text:
The Big Heart Disease Lie
BSA, body suface area; PLAX, parasternal long-axis ; LVIDd, left ventricular internal diameter at end diastole; LVIDs, left ventricular internal diameter at end systole; PSAX, parasternal short-axis; A4C, apical four chamber.
M-mode or 2D, essentially subtract ventricular cavity volume from the total ventricular volume to obtain the "shell" or myocardial volume (Fig. 15). This value
multiplied by the density of the myocardium gives the LV mass.
Left ventricular mass (MassLV) = 0.8 x [1.04 (IVS + PWT + LVIDd)3 - LVIDd3] + 0.6 g Accurate measures are crucial, as errors will be cubed.
3D echocardiography will likely replace current echocardiographic methods of calculating ventricular mass and volumes in the near future (Figs. 16A-D; please see companion DVD for corresponding video). The limitations and assumptions of 2D and M-mode echocardiography are overcome by both real-time and off-line reconstructive 3D echocardiography. Modern 3D equipment uses planar array transducer technology to obtain a pyramidal "volume" of data. This makes 3D echocardiography less dependent on the sonographer imaging the correct plane.
assessment of myocardial viability
Dobutamine echocardiography can provide additional information on the LV contractile reserve. This has value in predicting recovery of function following coronary revascularization procedures. Assessment of myocardial viability is also important in heart failure patients.
The important clinical question that frequently confronts the cardiology team is whether coronary revascu-larization procedures will benefit a particular patient with LV dysfunction. To answer this, we need to help predict the probability of improvement following the proposed revascularization procedure. Nuclear techniques assess myocardial perfusion, but not contractile reserve. A biphasic response on dobutamine stress echocardiography, however, can be a good predictor of improvement in patients scheduled to undergo coronary revascularization procedures (Fig. 17; see companion DVD for corresponding video; see also Chapter 8).
Fig. 14. (A,B) Modified Simpson's method. The American Society of Echocardiography recommends the modified Simpson's method (biplane method of discs) for calculating left ventricular volumes and ejection fraction. Manual tracing of ventricular endocardium at end-systole and end-diastole from two orthogonal planes, and summation of the volumes of discs derived, serve as the basis of this calculation.
Fig. 14. (A,B) Modified Simpson's method. The American Society of Echocardiography recommends the modified Simpson's method (biplane method of discs) for calculating left ventricular volumes and ejection fraction. Manual tracing of ventricular endocardium at end-systole and end-diastole from two orthogonal planes, and summation of the volumes of discs derived, serve as the basis of this calculation.
doppler assessment of ventricular systolic function
Doppler assessment provides complementary and alternative indices of ventricular systolic function (Table 7). Traditional Doppler indices are used to calculate SV and CO. SV is calculated from the equation: volume = area x velocity time integral; where area is the cross-sectional area of ventricular outflow or inflow tract of interest; velocity time integral corresponds to the velocity time integral across the same. CO is then calculated according to the equation:
Cardiac index calculated by dividing CO by body surface area.
Doppler indices have the advantage in being independent of geometric assumptions used in M-mode and 2D-based calculation of volumes. The most accurate and reproducible Doppler method for calculating SVs uses the left LV outflow tract (LVOT) diameter and the velocity
Area Mid-papillary level PSAX
Left Ventricular Mass
Area x Length Method
Left Ventricular Mass
Area x Length Method
cylinder hemi-ellipsoid
Volume = 5/g Area x Length cylinder hemi-ellipsoid
LV Mass (AL) 1.05{[5/6Ai (a+ d+t)] - [5/6A2<a+d)]}
Fig. 15. Left ventricular mass. The area-length method for using a cylinder hemi-ellipsoid of the left ventricle (LV) is the recommended equation for measuring LV mass. It is a simple formula with easily obtainable measurements. End-diastolic measurements using parasternal short-axis (PSAX) and apical four-chamber at the mid- or high-papillary muscle levels are made and inserted into the equation as shown. The sum of a + d is the end-diastolic LV cavity length; b = minor axis radius; t = wall thickness; Aj= total planimetered PSAX area at the mid- or high-papillary muscle level; A2 = LV cavity planimetered PSAX area.
time integral across the LVOT by pulsed Doppler examination (Fig.18A; see also "Continuity Equation" in Chapter 11) LVOT geometry most closely approximates a circle compared with the ellipsoid mitral annulus (Fig. 18B), and is logistically easier to measure than the pulmonary artery diameter (Figs. 18C). Tricuspid annular geometry is complex, and is almost never used to calculate SVs.
Continuous-wave Doppler of the mitral regurgitant jet can reveal clues about LV performance by assessing changes in LV pressure over time (dP/dT). The pressure is measured at two points (at ~1 m/s and 3 m/s after the onset of the mitral regurgitation) and the Bernoulli equation (dP = 4v2) applied. Normal dP/dT is greater than 1200 mmHg/s.
other doppler measures of ventricular systolic function
Tissue Doppler imaging is a useful tool in ventricular diastolic function assessment, but also shows promise in assessing systolic function (Fig. 19). Doppler interrogation of the mitral annulus can provide a measurable index of annular movement and velocity, and the information derived can be extrapolated to assess ventricular function. A good relationship exists between tissue Doppler assessment of myocardial contraction velocity and LVEF.
Tissue velocity imaging employs color codes to reflect ventricular longitudinal shortening using the scheme: red—for movement toward the transducer, and blue—movement away from transducer (Fig. 20; please see companion DVD for corresponding video). It is based on the rationale that most of the cardiac muscle fibers are oriented longitudinally. A direct relationship exists between pulsed-wave tissue velocity imaging and ventricular systolic function.
EF is not a load-independent measure of contractility. Load is important when considering contractility and this is not normally accounted for in traditional measures. Newer less load-dependent methods, e.g., Doppler strain imaging, are being investigated. Strain—a dimensionless quantity, measures deformation produced by the application of stress. It represents the percentage change in myocardial fiber length from its original or unstressed dimension (Fig. 21A-C). Comparisons of Doppler velocities at interrogation points along the myocardium are used to measure LV strain.
Fig. 16. Left ventricle (LV) quantification by three-dimensional (3D) echo. (A) Apical full-volume cropped 3D image. (B) Semiautomatic border detection with multiplanar reconstruction (MPR) in 3D echocardiography. (C) A 17-segment 3D volumetric data for left ventricular segmental analysis. 3D echocardiography overcomes several limitations of 2D echocardiography in quantification of systolic function including: endocardial border definition, foreshortening, off-axis views, and translational motion. It is slated to supercede 2D echocardiography in the assessment of LV function, mass, and volumetric assessments. 3D echo is especially valuable in right ventricular assessment and quantification, with utility comparable to that of cardiac magnetic resonance imaging. (D) LV systolic frame with diastolic reference mesh. (E) Systolic frame in patient with cardiomyopathy and asynchrony. (Please see companion DVD for corresponding video.)
Fig. 16. Left ventricle (LV) quantification by three-dimensional (3D) echo. (A) Apical full-volume cropped 3D image. (B) Semiautomatic border detection with multiplanar reconstruction (MPR) in 3D echocardiography. (C) A 17-segment 3D volumetric data for left ventricular segmental analysis. 3D echocardiography overcomes several limitations of 2D echocardiography in quantification of systolic function including: endocardial border definition, foreshortening, off-axis views, and translational motion. It is slated to supercede 2D echocardiography in the assessment of LV function, mass, and volumetric assessments. 3D echo is especially valuable in right ventricular assessment and quantification, with utility comparable to that of cardiac magnetic resonance imaging. (D) LV systolic frame with diastolic reference mesh. (E) Systolic frame in patient with cardiomyopathy and asynchrony. (Please see companion DVD for corresponding video.)
Fig. 17. Dobutamine stress echocardiogram: biphasic response. A biphasic response on dobutamine stress echocardiography may be a candidate for coronary artery revascularization procedures. This patient shows augmentation of a previously poorly functioning region on low dose dobutamine (10 |g), but demonstrates ischemia (decreased contractility) at higher doses. At baseline, this region of the heart (arrows) are hypokinetic—contractility improves at the 5 |ig infusion rate, is maintained at 10 |ig, worsens at 40 |ig. This represents an ischemic region that augmented at low doses that can benefit from revascularization. (Please see companion DVD for corresponding video.)
Fig. 17. Dobutamine stress echocardiogram: biphasic response. A biphasic response on dobutamine stress echocardiography may be a candidate for coronary artery revascularization procedures. This patient shows augmentation of a previously poorly functioning region on low dose dobutamine (10 |g), but demonstrates ischemia (decreased contractility) at higher doses. At baseline, this region of the heart (arrows) are hypokinetic—contractility improves at the 5 |ig infusion rate, is maintained at 10 |ig, worsens at 40 |ig. This represents an ischemic region that augmented at low doses that can benefit from revascularization. (Please see companion DVD for corresponding video.)
Table 7
Doppler Indices of Left Ventricular Systolic Function
Traditional Doppler indices
Newer Doppler indices
SV = VTI x CSA = VTI x nr2 = VTI x nD2/4 = 0.785 D2 x VTI
Measurement sites: LVOT
Left ventricular inflow (mitral valve) Pulmonary artery CO = SV x HR CI = CO/body surface area CW Doppler in mitral regurgitation: dP/dt = 32/time (mmHg/s)
Velocity/acceleration times, e.g., aortic flow/velocity acceleration, aortic ejection time
TVI for left ventricular dyssynchrony
Doppler strain imaging: strain and strain rate
SV, stroke volume; VTI, velocity time integral; CSA, cross-sectional area; D, diameter; TDI, tissue Doppler imaging; DTI, Doppler tissue imaging; LVOT, left ventricular outflow; CO, cardiac output; HR, heart rate; CI, cardiac index; TVI, tissue velocity imaging; CW, continuous wave; dP/dT, rate of ventricular pressure rise.
myocardial performance index (tei index)
The myocardial performance index (MPI) is a Doppler-derived integrated measure of ventricular systolic and diastolic function.
It has been the subject of much interest since its inception in 1995, and has been well received for its ability to assess both LV and RV function in a variety of patients—heart failure, cardiomyopathy, coronary heart disease, heart transplantation, and in prospective clinical trials. It is reproducible, easy to measure and can predict morbidity and mortality in patients with cardiomyopathy and heart failure.
When applied to the LV, it is the sum of the isovolumic contraction and relaxation times (ICT + IRT) divided by
Fig. 19. Tissue Doppler imaging (TDI). Tissue Doppler assesses myocardial velocities during the cardiac cycle. Doppler shift measured at the lateral (A) and septal annulus (B) are shown. Systolic shifts (Sm) are upward (positive). Shifts away from the transducer (Em and Am), reflecting early and late diastolic velocities, are downward (negative).
Fig. 20. Tissue velocity imaging (TVI). Differential tissue velocities by color Doppler can detect differential contractility of left ventricle (LV) segments—and color coded as shown. This reflects LV dyssynchrony and impaired LV systolic function. (Please see companion DVD for corresponding video.)
Fig. 20. Tissue velocity imaging (TVI). Differential tissue velocities by color Doppler can detect differential contractility of left ventricle (LV) segments—and color coded as shown. This reflects LV dyssynchrony and impaired LV systolic function. (Please see companion DVD for corresponding video.)
the ejection time. These measurements are obtained by Doppler assessment of both LV inflow and outflow and using the formula (Fig. 22):
Left Ventricular MPI =
The MPI has its limitations. It is not a load-independent measure, and one of its components, the IRT, is less discriminatory in patients with worsening diastolic dysfunction. Therefore, despite its utility, it should complement (not substitute) established measures of LV function, e.g., ventricular volumes and EF.
assessment of rv function in heart failure and postmyocardial infarction
In patients with heart failure, RV dysfunction is associated with increased mortality. RV dysfunction is an important predictor of risk and heart failure following myocardial infarction.
morphological considerations
The RV exhibits a far more complex geometry than that of the LV. It is thin walled (<0.5 cm) and assumes
a flattened pear-shaped appearance folded over the LV (Fig. 23). Such geometry makes it especially difficult to assess by 2D techniques. Most volumetric methods of RV assessment are complex and not well validated, especially in diseased states—when RV geometry is becomes even more complex (Chapter 18).
rv chamber dimensions
Like the LV, the RV should be assessed using multiple windows. The subcostal window provides the best visualization of the RV free wall. RV size, wall thickness, and systolic function should be recorded, and systolic function described as normal or reduced to varying degrees. RV enlargement can be estimated using the "rule of thirds" in the parasternal long-axis view, or by comparing its size relative to that of the LV in the apical four-chamber view. The RV diameter does not normally exceed one-third the total ventricular width in the apical four-chamber view (Fig. 24; Tables 8 and 9).
Attempts to quantify RV volumes and systolic function by echocardiography include indices like tri-cuspid annular motion, tricuspid fractional shortening, and RV fractional area change (RVFAC). Tricuspid annular motion refers to the distance the tricuspid annulus moves in the antero-posterior direction. Tricuspid fractional shortening is an assessment
of the difference between the maximal and minimal distance between the tricuspid annuli during the cardiac cycle. RVFAC is assessed by measuring RV areas in the apical four-chamber view and comparing the relative change between diastolic and systole. When all three approaches are compared to cardiac magnetic resonance imaging (MRI), the best correlation is seen with RVFAC measurements. RV MPI has also proven a useful measure of RV function. Standards for RV volumetric assessment, however, are yet to be established.
dilated LV with reduced systolic function. Pressure overload conditions, such as aortic stenosis, severe hypertension, or coarctation, usually lead to hypertrophy, although ventricular dilatation and dysfunction can occur late in the course of disease. Various forms of congenital heart disease can lead to systolic dysfunction and can usually be identified on echocardiography. Infiltrative diseases such as amyloidosis can cause severe LV dysfunction and can usually be identified by pathognomonic echocardiographic features. In the case of amyloid, severe LV hypertrophy, "speckled" appearing myocardium, atrial dilatation, nonspecific valve thickening and pericardial effusions are common. Occasionally, hypertrophic cardiomyopathy can ultimately lead to ventricular dilatation and dysfunction (so-called "burnt-out" hypertrophic cardiomyopathy).
echocardiography to determine etiology of systolic dysfunction
Echocardiography can be of use in determining the etiology of systolic dysfunction (Table 1). Patients with ischemic heart disease almost always have discrete regional wall motion abnormalities—most often secondary to prior myocardial infarction. In contrast, global systolic dysfunction, without regional variation, is more suggestive of nonischemic cardiomyopathy. Severe regurgitant valvular heart disease, such as mitral and aortic regurgitation, can lead to a use of contrast agents in echocardiography
As early as the late 1960s, it was noted that intravascular injection of almost any solution resulted in a contrast effect detectable by echocardiography. Contrast microbubbles are used nowadays to complement the imaging process in ultrasound. The advances in imaging modalities in the modern ultrasound systems in tandem with the development of newer agents has made contrast imaging more effective and applicable in daily clinical practice.
Table 8
Reference Limits and Partition Values of Right Ventricular Size
Reference range Mildly abnormal Moderately abnormal Severely abnormal
RV Dimensions
Basal right ventricular 2.0-2.8 2.9-3.3 3.4-3.8 >3.9
diameter (RVD1) (cm)
Mid right ventricular 2.7-3.3 3.4-3.7 3.8-4.1 >4.2
diameter (RVD2) (cm)
Base-to-apex length 7.1-7.9 8.0-8.5 8.6-9.1 >9.2
Table modified from Recommendations for Chamber Quantification. American Society of Echocardiography (ASE), 2005.
Table 9
Reference Limits and Partition Values of Right Ventricular Size and Function as Measured in the Apical Four-Chamber View
Reference range Mildly abnormal Moderately abnormal Severely abnormal
Right ventricular diastolic area (cm2) 11-28 29-32 33-37 >38
Right ventricular systolic area (cm2) 7.5-16 17-19 20-22 >23
Right ventricular fractional area 32-60 25-31 18-24 <17
Table modified from Recommendations for Chamber Quantification. American Society of Echocardiography (ASE), 2005.
Contrast agents are encapsulated bubbles of gas smaller than the red blood cells and, therefore, capable of circulating freely within the body. The use of contrast dates back to 1968 when Gramiak and Shah first used injected saline to enhance the signals from the blood pool. This was followed years later by encapsulated air bubbles, and more recently by the use of encapsulated low solubility gas bubbles (such as perfluorocarbons). These newer agents are capable of passing through the pulmonary circulation without destruction.
Contrast agents approved for use in the United States to improve LV opacification (LVO) in technically difficult echocardiograms include Optison®, an octafluoro-propane within albumin microspheres, Definity™, an octafluoropropane in a phospholipid shell, and Imavist®, a perfluorohexane and other perfluorocarbon gases encapsulated within a surfactant shell. In Europe, SonovueTM, which contains sulfur hexafluoride in a phospholipid shell, is widely used.
The ideal contrast agent should be a nontoxic, easily injectable intravenously (as a bolus or infusion) and should remain stable during cardiac and pulmonary passage for the duration of the ultrasound examination.
The agent should have strong echogenic interaction in response to incident ultrasound waves.
Preparation and Administration of the Contrast Agent
The ASE recommends that cardiac sonographers take the appropriate steps to become trained in the preparation and administration of contrast agents. The sono-grapher is often the first person to recognize the need for contrast, but the physician is ultimately responsible for prescribing its use, which should be done on a case-by-case basis.
Venous access and appropriate instrument settings should be performed prior to preparation of the contrast agent. Each agent has a different method of preparation and administration. Each manufacturer's separate instructions should therefore be followed. The choice between bolus vs continuous infusion depends on the indication for the study and the type of information required. Bolus administration is easier to perform and is sufficient for LVO and Doppler enhancement. However, continuous infusion may be required for myocardial perfusion studies and quantitative analysis. A registered nurse or physician usually administers the injection or infusion of the contrast agent while the sonographer acquires the images.
The mechanical index (MI) represents the normalized energy to which a target (such a bubble) is exposed in an ultrasound field. It gives an estimate of the peak negative pressure to which tissue is exposed. In simple terms, the MI is the intensity of the transmitted ultrasound beam. It varies with the depth in the image. In most of the ultrasound systems, the MI ranges from 0.1 to 2.0. In the absence of attenuation, the MI is maximal at the focus of the ultrasound beam.
Gas bubbles are very effective scatterers of ultrasound waves within the diagnostic frequency range compared to solids. The degree of scattering increases as the MI is increased. Echo signals from microbub-bles contain harmonics, which can be detected. Bubble destruction at high MI emits a strong harmonic echo.
There are three main patterns of scattering produced by microbubbles, depending on the peak pressure of the incident sound field. At a peak pressure of less than 100 kPa (MI < 0.1), bubbles produce "linear" oscillations resulting in backscatter enhancement. During this low MI imaging, bubbles act as simple, but powerful, echo enhancers. This is the principle utilized for enhancing spectral Doppler such as in pulmonary venous flow signals. At a peak pressure of 100 kPa to 1 MPa (MI 0.1-1.0), there is "nonlinear" oscillation resulting in harmonic backscatter. This principle is utilized in harmonic B-mode LVO and real-time perfusion imaging. At a peak pressure of more than 1 MPa (MI > 1.0), there is bubble disruption resulting in transient harmonic echoes. This is the principle utilized in power Doppler imaging.
Conventional grayscale imaging results in linear backscatter, and, hence, is useful for enhancement of the LV cavity, providing better endocardial definition (see Fig. 7B). The concept of "harmonic imaging" emerged from the observation that "nonlinear" oscillations of the microbubbles results in the generation of "second harmonics." Therefore, imaging can be improved by preferential detection of these "second harmonics" that emanate directly from the microbubbles themselves rather than the tissue. In harmonic B mode imaging, the transmitted frequency typically lies between 1.5 and 3 MHz and the received frequency between 3 and 6 MHz to enable detection of these bubble harmonics.
"Contrast-Specific" Imaging Modalities
Although harmonic imaging improves visualization of bubble harmonics, it imposes some fundamental limitations in bandwidth and hence fails to completely suppress the tissue harmonics. Detection of bubbles in myocardial capillaries (i.e., perfusion), therefore, would require tedious off-line background subtraction to suppress the echoes produced by the tissue. To overcome this, "contrast specific" methods are required for assessment of myocardial perfusion by enhancing contrast harmonics while suppressing tissue harmonics.
Examples of such modalities are:
1. Pulse inversion: high MI technique. By sending two pulses (one inverted) in rapid succession toward the tissue, summation occurs and results in a strong harmonic signal that is exclusively from the microbub-bles. However, wall motion artifacts could still attenuate image quality.
2. Harmonic power Doppler: intermittent imaging (high MI technique). The strong, transient echoes produced by bubble destruction provide a highly sensitive method of imaging the microbubbles. The disadvantage is that wall motion (which produces a Doppler shift), is also detected and this potentially interferes with image quality.
3. Low power "real-time" contrast imaging (power pulse inversion/power modulation/coherent imaging): this is a nondestructive, continuous real-time imaging (low MI) technique. In this mode, sequences of more than two pulses are transmitted in alternating phase. Although the sensitivity may be slightly lower than the high power technique, this method allows wall motion information to be available without the need for bubble disruption. This method is much easier to use and avoids many artifacts that occur with high power harmonic imaging. The echoes from the bubbles are well separated from those of tissues, thereby providing better characterization of "realtime" myocardial perfusion.
Clinical Uses of Contrast Echocardiography LV Opacification
One of the most common clinical indications for echocardiography is in the assessment of regional and global LV function. This should be accurate and reproducible. A pre-requisite for reliable assessment of LV function is accurate visualization of the endocardium. In up to 20% of resting studies, endocardial border definition is suboptimal—defined as the inability to visualize at least two myocardial segments of the LV. The advent of tissue harmonic imaging has significantly improved endocardial definition compared to fundamental imaging.
Fig. 25. Frame (i) is immediately following a high power ultrasound flash that destroys the microbubbles within the myocardium. Frames (ii) to (iv) show replenishment of microbubbles in the septum and lateral walls within two heartbeats. A clear apical perfusion defect (A) that persists is demonstrated. (Reproduced with permission from R Janardhanan, et al. Myocardial contrast echocardiography: a new tool for assessment of myocardial perfusion. Ind Heart J 2005;57:210-216.)
Fig. 25. Frame (i) is immediately following a high power ultrasound flash that destroys the microbubbles within the myocardium. Frames (ii) to (iv) show replenishment of microbubbles in the septum and lateral walls within two heartbeats. A clear apical perfusion defect (A) that persists is demonstrated. (Reproduced with permission from R Janardhanan, et al. Myocardial contrast echocardiography: a new tool for assessment of myocardial perfusion. Ind Heart J 2005;57:210-216.)
Nevertheless, 5-10% of studies employing tissue harmonics imaging are still suboptimal.
The primary clinical use of contrast echocardiography is for LVO (Chapter 5, Fig. 7B; Chapter 8, Figs. 8 and 10). By injecting microbubbles that traverse the pulmonary circulation, the LV can be opacified and endocardial definition significantly improved. Studies using contrast-enhanced LVO have shown excellent correlation with MRI in the determination of LV volumes and EF. Currently, this use is the only Food and Drug Administration-approved indication for echocardiography contrast agents.
Many studies have shown the incremental value of using contrast agents to improve image quality, the percentage of wall segments visualized, and the confidence of interpretation of resting and stress echocardiography images (Chapter 8, Figs. 8 and 10). Contrast agents in stress echocardiography should be used whenever resting image quality is suboptimal.
Contrast agents can assist in the identification of LV thrombi. Approximately 15-45% of echocardiography studies may fail to identify a LV thrombus. Fundamental imaging from the apical windows may fail to detect apical LV thrombi owing to near-field artifacts. The use of contrast agents permits almost 90% of initially nondiagnostic images to become diagnostic.
The accuracy of spectral Doppler velocity measurements depends on obtaining a clear envelope of the Doppler signal. The quality of Doppler recordings, e.g., tricuspid regurgitation velocity, pulmonary venous signals, and so on, can be augmented by using contrast agents. Contrast agents may also be useful in the detection of suspected intracardiac and intrapulmonary shunts.
Echocardiography Contrast Agents vs Saline Contrast. Echocardiography contrast agents that traverse the pulmonary circulation differ from agitated saline contrast used for detecting intracardiac shunts. Saline bubbles do not traverse the pulmonary circulation, except when an arterio-venous malformation is present. Because they do not traverse the pulmonary circulation, agitated saline contrast provide no LVO under normal conditions. Echocardiographic contrast agents that traverse the pulmonary circulation should not be used to diagnose intracardiac shunts.
Myocardial contrast echocardiography (MCE) can accurately assess both myocardial blood volume and microbubble velocity (both of which determine myocardial blood flow). Although not yet licensed for this indication, MCE shows great potential as a clinical tool to evaluate myocardial perfusion.
MCE may be superior to techniques like sestamibi SPECT in the detection of myocardial perfusion. This is most likely explained by the superior temporal and spatial resolution of MCE over SPECT. Furthermore, MCE can be performed at the bedside and does not involve ionizing radiations.
MCE detects contrast bubbles at the capillary level within the myocardium and hence, is marker of capillary integrity. This is the principle behind the use of MCE in patients post-MI in the detection of myocardial viability (Fig. 25).
Safety Considerations. Current contrast agents have an excellent safety profile, and complications are rare. Allergic reactions have been occasionally reported. However, in patients with intracardiac or intrapulmonary right-to-left shunts, the potential for adverse events are slightly greater. There are conflicting reports of increased frequency of premature ventricular complexes especially with high MI-triggered imaging. However, this has not been shown in larger studies.
suggested reading
2001 Heart and stroke statistical update. Dallas: American Heart
Association, 2000. Amico AF, Lichtenberg GS, Reisner SA, Stone CK, Schwartz RG, Meltzer RS. Superiority of visual versus computerized echocardiography estimation of radionuclide left ventricular ejection fraction. Am Heart J 1989;118:1259-1265. Bax JJ, Marwick TH, Molhoek SG, et al. Left ventricular dyssyn-chrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation. Am J Cardiol 2003;92:1238-1240. Becher H, Burns PN. Handbook of Contrast Echocardiography: LV function and Myocardial Perfusion. Frankfurt: Springer-Verlag, 2000.
Birnbaum Y, Luo H, Nagai T, et al. Noninvasive in vivo clot dissolution without a thrombolytic drug: recanalization of throm-bosed iliofemoral arteries by transcutaneous ultrasound combined with intravenous infusion of microbubbles. Circulation 1998;97:130-134. Boersma E, Poldermans D, Bax JJ, et al. DECREASE Study Group (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiogrpahy). Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobuta-mine echocardiography, and beta-blocker therapy. JAMA 2001;285:1865-1873.
Bommer WJ, Shah PM, Allen H, et al. The safety of contrast echocardiography: report of the Committee on Contrast Echocardiography for the American Society of Echocardiography. J Am Coll Cardiol 1984;3:6-13.
Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002;105:539-542.
Cho GY, Park WJ, Han SW, Choi SH, Doo YC, Oh DJ, Lee Y. Myocardial systolic synchrony measured by Doppler tissue imaging as a role of predictor of left ventricular ejection fraction improvement in severe congestive heart failure. J Am Soc Echocardiogr 2004;17:1245-1250.
Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial. Lancet 2001;357:1385-1390.
Devereux RB, Alonso DR, Lutas EM, et al. Echocardiography assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol 1986;57:450-458.
Devereux RB, Roman MJ, Palmieri V, et al. Left ventricular wall stresses and wall stress-mass-heart rate products in hypertensive patients with electrocardiographic left ventricular hypertrophy: the LIFE study. Losartan Intervention For Endpoint reduction in hypertension. J Hypertens 2000;18:1129-1138.
Devereux RB, Wachtell K, Gerdts E, et al. Prognostic significance of left ventricular mass change during treatment of hypertension. JAMA 2004;292:2350-2356.
Dickstein K, Kjekshus J; OPTIMAAL Steering Committee of the OPTIMAAL Study Group. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocar-dial infarction: the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan. Lancet 2002;360:752-860.
Effect of ramipril on mortality and morbidity of survivors of acute myocardialinfarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet 1993;342:821-828.
Gallik DM, Obermueller SD, Swarna US, et al. Simultaneous assessment of myocardial perfusion and left ventricular function during transient coronary occlusion. J Am Coll Cardiol 1995;25: 1529-1538.
Gillebert TC, Van de Veire N, De Buyzere ML, De Sutter J. Time intervals and global cardiac function. Use and limitations. Eur Heart J 2004;25:2185-2186.
Givertz MM, Colucci WS, Braunwald E. Clinical aspects of heart failure; pulmonary edema, high-output failure. In: Brauwald's heart disease: a textbook of cardiovascular medicine, 7th ed. Zipes DP, Libby P, Bonow RO, Braunwald E (eds). Philadelphia: Elsevier Saunders 2005;539-568.
Gopal AS, Shen Z, Sapin PM, et al. Assessment of cardiac function by three-dimensional echocardiography compared with conventional noninvasive methods. Circulation 1995;92:842-853.
Hammermeister KE. Survival in patients with coronary disease. Circulation 1979;60:1427.
Janardhanan R, Dwivedi G, Hayat S, Senior R. Myocardial contrast echocardiography: a new tool for the assessment of myocardial perfusion. Ind Heart J 2005;57:210-216.
Janardhanan R, Moon JCC, Pennell DJ, Senior R. Myocardial contrast echocardiography accurately reflects transmurality of myocardial necrosis and predicts contractile reserve after acute myocardial infarction. Am Heart J 2005;149:355-362.
Janardhanan R, Senior R. Accuracy of dipyridamole myocardial contrast echocardiography for the detection of residual stenosis of the infarct related artery and multivessel disease early after acute myocardial infarction. J Am Coll Cardiol 2004;43: 2247-2252.
Janardhanan R, Swinburn JMA, Greaves K, Senior R. Usefulness of myocardial contrast echocardiography using low-power continuous imaging early after acute myocardial infarction to predict late functional ventricular recovery. Am J Cardiol 2003;92:493-497.
Jessup M, Brozena S. Heart failure. N Engl J Med 2003 ;348: 2007-2018.
Kaul S. Myocardial contrast echocardiography: 15 years of research and development. Circulation 1997;96:3745-3760.
Khand A, Gemmel I, Clark AL, Cleland JG. Is the prognosis of heart failure improving? J Am Coll Cardiol 2000;36:2284-2286.
Kober L, Torp-Pedersen C, Carlsen JE, et al. A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group. N Engl J Med 1995;333:1670-1676.
Konstam MA. Progress in heart failure management? Lessons from the real world. Circulation 2000;102:1076-1078.
Kotler MN, Segal BL, Mintz G, Parry WR. Pitfalls and limitations of M-mode echocardiography. Am Heart J 1977;94:227-249.
Massie B. Heart failure: pathophysiology and diagnosis. In: Cecil textbook of medicine, 22nd ed.
McMurray J, Ostergren J, Pfeffer M, et al.; CHARM committees and investigators. Clinical features and contemporary management of patients with low and preserved ejection fraction heart failure: baseline characteristics of patients in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme. Eur J Heart Fail 2003;5:261-270.
McMurray JJ, Ostergren J, Swedberg Km et al.; CHARM Investigators and Committees. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. Lancet 2003;362:767-771.
Mueller X, Stauffer JC, Jaussi A, Goy JJ, Kappenberger L. Subjective visual echocardiographic estimate of left ventricular ejection fraction as an alternative to conventional echocardio-graphic methods: comparison with contrast angiography. Clin Cardiol.1991;14:898-902.
Mulvagh SL, DeMaria AN, Feinstein SB, et al. Contrast echocardio-graphy: current and future applications. J Am Soc Echocardiogr 2000;13:331-342.
Naik MM, Diamond GA, Pai T, Soffer A, Siegel RJ. Correspondence of left ventricular ejection fraction determinations from two-dimensional echocardiography, radionuclide angiography and contrast cineangiography. J Am Coll Cardiol 1995;25:937-942.
Palmieri V, Bella JN, Arnett DK, et al. Impact of type II diabetes on left ventricular geometry and function: the Hypertension Genetic Epidemiology Network (HyperGEN) Study. Circulation 2001;103:102-107.
Pitt B, Remme W, Zannad F, et al. Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;348:1309-1321.
Rasmussen S, Corya BC, Phillips JF, Black MJ. Unreliability of M-mode left ventricular dimensions for calculating stroke volume and cardiac output in patients without heart disease. Chest 1982; 81:614-619.
Roberto M. Lang et al. Recommendations for Chamber Quantification. A report from the American Society of Echocardiography's Nomenclature and Standards Committee and the Task Force on Chamber Quantification, developed in conjunction with the American College of Cardiology Echocardiography Committee, the American Heart Association, and the European Association of Echocardiography, a branch of the European Society of Cardiology, 2005 (in press).
Roman MJ, Pickering TG, Schwartz JE, Pini R, Devereux RB. The association of carotid atherosclerosis and left ventricular hypertrophy. J Am Coll Cardiol 1995;25:83-90.
Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements. Circulation 1978;58: 1072-1083.
Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements. Circulation. 1978; 58:1072-1083.
Schiller NB, Acquatella H, Ports TA, et al. Left ventricular volume from paired biplane two-dimensional echocardiography. Circulation 1979;60:547-555.
Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocar-diography. J Am Soc Echocardiogr 1989;2:358-367.
Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 1989;2:358-367.
Schnittger I, Gordon EP, Fitzgerald PJ, Popp RL. Standardized intracardiac measurements of two-dimensional echocardiogra-phy. J Am Coll Cardiol 1983;2:934-938.
Senior R, Soman P, Khattar RS, et al. Improved endocardial visualization with second harmonic imaging compared with fundamental two-dimensional echocardiographic imaging. Am Heart J 1999;138:163-168.
Shiina A, Tajik AJ, Smith HC, Lengyel M, Seward JB. Prognostic significance of regional wall motion abnormality in patients with prior myocardial infarction: a prospective correlative study of two-dimensional echocardiography and angiography. Mayo Clin Proc 1986;61:254-262.
Shohet RV, Chen S, Zhou YT, et al. Echocardiographic destruction of albumin microbubbles directs gene delivery to the myocardium. Circulation 2000;101:2554-2556.
St. John Sutton M, Pfeffer MA, Moye L, et al. Cardiovascular death and left ventricular remodeling two years after myocar-dial infarction: baseline predictors and impact of long-term use of captopril: information from the Survival and Ventricular Enlargement (SAVE) trial. Circulation 199718;96: 3294-3299.
Stevenson WG, Stevenson LW, Middlekauff HR, et al. Improving survival for patients with atrial fibrillation and advanced heart failure. J Am Coll Cardiol 1996;28:1458-1463.
Stevenson WG, Stevenson LW, Middlekauff HR, et al. Improving survival for patients with advanced heart failure: a study of 737 consecutive patients. J Am Coll Cardiol 1995;26:1417-1423.
Sugishita Y, Iida K, Ohtsuka S, Yamaguchi I. Ventricular wall stress revisited. A keystone of cardiology. Jpn Heart J 1994;35: 577-587.
Tei C, Ling LH, Hodge DO, et al. New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function—a study in normals and dilated cardiomyopathy. J Cardiol 1995;26:357-366.
Teichholz LE, Kreulen T, Herman MV, Gorlin R. Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence of absence of asynergy. Am J Cardiol 1976;37:7-11.
Thanigaraj S, Schechtman KB, Perez JE. Improved echocardiography delineation of left ventricular thrombus with the use of intravenous second generation contrast image enhancement. J Am Soc Echocardiogr 1999;12:1022-1026.
The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992;327: 685-691.
The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991;325:293-302.
Timperley J, Mitchell ARJ, Becher H. Contrast echocardiography in left ventricular opacification. Heart 2003;89:1394-1397.
Vasan RS, Larson MG, Benjamin EJ, Evans JC, Levy D. Left ventricular dilatation and the risk of congestive heart failure in people without myocardial infarction. N Engl J Med 1997;336: 1350-1355.
Verdecchia P, Schillaci G, Borgioni C, et al. Prognostic significance of serial changes in left ventricular mass in essential hypertension. Circulation 1998;97:48-54.
Waggoner AD, Ehler D, Adams D, et al. Guidelines for the cardiac sonographer in the performance of contrast echocardiography: Recommendations of the American Society of Echocardiography Council on Cardiac Sonography. J Am Soc Echocardiogr 2001; 4:417-420.
Wei K, Jayaweera AR, Firoozan S, et al. Quantification of myocardial blood flow with ultrasound-induced destruction of microbubbles administered as a constant venous infusion. Circulation 1998; 97:473-483.
Zornoff LA, Skali H, Pfeffer MA, et al. SAVE Investigators. Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction. J Am Coll Cardiol 2002;39:1450-1455.
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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...
Where to measure Pulmonary Regurge ED velocity echo?
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Poet in New York is one of the most important books written by Lorca. It was produced while Federico García Lorca was a student at Columbia University in 1929-30. During his stay the stockmarket crashed in October 1929, an event which profoundly affected his poetic vision.
Here you can see different projects about the poems by students of 2 Bachillerato at IES Mediterráneo:
From Granada to New York by Julia Escámez
Poet in New York by Natalie Giles

subset: commoncrawl


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Babcock, Mary Reynolds
By Hubert K. Wooten, 1979
8 Aug. 1908–17 July 1953
Mary Reynolds Babcock, philanthropist, was born in Winston of Scottish ancestry. Her father was R. J. Reynolds, founder of R. J. Reynolds Tobacco Company; her mother was Katherine Smith Reynolds. As a young girl, she attended a private school at Reynolda, the family estate. She later attended Salem Academy and Miss Wright's School in Bryn Mawr, Pa. After her graduation she spent several months in Paris studying art. On 16 Dec. 1929 she married Charles Henry Babcock, an investment banker from Philadelphia. They lived for a time in Greenwich, Conn., but moved to Winston-Salem in 1934 when she acquired Reynolda.
In 1936, when Mrs. Babcock inherited $30 million from her father, she was described as one of the richest women in the world. Her primary interest was in helping others, and she contributed generously to many worthwhile causes. In 1951 she and her husband gave three hundred acres at Reynolda to Wake Forest College, and the college moved from Wake County to Winston-Salem, where a completely new campus was built. Her will provided $12 million for a charitable trust, and the Mary Reynolds Babcock Foundation was established at Reynolda with her husband as the first chairman of the board. Since 1954, the foundation has contributed generously to Wake Forest University and to other organizations, particularly those concerned with private higher education, social welfare, and the arts.
Mary Reynolds Babcock was shy and retiring. She enjoyed a limited circle of friends and delighted in collecting recipes and growing flowers, but her primary interest was philanthropy.
She was the mother of Mary Katherine, Barbara, Betsy Main, and Charles Henry, Jr. One portrait of her hangs in Babcock Dormitory, Salem College, and another in the offices of the Mary Reynolds Babcock Foundation at Reynolda. She died in New York City and was buried in Winston-Salem.
Mary Reynolds Babcock Foundation Annual Report, 1973
New York Times , 18 and 19 July 1953, 19 Aug. 1953
Winston-Salem Journal , 18 July 1953
Winston-Salem Twin City Sentinel , 18 July 1953
Image Source:
"Charles Henry Babcock family, 1937." Image courtesy of Digital Forsyth."Charles Henry Babcock family, 1937. Mr. Babcock is standing, with Charles Jr. and Mary Katherine in front of him. Mrs. Babcock (Mary Katherine Reynolds) is seated, with Barbara Frances Babcock at her side." Available from http://www.digitalforsyth.org/photos/11688 (accessed April 4, 2012).
1 January 1979 | Wooten, Hubert K.
Mary Reynolds Babcock has
Mary Reynolds Babcock has been such an interest. She was a very meticulous flower arranger. I believe she truly loved flowers! I chaired the flower arranging committee at Reynolda House for a number of years. Mrs. Babcock left an inspired legacy which is still felt today throughout Winston-Salem.
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Posted at 12:01 am February 21, 1988, in Earlier Press Releases and Polls, Rutgers-Eagleton Poll
New Jerseyans have grown significantly more concerned about AIDS over the last two years, to the point that more than 6-in-10 now say it is a "very serious" threat to the general public here in New Jersey. Also, according to the latest Star-Ledger/Eagleton Poll, most residents believe AIDS is likely to spread beyond certain high risk groups and become a serious health threat to the population at large.
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Celebrating the Taste of Winter in Sigulda
12:00 - 16:00
The event will take place at the majestic Sigulda Livonion Castle, built in the 13th Century, where guests will be able to celebrate this magnificent time of the year by enjoying wintertime dishes prepared by the Riga and Gauja region's best chefs.
We invite guests to dress accordingly taking into account the weather, and come enjoy some winter fun in Sigulda!
Venue name:
Livonijas ordeņa Siguldas pils
Pils iela 18, Sigulda, LV-2150


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What are eating disorders?
Eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder, are mental disorders that involve extreme disturbances in eating behaviour and the persons perception of their body and weight. Eating disorders often co-occur with other mental disorders, such as obsessive-compulsive disorder, anxiety disorder, depression, substance abuse, or the person may engage in self-harming behavior. It is important to identify and address these co-occurring disorders if they are present. Eating disorders can affect both men and women, and it is important that young men also receive screening and care for eating disorders if necessary.
Anorexia nervosa is an eating disorder where you worry about your weight, want to lose weight and eat less and less food in an attempt to lose weight. If untreated, anorexia has the potential to become life-threatening. Anorexia has the highest death rate of any mental disorder, and without treatment, up to 20% of people with a serious eating disorder will die.
General symptoms of anorexia:
- Eating very little, or nothing at all
- Compulsively exercising
- Constantly worrying about the amount of calories in your meal
- Feeling anxious about eating in front of others or having a big meal
- Always feeling fat despite current weight or weight-loss
- Obsession with body image and comparing your body to others
- Low mood and irritability
- Losing lots of weight over a short period of time
- Monthly periods stopping or being unable to have an erection
- Feeling cold all the time
- Growing new downy hair on your body
- Insomnia
- Constipation
- Skin rash or dry skin
Bulimia nervosa is an eating disorder where you get into a cycle of overeating and then making yourself sick to try to control your weight. People who have bulimia typically appear to be of normal weight or overweight, rather than being extremely thin.
General symptoms of bulimia:
- Obsessive thoughts about your weight
- Binge eating (eating a large amount of food in a very short period of time)
- Exercising compulsivly
- Isolating yourself
- Poor sleep
- Low mood
- Sore throat (from vomiting)
- Dehydration
- Feeling weak and tired
- Damaged teeth (from vomiting)
- Heart problems
- Muscle spasms
- Swollen glands
- Change in monthly periods
- Stomach cramps
Binge eating disorder is a common eating disorder where you frequently eat large amounts of food while feeling powerless to stop and extremely distressed during or after eating. During a binge, you may eat even when you're not hungry and continue eating long after you're full. Unlike in bulimia, however, there are no regular attempts to "correct" for the binges through vomiting, fasting, or over-exercising.
General symptoms of binge eating disorder:
- The inability to stop eating or control what you're eating
- Eating large amounts of food very quickly
- Eating even when you're full
- Hiding or stockpiling food to eat later in secret
- Eating normally around others, but bingeing when you're alone
- Eating continuously throughout the day, without any planned mealtimes
- Feeling stress or tension that is only relieved by eating
- Feeling embarrassment over how much you're eating
- Feeling like you're not really there or you're on auto-pilot while bingeing
- Never feeling satisfied, no matter how much you eat
- Feeling guilty, disgusted, or depressed after overeating
- Desperation to control weight and eating habits
How do eating disorders affect young people?
According to the Healthy Teen Project:
95% of people with eating disorders are between the ages of 12 and 25
40-60% of girls between ages 6-12 are concerned about their weight or about becoming overweight
Among high-school students, 44% of females and 15% of males attempt to lose weight
Over one half of teenage girls and nearly one third of teenage boys use unhealthy weight control behaviours, such as skipping meals, fasting, smoking cigarettes, or purging
Eating disorders can affect people of all ages; however the onset of eating disorders typically occurs during pre-adolescence or adolescence. Puberty is a time when many young people feel self conscious about their physical appearance, and studies have shown that for many teenagers the onset of their eating disorder involved comments or teasing by peers or family members, usually about appearance.
Feeling shame, or being shamed, based on size or physical appearance can be powerful contributors to a teenager developing an eating disorder. Eating disorders affect millions of adolescents and young adults around the world. Given the serious medical complications that may result from eating disorders, it is very important to identify, diagnose and treat them as early as possible. If untreated, eating disorders may lead to serious health complications, hospitalisation, and even death.
What causes eating disorders?
Eating disorders are complex disorders, and their development is usually influenced by a number of factors. These include:
Genetics. Some people may have genes that leave them more vulnerable to eating disorders. Your chances of having an eating disorder are higher if you have a close relative who has or had the same condition.
Mental health problems. Emotional and psychological problems, such as low self-esteem, depression, anxiety, and obsessive compulsive disorder may all contribute to the development of an eating disorder.
Trauma. People who have experienced sexual or physical abuse or who have suffered some other form of trauma, may be more likely to develop an eating disorder.
Societal causes. Images in the media and peer pressure will often reinforce a negative body image, making young people more vulnerable to eating disorders.
Eating disorders can be treated. The first step is to see a mental health professional who will be able to make a formal diagnosis. Based on the diagnosis and your individual needs, a treatment plan will then be developed.
Treatment for eating disorders usually involves a multidisciplinary approach, and could include medical supervision, individual therapy, family therapy, and nutritional rehabilitation to restore health and body weight and change behaviours related to eating and exercise.
Medication may be required if certain mental disorders are also present; most commonly depression and anxiety disorders. The young person may have obsessive-compulsive disorder or tendencies, and may also suffer from trauma or substance abuse, or engage in self-harming behavior. It is important that eating disorder treatment works to identify and address these co-occurring disorders. Treatment helps the person recovering from an eating disorder create a healthier relationship with food and their bodies.
If you or someone you know has an eating disorder, you can contact Eating Disorders South Africa for more information and help in finding treatment.


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West Africa Meets South Africa Through Film ' Potato Potahto' – 38th Durban International Film Festival (DIFF) 2017
After a Cannes Film Festival premiere earlier in May, the star studded Shirley Frimpong Manso romantic comedy 'Potato Potahto' will premiere at the 38th Durban International Film Festival on Sunday, 16 July 2017 at 18h00 at the Gateway Theatre of Shopping in Durban.
Media interviews, Q & A sessions with the cast, directors and producers will be held before and after the film screening.
The delegates of the 38th Durban International Film Festival and the general public can look forward to seeing the award winning Shirley Frimpong-Manso, OC Ukeje, Joselyn Dumas, Nollywood veteran Joke Silva, Blossom Chukwujekwu, Lala Akindoju, Chris Attoh and Adjetey Anang.
Potato Potahto tells a story of a divorced couple who decides to share equal space in their ex-matrimonial home soon realise that the ingenious idea is easier said than done.
Bent on flexing their egos and scoring points, Tony (OC Ukeje) and Lulu (Joselyn Dumas) implore various hilarious tactics that soon inflames emotions and turns an already complicated situation into a roller coaster ride.
The film is a collaborative project between Ghanaian, Nigerian, British, French and Swedish film producers, who have co-produced with the aim to make African-made cinema more accessible to global markets.
The film is a fantastic showcase of how international co-operation, talent and creativity can combine to give a wonderful and universally attractive film experience.
Potato Potahto is a co-production of Ascend Studios, WB Entertainment, 19 April Entertainment, Virgo Sun Ltd and Lufodo Productions.
"The film has a fantastic creative team behind it and is definitely worth seeing and we look forward to a full house during the screenings on 16 July and 18 July in Durban at the Film Festival," said film producer, Inya Lawal.


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2017 W Jesse James Rd
Excelsior Springs, MO 64024-1853
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Structure My Deal tools are complete — you're ready to visit Heartland Chrysler Dodge Jeep Ram!
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By submitting your contact information, you consent to be contacted by telephone about purchasing a vehicle or obtaining vehicle financing. Clicking on the Submit button above is your electronic signature.


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This calculator will help you decide on the size of heater needed for your greenhouse, based upon your climate, desired greenhouse temperature, and the greenhouse covering. This calculator is designed for sizing a greenhouse heater, but it also works with other structures if you know the R- or U-factors.
Please note that this is an estimator only, and we offer no guarantee as to the reliability of these numbers. We recommend that you use this calculator for preliminary sizing work, and then consult a heating professional. Your orchid investment is worth the extra effort!
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In his afterword, author Casey Glanders says that he wanted to write an adventure story involving a female lead that didn't revolve around romance.
The author is trying to make a point (we think) about the preponderance of genre stories in which female protagonists are 1) consumed with love beyond everything else, and 2) subservient to a male character's agenda. To this we say "Right on."
But we also have to ask: "What's wrong with a little romance?" Surely Lady Sif, Big Barda, and Diana Prince all have time for matters of the heart? Why deny them a little happiness?
Don't get us wrong. We enjoyed Glanders' novel. It's actually quite good. It features a quirky heroine and her circle of morally flexible acquaintances. But we think the story would have been even better with some kind of romantic hook. Even a kick-ass superhero like Annalicia May Gailsone (code name: Dyspell) deserves a little love.
Gailsone was once second-in-command at Purge, a Hydra-like organization of super criminals. She was born with black magic powers that enabled her to rot, decompose, and break down any substance known to man. "While that alone was frightening, her unbridled mastery of it had been enough to earn her the title of Deadliest Woman in the World." She was also known as the Dark Witch of Entropy and the Queen of Pain.
But all things come to an end. Gailsone (and her adopted niece, Allison) saw an opportunity to defect from Purge when the Open Hand Act offered amnesty to all supervillains. It was time for Dyspell to change teams and become a superhero. Wave goodbye to Purge and say hello to the Collective Good.
Her first assignment out of the gate was to travel to Japan and recruit and reform Lotus, the second deadliest woman in the world. Immediately Gailsone butts heads with the Dead Talon (a ruthless yakuza gang), an over-zealous industrialist, an underground spy network of kitsune soldiers, a golem that walks the streets of Tokyo dressed in Gundam-like mecha, and (of course) Lotus herself, the chief assassin for the Dead Talon.
Naturally, things don't go smoothly for our newly christened hero. Yes, Dyspell ultimately completes her assignment and brings Lotus back the U.S. But in doing so she leaves a trail of death and destruction all over Japan. Annalicia May Gailsone was supposed to be one of the good guys now. But it turns out that she was very, very bad at it.
[Gailsone: Big in Japan / By Casey Glanders / First Printing: November 2013 / ISBN: 9781494283773]


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Lately, I have been thinking of upgrading my Alto with a Hyundai's. I have been really obsessed with their products, especially Verna. But the barrier was deciding the right selling price at which I should sell it so as to get a good response from buyers and not sound high priced.
Taking heed of my problem, a friend of mine told me about MSP (Maximum Selling Price) Calculator, a new concept by Quikr for finding out what the reasonable price of a used good should be. And since no one (not even the site owners themselves) has control over the variables, so the output price is genuinely reliable. So I finally decided to sell it over Quikr.
Since I now have a roundabout idea of what the exact selling price of my car should be, I can find how much I need to pay from my pocket for my new car. Next I posted an ad on Quikr using the Post Free Ad option. Rather than giving my number publically, I can set it to private and rather use the Facebook type chat system across Quikr's mobile app, mobile site and even the desktop site. This feature has truly transformed India's online classifieds market as it enables users to communicate with each other at their convenience and request more details about the product or service they are providing, without requiring a single phone call. Trust me, the phone call system was truly a pain in the ass. Getting calls from expected buyers every now and then and when most of them were just passing their time.
I now know how much I can expect to be paid for my over-the-hill car. And how much I can invest in buying a new used car from Quikr itself. So I just had a sneak peek at the buying option.
Next going to the Quikr's buy option. >> Cars and Bikes>> Cars>> Select Brand>> Model>> Year>> Fuel Type>> Calculate
From the product options I now had, some had put up a high price on their cars. Maybe they had not used the MSP feature and I realized how great I felt for I had used it. From the thousands of products that filled my PC screen, I chose I handful of products that befitted my requirements and seemed in a good working condition.
I contacted all of them individually with all my queries and dubieties. Chat is such a convenience for people like me who are online for most part of the day. Just as convenient as Facebook or Twitter.
Within a couple of days, I had my old car sold, and new car standing outside my house. I wonder if there is anything as convenient as some Qui(c)k(e)r shopping.
This post is a part of www.Indiblogger.in Contest for www.Quikr.com


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|Back to Career Search
Oenologist (Winemaker)
Not everyone is a wine drinker. But those who are can be fanatical about it. They love to discuss wine, sample wine, and tour through wineries and vineyards, learning all they can about this ancient and revered beverage. People who are truly facisnated by wine, and who are intrigued not only by the taste but by the science of wine, often become enologists.
Enologists, also known as winemakers, are scientists who study enology - the science of wine and winemaking. They often work with wineries, as either a researcher/developer or as the head winemaker. They are the people who make wine, which is basically just grape juice and yeast. The yeast turns the sugar and water in the juice to alcohol and carbon dioxide. Enologists, of course, could explain this natural process in much more scientific terms. Often armed with a university degree in enology, these experts monitor the wine during each step of the process, from watching the grapes on the wine to monitoring the acid, sulfur dioxide, and sugar levels in the fermenting juice. They watch for bacteria, oxygen, and other factors that could damage the final product.
Enologists have sharp senses - their tastebuds and noses are keen and able. They taste each final product, ensuring it is of high quality, and represents their company. If they are the managers or owners of the winery they work with, they are also excellent business people - because even if your wine would suit Dionysius, if you don't have an advertising campaign, your grapes might as well have stayed on the vine.
Interests and Skills
Typical Tasks
Workplaces, Employers and Industries
Long Term Career Potential
Educational Paths
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2014-15 Edition, http://www.bls.gov/ooh/
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Employment Statistics, 2002, http://www.bls.gov/oes/2002/oes_nat.htm
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Who will it affect?
If your organisation meets the qualification criteria you will be obliged to register and participate in CRC. Where an organisation is part of a wider corporate structure, the highest parent organisation or an alternative nominated primary member must act as the participant on behalf of everyone in that group.
Organisations qualify for Phase 2 if during the qualification year (1 April 2012 and 31 March 2013) they had:
at least one settled half hourly electricity meter
consumed at least 6000 megawatt hours (MWh) or more of qualifying electricity supplied on the settled half hourly market
If your organisation meets these criteria you should have registered for Phase 2 of the scheme between 4 November 2013 and 31 January 2014. Some public bodies must participate in CRC no matter how much electricity they consume. These are known as mandated participants. All qualifying organisations must register as participants via the CRC registry.
CRC registration deadline
Registration for CRC phase 2 started on 14 November 2013 and closed on 31 January 2014.
Scheme Administration and Regulation
The Carbon Reduction Commitment (CRC) scheme is administered by the Environment Agency, which also acts as the regulator for England. The other regulators are the Scottish Environment Protection Agency (SEPA), National Resources Wales (NRW) and NIEA.
All participants have to pay a registration fee of £950. You pay this as part of your online registration process. The fee covers the administrative costs of carrying out organisational checks and opening a compliance account on the CRC registry.
An annual subsistence fee is payable to your Regulator, for 2014/15 the fee is £1290.
The annual compliance cycle for Phase II:
|Submit annual report
|by 31 July
|Ordering period for allowances in forecast sale
|1 April to 30 April
|Payment period for forecast allowances ordered
|2 June to 20 June
|Allocation period for forecast allowances
|2 June to 15 July
|Order buy to comply sale allowances
|2 June to 31 July
|Payment for buy to comply sale allowances
|1 Sept to 19 Sept
|Allocation of buy to comply sale allowances
|1 Sept to 15 Oct
|Surrender of allowances
|Last working day October
CRC Registry
Use this account to:
- access and update contact details or organisation details
- notify the Environment Agency of any changes to your organisational structure
- submit your annual report
- order, buy, surrender and transfer allowances
- appoint an agent to act on your behalf
There is a screenshot guide which will help you to use the CRC registry.
For further information on the CRC, please contact us on 028 9056 9299 or email@example.com


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The best ways to start an Indian restaurant food business? To begin the Indian bistro business you should be educated about all assortments of meals that compose Indian food. If you are not a native Indian you should have a brief review. There should be at a minimum 2 major types of foods. The rice and bread are instances for these products.
The garam masala is assumed as the back bone of Indian dishes. The cold, tamarind, ghee, mustard etc are instances for it. There are wide kinds of garam masalas made use of by different dining establishments or households. You will certainly have to select a variety depending upon how you would certainly like your food to be.
The Indian food is not only tasty however additionally healthy. The fruits as well as veggies play a major role in Indian Cuisine so can add a healthy and balanced aspect.
A lot of food needed in Indian food is fairly conveniently offered. You could quickly locate them in markets.
Involving Indian dining establishments, you need to understand pertaining to the South Indian as well as North Indian recipes in India. The principal food product in North India is the wheat. However the main food product in South India is the rice. In the present, the south Indian dishes play a main function to bring in immigrants to India. The meals items in Kerala have a major grip in south Indian meals items. When you are starting your restaurant, you will really want o choose your food and cook
Indian wood furniture is available for a broad assortment of usages. The furniture is available for each room in your house, right from the bed room, the drawing area to the children's play room. Indian wood furnishings is additionally readily available for dining establishments – enabling you to include a quaint touch to your particular bistro. Likewise, Indian bistro furnishings includes the much required touch of Asian art to particular bistros and bars.
Providing a dining establishment or a bar is more hard than a residence, since it is a commercial worry and the furnishings ought to not just fit the customer's demands and be comfy for the individuals, but it ought to also interest the consumers in a certain method. Indian bistro furnishings comprises of several items of furnishings, like the honeycomb wine rack, the wood bar stool, the most elegant seating found, as well as monitors and other decorations to improve the feel and look of the dining establishment, and also to appreciate the privacy of the customers. There are additionally numerous attractive home furnishings, like the big urn, etc that contribute to the result of a real Indian bistro.
Retail bistro furnishings is offered for all type of dining establishments, be it a large banquet hall or a tiny hotel or a quite small eatery. Each of these facilities has their own needs and Indian wood furniture satisfies them. Inexpensive wood resort furnishings is also readily available, for those that are establishing an eating establishment on a spending plan.
Authentic Indian furnishings is a initial and uncommon art, and the individuals readying it are genuine experienced artisans with experience and talent. Indian wood furniture could be readied from assorted types of timber and material, and just the appropriate kind of product will certainly include the much needed ambiance and style to the Indian bistro.
You need to apply a Proper Business Plan to start an Indian dining establishment.
Carry out an effective restaurant business strategy. There are two factors for this –
If you require finance for any kind of factor they will certainly ask you for a company plan
You will desire a road map of where you are going to.
To plan a successful bistro company you will require to make certain you have your finance or cash in spot. The business strategies must team up with your monetary durability.
The final consideration is the existing market. You need to be extremely aware of a present advertising and marketing demands. The Indian bistro company decisions you apply should achieve the client needs and also be something you could give.
There are numerous various other techniques and insight you will certainly require to begin an Indian Restaurant, you will certainly intend to make certain you are prepared to open up an Indian Restaurant prior to you even begin intending any component of it. Read as long as you could to make on your own well readied to succeed.
For patrons venturing to BC in the White Rock and Surrey areas, check out the popular Indian restaurant – Curry Sensation – www.currysensation.ca


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Blues singer Lara Price along with Marianne Adoradio, a founding member of the Silicon Valley Blues Society, have put together a great show to raise money for Next Door Solutions to Domestic Violence.
Girls Got the Blues, an all-female group of singers and musicians led by Price, will take the stage at Theatre on San Pedro Square on Sunday at 8 p.m. What a great way to showcase some of the valley's talented women and recognize Domestic Violence Awareness Month.
I've heard Santa Clara County Supervisor Cindy Chavez has already purchased 10 tickets to bring her staff to the event, which includes a raffle to support Next Door.
Tickets are $20 in advance ($25 at the door) and are available at www.brownpapertickets.com/event/446485.
'YULAN' DELAYED: Visa processing delays for some of its Chinese artists have forced Dennis Nahat's Theatre Ventures International to push back by one week the premiere of its acrobatic ballet, "Yulan." It'll now make its debut at the California Theatre on Oct. 10, with five performances running through Oct. 13.
Also getting moved to the new date are the poolside gala dinner at the Fairmont Hotel and the San Jose-Dublin Sister City program's presentation of its Spirit of Ireland award to KRON-TV news anchor Catherine Heenan. For tickets and more information, go to www.sanjosedublin.org.
ARTISTIC MESSAGE: Congratulations to Evergreen Valley College student Christian Furuta and Pioneer High School junior Mimi Truong. The two San Jose artists won Working Partnerships' anti-smoking poster contest to get the message out to young people and communities of color about the city's outdoor smoking ordinance.
The powerful images — Furuta's oil painting of a smoker being reduced to a skeleton and Truong's drawing of a smoker taking a drag — have been reproduced for posters that'll be place in apartment buildings and outdoor dining areas. Visitors to MACLA's gallery in downtown San Jose voted for their favorite while entries were on display there in August.
IN THE HUDDLE: San Jose's Rose Garden neighborhood is buzzing with word that a member of the San Francisco 49ers has bought one of its gorgeous homes. Rumor has it the player is linebacker NaVorro Bowman, who had a stellar game against the Rams last week.
And while we're talking about football players, former Raider Tony Stewart partnered with Palo Alto mailing company Endicia to host a mini camp Sept. 23 for more than 120 students at Cesar Chavez Academy in East Palo Alto. On top of getting lessons on football drills and life skills, the kids got to meet current Raiders offensive tackle Jared Veldheer and practice squad quarterback Tyler Wilson.
Contact Sal Pizarro at email@example.com. Follow him at Twitter.com/spizarro.


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About us
We are the first
in the world.
What does this mean?
We grow our own vegetables and salads – right before your eyes and for your culinary pleasure. In doing this, we transform unused urban areas into productive farms from which produce can be harvested and used fresh.
We avoid using any kinds of pesticides or genetically modified seeds and protect the environment by removing the need for long cold chains, transportation and packaging waste.
It doesn't get fresher than this – and it's a difference you can taste. Our salad leaves also contain more nutrients than those farmed using conventional agricultural methods.
Naturally conscious
Our vision is to produce all our food self-sufficiently – starting with the three self-grown lettuce and vegetable varieties we currently offer. Others are set to follow.
We hope to play a role in the development and promotion of an increased awareness of sustainability.
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We look forward to your visit!


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Investor Overview
Corporate Profile
Histogenics historically focused on the development of restorative cell therapies, including its product candidate, NeoCart, which is an innovative cell therapy that utilizes various aspects of Histogenics' restorative cell therapy platform to treat tissue injury in the field of orthopedics, specifically cartilage damage in the knee. In the third quarter of 2018, Histogenics announced that its Phase 3 clinical trial of NeoCart did not meet the primary endpoint of a statistically significant improvement in pain and function in a dual threshold responder analysis one year after treatment as compared to microfracture. Based on the totality of the data, Histogenics initiated a dialogue with the FDA in the third quarter of 2018 to discuss the regulatory path forward for NeoCart.... read more
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Staying in a hotel should make you feel like a comfortable and relaxing experience.You want a pleasant experience that does not bust your hard earned money to be uncomfortable and unhappy. Read on for excellent information about picking the ideal hotel.
Check online hotel reviews before making any reservations. This lets you valuable information about the recent experiences of people at each hotel. What people say will help you make a wise decision.
Take advantage of tools provided online hotel searching for a hotel. These websites will help you quickly find great deals.
Check your room ahead of unpacking. Is the room clean and devoid of issues like mildew free? Are linens and towels you'll need present in the room? If you find obvious problems, make the front desk aware immediately so they can take care of it or move you to a room that meets your needs.
Don't make the assumption that all hotels will accept pets.
If you belong to AAA, check into your membership hotel discount. You might be surprised where hidden discounts may be lurking. You can save five percent or more on your hotel stay just by showing your membership card. This is a savings that can really add up on a long trip.
If you want to keep your regular running routine, continue your routine when traveling by bringing running clothes and your GPS.
If you tend to return to the same family of hotels for your vacation, ask about the "frequent stay" program. These programs give you rack up points. These points can be traded in for restaurant discounts, tickets to shows, free nights at the hotel, much more.
If you care about the environment, you may want to take a "green" vacation. The number of green hotels is steadily growing. Some of the newer hotels are built to green standards and are certified to be green. Some hotels simply choose a variety of eco-friendly practices to be environmentally aware. Talk with a travel agent in order to find green hotels for your needs.
The timing for your booking of a hotel room has much to do with what you book it. Rooms are often priced based on availability. This will usually ensure that you the very best hotel rates.
You can avoid disappointment on your vacation. With what you've gone over in the article above, you'll have an easier time getting a good hotel. By being informed, you will be able to select the best hotel room for you.


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Ships from the Japanese whaling fleet head south with the intention to kill and "process" more than 1000 whales in the Southern Ocean Whale Sanctuary.
The fleet intends to kill more than 1,000 whales while in the Southern Ocean, including 50 endangered fin whales, 50 threatened humpback whales and 935 minke whales.
The Greenpeace ship Esperanza is standing by off the coast of Japan. You can read the crew blog here or check out the live webcam.
Despite claims that the Japanese are conducting a "research project," the whale hunt isn't science. The International Whaling Commission has said the data the whalers gather isn't helpful, and virtually everything the Japanese will learn by harpooning the whales could be learned by non-lethal means.
The hunt for whales is in fact stealing money from Japanese taxpayers, and robbing other countries of much-needed tourist income. The threatened humpbacks targeted by the whalers are part of thriving whale watching industries elsewhere.
"The whaling fleet must be recalled now. If it is not, we will take direct, non-violent action to stop the hunt," said expedition leader Karli Thomas aboard the ship.
Humpbacks don't need to die for science. We're collaborating with Pacific-based scientists through the Great Whale Trail project, demonstrating that whale research can be done effectively and non-lethally. The Great Whale Trail has been monitoring the location of tagged humpback whales as they migrate to the Southern Ocean from the Pacific.
The Great Whale Trail website will also track the Japanese whaling fleet as it heads south.
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Feature Story
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I've known this guy since I was a child. He's about five years older than me, and one of my best friends.
I've always had a little crush on him.
In the past couple years, whenever I see him, he flirts with me and it's hard not to flirt back.
But he has a girlfriend, and I know she hates me because she thinks I want him.
When I came home from college, he told me he has feelings for me.
But my dad's the issue right now (they're very close, almost like father and son).
Neither my dad nor anyone else knows he said this.
I don't know what to do. I told him he has a girlfriend so this can't be a thing. Yet I don't want to lose him as a friend.
Also, he's the only guy who's ever made me feel truly beautiful and accepted. The way he looks at me makes me weak.
Confused Girl
He may be older than you but he's clearly not more mature. So you have to be the one to set the bar about what's acceptable.
Tell him this: So long as he has a girlfriend, you can't date him, especially not secretly.
If he does have real "feelings" for you, he should break off with that girlfriend, and also tell your father that he'd like to date you.
Otherwise, he's not a good friend to you because he's teasing you, playing with your emotions, and he knows it.
I've been separated for six months. We've done marital counselling for a year.
I met a great guy three months after separating, and fell in love.
I haven't told my mother, 90, about my separation because it'll be tough.
She adores my husband and puts him on a pedestal above me. The rest of the family knows that I'm separated.
The new man said that he'll wait for me, but I know he won't wait forever.
He wants me to move in with him, and lives in another state.
No one knows about the new man yet.
You've got yourself entangled in several huge changes simultaneously – ending a marriage, moving away, moving in with a new man. And you're worried that your elderly mother will disapprove.
Huge changes call for huge adjustments… and they don't come quickly or easily.
You need to take time and work out each move thoughtfully. If you just rush forward, you could be heading for a crash.
Make sure your marriage counselling has helped you see what went wrong in the dynamic between you two, and how your own reactions or actions may've contributed.
You don't want to repeat the same pattern in a new relationship.
Spend more time getting to know the new man before agreeing to move in.
Consider how you'll handle being away from old friends, family, familiar locale, work opportunities, etc.
Talk to your mother. Weigh the value of her general experience and wisdom against the realities of what you learned and feel about your ex.
Gently explain why you believe the separation is the only choice.
Meanwhile, check out how your boyfriend lives – both financially, and his lifestyle. Spend a month there with him, before you make a firm decision to move.
This is also a good time to get counselling again for yourself, to be certain that the new guy has the qualities that you want in a partner, beyond the allure of a convenient getaway from the past.
FEEDBACK Regarding the man discussing his menopausal wife (June 2):
Reader – "I wonder if his feeling that "nothing (he) does is ever enough," has always been their pattern.
"I've found there are men and women for whom nothing I did was ever enough, and others for whom whatever I did was enough.
"I ultimately ended relationships with those that I could never fully please, and I'm much happier.
"This gentleman has done the best he could (he's trying to figure this situation out, which is a good sign), yet he still refers to himself and other men as "jerks."
"This isn't fair to himself (some are jerks, some aren't, just as with some women).
"I'm mostly through menopause and haven't experienced a lot of the negative symptoms that this gentleman (and others) describe.
"He and his wife both deserve compassion and understanding. It sounds like he's not gotten that from her, which is their pattern."
Tip of the day:
Expressing "feelings" to someone when attached to another, is playing with fire, not friendship.


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Listed Building Consent
Listed Building Consent is required for any alterations or other works affecting the character, appearance or fabric of a Listed Building, regardless of grade, inside or out; this is in addition to any other permission required, such as Planning Permission or Advertisement Consent. This does not rule out all change, but all proposals must be very carefully considered, and usually must entail no significant harm either to the character, appearance or fabric of the Listed Building.
Design and Access Statements
In certain circumstances it may be necessary to submit a Design and Access statement as part of the Listed Building Consent application. For proposals affecting a Listed Building or its setting, you will need to demonstrate an understanding of the particular qualities and vulnerabilities associated with the building and its context, and to explain how these have been addressed in the proposals. The level of analysis should be commensurate with the significance of the Listed Building and its setting, and with the nature of the proposals. The statutory List entry provides a starting point, please:
- visit the Historic England website
Note that significant changes to more important structures may need a considerable depth of analysis, including specialist input.
Applications involving any of the following will generally require the Council to consult with external bodies, such as Historic England :
- A building Listed at Grade I or II* or its setting;
- Part or complete demolition of any Listed Building;
- A Scheduled Ancient Monument (SAM).
Listed Buildings and renewable energy
If you are considering installing some form of microgeneration equipment on your listed building (e.g. solar panels) you may require the benefit of planning permission and Listed Building Consent. Please contact the Planning Department to discuss your proposal.
Unauthorised Works
Unauthorised work to a Listed Building constitutes a criminal offence, and may lead to prosecution. There is no time limit within which the Council must begin legal proceedings, and liability for unauthorised work may pass to new owners.


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- ePSS WEB Search and Browse U.S. Preventive Services Task Force (USPSTF) recommendations online.
- Email Notifications Subscribe for ePSS PDA email notifications. Receive notifications of application and ePSS data updates.
- Get Adobe Reader
What's New
New Features
The Electronic Preventive Services Selector (ePSS) application is continually expanding mobile device support. Go to the Products page to review the supported devices and mobile platforms.
Functional enhancements have been made to the Electronic Preventive Services Selector (ePSS) Android, iOS, and Windows App applications. Download and upgrade to the latest ePSS to take advantage of these enhancements. This process only takes minutes. Nothing needs to be uninstalled and the installation process is the same as the initial application downloaded.
New features include:
- Browse by Grade
- View All tab on the Search Results page
- Search for recommendations by keyword text (keywords are highlighted in the search results)
- Bookmark any recommendations or topics for later viewing
- Save Search feature provides quick access to routinely viewed recommendations
- Update of ePSS recommendations data automatically on application launch (wireless or WiFi internet connection required)
- Print (iPhone, iPod touch, and iPad only) or email recommendations or saved search results
- Print ePSS Recommendations Rx (iPad only) or email patient specific customized recommendations
- Print Tools information (iOS only)
- Compatible with Android OS 7, iOS 11, and Windows 10
New Rationale and Grade Definitions
The USPSTF has modified the format for recommendation statements. The ePSS application update reflects these changes. More information about the modified recommendation statement can be found in the articles referenced below.
The letter grades used by the USPSTF remain the same (A, B, C, D, I), but the definitions have changed and are incorporated into the ePSS application:
- Recommendations to which the old grade definitions apply are marked with an asterisk (*)
- The grade definition appear in a "scroll-over" box associated with the grade letter.
- New and old grade definitions are described in the "Grade Definitions" section of the tool.
These changes are described in the articles referenced below.
For more information:
The USPSTF provides several resources that describe its methods and provide more information about its grades and recommendation statements.
"How to Read the New Recommendation Statement: Methods Update from the U.S. Preventive Services Task Force" , can be accessed via the U.S. Preventive Services Task Force website at http://www.uspreventiveservicestaskforce.org/uspstf07/methods/methupd.pdf
"Current Processes of the U.S. Preventive Services Task Force: Refining Evidence-Based Recommendation Development", can be accessed via the U.S. Preventive Services Task Force website at http://www.uspreventiveservicestaskforce.org/uspstf07/methods/currprocess.pdf.
"First Annual Report to Congress: High-Priority Evidence Gaps for Clinical Preventive Services", can be accessed via the U.S. Preventive Services Task Force website at http://www.uspreventiveservicestaskforce.org/annlrpt/index.html.


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