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Las valvulopatías son todas aquellas enfermedades que afectan a las válvulas cardíacas, independientemente de su etiología o la gravedad del cuadro clínico que produzcan. Cualquiera de las válvulas del corazón: aórtica o mitral en el lado izquierdo y válvula pulmonar o válvula tricúspide en el lado derecho, pueden obstruirse o presentar regurgitación de sangre a la cámara de procedencia bien de la  aurícula o  del ventrículo.

Las valvulopatías pueden ser congénitas, presentes en el momento del nacimiento, en cuyo caso se suelen denominar displasia valvular, o adquiridas a lo largo de la vida.  La valvulopatía más frecuente es la estenosis aórtica. El tratamiento depende de la severidad del trastorno e incluye la utilización de determinados medicamentos  o bien el reemplazo de la válvula afectada por una artificial.

Anatómicamente, las válvulas forman parte del denso tejido conectivo del corazón conocido como esqueleto cardíaco y son responsables de la regulación del flujo sanguíneo a través del corazón y los grandes vasos. La insuficiencia o disfunción de las válvulas puede dar lugar a una disminución de la funcionalidad del corazón, aunque las consecuencias particulares dependen del tipo y la gravedad de la enfermedad valvular. El tratamiento de las válvulas dañadas puede implicar la medicación sola, pero a menudo implica la reparación quirúrgica de la válvula (valvuloplastia) o su sustitución (inserción de una válvula cardíaca artificial).

Causas
Las causas más frecuentes de valvulopatía son la fiebre reumática, los procesos degenerativos debidos a la edad y las anomalías congénitas del corazón que provocan alteraciones en la formación de las válvulas en el periodo embrionario, en este caso la afección recibe generalmente el nombre de displasia valvular.

Clasificación

Si el problema radica en una disminución permanente del diámetro del orificio valvular, se denomina (estenosis) valvular, cuando existe disminución de la capacidad de la válvula para cerrarse se llama insuficiencia valvular, si existe un movimiento de las válvulas en sentido anómalo se designa como prolapso valvular.

La estenosis y la insuficiencia/regurgitación representan las consecuencias funcionales y anatómicas dominantes asociadas a la enfermedad valvular cardíaca. Independientemente del proceso de la enfermedad, se producen alteraciones en la válvula que producen una o una combinación de estas condiciones. Insuficiencia y regurgitación son términos sinónimos que describen la incapacidad de la válvula para evitar el reflujo de sangre cuando las valvas de la válvula no se unen (coaptan) correctamente. La estenosis se caracteriza por un estrechamiento del orificio valvular que impide la salida adecuada de la sangre. La estenosis también puede dar lugar a una insuficiencia si el engrosamiento del anillo o de las valvas da lugar a un cierre inadecuado de las hojas.

Cuadro clínico
La clínica y la evolución de cada cuadro es muy variable, atendiendo a la válvula afectada y la causa subyacente. Muchas veces el tratamiento sintomático es suficiente, mientras que en otros casos se hace necesario el recambio valvular mediante cirugía.

Trastornos de la válvula aórtica y mitral
La enfermedad de la válvula aórtica y mitral se denominan enfermedades del corazón izquierdo. Las enfermedades de estas válvulas son más frecuentes que las de la válvula pulmonar o tricúspide debido a las mayores presiones que experimenta el corazón izquierdo.

La estenosis de la válvula aórtica se caracteriza por un engrosamiento del anillo o las valvas valvulares que limita la capacidad de la sangre para ser expulsada del ventrículo izquierdo hacia la aorta. La estenosis es típicamente el resultado de la calcificación valvular, pero puede ser el resultado de una malformación congénita de la válvula aórtica bicúspide. Este defecto se caracteriza por la presencia de sólo dos valvas. Puede ocurrir de forma aislada o en conjunto con otras anomalías cardíacas.

La insuficiencia aórtica, o regurgitación, se caracteriza por la incapacidad de las valvas para cerrar adecuadamente al final de la sístole, permitiendo así que la sangre fluya inadecuadamente hacia atrás en el ventrículo izquierdo. Las causas de la insuficiencia aórtica en la mayoría de los casos son desconocidas o idiopáticas. Puede ser el resultado de trastornos del tejido conectivo o inmunológicos, como el síndrome de Marfan o el lupus eritematoso sistémico, respectivamente. Los procesos que conducen a la insuficiencia aórtica suelen implicar la dilatación del anillo de la válvula, desplazando así las valvas, que están ancladas en el anillo.

La estenosis mitral es causada en gran parte por la enfermedad cardiaca reumática, aunque rara vez es el resultado de la calcificación. En algunos casos se forman vegetaciones en las valvas mitrales como resultado de la endocarditis, una inflamación del tejido del corazón. La estenosis mitral es poco común y no depende tanto de la edad como otros tipos de enfermedades valvulares.

La insuficiencia mitral puede ser causada por la dilatación del corazón izquierdo, a menudo una consecuencia de la insuficiencia cardíaca. En estos casos el ventrículo izquierdo del corazón se agranda y causa el desplazamiento de los músculos papilares adjuntos, que controlan la válvula mitral.

Trastornos pulmonares y de la válvula tricúspide
Las enfermedades pulmonares y de la válvula tricúspide son enfermedades del corazón derecho. Las enfermedades de la válvula pulmonar son las menos comunes en los adultos.
La estenosis de la válvula pulmonar suele ser el resultado de malformaciones congénitas y se observa de forma aislada o como parte de un proceso patológico más amplio, como en la tetralogía de Fallot, el síndrome de Noonan y el síndrome de rubéola congénita. A menos que el grado de estenosis sea grave, los individuos con estenosis pulmonar suelen tener excelentes resultados y opciones de tratamiento. A menudo los pacientes no requieren intervención hasta más tarde en la edad adulta como consecuencia de la calcificación que ocurre con el envejecimiento.

La insuficiencia de la válvula pulmonar se produce comúnmente en individuos sanos en una medida muy leve y no requiere intervención. Una insuficiencia más apreciable es típicamente el resultado de un daño en la válvula debido a un cateterismo cardíaco, la inserción de una bomba de balón intraaórtica u otras manipulaciones quirúrgicas. Además, la insuficiencia puede ser el resultado del síndrome carcinoide, procesos inflamatorios como la enfermedad reumatoide o la endocarditis, o malformaciones congénitas. También puede ser secundaria a la hipertensión pulmonar grave.

La estenosis de la válvula tricúspide sin regurgitación co-ocurrente es muy poco común y normalmente es el resultado de una enfermedad reumática. También puede ser el resultado de anormalidades congénitas, síndrome carcinoide, tumores obstructivos de la aurícula derecha (típicamente lipomas o mixomas) o síndromes hipereosinofílicos.

La insuficiencia tricúspide menor es común en individuos sanos. En casos más graves es una consecuencia de la dilatación del ventrículo derecho, que lleva al desplazamiento de los músculos papilares que controlan la capacidad de la válvula para cerrarse. La dilatación del ventrículo derecho se produce como consecuencia de defectos septales ventriculares, derivación de sangre de derecha a izquierda, síndrome de Eisenmenger, hipertiroidismo y estenosis pulmonar. La insuficiencia tricúspide también puede ser el resultado de defectos congénitos de la válvula tricúspide, como la anomalía de Ebstein.

Signos y síntomas

Estenosis aórtica
Los síntomas de la estenosis aórtica pueden incluir síntomas de insuficiencia cardíaca, como la disnea por esfuerzo (el síntoma más frecuente), la ortopnea y la disnea paroxística nocturna,  la angina de pecho y el síncope, generalmente por esfuerzo.

Los signos médicos de la estenosis aórtica incluyen pulsus parvus et tardus, es decir, disminución y retraso del pulso carotídeo, cuarto sonido cardíaco, disminución del sonido A2, latido ápice sostenido   y emoción precordial. La auscultación puede revelar un soplo sistólico de tipo duro crescendo-decrescendo, que se oye en el segundo espacio intercostal derecho e irradia a las arterias carótidas.

Regurgitación aórtica
Los pacientes con regurgitación aórtica pueden experimentar síntomas de insuficiencia cardíaca, como disnea por esfuerzo, ortopnea y disnea paroxística nocturna, palpitaciones y angina de pecho. En los casos agudos los pacientes pueden experimentar cianosis y shock circulatorio.

Los signos médicos de la regurgitación aórtica incluyen el aumento de la presión del pulso por el aumento de la presión sanguínea sistólica y la disminución de la presión sanguínea diastólica. El paciente puede tener un soplo diastólico en decrescendo que se escucha mejor en el borde esternal izquierdo, pulso de martillo de agua, soplo de Austin Flint y un latido de ápice desplazado hacia abajo y a la izquierda.Puede estar presente un tercer sonido cardíaco.

Estenosis mitral

Los pacientes con estenosis mitral pueden presentar síntomas de insuficiencia cardíaca, como disnea por esfuerzo, ortopnea y disnea paroxística nocturna, palpitaciones, dolor en el pecho, hemoptisis, tromboembolia o ascitis y edema (si se desarrolla una insuficiencia cardíaca del lado derecho). Los síntomas de la estenosis mitral aumentan con el ejercicio y el embarazo.

En la auscultación de un paciente con estenosis mitral, típicamente el signo más prominente es un fuerte S1. Otro hallazgo es un chasquido de apertura seguido de un estruendo diastólico de tono bajo con acentuación presistólica. El chasquido de apertura sigue más cerca del tono cardíaco S2 con empeoramiento de la estenosis. El soplo se escucha mejor con la campana del estetoscopio situada en el lado izquierdo y su duración aumenta con el empeoramiento de la enfermedad. La enfermedad avanzada puede presentar signos de insuficiencia cardíaca del lado derecho, como el derrame parasternal, la distensión venosa yugular, la hepatomegalia, la ascitis y/o la hipertensión pulmonar (que se presenta con un fuerte P2). Los signos aumentan con el ejercicio y el embarazo.

Regurgitación mitral
Los pacientes con regurgitación mitral pueden presentar síntomas de insuficiencia cardíaca, como disnea por esfuerzo, ortopnea y disnea paroxística nocturna,palpitaciones o edema pulmonar.

En la auscultación de un paciente con estenosis mitral, puede haber un soplo holosistólico en el ápice, que se irradia a la espalda o a la zona clavicular, un tercer sonido cardíaco, y un fuerte y palpable P2,que se escucha mejor cuando se está tumbado sobre el lado izquierdo.  Los pacientes también suelen tener fibrilación auricular. Los pacientes pueden tener un latido del ápice desplazado lateralmente,a menudo con un tirón. En los casos agudos, el soplo y la taquicardia pueden ser sólo signos distintivos.

Regurgitación tricuspídea
Los pacientes con regurgitación tricuspídea pueden experimentar síntomas de insuficiencia cardíaca derecha, como ascitis, hepatomegalia, edema y distensión venosa yugular.

Entre los signos de regurgitación tricuspídea se incluyen el hígado pulsátil, las ondas V prominentes y los rápidos descensos y en la presión venosa yugular. Los hallazgos auscultatorios incluyen un tercer sonido cardíaco inspiratorio en el borde inferior izquierdo del esternón (LLSB) y un soplo holosistólico en el LLSB, que se intensifica con la inspiración y disminuye con la expiración y la maniobra de Valsalva. Los pacientes pueden tener un soplo parasternal a lo largo del LLSB. La fibrilación auricular se presenta generalmente en pacientes con regurgitación tricuspídea.

Diagnóstico

Estenosis aórtica

Los pacientes con estenosis aórtica pueden tener hallazgos en la radiografía de tórax que muestren la dilatación de la aorta ascendente, pero también pueden tener una radiografía de tórax completamente normal. La visualización directa de las calcificaciones en la radiografía de tórax es poco común.Otros hallazgos incluyen la dilatación del ventrículo izquierdo. El ECG típicamente muestra la hipertrofia del ventrículo izquierdo en pacientes con estenosis severa, pero también puede mostrar signos de esfuerzo del corazón izquierdo. La ecocardiografía es el estándar de oro del diagnóstico, que muestra la hipertrofia del ventrículo izquierdo, la calcificación de los folículos y el cierre anormal de los mismos.

Regurgitación aórtica
La radiografía de tórax no es tan sensible como otras pruebas, pero puede mostrar la dilatación de la raíz aórtica (especialmente en las causas que involucran a la raíz aórtica) y el desplazamiento del ápice. El ECG puede mostrar la hipertrofia del ventrículo izquierdo y signos de esfuerzo del corazón izquierdo. La desviación del eje izquierdo puede ser un signo de enfermedad avanzada. El ecocardiograma puede ser útil para determinar la causa de la enfermedad, ya que mostrará claramente la dilatación o disección de la raíz aórtica si existe. Típicamente la función de bombeo del corazón durante la sístole es normal, pero el ecocardiograma mostrará la inversión del flujo durante la diástole.Esta enfermedad se clasifica utilizando la fracción regurgitante (RF por sus siglas en inglés: Regurgitant Fraction), o el volumen que fluye de regreso a través de la válvula dividido por el flujo total hacia adelante a través de la válvula durante la sístole. La enfermedad grave tiene un RF de >50 %, mientras que la regurgitación aórtica progresiva tiene un RF de 30-49 %.

Estenosis mitral

La radiografía de tórax en la estenosis mitral mostrará típicamente un agrandamiento de la aurícula izquierda, y puede mostrar la dilatación de las venas pulmonares. El ECG puede mostrar el agrandamiento de la aurícula izquierda, debido al aumento de las presiones en la misma.La ecocardiografía es útil para determinar la gravedad de la enfermedad al estimar la presión sistólica de la arteria pulmonar. Esta prueba también puede mostrar la calcificación de la valva y el gradiente de presión sobre la válvula mitral.La estenosis mitral severa se define como un área de la válvula mitral <1,5 cm². La estenosis mitral progresiva tiene un área valvular normal, pero tendrá un aumento de la velocidad del flujo a través de la válvula mitral.

Regurgitación mitral
La radiografía de tórax en la regurgitación mitral puede mostrar un agrandamiento de la aurícula izquierda, así como congestión venosa pulmonar.  También puede mostrar calcificaciones valvulares específicamente en la combinación de regurgitación mitral y estenosis debido a enfermedad cardiaca reumática. El ECG típicamente muestra el agrandamiento de la aurícula izquierda, pero también puede mostrar el agrandamiento de la aurícula derecha si la enfermedad es lo suficientemente severa como para causar hipertensión pulmonar. La ecocardiografía es útil para visualizar el flujo regurgitante y calcular el RF. También se puede utilizar para determinar el grado de calcificación, y la función y cierre de las valvas. La enfermedad grave tiene un RF de >50 %, mientras que la regurgitación mitral progresiva tiene un RF de <50 %.

Causas y factores de riesgo

Calcificación
La calcificación de las valvas de la válvula aórtica es común con el aumento de la edad, pero es probable que el mecanismo esté más relacionado con el aumento de los depósitos de lipoproteínas y la inflamación que con el "desgaste" de la edad avanzada. La estenosis aórtica debida a la calcificación de la válvula aórtica tricúspide con la edad comprende >50 % de los afectados por la enfermedad. La estenosis aórtica debida a la calcificación de la válvula aórtica bicúspide comprende alrededor del 30-40 % de los afectados por la enfermedad. La hipertensión, la diabetes mellitus, la hiperlipoproteinemia y la uremia pueden acelerar el proceso de calcificación valvular.

Displasia
La displasia de la válvula cardíaca es un error en el desarrollo de cualquiera de las válvulas cardíacas, y una causa común de defectos cardíacos congénitos tanto en humanos como en animales; la tetralogía de Fallot es un defecto cardíaco congénito con cuatro anomalías, una de las cuales es la estenosis de la válvula pulmonar. La anomalía de Ebstein es una anormalidad de la válvula tricúspide, y su presencia puede conducir a la regurgitación de la válvula tricúspide.

Una válvula aórtica bicúspide es una válvula aórtica con sólo 2 cúspides en lugar de las 3 normales. Está presente en alrededor del 0,5% al 2% de la población general, y causa un aumento de la calcificación debido a un mayor flujo turbulento a través de la válvula.

Trastornos del tejido conectivo
El síndrome de Marfan es un trastorno del tejido conectivo que puede conducir a una regurgitación aórtica o mitral crónica. La osteogénesis imperfecta es un trastorno en la formación de colágeno de tipo I y también puede conducir a una regurgitación aórtica crónica.

Trastornos inflamatorios
La inflamación de las válvulas cardíacas por cualquier causa se llama endocarditis valvular; esto se debe generalmente a una infección bacteriana, pero también puede deberse al cáncer (endocarditis marántica), a ciertas condiciones autoinmunes (endocarditis de Libman-Sacks, vista en lupus eritematoso sistémico) y en el síndrome hipereosinofílico (endocarditis de Loeffler). La endocarditis de las válvulas puede conducir a la regurgitación a través de esa válvula, que se observa en las válvulas tricúspide, mitral y aórtica. Ciertos medicamentos se han asociado con la enfermedad valvular cardíaca, sobre todo los derivados de la ergotamina pergolida y cabergolina.

La enfermedad valvular cardíaca resultante de la fiebre reumática se conoce como enfermedad cardíaca reumática. El daño a las válvulas cardíacas se produce después de una infección con bacterias beta-hemolíticas, como las típicas del tracto respiratorio. La patogénesis depende de la reacción cruzada de las proteínas M producidas por las bacterias con el miocardio. Esto da lugar a una inflamación generalizada en el corazón, que se manifiesta en la válvula mitral como vegetaciones, y el engrosamiento o fusión de las valvas, lo que lleva a una válvula de ojal gravemente comprometida.

La enfermedad cardiaca reumática típicamente sólo involucra la válvula mitral (70 % de los casos), aunque en algunos casos las válvulas aórtica y mitral están ambas involucradas (25 %). La implicación de otras válvulas cardíacas sin dañar la mitral es extremadamente rara. La estenosis mitral casi siempre es causada por una enfermedad cardíaca reumática. Menos del 10 % de la estenosis aórtica es causada por una enfermedad cardíaca reumática. La fiebre reumática también puede causar una regurgitación mitral y aórtica crónica.

Si bien los países desarrollados tuvieron en su día una importante carga de fiebre reumática y enfermedades cardíacas reumáticas, los avances médicos y la mejora de las condiciones sociales han reducido drásticamente su incidencia. Muchos países en desarrollo, así como las poblaciones indígenas de los países desarrollados, siguen soportando una carga importante de fiebre reumática y enfermedades cardíacas reumáticas, y se ha producido un resurgimiento de los esfuerzos por erradicar las enfermedades en esas poblaciones.

Las enfermedades de la raíz aórtica pueden causar una regurgitación aórtica crónica. Estas enfermedades incluyen aortitis sifilítica, enfermedad de Behçet, y artritis reactiva.

Enfermedad cardíaca
La regurgitación tricuspídea suele ser secundaria a la dilatación del ventrículo derecho que puede deberse a una insuficiencia del ventrículo izquierdo (la causa más común), un infarto del ventrículo derecho, infarto de miocardio inferior o cor pulmonale. Otras causas de regurgitación tricuspídea son el síndrome carcinoide y degeneración mixomatosa.

Poblaciones especiales

Embarazo

La evaluación de las personas con valvulopatía cardíaca que están o desean quedar embarazadas es una cuestión difícil. Entre los temas que deben abordarse se encuentran los riesgos durante el embarazo para la madre y el feto en desarrollo por la presencia de la valvulopatía cardíaca materna como enfermedad intercurrente en el embarazo. Los cambios fisiológicos normales durante el embarazo requieren, en promedio, un aumento del 50 % del volumen sanguíneo circulante que va acompañado de un aumento del gasto cardíaco que suele alcanzar su punto máximo entre la porción media del segundo y tercer trimestre. El aumento del gasto cardíaco se debe a un aumento en el volumen sistólico y un pequeño aumento en la frecuencia cardíaca, con un promedio de 10 a 20 latidos por minuto. Además, la circulación uterina y las hormonas endógenas hacen que disminuya la resistencia vascular sistémica y una disminución desproporcionada de la presión arterial diastólica provoca una presión de pulso amplia. La obstrucción de la vena cava inferior por un útero grávido en posición supina puede provocar una disminución brusca de la precarga cardíaca, lo que conduce a hipotensión con debilidad y aturdimiento. Durante el preparto y el parto el gasto cardíaco aumenta más en parte debido a la ansiedad y el dolor asociados, así como debido a las contracciones uterinas que causarán un aumento de la presión sanguínea sistólica y diastólica.

Las lesiones valvulares cardíacas asociadas con un alto riesgo materno y fetal durante el embarazo incluyen:
 Estenosis aórtica grave con o sin síntomas
 Regurgitación aórtica con síntomas de clase funcional III-IV de la NYHA
 Estenosis mitral con síntomas de clase funcional II-IV de la NYHA
 Regurgitación mitral con síntomas de clase funcional III-IV de la NYHA
 Enfermedad de la válvula aórtica y/o mitral que resulta en una severa hipertensión pulmonar (presión pulmonar mayor al 75 % de las presiones sistémicas)
 Enfermedad de la válvula aórtica y/o mitral con disfunción grave del VI (EF menos de 0,40)
 Válvula protésica mecánica que requiere anticoagulación
 Síndrome de Marfan con o sin regurgitación aórtica

En los individuos que requieren una válvula cardíaca artificial, se debe considerar el deterioro de la válvula con el tiempo (en el caso de las válvulas bioprotésicas) frente a los riesgos de coagulación de la sangre en el embarazo con válvulas mecánicas con la consiguiente necesidad de medicamentos en el embarazo en forma de anticoagulación.

Tratamiento

Algunos de los tratamientos más comunes de la valvulopatía cardíaca son evitar el tabaco y el consumo excesivo de alcohol, antibióticos, medicamentos antitrombóticos como la aspirina, anticoagulantes, dilatación con balón y diuréticos.

En algunos casos, puede ser necesaria la cirugía.

Estenosis aórtica

El tratamiento de la estenosis aórtica no es necesario en pacientes asintomáticos, a menos que la estenosis se clasifique como grave basándose en la hemodinámica de la válvula. Tanto la estenosis aórtica asintomática grave como la sintomática se tratan con una cirugía de reemplazo de la válvula aórtica (AVR por sus siglas en inglés Aortic Valve Replacement). El reemplazo de la válvula aórtica trans-catéter (TAVR) es una alternativa a la AVR y se recomienda en pacientes de alto riesgo que pueden no ser aptos para la AVR quirúrgica. Cualquier angina se trata con nitrovasodilatadores de corta acción, beta-bloqueadores y/o bloqueadores de calcio. Cualquier hipertensión es tratada agresivamente, pero se debe tener precaución en la administración de beta-bloqueadores. Cualquier insuficiencia cardíaca es tratada con digoxina, diuréticos, nitrovasodilatadores y, si no está contraindicada, se debe tener precaución en la administración hospitalaria de inhibidores de la ECA. Las estenosis moderadas son monitoreadas con ecocardiografía cada 1-2 años, posiblemente con una prueba de esfuerzo cardíaco suplementaria. Las estenosis severas deben ser monitoreadas con ecocardiografía cada 3-6 meses.

Regurgitación aórtica
La regurgitación aórtica se trata con el reemplazo de la válvula aórtica, que se recomienda en pacientes con regurgitación aórtica grave sintomática. El reemplazo de la válvula aórtica también se recomienda en pacientes asintomáticos pero con regurgitación aórtica grave crónica y una fracción de eyección del ventrículo izquierdo inferior al 50 %. La hipertensión se trata en pacientes con regurgitación aórtica crónica, siendo los antihipertensivos de elección los bloqueadores de los canales de calcio, los inhibidores de la ECA o los BRA.  Además, la profilaxis de la endocarditis está indicada antes de procedimientos dentales, gastrointestinales o genitourinarios.

La regurgitación aórtica de leve a moderada debe ser seguida de una ecocardiografía y una prueba de esfuerzo cardíaco una vez cada 1-2 años. En casos severos moderados/graves, los pacientes deben ser seguidos con ecocardiografía y prueba de esfuerzo cardíaco y/o imagen de perfusión isotópica cada 3-6 meses.

Estenosis mitral
Para los pacientes con estenosis mitral sintomática grave, se recomienda la valvuloplastia mitral con balón percutáneo (PBMV por sus siglas en inglés Percutaneous Balloon Mitral Valvuloplasty). Si este procedimiento falla, puede ser necesario someterse a una cirugía de la válvula mitral, que puede implicar el reemplazo de la válvula, la reparación o una comisurotomía.  Se recomienda la anticoagulación para los pacientes que tienen estenosis mitral en el marco de una fibrilación auricular o de un evento embólico previo. No se requiere ninguna terapia para los pacientes asintomáticos. Los diuréticos pueden ser usados para tratar la congestión pulmonar o el edema.

Regurgitación mitral
Se recomienda la cirugía para la regurgitación mitral crónica grave en pacientes sintomáticos con una fracción de eyección del ventrículo izquierdo (FEVI) superior al 30 %, y en pacientes asintomáticos con un FEVI del 30-60 % o un volumen diastólico final del ventrículo izquierdo (VDFVI) > del 40 %. Se prefiere la reparación quirúrgica de las valvas a la sustitución de la válvula mitral siempre que la reparación sea factible.

La regurgitación mitral puede ser tratada médicamente con vasodilatadores, diuréticos, digoxina, antiarrítmicos y anticoagulación crónica. La regurgitación mitral de leve a moderada debe ser seguida con ecocardiografía y prueba de esfuerzo cardíaco cada 1-3 años. La regurgitación mitral severa debe ser seguida con ecocardiografía cada 3-6 meses.

Epidemiología
En Estados Unidos, alrededor del 2,5 % de la población tiene una enfermedad cardíaca valvular de moderada a grave. La prevalencia de estas enfermedades aumenta con la edad, y las personas de 75 años de edad en los Estados Unidos tienen una prevalencia de alrededor del 13 %. En las regiones industrialmente subdesarrolladas, la enfermedad reumática es la causa más común de las enfermedades valvulares, y puede causar hasta el 65 % de los trastornos valvulares vistos en estas regiones.

En España el número de afectados por alguna valvulopatía está en el 3 % de la población mayor de 65 años y en el 7,4 % en los mayores de 85 años.

Estenosis aórtica
La estenosis aórtica es típicamente el resultado del envejecimiento, ocurriendo en el 12,4 % de la población mayor de 75 años de edad y representa la causa más común de obstrucción de salida en el ventrículo izquierdo. Las válvulas aórticas bicúspides se encuentran en hasta el 1 % de la población, convirtiéndola en una de las anormalidades cardíacas más comunes.

Regurgitación aórtica
La prevalencia de la regurgitación aórtica también aumenta con la edad. La enfermedad moderada a grave tiene una prevalencia del 13 % en pacientes de entre 55 y 86 años. Esta enfermedad valvular es causada principalmente por la dilatación de la raíz aórtica, pero la endocarditis infecciosa ha sido un factor de riesgo creciente. Se ha encontrado que es la causa de la regurgitación aórtica en hasta el 25 % de los casos quirúrgicos.

Estenosis mitral
La estenosis de la válvula mitral es causada casi exclusivamente por la enfermedad cardiaca reumática y tiene una prevalencia de alrededor del 0,1 % en los Estados Unidos. La estenosis mitral es la enfermedad valvular del corazón más común en el embarazo.

Regurgitación Mitral
La regurgitación mitral se asocia significativamente con el envejecimiento normal, aumentando su prevalencia con la edad. Se estima que está presente en más del 9 % de las personas mayores de 75 años.

Referencias

Valvulopatías


Everything Is Okay: Monique Munoz on Art, Development, and Strength.
Marvelous messages about childhood, compassion, and positivity are prevalent themes throughout her work and it's wonderful to see that she is beginning to make waves with her art.
Photified: An Interview With Artist Justin Main.
If you have spent some time perusing photography pages on Instagram, there is a good chance that you have been introduced to the reality defying works of Justin Main A.K.A Photified.
Waveloop: Ricardo Rodrigues On Art, CyberPunk, and Imagination.
Meet Portugal's Ricardo Rodrigues, (or perhaps better known as Waveloop) an artist creating excellent contemporary works by utilizing his love of popular entertainment.
I have spoken with artist Brian Pollett before and i am still fascinated by the concept of his Binge series. Over a set course of days, Brian consumes various drugs and creates pieces that attempt to represent elements of each particular substance. It's a very underrated concept in my opinion and manages to showcase both Brian's virtuoso talent, as well as his incredible ability to translate these spaces into reality for us to admire without being pretentious.
With his futuristic take on natural landscapes and architectural structures, Justin has seamlessly incorporated elements of Science Fiction and Transhumanism into his works. Subtle cubist influences are woven into his pieces giving them an interesting verve and very post-modern warmth. His knack for this type of "cyber-punk" has set done much to set him apart from many of his contemporaries in the ever expanding digital art movement.
Interview With Artist, Ashley Christudason.
Ashley Christudason is a digital artist out of Singapore who is dedicated to creating pieces that promote the inherent (but unfortunately obscured) oneness within all of mankind.
Interview With Visual Artist, Melissa Williams of Misprint.
Melissa Williams is a freelance artist (operating out of Melbourne, Australia) that has used her impressive eye for color to create epic art for musicians, retailers (which has given her an insider look at the entrepreneurial side of the business), and everyday consumers.
Interview With Visual Artist, Cameron Gray.
Visual artist Cameron Gray (operating out of Melbourne, Australia) is using his skills in several different mediums to create spiritually tinged, hyper-realistic canvases that showcase the divinity of the highly coveted psychotropic landscape. Although careful not to proselytize, his work does a masterful job of telling stories of ascension and oneness, while giving the experiencer the space to project his or her own meaning onto his works.
Interview With Artist and Musician, Simon Haiduk.
Like many other artists in this fascinating genre, Simon has done a commendable job at replicating the energies that one may find themselves coming into contact while under the tutelage of spiritual or psychedelic sacraments. With a reverence for nature and the beings that dwell within it, Simon has consistently used this as a source of inspiration and empowerment, allowing him to produce magnificent portraits and tapestries.


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« CASA – How many personell do they have to deal with in the industry??
Should the CASA Board meet the new ASX requirements?? »
An old report reminds us of the Annex 13 requirements ASRR report due soon
An old report reminds us of the Annex 13 requirements and maybe reminds us of the ATSB reports and the errors exposed by "interested parties" in getting the actual answers.
Unfortunately there are too many since Whyalla, where ATSB has some serious answers to give:
for a start – and the effect of the regulator as so well exposed in the Senate PelAir inquiry.
The Many Faces of Aviation
Swissair Flight 111 departed JFK Airport, New York, USA, at 2018 eastern daylight savings time on a scheduled flight to Geneva, Switzerland and approximately 73 minutes later crashed into the sea off the coast of Nova Scotia, Canada. Within hours, there was growing speculation that a catastrophic electric failure aboard the seven-year old MD-11 was a likely culprit considering the pilot had reported an abnormal odour in the cockpit nineteen minutes before impact. It was also the case that the plane's flight recorder had not recorded the final six minutes of the flight, suggesting that the plane had lost all electrical power prior to impact.
If only it was that simple.
The official investigation into the crash, carried out by the Transportation Safety Board of Canada (TSB), took four and a half years and cost in excess of $40m. When the TSB released their final report on March 27th 2003 they cited the investigation as '…the largest, most complex aviation safety investigation the TSB has ever undertaken'.
What the crash of Swissair Flight 111 has demonstrated is that when considering the circumstances in which an aircraft crashes one has to look not only at the conduct of the airline and the crew concerned but also the conduct of the aircraft manufacturer, the third parties who carry out modifications to aircraft and most importantly in this case the regulator; the US Federal Aviation Administration (FAA).
As an industry, aviation is elitist. It is an industry made up of a number of clubs. There are clubs made up of airlines, manufacturers and regulators amongst others. Each of these clubs unites when their collective commercial and political interests are under scrutiny. This is traditionally the case when an aircraft crash is under investigation. A finding of fault can result in financial penalties both in the short and longer term. In the case of Swissair Flight 111, Swissair was not just an airline. It was a national emblem of Switzerland's efficiency, excellence and propriety. There was a lot at stake and it cannot go unnoticed that within three years of the crash of Swissair 111, Swissair filed for bankruptcy and a criminal investigation was launched into whether Swissair's parent company acted illegally in amassing losses of 2.9bn Swiss francs ($1.7bn) in 2000.
The individual who guides IASA is a member of the most exclusive of clubs; a club whose membership is restricted to those who have lost loved ones in aviation disasters. Bureaucracy does not perturb such individuals nor are they intimidated by protocol or the customary way of doing business. Their motivation is to see that justice is done and the factors that contributed to the needless deaths of their loved ones are not imposed on other innocent individuals. As Chairman of IASA, Lyn has always strived to give a voice to both the technical issues that brought Swissair 111 crashing down into the sea and to the humanitarian issues that surfaced as a result.
Whilst each faction has different resources at their disposal and is motivated by different interests, there is room for both. Indeed balance is critical in ensuring that all possible measures are taken regardless of other interests. What we have come to realize is there is much work to be done in this regard and until then it is the responsibility of organizations such as IASA to ask the difficult questions and put a human face to aviation safety.
May 22nd, 2014 | Tags: #ASRR, #casa, #casa Board, #PelAir, Aeromedical, Albanese, Coroner, Minister Truss, Norfolk Island, Safety Case | Category: #ASRR, #PelAir, Aviation, CASA, Department Infrastructure, Forsyth, Lockhart River, Minister Truss, Mrdak, Regulatory Capture, Safety Case, Senate Inquiry

redpajama_set_name: RedPajamaCommonCrawl


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https://www.westport-news.com/news/article/Family-feud-new-tastes-changing-the-face-of-13706515.php
Family feud, new tastes changing the face of Railroad Place
By Sophie Vaughan
Published 2:25 pm EDT, Thursday, March 21, 2019
Westport's Railroad Place has seen several business closures in the past year.
Photo: Sophie Vaughan / Hearst Connecticut Media
WESTPORT — It's the last day of February and Sudhkar Rau, a salesperson at Desi's Corner on Railroad Place, is packing up the remaining inventory in the near-empty convenience store.
"It's very slow. What we used to make, we're not making, and on top of that the rent is high," Rau said.
The following day, Desi's closed its doors after seven decades on Railroad Place, further changing the face of the small street opposite the Saugatuck Train Station where several long-standing shops have shuttered in favor of high-end establishments.
Commuter Coffee, a staple of Railroad Place, closed in June after 42 years serving classic diner food to customers on the go and in the shop's rose colored booths. In 2015, Mario's Place, an iconic family restaurant, folded following a half-century in business on the street.
"It was just time. Things had changed with the habits of people. Costs were going up, business was slowing down," said Fred Whelan, who managed Commuter Coffee on behalf of his in-laws who owned the establishment. "It was a good living for a long time and then it eventually wasn't anymore."
The expected arrival of Mystic Market, a gourmet eatery that opened in February just around the corner from Commuter Coffee's former location, influenced his decision to close the shop, Whelan said.
A new shop has yet to replace Commuter Coffee in its old spot, but the remaining storefronts are near fully-populated, mostly with high-end furniture and gift shops and restaurants, in addition to a hair salon and sports store.
But not all Railroad Place closures can be attributed to changing customer tastes, said Breno Donatti, whose Winfield Street Coffee shop closed the same week as Desi's.
Donatti, who also owns Winfield Street Italian Deli in downtown Westport and a Winfield Street Coffee shop in Hudson, N.Y., and another soon to open in Stamford, said a shift in the landlord on Railroad Place spurred his leave.
"It was really a hostile takeover of the building," Donatti said of the transfer in ownership of Hanes Realty Corporation, which owns most of the real estate on Railroad Place, from the Girden family to Shepard family.
The buildings on Railroad Place have been in his family for over 110 years, ever since his grandfather started the Saugatuck Grain and Supply Company in 1911 on Railroad Place, Steve Girden said. Later, his grandfather acquired several properties on the street before forming the Hanes Realty Corproation in 1952.
Girden's mother had one sister, whose children and Girden's cousins — the Shepards — have run Hanes Realty for the last two years.
"It's a private negotiation between two sides of the family," Girden said of the dispute between his siblings and the Shepard brothers, adding he could not speak further about the negotiation for legal reasons.
Jon Shepard, who is listed as vice president and secretary of Hanes on the Secreatry of the State's website along with his two brothers who serve as president and treasurer, would not comment on the circumstances surrounding his acquisition of the company.
Shepard is unresponsive to tenant needs, Donatti said, alleging Shepard exploited a clause in his lease to deny Winfield a lease renewal.
"We were willing to pay more; they just didn't offer us to re-sign," Donatti said.
One other Railroad Place tenant who wished to remain anonymous also cited the Shepard family's management was not receptive to tenant needs.
The greatest challenge to business, however, is running a small shop in an economy unfriendly to brick-and-mortar retail, said Mersene Norbom, owner of the Railroad Place gift shop Indulge by Mersene.
"It's difficult to stay afloat if you're not a chain," said Norbom, whose shop opened in 2012.
The prevalence of pricey shops on Railroad Place is a sharp divergence from the old-time shops symbolic of the neighborhood's traditional working-class identity.
Starting in the early 1900s, Italian immigrants settled in Saugatuck to be close to the river, railroad and all the oil and work that came in through the Long Island Sound, Saugatuck Sweets owner Chris Diguidio said in a 2017 interview.
For some Railroad Place customers, the changes on the street are bittersweet.
"It's an inconvenience because there's nowhere else around to get coffee and cigarettes and stuff like that besides the gas station," said Zony Bruany, a frequent Desi's customer who was in the shop the day before it closed. The new Mystic Market, nonetheless, is phenomenal Bruany added, noting he has been going to the market to eat every day.
"I think it's a shame to see so many businesses closing on Railroad Place at a time when things have turned around so much in Saugatuck," said Matthew Mandell, executive director and president of the Westport-Weston Chamber of Commerce.
Others like Brian Rosenchein, the head chef at Romanacci Pizza Bar, are more optimistic. Romanacci's took over the adjacent Winfield Coffee location when it closed and will continue to sell coffee at the location, Rosenchein said.
"We are revitalizing this area," he said.
svaughan@hearstmediact.com; 203-842-2638; @SophieCVaughan1


This specialization covers common topics in intermediate grammar, such as perfect verb tenses and adjective clauses. It will also cover "tricky English" grammar topics that learners of English often find frustrating. The capstone will give you a chance to review all of the knowledge you've learned in the courses and create a multi-media "scrapbook" of grammar to keep with you after the specialization ends.
Each course is designed to be completed in about 4 weeks. The capstone will take about 6 weeks. Therefore, the whole specialization can be completed in about 18 weeks.
Learners are expected to have some basic knowledge of English grammar, such as the simple present and simple past verb tenses.
It is recommended that you take the courses in order, but they can be taken in any order.
You should talk to your university to find out if they will give you credit. The University of California, Irvine does not give credit for this specialization.
Upon completing the specialization, you will be able to use the perfect verb tenses and modals correctly most of the time. You will also be able to use adjective clauses and other concepts of intermediate grammar more effectively.


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Electric Utility Contractor
Overhead Distribution
Underground Electric
Gas Utility Contractor
Municipal & Co-Op Contractor
WBE Certified
Baltimore Careers
Philadelphia Careers
L2CMS
Municipal & Co‑Ops Contractor
Stewardship News
I take pen in hand to communicate to you my sincere thanks for allowing and releasing crews to aid the Long Island area following super storm Sandy! My home is on a busy road that was perpendicular to an intersecting street, where a 70 foot pine tree 200 feet away came down on primary wires and snapped off the top of the pole fronting my house taking, downing a number of house drops, communications, and street lights. We were out for 5 days. Mr. Waters (Foreman) and linemen Mr. Prior and Mr. Hall worked into the dark to get us corrected and back on line. They were efficient and cheerful when those around them not so much! They are a living and breathing testament to your operation and your should be very proud of them! So I want to thank you again for your aid…
-Homeowner Affected by Hurricane Sandy
INTREN Shines in ENR Magazine's Rankings
Category: Company News
ENR's Top 600 Specialty Contractors issue is out and INTREN ranked #54 overall and #7 among the top utility firms in the U.S.
In the ENR Midwest 2018 Top Specialty Contractors rankings INTREN ranked #4, while five of our regional offices also placed in the Top 10.
#2 in Illinois
#8 in Kansas
#9 in Ohio
#10 in Missouri
#10 in Wisconsin
Thank you to our customers who continue to support us and to all our employees who outperform every day!
The History of INTREN
In 1988, Loretta Rosenmayer's husband was diagnosed with a chronic illness and forced to stop working. As a stay-at-home mom with four young boys, it was clear that she had to become the breadwinner in the family. With a minimum wage job out of the question, and no money or construction experience, she accepted donations of used equipment from a friend's out-of-business landscaping company and started trenching work for farms in Crystal Lake, IL. With four employees and meetings conducted at a local diner, Trench-It was born.
Shortly after, Illinois experienced a housing boom and utility companies couldn't keep up with installing new home services. With a $15,000 loan from a female friend, Loretta was able to afford insurance premiums and started bidding jobs for the local utility.
In 1993, Loretta had the foresight to become certified with WBENC (Women's Business Enterprise National Council). That relationship gave her an early edge with utility companies who were looking to expand their minority diversity spend.
As the only female, she was met with opposition. However, all the utility companies were concerned with was delivery and Loretta delivered. Soon Trench-It moved into electric overhead and underground and then gas services. By 2009, she changed the name to INTREN; the "IN" standing for integrity.
During the late 2000 recession when the business slowdown forced cutbacks, Loretta started looking outside of Illinois and took small jobs that no one else wanted. When the economy came back, INTREN's footprint quadrupled and they were instantly in 10 markets across the country.
To Loretta, stewardship "caring for other's priorities as if they were our own" is not just a way of doing business; it is a way of life. By weaving this into the very fabric of INTREN's culture, Loretta and the company have succeeded in earning the respect and support of peers, customers and the communities INTREN serves. And that has always been Loretta's purpose--to serve and to make a difference. You see it in her mentoring of dozens of MWBE companies and the hundreds of charitable organizations she supports and how she passionately takes care of her customers and employees.
In 2017, Loretta stepped up to Chairwoman of the Board, and hired utility industry-veteran Kelly Tomblin as CEO. Together, their vision for the future is to acquire and mentor additional MWBE companies, while continuing to strategically expand into new regions and deepen INTREN's breath of services.
Now with 13 regional offices, 2,000 employees from coast-to-coast, and additional services in transmission and vegetation management, their vision is becoming a reality.
Dennis Bednarski Promoted to Senior Vice President; Will Lead INTREN's Electrical Operations Division
Industry-Veteran Drove Tremendous Growth Throughout the Midwest
Union, IL, October 10, 2018 - INTREN is proud to announce that Regional Vice President of Midwest Operations, Dennis Bednarski, has been promoted to Senior Vice President of Electrical Operations, effective immediately.
"Dennis has been instrumental in driving tremendous growth throughout the Midwest region, while continuing to improve operational performance and service levels for our customers," said INTREN CEO Kelly Tomblin. "His leadership ability has expanded his region by 300%, both geographically and in depth of services."
Since joining INTREN in October of 2015, Bednarski managed the Midwest region, which served utility customers in Ohio, Wisconsin, Missouri, Kansas, Oklahoma, Iowa and Michigan. reporting to Dennis will be Regional Vice President Sean Hughes, Jason Combs and Andy Carmean.
"Dennis' ability to align his team on training, safety, quality and work force development has made him an exceptional leader," said President Lance Rosenmayer. He empowers his people and brings synergies across the organization, which was also a kay factor in promoting him to run the electrical services divisions."
Prior to INTREN, Dennis was the General Manager of Electric Distribution, Water and Fleet for the City of Oconomowoc, Wisconsin. He also managed multiple departments for the City with a focus on safety, efficiencies, responsible budgeting and customer satisfaction.
Dennis also worked at ComEd for 22 years, serving in his later years as Manager, Joliet and Area Manager of the Elgin/Aurora offices. He has also been on the Board of Directors of the Municipal Electric Utilities of Wisconsin (MEUW) and the Wisconsin Public Power Association (WPPI), along with serving on numerous boards and tech schools in Wisconsin.
Dennis earned his bachelor's degree in Business and Management from National Louis University. Along with his wife Karen, and son Anton, he also farms in Watertown, Wisconsin.
INTREN Employees Graduate from BGE's Focus Forward Academy
Regional Vice President of Business Development, Keith Garvey and Business Development Manager, Lloyd Gillespie graduated from BGE's 1-year Focus Forward Academy in September. BGE launched this Academy, a diverse business empowerment initiative, in 2013. The program provides rigorous technical assistance, coaching and direct access to BGE leaders and business partners who are committed to growing diversity and certified partnerships.
"The Focus Forward Diversity Academy was an exceptional program that offered multiple benefits," said Keith Garvey, "It gave us the opportunity to meet BGE buyers and better understand their processes and selection criteria. The academy also gave us a chance to interact and build stronger relationships with both diverse regional companies and senior executives from BGE."
The Academy is one of several initiatives which helped BGE receive national recognition by Edison Electric Institute (EEI) this spring for its commitment to increase business and relationships with diverse suppliers.
The graduation's guest speaker Calvin Butler, CEO of BGE, said since becoming CEO at BGE he has seen a steady improvement in efficiencies and productivity by having a diverse team. He said BGE has done better financially each year, and the company's diversity spend increased from 14% in 2013 to what will be near 33% this year. Butler also shared that 29 companies that graduated from Focus Forward received contracts valued at $150M.
"Our opportunity to participate in the Focus Forward Academy means that we are joining a very distinguished group of graduates. Last year, several graduates of this program successfully competed and won major awards," said Lloyd Gillespie.
BGE is a subsidiary of Exelon Corporation. With headquarters in Baltimore, MD, BGE was founded in 1816 as the nation's first gas utility and currently is Maryland's largest natural gas and electric utility.
For more information regarding the Focus Forward Academy, please contact Keith Garvey at This email address is being protected from spambots. You need JavaScript enabled to view it.
INTREN Hires New Director of Operations to Bolster East Coast Gas
George Castellano has been hired as Director of Operations for INTREN's East Coast Gas Division to significantly bolster efforts to provide gas services to an expanding market of customers. As such, George has direct operational oversight of all gas projects currently being performed in the Baltimore and Philadelphia areas as well as future opportunities for east coast growth. George brings over 30 years of experience in underground utility construction working on both coasts and has a Bachelor of Science in business administration.
In accordance with INTREN's 2018 strategic initiatives, the INTREN Gas Division is experiencing significant growth. INTREN has been recently awarded a series of contracts across its various operating regions, and more manpower is crucial in preparations for this dramatic growth. George will continue to build upon East Coast Regional offices, increase INTREN's market share with existing major utility companies, and identify new revenue streams and market opportunities.
"We're very excited to have George join our team," Jeff Nauman, Vice President of Gas Operations, stated. "With our east coast gas teams in Philadelphia and Baltimore experiencing such rapid growth, combined with numerous new opportunities, the timing was right to add a Director of Operations located on the east coast who is solely dedicated to our customers in that region. This move also allows Doug Anderson [Director of Operations, Midwest Gas] to focus on our Midwest gas customers where we are also experiencing significant growth with several other new opportunities."
Matt Turk, Executive Vice President of Customer Solutions, gave his opinion on the hire. "With growth in our gas division, this is the perfect time to have both Midwest and East Coast directors of operations. We're excited that George joined the team and that Doug can focus on the Midwest."
INTREN Finalizes Transaction to Acquire Miller Construction Company
Unique Woman-Controlled Board Welcomes Miller CEO Christina Ernst
INTREN, one of the nation's largest certified Women Business Enterprise (WBE) specialty utility contractors, today announced they have closed the transaction to acquire Indiana-based Miller Construction Company, Inc., a third-generation full-service electrical contracting company, which is also a leading WBE. INTREN's focus now is a thoughtful integration of both companies.
"An acquisition evokes a myriad of emotions for employees and our focus now is on bringing our teams together in a way that minimizes any concerns," said INTREN CEO Kelly Tomblin. Miller has an extraordinary team and we want to make sure they continue operations with as little interruption as possible. My intention is to assemble a creative integration team that will uncover and implement the best practices of both companies."
Miller Construction's 175 employees join INTREN's 1,700-strong team to provide more to complete service offering through a wider geographic reach. Company President Andy Carmean will continue to oversee Miller activities and will join INTREN as Regional Vice President serving the Indianapolis and St. Louis markets. Christina Ernst, CEO of the Miller Construction Company, will join the woman-controlled INTREN Board of Directors, one of the few in America's utility contractor space.
"Today, Miller employees are officially a part of the INTREN family, said Tomblin. However, we will continue to honor the Miller legacy and the three generations that built this extraordinary company. Our companies share similar roots, along with the same culture and values that are centered upon a deep customer focus, an ongoing commitment to safety, and a true caring for our employees and the communities we serve."
INTREN Founder and Board Chair Loretta Rosenmayer stressed that INTREN's acquisition furthers her vision of creating a national full-service company. "Our goal is not only to build the best women-owned business and woman-controlled board, but to be the best overall total-solutions provider for our customers. INTREN's and Miller's shared values of stewardship, integrity and customer focus will guide us, and firmly support our belief that companies do well in the marketplace by doing good," Rosenmayer added.
This acquisition is in response to requests from our customers and the marketplace. We are expanding our transmission capabilities and expertise, and adding other services such as equipment testing, vegetation management and innovative professional services while maintaining the same safety, quality, and customer focus that INTREN has provided for nearly thirty years. We are now well-positioned to grow further and be even better partners for our customers in the future," added Tomblin.
"As a family-owned and operated WBE, Miller Construction Company is thrilled to join the INTREN family," Christina Ernst said. "Not only does INTREN embody the principles and values of Miller Construction Company, but we provide complementary services that will help INTREN achieve continuous growth and become a total utility solutions provider. Together we are well-positioned for industry leadership that will provide creative solutions for our customers. I look forward to serving on the Board and continuing to help advise the combined companies."
INTREN's acquisition of Miller Construction Company shows the industry that diverse companies can combine to create a different and innovative workplace offering. INTREN's latest growth to meet the infrastructure needs of the utility marketplace reflects their 30-year trajectory that was bolstered in 2017, when One Equity Partners became a minority investor, providing significant funding for future growth.
James Althoff Graduates from LGMC
On Thursday, June 14, 2018, James Althoff from our Business Development department graduated from a nearly year-long leadership program in McHenry County: Leadership Greater McHenry County (LGMC). Unlike a more traditional skills based approach to leadership, James described LGMC as teaching its students to focus on understanding "what issues affect us, regionally, locally, and nationally".
Leadership can be viewed through a narrow lens as a tool to only be utilized in the workplace, but James learned how to utilize leadership skills to better serve the community. To that end, he studied Human Trafficking.
Human trafficking is an insidious problem in the Midwest, often times connected to drug routes flowing through Chicago. "Chicago, Rockford, McHenry are known as the trafficking triangle," James said. In addition to learning communication skills and other typical facets of leadership, James also learned to apply a leadership perspective to a broader angle. Part of why human trafficking continues to plague this region is that "we live in a bubble, so we don't see the periphery". People have to step up in their communities and assume leadership roles in order to combat issues pervading the local area.
Other teams in the program studied issues such as opioid addition or economic issues. James and the other graduates learned to "connect, educate, [and inspire engagement] in the community", and doing so manifested itself through the variety of topics people dove into.
"It's really harder than it seems, it's trying to find out what your passion is and giving back to the community in some way," James said.
James is the 4th INTREN employee to complete the program, joining Sue Clarke, Mary Lucarelli, and Christina Mazhary as a fellow graduate of LGMC.
INTREN Announces Plan to Acquire Miller Construction Company, Strengthening WBE Utility Contractor
Unique Woman-Controlled Board Responds to Customers
INTREN, one of the nation's largest certified Women Business Enterprise (WBE) specialty utility contractors, today announces continued growth through its plan to combine with Indiana-based Miller Construction Company, Inc., a third-generation full-service electrical contracting company, and also a leading WBE. By joining forces, INTREN will broaden its marketplace offerings, including Miller Construction's deep expertise in transmission.
"With Miller Construction, we have found a culture match and an experienced execution partner, as well as a company that shares our values and our vision of transforming the way business is done," said INTREN founder and Chairwoman of the Board Loretta Rosenmayer. "Miller Construction is a family-owned business with a long history of exceptional safety and meeting customers' needs, which makes them a natural fit for the INTREN family."
Rosenmayer stressed that INTREN's acquisition furthers her vision of creating a national full-service company. "Our goal is not only to build the best women-owned business and woman-controlled board, but to be the best overall total-solutions provider for our customers. INTREN's and Miller's shared values of stewardship, integrity and customer focus will guide us, and firmly support our belief that companies do well in the marketplace by doing good," Rosenmayer added.
"INTREN is known for anticipating and fulfilling the needs of our customers and we are doing just that by broadening our capabilities through the acquisition of Miller Construction Company," said Kelly Tomblin, INTREN's Chief Executive Officer. "By joining forces, we are continuing our evolution to serve customers in every business segment, wherever they need us geographically," she said.
"This acquisition is in response to requests from our customers and the marketplace. We are expanding our transmission capabilities and expertise, and adding other services such as equipment testing, vegetation management and innovative professional services while providing the same safety, quality, and customer focus. We are now well-positioned to grow further and be even better partners for our customers in the future," added Tomblin.
Christina Ernst, the CEO of the Miller Construction Company, will join the woman-controlled INTREN Board of Directors, one of the few in America's utility contractor space.
Miller Construction's 175 employees will join forces with INTREN's 1,600-strong team to provide more work to customers through a wider geographic reach. Company President Andy Carmean will continue to oversee Miller activities and will join INTREN as Regional Vice President serving the Indianapolis and St. Louis markets.
"As a family-owned and operated WBE, Miller Construction Company is thrilled to join the INTREN family," Christina Ernst said. "Not only does INTREN embody the principles and values of Miller Construction Company, but we provide complementary services that will help INTREN achieve continuous growth and become a total utility solutions provider. Together we are well-positioned for industry leadership that will provide creative solutions for our customers. I look forward to serving on the Board and continuing to help advise the combined companies. "
About INTREN
For 30 years, INTREN has been an innovative solution partner, dedicated to building and maintaining the infrastructure of
the energy industry. The company's culture of stewardship guides INTREN to care for others' priorities as if they were their own. Through an unwavering commitment to safety, integrity, customer focus and employee empowerment, the company has succeeded in offering turnkey services to a long list of satisfied clients. As an industry leader, INTREN is proud to serve many of the country's foremost utility companies, private contractors and developers, municipalities and cooperatives. For more information, please visit INTREN.com.
About Miller Construction Company
Miller Construction Company is a full-service electrical contracting company, providing deep expertise and services throughout the Midwest in overhead transmission and distribution, along with emergency storm restoration services, nationwide. Miller also provides extensive in-house project management and estimating, along with vegetation management and electrical testing services.
The Vincennes, Indiana-based third-generation family business is a certified Women Business Enterprise (WBE) and possesses a long history of exceptional safety, exceeding customers' needs, and deeply caring for their employees and their communities. For more information, please visit MillerPower.com.
About Intren (PDF)
About Miller (PDF)
Acquisition FAQ (PDF)
INTREN Adds In-House General Counsel Doug Graham
Former Utility Attorney to Help Spearhead Growth
INTREN is excited to announce the addition of Douglas Graham as in-house General Counsel to support the company's growth and acquisition strategy.
"With One Equity Partners as our minority investor, we have significant opportunities to partner with like-minded, diverse companies to serve our customers," said INTREN CEO Kelly Tomblin. "Doug will help integrate these companies under the INTREN umbrella, and allow us to provide a total-solutions offer from coast-to-coast."
Most recently, Doug was General Counsel for Oil-Dri Corporation of America, a worldwide leader in sorbent mineral technology, where he led all legal, including managing acquisitions, real-estate and labor relations.
Prior, he served as Assistant General Counsel for Commonwealth Edison Co. for 11 years, where he focused on business counseling, governmental relations, compliance, and regulatory matters, along with litigation, labor and employment advice. Doug also worked in house for the Tribune Media Company, United Airlines, as well as at the law firm of Jenner & Block.
As the country's largest owned and operated union WBE specialty contractor, INTREN will utilize Doug's real estate and labor expertise to open new offices across the country and expand our range of capabilities.
"As we approach INTREN's 30th Anniversary, it's been our ability to continually evolve to serve our customers' changing needs that has made us successful," said INTREN President, Lance Rosenmayer. "Employing an in house attorney that understands our business, like Doug, is vital to INTREN's next chapter."
Graham received his Juris Doctor with Distinction from the University of Michigan Law School. He also has an undergraduate degree in Economics and History Honors from the University of Michigan. Among many honors received, Graham was previously recognized by the Chicago Lawyer as one of Illinois' "Forty Under 40" lawyers to watch.
Doug is based out of INTREN's corporate headquarters in Union, IL.
INTREN Builds on Quality Reputation
WBE Specialty Utility Contractor INTREN Does Quality Differently
Not since the Industrial Revolution have companies been so challenged with the absolute need to change the way they manage and operate. Technological, regulatory, and competitive forces are shifting the utility landscape which will change dramatically in the not so distant future with quality performance being a leading differentiator.
WBE specialty utility contractor, INTREN has faced these evolving changes head-on by announcing a unique, innovative approach to quality management that is designed to involve every employee, in every department, at every level and at every INTREN office throughout the country. With ISO 9001:2015 standards as their guide, INTREN has successfully implemented an updated quality management system that addresses the individual concerns of each customer while creating a strategic advantage for INTREN internally by providing a platform for continuous improvement.
"How we approach quality is more important than the progressive tools we use," states Scott Fowler, INTREN's Quality Manager.
While no one approach will meet the needs of every customer, the INTREN leadership team has chosen to follow the latest ISO model to ensure a high level of integrity within its Quality program.
As the company enters its 30th year in business, INTREN continues to earn the trust of many of the nation's largest utilities, municipalities and cooperatives dedicated to building and maintaining the infrastructure of the energy industry. Now, this award-winning company has expanded its brand into new markets by integrating a customer centric, scalable quality management system into the way they do business.
"We believe our commitment and approach to quality provides us with a unique competitive advantage," states Fowler. "We've listened carefully to our customers and responded in a professional way by providing all stakeholders with scalable, expandable and cost-effective solutions to quality.
Our CEO, Kelly Tomblin, along with INTREN's senior leadership, are the champions behind this effort and are clearly committed to its success. We've all been empowered to personally deliver the best quality possible each and every day."
INTREN has strengthened its internal culture of 'OutPerforming. Everyday.' by developing a strategic process and structured model behind its quality improvements. The INTREN process is based on integrity and is designed to ensure every customer gets consistent quality service every time. "We're focused on producing quality work the first time, every time, because people's lives and livelihoods depend on the services we deliver. One of our shared goals is to self-identify risk and reduce rework to increase our competitiveness," stated Fowler.
Both field and office teams regularly review operating processes to identify current or potential quality issues. Each day, every work group is expected to "Self-Identify" Quality shortcomings in order to prevent future consequences. The identified risks are communicated as "Lessons Learned" across the entire INTREN organization.
INTREN is a leading specialty contractor, well known for serving the needs of its customers. Their customer-centric approach ensures that every INTREN employee is trained to clearly understand how Quality is defined for each specific customer but also how to best deliver that Quality. Since quality is not a one size fits all concept, listening to understand is INTREN'S first step in delivering a customer focused Quality solution.
Regular status updates consist of high-level graphical reports, along with location specific detailed reports that outline Quality compliance as well as self-identified deficiencies. "We've learned to take the Quality message to where the audience is," stated Fowler. "By using a wide variety of communication tools, we are able to deliver a consistent Quality message to a broad audience."
In the end INTREN hopes to accomplish two goals: First, that customers will appreciate the company's full transparency and know that placing their trust in INTREN is good for business. Second, that all stakeholders see quality as a personal responsibility.
"This is a game changer in the industry. We are clearly demonstrating that as our customer's needs evolve, so has the way INTREN responds. We want to be known as a trusted partner that delivers economical, quality solutions to our customers every time," stated Fowler.
As the economic spotlight in utility operations continues to drive efficiencies, INTREN has identified Quality as a strategic advantage and uses Continuous Improvement as a way to reduce costs associated with previously unidentified opportunities. The INTREN approach to Quality stresses that every employee validate quality work at every step of a project. While the INTREN team is reminded daily of the benefits of completing work error free, understanding how to deliver Quality to each specific customer is what sets them apart.
INTREN has always used Quality as a cornerstone for success. Now they are advancing their efforts by putting this unique process and structured model behind its plan for continued growth and future success.
To learn more about INTREN's, focus on quality, visit https://www.intren.com/about-us/quality-commitment
18202 W. Union Road | Union, IL 60180 | 815-923-2300
INTREN is signatory to numerous labor unions
Contract Management at L2CMS.com
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New Delhi, Apr 14 (UNI) The crisis in cash-strapped airlines Jet Airways has deepened as their pilots have decided not to fly on Monday.
The decision taken by the airlines pilot's body 'National Aviators Guild'(NAG) which has over 1100 pilots associated with.
The Jet Airways has 1600 pilots as of now.
The engineers and senior management staffs have also not been paid since January this year while the junior staffs were paid partially and they also have not got the salary of March yet.
However, the airline's management has assured the employees that that entire dues would be cleared soon once Rs 1500 crore loan would infuse by the State Bank of India.
The SBI-led consortium had also invited expressions of interest to sale the stake in airline. The deadline for the EoI ended on Friday. Now the bankers would invite prominent bidders by April 30.
The airline has been facing a mounting debt of more than Rs 8,000 crore. The airline has forced to ground its more planes due to non-payment of amounts outstanding to lessors under their respective lease agreements.
Few months before, the Jet Airways use to operate 120 flight a day but due to cash crunch now the operation was limited to just 15 flights a day.


Last weekend, Archaia Comics sat down with fans at WonderCon to discuss their new and upcoming projects. The panel included PR & Marketing manager Mel Caylo, Assistant Editor Rebecca Taylor, Editor Joe LeFavi, and writer/editor Nate Cosby. Archaia Editor-In-Chief Stephen Christy moderated the panel.
Stephen Christy opened the panel by introducing the "Immortals" anthology, a companion piece for the upcoming "Immortals" film helmed by Tarsem Singh starring Henry Cavil and Mickey Rourke, loosely based on the Greek myth of Theseus and the Minotaur and the Titanomachy, that will be released in November. Featuring a cover by David Mack and contributions from, among others, Jock, Ben Templesmith, and Francesco Francavilla, the anthology will be released in September. A video documentary series will also be released to support the "Immortals" film and anthology, and Cosby joked that he managed to touch Henry Cavill during film, remarking, "He was so soft. He is my Kryptonite."
Christy discussed Archaia's upcoming series of "Dark Crystal" graphic novels, which will feature covers, art direction, and concepts by Brian Froud, the concept artist for both "Dark Crystal" and "Labyrinth", and the "Storyteller" Anthology, which Nate Cosby discussed with CBR in an exclusive report on Saturday. The "Storyteller" anthology will also be released in September, and features contributions by Roger Langridge, Jimmy Palmiotti and Justin Gray, Jeff Parker, Paul Tobin, Colleen Coover, Francesco Francavilla, Brian Clevinger, Tom Fowler, Marjorie Liu, Evan Shaner, Jennifer Meyer, Katie Cook, Chris Eliopoulos, Ron Marz, Jim McCann and Janet Lee, as well as an unpublished story by the late Anthony Minghella. Also noted was the upcoming graphic novel "A Tale of Sand," an adaptation of a never-before-seen story by the Jim Henson & Jerry Juhl, which had been locked away in the Henson Company archives for the past 40 years.
Two original graphic novels edited by Rebecca Taylor, "Old City Blues", and "Rust", will be released this summer. Available in June, Giannis Milonogiannis' "Old City Blues" is a black and white cyberpunk police thriller set in a futuristic Greece that originally started as a webcomic, and Royden Lepp's "Rust" is a sepiatone adventure starring a struggling farmer and his family, a forty foot tall war robot, and Jet Jones, a mysterious kid with a jet pack.
Mel Caylo noted that Michael McMillan's "Lucid", a six-issue miniseries originally produced by Zachary Quinto's Before The Door production studio, would be collected as a hardcover featuring an introduction by Alan Ball, creator of the television shows "True Blood" and "Six Feet Under." Christy described "Lucid" as "what if Harry Potter grew up and joined the CIA." Victor Quniaz's "Mr. Murder is Dead", also produced by Before The Door, will be collected as well.
The second collection of "Days Missing: Kestus," produced by Archaia and Roddenberry Productions, and written by Phil Hester and illustrated by David Marquez, will be released in May. The five-chapter collection features a cover by Alex Ross and an introduction by sci-fi fan favorite Wil Wheaton.
Archaia's new publisher Mike Kennedy introduced the "Bleedout" anthology, a peak oil scenario featuring contributions by Howard Chaykin, Ben Templesmith, Zach Howard, and a cover by Tim Bradstreet. Kennedy noted that the anthology would come out somewhere around the end of April and the beginning of May.
The panel opened for questions, and a fan asked for more information on "A Tale of Sand." Christy replied that the book would be "our blockbuster of the year", and that the source material was fully realized before Jim Henson's "Muppet Show" took off and became a hit. Christy also noted that "A Tale of Sand" would be released on Henson's birthday.
When asked how closely "Immortals" would follow Greek mythology, Nate Cosby responded that the stories are grounded in a pseudo-reality, and that the anthology's version of the story of the Minotaur adhered closely to the original tale.
Steven Christy closed the panel by explaining that Archaia envision their comics as hand-held "destination material", and carefully consider the size, weight and feel of every release. The company believes that this approach is "the only way to survive the digital age."


text:
Prosenjakovci (; ) is a village in the Municipality of Moravske Toplice in the Prekmurje region of Slovenia, close to the border with Hungary.

Unmarked grave
Prosenjakovci is the site of an unmarked grave associated with the Second World War or its aftermath. The Prosenjakovci Grave () lies southwest of the village, behind the funeral chapel in the village cemetery. It contains the remains of a Hungarian that was shot while crossing the border illegally.

Churches

There are two small churches in the settlement, a Catholic chapel dedicated to Saint Joseph and a Lutheran chapel with a three-storey belfry, built in 1927.

References

External links

Prosenjakovci on Geopedia

Populated places in the Municipality of Moravske Toplice

redpajama_set_name: RedPajamaWikipedia


The VALUE cap with your needs in mind.
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By some modifications to the old Supreme mold, leveling the roof and widening the top in the front...we have the "largest mid-height cap" in the market.


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Rediff.com » Sports » Mike Bryan wins Wimbledon for 17th Slam, 1st without brother
Mike Bryan wins Wimbledon for 17th Slam, 1st without brother
Last updated on: July 15, 2018 11:59 IST
IMAGE: Jack Sock and Mike Bryan of the United States pose with their trophies after winning the Wimbledon men's doubles title at the All England Lawn and Croquet Club on Saturday. Photograph: Susan Mullane-USA TODAY Sports/Reuters
Mike Bryan of the United States claimed his 17th Grand Slam men's doubles title when he and Jack Sock beat Raven Klaasen and Michael Venus 6-3, 6-7(7), 6-3, 5-7, 7-5 in a thrilling Wimbledon final on Saturday.
It was the 40-year-old Bryan's first major title without his twin brother Bob, who missed the tournament due to injury.
The American pair started strongly to take the first set but South African Klaasen and New Zealander Venus fought back to level.
Klaasen and Venus dug deep again to take the match into a deciding set but Bryan and Sock, who won the men's doubles title at the All England Club in 2014 with Canadian Vasek Pospisil, sealed victory in three hours 39 minutes.
The Bryan brothers won the Wimbledon doubles title together in 2006, 2011 and 2013.
Czech duo Krejcikova-Siniakova win women's doubles
IMAGE: Barbora Krejcikova and Katerina Siniakova of the Czech Republic, left, pose with Nicole Melichar of the United States and Kveta Peschke of the Czech Republic after receiving their trophies. Photograph: Susan Mullane-USA TODAY Sports/Reuters
Czech duo Barbora Krejcikova and Katerina Siniakova won the Wimbledon women's doubles final -- five years after they won the junior title together -- and dedicated the victory to their late compatriot Jana Novotna.
They beat American Nicole Melichar and Czech Kveta Peschke 4-6, 6-4, 6-0 to add the Wimbledon title to the French Open crown they won last month.
Krejcikova said the triumph was a fitting way to mark the 20-year anniversary of the Wimbledon singles title won by Novotna who died last year.
"She really deserves for us to think about her in really good spirit, in really good way," she said.
"I think it's really good that it was mentioned that she won title here 20 years ago. It was her biggest title. She really wanted to win it, as I know from the stories she told me.
"Right here, like 20 years after her winning Grand Slam. Only doubles, but still it's perfect. I think she would be really proud too."
The only blemish on an otherwise great afternoon was that they did not get to play the title match on Centre Court because of delays caused by the over-running men's singles semi-final between Novak Djokovic and Rafael Nadal.
The last pair to win the Wimbledon women's doubles title on the back of the French were Kim Clijsters and Ai Sugiyama 15 years ago.
Related News: Mike Bryan, All England Lawn and Croquet Club, Raven Klaasen, Jack Sock, Michael Venus
PHOTOS: Djokovic outlasts Nadal in classic Wimbledon semi-final
Weary Nadal bows out of Wimbledon with pride
PIX: Kate and Meghan take center stage at Wimbledon
Meet Wimbledon champion Angelique Kerber
PHOTOS: Kerber stuns Serena to win Wimbledon title


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text:
Home AICPA historical collection using family partnerships 1999 1
Using family partnerships and refuting IRS challenges: AICPA FLP valuation discount white paper
using family partnerships 1999 1
AICPA FLP Valuation Discount White Paper Page 1 of 16
Home • Members • Teams • Taxation Team • FLP Valuation Discount White Paper
Using Family Partnerships and Refuting IRS Challenges
This article intends to highlight the AlCPA's position concerning the legitimate use of family partnerships. In particular, the AICPA takes exception with the Internal Revenue Service's ("Service's") refusal to recognize for transfer tax purposes the validity of many family partnership's under examination. In setting a framework for this discussion, we will examine the development of the family partnership as well as the major cases and laws which have focused on their transfer tax ramifications. We will then discuss the Service's current position, where it is appropriate and how it is being used to discourage practitioners from using the family partnership structure. Finally, we will rebut the technical basis for the Service's blanket challenge to family partnerships and suggest some guidelines for structuring family partnerships to minimize the potential for IRS challenge.
II. Historical Development of Family Partnerships
The use of family partnerships started back in the mid-1960s but really became popular in the mid-1970s. Prior to then, business and investment assets were held largely in corporations rather than partnerships. This was largely due to two factors. First, the law governing the formation and operation of corporations as compared to partnerships is far better understood by most attorneys. To a limited extent, this remains true today. Thus, absent other compelling reasons, a client's attorney typically urged the formation of a corporation rather than a partnership. Second, corporate income tax rates were significantly less than individual rates making the corporate structure the preferred structure for income tax deferral. Beginning in 1976, the spread between individual and corporate income tax rates narrowed markedly making partnerships and single level taxation far more attractive. Of equal significance, the 1986 Act brought the repeal of the General Utilities doctrine and eliminated the ability to liquidate a corporation tax free and avoid double level taxation. After 1986, the clearly preferred choice of entity for holding any business or investment became the limited partnership if for no other reason than income tax considerations. The adoption of the Uniform Limited Partnership Act by most states made the laws governing limited partnerships doing business in multiple states relatively similar and understandable. In addition, to their single level income taxation, limited partnerships are attractive entities because of:
A. limited liability for most partners, particularly if the sole general partner is a corporation;
B. very flexible equity structure;
http://www.aicpa.org/members/div/tax/flapap.htm 11/30/99
Title Using family partnerships and refuting IRS challenges: AICPA FLP valuation discount white paper
Author American Institute of Certified Accountants
Subject Family partnership -- United States
United States. Internal Revenue Service
Identifier using family partnerships 1999
Title using family partnerships 1999 1
Description-Abstract AICPA FLP Valuation Discount White Paper Page 1 of 16 Home • Members • Teams • Taxation Team • FLP Valuation Discount White Paper Using Family Partnerships and Refuting IRS Challenges I. Introduction This article intends to highlight the AlCPA's position concerning the legitimate use of family partnerships. In particular, the AICPA takes exception with the Internal Revenue Service's ("Service's") refusal to recognize for transfer tax purposes the validity of many family partnership's under examination. In setting a framework for this discussion, we will examine the development of the family partnership as well as the major cases and laws which have focused on their transfer tax ramifications. We will then discuss the Service's current position, where it is appropriate and how it is being used to discourage practitioners from using the family partnership structure. Finally, we will rebut the technical basis for the Service's blanket challenge to family partnerships and suggest some guidelines for structuring family partnerships to minimize the potential for IRS challenge. II. Historical Development of Family Partnerships The use of family partnerships started back in the mid-1960s but really became popular in the mid-1970s. Prior to then, business and investment assets were held largely in corporations rather than partnerships. This was largely due to two factors. First, the law governing the formation and operation of corporations as compared to partnerships is far better understood by most attorneys. To a limited extent, this remains true today. Thus, absent other compelling reasons, a client's attorney typically urged the formation of a corporation rather than a partnership. Second, corporate income tax rates were significantly less than individual rates making the corporate structure the preferred structure for income tax deferral. Beginning in 1976, the spread between individual and corporate income tax rates narrowed markedly making partnerships and single level taxation far more attractive. Of equal significance, the 1986 Act brought the repeal of the General Utilities doctrine and eliminated the ability to liquidate a corporation tax free and avoid double level taxation. After 1986, the clearly preferred choice of entity for holding any business or investment became the limited partnership if for no other reason than income tax considerations. The adoption of the Uniform Limited Partnership Act by most states made the laws governing limited partnerships doing business in multiple states relatively similar and understandable. In addition, to their single level income taxation, limited partnerships are attractive entities because of: A. limited liability for most partners, particularly if the sole general partner is a corporation; B. very flexible equity structure; http://www.aicpa.org/members/div/tax/flapap.htm 11/30/99
Using family partnerships and refuting IRS challenges:...
using family partnerships 1999 10