Life as a new mum is one full of boundless changes. Frazzled as you may be, you should grace it with preparedness and utmost calmness. As is usually customary, you will be swamped and flooded with advice. An inescapable part and parcel of becoming a mum, information will come from everywhere—from relatives, well-wishers, friends, and even your own research on parenting.
It would seem daunting, assisting your brain to evaluate and process all that information, all whilst keeping your energy on top form. You ask how? By keeping your nutrition in tip-top condition of course!
A diet replete in nutritional powerhouse foods is exactly what every new mum needs for her wellbeing and that of her baby. Eating the right kinds of food will assist you vitally, while you cope with this life-changing experience. Helping you recover from birthing, keeping the breast milk flow adequate, and helping you get back in shape with time are just a few of the benefits. Remember, you are also eating for two—for the new bundle of joy who will benefit just as much from a proper, healthy eating plan.
resources that breastfeeding demands. That, combined with a range of veggies, fruits, and whole grains will ensure that your energy levels are running at full power.
Then again, you can take your nutrition many levels up with some extra powerhouse ingredients. Delicious and versatile enough to be a part of different meals, the below will put you on the road to wellbeing in no time.
All that hype about avocados? It is true. Avocados are protein-filled fruits vital for cell growth in the new mum and the baby. Not only do avocados guarantee a noteworthy amount of protein, they also serve as a creamy and sumptuous addition to a variety of meal plans for the new mum.
Guava is a tropical wonder fruit opulent in high-profile nutrients. With its distinctive flavor, unique taste, and health-stimulating qualities, the fruit fits into that exemplary powerhouse category which is very paramount to a new mum.
These high-protein beasts can hugely benefit the new mum and her baby. Are you someone who likes variety? Beans and lentils come in many different types and they all still deliver much needed nutrients. In fact, soybeans have more protein content than any other beans; the same amount of protein in 150 grams of chicken will be provided by a single portion of cooked soybeans. These wonder beans promote digestive health in the new mum, thus ensuring a perfect breastfeeding experience for her and the baby.
Research has indicated that seeds, specifically chia seeds, boast a fair volume of protein. It is also one of the most weight loss-friendly ingredients that allows the new mum to attain the leanest of proteins. A great alternative to animal products, its richness will definitely trickle down to the baby as well. It gets better though. Chia seeds don't contain cholesterol unlike many other seeds, and are high in calcium making your teeth and bones stronger. Other great seed additions you can try are pumpkin, squash, sunflower, sesame, and flax seeds.
The versatility of spinach is quite unbelievable and not really well known. A new mum should consider having spinach incorporated into her meals regularly. Although it can be included in both cooked and raw forms, I choose to blend mine alongside other fruits and vegetables. But then again, I have also been known to blend it with my pancake batter! A good intake of spinach will fill you up on iron, alongside giving a decent dose of protein and calcium.
Crunchy, buttery, and sumptuous nuts are delightful gifts to a new mum from Mother Nature. They serve as protein-packed, ready-to-eat snacks that are easy to enjoy anywhere and anytime. Roasted peanuts, macadamia nuts, chestnuts, hazelnuts, almonds, cashew nuts, and walnuts are extremely rich in protein. They should however be eaten in moderation due to the high fat content.
Good nutrition is thus just as paramount for your health as it is for the baby. A balanced, nutritious diet high in proteins is an important principle of breast-feeding. Make the best out of these heart-healthy powerhouse ingredients to get the best out of eating habits. After all, being a great new mum starts by taking good care of you first, enabling you to look after your baby better.


text:
Q: Deleting object from an array in collections [performance / best practice / issues] So I have a Collection named Pages, and inside of this collection, each page has an array of Widgets, each widget has an uuid which I use to identify each widget.
Pages [
     widgets : [{uuid : "someuuid"}, {uuid : "otheruuid"}]
]

I need to remove an item from a widgets array and update the collection. So I read in this post about how to remove items in an array (Mongo DB approach).
Example of the post:
db.people.update({"name":"dannie"}, {'$pull': {"interests": "guitar"}})

I tried it, but it didn't work for my project, Dont know why, I am not sure why, I don't know how to write the mongodb instructions
So since I have to keep working I did something like this:
//random function to get index of an object in the array;
var indexOf = myfunction.getIndexOfObject()
if (indexOf > -1) {
    //remove the item in the array of the Active Page
    activePage.widgets.splice(indexOf, 1);
    //update the collection
    Pages.update({_id : activePage._id},activePage);
}

I would like to know if my approach is correct; it works fine without any problems. But I dont know if could have any issue or caveat in performance or security or whatever other thing, since the documentation approach is totally different:
Documentation approach:
http://docs.mongodb.org/manual/reference/operator/update/pull/
db.cpuinfo.update(
                   { flags: "msr" },
                   { $pull: { flags: "msr" } },
                   { multi: true }
                 )

thanks for the support.

A: Although whatever you are doing seems to be correct but I tired using $pull for updating array I could do it.
I created a sample page collections and inserted following docs
db.pages.insert({widgets : [{uuid : "someuuid1"}, {uuid : "otheruuid2"}]});
db.pages.insert({widgets : [{uuid : "someuuid2"}, {uuid : "otheruuid3"}]});
db.pages.insert({widgets : [{uuid : "someuuid3"}, {uuid : "otheruuid3"}]});
db.pages.insert({widgets : [{uuid : "someuuid3"}, {uuid : "otheruuid4"}]});

The I ran update query to pull elements
db.pages.update({},{$pull : {"widgets" : {uuid : "otheruuid3"}}}, {multi:true});

I can see document 2 and 3 do not have "uuid : otheruuid3" in widgets. Not really sure what issue you are facing

redpajama_set_name: RedPajamaStackExchange


text:
Q: Insert command works on command line but not in pymongo Error: key '$date' must not start with '$' I am trying to populate a table with data automatically using pymongo where I have been manually inserting before. The issue I am having is that my insert statement is working in the command line but throwing a "key '$date' must not start with '$'" error in pymongo. Note: I have recieved this same error when trying to use update() in the mongo command line.
Im using python3 and mongodb 4.0.10
Here is my code:
Command line query:
device_query = {
    "_id":device_ids[i],
    "customer_id":"18012320",
    "rep":"MVO2",
    "active":"true",
    "description":descriptions[i],
    "location":"test, test" ,
    "system":"MM 60 gallon, 40 LPM, pre-HPR",
    "device_type":"O2",
    "iot_start_date":{
        "$date":{
            "$numberLong":"1563598800000"
        }
    },
    "iot_expire_date":{
        "$date":{
            "$numberLong":expirations[i]
        }
    }
}
device.insert_one(device_query)`

This code inserts the document successfully
pymongo code:
device_query = {
    "_id":device_ids[i],
    "customer_id":"18012320",
    "rep":"MVO2",
    "active":"true",
    "description":descriptions[i],
    "location":"test, test" ,
    "system":"MM 60 gallon, 40 LPM, pre-HPR",
    "device_type":"O2",
    "iot_start_date":{
        "$date":{
            "$numberLong":"1563598800000"
        }
    },
    "iot_expire_date":{
        "$date":{
            "$numberLong":expirations[i]
        }
    }
}
device.insert_one(device_query)`

This code throws
key '$date' must not start with '$'

A: You dont need to use $date and $numberLong in pymongo code, just simply pass the value in the field.
Try this :
device_query = {
    "_id":device_ids[i],
    "customer_id":"18012320",
    "rep":"MVO2",
    "active":"true",
    "description":descriptions[i],
    "location":"test, test" ,
    "system":"MM 60 gallon, 40 LPM, pre-HPR",
    "device_type":"O2",
    "iot_start_date":1563598800000,
    "iot_expire_date":expirations[i]
}
device.insert_one(device_query)


One of the surest ways to learn more about culture and tradition is food.
The late Anthony Bourdain once said: "Walk in someone else's shoes or at least eat their food. It's a plus for everybody." And he was spot on.
Foosion by UNO is an ambitious project run by public service officers under the Young Executive Program (YEP), an initiative by the Prime Minister's Office to identify and mentor young leaders so they achieve their potential.
The goal was simple: To feature Bruneian ingredients in modern cooking in a competition in order to increase awareness about local produce among the young generation.
The competition took place at the Eco Ponies Garden in Tutong, a place known for its richness and diversity in local food ingredients.
Participants in the competition were asked to come up with their best dishes using two 'secret' ingredients — Bunga Telang (Butterfly Pea or Asian Pigeonwings) and Terung Iban (Iban Eggplant) —both ingredients which are used extensively by the indigenous groups of Borneo.
Their dishes were later brought to a panel of judges comprising chefs from restaurants and culinary institutions.
Hj Sawaz Hj Ali and Jamilatul Wahidah Wahid, of Team Jongsarat, beat 10 other contestants buy creatively using the Terung Dayak as part of their Balutak (cow's intestines, organs and trimmings) Lasagna.
They also wowed the judges with their mocktail and vanilla sky-blue cake, both of which were infused with Bunga Telang.
Events like Foosion are important for Brunei because this helps ensure the continuity of local traditions, including the passing down of knowledge to the youth.


text:
Leeds 521
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Popular Leeds Hotels
This contemporary Leeds hotel is situated within a 10-minute stroll of Leeds City Bus Station. It is conveniently located in the city centre.
Leeds Marriott Hotel
Hotel in Leeds, United Kingdom
Conveniently located in the middle of the city, this 4-star hotel makes for an excellent base in Leeds. It is set amongst a variety of dining options and is minutes on foot from Leeds Railway Station.
DoubleTree by Hilton Hotel Leeds City Centre
Situated only a short stroll from Leeds City Bus Station, the hotel provides guests with a convenient base when in Leeds. It is conveniently located for guests wishing to visit local attractions.
Ibis Budget Leeds Centre
Conveniently located in the centre of the city, this 4-star hotel makes for an ideal base in Leeds. It also provides a sauna, an express check-in and check-out feature and an indoor pool.
Hilton Leeds City
Conveniently positioned, Radisson Blu Hotel Leeds offers easy access to Leeds's main sightseeing areas. It provides 4-star accommodation with air-conditioned rooms.
Radisson Blu Hotel Leeds City Centre
Situated a short drive from Headingley, Holiday Inn Express Leeds City Centre provides stylish accommodation in Leeds. It offers 3-star accommodation with air-conditioned rooms.
Holiday Inn Express Leeds - City Centre
Located amongst a variety of well-known tourist hot spots, shops and dining options, Ibis Budget Bradford is ideal for those wanting to explore Bradford and its surroundings. It also offers wireless internet access in public areas, an express check-in and check-out feature and a tour desk.
Ibis Budget Bradford
Hotel in Bradford, United Kingdom
Conveniently located in the middle of the city, this 5-star hotel makes for an ideal base in Leeds. It also provides room service, a safe and a 24-hour reception.
Dakota Leeds
All 521 hotels in Leeds
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Tips when booking a hotel in Leeds
High season: August
Low season: April
Average price: $87/night
Cheapest price: $67/night
(LBA)
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Hotel pricing outside of Leeds
Headingley 2.3 mi 6 hotels From $60/night
About Leeds
A city of contrasts, Leeds is home to gleaming skyscrapers and historic Victorian arcades. Its modern malls make it a mecca for shopping enthusiasts, while it also boasts fantastic restaurants, trendy craft breweries and cosmopolitan nightlife.
Famous for its beauty, the Victoria Quarter shopping arcade is brimming with luxury retailers. The building is adorned with a tiled mosaic floor, wood-panelled shopfronts and a stained-glass ceiling. Inside you'll find high-end retail outlets, such as Louis Vuitton and Harvey Nichols.
Book tickets to a show at the Belgrave Music Hall & Canteen, one of the city's top live music venues. It hosts everything from comedy acts and burlesque shows to folk concerts and rock gigs. There's also a breezy roof terrace with sweeping views of the city.
Originally built to house relics from the Tower of London, today the Royal Armouries showcases weaponry from across the United Kingdom. Highlights include fencing swords, medieval chainmail, jousting lances and Indian elephant armour.
Leeds is a city of diverse neighbourhoods, such as Chapel Allerton, known as the "Notting Hill of the North". It's filled with independent boutiques, galleries and bars. Headingley and Hyde Park are popular with students, with plenty of organic cafes, craft beer bars and thrift stores to explore.
Central Leeds is easy to navigate on foot, as many of its streets are reserved for pedestrians. Leeds is also well-serviced by a network of buses that run throughout the city. Leeds-Bradford International Airport is 15 kilometres north of the city centre, with local buses making the trip in around 30 minutes.
Leeds Railway Station

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Google charts table random display I have multiple tables in my app. In the app I cannot control the numbers of columns of the strings lengths in the column. Also I cannot control the numbers of columns of the orders of the columns.
Right now i have 4 tables in a set and one table in another set. I will put only the headers as the other data is confidential in this image.
The problem I encounter is: since the string length in a column in the table is not the same as the same column in other table. The width of the columns are not the same within a table set. I have tried to check on page load the length of the columns but the tables is not drawn on page load. When i say a table set i refer a list of tables with same properties, same columns number and name.
I cannot set fixed size on a certain column because I am not able to know if for next table set how the columns distribution is.
How can I make all the columns to look alike? How can I catch event when the table is fully drawn?


The maximum daily temperature 34.3°C — 7 April 2016.
The maximum night temperature 30°C — 24 April 2018.
The minimum daily temperature 27.5°C — 26 April 2018.
The minimum night temperature 24.5°C — 12 April 2013.
The warmest water 31.3 °C — 19 April 2016. The coldest water 29.6 °C — 1 April 2014.


text:
Seville enchants
It is the oldest bullring in the province of Seville and is built on the parade ground of a Muslim castle dating from around 1400, with archaeological remains of a wall, minarets and the main door of the town's old Andalusian castle integrated into its interior.
Carmen de los Arrayanes
"Carmen de los Arrayanes" Andalusí Palace. The owner, José Luis Romero Núñez, made his dream a reality. He built a Nasrid-style house in the centre of Paradas.
Municipal Historical Museum
Ecija's Municipal Historical Museum has allowed the city to recovery the Benamejí Palace -a magnificent example of 18th-century Ecijan Baroque, listed as a Historical-Artistic Monument. The extraordinary historical and archaeological heritage, both of the city and its municipal district can now be exhibited, preserved and remembered as one of the richest in Andalusia.


text:
News Sports Ticket Lifestyle Opinion Nation / World Obituaries E-Edition Legals
Hall-of-Famer a voice to be reckoned with
Doug Fernandes
doug.fernandes@heraldtribune.com
At his induction speech for the Broadcast Pioneers of Philadelphia Hall of Fame, Don Henderson had his opening line ready.
And the 86-year-old, part-time Sarasota resident for 20 years wasn't about to use his time at the microphone to lie.
"I started off by saying, 'You are looking at the most unlikely guy to ever be standing up here for the Hall of Fame. You're talking about a bartender.' "
Henderson was being modest, though for a time he did run a bar in Trenton, New Jersey, started by his father.
He also was a pretty fair swimmer at Trenton Central High School, good enough to earn a scholarship to the University of Texas.
That wasn't the unlikely part Henderson talked about. He always had the deep rich voice one might expect to hear on radio or television, but that wouldn't portend a career in both sports TV and radio lasting from 1957 to 2000.
Don Henderson merely took each opportunity he was given and parlayed it into another. "I just went from one thing to the other thing and it came up roses."
Ask any Philadelphia 76ers fan about Don Henderson. Or the Phillies. Ask any fan of Temple Owls basketball about him. With those teams, Henderson's voice became synonymous.
There just wasn't a clue to any of it. Henderson also played baseball for a year at Texas before doing both sports became too much. But with a semester to go before earning his degree in business, Henderson was offered a tryout by the Cleveland Indians.
He left Texas and reported to Tucson, Arizona. Henderson didn't make the Indians, and five weeks in their minor-league system convinced him he wasn't good enough.
So at age 21, he returned to Trenton and managed the bar, Club 50, with a brother. Soon a guy suggested Henderson add music to the play. It turned into one of the only jazz clubs in the Trenton area, attracting talent such as Doc Severinsen, Clark Terry and Coleman Hawkins.
Around this same time, a writer for the Trenton newspaper was hosting a one-hour nightly sports radio show. The guy was going away on vacation and asked Henderson, who had never before done radio, to sit in for him.
"It's an hour," Hendeson said. "How tough can this be."
When the regular host got another job, the owner of the station asked Henderson to keep doing the show. That led him to start a Sunday night jazz radio show from his bar.
Henderson was doing the nightly radio sports show and Sunday night jazz show when a man from Philadelphia, named Ed Moore, called. He listened to Henderson's radio shows and liked what he heard. He was also starting up a new TV station in Philadelphia, channel 29, and wanted Henderson, with no prior experience, to do the sports segments on the 6 and 11 newscasts.
And Moore also made Henderson's wife, again with no prior experience, the station's weather person. Hubby doing sports, wife the weather.
Henderson did this for about five years when his station got the rights to Notre Dame football. On a Monday night, along with Norm Snead, Henderson would recap the game while previewing the Irish's next one.
Now known around the area, Henderson stayed at channel 29 for a few more years before the CBS station in Philadelphia, the country's No. 4 market, hired him to do a two-hour daily talk-radio and pre- and post-game shows for the Phillies.
Henderson got to know all the players and even managed to get Steve Carlton, who hated the media, for an interview. Then, after some time, Temple wanted Henderson to do football and basketball play-by-play.
He did this for two years and then Pat Williams became GM of the 76ers. The team's broadcaster was leaving and Williams wanted to know if Henderson wanted the job.
He did and got to call some memorable games, including Portland's Game 6 win over the 76ers in the 1977 NBA Finals and their Game 7 loss to the Celtics in the 1981 Eastern Conference Finals.
But when the 76ers, with Moses Malone, won the title in 1983, Henderson wasn't there to broadcast it. His contract up, he went back to Temple, where he remained for the next 17 years.
After doing one year of Miami Hurricanes football in 2000, Henderson called it quits, though he still does a once-a-week sports internet show.
"Just lucky breaks, that's all."
Breaks that Don Henderson got, then made into something suitable for a hall of fame.
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How do I sort a select box, using metadata?
How do I automatically sort (using metadata) the pop up window that comes up when a user selects record to relate to another record?
How would I change that to sort by account name instead?
By rendering this field in a regular popup you should need to specify a custom popup. In my opinion this approach is painfull.
I preffer to convert that field into a regular dropdown on EditView whose list will be dynamically loaded on function preDisplay of view.edit.php. This way it is easier to properly filter the list and sort as you wish. By the way, in a popup the initial filter is lost as soon as you apply some other filter or paginate it.


text:
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Electric Cars Are Getting a Strange New Feature in the EU
President Trump Raises $100 Million for the 2020 Re-Election Campaign
By Guilherme Assis | Oct 16 2018, 8:48pm in Politics
President Donald Trump has managed to raise over $100 million to support his bid for re-election in 2020. Source: The Hill
President Donald Trump has managed to raise over $100 million to support his bid for re-election in 2020. This is a huge financial advantage over potential contenders from the Democratic Party. A number of Democrats have expressed their desire to challenge Trump in 2020 but so far no single candidate has emerged from the crowded field. Trump's campaign raised over $18 million jointly with the Republican National Committee in the July to September quarter alone. So far the funds stand at $106 million and more could still be raised over the coming months. After all, the 2020 election is still 2 years away and a lot can happen between now and then.
Trump's unorthodox style in politics has challenged many political rules. In fact, as soon as he was sworn into office back in 2017, the President filed for re-election immediately. This is quite unusual in the US. In addition to this, Trump has been on the campaign trail not just on the run-up to the midterms but also during the first few months of his presidency. The fundraising has also started early compared to other presidents. For example, former president Barack Obama waited until the last year of his term to start fundraising.
Donations of less than $200 accounted for 98% of the total money raised. Source: NBC News
The $106 million raised so far has largely come from small donors. The filings with the Federal Election Commission show that donations of less than $200 accounted for 98% of the total money raised. This was confirmed by Lara Trump, the president's daughter-in-law and head of his 2020 re-election team. Lara said that the president's track record for the months he has been in office has inspired grass root Americans to respond with donations of all amounts. Lara also called on Trump supporters to turn up in large numbers in the upcoming midterms and support the president in his agenda.
The 2020 race has not yet shaped up definitively. Although it's now confirmed that Trump will run on the GOP ticket, we still don't know yet who will be the ultimate challenger. Many Democrats have expressed their intention to rival the president including Senators Kamala Harris, Elizabeth Warren, Bernie Sanders etc. Former New York City Mayor Michael Bloomberg may also run for the Democratic ticket.
A recent poll showed that former Vice President Joe Biden is leading in popularity among Democratic voters. Source: Express
However, the focus as for now for the Democrats is to retake the house and possibly the Senate. Although the Senate would be relatively harder to flip, there's increasing confidence that the party is well on its course to regain the majority in the House. This will, of course, complicate things for the Trump administration and may be used as a momentum builder on the run up to the 2020 election.
President Trump has expressed confidence a number of times that he will easily win. He sees no real challenger from the Democratic Party so far but this could change in the months ahead. A recent poll conducted by CNN showed that former Vice President Joe Biden is leading in popularity among Democratic voters and could enter the presidential race in 2020. But with the $100 million war chest that Trump now has, it won't be easy to compete with him.
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Severely threatened by climate change, Bangladesh is showing the world how to take an active role in adapting to this situation. Learning from its own experience in coping with floods and cyclones, Bangladesh is taking the lead in international climate change negotiations and attempting to persuade the industrialized world to curb emissions.
Bangladesh is one of the countries most vulnerable to climate change – but it is also a country that is capable of coping. Far from being a victim, Bangladesh has lessons for activists, scientists, government and donor officials and concerned citizens who want to know what climate change looks like and how to respond to it.
This densely populated country feeds itself because it is in a rich delta. But that comes at the price of a volatile environment – three huge rivers bring floodwaters from the Himalayas and massive cyclones sweep up the Bay of Bengal. Once accurately described as a 'basket case' of hunger and disaster, its scientists and engineers, working with local communities, have transformed the country. Strong cyclone shelters and early warning systems now protect at-risk coastal people. Improved rice varieties and irrigation feed the nation and rapidly cut child malnutrition. Women's education has curbed population growth. Along with these changes have come measures to cope with the volatile environment.
Climate change makes the problems worse, with higher temperatures and rising sea levels, heavier rain and bigger floods and stronger cyclones. Bangladeshis know what the damaged climate change will bring. The government, researchers and communities are already adapting, raising land levels to match the rise in sea level, strengthening dykes to protect against floods, producing more adaptable rice varieties and improving disaster preparation. Bangladesh is a model of climate change adaptation and a lesson for those who continue to ignore global warming.
Bangladeshis have taken a leading role in international campaigning and negotiating, helping to convince industrialized countries to curb greenhouse gas emissions. Because it cannot wait for help from rich countries, Bangladesh has shouldered most of its adaptation costs. Will industrialized countries make the task harder – or will they help Bangladesh by reducing emissions and paying for the damage already done?
Manoj Roy is a lecturer in sustainability at Lancaster Environment Centre, Lancaster University, UK.
Joseph Hanlon is a visiting senior fellow at the London School of Economics and a visiting senior research fellow at the Open University, Milton Keynes, UK.
David Hulme is a professor of development studies and executive director of the Global Development Institute, University of Manchester, UK.
1. Actors, not victims; 2. How will climate change hit Bangladesh; 3. Taking the lead in negotiations – and moving forward; 4. Sea level rise and the vulnerable coast, where farmers know more than engineers; 5. Saving lives with cyclone shelters; 6. Living with floods; 7. Agronomists keeping ahead of climate change; 8. No climate change migrants – yet; 9. How can the privatised megacity cope with climate change?; 10. Is climate change only a problem for the urban poor?; 11. Power – political, financial and electrical; 12. The front line of climate change; Index.


The Four Columns Krakow at night Museu Nacional d`Art de Catalunya Industrial buildings in Barcelona Industrial buildings in Barcelona Shipping industry in the the Port of Barcelona. Museu Nacional d`Art de Catalunyan Shipping industry in the the Port of Barcelona. Narrow street in barcelona.


Corresponding to: Tristan D. Yan, MD, MS, PhD, FRACS, Associate Professor. Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney; The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia. Email: tristanyan@annalscts.com.
Background: Surgical ablation has emerged as an acceptable treatment modality for patients with atrial fibrillation (AF) undertaking concomitant cardiac surgery. However, the efficacy of surgical ablation in patient populations undergoing mitral valve surgery is not well established. The present meta-analysis aims to establish the current randomized evidence on clinical outcomes of surgical ablation versus no ablative treatment in patients with AF undergoing mitral valve surgery.
Methods: Electronic searches were performed using six databases from their inception to September 2013, identifying all relevant randomized controlled trials (RCTs) comparing surgical ablation versus no ablation in AF patients undergoing mitral valve surgery. Data were extracted and analyzed according to predefined clinical endpoints.
Results: Nine relevant RCTs were identified for inclusion in the present analysis. The number of patients in sinus rhythm (SR) was significantly improved in the surgical ablation group compared to the non-ablation group at discharge. This effect on SR remained at all follow-up periods until >1 year. Results indicated that there was no significant difference between surgical ablation and no ablation in terms of 30-day mortality, all-cause mortality, pacemaker implantation, stroke, thromboembolism, cardiac tamponade, reoperation for bleeding and myocardial infarction.
Conclusions: Results from the present meta-analysis demonstrate that the addition of surgical ablation for AF leads to a significantly higher rate of sinus rhythm in mitral valve surgical patients, with no increase in the rates of mortality, pacemaker implantation, stroke and thromboembolism. Further research should be directed at correlating different surgical ablation subtypes to cardiac and cerebrovascular events at long-term follow-up.
Submitted Dec 09, 2013. Accepted for publication Jan 08, 2014.
Atrial fibrillation (AF) is the most common cardiac arrhythmia observed in clinical practice and confers a high incidence of thromboembolic events and deaths. Although anti-arrhythmic drugs are the first-line treatment for some AF patients, controversy exists regarding their limited efficacy and adverse outcomes (1-3). Surgical ablation represents a non-pharmacological treatment for AF in patients undergoing concomitant cardiac surgery for valvular repair or replacement or coronary artery bypass.
The Cox-Maze III procedure was the first curative option for AF patients and remains the gold-standard treatment today (4). Following animal and human mapping studies, the Cox-Maze III procedure that evolved in 1992 enabled efficacious elimination of abnormal re-entry circuits (5). A series of endocardial incisions through the walls of both atria via median sternotomy and cardiopulmonary bypass (CBP) led to the advent of the pioneering "cut and sew" method. Although this technique is effective in maintaining sinus rhythm (SR) and atrial mechanical function, its widespread application is limited by an associated increase in operative times, morbidity and technical complexity (6-10).
Recent technological advances and an improved understanding of AF etiology have given rise to newer surgical ablation techniques. The discovery by Haïssaguerre and colleagues that the pulmonary veins are the source of ectopic activity in paroxysmal AF led to the development of the pulmonary vein isolation approach, which employs a minimal left atrial lesion set (11). Furthermore, the advent of alternative energy sources has greatly simplified the "cut and sew" technique. Because radiofrequency, microwave and cryothermal energy can be used to create lines of transmural necrosis, surgical incisions used in the Maze procedure are no longer required (12-15). Such developments have transformed surgical ablation into an easier and faster procedure with reduced morbidity.
Previous meta-analyses and systematic reviews have assessed diverse populations undergoing multiple types of surgery, including mitral valve surgery, coronary artery bypass grafting and aortic valve replacement (16-19). However, there are high levels of heterogeneity in some of the outcomes reported, likely derived from such mixed surgical populations. The efficacy of surgical ablation in patient populations undergoing only mitral valve surgery is not well established. Thus, the present meta-analysis aims to provide randomized evidence to evaluate clinical outcomes of surgical ablation in AF patients undergoing mitral valve surgery.
Electronic searches were performed using Ovid Medline, PubMed, Cochrane Central Register of Controlled Trials (CCTR), Cochrane Database of Systematic Reviews (CDSR), ACP Journal Club and Database of Abstracts of Review of Effectiveness (DARE) from their dates of inception to September 2013. To achieve maximum sensitivity of the search strategy and identify all studies, we combined the terms: "AF" and "ablation" or "pulmonary vein" or "maze" and "RCT" as either keywords or MeSH terms. The reference lists of all retrieved articles were reviewed for further identification of potentially relevant studies. All identified articles were systematically assessed using the inclusion and exclusion criteria.
Eligible randomized controlled trials (RCTs) for the present systematic review and meta-analysis included those in which patient cohorts underwent mitral valve surgery concomitantly with treatment of AF, which utilized surgical ablation techniques including Cox-Maze, radiofrequency ablation, cryoablation and microwave ablation. Studies that did not include SR or AF-free survival as endpoints were excluded. When institutions published duplicate studies with accumulating numbers of patients or increased lengths of follow-up, only the most complete reports were included for quantitative assessment at each time interval. All publications were limited to those involving human subjects and in the English language. Abstracts, case reports, conference presentations, editorials and expert opinions were excluded. Review articles were omitted because of potential publication bias and duplication of results.
All data were extracted from article texts, tables and figures. Two investigators independently reviewed each retrieved article (K.P. and A.X.). Discrepancies between the two reviewers were resolved by discussion and consensus with a third reviewer (D.H.T.). Assessment of risk of bias for each selected study was performed according to the most updated Cochrane statement. Discrepancies between the two reviewers were resolved by discussion and consensus. The final results were reviewed by the senior investigator (T.D.Y.).
The odds ratio (OR) was used as a summary statistic. In the present study, both fixed- and random-effect models were tested. In the fixed-effects model, it was assumed that treatment effect in each study was the same, whereas in a random-effects model, it was assumed that there were variations between studies. χ2 tests were used to study heterogeneity between trials. I2 statistic was used to estimate the percentage of total variation across studies, owing to heterogeneity rather than chance, with values greater than 50% considered as substantial heterogeneity. I2 can be calculated as: I2 = 100% × (Q – df)/Q, with Q defined as Cochrane's heterogeneity statistics and df defined as degree of freedom (20). If there was substantial heterogeneity, the possible clinical and methodological reasons for this were explored qualitatively. In the present meta-analysis, the results using the random-effects model were presented to take into account the possible clinical diversity and methodological variation between studies. Specific analyses considering confounding factors were not possible because raw data were not available. All P values were 2-sided. All statistical analysis was conducted with Review Manager Version 5.2.1 (Cochrane Collaboration, Software Update, Oxford, United Kingdom).
A total of 588 references were identified through six electronic database searches (Figure 1). After exclusion of duplicate or irrelevant references, 474 potentially relevant articles were retrieved. After detailed evaluation of these articles, 62 studies remained for assessment. Manual search of reference lists yielded one new study. After applying the selection criteria, nine RCTs were selected for analysis. The study characteristics of these trials are summarized in Table 1. In these nine studies, 496 patients underwent procedures that involved mitral valve surgery with surgical ablation (MV + SA group; n=270) or without surgical ablation (MV group; n=226). Baseline patient characteristics and risk factors are summarized in Table 2.
Figure 1 Search strategy of meta-analysis on aortic arch surgery utilizing surgical ablation with mitral valve surgery (MV + SA) versus mitral valve surgery alone (MV) in atrial fibrillation (AF) patients.
All of the included studies were RCTs (Level 1 evidence) (21-29). Four studies had >50 patients (range, 29-97 patients) (22,25-27), while the remaining studies had less than 50 patients (range, 29-49 patients) (21,23,24,30,31). Four studies used radiofrequency ablation (21,25,26,29), one study used radiofrequency with port-access (22), three studies used Cox-Maze cut-and-sew (23,24,28), one study used cryoablation (27) and one study reported patients undergoing pulmonary vein isolation (28). Permanent AF, persistent AF and a mixture of permanent, persistent and paroxysmal AF populations were evaluated by six studies (21,23,25,27-29), one study (24) and two studies (23,26), respectively.
One study reported follow-up of greater than 3 years (56 months) (28). Two studies had follow-up between 2-3 years (range, 26-29 months) (21,24), while six studies had follow-up <2 years (12-18 months) (22,23,25-27,29). SR was the primary endpoint in seven studies (21,23,25-29), while AF-free survival was the primary endpoint in two studies (22,24). 1-, 3-, 6-, 12-month and >1 year SR outcomes were reported in one study (24), seven studies (21-26,29), six studies (21,22,24-27), nine studies (21-29) and three studies (22,24,28), respectively. 30-day mortality was reported by all nine studies (21-29).
The 9 RCTs were also assessed qualitatively using tools recommended by the Cochrane Collaboration for the risk of bias. A graph and summary of selection bias, performance bias, detection bias, attrition bias, reporting bias and other bias identified in each individual RCT is shown in Figure 2.
Figure 2 (A) Methodological quality graph and (B) Methodological quality summary for the risk of bias from randomized controlled trials comparing concomitant surgical ablation and mitral valve surgery versus mitral valve surgery alone.
Similar baseline characteristics were observed in both comparison arms. Males accounted for 24-83% of patients undergoing MV + SA and 20-74% undergoing MV alone (weighted mean: 46% vs. 47%; P=0.85). The average age ranged between 50-70 years for both MV + SA and MV groups (weighted mean: 60.1 vs. 59.9; P=0.60) for MV + SA and MV groups respectively. A greater number of patients in each study presented with mitral regurgitation compared to stenosis. However, no significant difference was found between MV + SA and MV groups in the proportion of patients with mitral valve stenosis (weighted mean: 35.8% vs. 25.8%; P=0.29), mitral valve regurgitation (weighted mean: 62.0% vs. 71.5%; P=0.47) or mixed mitral pathology (weighted mean: 9.7% vs. 9.6%; P=0.89). Furthermore, most patients recruited presented with persistent or permanent AF, with no significant differences between the treated and control groups (weighted mean: 93.1% vs. 98.6%; P=0.89). All other comparative preoperative characteristics were infrequently reported, including chest/sternal infection, mediastinitis, endocarditis, pneumonia and sepsis.
CBP time was significantly longer when MV surgery was performed concomitantly with surgical ablation. With the exception of two studies (21,29) which did not report CBP, all other studies reported CBP times which demonstrated longer average CBP for the MV + SA group (weighted mean: 144.4 vs. 101.3 minutes; P=0.02). Similarly, cross-clamp time was significantly longer for the MV + SA group compared to MV (weighted mean: 76.4 vs. 63.8 minutes; P<0.00001). For both cohorts, the frequency of the different subtypes of MV surgery was comparable. Mitral valve repair ranged from 0-77% and 0-80% for MV + SA and MV (weighted mean: 45.4% vs. 46.3%; P=0.92) respectively. Mitral valve replacement ranged from 23-100% and 20-100% for MV + SA and MV (weighted mean: 52.2% vs. 57.4%; P=0.33) respectively.
Mortality outcomes at 30 days were reported in all studies. The risk of 30-day all-cause mortality was not significantly different between MV + SA and MV groups at 30 days [4.4% vs. 2.7%; OR, 1.45; 95% confidence interval (CI), 0.55-3.83; P=0.46; I2=0%]. Furthermore, all-cause mortality was also not significantly different (6.3% vs. 4.0%; OR, 1.40; 95% CI, 0.30-3.26; P=0.43; I2=0%; Figure 3). No significant heterogeneity was observed in these two comparisons.
Figure 3 Forest plot of the odds ratio (OR) of all-cause mortality in AF patients with surgical ablation (SA + MV) or without ablation (MV). The estimate of the OR of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). On each line, the number of events as a fraction of the total number randomized is shown for both treatment and control groups. For each subgroup, the sum of the statistics, along with the summary OR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics. M-H, Mantel-Haenszel.
All but one study reported outcomes for pacemaker implantation. Overall, there was no difference in pacemaker implantations whether surgical ablation was performed or not (7.0% vs. 7.5%; OR, 1.00; 95% CI, 0.47-2.13; P=1.00; I2=0%; Figure 4).
Figure 4 Forest plot of the odds ratio (OR) of permanent pacemaker implantation in AF patients with surgical ablation (MV + SA) or without ablation (MV). The estimate of the OR of each trial corresponds to the middle of the squares and the horizontal line shows the 95% confidence interval (CI). On each line, the number of events as a fraction of the total number randomized is shown for both treatment and control groups. For each subgroup, the sum of the statistics, along with the summary OR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics. M-H, Mantel-Haenszel.
Stroke outcomes were reported in eight out of nine included RCTs, with comparable results between MV + SA and MV groups (5.5% vs. 3.9%; OR, 1.43; 95% CI, 0.56-3.65; P=0.45; I2=0%; Figure 5).
Figure 5 Forest plot of the odds ratio (OR) of stroke and thromboembolic events in AF patients with surgical ablation (MV + SA) or without ablation (MV). The estimate of the OR of each trial corresponds to the middle of the squares and the horizontal line shows the 95% confidence interval (CI). On each line, the number of events as a fraction of the total number randomized is shown for both treatment and control groups. For each subgroup, the sum of the statistics, along with the summary OR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics. M-H, Mantel-Haenszel.
The frequency of cardiac tamponade and pericardial effusion as perioperative complications was favorable for MV + SA compared to MV groups (2.4% vs. 9.0%; OR, 0.27; 95% CI, 0.08-0.94; P=0.04; I2=0%). This study showed no difference between the treated and control groups with regards to reoperative bleeding (6.8% vs. 5.8%; OR, 1.19; 95% CI, 0.46-3.06; P=0.71; I2=0%). Additionally, the incidence of myocardial infarction was comparable between both groups (35% vs. 29%; OR, 1.31; 95% CI, 0.70-2.48; P=0.40; I2=0%). Other clinical outcomes including low cardiac output syndrome, hypertension and heart failure were not reported in more than two studies (Table 3).
The number of patients in SR at discharge was significantly higher in the MV + SA group compared to the MV group (67.9% vs. 17.0%; OR, 13.96; 95% CI, 6.29-30.99; P<0.00001; I2=31%). The MV + SA group also had a significantly higher proportion of patients in SR compared to MV only at 3-month (65% vs. 21.2%; OR, 7.46; 95% CI, 4.16-13.37; P<0.00001; I2=0%), 6-month (67.2% vs. 23.2%; OR, 7.87; 95% CI, 3.96-15.66; P<0.00001; I2=38%), 12-month (75.5% vs. 26%; OR, 10.41; 95% CI, 5.30-20.44; P<0.00001; I2=46%) and >12-month (64.4% vs. 17.9%; OR, 11.61; 95% CI, 4.53-29.79; P<0.00001; I2=0%) follow-up periods. The results are summarized in Figure 6. Subgroup analysis of the different surgical ablation techniques including radiofrequency ablation, cut and sew, pulmonary vein isolation and cryoablation demonstrated no significant difference affecting SR outcomes any all follow-up periods.
Figure 6 Forest plot of the odds ratio (OR) of discharge, 6-month, 12-month and >1-year SR in AF patients with surgical ablation (MV + SA) or without ablation (MV). The estimate of the OR of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). On each line, the number of events as a fraction of the total number randomized is shown for both treatment and control groups. For each subgroup, the sum of the statistics, along with the summary OR, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is given below the summary statistics. M-H, Mantel-Haenszel.
A substantial increase in the incidence of AF has been reported in patients with indications for cardiac surgery, which has also been demonstrated to be a profound risk factor for mortality in multiple studies (32-35). The weight of this evidence has provided the impetus for the combination of surgical AF treatment and core cardiac surgical intervention, with the hope of synergistic improvements in both SR prevalence and risk of morbidity and mortality (36). A recent prospective RCT revealed differing outcomes between various types of cardiac surgery, with MV surgery demonstrating superior benefit from surgical ablation compared to coronary artery bypass and aortic valve procedures (37). Despite this, robust evidence regarding the efficacy of surgical ablation in MV surgery is still lacking. The present meta-analysis is the first comprehensive review, to our knowledge, of all published RCTs reporting the clinical outcomes of MV + SA versus MV alone.
Given that AF has consistently been shown to be an independent predictor of mortality (38-40), the maintenance of SR is vital for quality of life and survival. For example, the AFFIRM study demonstrated that the prevalence of SR was a profound, independent predictor of survival, even after adjustment for all other clinical variables including age and various comorbidities (41). Patients in SR were almost half as likely to die compared to patients who did not improve from AF (adjusted hazard ratio, 0.53; 99% CI, 0.39 to 0.72; P<0.0001). As such, the prevalence of SR at both short- and long-term follow-up is the most important endpoint considered for AF patients. Our results demonstrate significant improvement in restoration of SR in the ablation group compared to the control group at discharge (67.9% vs. 17.0%), 3-month (65% vs. 21.2%), 12-month (75.5% vs. 26%), and >1-year (64.4% vs. 17.9%) follow-up periods. These results are consistent with previous meta-analyses involving mixed surgical populations including MV and CABG. For example, Cheng et al. published a meta-analysis, which included ten RCTs and 23 non-RCTs with an overall study population of 4,647 patients (18). They found SR prevalence at >1-year follow-up to be 74.6%, which is very similar to that reported in the current meta-analysis. However, this result had significant heterogeneity (I2=84%), with only one RCT included in the analysis. Their meta-analysis also grouped RCTs with retrospective observational studies, some of which had controversial study designs and outcomes.
With the increased incidence of AF, the short- and long-term mortality following surgical ablative treatment is of key clinical interest. The present review found acceptable overall mortality rates at 30-day (range: 0-15%) follow-up periods with no difference between MV + SA and MV groups. Similar results were attained by Boller et al. at both short- and long-term follow-up (mean: 16.2% vs. 17.4%; P=0.80) in their large multicenter, prospective RCT (n=224) (30). However, the patient cohort for this RCT predominantly underwent cryoablation, a less invasive thoracoscopic procedure, which involves creation of transmural lesions and scarring via tissue freezing. This highly specific cohort means that their results cannot be widely applied to all surgical ablation techniques, thus justifying the importance and necessity of the current study. While a previous meta-analysis of non-RCT studies suggested that all-cause mortality is reduced in surgical ablation groups compared to control cardiac surgery groups, such a trend was not reflected in the present study, with no difference in all-cause mortality found at the latest follow-up ≥1 year (overall: 0-17.4%). This can be attributed to the susceptibility of non-RCT studies to bias in patient selection and incomplete ascertainment of outcomes. The resultant higher level of heterogeneity (I2=44%) warrants caution when interpreting their study outcomes.
The current study revealed no difference in permanent pacemaker implantation in the surgical ablation group compared to the control group (mean: 7.0% vs. 7.5%; P=1.00). In contrast, a previous meta-analysis by Khargi et al. argued that there was a small difference in post-operative pacemaker implantation in favor of the ablation group (mean: 4.9% vs. 5.8%), albeit this difference was not found to be significant (19). While it is plausible that surgical ablation may reduce the incidence of pacemaker implantation due to enhanced SR outcomes, this interpretation is brought into question once the variability of indications for pacemaker implantation is considered. Some groups have aggressively reported atypical bradycardic arrhythmia (24,25) as indications for pacemaker implantations, while other groups are more conservative in their approach, reporting atrioventricular block or bundle branch block as indications (22,27,29).
In previous studies, surgical ablation using the Cox-Maze technique in AF patients undergoing concomitant surgery was demonstrated to have a potential protective effect from stroke and thromboembolism in the long term (4,10,18,42). However, it is not clear whether this effect is due to the nature of the Maze operation, resumption of SR, removal of the left atrial appendage, or even continued anticoagulation with warfarin. The results of the present meta-analysis also indicate no significant difference in the incidence of stroke and thromboembolic events in favor of the surgical ablation group compared with the control MV surgery group (mean: 5.5% vs. 3.9%; P=0.45). In contrast, Boersma et al. published a RCT comparing surgical ablation with catheter ablation for treatment of AF, with fewer incidents of stroke and thrombus formation reported in the surgical ablation group at 12-month follow-up (43). These superior outcomes can be explained by the nature of the surgical procedure, where any thrombus formation or occlusion of the left atrial appendage can be easily resolved by intraoperative resection of the left auricle. For the same reason, our lack of difference in stroke incidence between MV + SA and MV groups is expected, considering both procedures involve left atrial incisions. Thus, our meta-analysis demonstrates that superior long-term SR prevalence can be achieved via surgical ablation with no additional risk of stroke or thromboembolism.
Other clinical outcomes were poorly reported in the RCTs included in this meta-analysis. There was a significantly lower incidence of cardiac tamponade in the MV + SA group compared to the MV group. No significant difference between MV + SA and MV groups was found in terms of incidence of re-operative bleeding and myocardial infarction. However, it is likely, although it cannot be proven, that the incidence of these perioperative complications is underestimated in these studies as some patients did not survive the operation and thus such events were not diagnosed. This emphasizes the importance of consistent reporting of composite clinical complications, including low cardiac output syndrome, hypertension and heart failure. Some groups have posited that the lack of improvement in clinical outcomes supports the argument that surgical ablation should be re-evaluated as an option for AF treatment (31,44). In contrast, an alternative interpretation of such outcomes is that surgical ablation can effectively maintain SR rhythm for long follow-up periods without significant increases in morbidity and mortality. For these reasons, surgical ablation should still be considered an effective and safe treatment option that addresses AF at its electrophysiological origin and offers a reasonable chance of an enduring cure.
The present findings are limited by a number of key constraints. Firstly, although the RCTs included in the present meta-analysis include a highly selected cohort who underwent isolated MV surgery, the greater proportion of patients had undergone MV replacement compared to mitral valve repair. Future subgroup analysis of the types of MV surgery will elucidate whether this factor influences the efficacy and mortality outcomes of surgical ablation. Secondly, subgroup analysis of the outcomes according to the type of surgical ablation technique was not feasible, due to the low number of RCTs in each subgroup. Indeed, only 4 radiofrequency and 3 cut-and-sew studies, and one cryoablation and one pulmonary vein isolation study were identified in this meta-analysis, which highlights the need for future RCTs or large registries which evaluate surgical ablation techniques according to subgroup. Thirdly, although >1-year follow-up SR is significantly more favorable for patients who underwent surgical ablation, this was based only on three studies. The shortage of long-term data beyond one year limits the provision of evidence-based guidelines and recommendations and thus more long-term data are required. Long-term studies are also required to compare perioperative complications between MV + SA and MV groups, because very few complications were consistently reported in the RCTs included in this meta-analysis. However, owing to the randomization process, confounding factors were reduced within each individual study, and the present meta-analysis represents a summary of the available randomized evidence in the current literature.
In summary, we conclude that concomitant surgical ablation and mitral valve surgery for AF offers better short- and mid-term SR outcomes than for patients who do not undergo surgical ablation. No differences were found between the two groups in terms of 30-day mortality, all-cause mortality, pacemaker implantation, stroke and thromboembolic events. Thus, this meta-analysis indicates that surgical ablation can be performed in AF patients without increased risk of morbidity and mortality.
Vasconcelos JT, Scanavacca MI, Sampaio RO, et al. Surgical treatment of atrial fibrillation through isolation of the left atrial posterior wall in patients with chronic rheumatic mitral valve disease. A randomized study with control group. Arq Bras Cardiol 2004;83:211-8; 203-10.
Boller C, Buderath M. Fatigue in aerostructures--where structural health monitoring can contribute to a complex subject. Philos Trans A Math Phys Eng Sci 2007;365:561-87.
Whitlock RP, Healey JS, Connolly SJ. Left atrial appendage occlusion does not eliminate the need for warfarin. Circulation 2009;120:1927-32; discussion 1932.


January 20 – According to legend, freeholder Lalli slays English crusader Bishop Henry with an axe on the ice of the lake Köyliönjärvi in Finland.
The Privilegium Minus elevates Austria to the status of a duchy ruled by the Babenburgs family. (see History of Austria).
Mosan artists create the Stavelot Triptych, a masterpiece of goldsmithing, as a reliquary to house purported pieces of the True Cross.
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Ulysses Grant Murrell, Miami Medical College Graduate, 1896
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Victor Ray, Miami Medical College Graduate, 1897
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W. E. Totten, Miami Medical College Graduate, 1873
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Wade McMillan, Miami Medical College Faculty, 1897
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Walter Eugene Murphy, Miami Medical College Graduate, 1897
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Walter R. Griess, Miami Medical College Graduate, 1897
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Wilbur Sibley Ellis, Miami Medical College Graduate, 1896
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Will Carleton Harris, Miami Medical College Graduate, 1897
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William C. Chapman, Miami Medical College Graduate, 1873
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William C. Herman, Miami Medical College Graduate, 1902
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William Donald Kempton, Miami Medical College Graduate, 1873
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William Edward Hastings, Miami Medical College Graduate, 1897
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William Everett Hogan, Miami Medical College Graduate, 1896
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William H. Falls, Miami Medical College Graduate, 1873
Porter, W. J. (University of Cincinnati. Libraries; University of Cincinnati. Henry R Winkler Center for the History of the Health Professions; University of Cincinnati; University of Cincinnati. Henry R Winkler Center for the History of the Health Professions, 1873)
William H. Taylor, Miami Medical College Faculty, 1902
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William Henry Klayer, Miami Medical College Graduate, 1897
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William Joseph Graf, Ohio-Miami Medical College Graduate, 1910
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William Judkins, Miami Medical College Graduate, 1873
Van Loo, Leon (University of Cincinnati. Libraries; University of Cincinnati. Henry R Winkler Center for the History of the Health Professions; University of Cincinnati; University of Cincinnati. Henry R Winkler Center for the History of the Health Professions, 1873)


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Santa Ana is considered the county seat and is the largest city in Orange County, California by population, or the 53rd in all of America with an approximate population of 340,000. The City was founded in 1869 and has a location in Southern California right on the Santa Ana River, just 11 miles away from the Pacific Ocean. Santa Ana is part of the Los Angeles Metropolitan area which is ranked the 2nd largest in the U.S. with over twelve million people. It is also the fourth most densely populated city after New York, San Francisco, and Chicago.
According to the US Census 2007, 327,780 people call Santa Ana home in approximately 77,922 housing units. It has the highest occupation density in America at 4.6, over New York's 2.8 and Los Angeles's 2.8. The city has a very diverse racial mix; White 42.6%, African American .2%, Native American 9.4%, and Asian .4%. It has a median household income of just over $43,412.
Santa Ana is located in the 34th California Senate District and is represented by Democrat Lou Correa and in the 69th California Assembly by Democrat Jose Florio. On a Federal level, Santa Ana is represented by Democrat Loretta Sanchez for the 47th US Congressional District.
View map of Santa Ana, CA for directions to our car title loan store.
92701, 92702, 92703, 92704, 92705, 92706, 92707, 92708, 92799 plus more.


text:
Ubisoft Reflections Limited — компанія-розробник відеоігор, заснована в 1984 році в місті Ньюкасл-апон-Тайн, Велика Британія під назвою Reflections. Студія фокусується на гоночних іграх і найвідомішим проектом цієї компанії є серія Driver. Компанія Reflections була придбана GT Interactive у 1998 році, а потім продана Ubisoft у 2006 році. Компанія працює над іграми у кооперації зі студією Ubisoft Leamington.

Посилання

Підприємства Ньюкасл-апон-Тайна
Розробники відеоігор Великої Британії
Засновані у Великій Британії 1984
Розробники відеоігор

redpajama_set_name: RedPajamaWikipedia


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redpajama_set_name: RedPajamaGithub


text:
ENI CBC Stories
People-to-People
Boosting heritage potential to create culture
23 November 2021 People-to-People Poland-Belarus-Ukraine
"The touristic potential of our region is far greater than the flow of tourists that comes to us. We keep losing opportunities because the region has an underdeveloped tourist infrastructure."
Krzysztof Michalski, representative of the lead beneficiary (Poland)
When we think of historical sites and tourist destinations in a country, we generally consider big cities, without giving much thought to the treasures hidden in smaller towns and villages. The Liachowice district (Belarus) and the Puchaczów commune (Poland) present common features, with the population of both regions living out of agricultural activities, with modest income. At the same time, both settlements are close to famous tourist destinations – Lublin (Poland) and Brest (Belarus), but do not seem to benefit from this flow.
A well-developed tourism infrastructure is a prerequisite for attracting visitors to any region. However, local governments often do not have the capacity to engage in this direction. And this is where a project like ROCCO – implemented in the framework of the ENI CBC Poland-Belarus-Ukraine Programme – comes in, with the idea to enhance the potential of cultural heritage in the region, to attract visitors and ultimately to favour economic development. Tourists who go to Lublin and Brest could be drawn to the neighbouring regions, which would help not only to generate additional income for local populations, but also to preserve the cultural heritage of the area. In the end, to create a platform where local communities from both sides could meet, exchange, communicate.
To do so, the partners have started the reconstruction of two historical farmsteads which were in extremely poor condition, the Lachert Manor in Ciechanki (Poland) and the Rejtan Manor in Hrušaŭka (Belarus). These two historic farmhouses were not chosen by chance. The first building was built in the 19th century: it is an historic manor of great interest to architecture professionals because it belonged to one of the most popular Polish architects of the 20th century, Bogdan Lachert, who reconstructed it in a modern style. The building was last restructured after World War II, therefore it is easy to imagine the enormous amount of work that needs to be done. But once finalised – most probably in autumn 2021 – the manor will be hosting a museum dedicated to Lachert, a permanent exhibition, and temporary exhibitions of furniture and objects presenting the contribution of Polish artists to the development of industrial design. Among the featured group have been chosen the Arts and Crafts Movement, the Lada Artists Cooperative, the Kraków Group and the Praesens Art Group. The building is also going to accommodate a wide range of educational activities: workshops, lectures, seminars and meetings, cultural events for tourists, researchers, architects, and people interested in visual arts. "We expect also the flow of foreign tourists to increase – says Krzysztof Michalski, from the Puchaczów Commune – as many residents of the region have relatives who have immigrated to Western Europe and the USA."
The second manor is a wooden house in Hrušaŭka (5 km away from Liachowice, Belarus). The architectural complex consists of a main building, a chapel, a park, and the stables. In recent years, the site has attracted about 1.000 tourists annually, including visitors from Poland, even though it remains unusable and can only be seen from the outside. Its conditions were worse than in the other manor: since it is made from wood, the first step was about reinforcing the basement, then, the walls and roof were repaired, followed by stairs, windows, and doors. The walls and basement of the nearby chapel have also been drained, and the roof replaced. Both buildings are going to host a cultural centre for tourists and citizens, to be used for different events. "Many tourists come to Hrušaŭka for two to three hours – says Dmitry Makaruk, coordinator and representative from the Belarusian partner – If we create a proper infrastructure, we could be able to retain them for three to four days."
The pandemic has affected the implementation of some activities: twelve events were planned, but most have been postponed, and some must be replaced because they cannot be conducted on-line. For example, the re-enactment of the Liachavičy fortress battle will be replaced by a festival of artistic folk groups.
Youth exchanges and cooperation of artistic groups, as well as meetings of both communities, are planned after the reconstruction is completed and the pandemic restrictions are lifted. Both partners expect that the number of people who participate in cross-border events in the region will increase from 1.000 to almost 6.000. "This is the first project we have done together, and it is an exceptionally good experience for both sides – continues Krzysztof Michalski – we have learned a lot, also how to be patient, to listen to each other. Patience is one of the keys for successful cooperation."
The project has an important long-term mission: to raise awareness of the shared history of Poland and Belarus. So, it could remain relevant even in the next programming period. Dmitry Makaruk: "I would like to give a piece of advice to new applicants: they need to learn how to work together, how to dedicate a great deal of interest in everything that is happening on both sides of the project." "This program is a fantastic base for implementing small projects. Some beneficiaries are afraid to apply because they cannot prove a cross-border effect – concludes Michalski – but in cultural projects, the cross-border effect in border areas can be found in everything."
Check out the programme
Poland-Belarus-Ukraine Programme
This story was written by:
Volha Prokharava
Enhancing traditions to revitalize tourism in lower Danube
From fossil to wood-based plastic


text:
Il Teltowkanal è un canale artificiale navigabile che attraversa i quartieri meridionali della città di Berlino e alcune località del Brandeburgo.

Lungo 37,83 km, ha origine dal fiume Dahme, affluente della Sprea, e sfocia nel Griebnitzsee, un lago formato dalla Havel nelle vicinanze di Potsdam.

Il nome del canale deriva dal circondario di Teltow, che ne finanziò la costruzione (avvenuta dal 1900 al 1906) per sostenere lo sviluppo industriale dei territori attraversati.

L'autostrada A 113, che costeggia per un lungo tratto il canale, è detta Teltowkanal-Autobahn.

Altri progetti

Collegamenti esterni

Canali artificiali della Germania
Geografia di Berlino
Trasporti a Berlino


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Fashion, Trending, Trends
White Booties- The Hottest Shoe Trend Right Now
Transform your outfits and spice things up this season with some white transitional booties! Let's…
Humbers Fashion Arts Business Students January 30, 2019
Don't Go Breaking the Bank
While most of us want to wear garments that help us look our best, not…
Maria James March 26, 2019
Sustainability, Trending
What is Greenwashing?
Greenwashing is that all-purpose cleaner you see in a green bottle with phrases like "natural"…
Humbers Fashion Arts Business Students December 22, 2018
Fashion, Sustainability, Trending
Fabrics of the Future: Cotton Alternatives
In this mini-series, we will be looking at sustainable alternatives to well-known fabrics, starting with…
Cara Presta February 2, 2019
Ontario to Ban Single-Use Plastics
We all know how toxic plastic is to our environment, and how much of it…
Cara Presta March 26, 2019
Fashion, History
It's Getting Haute in Hollywood
by Lindsay Kalliokoski
Joan Crawford in the film Letty Lynton (1932), wearing an iconic design by Adrian. Photo by George Hurrell
Source: https://www.smithsonianmag.com/arts-culture/when-hollywood-glamour-was-sold-local-department-store-180962262
Marion Davies in a tiered ruffled gown. Photo by Everett
Source: https://fineartamerica.com/featured/marion-davies-ca-mid-1930s-everett.html
Jean Harlow in a backless dress. Photo by Everett
Source: https://fineartamerica.com/featured/jean-harlow-ca-early-mid-1930s-everett.html
The incredibly talented designer, Adrian
Studios began employing high-end designers for costuming purposes. Haute couture greats like Coco Chanel and Elsa Schiaparelli worked on a few films during the 30s (Bruzzi), but the most iconic name from this Golden Age of film and fashion was Adrian Adolph Greenburg, more commonly known as Adrian.
Source: https://www.star-news.org/adrian-net-worth
Dorothy's ruby red slippers from Wizard of Oz (1939), designed by Adrian, courtesy of Metro-Goldwyn-Meyer
Adrian worked on hundreds of films for the production company Metro-Goldwyn-Mayer, (MGM). His work was innovative and jaw-droppingly beautiful; his costumes had a profound impact on all of the film industry. You might know him best for his work with a blue and white checkered dress and ruby red slippers…Wizard of Oz (1939) is undoubtedly a classic, and a lot of credit goes to Adrian's brilliant costume design (Fashion Sizzle, 2014).
Source: https://www.hollywoodreporter.com/gallery/ruby-slippers-delorean-marilyn-monroe-wedding-ring-auction-272009/1-dorothys-ruby-red-slippers-from-the-wizard-of-oz
The "Letty Lynton Dress" worn by Joan Crawford, designed by Adrian
Adrian is also famous for the "Letty Lynton Dress" worn by Joan Crawford in the 1932 film Letty Lynton. This iconic dress had a creative silhouette - one that featured huge, ruffled statement cap sleeves. This high-end dress had become so popular that MGM sold the design to the ready wear market; thousands of dresses and blouses were sold – it was haute couture for all! (Bruzzi)
Source: https://nypost.com/2009/11/11/must-see-letty-lynton-yes-letty-lynton/
Another Adrian gown worn in Letty Lynton (1932) by Joan Crawford, photographed by George Hurrell
Source: https://fashionsizzle.com/2014/01/02/costume-designer-adrian-influence-in-fashion-and-the-movies/
Actress Kay Johnson in a dramatic sequined cape and gown by Adrian; Madam Satan (1930), courtesy of MGM
Adrian's work on the avant-garde film Madam Satan (1930) is an awe-inspiring blend of high-end fashion and costume design. His creative silhouettes and use of materials kept cinema-goers constantly guessing.
Source: http://www.montsecamarastudio.ca/2017/05/04/the-10-wildest-costumes-in-film- history/
Madam Satan (1930)
Source: http://www.montsecamarastudio.ca/2017/05/04/the-10-wildest-costumes-in-film-history/
Haute Couture at its finest; gown by Adrian on actress Ilona Massey
Hollywood had never looked better. Adrian's designs matched the glitz and glam of the decade perfectly.
Joan Crawford in a stunning dress by Adrian from the 1939 film The Women by George Cukor
Those details! Katherine Hepburn in the film Break of Hearts (1935) wearing Adrian
Cape goals: Joan Crawford in a glimmering sequin creation by Adrian for the film Sadie McKee (1934)
Glamour beyond your wildest dreams: Jean Harlow, 1933, Dinner at Eight, costume by Adrian
There's only a lucky few who will ever have the chance to wear an haute couture garment. Masterfully crafted, customized to your body, and totally one-of-a-kind.
Paris has always been the central location for these luxurious styles, but there was a decade when another part of the world stole the spotlight.
In the 1930s, it began "haute-ing" up in Hollywood.
The popularity of film blossomed during this era, and the glamour of the decade was witnessed on the silver screens. People loved going to the cinema and fell in love with the larger-than-life, beautiful starlets. Movies were becoming more extravagant due to large studios and production companies in Los Angeles, and the actors had to dress the part.
Film has evolved and changed over time, and so has the fashion and costuming that goes along with it.
However, one thing is for sure: in the 1930s, it was haute in Hollywood.
Sources: Love to Know & Fashion Sizzle
Lindsay Kalliokoski January 24, 2019
ALL COPYRIGHTS ARE RESERVED BY INFUSE HUMBER 2018


Recently I had the opportunity to sit at a book signing table with another talented writer, Kerry McAvoy and a dear friend, Vicki. Just like in past signings, I am amazed at the similarity of people who cross our paths (or stop at our table). We received words of affirmation, shared stories, and even received hugs from total strangers. Connectedness. Relational. Each of us has a story to tell; some put the words down on paper, others tell their story with just the words from their mouth. Either way, the story deserves to be told. Told to the current generation and then the next generation will become a part of the original whole.
In conferences I've heard that if you intend to go into the writing business to make tons of money, you'd better chose a different vocation because that probably won't happen. But then again, maybe those people weren't counting new friendships, words of thanks and praise. Today my gifts equaled much more than money can buy. Like finding a pot of gold at the end of a rainbow. Thank you all for the vital part you play in shaping my world which causes me to thank my Creator. The one who gifted me with insight, courage, and the talent and motivation to write my story.
This entry was posted in God, Life is fragile (body), Praise, Writers Conference, Writing and tagged courage, Creator, friendship, generation, story, Thanksgiving, writers conference. Bookmark the permalink.


HILLSBORO – Justin Welch, principal of McKinney elementary school here, has been through this before.
"I spent a lot of my time at my last school in Utah tracking down families who owed lunch money," he recalls, not exactly nostalgically.
Only if you think principals could be focused on, you know, education.
Welch has been able to think about education more lately because of a change in the school lunch rules in 2010, allowing schools with at least 40 percent of their students on food stamps or Medicaid to serve everybody free lunch. (Lots of the remaining kids would qualify for free lunch by family income, or lack thereof.) Community eligibility might cost a few nickels that the school might have collected – probably, very few – but it allows principals, and other folks at the school, to think more about math and less about chicken fingers.
It also makes sure that kids whose parents aren't great at paperwork don't flunk lunch and breakfast – a problem that can spread to other subjects.
But in the current reauthorization of children's nutrition programs – already a year late – the Republican majority of the House Education and Workforce Committee has another idea. In a party-line vote late last month, they endorsed a reauthorization that would raise the community eligibility requirement to a hard-to-reach 60 percent. That would mean that McKinney – and more than 150 other Oregon schools, and 7,000 across the country – would no longer qualify, and that Justin Welch would be back to worrying about whose family had and hadn't paid for beefaroni.
McKinney, a modern, well-kept school in a pleasant neighborhood, doesn't look like what you'd consider a high-poverty school. But in the way we've arranged our society – children on the bottom – 80 percent of its students would qualify for a break on school lunch costs.
Bonamici visited Mckinney this spring, and talked with students about what the lunch program meant to them. It made her curious why "My colleagues are so alarmed that a student who might be able to afford lunch might get one for free." She even wonders why House members who just cheerfully passed a $600 billion military budget are so concerned about the source of each kid's turkey hot dog.
The reauthorization sets up a pilot program for three states that would roll all the school nutrition programs into an underfunded block grant to the state. Governors and legislators could then ignore nutritional advances made in the 2010 reauthorization, and find strategies to save money on kids' lunches they could spend in other ways.
It also caps and discourages a successful pilot program, tried last summer in Oregon and five other states, providing $30 a month in food stamps for free lunch kids in summer, when the lack of school meals can leave them in stomach-growling condition. The U.S. Department of Agriculture concluded that the program cut summer child hunger by a third, a dam of sandwiches and fruit.
The House education committee may not get much applause.
In fact, people may be throwing fish sticks.
NOTE: This column appeared in The Sunday Oregonian, 6/5/16.


A village and appellation at the southern end of the Côte de Beaune covering over 300 hectares, that is now widely acclaimed for its white wines, though was once very much a red wine village. Plantings of Pinot Noir are still relatively high when compared to Puligny or Meursault, however it is the white wines that enjoy international acclaim. Within the commune sit part of Le Montrachet and Bâtard-Montrachet Grand Cru vineyards as well as Criots-Bâtard-Montrachet Grand Cru in its entirety. There are a total of 51 Premier Crus vineyards, though many of these are part other larger, better known vineyards and carry that name on the label, Morgeot being a good example of this. The wines are plump and racy, less elegant and refined than Puligny, full bodied but less fat and more vitality than a Meursault.


A record number of teams entered for this year's indoor hockey season which will kick off on the weekend of 9 and 10 February at the DTS Indoor Hall.
Bank Windhoek Premier League –With 5 mens' teams & 5 womens' teams; Reserve Premier League – (7teams for both); First League (7teams for both); Second League – 10 mens' teams, 8 womens' teams and the Masters League –comprising 5 Mens' teams.
"For the first time we have established the Bank Windhoek Reserve Premier League for Men and Women which is the second strongest tier league in indoor hockey and is especially created for those clubs who want to earn promotion in the future to play in the Bank Windhoek Premier League. All clubs from Windhoek, Walvis Bay, and Swakopmund have entered 62 teams, up from 54 teams last year, who will compete in five different leagues. There will be approximately 600 players involved in indoor hockey over the next three months," said Nel.
The venues where the Bank Windhoek National Indoor Leagues will be played are DTS, Wanderers, the Dome in Swakopmund, the Sports Hall in Walvis Bay and a few games at the Show Grounds in Windhoek.
Pack eluded to the partnership between Bank Windhoek and the NHU over the past four years, where the sports code has thrived and the development of the sport at grassroots level was taken seriously, resulting in well developed talent feeding into the sport.
"Thanks to Bank Windhoek's continued sponsorship, the past four years have enabled Namibian Hockey to develop and grow as one of the more prominent sports codes in Namibia. Look at the successes which our Junior and Senior National teams had the past two years internationally. Bank Windhoek's sponsorship truly shows the Bank's commitment to the development of the sport," Nel concluded.
Meanwhile, the Bank Windhoek Outdoor League will commence in July 2019 up to middle of October 2019.
Caption: Jacquiline Pack, Executive Officer for Marketing and Corporate Communication Services at Bank Windhoek, and Marc Nel, President of the Namibian Hockey Union.


Train to become a professional tennis player and experience the methods and coaching that made Rafa Nadal one of the greatest players in tennis history!
The Rafa Nadal Academy by Movistar opens its doors in 2016 for young tennis players to train with the method that has taken Rafa to the number one spot.
With their experience on tour, Rafa Nadal, Toni Nadal and his team havedeveloped a training method designed to develop the next-generation of top tennis players in an environment where the game is becoming increasingly quick; and players, stronger and faster.
The Rafa Nadal Academy by Movistar incorporates a high quality residential complex and enables players to develop an education through the Rafa Nadal International School, while also training to become professional players. In addition, the academy includes a programme for those students that don't make the jump to professional tennis to obtain a scholarship at American universities to continue competing.
Choices International, officially representing Rafa Nadal Academy by Movistar in the UK and Ireland, offers a selection of professional tennis programmes.
This programme runs from June to August and It includes 20.5 hours of tennis training from Monday to Saturday and 10 hours of physical fitness & sports games per week, 6 hours of "Building a Champion" and 4 hours of activities, leisure and excursions.
which is divided into separate areas according to age and gender. Free Wi-Fi available across the campus.
26 tennis courts of different surfaces (Clay, Greenset), outdoor and indoor.
Fitness Centre with all the latest equipment.
2 swimming pools; one outdoor and one indoor.
Mini-football pitch (Football 7) and 7 padel courts.
Restaurant and café and Pro Shop.
Specialised clinic in sports medicine, physiotherapy and nutrition.


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text:
ASUS Accelerating Climate Action with UL through Turbo Carbon Software
To further accelerate their commitment to United Nations' Sustainable Development Goal 13 on Climate Action, ASUS announced today they deployed Turbo Carbon™ software across the facilities they operate to measure and manage their carbon emissions in a more efficient way.
TAIPEI, TAIWAN, December 10, 2019— To further accelerate their commitment to United Nations' Sustainable Development Goal 13 on Climate Action, ASUS announced today they deployed Turbo Carbon™ software across the facilities they operate to measure and manage their carbon emissions in a more efficient way. This step enables ASUS to spend less effort on reporting and more effort on taking action to achieve their goal of reducing carbon emissions by half in 2025 against 2008 as a base year.
UL's Turbo Carbon tool will gather activity data from across global facilities and automatically calculating the associated emissions data in real time to produce dynamic and intuitive performance dashboards for sustainability teams across the business.
TS Wu, chief sustainability office for ASUS said "We have always taken a data driven approach to carbon management. UL's Turbo Carbon tool allows us to gather more data and generate clearer insight faster than our previous approach. This enables us to reallocate our sustainability team away from reporting to taking action."
This represents another step forward in the collaboration between ASUS and UL, who recently worked together on a series of supplier sustainability conferences to educate and inspire suppliers to ASUS on why and how they should take climate action, with the key message being that accurate carbon emissions data must be central to their approach.
Alberto Uggetti, vice president and general manager of UL's Environment and Sustainability Division said "it is always a pleasure to support ASUS on the journey toward sustainability. We are delighted to be able to extend our relationship to climate action through the sharing of our expertise and the deployment of digital tools such as Turbo Carbon."
UL helps create a better world by applying science to solve safety, security and sustainability challenges. We empower trust by enabling the safe adoption of innovative new products and technologies. Everyone at UL shares a passion to make the world a safer place. All of our work, from independent research and standards development, to testing and certification, to providing analytical and digital solutions, helps improve global well-being. Businesses, industries, governments, regulatory authorities and the public put their trust in us so they can make smarter decisions. To learn more, visit UL.com.


text:
Bel Canto (it. "skøn sang") kan have flere betydninger:

 Bel Canto (bel canto, belcanto, bel-canto): en sangstil inden for den klassiske musik.
 Bel Canto (band): en norsk musikgruppe.
 Bel Canto (roman): en roman fra 2001 af den amerikanske forfatter Ann Patchett (f. 1963) – for hvilken hun modtog Orange Prize for Fiction 2002
 Bel Canto (kor): et mandskor, hvis leder 1934-1966 var Harald Agersnap
 Bel Canto Koret: et blandet kor fra Slagelse, oprettet 1990
 Bel Canto: arier af Donizetti, Bellini, Rossini indspillet af den amerikanske sopran Renée Fleming i 2002