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It's been a few months since we last checked in on New York-based pop singer Warren Nomi. But in the wake of the recent legal victories for gay couples living in the United States, he's decided to offer up a brand new track for free download. And we have a sneaking suspicion that it's going to (ahem) spice up your life.
"I fell in love with this song when I heard it and had to fly to Los Angeles to record it in spite of ego and prejudice from a particular party," Warren says of the song. "This is in celebration of same sex marriages legalized in the state of California."
'My Love Is For Real' is a cover version of an unreleased Victoria Beckham single which was recorded for her unreleased second album project back in 2004.
The Goh Hotoda remix of Nomi's version is available free from the Soundcloud link below.
Meanwhile, Warren is continuing work on his forthcoming debut album.


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NRA Breaks Social Silence With First Tweet Since Newtown Shooting
The National Rifle Association broke its four-day social media silence Tuesday by announcing via Twitter a "major news conference" in Washington, D.C. set for Friday. In a linked release, the NRA promised "meaningful contributions" to "make sure this never happens again."
Important Statement from the National Rifle Association nraila.org/news-issues/ne… #NRA
— NRA (@NRA) December 18, 2012
The NRA's Facebook page has also returned after being disabled, featuring a link to the release and a new cover photo reading "PRESS CONFERENCE."
The NRA's full statement is copied below:
National Rifle Association of America is made up of four million moms and dads, sons and daughters – and we were shocked, saddened and heartbroken by the news of the horrific and senseless murders in Newtown.
Out of respect for the families, and as a matter of common decency, we have given time for mourning, prayer and a full investigation of the facts before commenting.
The NRA is prepared to offer meaningful contributions to help make sure this never happens again. The NRA is planning to hold a major news conference in the Washington, DC area on Friday, December 21.
The tweet and release are the NRA's first statements on social media or otherwise since Friday's shooting.
Do you think the NRA was right to maintain social silence for days after the tragic shooting? Share your thoughts in the comments.
Photo via Justin Sullivan/Getty Images News/Getty Images


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- Curse of the Crimson Altar (The Crimson Cult; The Reincarnation; Spirit of the Dead; Witch House) (1968) [Sacrifice Victim]: Stabbed in the chest by Denys Peek (acting on Barbara Steele's urging) in Denys' hallucination/dream sequence.
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Delivery Partner Management Policy
Welcome to Interserve Learning and Employment's Delivery Partner and Sub-Contractor Management Framework. This document is intended as an overview for all Delivery Partners covering the lifecycle of your journey with us and what you and we should expect from the relationship. It is our intention to work closely alongside our Delivery Partners and Sub-Contractors to assist with capacity building, offer appropriate support when required and manage the contracts in an effective manner. We aim to ensure every aspect of our learners and customers' requirements are not just complied with, but that the highest levels of performance and quality are also achieved and we can only do this together.


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Holiness and Victory Over Sin #13
by Karl Kemp
10/20/2011 / Bible Studies
Holy Father, we humble our hearts before you. We want to know the truth. We want to know the balanced truth of what your Word teaches. We want to understand it. We want to live it. In Jesus' mighty, holy name, Amen!
I'll always quote from the New American Standard Bible, 1995 edition, unless otherwise noted. Frequently I'll make comments in the middle of quotation using brackets [ ] or [[ ]] to make the brackets more obvious.
Last time when we stopped I was quoting from the lengthy Introduction of my paper titled, "The Interpretation of Romans Chapter 7 and Righteousness and Holiness." I'll quote a few more paragraphs from that Introduction. Another important point that we should discuss further is that is isn't a reasonable interpretation of Paul's words in Rom. 7:14-25 to say that he is speaking of a person only having wrong thoughts and desires. In Rom. 7:14b (the second half of the verse) the apostle Paul says, "But I am of flesh [to be of flesh/in the flesh means to be in spiritual death, without the Holy Spirit], sold [better yet, "having been sold," referring back to the rebellion and fall of Adam (see Romans 5:12-21)], having been sold into [the abiding state of] bondage to sin." These words, and the following words, speak of an abiding state of bondage to sin, a state far more serious than a person's having an occasional wrong thought or desire. In the verses that follow (in Rom. 7:15-25), Paul powerfully illustrates the fact that fallen man truly is in a state of slavery to sin by using for exhibit A the predicament of a very sincere Jew, one who is totally convinced that the Mosaic Law is from God and true and that it must be obeyed from the heart (he may have even memorized the Law), but, nevertheless, his life frequently demonstrates that he truly is a slave of sin. Paul's primary point in these verses is to show that all mankind is so fallen that the Mosaic Law (even though it is from God and is good) isn't able to save fallen man from sin and death (it wasn't given by God for that purpose). All mankind, therefore, needs new-covenant salvation in Christ Jesus.
There are some Christians in our day who understand Rom. 7:14-25 to speak of a Christian(s), but who don't believe Paul is speaking of the normal Christian life in these verses. One such view is that Paul was speaking of an immature Christian, who hadn't yet learned to walk after the Spirit. This view is far from what Paul was dealing with in context, but it is a great improvement over any viewpoint that understands these verses to teach that Christians continue in bondage to sin, that they cannot stop sinning as long as they live, that they must necessarily fulfill their daily quota of sin.
I'm not making an attempt in this paper to equally present the different interpretations of Romans chapter 7. I'm putting most of the emphasis on what I'm sure is the correct interpretation, that Paul was not speaking of a Christian(s) in Rom. 7:14-25.
After the Introduction, this paper consists mostly of excerpts from others, but I'll make quite a few comments too; my comments are typically enclosed in brackets. I quoted the most extensively from Douglas Moo's recent commentary on Romans because I agree with him so much, and because he was so thorough. I also quote extensively from Arminius's dissertation on Romans chapter 7; I found this work to be very helpful. His dissertation was about two-hundred pages. Arminius lived from AD 1560 to 1609. The Arminians are named after him. (His name is spelled Arminius.) I also quote extensively from John Chrysostom (AD 347-407). His ancient homilies (sermons) on Romans chapter 7 convince me that he understood this chapter very well. I also quote extensively from Augustine (under Arminius) and from Methodius. ...
I'm writing this Introduction last. May God's will be accomplished through this paper, and may His people be edified! A primary goal for this paper is to help bring about transformation in the Body of Christ, where it is needed. As I mentioned, we don't need more condemnation. Thank God for His mercy and grace toward us! But let's make it a top priority to do everything we can do to refrain from abusing His grace, for His full glory, and for our full good. His will be done! Amen!
I'll conclude this Introduction with the prayer the apostle Paul prayed for the newly founded church at Thessalonica, "Now may the God of peace Himself sanctify you entirely [in the very near future; that's what the apostle meant]; and may your spirit and soul and body [having been sanctified entirely] be preserved [or, be kept] complete [or, be kept sound], without blame at the coming of our Lord Jesus Christ." Amen!
Now I'm going to turn to pages 104-107 of my book and read several paragraphs. Based on my studies and observations, I consider the viewpoint that Rom. 7:14-25 refer to a regenerate (born-again) Christian to be a serious mistake. I am totally convinced that the apostle Paul never intended that these verses be applied to Christians. This one misinterpretation tends to have enough power to override (or at least greatly dilute) the clear teaching of Romans chapter 6; Rom. 8:1-14; and the many other passages of the New Testament which teach that Christians can and should walk in victory over sin by grace through faith. This is good news, very good news!
If the view that Rom. 7:14-25 refer to a regenerate Christian(s) is in error, we need to face up to it. There won't be any rewards for defending and perpetuating doctrines or traditions that are wrong. Erroneous doctrines and traditions cause great damage to the Body of Christ. I'm not suggesting that there are many who are teaching views they know to be in error (though this does happen), but I am suggesting that many are very slow to consider the possibility of error in their doctrines or traditions. Victory over sin can only be realized by grace through faith, and we certainly cannot have a solid, Bible-based faith for victory over sin if we believe that the apostle Paul taught that we cannot have this victory. Victory over sin must be a very high priority item in the Christian faith according to the Scriptures.
Now we come to the heading, "Romans chapter 7 and Romans 6:14." There is widespread agreement that Romans chapter 7 expands on Rom. 6:14. I'll read Rom. 6:14, "For sin shall not be master over you [or, have dominion over you], for you are not under law, but under grace." The Law [the Mosaic Law, or any other law] cannot save us from sin. The saving grace of God in Christ can save us from sin. In Rom. 6:14 the apostle Paul makes the important point that Christians have been set free from slavery to sin through the grace of God in Christ Jesus. He clearly infers that if we were still under the Mosaic Law, we would still be under the authority of sin. (Romans chapters 1-8 confirm this understanding.) In Romans chapter 7 the apostle shows that Christians, even Jewish Christians, are not under the Mosaic Law (see Romans 7:1-6). He also shows, at some length and in dramatic detail, that those under the Mosaic Law were definitely in bondage to sin.
It was necessary for the apostle to show that the Mosaic Law (the old covenant) could not dethrone sin (the "sin which reigns in [spiritual] death," Rom. 5:21) for at least two reasons. For one thing, many of the sons of Israel were clinging to the Law and not coming to the Lord Jesus Christ (the only One who could save them from sin). Also, the Judaizers were trying to bring the Mosaic Law into the Christian church in a manner that led to a very serious distortion of the gospel (see Gal. 1:6-10; 3:1-29; 5:1-12; and 6:12-16). The apostle had to show the weakness of the Law and the need for new covenant salvation in Christ Jesus. Fallen man (man in the flesh; man having been sold into bondage to sin, see Rom. 7:14, for example) cannot be saved by the Law
Does the apostle Paul give a comprehensive and balanced treatment of the Law in Romans chapter 7? Hardly. He could have written extensively on the blessings of the Law (see Rom. 3:1, 2; 7:12-14; and 9:4, 5), but that wasn't part of his commission. He knew that all men need the Lord Jesus Christ, and he had been sent to proclaim the gospel of new covenant salvation. Even though the apostle did not give a full and balanced treatment of the Law in Romans chapter 7, what he said was true and needed to be said
Before we turn to a verse-by-verse study of Romans chapter 7, I want to include another excerpt from my paper titled, "The Interpretation of Romans Chapter 7 and Righteousness and Holiness," starting on page 12. As this excerpt begins I'll be quoting from Douglas Moo's "Epistle to the Romans," published by Eerdmans in 1996, pages 443-446. I start out quoting from him, but I make many comments myself in brackets. "The most important reasons for thinking the experience depicted in vv. 14-25 is that of an unregenerate person are the following [I believe the first five reasons of the six reasons Moo listed here are all very significant.]
Reason #1. The strong connection of ego [that's the "I"] The strong connection of ego with 'the flesh' (vv. 14, 18, and 25) suggests that Paul is elaborating on the unregenerate condition mentioned in 7:5: 'being in the flesh.' [There's no doubt about it. The person in Rom. 7:14-25 is in the flesh.]
Reason #2. Ego throughout this passage struggles 'on his/her own'without the aid of the Holy Spirit. [Yes, I might add that the Holy Spirit is not mentioned at all in Rom. 7:14-25, but He is frequently mentioned in chapter 8.]
Reason #3. Ego is 'under the power of sin' (v. 14b); a state from which every believer is released (6:2, 6, 11, 18-22). [That's another very important reason.]
Reason #4. As the unsuccessful struggle of vv. 15-20 shows, ego is a 'prisoner of the law of sin' (v. 23). Yet Romans 8:2 proclaims that believers have been set free from this same 'law of sin (and death).' [That's another very important reason.]
Reason #5. While Paul makes clear that believers will struggle with sin (cf., e.g., Rom. 6:12-13; 13:12-14; Gal. 5:17 [I might add that Paul didn't say in any of these verses that Christians will sin; a struggle with sin, yes; temptation, yes; we could sin, yes; but the apostle didn't say we will sin, and we won't sin if we walk by faith according to the terms of the new covenant, which includes walking by the Holy Spirit.], what is depicted in 7:14-25 is not just a struggle with sin but a defeat by sin. This is a more negative view of the Christian life than can be accommodated within Paul's theology. [Very much so! I'll skip his reason 6 and continue to quote from Moo.] For those who find these arguments decisive, vv. 14-25 describe the struggle of the person outside Christ to do 'what is good,' a struggle that is doomed to failure because it is fought without the power of God that alone is able to break the power of sin. Deliverance from the situation comes with the converting, regenerating work of God in Christ, who transfers the believer from the realm of 'sin and death' to the realm of 'the Spirit of life' (v. 24b; 8:2). Within this general 'unregenerate' interpretation are various subdivisions. Some think that the text portrays Paul's own experience under the law. Others think that Paul is describing Jews under the Law generally, or even all people confronted with 'the law of God.' There is further disagreement over the extent to which the description reflects the conscious experience of those 'under the law' and the extent to which Paul portrays the pre-Christian past from a Christian perspective." As I mentioned, I believe it is important to see that Rom. 7:14-25 incorporates Paul's Christian perspective. It does not, therefore, adequately reflect the pre-Christian experience of Paul (compare, for example, Phil. 3:4-6; Acts 23:1; 2 Tim. 1:3), or of the Jews in general. I'll quote Acts 23:1, "Paul, looking intently at the council [the Sanhedrin], said, 'Brethren, I have lived my life with a perfectly good conscience before God up to this day.' " For one thing, as Moo points out in the next excerpt in my paper (which I won't quote here), and as I mentioned in my discussion of Romans chapter 7 in my book, the apostle Paul wasn't aiming to give a balanced presentation of the Law, but to emphasize its weaknesses and our attendant need for new-covenant salvation in Christ. Douglas Moo agrees, by the way, that Paul incorporated something of his Christian understanding when he wrote Rom. 7:14-25
I'm going to quote a few verses from the apostle Paul to show how different his life was as a Christian than the person described in Rom. 7:14-25. Paul had quite a testimony as a Christian. 1 Corinthians 11:1, "Be imitators of me, just as I also am of Christ." That's quite a testimony, isn't it? 1 Thessalonians 2:9-12, "For you recall, brethren, our labor and hardship, how working night and day so as not to be a burden to any of you, we proclaimed to you the gospel of God. (10) You are witnesses, and so is God, how devoutly and uprightly and blamelessly we behaved toward you believers; (11) just as you know how we were exhorting and encouraging and imploring each one of you as a father would his own children, (12) so that you would walk in a manner worthy of the God who calls you into His own kingdom and glory."
Let's start our verse-by-verse study with Rom. 7:5. I'm turning to page 108 of my book, and I'll read the verse here. The New American Standard Bible, 1977 edition is used in the book. "For while we were in the flesh, the sinful passions, which were aroused by the Law [referring to the Mosaic Law], were at work in the members of our body to bear fruit for death."
I'll comment on the words, "while we were in the flesh." Typically I'll be reading what I said in the book, but sometimes I modify what I said in the book for these articles. "while we were in the flesh." The NIV has, "when we were controlled by the sinful nature." In this context, "we" refers to Christians from a Jewish background; however, all Christians were "in the flesh" before being born again by the Spirit of God. But Gentiles were not under the Mosaic Law. Fallen man, by definition, is in the flesh, devoid of the Spirit of God (see Rom. 8:1-16, for example).
Now we'll discuss the words, "the sinful passions, which were aroused by the Law." The Mosaic Law did not solve man's one basic problem, the sin problem; it intensified the sin problem. For example, when the Law tells man in the flesh that some things are forbidden, he is liable to say, "What have I been missing?" or, "Nobody is going to tell me what to do." See Rom. 7:8, 11. I'll read those verses, Rom. 7:8, "But sin, taking opportunity through the commandment, PRODUCED IN ME COVETING OF EVERY KIND, for apart from the Law sin was dead." Rom. 7:11, "For sin, taking opportunity through the commandment [a commandment of the Mosaic Law], deceived me and through it killed me." The apostle was speaking of the commandment not to covet in both verses, by the way. We discussed (under Rom. 5:20) that the Law intensified the sin problem; for one thing, it was rebellion to transgress God's commandments, after He had given them through Moses.
Now we'll briefly discuss the words, "to bear fruit for death" of Rom. 7:5. See Rom. 6:21, 23. We were producing sinful fruit, and sinful fruit brings forth death, ultimately the second death of Revelation chapter 20.
Romans 7:6. "But now we have been released from the Law, having died to that by which we were bound, so that we serve in newness of the Spirit and not in oldness of the letter." Now we'll briefly discuss the words, "But now we have been released from the Law, having died to that by which we were bound." In Rom. 7:1-4 the apostle Paul showed how these Christians from a Jewish background were released from the Law. They died to the Law when they were united with the Lord Jesus Christ and became Christians. But the really important thing is that they died to spiritual death and being in bondage to sin when they became Christians.
Now we'll discuss the words, "so that we serve in newness of the Spirit and not in oldness of the letter." The old covenant centered in "the letter" of the Mosaic Law. In Rom. 2:29 the apostle also contrasts "the Spirit [the Holy Spirit]" with "the letter [of the Law]." 2 Corinthians 3:1-18 are another important cross-reference. 2 Corinthians 3:6 says, "who also made us adequate as servants of a new covenant, not of THE LETTER [the letter of the Mosaic Law], but of THE SPIRIT [the Holy Spirit]; for THE LETTER kills, but THE SPIRIT gives life." In 2 Cor. 3:7 Paul calls the old covenant "the ministry of death, in LETTERS engraved on stones"; and in 2 Cor. 3:9 he calls it "the ministry of condemnation," in contrast with "the ministry of THE SPIRIT" of 2 Cor. 3:8. The Law brought "condemnation" and "death" in that it did not solve the sin problem, but rather intensified it.
In contrast with the letter of the Law, the new covenant is immersed in the Holy Spirit. Christians walk in "newness of life" by the Holy Spirit (see Rom. 6:4, for example); they have life by the "Spirit of life" (see Rom. 8:2; compare Rom. 8:10; 2 Cor. 3:6); and, significantly, they are sanctified and have the victory over sin by the Holy Spirit (see, for example, Rom. 2:29; 8:2-4, 13, 14; Gal. 5:5, 16; 2 Thess. 2:13; and Titus 3:5).
Romans 7:7. "What shall we say then? Is the Law sin? May it never be! [Emphatically not! The Mosaic Law came from God, and it was good.] May it never be! On the contrary, I would not have come to know sin except through the Law; for I would not have known about coveting if the Law had not said, 'YOU SHALL NOT COVET.' " That's the tenth commandment (of the ten commandments) of the Mosaic Law.
Now let's discuss the pronoun "I" here. Paul is speaking for Israel, but in a fuller sense he is speaking for all mankind. I'm going to turn to page 9 of my paper on the Interpretation of Romans Chapter 7 and read part of a paragraph. This is quite important. These verses speak, for the most part, for those who were under the Mosaic Law (the people of Israel), but it seems that Paul intended his pronouns "I" (and "me") to have much application for all mankind, for all the descendants of fallen Adam. I believe it would be accurate to understand Rom. 7:7-25 under a heading like "Fallen man confronted with the Mosaic Law. It cannot save us! We desperately need a Savior! He has come!" Gentiles can read this passage and see themselves if they would have only the Mosaic Law to save them. No matter how devoted to the Law we are, it cannot save us. All Christians, whether from Jewish or Gentile backgrounds, must understand that the Mosaic Law (or any other law) is not able to save us from spiritual death and bondage to sin. The Law, in fact, as Paul shows in Romans chapter 7 and other places, intensifies rather than solves the sin problem.
Now back to page 109 of my book. We are discussing Rom. 7:7. We'll discuss the words, "Is the Law sin?" Emphatically, NO! (See Rom. 7:12-14, 16.) However, as we discussed under Rom. 7:5, 6, and as we will discuss further as we continue, the Law did intensify the sin problem. That's a very important point. The Law gave knowledge about sin, but it did not give the victory over sin (see Rom. 3:20, for example). Before the tenth commandment was given ("you shall not covet"), people could have done quite a bit of coveting without realizing it was sinful. After the Law was given, it became a transgression of God's Law to covet; and as Rom. 7:5, 6 show, the commandment aroused/produced coveting. Thank God for new covenant salvation in the Lord Jesus Christ!
Romans 7:8. This is a very important verse, and it goes with the following verses; they help explain one another. "But sin, taking opportunity through the commandment, produced in me coveting of every kind. For apart from the Law sin is dead." The New American Standard Bible has the verb "is" in italics. (The format doesn't allow me to use italics in this article.) We'll talk about that very important detail in just a minute. Sin, not the Mosaic Law, was the basic problem, but sin used "the commandment" of the Law to help produce coveting. (See Rom. 7:5, 11. I'll read Rom. 7:5 again, "For while we were in the flesh, the sinful passions, which were aroused by the Law, were at work in the members of our body to bear fruit [sinful fruit] for death."
Now we'll discuss the words, "for apart from the Law sin is dead." I believe the translation of the KJV (and the NKJV) conveys the intended meaning, "sin was dead." The Greek behind these words does not include a verb corresponding to "is" or "was"; we must supply the verb in the English translation. I'm sure that the apostle Paul and the One who sent him intended the verb "was." Verses 8-13 are set in the past tense. We will discuss the meaning of these words, "apart from the Law sin was dead" as we continue.
Now we come to a subheading, "When was sin dead?" Before the Mosaic Law was given, sin was (relatively) dead in the sense of that which Paul said in Rom. 4:15; 5:13, 14, 20; 7:5, 7-13; 1 Cor. 15:56 and Gal. 3:19. I'll read most of these verses. Romans 4:15, "for the Law brings about wrath, but where there is no law, there also is no violation." Romans 5:13, "for until the Law sin was in the world, but sin is not imputed when there is no law." I'll read the first half of Rom. 5:20, "The Law came in [The apostle is speaking of the Mosaic Law] so that the transgression would increase." I'll read Rom. 7:9-11 and then 13, "I was once alive apart from the Law; but when the commandment came, sin became alive and I died; (10) and this commandment, which was to result in life, proved to result in death for me; (11) for sin, taking opportunity through the commandment, deceived me and through it killed me. ... (13) Therefore did that which is good [the Law] become a cause of death for me? May it never be! Rather it was sin, in order that it might be shown to be sin by effecting my death through that which was good [the Mosaic Law], so that through the commandment sin would become utterly sinful." And I'll read 1 Cor. 15:56, "The sting of death is sin, and the power of sin is the law."
Sin was in the world before the Mosaic Law was given (see the book of Genesis, the book of Exodus up to the time the Mosaic Law was given; and Rom. 1:18-32; 2:12, 14, 15; and 5:12-14). However, the verses I quoted in the preceding paragraph show that sin was less alive before the Mosaic Law was given. We will discuss this important point further under Rom. 7:9-13. Before the Mosaic Law was given, "I" was more alive and sin was more dead. After the Law was given, sin was more alive, and I (speaking for those under the Law) was more dead.
God bless you!
Copyright by Karl Kemp
http://www.karlkempteachingministries.com Karl Kemp worked as an engineer in the space field throughout the 60s. He became a born-again Christian in 1964. He received an MA in Biblical Studies in 1972. He has been a Bible teacher for 45 years. See the website for more info on his books, papers, etc.
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Even though at this time the weather has been mild with little snow, the prevailing winter winds make sea conditions difficult and challenging to perform fishing operations. Water temperatures have changed, causing fish and lobsters to go into winter modes of behavior and availability.
Even though at this time the weather has been mild with little snow, the prevailing winter winds make sea conditions difficult and challenging to perform fishing operations. Water temperatures have changed, causing fish and lobsters to go into winter modes of behavior and availability.
When all is said and done, most everyone tones down their fishing operations and prepares for better months to arrive, but there is still a gang that pushes through the winter and its struggles.
Most fishermen spend these months bringing gear and traps ashore for repair and rebuilding. Along with tending to the gear is the need to catch up with vessel maintenance and improvements so all is in good order when the pace picks up in the spring. The cost of maintaining gear and vessels has outpaced the price fishermen receive for their catch.
Those committed to the profession still contribute greatly to this local economy with their spending, which make them an integral and longstanding participant in this community. Regardless of how fast changes are taking place, communities need to be careful not to lose their founding industries that add so much to the local identity.
I hope that most might agree the fishing industry presents a positive component of our community that needs attention and elevated exposure, considering the variety of challenges that it endures.
The winter months represent a time when the upcoming season's regulations are formulated and changed.
For groundfish, this is done by the New England Fisheries Management Council, which will hold one of its regional meetings in Portsmouth, Jan. 28-31. This meeting is expected to decide what will be available to be caught during the next fishing season. It won't be a pleasant meeting since there have been recommendations to reduce catch levels of certain species by up to 80 percent.
Equally contentious is the complicated federal management policy. The decisions made at this meeting will be critical to the future of many, but our local, small-boat fishing fleet will be especially sensitive to this regulatory regime. Reducing catch levels to those suggested could collapse these businesses and the infrastructure that supports them, with limited prospect for them to return in the future. The current fleet is a fraction of what it was and those that remain will be hard pressed to be viable pending the outcome of these decisions. Struggling with a perspective of balance to ensure the health of both the resource and sufficient food and protein for consumers is difficult. But a tragedy is in the making if it is not achieved.
The upcoming winter shrimp season will begin with the first day of landings on Jan. 23. It will be a very short season of possibly two to four weeks, so those who enjoy this local product should be aware that it won't be available as long as it has been in past years.
Lobster landings are falling off with the winter months and with retail prices climbing as they do during this time, but there is still good value available.
Although not yet completely tabulated, the yearly landings are considerably up from past years, and from all indications, the resource is healthy.


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The scarcity of games on these NFL playoff weekends is a huge reason why wagering in the postseason can be a death trap of second-guessing for me. Fewer games on the board means there's way more time to focus (and, frankly, OVER-focus if there is such a thing) on the scant few games being played.
It doesn't help that this week, you can make a great case for all four underdogs to cover, and three of them winning outright (sorry, Denver), because inherently with underdogs you feel like you're going in with "lesser team." I've spent more time this week talking myself into and out of my picks than any week I can remember in the last couple years.
Let's see what the weekend has in store, shall we?
Saints -3 over 49ERS Classic example of the waffling I just mentioned -- I had been thinking that the 49ers were the perfect team to upset the Saints even before the Saints -3 1/2 spread came out. The Niners with their stout defense, solid running game, and playing at home all seemed to add up to the perfect mix to knock off Drew Brees and company. Then I had more and more people getting in my ear about Drew Brees looking unstoppable lately (granted, he is at his most unstoppable at home; this game is in San Francisco), and, more importantly, the Saints have the ability to run the ball with Ivory, Thomas and Sproles. In short, the Saints have evolved from a "dome team" into a "team that happens to play in a dome," if that makes sense. I'll probably buy the half point so the number is a field goal, but for Best Bet purposes I'll still lay the 3 1/2.
Broncos +13 1/2 over PATRIOTS You are judged as a player and coach (and frankly, as a wagerer) on the final score, so the 41-23 final score the first time these teams played is what it is. But in handicapping, you have to look at reasons why things happened. The fact of the matter is that the Broncos were leading that game 16-7 before a six-minute period of unforced errors in the second quarter gave Tom Brady a few too many chances to take control of the game. Next thing you knew, the Pats had the lead and the Broncos had to get out of their game plan.
The Broncos can run the ball against the Patriots, this we know. (They averaged 8.1 yards per carry in the first game.) If the Broncos can protect the football this time around, then they can stay on schedule long enough to keep the Patriots offense on the sideline and, yes, cover the 13 1/2. Can they win outright? Well, I don't know if Tim Tebow's fire is burning in me that strong....
....but it's burning strong enough for me to take the over as well! (If the Broncos get to 19 points, you'll win one of the two bets, side or total.)
Texans +7 over RAVENS I'll likely have more on this game in a post before the week is out, but let's just say I think the Texans keep it close. The question we've been batting around all week on our show on 1560 The Game -- are you better equipped to beat the Ravens on the road with Matt Schaub and no Andre Johnson (as the Texans were in Week 6) or with T.J. Yates and a healthy Andre Johnson? It's a debate that some of the experts we talked to were split down the middle on. The teams are real mirror images of each other, and if you're forecasting mistakes from T.J. Yates in this game, don't think the Texans can't force Joe Flacco into similar slip-ups, which makes me think....
Texans/RAVENS over 35 1/2 ....that a lot of short fields could lead to more points than the experts think. Thirty-five and a half feels way too low to me.
Giants +7 1/2 over PACKERS Of the three games that are rematches from the regular season, I think this game will most closely mirror its predecessor. If you recall, in Week 13 the Giants gave the Packers everything they could handle in a 38-35 barnburner in New Jersey. Now, the Giants are actually playing better football and (wait for it....I'm about to pin my hopes on Eli Manning) Eli Manning has been in this spot before. In January 2008, the Giants went through Green Bay to win the NFC title in Brett Favre's final game as a Packer. And I feel slimy for even bringing it up as a variable affecting the outcome of a sporting event, but the tragic death of Packer offensive coordinator Joe Philbin's son Michael has to affect the Packers' preparation. I think the Giants pull off the outright upset, 31-28.
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Aliens among 7 militants killed in Zabul, Logar
Aliens among 7 militants killed in Zabul, Logar
PUL-I-ALAM/QALAT (Pajhwok): Seven militants have been killed in two separate incidents of violence in central Logar and southern Zabul provinces, officials said on Tuesday.
Logar governor's spokesman, Salim Saleh, told Pajhwok Afghan News a US drone struck a vehicle carrying suspected militants in Pangram area of Charkh district on Tuesday morning.
Two militants were killed and five others were wounded in the strike, he said, adding the dead included Pakistani, Chechen and Arab fighters.
Syed Anayatullah, a resident of Pangram district, confirmed the drone strike in their area, but had no details.
Separately, four Daesh rebels and one Taliban gunman have been killed during an operation in southern Zabul province.
Zabul police chief Col. Ghulam Jilani Farahi told Pajhwok the clearing operation was carried out in Sherana and Solan areas of Khak-i-Afghan district late on Monday night.
He said Khalid Akhondzada, a notorious Taliban commander, and four Daeh rebels were killed and several others were wounded in the raid. He declined to elaborate.
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Hey all! Just wanted to know if you got any tips for me to improve my game. More specifically towards footwork/taking the ball earlier. I also feel as though I get jammed on my backhand when trying to position for it. I haven't had a coach in years, have been learning the game myself haha. Anything would help!
btw I started off warming up. picked up the hitting after
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- ISIL fighters in Syria.
French President Francois Hollande has declared war on ISIL. Republicans are appalled, shocked, chagrined, that a French president is more bellicose than the American president.
Putin is charged up for war, too. American pundits and politicians are in a state of semi-hysteria over the concept of Russians shooting Middle Easterners before the United States does. What will it do to America's standing as the Leader of the Whole World?
What will this war look like? Can it be won? Or does it just mean that more people will die and be displaced, with everyone deeper in the muck than when the war started?
Right now, France and Russia are just launching air attacks. As is the US, which has actually been doing it as much or more than others for quite awhile, but let's not let reality creep into the reporting.
Will that do the trick?
No. Nobody has ever won a war with air power alone. Only ground troops can take and hold territory.
How about if the US, France, and Russia arm, aid, and train local anti-ISIL good guys, give them amazing air support, and let them take out the evil-doers? The US just spent half a billion dollars on such a program. When the general in charge was asked by a Senate committee how many Western-friendly, moderate anti-ISIL Syrian freedom fighters the program had trained, he said, "Four or five." Four or five? At a hundred million dollars apiece, he really should have known if one of them went missing. It was a symptom, not an aberration. The US had previously spent $25 billion to train and equip the Iraqi army that broke and ran when they were attacked by ISIL.
Jeb Bush said, "This is the war of our time." As for sending American ground forces in, he said, "Absolutely we will. We fight to win and then we pull out." Which is an astonishing statement because it demonstrates that he is dumber than his brother.
George W. Bush went into Iraq and Afghanistan with the exact same plan, "Fight to win and then we pull out." He and his crew, raised on movies about World War II and inspired by the collapse of the USSR, imagined that it was only Hitler-Lite dictators who stood between the peoples of the world and their natural, innate yearning, to live in free-market democracies. Remove the evil doers and the rest would just fall into place. But now we've seen what disasters can follow the get-in, pull-out plan, and there's no excuse.
ISIL controls and administers territory. It raises taxes, supplies services, and fields an army. It is a de facto state. The goal is to have someone different, someone benign, take over. Regime change.
Can that produce a better world? Or will a new group rise up, worse than ISIL?
Regime change, as President Obama has noted, won't succeed without an occupation. The two most successful US occupations—the ones that made George Bush think it would all be as easy as it was inevitable—were of Germany and Japan. But not all occupations are created equal.
There are three conditions that set up an occupation for success:
It's young men who fight, kill, and provoke. So first, kill all the young men. In Germany and Japan, that wasn't a matter of policy, just a matter of fact. By the time of their surrender, all the able-bodied men between the ages of 15 to 60 were dead or wounded. Then convince the people who are left that it's their own fault, that their own leaders started it, and that the disasters visited upon them are justified. It also helps if the alternative is even worse. Most Germans had to have figured that being occupied by the Americans was far better than what they could have expected from the Russians.
ISIL has eliminated or suppressed so much of the population on sectarian, ethnic, cultural, and political grounds that people left are supporters or suppressed victims. Each atrocity is a deliberate provocation. If they're beaten and their territory is occupied, an effective and reasonably benign occupation authority may well be preferable to Assad on the Syrian side and the Shi'a regime on the Iraqi side.
Conventional wisdom, now, is that a Muslim population will only accept being ruled by fellow Muslims, and Muslims of the same sect. This may be exaggerated. Iraqis seemed to accept the American occupation. But by the time the Americans realized that they were in fact an occupying power, it was too late.
A successful occupation should be so overwhelming that it never needs a counterinsurgency. The official history of the German occupation makes this very clear: "On V-E Day, Eisenhower had 61 US divisions, 1,622,000 men, in Germany, and a total force in Europe numbering 3,077,000. When the shooting ended, the divisions in the field became the occupation troops, charged with maintaining law and order and establishing the Allied military presence in the defeated nation. This type of occupation was presumably capable of squelching incipient resistance since none was evident." (The US Army In The Occupation Of Germany: 1944-1946 by Earl F. Ziemke)
A failing occupation is a counter-insurgency. The US Army's counter-insurgency manual was rewritten in 2006 by General David Petraeus. It says that the counterinsurgents have to provide security from political violence and from ordinary crime, provide basic economic needs, essential services (water, electricity, sanitation, medical care), sustain key social and cultural institutions and the society's basic quality of life. This list is essentially identical to what the Nuremberg principles said was required of an occupying force. Indeed, failure to provide them would constitute a war crime. Successful regime change and occupation requires that kind of commitment.
Against ISIL, there are additional complications. Ideally, perhaps necessarily, there has to be a coalition that includes the US, France, other EU countries, the Gulf States, Jordan, Egypt, and possibly other Muslim countries, all of which are Sunni. The people in the regions of Iraq and Syria controlled by ISIL are also Sunni.
They will not accept returning ISIL's portion of Syria to Assad, a murderous dictator who's killed far more people than ISIL. And worse, he's an Alawite, which is type of Shi'a.
Iran—the main Shi'a power—and Russia must also be part of the coalition. They won't tolerate the removal of Assad unless there is some substitute to protect their interests.
Iraq's government is dominated by Shi'a. Their sectarianism is often blamed for the rise of Sunnis who then embraced ISIL. They are also so inept and corrupt that their brand new $25 billion army fell to pieces. Giving them control back of the territories they've lost is practically a guarantee that the cycle starts again the moment anyone's back is turned. Also, the Gulf States would see it as increasing Iran's power.
Here's what's needed: A grand coalition. With all the powers named. Assad keeps the territory he currently controls. So does the government of Iraq. ISIL's territory, no matter what country it was in, goes under an occupation that will provide stability, employment, law enforcement, and a decent quality of life. It uses the UN Charter, or something like it, for a slow turnover to a local government. The interests of the Kurds and the Turks must also be accounted for.
This is not a call to arms. Or an endorsement of war. It is just an analysis. Lashing out with jets and drones just means more of what we have now. Anyone who talks about defeating ISIL with any less commitment than described above, and without accounting for the complexities, is a bloviating, lying, dangerous sociopath, a TV news commentator, or worse, a candidate for US president.


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|Map of Lincolnshire, extracted from the map of England by Matthew Paris, c. 1250. Norfolk is at the bottom with an thin depiction of The Wash above it and then the Holland district; the Witham and Humber (with its many tributaries) are depicted in blue with the district of Lindsey located between them (Image: BL Cotton MS Claudius D VI, fol. 12v, via Wikimedia Commons).
|A map of England attributed to Genoese cartographer Pietro Vesconte in Marino Sanudo's Liber secretorum of c. 1325, based on his earlier portolan chart and mariners' reports; click for a larger view. The Wash is clearly visible as a deep, circular bay halfway up the eastern side of the island; however, whilst numerous ports are marked along the south coast of England and up the east coast as far as The Wash, Lincolnshire is left empty aside from indications of two rivers (the Witham and the Humber?), with the first name inscribed north of The Wash probably representing Ravenserodd, the important thirteenth- and fourteenth-century island port near Spurn Head, East Yorkshire, that was destroyed by the sea in 1362 (Image: Wikimedia Commons).
|Close up of Lindsey (the northern district of Lincolnshire) on the fourteenth-century Gough Map, with north on the left and major roads, rivers and settlements marked. Lincoln is shown at the bottom right with the Trent running along the bottom edge of the image; Boston is at the top right; and Grimsby is at the top left, with the Humber then running down the left edge of the image. Note the curious name 'Ageland' assigned to roughly the area of the Wolds between Grimsby and Louth, being written in a very similar way to the district-name Lindsey. This name also appears in the fifteenth-century work of Osbern Bokenham, where it seems to again be associated with the Lindsey district of Lincolnshire (Bolingbroke is mentioned shortly afterwards), and it also appears on some sixteenth-century maps of Lincolnshire as a district-name for eastern Lindsey written in the area around Louth, as can be seen below. There are few discussions of this name and its import, sadly; the editors of the Gough Map assume it reflects the wapentake-name Aveland, but it is not clear why this wapentake-name alone would be highlighted like this nor why it would be spelled with a -g- here but nowhere else and then placed in totally the wrong part of Lincolnshire, Aveland wapentake being part of the southern Lincolnshire district of Kesteven, not north-eastern Lindsey (Image: Wikimedia Commons).
|Extract from the Angliae Figura, a vellum map probably created in the 1530s and perhaps hanging at Hampton Court (included on the map) as the property of Henry VIII. The coastline of Lincolnshire is clearly faulty between Wainfleet and Spalding, but is close to that seen on the Gough Map; both are thought to derive from a common source map dating from around 1290. As on the Gough Map, the curious name 'Ageland' appears highlighted in red as a major (?district-)name and is once again placed in eastern Lindsey, close to Louth (Image: British Library).
|Extract from Sebastian Münster's 1540 map of Britain, showing Lincolnshire. The coastline appears derivative of the tradition of the Gough Map/Angliae Figure, but with more of an indication of The Wash than the latter (as is the case on the 1546 Lily map as well). Only the major rivers are shown along with just a handful of Lincolnshire place-names: Lincoln, Stamford, the Isle of Axholme, Sleaford and 'Walflet', which looks to be Wainfleet or a combination of Wainfleet and Saltfleet. Only two district names appear in Lincolnshire, Axholme and 'Agelon', the latter clearly being equivalent to the earlier 'Ageland' and written across Lindsey in a larger font than the other names, whilst the district-name Lindsey is left out entirely (Image: Lancaster University).
|John Leland's sketch map of the Humber district, created c. 1544 to show the drainage basins of the Humber and Witham rivers. Leland's sketch includes a rough approximation of the coastline, rivers and key settlements of Lincolnshire; despite it being a rough sketch, the north and east coasts of Lincolnshire appear to be more realistically rendered than they are on the earlier maps discussed above, although his depiction of the northern Wash coastline continues to be in the Gough Map/Angliae Figura tradition (image: Sheppard 1912).
|Detail of eastern Lincolnshire from John Leland's sketch map of c. 1544, showing his attempt to sketch both Saltfleet Haven and the early Wainfleet Haven, including the latter's associated tributaries and lakes. Note, Northlod is also mentioned on the 1570 plan of the proposed New Cut at Wainfleet (Image: Sheppard 1912).
|Gerard Mercator's engraving of a map of Lincolnshire, originally produced in 1564 and put together into atlas form in the 1570s; north is on the right hand side for this map, which is thought to have been simply engraved by Mercator from an English original, possibly produced by John Elder to assist the French or Spanish in planning an invasion to overthrow Queen Elizabeth I. It is worth noting that not only does the map offer considerably a much improved coastline for Lincolnshire and more detail than many earlier maps, in terms of both rivers and settlements depicted (though Mercator seems to have misread some of the names on his original), but that it also once more includes the odd district-name 'Agland' in the area around Louth, despite the fact that the whole area had clearly been resurveyed. As was observed above, versions of this name also occur on the fourteenth-century Gough Map of Lincolnshire in approximately this position, in a fifteenth-century text relating to Lincolnshire, and on the earlier sixteenth-century Angliae Figura and Münster maps too; it also continued to appear on maps in the later sixteenth-century—being found on, for example, Gerard de Jode's 1578 and 1593 maps and on Sebastian Petri's 1588 map—and even appears on some seventeenth-century maps, as can be seen below (Image: British Library).
|Map of Lincolnshire drawn by Humphry Lhuyd before his death in 1568 and published in Abraham Ortelius's Atlas in 1573. The map shows the Lincolnshire Wolds for the first time and other areas of local high ground, along with major rivers and key settlements (Image: Wikimedia Commons).
|Proof version of John Speed's 1611/12 map of Lincolnshire, which closely followed the Saxton map of 1576 in offering a much more accurate and detailed depiction of the county; a zoomable version of this map is available here. Of particular interest on both maps is the fact that nearly every settlement in Lincolnshire is mapped and so too are the courses of most of the rivers; the latter are of especial note, given how much these courses changed over the following two centuries—note, for example, the original course of the Lud before its canalisation, with its dual outfalls either side of Conisholme, and the fact that the Long Eau and Great Eau were originally separate rivers (Image: Cambridge University, CC-BY-NC 3.0).
|Detail from John Speed's early seventeenth-century proof map of Lincolnshire, showing the coastline of north-east Lincolnshire and a whale menacing the Humber estuary! (Image: Cambridge University, CC-BY-NC 3.0).
|Extract from a map of Britain by Johannes Janssonius, printed in 1621 and reprinted in 1630, one of the last maps to feature Agland/Ageland as a district-name located in eastern Lindsey. As to what the name Ageland/Agland might mean if it is in fact a genuine north-east Lincolnshire district-name that somehow largely avoided being recorded outside of maps, this must remain a matter of speculation in the absence of early evidence. However, if it is a real name, then the second element might be either OE land or ON lundr, both of which appear in early district-names in the form 'land' (cf. Rutland/Holland & Framland/Wayland), most probably the former, with the first element potentially then being either a personal name or perhaps OE for oak, āc/āca (gen. pl.), with c > g as in medieval and later spellings of other place-names, cf. for example Acthorpe nr Louth (Aggetorp in 1200 & Agthorp in 1485–96) and Agden, South Yorks & Cheshire East? For what it is worth, Ageland does make an appearance in medieval surnames, which would seem to add weight to the case for Ageland being a genuine place-/region-name—see, for example, the fourteenth-century merchant and bailiff of York named William de Agland/William Ageland (Image: BnF).


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Featured Duel: Yami Marik vs. Yugi Muto - Part 4
Duel continues from previous episode.
Turn 13: Yami Marik
- Marik has just managed to take "Monster Reborn" card back from his Graveyard.
- Sets two cards.
- Summons "Swallowtail Spike Lizard" (1900 ATK / 700 DEF) in Defense Position. As long as it remains in Defense Position, Marik will receive 1000 Life Points during each of his Standby Phases (NOTE: in the real game, "Swallowtail Spike Lizard" is called "Granadora" and it increases your life points by 1000 when you summon it to your side of the field and decreases your life points by 2000 when it is sent to the graveyard from the field).
Turn 14: Yami Yugi
- Summons "Gazelle the King of Mythical Beasts" (1500 ATK / 1200 DEF) in Defense Position.
- Sets two cards.
- "Bowganian's" effect inflicts 300 damage to Yami on the End Phase (Yugi: 1000 → 700 Life Points). (NOTE: Bowganian's effect inflicts 600 damage to the opponent, and its effect also only works during the controller's standby phase.)
Turn 15: Yami Marik
- Draws "Surprise Attack from Beyond".
- Marik gains 1000 Life Points due to "Swallowtail Spike Lizard's" effect (Marik: 700 → 1700 Life Points).
- Marik activates Spell Card "Monster Reborn" to Special Summon "The Winged Dragon of Ra" in Phoenix Mode (0 ATK / 0 DEF).
- Marik pays 1000 Life Points (Marik: 1700 → 700 Life Points) to activate "The Winged Dragon of Ra's" first special ability to destroy "Obelisk the Tormentor".
- Yami activates his own "Monster Reborn" to Special Summon "Slifer the Sky Dragon" (2000 ATK / 2000 DEF) in Attack Position and intercept Ra's effect: Slifer is destroyed instead (NOTE: in real life, "Monster Reborn" could not be played during an opponent's turn even if it was set).
- Because Ra was Special Summoned, "The Winged Dragon of Ra" returns to Marik's Graveyard.
- Marik activates Spell Card "Surprise Attack from Beyond", allowing him to repeat his Battle Phase. "The Winged Dragon of Ra" returns to the field, this time under its normal form (0 ATK / 0 DEF).
- Pays all but 1 of his Life Points (Marik: 700 → 1 Life Points), in order to activate "The Winged Dragon of Ra's" second special ability and increase its power by the total amount of Life Points tributed ("The Winged Dragon of Ra": 0 → 699 ATK / 0 → 699 DEF). This effectively "fuses" Marik with Ra.
- Yami activates Spell Card "Soul Taker", allowing Marik to gain 1000 Life Points (Marik: 1 → 1001 Life Points) but also allowing Yugi to use one of Marik's monsters as a Tribute. He chooses "Egyptian God Slime" and, according to Battle City Rules, a Fusion Monster is treated as a number of Tribute Monsters equal to its number of Fusion Material Monsters. Yugi Tributes Egyptian God Slime and, since it is treated as a double Tribute, Yugi can activate "Obelisk the Tormentor's" special ability: destroying all of Marik's monsters and inflicting 4000 damage to his Life Points ("The Winged Dragon of Ra's" special effect makes it immune, but Marik would still lose 4000 Life Points). (NOTE: To represent how destructive the effect is, Obelisk's ATK is shown to increase to ∞ while it activates it).
- Marik tributes "Bowganian" and "Swallowtail Spike Lizard" and pays all but 1 of his Life Points (Marik: 1001 → 1 Life Points), in order to activate "The Winged Dragon of Ra's" second special ability and increase its power by the total amount of ATK/DEF and Life Points tributed ("The Winged Dragon of Ra": 699 → 3899 → 4899 ATK / 699 → 2399 → 3399 DEF).
- Marik activates Set Quick-Play Spell Card "Class System": since "The Winged Dragon of Ra" and "Obelisk the Tormentor" have the same Level, Obelisk the Tormentor's effect is negated.
- Marik uses "The Winged Dragon of Ra" to attack "Obelisk the Tormentor".
- Since Yugi controls "Dark Magician Girl" he is able to activate Quick-Play Spell Card "Magical Dimension": he tributes "Obelisk the Tormentor" and "Gazelle the King of Mythical Beasts" to Special Summon "Dark Magician" (2500 ATK / 2100 DEF) in Attack Position (NOTE: in the real game, "Magical Dimension" requires only one tribute and it allows you to Special Summon 1 Spellcaster monster from your hand then you can destroy 1 monster on the field). Since "Obelisk" has left the field, the attack made by "Ra" is negated as it has lost its original target.
- Yami activates Quick-Play Spell Card "Ragnarok", and is about to remove all monsters in his Hand, Deck and Graveyard from play in order to negate the effects of "The Winged Dragon of Ra" and remove it from play.
Differences in adaptations
- In the dub, whilst Marik is possesing Téa, yellow light has been added to Téa's eyes.
- When Marik is thinking how Yami could be so forgiving after all he has done to him, Marik's flashback is changed in the English version to show Marik on his ship, then Lumis and Umbra and various Rare Hunters, before showing mind-controlled Téa and Joey. In the Japanese version, the flashback shows Pandora, then the Silent Puppet.
- As in previous episodes, cut is a shot of Marik wagging his tongue.
Featured cards
The following cards appeared in this episode. Cards in italics debuted here.


text:
Insights From a Cardiac Resynchronization Optimization Clinic as Part of a Heart Failure Disease Management Program
Author + information
- Received August 13, 2008
- Revision received November 10, 2008
- Accepted November 12, 2008
- Published online March 3, 2009.
Author Information
- Wilfried Mullens, MD,
- Richard A. Grimm, DO, FACC,
- Tanya Verga, RN,
- Thomas Dresing, MD,
- Randall C. Starling, MD, MPH, FACC,
- Bruce L. Wilkoff, MD, FACC and
- W.H. Wilson Tang, MD, FACC* (tangw{at}ccf.org)
- ↵*Reprint requests and correspondence:
Dr. W. H. Wilson Tang, Section of Heart Failure and Cardiac Transplantation Medicine, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, Ohio 44195
Objectives Our aim was to determine the feasibility and value of a protocol-driven approach to patients with cardiac resynchronization therapy (CRT) who did not exhibit a positive response long after implant.
Background Up to one-third of patients with advanced heart failure do not exhibit a positive response to CRT.
Methods A total of 75 consecutive ambulatory patients with persistent advanced heart failure symptoms and/or adverse reverse remodeling and CRT implanted >6 months underwent a comprehensive protocol-driven evaluation to determine the potential reasons for a suboptimal response. Recommendations were made to maximize the potential of CRT, and adverse events were documented.
Results All patients (mean left ventricular [LV] ejection fraction 23 ± 9%, LV end-diastolic volume 275 ± 127 ml) underwent evaluation. Eighty-eight percent of patients had significantly better echocardiographic indexes of LV filling and LV ejection with optimal setting of their CRT compared with a temporary VVI back-up setting. Most patients had identifiable reasons for suboptimal response, including inadequate device settings (47%), suboptimal medical treatment (32%), arrhythmias (32%), inappropriate lead position (21%), or lack of baseline dyssynchrony (9%). Multidisciplinary recommendations led to changes in device settings and/or other therapy modifications in 74% of patients and were associated with fewer adverse events (13% vs. 50%, odds ratio: 0.2 [95% confidence interval: 0.07 to 0.56], p = 0.002) compared with those in which no recommendation could be made.
Conclusions Routine protocol-driven approach to evaluate ambulatory CRT patients who did not exhibit a positive response is feasible, and changes in device settings and/or other therapies after multidisciplinary evaluation may be associated with fewer adverse events.
Cardiac resynchronization therapy (CRT) restores the coordination of contraction and relaxation among cardiac chambers, leading to improved exercise tolerance, cardiac remodeling (reduction in left ventricular [LV] volumes and improvement in LV ejection fraction), and a better survival in patients with advanced heart failure and evidence of ventricular conduction delay (1–3). However, up to one-third of patients may not experience any improvement in clinical status and/or reversal of cardiac remodeling after CRT based on current selection criteria (2,4–7).
The literature regarding post-implantation management of CRT is sparse, particularly long after device implantation. While the extent of the response can be heterogeneous, most studies have focused primarily on refining pre-implantation patient selection to predict favorable response (such as detecting evidence of basal dyssynchrony) (8–13). However, a variety of post-implant issues besides patient selection can also contribute to suboptimal responses, although less is known about their prevalence and impact. There has been a paucity of data to systematically evaluate how to best manage patients with CRT after their implantation, and to troubleshoot their settings post-implant in order to maximize the potential of the resynchronization therapy. In particular, the feasibility and value of a systematic, post-implantation, protocol-driven, multidisciplinary approach to diagnose potential contributors for a suboptimal response and to optimize or titrate CRT in these patients is unknown.
The aim of this pilot study is to describe the feasibility of a multidisciplinary protocol-driven approach of ambulatory CRT patients who did not experience clinical or echocardiographic improvement (or improved only transiently) after CRT implantation. We aim to identify potential clinical or device-related contributors associated with suboptimal responses and to estimate the requirements and potential clinical impact if such a strategy were to be incorporated in a heart failure disease management program.
Study population
We evaluated 75 consecutive ambulatory patients between April 1, 2007, and April 1, 2008, who were referred to the CRT optimization clinic for comprehensive evaluation. All had received a CRT plus defibrillator device for at least 6 months (54% implanted at our own institution) but experienced persistent advanced heart failure symptoms (New York Heart Association functional class III or IV symptoms), and/or continuation (or lack of reversal) of adverse cardiac remodeling. The CRT device was implanted because of stable but advanced heart failure despite optimal medical therapy, an impaired LV ejection fraction (≤35%), and prolonged QRS duration (≥120 ms). The Cleveland Clinic Institutional Review Board approved this research project.
CRT optimization clinic protocol
The CRT optimization clinic protocol has been established as part of a multidisciplinary approach incorporated in a heart failure disease management program accessible to any referring cardiologist (Fig. 1).Briefly, on the day of the clinic visit, a heart failure nurse recorded an electrocardiogram with and without CRT pacing to ensure biventricular pacing, and the patient performed a 6-min walk test to objectively assess his/her exercise tolerance. An anterior-posterior and lateral chest X-ray were performed to ensure adequate positions of the right atrial, right ventricular, and LV lead (basal or midlateral and posterior position), and routine laboratory tests were obtained (including standard electrolyte and renal panel, complete blood count, and B-type natriuretic peptide) to detect occult anemia and metabolic derangements. Afterward, a physician performed a careful clinical evaluation and data review, and a comprehensive device interrogation was performed including assessment of battery status, lead impedances and thresholds, heart rate and activity histograms, percentage of atrial and ventricular pacing, and the presence of atrial and ventricular tachyarrhythmia.
Next, a comprehensive 2-dimensional echocardiographic examination was performed (Vingmed, System VII, General Electric, Horton, Norway) with nominal settings of the CRT device. All reported echocardiographic measurements were averaged from at least 3 consecutive cycles as recommended by the American Society of Echocardiography (14). Interventricular mechanical dyssynchrony was assessed as the difference between the pre-ejection intervals from QRS onset to the beginning of ventricular ejection at the pulmonic and aortic valve levels using pulsed-wave Doppler (1,2). Intraventricular mechanical dyssynchrony was assessed from regional time intervals between the onset of the QRS complex to the peak of the systolic myocardial velocity in 4 basal segments of the LV (septal, lateral, anteroseptal, posterior) using color tissue-Doppler imaging (11). Then, an effort was always made to optimize the LV diastolic filling (if other than stage I) by altering atrioventricular (AV) timing using conventional Doppler echocardiography. The optimal AV interval was determined by sampling mitral inflow with pulsed-wave Doppler and corresponded to the shortest AV interval that dissociated the E- and A-wave but did not interrupt the end of the A-wave (15–17). Next, the CRT device was programmed into a nonfunctional pacing mode (VVI, backup 40 beats/min) for 10 min, after which collection of echocardiographic data was repeated to ensure that CRT pacing itself was not detrimental. If the patient had no underlying atrial rhythm or a total AV nodal block, the pacemaker was programmed in an AAI or DDD mode, respectively, at heart rates similar to the nominal settings.
Multidisciplinary hypothesis and recommendations
Based upon the findings of the CRT optimization clinic, a working hypothesis for the lack of optimal response was formulated, and a multidisciplinary recommendation was proposed to the patient and referring cardiologist based on consensus of a designated electrophysiologist, cardiac imaging, and heart failure specialist to maximize or improve the potential of the CRT. These recommendations were not mutually exclusive, and such changes were made only upon agreement by the patient and referring cardiologist after a discussion of risks, benefits, and alternatives of the interventions. Appropriate actions can be categorized as repositioning of the LV lead in the case of inappropriate lead position, a change in device programming in the case of suboptimal device programming (mostly AV timing), treatment of arrhythmias either medically or invasively, adding and up-titrating of medical therapy, as well as nonpharmacologic interventions (such as recommendations of diet and fluid restriction). The option of programming the CRT device to a back-up mode (VVI 40 beats/min) was considered in the case of an absence of underlying electrical dyssynchrony and improvement of hemodynamics without CRT as assessed by echocardiographic parameters of global LV function. Finally, patients were scheduled for long-term clinical follow-up and device checks.
End points
Since interventions performed can vary widely, we also established a dichotomous grading scheme ("favorable" vs. "neutral" intervention) to capture and qualitatively assess the subjective impression of the multidisciplinary team with regard to the propensity of subsequent clinical improvement based on the implemented recommendation. These data were documented at the conclusion of the CRT optimization session after the recommendation was made and implemented.
We pre-specified the primary end point for this analysis as the time to first occurrence of any of the following outcomes followed up to July 31, 2008: all-cause mortality, cardiac transplantation, ventricular assist device implantation, and/or first readmission for heart failure after the CRT optimization clinic visit. Death was determined using data documented in the medical record and confirmed by the Social Security Death Index. These end points were collected independently from the aforementioned grading scheme.
Statistical analysis
All data were expressed as mean ± SD for continuous data and as a ratio for categorical data. Univariate comparisons of these variables were performed between patients with "favorable" intervention versus those with "neutral" intervention. The Cox proportional hazards regression model was used to determine if patients with a favorable intervention had a reduction in the combined end point during the follow-up period compared with patients with neutral intervention. Kaplan-Meier survival curves were constructed for the combined end point for patients with and without a favorable intervention. Statistical significance was set at a 2-tailed probability level of <0.05. All statistical analyses were performed using SPSS for Windows, version 13.0 (SPSS Inc., Chicago, Illinois).
Patient characteristics
Tables 1 and 2⇓⇓summarize the baseline characteristics of the study population. All patients were classified as experiencing New York Heart Association functional class III or IV symptoms, with a mean LV ejection fraction of 23 ± 9% and mean LV end-diastolic volume of 275 ± 127 ml. Device and lead implantation were successful in all patients without major complications, on average 24 ± 22 months before enrollment in the study.
Potential clinical contributors to suboptimal response
Patients presented with low normal systemic blood pressures and mildly elevated jugular venous pressure (Fig. 2,Table 2). Up to 24% of patients were not prescribed an evidence-based drug therapy despite having no noticeable contraindications (this does not imply that they have never been prescribed, only that at the time of evaluation they were found not to be taking them). Another 8% of patients were identified to be noncompliant with regard to medication or fluid/diet intake after careful interview. In addition, 41% of patients had a body mass index of ≥30 kg/m2, and 16% qualified as being morbidly obese (body mass index ≥40 kg/m2). Finally, 30% of patients experienced anemia (defined as hemoglobin <11 g/dl for female subjects/<12 g/dl for male subjects), although only 3 patients (4%) had hemoglobin <10 g/dl. One patient had primary right ventricular dysfunction without LV dysfunction.
Potential electromechanical related issues to suboptimal response
All patients had a lead in the right atrium, right ventricle, and on the LV, either via the coronary sinus (95%) or epicardially (5%) (Fig. 2). No lead dislodgement was detected, but 21% of patients had their LV lead placed in an inappropriate position (Fig. 3,Patient #1), mostly anteriorly. The mean QRS width was 152 ± 44 ms for the overall patient cohort at the time of evaluation at the CRT optimization clinic. An underlying narrow QRS (<130 ms) was detected in 9% of patients, and another 16% of patients had persistent significant mechanical dyssynchrony with biventricular pacing (11% interventricular mechanical dyssynchrony and 9% intraventricular mechanical dyssynchrony). Finally, inefficient LV filling due to suboptimal programming of AV timings was found in 47% of patients.
Potential electrophysiological and device-related issues to suboptimal response
Device interrogation was successful in all patients (Fig. 2). All were being paced in a biventricular mode on average 90% of the time, predominantly in an atrial sensing-ventricular pacing mode (Table 3).No battery depletion, lead threshold/impedance problem, or lack of rate response was noted (all but 2 patients were programmed in DDDR/VVIR mode with adequate heart rate histograms). Underlying arrhythmias were common, with 15% of patients being in permanent atrial fibrillation and another 17% of patients demonstrating a significant amount of supraventricular and ventricular ectopy (Fig. 3, Patient #3), contributing to an insufficient percentage of biventricular pacing (<90% of time).
Multidisciplinary recommendation and actions
All patients and referring physicians agreed to follow the outlined recommendations (average 1.6 recommendations per patient) with the exception of LV lead replacement (which is dependent on patient preferences) (Table 4).In 53% of the patients, appropriate clinical measures were recommended at the time of the visit to improve patient compliance to diet, fluid restriction, and medication adherence, including initiation and up-titration of neurohormonal blockade to guideline-recommended doses whenever possible. Patients with obesity were scheduled to see a nutritional therapist as well. All patients with inappropriate LV lead positions were advised to replace their LV leads. However, only 7 of 16 patients (9% of total) opted to do so because they either felt better with other instituted measures (5 of 16) or were deemed too sick by their referral cardiologist to undergo the procedure (4 of 16). AV timings could be optimized (stepwise changes by ≥30 ms), resulting in improved LV filling, in 45% of patients with conventional Doppler echocardiography (Fig. 3, Patient #2). The arrhythmia burden was successfully reduced, leading to biventricular pacing in >90% of all patients with institution of medical therapy, although 3 patients also underwent invasive electrophysiological procedures.
Eighty-eight percent of patients had significantly better echocardiographic indices of LV filling and LV function with optimal setting of their CRT compared with a temporary VVI back-up setting. However, 9 patients (12%) had an immediate improvement in their hemodynamics when the CRT was turned off. Overall, baseline characteristics were similar between patients who improved or deteriorated when CRT was temporarily withheld. In 7 patients, the CRT was programmed in a permanent VVI back-up mode. Five of the 7 had an underlying narrow QRS complex (<130 ms) without any mechanically significant dyssynchrony. One other patient had an inadequate anterolateral LV lead position and was scheduled for revision of the LV lead, and the other patient had an AV nodal tachycardia, which was successfully ablated after which CRT pacing was resumed. The 2 remaining patients had a QRS width between 120 to 130 ms, and the CRT was kept on.
Feasibility and outcomes
Mean clinic visit duration was 75 min with involvement of a designated nurse (75 min) and cardiologist (60 min). At the end of the follow-up period (mean follow-up duration 6.1 months), 23% of the patients had either died, undergone cardiac transplantation, were hospitalized for decompensated heart failure, or underwent implantation of an LV assist device. As shown in Table 4, patients categorized as being in the favorable intervention group (n = 55, 73%) had more changes in device settings including AV timing reprogramming (20% vs. 69%, p < 0.001) and LV lead repositioning (0% vs. 9%, p = 0.006) compared with those in the neutral intervention group (n = 20, 27%). Baseline characteristics between the 2 groups were similar, other than a more impaired LV ejection fraction (19 ± 8% vs. 24 ± 10%, p = 0.03) in the neutral intervention group. However, even corrected for LV ejection fraction, the favorable intervention group was associated with a lower adverse event rate during follow-up (13% vs. 50%, odds ratio: 0.2 [95% confidence interval: 0.07 to 0.56], p = 0.002) (Fig. 4).Importantly, within the favorable intervention group, the potential to optimize AV timings indicated a group with fewer adverse events during follow-up (Fig. 4).
We present our clinical experience in a multidisciplinary, protocol-driven CRT optimization clinic as part of a heart failure disease management program for ambulatory patients with persistent symptoms and/or disease progression long after their implantation. Using an algorithm with standard equipment and testing that can be reproduced in any outpatient cardiology clinic, we identified suboptimal medical treatment, LV lead position, and uncontrolled arrhythmias to be associated most often with a suboptimal response. The remaining changes that resulted from a perceived favorable intervention by the multidisciplinary team commonly involved optimization of AV timing interval titrating to the best LV filling efficiency based on transmitral Doppler flow. Although hypothesis generating, our data suggest that like any interventions, optimal titration should be considered to maximize the benefits of CRT in those who lack optimal or sustained responses (i.e., a "nonresponder" can improve if optimal adjustments can be identified, and some may be perceived to have favorable expectations).
The design of our CRT optimization clinic protocol in ambulatory patients who did not exhibit a beneficial clinical response and/or reverse remodeling at a time period long after implantation is unique in several aspects. First, it utilized a combination of a comprehensive clinical and device-based evaluation, as well as an echocardiographic examination embedded in a single centralized multidisciplinary outpatient evaluation without additional appointments for the patient to visit, thus allowing a comprehensive evaluation of the impact of CRT on cardiac structure, function, and hemodynamics, as well as on electromechanical events, which is universally available to all physicians. Second, the multidisciplinary approach including input of electrophysiological and cardiac imaging expertise, coupled with a heart failure disease management strategy, allowed the CRT optimization clinic to provide insights into reasons for a suboptimal response to long-term CRT above and beyond the standard of care. Third, by classifying these cases individually, a management strategy of titrating resynchronization therapy could be prospectively validated.
The clinical and echocardiographic responses to CRT may vary significantly among individuals, and it is important to recognize that like any effective drug or device therapy for patients with heart failure, response to therapy can be heterogeneous. This report is the first to explore the potential reasons for suboptimal response to CRT in patients with ongoing disease progression and/or persistent (or returning) symptoms at a time period long after implantation. Although various reversible device-related issues that may affect the efficacy of resynchronization therapy were anticipated, the prevalence at which they occurred was higher than expected. Issues including inappropriate lead positioning (21%), the presence of rhythm abnormalities (32%) with concomitant inadequate delivery of biventricular pacing, and suboptimal device programming (47%) were surprisingly high, especially since these patients were implanted on average 2 years before enrollment into the study. These observations highlight the notion that current post-implant approaches to longitudinal monitoring may overlook treatable problems. Finally, a subset of patients clearly demonstrated an improvement of their hemodynamics without biventricular pacing, either secondary to lack of underlying dyssynchrony or inappropriate lead positioning.
Importantly, the multidisciplinary design of the clinic also potentially impacted the clinical condition of more than two-thirds of the patients. Despite the challenge of up-titration guideline-recommend medical therapy in this patient population with advanced heart failure, we were able to modify the medical regimen in more than one-half of the cases, in addition to providing standard patient education materials by a heart failure disease management clinic. Device-related issues such as replacement of the LV lead or device reprogramming of the AV interval based on a simple echocardiographic protocol were also prevalent and under-recognized. Indeed, AV optimization has been shown to be safe, feasible, and associated with reduced filling pressures and improved cardiac output, thereby creating a more favorable hemodynamic profile, which might be associated with reduced adverse events (18–21). The fact that this benefit was mostly observed in patients without overt mechanical ventricular dyssynchrony (but with symptomatic disease progression) lends credence to the suggestion that combining heart failure disease management measures and optimization of the AV interval may have been synergistic.
Clinical implications
There might be a reluctance of physicians to use a dedicated CRT optimization clinic protocol as part of their routine follow-up of patients with CRT who experience ongoing disease progression. The lack of data to illustrate the incremental benefit (in the form of clinical outcomes), the lack of resources to support such an ambitious venture, or the impression that one might be able to also detect subtle inefficiencies of CRT programming without a dedicated protocol may all contribute to physicians' lack of enthusiasm in establishing such a process. In addition, there might be realistic concerns that such an approach might lead to an increased workload, unnecessary treatments based on inaccurate information, and even costs incurred due to excessive investigations and/or procedures. It is, therefore, reassuring to observe in our "real-life" experience that a routine protocol-driven approach, without using complex, expensive additional testing or invasive procedures, resulted in the identification of mostly clear-cut easily correctable reasons for suboptimal response in more than two-thirds of patients. By combining the imaging, heart failure, and electrophysiology evaluation within 1 centralized outpatient visit, total cost could be contained. It is conceivable that this approach can be performed by any practicing cardiologist interested in maximizing the potential of CRT in patients with advanced heart failure who lacked optimal responses. In our protocol, we adopted many commonly available tools that can be scalable for adoption by any multispecialty cardiology practice. As in our experience, a multidisciplinary clinic is perhaps the most direct path to getting the appropriate care and cross-training among subspecialties, although it is conceivable that this approach can be performed by any number of practicing cardiologists knowledgeable and interested in maximizing the potential of CRT in patients with advanced heart failure who lacked optimal responses. It is reassuring that the time commitment is likely acceptable as part of any heart failure disease management program, and these data illustrate the inadequacy of management regarding current approaches to post-implant care that warrant further investigations.
Study limitations
It is important to recognize that this is not a randomized comparison between optimization versus no optimization and that referral of patients was based on the referring physicians' clinical impression of "nonresponse," which might have introduced some bias toward referral of patients who were less sick and, therefore, more prone to be successfully optimized. Although some patients might have experienced an immediate or short-term (3 to 6 months) response to CRT, the design of our protocol focused on long-term (>6 months) response, which is more representative of the true clinical impact of the therapy. Although optimal AV intervals were assessed at rest and not during exercise, we were still able to demonstrate a significant benefit from AV optimization based on a standard, clinically applicable echocardiographic approach without extensive post-imaging data processing. Improved LV filling (Fig. 3, Patient #2) surely led to improved hemodynamics in certain cases. We did not optimize ventriculo-ventricular timings since there is no reliable methodology to do so in the clinical setting, and we cannot exclude the possibility that optimization of ventriculo-ventricular timings may have provided better clinical and echocardiographic responses. Finally, patients were not routinely scheduled for a follow-up CRT optimization clinic visit, so any effect of optimization on reverse remodeling or clinical improvement could not be demonstrated in this analysis.
A multidisciplinary protocol-driven approach to ambulatory CRT patients who did not exhibit a positive response long after implant may uncover potential contributors to a suboptimal response, may potentially maximize the potential of CRT, and may be associated with a reduction in adverse events.
Dr. Mullens was supported by a fellowship training grant sponsored by Boston Scientific and St. Jude. Drs. Starling, Dresing, and Tang are consultants for Medtronic. Drs. Dresing and Tang are consultants for Boston Scientific. Dr. Dresing is a consultant for St. Jude. Dr. Grimm is a consultant/advisory board member for Medtronic, St. Jude, and GE Healthcare. Dr. Wilkoff is a consultant and receives research support from Medtronic, Boston Scientific, and St. Jude. Dr. Wilkoff is a consultant for LifeWatch. The authors had full access to the data and take responsibility for its integrity. All authors have read and agree to the paper as written.
- Abbreviations and Acronyms
- atrioventricular
- cardiac resynchronization therapy
- left ventricle/ ventricular
- Received August 13, 2008.
- Revision received November 10, 2008.
- Accepted November 12, 2008.
- American College of Cardiology Foundation
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