add header or footers. Quickly see what is edited with new changing text boundaries. Quickly edit or remove headers and footers without going through page styles formatting. (Cédric Bosdonnat)
- New faster built-in grammar checker for English and several other languages. (László Németh)
- New multi-line input bar in Calc. The arrow-control at the end of the toolbar allows to switch this on/off. (Anurag Jain, Noel Power)
- Import filter for Microsoft Visio documents. (Fridrich Štrba, Eilidh McAdam, Valek Filippov)
- Custom Shapes import was greatly enhanced, many bugs were fixed and new presets implementation added. (Radek Doulik)
- and many more…
Related articles
- The Bright Future of LibreOffice (pcworld.com)
- LibreOffice 3.5 Released (news.slashdot.org)
- Jono Bacon: Kudos, LibreOffice (jonobacon.org)
- Intel backs Libre Office by joining The Document Foundation (thetechscoop.net)
Link to this post!


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Pediatric Surgery locum tenens jobs in Michigan are constantly in demand in a seemingly always underserved healthcare system. Enjoy your Pediatric Surgery assignment in the beautiful state of Michigan. To get started, just simply browse below. Apply today, and pack your bags for your exciting next Pediatric Surgery job tomorrow. Why wait? Locum Jobs Online is your #1 source for landing your dream assignment.