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Coronary artery bypass surgery
Coronary artery bypass surgery, also known as coronary artery bypass graft (CABG, pronounced "cabbage") surgery, and colloquially heart bypass or bypass surgery, is a surgical procedure to restore normal blood flow to an obstructed coronary artery. A normal coronary artery transports blood to and from the heart muscle itself, not through the main circulatory system.
Coronary artery bypass surgery | |
Early in a coronary artery bypass operation, during vein harvesting from the legs (left of image) and the establishment of cardiopulmonary bypass by placement of an aortic cannula (bottom of image). The perfusionist and heart-lung machine are on the upper right. The patient's head (not seen) is at the bottom. | |
Other names | Coronary artery bypass graft |
MeSH | D001026 |
MedlinePlus | 002946 |
There are two main approaches. In one, the left internal thoracic artery, LITA (also called left internal mammary artery, LIMA) is diverted to the left anterior descending branch of the left coronary artery. In this method, the artery is "pedicled" which means it is not detached from the origin. In the other, a great saphenous vein is removed from a leg; one end is attached to the aorta or one of its major branches, and the other end is attached to the obstructed artery immediately after the obstruction to restore blood flow.
CABG is performed to relieve angina unsatisfactorily controlled by maximum tolerated anti-ischemic medication, prevent or relieve left ventricular dysfunction, and/or reduce the risk of death. CABG does not prevent myocardial infarction (heart attack). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass. However, two alternative techniques are also available, allowing CABG to be performed on a beating heart either without using the cardiopulmonary bypass, a procedure referred to as "off-pump" surgery, or performing beating surgery using partial assistance of the cardiopulmonary bypass, a procedure referred to as "on-pump beating" surgery. The latter procedure offers the advantages of the on-pump stopped and off-pump while minimizing their respective side-effects.
CABG is often indicated when coronary arteries have a 50 to 99 percent obstruction. The obstruction being bypassed is typically due to arteriosclerosis, atherosclerosis, or both. Arteriosclerosis is characterized by thickening, loss of elasticity, and calcification of the arterial wall, most often resulting in a generalized narrowing in the affected coronary artery. Atherosclerosis is characterized by yellowish plaques of cholesterol, lipids, and cellular debris deposited into the inner layer of the wall of a large or medium-sized coronary artery, most often resulting in a partial obstruction in the affected artery. Either condition can limit blood flow if it causes a cross-sectional narrowing of at least 50%.
There are many variations in terminology, in which one or more of "artery", "bypass" or "graft" is left out. The most frequently used acronym for this type of surgery is CABG (pronounced 'cabbage'),[1] pluralized as CABGs (pronounced 'cabbages'). Initially the term aortocoronary bypass (ACB) was more popularly used to describe this procedure.[2] CAGS (coronary artery graft surgery, pronounced phonetically) should not be confused with coronary angiography (CAG).
Number of arteries bypassed
The terms single bypass, double bypass, triple bypass, quadruple bypass and quintuple bypass refer to the number of coronary arteries bypassed in the procedure. In other words, a double bypass means two coronary arteries are bypassed (e.g., the left anterior descending (LAD) coronary artery and right coronary artery (RCA)); a triple bypass means three vessels are bypassed (e.g., LAD, RCA and left circumflex artery (LCX)); a quadruple bypass means four vessels are bypassed (e.g., LAD, RCA, LCX and first diagonal artery of the LAD) while quintuple means five. Left main coronary artery obstruction requires two bypasses, one to the LAD and one to the LCX.
A coronary artery may be unsuitable for bypass grafting if it is small (< 1 mm or < 1.5 mm), heavily calcified, or located within the heart muscle rather than on the surface. A single obstruction of the left main coronary artery is associated with a higher risk for a cardiac death and usually receives a double bypass.
The surgeon reviews the coronary angiogram prior to surgery and identifies the number of obstructions, the percent obstruction of each, and the suitability of the arteries beyond the obstruction(s) as targets. The presumed number of bypass grafts needed as well as the location for graft attachment is determined in a preliminary fashion prior to surgery, but the final decision as to number and location is made during surgery by direct examination of the heart.
- The 2004 ACC/AHA CABG guidelines state CABG is the preferred treatment for:[3]
- Disease of the left main coronary artery (LMCA).
- Disease of all three coronary arteries (LAD, LCX and RCA).
- Diffuse disease not amenable to treatment with a PCI.
- The 2005 ACC/AHA guidelines further state that CABG is the preferred treatment with other high-risk patients such as those with severe ventricular dysfunction (i.e. low ejection fraction), or diabetes mellitus.[3]
- Bypass surgery can provide relief of angina when the location of partial obstructions precludes improving blood flow with stents.
- There is no survival benefit with bypass surgery vs. medical therapy in stable angina patients.
- Bypass surgery does not prevent future myocardial infarctions.[4]
Age per se is not a factor in determining risk vs benefit of CABG.[5]
Prognosis following CABG depends on a variety of factors, and successful grafts typically last 8–15 years. In general, CABG improves the chances of survival of patients who are at high risk (generally triple or higher bypass), though statistically after about five years the difference in survival rate between those who have had surgery and those treated by drug therapy diminishes. Age at the time of CABG is critical to the prognosis, younger patients with no complicating diseases doing better, while older patients can usually be expected to suffer further blockage of the coronary arteries.[6]
Veins that are used either have their valves removed or are turned around so that the valves in them do not occlude blood flow in the graft. External support may be placed on the vein prior to grafting into the coronary circulation of the patient. LITA grafts are longer-lasting than vein grafts, both because the artery is more robust than a vein and because, being already connected to the arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the left anterior descending coronary artery (LAD) because of its superior long-term patency when compared to saphenous vein grafts.[7][8]
Results compared to stent placement
CABG or stent placement is indicated when medical management - anti-anginal medications, statins, antihypertensives, smoking cessation, and /or tight blood sugar control in diabetics - do not satisfactorily relieve ischemic symptoms.
- Both PCI and CABG are more effective than medical management at relieving symptoms,[9] (e.g. angina, dyspnea, fatigue).
- CABG is superior to PCI for some patients with multivessel CAD[10][11]
- The Surgery or Stent (SoS) trial was a randomized controlled trial that compared CABG to PCI with bare-metal stents. The SoS trial demonstrated CABG is superior to PCI in multivessel coronary disease.[10]
- The SYNTAX trial was a randomized controlled trial of 1800 patients with multivessel coronary disease, comparing CABG versus PCI using drug-eluting stents (DES). The study found that rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the DES group (17.8% versus 12.4% for CABG; P=0.002).[11] This was primarily driven by higher need for repeat revascularization procedures in the PCI group with no difference in repeat infarctions or survival. Higher rates of strokes were seen in the CABG group.
- The FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus—Optimal Management of Multivessel Disease) trial will compare CABG and DES in patients with diabetes. The registries of the nonrandomized patients screened for these trials may provide as much robust data regarding revascularization outcomes as the randomized analysis.[12]
- A study comparing the outcomes of all patients in New York state treated with CABG or percutaneous coronary intervention (PCI) demonstrated CABG was superior to PCI with DES in multivessel (more than one diseased artery) coronary artery disease (CAD). Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent. Patients undergoing CABG also had lower rates of repeat revascularization.[13] The New York State registry included all patients undergoing revascularization for coronary artery disease, but was not a randomized trial, and so may have reflected other factors besides the method of coronary revascularization.
- A meta-analysis with over 6000 patients showed that coronary artery bypass was associated with lower risk for major adverse cardiac events compared to drug-eluting stenting. However, patients had a higher risk of stroke events.[14]
A 2018 meta-analysis with over 4000 patient cases found hybrid coronary revascularization (LIMA-to-LAD anastomosis combined with percutaneous stents at other atherosclerotic sites) to have significant advantages compared with conventional CABG. Reduced incidence of blood transfusion, reduced hospital stay duration and reduced intubation duration were all reported. In contrast, HCR was found to be significantly more expensive compared to CABG.[15]
CABG associated
- Postperfusion syndrome (pumphead), a transient neurocognitive impairment associated with cardiopulmonary bypass. Some research shows the incidence is initially decreased by off-pump coronary artery bypass, but with no difference beyond three months after surgery. A neurocognitive decline over time has been demonstrated in people with coronary artery disease regardless of treatment (OPCAB, conventional CABG or medical management). However, a 2009 research study suggests that longer term (over 5 years) cognitive decline is not caused by CABG but is rather a consequence of vascular disease.[16] Loss of mental function is a complication of bypass surgery in elderly people, and might influence procedure cost benefit considerations.[17] Several factors may contribute to immediate cognitive decline. The heart-lung blood circulation system and the surgery itself release a variety of debris, including bits of blood cells, tubing, and plaques. For example, when surgeons clamp and connect the aorta to tubing, resulting emboli block blood flow and cause mini strokes. Other heart surgery factors related to mental damage may be events of hypoxia, high or low body temperature, abnormal blood pressure, irregular heart rhythms, and fever after surgery.[18]
- Nonunion of the sternum; internal thoracic artery harvesting increases the sternum devascularization risk.[19]
- Myocardial infarction due to embolism, hypoperfusion, or graft failure. While remote ischaemic preconditioning (RIPC) reduces the cardiac troponin T (cTnT) release measured at 72 hours after surgery and cardiac troponin I (cTnI) release measured at 48 hours and 72 hours after surgery, it does not reduce reperfusion injury in people undergoing cardiac surgery.[20]
- Late graft stenosis, particularly of saphenous vein grafts due to atherosclerosis causing recurrent angina or myocardial infarction.[21]
- Acute renal failure due to embolism or hypoperfusion.[22][23]
- Stroke, secondary to embolism or hypoperfusion.[24]
- Vasoplegic syndrome, secondary to cardiopulmonary bypass and hypothermia
- Graft failure: grafts last 8–15 years, and then need to be replaced.
- Pneumothorax: An air collection around the lung that compresses the lung[23]
- Hemothorax: Blood in the space around the lungs
- Pericardial tamponade: Blood collection around the heart that compresses the heart and causes poor body and brain perfusion. Chest tubes are placed around the heart and lung to prevent this. If the chest tubes become clogged in the early post operative period when bleeding is ongoing this can lead to pericardial tamponade, pneumothorax or hemothorax.
- Pleural effusion: Fluid in the space around the lungs. This can lead to hypoxia which can slow recovery.
- Pericarditis
- Lower extremity edema, extravasation, inflammation, and eccymoses from vein harvest; entrapment of up to 9 pounds (4.1 kg) of fluid in the extremity is common. This is managed with a thigh length compression stocking, elevation of the limb, and early and frequent slow walking; as well as avoidance of standing in place, sitting, and bending the leg at the knee more than a few degrees.
Open heart surgery associated
- Post-operative atrial fibrillation and atrial flutter.[25]
- Anemia - secondary to blood loss, plus the anemia of inflammation, inflammation being inevitable with opening the chest plus harvesting of leg vein(s) for grafting. A fall in the hemoglobin from normal preoperative levels (e.g. 15) to postoperative levels of 6 to 10 are inevitable. There is no benefit from transfusions until the hemoglobin falls below 7.5.[26] Institutions should establish protocols to ensure transfusions are not given unless the hemoglobin falls below 7.5 without some additional compelling reason(s).[27]
- Delayed healing or refracture of sternum - the sternum is bifurcated logitudinally (a median sternotomy) and retracted to access the heart. Failure to follow "sternal precautions" following surgery could result in delayed healing or refracture of the sternum which was sutured at the closure of the chest wound:
- Hold a pillow against the chest whenever getting out of or into a chair or bed; or coughing, sneezing, blowing nose, or laughing, in order to oppose the intrathoracic outward force created by these activities on the healing sternum.
- Avoid using the pectoral muscles, such as by pushing on the chair arms to assist one's self out of a chair, or by using the arms to assist in sitting down. Proper standing technique is to rock three times in the chair and then stand to provide momentum for moving the center of gravity from the sitting to the standing position. Proper sitting technique is to slowly lower the bottom toward the chair seat using gluteus and quadriceps muscles ("legs only") without grabbing the chair arms. Second, patients should avoid lifting objects utilizing the pectoral muscles: carrying light objects with arms extended down at sides, and lifting light objects with the elbows pressed to the chest and using the biceps, are acceptable. Also, avoid using the arms overhead.
- Avoid sitting in the car front seat (no driving) for at least four weeks: the explosion of the deployment of an airbag could refracture the sternal union.
General surgery associated
- Infection at incision sites
- Sepsis
- Deep vein thrombosis
- Anesthetic complications such as malignant hyperthermia
- Keloid scarring
- Chronic pain at incision sites
- Chronic stress related illnesses
- The patient is brought to the operating room and moved onto the operating table.
- An anaesthetist or anesthesiologist places intravenous and arterial lines and injects an analgesic, usually fentanyl, intravenously, followed within minutes by an induction agent (usually propofol or etomidate) to render the patient unconscious.
- An endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General anaesthesia is maintained with an inhaled volatile anesthetic agent such as isoflurane.
- The chest is opened via a median sternotomy and the heart is examined by the surgeon.
- The bypass grafts are harvested – frequent vessels are the internal thoracic arteries, radial arteries and saphenous veins. When harvesting is done, the patient is given heparin to inhibit blood clotting.
- In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart.
- In the case of "on-pump" surgery, the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary bypass (CPB) normally instructing the perfusionist to "Go on pump". Once CPB is established, there are two technical approaches: either the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver cardioplegia with a cooled potassium mixture to stop the heart and slow its metabolism or performing bypasses on beating state (on-pump beating).
- One end of each vein graft is sewn on to the coronary arteries beyond the obstruction and the other end is attached to the aorta or one of its branches. For the internal thoracic artery, the artery is severed and the proximal intact artery is sewn to the LAD beyond the obstruction. Aside the latter classical approach, there are emerging techniques for construction of composite grafts as to avoiding connecting grafts on the ascending aorta (Un-Aortic) in view of decreasing neurologic complications.
- The heart is restarted by removing the aortic cross clamp; or in "off-pump" surgery, the stabilizing devices are removed. In cases where the aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating.
- Once the grafts are completed distally and proximally, the patient is rewarmed to a normal temperature and the heart and other pressures are normal to support coming off the bypass machine, weaning off the bypass machine begins.
- The perfusionist makes sure they have enough volume to come off bypass, confirms that anesthesia is ventilating the patient, confirms that vacuum assist is off (if used), and vocalizes each step in the weaning process to the surgeon and anesthesia. Volume can be given to the patient through the arterial line of the bypass machine while the aortic cannula is still in.
- Protamine is given to reverse the effects of heparin.
- Chest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs.
- The sternum is wired together and the incisions are sutured closed.
- The patient is moved to an intensive care unit (ICU) or cardiac universal bed (CUB) to recover. Nurses in the ICU monitor blood pressure, urine output, respiratory status, and chest tubes for excessive or no drainage.
- After awakening and stabilizing in the ICU for 18 to 24 hours, the person is transferred to the cardiac surgery ward. If the patient is in a CUB, equipment and nursing is "stepped down" appropriate to the patient's progress without having to move the patient. Vital sign monitoring, remote rhythm monitoring, early ambulation with assistance, breathing exercises, pain control, blood sugar monitoring with intravenous insulin administration by protocol, and anti-platelet agents are all standards of care.
- The patient without complications is discharged in four or five days.
Minimally invasive technique
Alternate methods of minimally invasive coronary artery bypass surgery have been developed. Off-pump coronary artery bypass (OPCAB) is a technique of performing bypass surgery without the use of cardiopulmonary bypass (the heart-lung machine).[28] Avoidance of aortic manipulation may be achieved through the "anaortic" or no-touch OPCAB technique, which has been shown to reduce stroke and mortality compared to on-pump CABG.[29] Further refinements to OPCAB have resulted in minimally invasive direct coronary artery bypass surgery (MIDCAB), a technique of performing bypass surgery through a 5 to 10 cm incision.[30]
Hybrid Coronary Revascualrisation, where the LIMA-to-LAD anastomosis is combined with percutaneous stents in other atherosclerotic sites, has been shown to have significant advantages compared to conventional CABG, including a decrease in the incidence of blood transfusion, and a reduced intubation time. A 2018 meta-analysis has however demonstrated a greater financial cost when compared to conventional CABG.[31]
Choice of source of grafts
The choice of vessel(s) is highly dependent upon the particular surgeon and institution. Typically, the left internal thoracic artery (LITA) (previously referred to as left internal mammary artery or LIMA) is grafted to the left anterior descending artery and a combination of other arteries and veins is used for other coronary arteries.[32] The great saphenous vein from the leg is used approximately in 80% of all grafts for CABG.[33] The right internal thoracic (mammary) artery (RITA or RIMA) and the radial artery from the forearm are frequently used as well; in the U.S., these vessels are usually harvested either endoscopically, using a technique known as endoscopic vessel harvesting (EVH), or with the open-bridging technique, employing two or three small incisions. The right gastroepiploic artery from the stomach is infrequently used given the difficult mobilization from the abdomen.
Follow up
- Acute - patients without complications are typically seen 3–4 weeks post operatively, at which time driving may be resumed and formal cardiac rehabilitation begun to increase aerobic endurance and muscular strength.
- Chronic -
- a cardiac stress test at five years is recommended, even in the absence of cardiac symptoms.[34][35]
- an intensive medical regimen including statins, aspirin, and aerobic exercise is essential to delaying the progression of plaque formation in both the native and grafted vessels.
- Illustration depicting coronary artery bypass surgery (double bypass)
- Illustration of Single bypass
- Illustration of Double bypass
- Illustration of Triple bypass
- Illustration of Quadruple bypass
Number performed
CABG is one of the most common procedures performed during U.S. hospital stays; it accounted for 1.4% of all operating room procedures performed in 2011.[36] Between 2001 and 2011, however, its volume decreased by 46%, from 395,000 operating procedures performed in 2001 to 213,700 procedures in 2011.[37]
Between 2000 and 2012, the number of CABG procedures carried out decreased across the majority of OECD countries. However, there remained substantial variation in the rate of procedures, with the U.S. carrying out four times as many CABG operations per 100,000 people as Spain.[38] These differences do not appear to be closely related to the incidence of heart disease, but may be due to variation in financial resources, capacity, treatment protocols and reporting methods.[39]
- The first coronary artery bypass surgery was performed in the United States on May 2, 1960, at the Albert Einstein College of Medicine-Bronx Municipal Hospital Center by a team led by Robert H. Goetz and the thoracic surgeon, Michael Rohman with the assistance of Jordan Haller and Ronald Dee.[40][41] In this technique the vessels are held together with circumferential ligatures over an inserted metal ring. The internal mammary artery was used as the donor vessel and was anastomosed to the right coronary artery. The actual anastomosis with the Rosenbach ring took fifteen seconds and did not require cardiopulmonary bypass. The disadvantage of using the internal mammary artery was that, at autopsy nine months later, the anastomosis was open, but an atheromatous plaque had occluded the origin of the internal mammary that was used for the bypass.
- Soviet cardiac surgeon, Vasilii Kolesov, performed the first successful internal mammary artery–coronary artery anastomosis in 1964.[42][43] However, Goetz has been cited by others, including Kolesov,[44] as the first successful human coronary artery bypass.[45][46][47][48][49][50] Goetz's case has frequently been overlooked. Confusion has persisted for over 40 years and seems to be due to the absence of a full report and to misunderstanding about the type of anastomosis that was created. The anastomosis was intima-to-intima, with the vessels held together with circumferential ligatures over a specially designed metal ring. Kolesov did the first successful coronary bypass using a standard suture technique in 1964, and over the next five years he performed 33 sutured and mechanically stapled anastomoses in Leningrad (now St. Petersburg), USSR.[51][52]
- René Favaloro, an Argentine surgeon, achieved a physiologic approach in the surgical management of coronary artery disease—the bypass grafting procedure—at the Cleveland Clinic in May 1967.[43][53] His new technique used a saphenous vein autograft to replace a stenotic segment of the right coronary artery. Later, he successfully used the saphenous vein as a bypassing channel, which has become the typical bypass graft technique we know today; in the U.S., this vessel is typically harvested endoscopically, using a technique known as endoscopic vessel harvesting (EVH).
- Soon Dudley Johnson extended the bypass to include left coronary arterial systems.[43]
- In 1968, doctors Charles Bailey, Teruo Hirose and George Green used the internal mammary artery instead of the saphenous vein for the grafting.[43]
According to the CDC, the average cost of hospitalization (only) associated with a coronary bypass operation in the United States in 2013 was $38,707, for an aggregate hospitalization cost of $6.4 billion.[54] The International Federation of Healthcare Plans[55] has estimated the average cost of hospitalization and physician fees for a coronary bypass operation in various countries as shown in the Table below.[56]
Country | Cost |
United States | $75,345 |
Australia | $42,130 |
New Zealand | $40,368 |
Switzerland | $36,509 |
Argentina | $16,492 |
Spain | $16,247 |
Netherlands | $15,742 |
India | $1,583[57] |
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- Mawhinney JA, Mounsey CA, Taggart DP (June 2018). "The potential role of external venous supports in coronary artery bypass graft surgery". European Journal of Cardio-Thoracic Surgery. 53 (6): 1127–1134. doi:10.1093/ejcts/ezx432. PMID 29228235.
- American College of Cardiology. "Five Things Physicians and Patients Should Question" (PDF). Choosing Wisely: An Initiative of the ABIM Foundation. Archived from the original (PDF) on June 24, 2012. Retrieved August 17, 2012.
- Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, et al. (March 2011). "ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians". Journal of the American College of Cardiology. 57 (9): 1126–66. doi:10.1016/j.jacc.2010.11.002. PMID 21349406.
- Weiss AJ, Elixhauser A, Andrews RM (February 2014). "Characteristics of Operating Room Procedures in U.S. Hospitals, 2011". HCUP Statistical Brief #170. Rockville, MD: Agency for Healthcare Research and Quality.
- Weiss AJ, Elixhauser A (March 2014). "Trends in Operating Room Procedures in U.S. Hospitals, 2001—2011". HCUP Statistical Brief #171. Rockville, MD: Agency for Healthcare Research and Quality.
- "Indicator: International comparisons of surgical procedures". QualityWatch. Nuffield Trust & Health Foundation. Retrieved 5 May 2015.
- Lafortune, Gaetan. "Comparing activities and performance of the hospital sector in Europe: how many surgical procedures performed as inpatient and day cases?" (PDF). OECD. OECD. Retrieved 5 May 2015.
- Dee R (2003). "Who assisted whom?". Texas Heart Institute Journal. 30 (1): 90. PMC 152850. PMID 12638685.
- Haller JD, Olearchyk AS (2002). "Cardiology's 10 greatest discoveries". Texas Heart Institute Journal. 29 (4): 342–4. PMC 140304. PMID 12484626.
- Kolessov VI (October 1967). "Mammary artery-coronary artery anastomosis as method of treatment for angina pectoris". The Journal of Thoracic and Cardiovascular Surgery. 54 (4): 535–44. PMID 6051440.
- Mehta NJ, Khan IA (2002). "Cardiology's 10 greatest discoveries of the 20th century". Texas Heart Institute Journal. 29 (3): 164–71. PMC 124754. PMID 12224718.
- Kolesov VI, Potashov LV (1965). "[Surgery of coronary arteries]". Eksperimental'naia Khirurgiia I Anesteziologiia (in Russian). 10 (2): 3–8. PMID 5851057.
- Olearchyk, AS (1988). "Coronary revascularization: past, present and future". J Ukr Med Assoc North Am. 1 (117): 3–34.
- Olearchyk AS, Olearchyk RM (January 1999). "Reminiscences of Vasilii I. Kolesov". The Annals of Thoracic Surgery. 67 (1): 273–6. doi:10.1016/S0003-4975(98)01225-9. PMID 10086577.
- Glenn WW (April 1972). "Some reflections on the coronary bypass operation". Circulation. 45 (4): 869–77. doi:10.1161/01.CIR.45.4.869. PMID 5016019.
- Ochsner JL, Mills NL (1978). Coronary artery surgery. Philadelphia: Lea & Febiger.
- Cushing WJ, Magovern GJ, Olearchyk AS (November 1986). "Internal mammary artery graft: retrospective report with 17 years' survival". The Journal of Thoracic and Cardiovascular Surgery. 92 (5): 963–4. doi:10.1016/S0022-5223(19)35860-X. PMID 3773554.
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- "www.cdc.gov" (PDF).
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- Gokhale K (July 28, 2013). "Heart Surgery in India for ,583 Costs $106,385 in U.S". Bloomberg.


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UNITED KINGDOM (CNN) — Tom Daley wanted the world to hear the truth straight from his mouth.
The 19-year-old diver, who was one of Britain's heart-throb poster-boys for the London 2012 Olympics, took to YouTube Monday to reveal he is in a relationship with a man.
After complaining that he had been misquoted in an interview over his sexuality, Daley recorded a five-minute clip before tweeting: "Got something I need to say...not been an easy decision to make, hope you can support me! :)."
In the short video, he said: "In spring this year my life changed massively when I met someone, and they make me feel so happy, so safe and everything just feels great.
"That someone is a guy."
Earlier this year, in September, the London 2012 bronze medalist was voted the world's sexiest man by leading gay magazine, Attitude.
While Daley has always been cautious in commenting on his private life, he felt the time was right to make the revelation after being angered by quotes attributed to him in a recent interview.
"One thing I consider to be pretty important is having a private life and you're probably thinking, 'Why did you do a book, why did you do a documentary?'" Daley said in the video.
"In an ideal world I wouldn't be doing this video because it wouldn't matter, but recently I was misquoted in an interview and it made me feel really angry.
"For me honesty is important and I've always been honest. I may have been vague in some of my answers, but I've always been honest.
"One thing I've never really felt that comfortable with talking about is relationships. I've never really had a serious relationship to talk about."
Of course I still fancy girls. Right now I'm dating a guy and couldn't be happier. I feel safe and it really does just feel right. People are going to have their own opinions and I think people are going to make a big deal about this.
–Tom Daley
Daley said he has been dating the man for several months.
"It did take me by surprise a little bit," he said. "I did have in the back of my mind that something like that could happen.
"It wasn't until spring this year that something just clicked and felt right. My whole world just changed there and then.
"Of course I still fancy girls. Right now I'm dating a guy and couldn't be happier. I feel safe and it really does just feel right. People are going to have their own opinions and I think people are going to make a big deal about this.
"Is it a big deal? I don't think so. I wanted to say something and I feel like now I am ready to do it."
Daley shot to prominence in 2008 after reaching the finals of both the individual 10-meter platform and 10-meter platform synchro events at the Beijing Olympics at the age of 14.
He has since go on to establish himself as a celebrity both in and out of the diving arena, gaining over 2.4 million Twitter followers and even having his own television show in the UK, called "Splash."
His life in the public eye has not come without its problems.
He also lost his father Rob in 2011 following a five-year battle with cancer.
But Daley says his announcement would not have been a problem for his father, although he does concede there have been "mixed opinions" within his family.
"People think: what would your dad say? He always said to me, 'As long as you are happy, I'm happy.' And right now I couldn't be happier.
"My mum (Debbie) has been so supportive as well. All the friends and family I have told have been so supportive, which has been great.
"I told the rest of my family today, and let's just say they had mixed opinions. Lots of them did not believe it. Lots of them wanted me to keep it quiet.
"I didn't want to get my words twisted. I wanted to put an end to all the rumors and speculation, and just say it and tell you guys. It's what I want to do.
"My friends and family are always there to support me. And I hope you guys can be too. I mean I'm still Tom, I still want to win an Olympic gold medal in Rio 2016 for Great Britain. I am still as motivated as ever to do that. It would be great to have you guys on that journey, too."
Daley will now head to Houston, Texas, for the Team GB training camp until Christmas.
He follows other leading divers in making a public statement about their sexuality.
Australia's Matthew Mitcham announced he was homosexual before he won gold in Beijing, while four-time Olympic champion Greg Louganis came out as gay after quitting the sport in 1995.
The-CNN-Wire™ & © 2013 Cable News Network, Inc., a Time Warner Company. All rights reserved.

subset: commoncrawl


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UNITED STATES—Here on the west coast, autumn and winter weather is so mild that the native coral bells are already starting to develop new foliage on top of the old foliage from this last year. Technically, they are evergreen, so the old foliage does not need to be shed; but if it is not too much to ask, some types look better with a bit of grooming.Other perennial plants that are from climates with stronger seasons and colder winters are not quite so evergreen. Many shed all of their foliage and are completely bare for at least part of the winter. Only a few, like cyclamen, are at their best through autumn and winter.
Dried watsonia foliage should be removed now if it has not been removed already. It is not so easy to pluck off like gladiola foliage is, so should be cut off with shears. Because new foliage for next year develops before the old foliage of this past year is completely brown, it is often necessary to cut the old a few inches above the ground in order to avoid damaging the new.
The so called 'evergreen' daylilies can be even messier. New foliage is rather delicate, so is easily tattered by the removal of old foliage. The 'deciduous' types may seem to be less appealing because they are bare for part of autumn and winter, but are so much easier to groom by simply removing all of the deteriorating old foliage as soon as it separates easily from the roots.
Deteriorating flowers can be removed from cannas; but their lush foliage can stay until it starts to deteriorate later in winter. Even if it survives winter, it should eventually be cut to the ground as it gets replaced by new growth in spring.
The many different iris have many different personalities. Most should be groomed sometime between summer and late autumn, although Dutch iris were groomed much earlier. Bearded iris that do not get divided can be groomed simply by plucking off big old leaves to expose smaller new shoots below.
Some dahlias bloom until they get frosted. Most though, are already finished. They do not need to be cut back all at once, but can be cut back in phases as leaves and stems dry and turn brown.
Highlight: Coral Bells
From Santa Barbara to Vancouver, and also in central Idaho, the humble native coral bells, Heuchera micrantha, is not much to look at, with compact rosettes of relatively small and bronzy rounded leaves with weird tomentum (hairs). In spring and early summer, and sometimes again in autumn, sparse trusses of minute brick red flowers hover about a foot above on wiry and slightly fuzzy stems. Old plants that get bare in the middle can be divided into several small plants in spring or autumn.
Modern cultivars are considerably more interesting, with more substantial foliage in various shades of green, gold, tan, brown, bronze and purplish bronze. The larger and variably lobed leaves can be two inches wide or slightly wider. The flowers stand as much as two feet high, but lack color. Most are pale greenish white. 'Palace Purple' has deep bronze or almost purplish foliage. 'Ruffles' has deeply lobed and ruffled green leaves. Unlike undemanding wild plants that can grow in cracks in exposed stone, modern cultivars like rich soil. Harsh exposure can scorch foliage, so a bit of partial shade is preferred.
By Tony Tomeo


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This article is more than 1 year old
PSP owners to get Lost early 2008
Sky punts content to Sony
Sky has announced a deal with Sony to provide video content to UK PSP users, which can be downloaded over Wi-Fi or via their computer.
Due to launch early next year, this will be the first official video service for the PSP in Europe.
But Sky isn't just promising content from its own channels. Its hope is to manage a video portal for selling content from other brands and channels.
Sky will develop, and own, the user interface for the service - giving it the opportunity to sell all sorts of content to PSP owners, as well as testing its capabilities for selling to other platforms.
Sky By Mobile, the video streaming service Sky's been punting to mobile phone users, hasn't been doing much business. The quality of video has proved inconsistent, so the hope is a download-then-play model will prove more attractive to punters.
More details, and an official launch date, are promised at the Leipzig Games Convention in August. ®


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The Glorious Sun: An Idea for Christmas Ornaments
I was looking at images from NASA's Solar Dynamics Observatory, the latest satellite to study our star, and was struck by their beauty. SDO records the Sun in several wavelengths, producing gorgeous images of its ever-changing surface. And then I had a great idea: wouldn't these make fabulous ornaments for the Christmas tree? Sadly, I lack the artistic talent to make that happen, but with the wealth of amazing imagery of the Sun and other objects in our solar system that has become available in recent years, this seems like a grand opportunity for some talented person to create a unique Christmas tree.
Why was I looking at SDO imagery? Well, the pictures are simply wonderful (I even downloaded the 3D Sun App for my phone), but there was also a magazine-related reason: the magazine's next collector's edition is Mysteries of the Universe, and one of the stories is about SDO and the Sun. Check it out; the special issue goes on sale at newsstands and bookstores next week.


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Jason Grill – Attorney, Advocate and Consultant for Entrepreneurs and Startups
Jason Grill connects entrepreneurs, startups, mobile, technology and small to medium size business with the right exposure, resources and connections. Jason Grill owns JGrill Media which is a strategic consulting firm that focuses on media relations, public affairs, public relations, public strategies, professional branding, content marketing, publicity, government relations, contributing and commentating.
Jason Grill connects individuals, entrepreneurs, startups, small to large businesses, cities, communities, political figures/entities, policy makers, CEO's/C-suite executives, founders, organizations, associations and nonprofits with the media outlets (tv, radio, online, print) on a local and national level to get the exposure they deserve to grow their brand. JGrill Media gets individuals and businesses published in reputable online publications that reach their target markets. JGrill Media specializes in building credibility through thought leadership and content marketing. Jason Grill helps build a professional brand by getting bylined articles published in national online publications and identifying and helping clients get awards and on lists that will gain them authority in their industry. By getting bylined articles and interviews published and winning the best awards, JGrill Media helps take a professional brand to the next level. By building up this brand, JGrill Media helps establish you as a credible, authority in your industry, thus bringing you or your company more business.
Jason Grill, in his legal and attorney work, helps clients with wrongful death and personal injury claims, civil and business litigations, vehicular accidents, traffic and speeding related offenses, bankruptcy, medical malpractices, guardianship (related to Autism, special needs, and down syndrome), employment and contract related issues, nursing home negligence, trusts and wills, real estate, and economic development cases, etc. He is not only registered with Missouri Bar Association but also associated with the Kansas Bar Association and is providing his valuable services as an attorney in the Kansas City area.
Jason is an avid fan of Missouri Tigers, Kansas City Chiefs, Sporting KC, Liverpool and the Kansas City Royals. He represented Kansas City in Missouri House of Representatives, and made a remarkable contribution by getting landmark legislation passed to help families of children with autism. Jason Grill played a significant role as philanthropy chairman in the Sigma Chi Fraternity, and collected funds for Children's Miracle Network. While in college, he conducted community service for many organizations that include Big Brothers Big Sisters of America, St. Louis inner-city mentorship programs, etc. While pursuing his BS at St. Louis University, he connected himself with the Omicron Delta Epsilon and various other societies such as Beta Gamma Sigma Business Honor Society, National Deans List Honors Society, the Phi Alpha Delta Pre Law Fraternity, the Golden Key National Honor Society, Economics Honor Society, and he mentored for the Oriflamme organization.
Jason Grill – Attorney, Advocate and Consultant for Entrepreneurs and Startups Read More »


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Third Point Investors Ltd - Transaction in Own Shares
PR Newswire
London, January 19
Third Point Investors Limited
(A closed-ended investment company incorporated in Guernsey with registration number47161)
LEI Number: 549300WXTCG65AQ7V644 Renewal Date- 02/02/2023
(The "Company")
25 January 2023
The Board of Third Point Investors Limited announces that it has purchased the following number of ordinary shares of $0.01 each in the capital of the Company (the "Ordinary Shares") in accordance with the Company's share repurchase programme detailed below.
Date of purchase | 25 January 2023 |
Number of Shares purchased | 15,000 shares |
Highest price paid per share | $20.6000 |
Lowest price paid per share | $20.6000 |
Average price paid per share | $20.6000 |
The purchased Ordinary Shares will be cancelled. Following this purchase, the Company's issued share capital consists of the following:
- 27,335,937 US Dollar Ordinary Shares with one voting right per share.
- 18,223,958 US Dollar B Shares with one voting right per share and no rights to distribution of profits.
Following the above purchase, the total number of Shares in issue is 45,559,895. This number represents the total voting rights in the Company and may be used by shareholders as the denominator for the calculations by which they can determine if they are required to notify their interest in, or a change to their interest in the Company under the Financial Conduct Authority's Disclosure Guidance and Transparency Rules.
Any Ordinary Shares traded mid-month will be purchased and held by the Third Point Offshore Master Fund LP (the "Master Partnership") until the Company is able to cancel the shares following each month-end. Shares cannot be cancelled intra-month because of legal and logistical factors. The Company and the Master Partnership do not intend to hold any shares longer than the minimum required to comply with these factors, expected to be no more than one month.
Company Website: www.thirdpointlimited.com
Northern Trust International Fund Administration Services (Guernsey) Limited
The Company Secretary
Trafalgar Court
Les Banques
St Peter Port
Tel: 01481 745001


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From a design perspective, the Im Watch smartwatch is among the coolest, with a touch screen that allows users to drag, swipe, or pinch their way through the intece. It syncs with Apple iPhones and Google Android smartphones. The device acts as an extension of your smartphone, allowing you to answer calls by hitting a button on your watch. You can also receive text messages, emails, and notifications. In addition, paul daugherty keystone beer MN 1880 it allows you to view your calendar, pictures, weather apps, as well as listen to music from your wrist. It has a 1.55-inch, 240x240 color display, and comes with 4GB of built-in storage. The tiny gadget uses a 450MHz Atom 9 processor and comes with 128MB of RAM. All this technology and swanky design come at a price. The Im Watch starts at $349. The device was first shown off at CES last year.
Im Watch
The COOKOO smartwatches
Basis Technology watch
So r I havent seen anything that really knocks my socks off. I know many companies have attempted to make devices in this category, but no one has really been successful. My question for you, Maggie is, in your opinion, what do you feel is the best smartwatch on the market? And are there any that a middle class customer can really afford? I know some big tech companies have tried to sell smartwatches in the past. But what will it take to finally make this product category mainstream? Your feedback would be greatly appreciated.
Will this category ever take off?
Basis Science
The company says on its Web site that apps bring Pebble to life. The device is infinitely customizable. This means you can download everything different watch ces to Internet-connected apps that will allow you to use your smartwatch as a fitness tracker, accessing GPS on your smartphone to display speed, distance, and pace data. You can also use the music control app to play, pause, or skip tracks on your phone.
You can buy one of the latest and greatest Android smartphones and hope that it gets at least the next update to Android. Im thinking of a device like the Galaxy S3 from Samsung. Its true that the company hasnt been particularly st about keeping up with upgrades. But the Galaxy S mily of devices is the hottest Android product on the market, so its likely to be slated for updates sooner than others.
Dear Monty Python,
You asked this question at just the right time. Wearable technology is in. And it was all the rage this week at the Consumer Electronics Show. And luckily for you, price points have also come down. Of course, these watches arent as inexpensive as a Swatch. But the price tags arent as hefty as a Rolex either.
Ask Maggie is an advice column that answers readers wireless and broadband questions. The column now appears twice a week on CNET offering readers a double dosage of Ask Maggies advice. If you have a question, Id love to hear from you. Please send me an e-mail at maggie dot reardon at cbs dot com. And please put Ask Maggie in the subject header. You can also follow me on Facebook on my Ask Maggie page.
Right now, the possibility of an iWatch is still in the rumor stage. But this is a product category that Apple could easily move into and dominate. Apple ns have already been turning their older versions of the popular iPod Nano into watches. Accessory makers made bands so that users could put the small, square device on their wrists.
Im Watch
So what should you do? The way I see it, you have three main options.
Basis Science is one of several companies offering devices that are geared to helping you stay fit via a wearable smartwatch. Similar to FitBit and Nike+ Fuel Band, the Basis Science device tracks your workouts and activity and measures a wide range of biometric data in real time. Sensors measure things like heart rate, skin temperature, and your sleep patterns. And the device is also able to measure how active youve been as well as how much you sweat during a workout.
A better option for you if you want to stick with Android and want to make sure you have the latest and greatest software is to simply get a Google Nexus device. These smartphones do not come with the added software from the device manucturers. They are considered pure Google phones. While theyre supposed to offer the latest and greatest in terms of technology, sometimes they ll short of other devices on the market. For example, the LG Nexus 4, which is the latest Nexus device, doesnt support 4G LTE network speeds. While I believe that software is important, I also think its key to consider what you have to give up to ensure you have the next software update.
Remember that hard-hitting, st-shooting, comic strip police detective Dick Tracy, who wore the wrist watch with a two-way radio? Now you can be like Dick Tracy too with your own smartwatch that lets you answer phone calls and keep track of how r youve walked.
Monty Python
Martian Watch
Like other devices in its category, it uses Bluetooth to communicate with your iPhone or Android smartphone. And it allows you to check text messages, email, and all kinds of social-networking apps such as Facebook and Twitter.
A new day dawns for apps in your dash and we find the most high-tech car at the Detroit auto show - its not what you think.
This is the only smartwatch that I have seen that actually allows you to make phone calls. It uses Bluetooth to connect to either an iPhone or Android phone. If you have an iPhone 5 or iPhone 4S, it also allows you to initiate Siri voice commands and listen to Siri replies through the watch. You can access the integrated voice controls in iPhone 4 and iPhone 3GS.
Why? Since the proliferation of cell phones, watches have stopped being a necessity. And for years theyve been more shion than function. As my good friend and CNET colleague Scott Stein wrote in a piece about turning his nano into a smartwatch, In this day and age, watches are a novelty anyway.
Cookoo Watch
OK, Ill admit I am r too young to remember when Dick Tracy sported his now iconic radio wristwatch in the 1940s comic strip. But for years, this idea of a watch doing more than telling time has seemed like a very cool idea that has found its way into other mous characters and their stories -- think James Bond and Inspector Gadget.
The Pebble watch connects with the iPhone and Android to deliver email, text messages, and calendar alerts, among other things.
The Nano could play music, display photos, and keep track of fitness history. Apple bumped up the size of the 2012 Nano, so newer versions of the Nano can no longer serve as a watch. But there are plenty of people who have used these bands to turn their older Nanos into watches, including CNETs own Scott Stein. While Stein said he was impressed with how cool the Nano looked on his wrist and how easy it was to use as a watch, he said the ct that the device was not water resistant and had open ports could be problematic when used on a regular basis as a watch.
These smartwatches have been on the market for consumers for more than a decade. But theyve never really taken off in any big way. But with a slew of new devices shown off this year at the Consumer Electronics Show, plus rumors that Apple may jump into the market, is 2013 finally the year of the smartwatch? In this Ask Maggie, I explore this question and look at some of the newest and hottest devices shown off at CES.
This new smartwatch has a 1.26-inch screen that uses e- technology so that it can be viewed even in bright sunlight. The device is water resistant, and its battery should last a week on one charge.
The list I just gave you is just a sampling of whats available in this category. There are tons of other devices out there that offer similar functionality. Even though such devices have been around for some time, this category of product has not really hit the mainstream, as you point out in your question. And to some extent, I think the smartwatch is destined to always be a bit of a niche product category.
The idea is that people can use this information to improve their lives by changing behaviors and living a healthier lifestyle. Currently, the device does not sync directly to an Android or iOS app. But the companys executives say thats in the works. Currently, the data can be viewed and manipulated via a Web intece. The Basis fitness gadget sells for $199.
I also offer some advice about whether to ditch Android for iOS to ensure you get the latest software updates for your smartphone.
Dear Brandon,
That said, I think this could finally be the year that the smartwatch comes of age. In addition to all the new devices showcased at CES and the $10 million funding Pebble mustered on Kickstarter, there are rumors that Apple may launch its own smartwatch dubbed the iWatch. Business Insider reported in late December that Apple has partnered with Intel to develop an iOS watch. Supply chain sources reportedly told Chinese blog site Tech163.com that the watch would be Bluetooth-enabled and sport a 1.5-inch OLED screen. The reports said that the new iWatch could debut as early as the first half of 2013.
The Basis Band was also a finalist for CNETs Best of CES in the category of wearable technology.
If youre looking for an all-around smartwatch that can do almost everything, from running fitness apps to connecting to Facebook, then Id go with the Pebble smartwatch. This Kickstarter-funded startup has raised more than $10 million, and it officially kicked off its new product at CES.
Part of the problem is the ct that device manucturers layer their own software onto Android devices, so when new releases of Android come out, aduedu632.typepad.com they must be tested and tweaked to work on that specific device. The other problem free evening classes Will 2013 be the year of the smartwatchis that some carriers also have rigorous testing procedures, so even some Android devices which are already getting an upgrade on a different carrier or in a different country, may not get the update here in the U.S. Unfortunately, for you, Verizon is notoriously slow in being able to upgrade its Android devices.
The bottom line is that the mobile market is moving so st that its easy to feel like your device is outdated the day after you buy it. The truth is that any new smartphone you buy today is way more advanced than the one you already own. So use the technology available to you today, and stop worrying about the technology you might miss in the future. For more details on comparing the LG Nexus 4 with the Samsung Galaxy 3, check out this previous Ask Maggie.
Dear Maggie,
The Pebble watch will begin shipping to Kickstarter backers on January 23. After that, it will be available to the public. And it will only cost $150. It comes in several colors, including red, white, black, orange, and gray. And it also uses a standard watch strap, so that you can swap the style and color that you like best.
If youve always dreamed of having a Dick Tracy watch so you could talk directly into your wrist, then look no further than the Martian smartwatch. The company claims on its Web site that it has taken the SmartWatch to the next level by adding hands-free voice communication. Use your Martian Watch to talk, listen, initiate voice commands, and be notified of incoming calls and texts, all without your phone leaving your pocket, purse or backpack!
I am a Verizon customer currently using an HTC Thunderbolt stuck in the Gingerbread world. I am eligible for an upgrade 1/13/13, but I am torn on what to do. I really like the Android OS, but Ive grown a bit peeved about how fragmented software on Android devices are, to the point where I think my money is more well spent over the life of my two-year contract with Apple since iPhone devices typically receive software updates over multiple generations of devices in a timely shion. Do you have any advice that can help me feel more confident before locking myself into another two-year contract?
The last option for you is to get an iPhone, as you have suggested. This is perfectly fine to do. But beware that switching between device ecosystems can be tricky. So you may want to consider all the ins and outs of re-downloading and repurchasing apps that you used on your Android phone onto a new iPhone. Depending on what apps you use, and whether theyre available for free on iOS devices, you may have to spend a lot of extra money. And even though iPhones have a more consistent software update schedule, just keep in mind that many people would say that Androids software is a bit more advanced, offering new features and functionalities months, if not years, before theyre introduced in iOS.
Its difficult to pick just one product and say that its the best smartwatch on the market, because smartwatches often arent just watches. These devices do a lot more than just tell time.
The Cookoo watch is one of the more basic smartwatches. It has a digital ce of an analog watch and looks a lot like a real watch. But compared with some of the other smartwatches on the market its pretty limited in functionality. Telling time is the most important feature. And it syncs with your iOS devices (iPhone or iPad) to provide updates. You can also check into some social-networking sites like Facebook. The device will soon work with Google Android devices. It costs $130. It supposedly has a long-lasting disposable battery thats good for a year. And its waterproof for up to 50 meters.
This means that picking the one that is best for you requires you to figure out what additional features and functionality you want. For instance, tumour293.typepad.com do you want a music player on your wrist? Or maybe you want a device that will also help you stay fit and healthy, tracking your workouts and even how well you sleep. Perhaps youre looking for something thats an extension of your phone that will allow you to answer calls on the go. There are different devices focused on these different areas.
Im an avid reader of Ask Maggie. And Ive seen you answer a wide variety of topics from countless other avid readers who are in need of insightful opinions. Im next on that list. Ive been in the market for a smartwatch. Yes, you read that correctly: a smartwatch, not a smartphone, tablet, or smart TV, but a watch.
Dear Maggie,
The watch sports a traditional analog ce, and it has a tiny screen at the bottom of the device where you can see who is calling your phone. It also gives you a 40-character preview of text messages sent to your smartphone. Like some other devices in this category, the Martian doesnt come cheap. There are currently three styles of the watch available ranging in prices from $249 to $299. The Martian Watch was a finalist for CNETs Best of Show at this years CES.
You touch on one of the biggest problems with the Google Android ecosystem. On the one hand, I applaud Google and the open-source community for rapidly innovating on the Android software. And its terrific that manucturers are cranking out new models of devices in what seems to be a ster and ster pace.
Still, it seems like Apple could easily adapt the technology and design of the Nano into a more ruggedized iWatch. If that happens, you can bet that the category will take off.
But that also means that a device you buy today with the latest and greatest software is likely to be outdated within six months. And by the end of your two-year contract with your carrier, your old Android device is really looking ancient.
Whats out there?
free evening classes Will 2013 be the year of the smartwatch,In this edition of Ask Maggie, CNETs Marguerite Reardon highlights some new devices in the smartwatch category and discusses why this may finally be the year the gadgets take off.
As mentioned earlier, there are tons of wearable fitness devices that are not smartwatches per se. Their primary use isnt to be a watch, but because these devices are typically worn on the wrist and keep time as well as keep track of your activity and fitness levels, they can be used as watches.
Lindsey Turrentine and Brian Cooley talk to folks from Fitbit, Nest and Leap Motion about how humans interact with this next generation of tech.
Marguerite ReardonMarguerite Reardon has been a CNET News reporter since 2004, covering cell phone services, broadband, citywide Wi-Fi, the Net neutrality debate, as well as the ongoing consolidation of the phone companies.


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When Teens Reject Their Parents
- Mark Gregston Heartlight Ministries
- Published Mar 29, 2019
We want our children to become independent; to be able to take control of their own lives. But their choices won't always be in line with ours, and that's when we can feel rejected.
A natural and essential part of your child's maturing process is to make choices for themselves. Every decision they make is another step along the path from total dependence at birth to maturity and independence when they leave home. But not every choice teenagers make is going to seem "right" to you.
There is a process they go through to establish their own beliefs, and that often includes rejecting our beliefs, and even us, for a time. So, when they make a choice with which we don't agree, we have two options. We can step in and assert control over them (treating them like a child again), or we can work through the process with them; taking time to understand why they made the choice they did. I suggest you do the latter. Let me give you some tips to help you work with your teen through this sometimes painful process.
The Lord is compassionate and gracious, slow to anger, and abounding in love. – Psalm 103:8
Stay Positive… Compassionate…
When your child is doing things and making choices that are against your values, it's easy to blow it all out of proportion. But rather than immediately condemning and preaching, position yourself in the role of a coach and mentor.
If you have done your job instilling values in your kids in the earlier years, they already know when they're doing wrong as teenagers. You don't have to tell them again and again and again. That badgering will wear out your welcome in their increasingly independent life. They are already struggling with feelings of guilt and confusion, so they need a positive, encouraging voice in those teaching moments.
Please note that I'm not saying you should approve of what they're doing or forsake your role as a parent. What's right and wrong doesn't change, and consequences still need to be applied. What I am suggesting is that you maintain your relationship in such times in a way that you will be able to continue to speak truth into their heart and be heard. Start by talking through various options that were available to them, until they can identify for themselves what would have been a better course of action. This process promotes independence and good decision making skills.
Allow Independence to Grow…
It's common to hear a teen say, "I don't need you anymore. I can do it on my own." There's something in the heart of parents that doesn't want to hear those words (sometimes delivered in a loud and angry tone), but those are good words. They show a drive for independence that your child will need to launch into life on his own. Now, in reality you and I both know that if you shut off the electricity to his room he'd find out real quick that he does still need you, but don't let those words drive a wedge between you.
Instead accept those words for what they are and work to find ways to promote independence. Along with their desire to be independent in their decisions, make them responsible for their own daily life, like getting out of bed in the morning, managing their own finances, and getting a job for a few hours a week. This is a great way to show them the responsibility that goes along with being independent.
Pick Your Battles…
One question that I often hear from parents is about church attendance. This can be a real flashpoint issue in the home. If a teen says, "I don't want to go to your church anymore," that can feel like a real rejection and a threat. I know about that feeling, not just from talking to other parents, but from being a parent. When my children were older teens they didn't like the church we were going to, so Jan and I decided to move to a church they did like.
But I hated it. The pastor and I didn't connect, the music was too stale for me, and I just couldn't see us "fitting in," so Jan and I went back to our church and the kids kept going to theirs. It kept our kids in proper fellowship with other kids their age, and it reduced the tension on Sunday mornings. Our solution may seem a little radical, and it may not be applicable to others, but it worked for us. Jan and I went to the church we liked; the kids went to the church they liked. We then met for lunch afterward and shared what we had heard in our separate churches. It let us focus on what mattered most—that they were active and involved in church, not that they liked the kind of worship service we liked. I'd far rather them go to a different church–one they like and teaches the same biblical values–than to abandon church altogether. The point is this…maybe there is a creative compromise you can come up with that solves the more important issue.
Identify What's Going On…
There's a difference between struggles in the home that occur due to outright rebellion and those due to hormones and the normal growing process. A rebellious teen will end a fight with a slammed door and a feeling of satisfaction. A teen who is trying to process a changing world and find her place in it is more likely to show up with an apology a few minutes later (or at least act apologetic). Full blown rebellion is an intentional rejection of parents and their values—a deeper hatred for the parents and their values–and it's actually pretty rare.
If we respond to the hard times and struggles our teens are having as if they are rebelling, we run the risk of alienating them and damaging our relationship at the time they need it most. I encourage you to try to get beyond the surface to understand exactly what you're dealing with…and remember the transfer to independence that's underway throughout the process.
Let us not become weary in doing good, for at the proper time we will reap a harvest if we do not give up. –Galatians 6:9
Don't Ever Give Up…
I say this a lot, but it bears continuous repeating ,"Don't give up!" Just because a child rejects you, at whatever level, don't give up or walk away. And don't take it personally. We've had more than 2,500 teens come to stay with us at Heartlight. More than once I've wondered if we could make a dent in the pile of troubles that a young person brought along with their luggage. But what I've learned is to keep going—keep talking, keep praying, keep loving. We've seen wonderful transformations, and usually the worst kids turn out to be the greatest and most appreciative ones once they get on the other side of it. When I'm tempted to give up, I often think about the hundreds of weddings I've conducted for kids who lived with us here. Many of those cases seemed difficult; even hopeless, but they turned out just fine because we didn't give up on them.
Mark Gregston is an author, speaker, radio host, and the founder and director of Heartlight, a therapeutic boarding school located in East Texas. Call 903-668-2173. Visit http://www.heartlightministries.org, or to read other articles by Mark, visit http://www.markgregston.com.


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1. What interesting things are going to happen Friday evening? Good question. There will be a huge crush of humanity trying to meet and greet and set up plans for Friday after the games and Saturday lunch and Saturday night and Sunday lunch and Sunday after the awards. One group getting together Saturday noon will discover that none of them actually knew each other previously, and three romantic couples will form in the protoplasm. Eric Berlin will come up with something interesting, specifically awarding Tyler Hinman and Merl Reagle a free drink from the hotel bar. The rest of the time will be filled with an old tape featuring news reports of the ACPT from 1984, incorrectly indignant letters-to-the-editor from Will's pile, and a pick-your-poison contest where everyone will do the cryptic (as they always do), despite the alternatives of (1) a page of 4x4 Kenken(TM)(R)(K)(P), (2) guessing what's in Henry Hook's pocket, (3) a page of 6x6 Kenken(TM)(R)(K)(P), and (4) a diagramless.
2. What's up with Saturday night? Pliska and Chaneski will come up with something, and will stretch it too far because nobody else will have volunteered something, although this year we'll be able to legitimately do 1 vs. 100 on Saturday night because only 100 people will have bothered to show up.
3. Aren't there some crossword puzzles? Yes.
3a. Well? Byron Walden will make his triumphant return to puzzle #5, which will be a rebus theme involving two Greek letters, two Cyrillic letters, and two Hebrew letters. The subsequent applause after announcing Maura Jacobson's name for puzzle #6 will delay the tournament for ten minutes. Merl will have the Sunday puzzle, and will manage to get 21 puns in a 21x21. Five contestants will break 2:00 on puzzle #1, and Trip Payne will pull a muscle trying to break 2:00 on puzzle #4.
4. Who gets the money? I think it's just reckless enough to answer: Dan Feyer, 2010 ACPT champion.
5. A talent show? Again? Not a talent show: a "variety program", just like Milton Berle used to do. Guests will include Ed Wynn, Martha Raye, and Francis Heaney, who will be so vaguely discomfited at being unable to boycott the awards banquet this year that he will write and perform a self-mocking parody of "Howl".
6. What will be the biggest surprise of the weekend? Will not announcing time/location of the next tournament, as he will be investigating taking the show on the road rather than continue to pay the extortionate fees charged by the Brooklyn site. [Who am I kidding; that will never happen. The real surprise: the hotel security team not kicking puzzlers out of the lobby at the stroke of midnight this year.]
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A lopsided vote in the U.S. House of Representatives this week to rein in the National Security Agency's domestic telephone records dragnet won muted praise, with many supporters calling on Congress to take stronger action.
Critics, meanwhile, slammed the USA Freedom Act for extending the section of the antiterrorism Patriot Act that the NSA has used to collect the telephone records of nearly all U.S. residents. The bill, passed by a 338-88 vote late Wednesday, would end the NSA's bulk collection of domestic telephone records, while allowing the agency to continue to collect phone and other business records in a more targeted manner.
The bill's failure to kill the business and telephone records section of the Patriot Act, which would expire on June 1 without congressional action, is "fake reform," according to digital rights groups Fight for the Future and Demand Progress and progressive carrier CREDO Mobile. The bill would expand NSA surveillance powers to VoIP and video chats and would take the "wind out of the sails of real reform by appearing to have addressed mass surveillance," the groups said on a new website, USAFreedom.fail.
The USA Freedom Act is "the opposite of reform," Tiffiniy Cheng, co-founder of Fight for the Future, said by email.
There's no reason for the NSA to be surveilling "everyone and their mom in order to go after their targets," she added. "That's just rogue and illegal behavior and part of selling a culture of fear. We're demanding to see them build a case to surveil my mom and millions of Internet users around the world before they get one more peek at our private lives."
Other digital rights and tech groups praised the House for advancing the bill, but several called on lawmakers to broaden their focus on surveillance reform. The USA Freedom Act addresses only domestic records collection by the NSA and the FBI; it takes no action to limit the NSA's controversial overseas surveillance of the content of email, texts, telephone calls and other electronic communications.
The House bill also faces a tough fight in the Senate, where Majority Leader Mitch McConnell, a Kentucky Republican, has introduced legislation to extend the business and telephone records section of the Patriot Act with no new limits on the NSA.
Senator Ron Wyden, an Oregon Democrat, promised to fight any renewal of the Patriot Act that doesn't include reforms. "Supporters of dragnet surveillance are fighting to preserve the status quo, but the American public is rightfully demanding a change," he said in a statement. "It is time for mass surveillance to end, and I will filibuster any attempt to extend this illegal surveillance, which violates core American rights without making our country any safer."
The House passage of the USA Freedom Act is an "important first step" toward reforming surveillance, even though other reforms are needed, Kevin Bankston, policy director at the New America Foundation's Open Technology Institute, said by email. The vote sends an "unequivocal message" to the Senate that a simple renewal of the Patriot Act is off the table, he added.
Congress needs to pass additional reforms, including so-called backdoor searches of U.S. communications inadvertently collected by the NSA when it targets the foreign communications of people suspected to be connected to terrorist groups, Wyden said.
Sponsors of the USA Freedom Act defended it, calling it the first major step toward surveillance reform since former NSA contractor Edward Snowden leaked information about the agency's programs starting in mid-2013.
By ending the NSA's bulk collection of U.S. phone records, the bill ends an "assault on Americans' civil liberties," Representative Bob Goodlatte, a Virginia Republican and sponsor of the bill, said in a video. "This bill reforms our intelligence-gathering programs so that they operate in a manner that reflects core American values."
Grant Gross covers technology and telecom policy in the U.S. government for The IDG News Service. Follow Grant on Twitter at GrantGross. Grant's email address is firstname.lastname@example.com.


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WASHINGTON (REUTERS) - US President Barack Obama pushed back on Wednesday against critics who complain that his former top economic adviser, Dr Lawrence Summers, was not aggressive enough in seeking more economic stimulus funds than Congress ultimately approved in 2009.
House of Representatives Democrats left a closed-door meeting with Mr Obama saying the president defended the size of his administration's nearly US$800 billion (S$1 trillion) stimulus law and said it was all he could get from Congress at the time.
Dr Summers and Federal Reserve Board Vice-Chairwoman Janet Yellen are seen as Mr Obama's leading candidates to replace Fed Chairman Ben Bernanke when his term ends next January.
At the closed-door meeting, Mr Obama said that he had not made any decisions on his choice of Mr Bernanke's replacement, according to a number of House Democrats.
"The decision is not ready to be made. He was quite clear about that," Representative Steve Israel said.
"He did talk about Larry Summers' qualities, but he also said there were many other candidates with their own qualities.
This meeting was not an endorsement or lack of endorsement of Larry Summers or anybody else," Mr Israel said.
Representative Carolyn Maloney, a member of the House Financial Services Committee, said that published speculation about a Bernanke replacement - which has suggested Mr Obama was primarily focusing on two candidates - may not be accurate, but she did not elaborate.
House Democratic leader Nancy Pelosi told reporters following the meeting that Mr Obama did not bring up a discussion of the pending Fed nomination, but was responding to a question from a House Democrat.


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As Democrats and Republicans struggled to gain the upper hand in this week's bitter budget battle, Harry Reid accused the Republicans of being ruled by "Tea Party extremists"—and John Boehner, in his own way, agreed. The House speaker said flatly that there is no daylight between him and the grassroots movement's budget-hawk activists.
But Tea Party members from Boehner's own district insisted that they are nobody's tools in the budget showdown that has paralyzed Washington and threatens to shut down the federal government.
To prove their point, the Tea Party members from Boehner's home turf in Ohio fired off a letter late Thursday, warning him to hold the line on government spending, especially on the looming clash over raising the federal debt ceiling. One leader went so far as to warn that the locals would not rule out mounting a primary challenge to the speaker if he doesn't show more fight than he has so far. "At this point I don't think it's off the table," said Dan Lillback of the Cincinnati Tea Party, which is based in Boehner's district.
Although Tea Party activists in Cincinnati have regular access to Boehner's staff, Lillback and other members of the group recently took the unusual step of launching robocalls to Boehner's top 1,000 donors, urging them to contact him about the upcoming debt-ceiling issue.
"I think they kind of see us as kind of a fly buzzing around their ear right now because we're not doing anything to truly impact them," Lillback said of the GOP leaders. "But at the end of 2012, when Election Day happens, is the debt ceiling going to be $16 trillion? $17 trillion? When is it going to be less than it is today? That's not an answer that we're going to like."
• Michelle Cottle: Why I Pity Boehner• Daniel Stone: The Capitol Hill Shutdown Slumber Party • Government Shutdown: Full coverage Ann Becker, a stay-at-home mom and vice president of the West Chester Tea Party that meets about three times a month with Boehner's staff, said she respects the speaker but "we want leadership, we don't really want a politician right now."
A short distance from West Chester, Ray Warrick of the Mason Tea Party said that he and other Republicans in Ohio are "not happy" with Boehner and the party's leadership for what they see as Republicans failing to live up to their campaign promises to drastically cut the budget. "I think that some of us are beyond patience," he said. "Whereas it used to feel hopeless, sometimes now it seems pointless."
"If you don't have the political will to cut $61 billion, then what are you doing there? Get out of Congress."
While local Tea Party leaders aired their frustration with Boehner, others across the country pinned the blame for the ballooning federal deficit on Democratic leaders in Washington.
"Harry Reid says we're being unreasonable, but he wants to keep cowboy poetry alive," said Jamie Radtke, a former chair of the Virginia Tea Party Patriot Federation who is now running for the state's open Senate seat. He was ridiculing the Senate majority leader for defending the poetry festival in Nevada, which is financed in part with federal dollars.
But Radtke doesn't let Republicans off the hook either, saying that any more compromises from the GOP leadership, including Majority Leader Eric Cantor, on the 2011 budget will trigger a backlash from the Tea Party. "If you don't have the political will to cut $61 billion, then what are you doing there? Get out of Congress," she said.
While the national media are focused on the possible government shutdown this weekend, Chris Littleton of the Ohio Liberty Council called the battle "the pre-game show" for the real spending wars over the 2012 budget. "We're arguing over crumbs falling off the table at this point," Littleton said, adding that their message to both parties is to tackle the country's spiraling debt—which he likened to a black hole. "Stop yelling. Play nice in the sandbox. The world is on fire," he said.
With anger in the heartland clearly on the rise, it has fallen to national spokesmen to counsel something that is in short supply among the local activists: patience.
Adam Brandon of FreedomWorks, the national Tea Party-affiliated organization, urged local groups to give the GOP leadership time to see the battle through to the end. He also called the notion of a primary challenge to Boehner a distraction from the real fight. "Give them time to work it out instead of setting up primary challenges," he said. "There's a lot of Congress left in this Congress."
Patricia Murphy is a writer in Washington, D.C., where she covers Congress and politics.