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Frontiers in Surgery
Reconstructive and Plastic Surgery
Applications of Fluorescence in Surgery and Interventional Diagnostics View all 31 Articles
Mark Preul
Barrow Neurological Institute (BNI), United States
Hiroo Suami
Macquarie University, Australia
James Mankin
Dignity Health, United States
Front. Surg., 02 July 2019 | https://doi.org/10.3389/fsurg.2019.00039
Enhancing Safety in Reconstructive Microsurgery Using Intraoperative Indocyanine Green Angiography
Ingo Ludolph*, Raymund E. Horch, Andreas Arkudas and Marweh Schmitz
Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nuernberg FAU, Erlangen, Germany
Intraoperative assessing and postoperative monitoring of the viability of free flaps is of high relevance in reconstructive microsurgery. Today different methods for the evaluation of tissue perfusion are known. Indocyanine Green angiography is an emerging technique among plastic surgeons with a broad scope of applications especially in microsurgical free flap transfer. We demonstrate the value and clinical application of this technique based on representative selected cases where Indocyanine Green angiography was used in microsurgical free flap transfers from different anatomic donor sites during the operation. Hereby perforator selection, flap tailoring, changes of blood flow and patency of anastomoses was judged and decision making was based on the angiographic findings. This method has proven to be valid, reproducible and easy to use. The application is not limited to the evaluation of skin perfusion, but is also applicable to muscle tissue or chimeric or composite flaps. Reliable judgement is especially given for the extent of arterially perfused tissue following complete flap dissection. Moreover, this real-time angiography revealed a high sensitivity for the detection of poorly perfused flap areas, thus supporting the conventional clinical judgement and reducing complications. In summary Indocyanine Green angiography has the potential to reduce flap related complications and to contribute to enhancing and extending the possibilities of free flap surgery.
In plastic reconstructive surgery, the number of free tissue transfers has increased significantly in recent decades. Given the appropriate indication recent advancements in operative techniques and imaging modalities have facilitated microvascular reconstructions to become safer, more reliable procedures almost independent from the patient's age (1–4).
Preoperative assessment of the microvasculature anatomy at the tissue harvesting site with advanced imaging modalities has assisted surgeons in the appropriate selection of the donor site, perforator, and flap and has led to an overall improvement in the flap outcomes (1, 5). Furthermore, the question of the intraoperative decision making especially in critically large free flaps, the individual intraoperative perforator constellation and the patency of anastomoses is as relevant as the question of the postoperative flap monitoring. Since the early days of microsurgical reconstructive procedures postoperative flap monitoring in particular is of high relevance for a successful outcome. Hence many clinical and experimental studies deal with this issue. Therefore, modern imaging devices ideally should address the entire scope of a reconstructive procedure, from the planning to the postoperative perfusion monitoring. Today several different techniques are available, all of them with the aim of decreasing flap associated complications.
Laser assisted Indocyanine Green angiography (ICG angiography) in its advanced technical version provides real-time angiography, which enables decision making on tissue perfusion in free and pedicled flaps to be made with high reliability both intraoperatively and postoperatively. ICG was introduced into clinical routine in the 1950's. It was initially used in hepatology as a function test, in cardiologic diagnostics and later by ophthalmologists as it shows less leakage from blood vessels as compared to fluorescein (6, 7). In ophthalmology it is valuable because it remains for a long time in more blood-perfused tissues such as the choroid and the blood vessels.
In this study we give insight into the spectrum of the application of ICG angiography in plastic reconstructive surgery based on representative and selected clinical cases and demonstrate the advantages and disadvantages of this procedure in the context of the current literature.
Among the variety of more than 150 free flaps and pedicled flaps performed in our institution per year four representative clinical cases with different indications for a reconstructive procedure at varying anatomical locations were selected to highlight the status of ICG angiography.
Written informed consent was obtained from all patients in accordance with the Declaration of Helsinki and ICG measurements were performed within a study protocol which was approved by the institutional Review Board (registration number 85_13 B).
As a method for skin perfusion analysis we used ICG-angiography (SPY Elite System, Novadaq Technologies Inc., Toronto, Canada) which has been utilized by our group in more than 300 cases since 2014. Exclusion criteria were solely based on contraindications for the application of Indocyanine Green, e.g., iodine allergy, autonomous adenoma of thyroid gland, hyperthyroidism or due to refusal by the patient. In all free flaps, independent of the anatomic region or the tissue included, it was routinely performed in a standard mode using a 12.5 mg bolus of ICG dye through a venous line.
After intravenous injection of ICG dye, it binds to plasma proteins. The short plasma half-life period of ICG of 3 to 4 min allows repeated injections. It is not metabolized and is excreted by the liver into bile. At the area of interest the ICG is excited by a near-infrared laser. The laser device has no potential for causing damage to the tissue or the observer. The fluorescent substance displays an absorption maximum at 805 nm and an emission maximum at 835 nm. Light at a wavelength of 800 nm in the near-infrared range is minimally absorbed by water or hemoglobin and is not scattered by tissues, which allows visualization of blood vessels (7). The dye highlights vessels up to a minimum of 3 to 5 mm in the tissue. The perfusion pattern, the intensity of the fluorescence as an indicator for dye uptake and the clearance within the tissue is displayed on a video monitor. Well-perfused areas appear bright due to dye uptake, whereas mal-perfused areas are relatively dark. In a standard mode the device displays the video in a gray scale. An additional analysis tool provides color modes and calculation of ingress and egress rates in absolute or relative values. Furthermore, contour levels can be defined for determination of perfusion areas in relation to an automatically or individually set references point in the field of interest. The analysis tool allows the user to work on the videos and pictures at a later time.
A 71 year old male patient suffered from an extensive tissue defect at the dorsum of the left hand as a result of a bicycle incident. After multiple debridement and wound conditioning using negative pressure wound therapy the defect had to be reconstructed by a large free anterior lateral thigh flap from the left thigh. During flap harvesting two distant main perforators were detected, located very lateral within the flap. Following complete flap dissection the first ICG measurement was performed with the flap left in place at the thigh. Thus, the special perforator constellation and the borders of the adjacent perforasomes could be determined. Figure 1 clearly displays the perforasome border nourished by the proximal perforator in the flap which was not to judge sufficiently by clinical signs. After a few seconds the distal perforasome was also perfused shown by an uptake of the ICG dye. Due to this analysis both perforators were then included in the flap.
Figure 1. Free anterior lateral thigh flap (ALT) for reconstruction of the dorsum of the left hand. (A) (left) ALT flap after harvesting at the left thigh. ICG angiography marking the perforasome perfused by the proximal perforator revealing a distinct perfusion border. (B) (middle left) Flap perfused via a proximal and distal perforator showing perfusion of adjacent perforasomes. (C) (middle right) ICG angiography color mode. (D) (right) ALT flap after inset at the left hand. Asterix within the flap marking the distal (right) and proximal (left) perforator.
The flap was anastomosed to the left radial artery in an end-to-side fashion as well as to concomitant recipient veins. Hereupon another ICG measurement revealed a well-perfused flap without changes of blood flow pattern compared to the point after flap harvesting. The perforasome constellation was confirmed and the flap exactly trimmed to the defect size dependent on the ICG perfusion pattern (Figure 1).
A 49 year old female patient presented a progressive lymphedema at the right leg refractory to conservative measures. In the medical history 4 years ago a laparoscopic hysterectomy and adnexectomy as well as a radical pelvic lymphadenectomy on the right side were performed because of a uterine cervical carcinoma. Despite conservative treatment the lymphedema exacerbated resulting in functional impairment and loss of quality of life. After inconspicuous follow up care and lymphoscintigraphy scan a microsurgically transplanted omentum majus flap containing lymph nodes and lymph vessles was planned. Using a laparoscopic approach the omentum majus flap was raised including the right gastroepiploic artery and vein. The flap was then anastomosed to the right femoral artery and vein. Figure 2 shows the ICG measurement after anastomosis. The well-perfused vessel arcades via the right gastroepiploic artery could be defined, whereas ICG angiography revealed the mal-perfused parts of the omentum majus which could not be determined by clinical signs. Especially in free flaps where no skin is included and peripheral bleeding on the wound edges is not common as well as residual perfusion is not sufficient for tissue survival, conventional clinical judgement by means of capillary refill or color change is not a reliable option. Discarding of too much or too less tissue is the possible consequence in these cases. Finally after discarding mal-perfused tissue parts the omentum majus was placed and spread out in the subcutaneous tissue to enable lymph vessels to grow in and establish a new lymph collector for the right lower extremity.
Figure 2. Free omentum majus flap at the right inguinal region. (A) (left) ICG angiography of the omentum majus after anastomosis to the femoral vessels showing exact perfusion of the vessel arcades and the adjacent tissue. (B) (middle) Mal-perfused part of the omentum majus flap. (C) (right) Flap at the inguinal region after anastomosis. Red bar indicates the border between well-perfused (top) and mal-perfused (bottom) parts of the omentum majus defined by ICG angiography.
In a 55 year old female patient invasive breast cancer was diagnosed in her right breast. Neoadjuvant chemotherapy was recommended followed by modified radical mastectomy and radiotherapy. After an uneventful follow up period without tumor relapse during 1 year after mastectomy the patient presented for autologous breast reconstruction with abdominal tissue. A preoperative computed tomography angiography showed a strong lateral perforator from the inferior epigastric artery. Finally a so called DIEP flap (deep inferior epigastric artery perforator flap) was harvested based on the aforementioned lateral perforator on the left side of the abdomen. Because it was hypothesized that lateral located perforators do not constantly perfuse the flap tissue across the midline and often a possibly large flap volume is necessary especially in thin patients, ICG measurement is used to define the perfusion pattern.
In this case ICG angiography showed a well perfused flap area across the midline and flap shaping was performed due to the ICG dye uptake to gain the maximum flap tissue. After anastomosis of the flap to the internal mammary artery and vein in an end-to-end fashion the repeated ICG measurement presented patent anastomoses and a well perfused DIEP flap also in the peripheral zones with no relevant change of the blood flow pattern (Figure 3).
Figure 3. Deep inferior epigastric perforator flap after complete harvesting at the abdomen based on a single lateral located perforator. (A) (left) ICG angiography showing the perfusion pattern on the contralateral side of the perforator across the midline. (B) (middle left) Analysis by using a contour level of 20% in relation to a reference point of maximum fluorescence within the flap. (C) (middle right) Color mode showing the surgeons hand marking the flap borders due to the ICG perfusion pattern. (D) (right) ICG angiography of the ipsilateral part of the flap indicating excellent perfusion.
An 83 year old female patient presented with a skin necrosis at the right knee and an infection of her knee joint prosthesis after multiple operations necessitating replacement of the joint prosthesis due to relapsing implant infections in the past. Because a total knee arthrodesis was not possible due to relevant shortening of the lower extremity and a high risk of osteomyelitis, wound conditioning using negative pressure wound therapy and defect reconstruction was planned to salvage the knee prosthesis and to prevent limb amputation as an ultima ratio procedure. In an interdisciplinary approach with the department of orthopedic surgery the mobile parts of the prosthesis were changed and the defect was closed with a free myocutaneous latissimus dorsi flap. The whole latissimus dorsi muscle was harvested with a large cutaneous flap island as this was necessary due to the defect size. Also in this case ICG measurement was done after harvesting and after anastomosis to the superficial femoral artery and vein. Based on the perfusion analysis the very peripheral parts of the muscle had to be discarded, whereas the cutaneous island showed normal dispersion of the dye indicating normal perfused tissue (Figure 4).
Figure 4. Myocutaneous latissimus dorsi flap for coverage of a defect at the right knee. (A) Latissimus flap after complete harvesting at the left axilla. (B) (middle left) ICG angiography revealing mal-perfused flap areas at the periphery. (C) (middle right) Color mode and contour level at 20% in relation to a reference point of maximum fluorescence within the flap. (D) (right) Flap after inset and anastomosis at the right knee.
Due to technical advancements and the increased knowledge in the field of plastic reconstructive surgery within the last 2–3 decades, the possibilities of microsurgically free tissue transfers have increased massively. As a result, free tissue transfers on the one hand and pedicled flaps on the other hand are now so called standard procedures in a high volume center almost independent of the patient's age (2, 3). In particular, plastic reconstructive surgeons have dealt with the question of flap monitoring since the beginning of microsurgery. In the early 1980s plastic surgeons were already aware of the importance of flap monitoring, which then relied on clinical observation (8). It is generally accepted that nowadays the intraoperative analysis of flap perfusion becomes more and more important in addition to the preoperative perfusion assessment, e.g., the so-called perforator mapping (1, 9–12). Besides the perfusion assessment after flap harvesting and anastomosis, the intraoperative use of imaging techniques is of particular interest in complex constellations of the donor vessels, especially when large flaps are required that challenge the classical perforasomes. It has added a highly valuable tool for intraoperative flap shaping and designing the flaps according to their optimal perfusion zones. Only few imaging methods are actually evaluated and established in clinical routine (9–11, 13, 14). The most common methods today are the laser assisted Indocyanine Green angiography, thermography, combined laser Doppler spectrophotometry, the laser speckle contrast imaging, hyperspectral imaging or near infrared spectroscopy, respectively (15–22). Most techniques are predominantly used in the context of experimental or clinical studies and have their own advantages and disadvantages in the context of the abovementioned fields of application. The ideal monitoring instrument should primarily meet the following requirements: non-invasive and contactless, spatial resolution about the flap, accurate, and easy to use even for inexperienced personnel and providing timely information (17).
ICG angiography has been used for more than 50 years in the clinical assessment of cardiovascular function, hepatic clearance, and retinal angiography. Up to now, it is well-standardized and the laser technologies as well as the analysis options have evolved significantly. The ICG dye itself has proofed to be safe and it features for assessing tissue perfusion have enabled to develop other applications in various surgical procedures, especially in plastic surgery (10).
Denneny et al. performed an experimental study in 1983 (8) using neurovascular island flaps in rats which were transected and re-anastomosed after flap harvesting. Hereafter Fluorescein dye was injected and uptake and elimination of the dye was visualized by a fiberoptic perfusion fluorometer. They stated that this method provides reliable data about flap perfusion and predicts viability. In recent years more studies concerning tissue perfusion analysis were published (23–25). Especially in the field of immediate alloplastic breast reconstruction the perfusion of the mastectomy skin flap was evaluated using ICG angiography, because judgement of inadequate microcirculatory perfusion can be difficult and may result in skin flap or fat necrosis and reoperation. Nevertheless, for the application in free flap surgery there is still a lack of literature.
As presented in our study the advantages of this method, however, are obvious. ICG angiography offers a real-time determination of tissue vascularity and perfusion, showing a high sensitivity especially in the arterial phase of dye distribution (13). The selected representative cases prove the reproducible practicability for intraoperative perforasome definition in perforator flaps and individualized flap tailoring as well as for the judgement of muscle flaps or even the omentum majus flap.
In autologous breast reconstruction after mastectomy due to breast cancer, microsurgically transplanted tissue from the abdomen, the so-called DIEP- or muscle sparing TRAM flap, represents the gold standard today. Particularly in obese patients or in DIEP flaps where the perforator distribution and the vascular pattern within the fat layer is not predictable, clinical flap tailoring according to the zonal classification by Hartrampf or Holm might be misleading (26, 27). As shown in case 3, individual flap planning is possible by ICG angiography with a high sensitivity for mal-perfused tissue parts. Therefore, partial flap necrosis or fat necrosis can be reduced.
As we could observe in our patients, the initial phase of dye uptake within the flap tissue can be defined as safely perfused tissue. The method is independent of the investigator, reproducible as well as contactless and with a high spatial and temporal resolution. It is an external device and therefore the use is not limited to the operating room. Due to the short half-life, multiple measurements are possible at short intervals. Additionally it can be applied for postoperative flap monitoring in critical cases or if flap perfusion is not distinct by using other methods.
The application possibilities in plastic reconstructive surgery are manifold. Thus, ICG angiography can be applied not only to assess skin or muscle flaps, but also to chimeric flaps, e.g., osteomyocutaneous as well as free vascularized bone grafts such as the free medial femoral condyle bone graft or even after finger replantation (28, 29). If the technique can also contribute to judge flap autonomisation and further clarify the long term vascular changes in transplanted flaps in the long term run seems evident, but is not completely clear yet (30, 31). Further studies are required to address this topic.
However, some inherent limitations regarding ICG angiography need to be discussed also. It represents an invasive procedure in which the intravenous application of a dye is required. Throughout the years of experience with ICG the incidence of adverse effects of the dye has been infrequent and they have generally been of low severity (32, 33). Relative contraindications such as iodide allergy or severe renal failure have to be considered. In addition, the venous phase after dye uptake in the tissue is not comparable in its precision to the very sensitive arterial uptake phase. Thus, the judgement of a venous congestion is more difficult and requires more general experiences with the technique. In addition increasing background fluorescence develops in the tissue when measurements are taken repeatedly in short intervals. The latter can lead to an indistinct perfusion assessment. By using ICG angiography intraoperatively different factors could potentially influence skin perfusion. These included variables such as the use of epinephrine containing tumescent solution, administration of vasopressors, blood pressure, oxygen saturation, fraction of inspired oxygen, temperature and hematocrit as well as individual anatomical differences (34).
Despite the broad application, still no absolute or relative perfusion levels correlating with fluorescence intensity of the dye—which would allow defining parts of the tissue as well-perfused or mal-perfused, respectively—have been standardized. In our experience, a "relative perfusion level" between 20 and 30% in relation to the most fluorescent area within the relevant tissue turned out to be safely perfused tissue. Concerning the postoperative monitoring the non-continuous nature of capturing data and the large size of the device we used the application for a routine bedside monitoring postoperatively is limited (35). Nevertheless, frequent measurements are possible in principle also on the ward or in an outpatient setting.
ICG angiography enables a standardized and reproducible real-time angiography of different tissues and provides a high sensitivity in detecting well-perfused and non-perfused tissue in the field of plastic reconstructive surgery. It has the potential to reduce flap related complications and to optimize and extend the possibilities of free flap surgery. Further studies in different applications fields are required to standardize application and enhance the possibilities of this method in plastic surgery.
IL: study conception. IL, RH, AA, and MS: acquisition of data. IL, RH, and MS: analysis and interpretation. IL and RH: drafting of manuscript. IL, RH, AA, and MS: critical revision.
IL received once-only an honorary for a lecture by Novadaq but has no conflict of interest concerning this study.
The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: ICG, Indocyanine Green angiography, microsurgery, free flap, imaging
Citation: Ludolph I, Horch RE, Arkudas A and Schmitz M (2019) Enhancing Safety in Reconstructive Microsurgery Using Intraoperative Indocyanine Green Angiography. Front. Surg. 6:39. doi: 10.3389/fsurg.2019.00039
Received: 06 January 2019; Accepted: 13 June 2019;
Published: 02 July 2019.
Mark Preul, Barrow Neurological Institute (BNI), United States
Hiroo Suami, Macquarie University, Australia
James Mankin, Dignity Health, United States
Copyright © 2019 Ludolph, Horch, Arkudas and Schmitz. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ingo Ludolph, ingo.ludolph@uk-erlangen.de


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Elisabeth Pares (PhD student)
@elisabethpares
The feeling that we can initiate movements at will or stop ourselves from doing things we don't to do want is central to our experience as agents. Further, the idea that individuals can control their behaviour is fundamental to most contemporary legal systems. However, some recent studies challenge these assumptions. For conscious control to be possible, people need to know about their intentions before acting. But do they? This talk explores the brain mechanisms underlying intention, the extent to which intentions could just be reconstructed post-hoc, and the implications of these findings.
Thinking meta: how to build a self-aware brain
Dr Steve Fleming (Principal Research Associate)
Self-awareness is often held up as a crowning achievement of the human mind. But it remains unclear what it is about the brain that gives it this weird and wonderful ability to think about itself – what psychologists refer to as "meta" cognition. In my talk I will reveal how we can measure metacognition in the lab, ask whether it's really uniquely human, and explore whether it's possible to build a metacognitive machine.
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"Agreeable to the order of the day, the Congress resolved itself into a committee of the whole, to take into farther consideration, the declaration; and the president resumed the chair. Mr. Harrison reported, that the committee of the whole Congress have agreed to a Declaration, which he delivered in. The Declaration being again read, was agreed to as follows: [Text of the Declaration of Independence] Ordered, That the declaration be authenticated and printed. That the committee appointed to prepare the declaration, superintend and correct the press. That copies of the declaration be sent to the several assemblies, conventions and committees, or councils of safety, and to the several commanding officers of the continental troops; that it be proclaimed in each of the United States, and at the head of the army."
"That the Declaration passed on the 4th, be fairly engrossed on parchment, with the title and stile of 'The unanimous declaration of the thirteen United States of America,' and that the same, when engrossed, be signed by every member of Congress."
What does "fairly engrossed on parchment" mean?
The engrossed parchment is what most people think of as "the" Declaration of Independence: the document on display in the National Archives, alongside the United States Constitution and Bill of Rights. It is a parchment sheet measuring 29 3/4 inches high by 24 1/4 inches wide. Unlike paper, parchment was a sturdier, longer-lasting material, and was also used for the Articles of Confederation, United States Constitution, and Bill of Rights.
To "fairly engross" means to copy in large, legible script, to create an official copy of a document. The person tasked with engrossing the Declaration of Independence was most likely Timothy Matlack. No official record exists, so historians rely on comparisons of Matlack's handwriting and his position as an assistant to Secretary of Congress Charles Thomson as evidence. Matlack used an English Roundhand script, and neatly wrote with a quill pen, making only two errors. He also engrossed the 1774 Petition to the King and George Washington's Commission as Commander-in-Chief. National Treasure fans may remember Matlack's name from a riddle Nicholas Cage's character discovered in the pipe from the Charlotte: "The legend writ, the stain affected. The key in Silence undetected. Fifty-five in iron pen, Mr. Matlack cannot offend." Technically it should be fifty-six, but if we start quibbling with National Treasure, this blog will be too long... And for the record, here is what the back of the engrossed parchment looks like (no treasure map...).
"The declaration of independence being engrossed and compared at the table was signed."
49 delegates most likely signed on August 2nd, including President of Congress John Hancock. Seven delegates were absent from Continental Congress on August 2nd, and must have signed later. Due to his exclusion from the Goddard broadside, we believe Thomas McKean was the last delegate to sign, sometime after January 1777.
56 delegates (including President of Congress John Hancock) representing each of the United States signed the Declaration of Independence. But as we explored in No John Trumbull, not every signer was present for the debates and the vote for independence, and not everyone who voted for independence went on to sign the engrossed parchment.
Eight men who were present on July 2nd never signed the Declaration, including most of the Pennsylvanians who either abstained from voting or voted against independence: John Dickinson, Charles Humphreys, and Thomas Willing. The other Pennsylvanian delegate who abstained -- Robert Morris -- signed on August 2nd. The New York delegation abstained from voting on July 2nd, and four delegates -- John Alsop, George Clinton, Robert R. Livingston, and Henry Wisner -- never signed the Declaration of Independence. Remember, Robert R. Livingston was a member of the Committee of Five, and yet not a signer.
Conversely, eight men signed who weren't even elected to Congress until after July 4th: Matthew Thornton (NH), William Williams (CT), Benjamin Rush (PA), George Clymer (PA), James Smith (PA), George Taylor (PA), George Ross (PA), and Charles Carroll of Carrollton (MD). Thornton famously requested permission to sign the Declaration of Independence, even though he wasn't elected to the Continental Congress until September 1776.
The one delegate who voted for independence and never signed the Declaration of Independence was John Rogers of Maryland. The one delegate who voted against independence and still signed the Declaration of Independence was George Read of Delaware.
Did everyone sign on the same day?
*Taylor's name is never mentioned in the Journals of the Continental Congress, so it is difficult to tell when exactly he attended Congress. He most likely arrived on July 20, and without evidence that says otherwise, we assume he signed the Declaration of Independence on August 2nd. It is also possible that several other Pennsylvania delegates signed after August 2nd, including George Clymer, George Ross, and James Smith. But for now, we will assume they signed with the majority.
So, the Declaration of Independence was signed by the majority on August 2nd, but it took several months if not years for all of the signatures to be added. This makes the Declaration of Independence a little different from other documents from the Continental Congress. The Olive Branch Petition, for example, was signed on one specific day. The Journals of the Continental Congress show that the petition was ordered to be engrossed on July 5th, 1775, and on July 8th, "The Petition to the King being engrossed, was compared, and signed by the several members." Two copies of the Petition were actually prepared and signed, and according to John Adams, one copy was sent with Richard Penn on one ship on July 9th, and the duplicate was sent in another ship on July 10th. So everyone who signed must have done so at the same time.
The US Constitution is another interesting example. We celebrate Constitution Day on September 17, 1787, which is THE DAY when delegates to the Constitutional Convention signed the engrossed parchment document. 38 delegates were present on that day, and there are 39 signatures on the engrossed parchment. John Dickinson was ill, and had George Read sign his name by proxy -- something that didn't happen with the Declaration of Independence, as far as we can tell. Elbridge Gerry wrote to John and Samuel Adams on July 21st, 1776, "Pray Subscribe for me the Declaration of Independence if the same is to be signed as proposed. I think We ought to have the privilege when necessarily absent of voting and signing by proxy." So, unlike the later Constitution, no one voted or signed by proxy for the Declaration of Independence, but they did have the opportunity to sign after the initial day of signing.
One interesting note: for most of the states, the signatures added after August 2nd are found at the end of their states' list of delegates. In other documents, the Delaware delegates typically signed in this order: Rodney, McKean, Read. But since McKean signed after August 2nd, his name is last. Matthew Thornton even had to sign at the end of the first column, since there was no room left under the other New Hampshire delegates' signatures. The exception is Virginia, where the two names added after August 2nd are the first two names listed for their state. It would seem as though Jefferson intentionally left room for his friends and colleagues Wythe and Lee to sign ahead of him.
Why do people assume the Declaration was signed on July 4th?
"the debates having taken- up the greater parts of the 2d. 3d. & 4th. days of July were, in the evening of the last closed. the declaration was reported by the commee., agreed to by the house, and signed by every member present except Mr. Dickinson."
"the Declaration thus signed on the 4th. on paper was engrossed on parchment, & signed again on the 2d. of Aug."
Jefferson claims that the delegates signed a paper copy of the Declaration of Independence on July 4th, and then signed the engrossed parchment on August 2nd. If this signed paper copy actually existed, it has been lost. Pauline Maier and other historians are skeptical of Jefferson's memory (see Maier's American Scripture: Making the Declaration of Independence, p. 150).
There is a long historiography of the signing of the Declaration of Independence. Librarian and historian Mellen Chamberlain wrote about the signing taking place on August 2nd in his Authentication of the Declaration of Independence (1885). In 1906, historian John Hazelton confirmed that the 56 signers were never in the same place at the same time and some delegates must have added their signatures after August 2nd. His The Declaration of Independence: Its History is still regarded as an important resource on the Declaration of Independence. Some historians still fall on the other side, claiming the Declaration was in fact signed on July 4th. See, for example, Wilfred Ritz's 1986 article, "The Authentication of the Engrossed Declaration of Independence on July 4, 1776". We argue that the evidence supports the majority of the delegates signing the engrossed parchment on August 2nd, with signatures added after that date. But if there is a paper copy of the Declaration with signatures from July 4th somewhere out there, we'll do our best to find it!
The fact that we celebrate the United States Constitution on the day it was signed adds another element to this confusion. Howard Chandler Christy's portrait of the Scene at the Signing of the Constitution of the United States hangs in the Capitol, as does Trumbull's Declaration of Independence, so it's easy to assume that these portraits both depict the signing of their respective documents.
Why was John Hancock's "John Hancock" so large?
What was it like in Independence Hall on August 2nd?
To begin, the legend of Hancock signing his name large enough for King George III to read it without his spectacles is just that -- legend. There is no contemporary evidence for what Hancock said as he signed, and at the very least, we know that the engrossed parchment was not sent to King George III. But Hancock did sign front and center, and it is assumed that, as President of Congress, he signed the Declaration of Independence first. The next signature would have likely been Josiah Bartlett of New Hampshire. Perhaps it was his signature that started the trend of signing slightly smaller than Hancock.
Besides the spectacles comment, there are a number of quotations from the signing for which we have no evidence. Stephen Hopkins declaring "My hand trembles, but my heart does not!" Benjamin Franklin's acknowledgement that, "We must, indeed, all hang together, or most assuredly we shall all hang separately." The rotund Benjamin Harrison commenting that, should they hang, he would have the advantage of dying quickly while skinnier delegate Elbridge Gerry would "kick in the air half an hour after it is over with me."
Though there may have been one-liners such as these and moments of levity, according to Benjamin Rush, the mood was somber on August 2nd. In a letter to John Adams in 1811, Rush recalled, "the solicitude and labors, and fears, and sorrows and sleepless nights of the men who projected, proposed, defended, and Subscribed the declaration of independance..." and asked Adams, "Do you recollect the pensive and awful silence which pervaded the house when we were called up, one after another, to the table of the President of Congress, to subscribe what was believed by many at that time to be our own death warrants?"
How are the signatures arranged?
In our March Highlight on Mary Katherine Goddard and her broadside of the Declaration of Independence, we briefly explored the significance of the signing order on the engrossed parchment. To recap, the states are in order from north (New Hampshire) to south (Georgia), and from right to left.
The engrossed parchment represents a shift in practice for documents signed by the Continental Congress. In the Articles of Association (1774), Petition to the King (1774), and Olive Branch Petition (1775), the signatures are organized by state, in order from north to south, but from left to right. In the later Articles of Confederation (1778-1781) and United States Constitution (1789), the signatures are organized by state in order from north to south, and from right to left.
The Declaration of Independence also differs from other documents in a more subtle but possibly more powerful way. Unless you are very familiar with the Founding Fathers, it is difficult to know which signer represented which state. In other Congressional documents, the state delegations are labeled. In some, they are even labeled with the date of the signatures.
Take the Articles of Confederation (right). They were adopted on November 15, 1777, but ratification by all thirteen states didn't happen until March 1, 1781. On June 26, 1778, the Articles were ordered to be engrossed, and the next day they were ordered to be engrossed again after errors were found in the first engrossed copy. On July 9, 1778, this second engrossed copy of the Articles of Confederation was signed and ratified by delegates from New Hampshire, Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, Virginia, and South Carolina (eight of the thirteen United States). North Carolina signed on July 21st, Georgia on July 24th, New Jersey on November 26th, and Delaware on May 5th, 1779. Maryland was the last state to ratify, signing on March 1, 1781. You can see how signatures were added over time, and dated accordingly. If only there was such clear physical evidence for the signing of the Declaration of Independence!
The other documents mentioned -- the Articles of Association, Petition to the King, Olive Branch Petition, and United States Constitution -- also have state/colony labels. But not the Declaration of Independence. Why?
Articles of Association (1774): "We, his majesty's most loyal subjects, the delegates of the several colonies of New-Hampshire, Massachusetts-Bay, Rhode-Island, Connecticut, New-York, Pennsylvania, the three lower counties of Newcastle, Kent and Sussex on Delaware, Maryland, Virginia, North-Carolina, and South-Carolina, deputed to represent them in a continental Congress, held in the city of Philadelphia, on the 5th day of September, 1774, avowing our allegiance to his majesty, our affection and regard for our fellow-subjects in Great-Britain and elsewhere, affected with the deepest anxiety, and most alarming apprehensions, at those grievances and distresses, with which his Majesty's American subjects are oppressed;..."
Petition to the King (1774): "We, your Majesty's faithful subjects of the Colonies of New-Hampshire, Massachusetts Bay, Rhode-Island and Providence Plantations, Connecticut, New-York, New-Jersey, Pennsylvania, the Counties of New-Castle, Kent, and Sussex, on Delaware, Maryland, Virginia, North Carolina, and South Carolina, in behalf of ourselves and the inhabitants of those Colonies who have deputed us to represent them in General Congress, by this our humble Petition, beg leave to lay our Grievances before the Throne."
Olive Branch Petition (1775): "We, your Majesty's faithful subjects of the Colonies of New-Hampshire, Massachusetts-Bay, Rhode-Island and Providence Plantations, Connecticut, New-York, New-Jersey, Pennsylvania, the Counties of Newcastle, Kent, and Sussex, on Delaware, Maryland, Virginia, North Carolina, and South Carolina, in behalf of ourselves and the inhabitants of these Colonies, who have deputed us to represent them in General Congress, entreat your Majesty's gracious attention to this our humble petition."
Conversely, the original title of the Declaration of Independence was "In Congress, July 4, 1776. A Declaration by the Representatives of the United States of America, in General Congress assembled." Later, the official title became "In Congress, July 4, 1776. The unanimous Declaration of the thirteen united States of America." Unlike earlier documents, the delegates were no longer subjects. In the Declaration of Independence, they aren't addressing the King. They're addressing "a candid world", talking about the King.
The signatures on all of these documents are important, because they record who exactly was speaking on behalf of each colony-turned-state. But the signatures on the Declaration of Independence are perhaps even more important because they lack those state labels. Yes, these were delegates voting on behalf of their respective states. But take a look at the final sentence: "we mutually pledge to each other our Lives, our Fortunes, and our sacred Honor." Beyond serving as a delegate, these men were pledging everything in support of independence. If the Revolution had failed, the Declaration would have been a list of those who had committed high treason. This is also why the legend of Hancock writing his name large enough for KGIII to read is only a legend -- they didn't intend to send the engrossed and signed parchment to the King (as they had with their previous petitions). They intended to keep it, to let it form the foundation for their new union.
When did the public know who had signed the Declaration of Independence?
The engrossed parchment was rolled up and kept with other important documents by Charles Thomson, Secretary of the Continental Congress. It would have barely been seen by the eyes of the Continental Congress, much less the eyes of the public. The first printing to include the names of the signers was also a tightly controlled document. The Goddard broadside was printed specifically to be kept in the archives of each state. The first publicly accessible printing of the Declaration of Independence with the signers would have been the printed edition of the Journals of the Continental Congress for 1776, published in 1777 by Robert Aitken and again in 1778 by John Dunlap.
However, these first printings (and many, many subsequent printings) left off Thomas McKean's name. The first printing to include all 56 signers was in 1782, six years after August 2nd, 1776.
Still have a question about the signing of the Declaration of Independence? Ask in the comments, or submit it on our FAQs page, and we will do our best to answer it!


The Services PMI is tradable with a minimum deviation of 2.5 between the forecast and the actual release. If we get at least 55.0 or better, we could see some demand in the GBP and we will consider BUYING GBP/USD or GBP/JPY pairs. If we get a 49.9 (anything below the medium 50 level), GBP could weaken and we should look to SELL GBP/USD or GBP/JPY pairs.
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I'm not sure what is behind this move but it's a pretty big announcement. While the press release says all the normal stuff people say when they are stepping down from a CEO position, I do like what Iribe said about heading up the PC VR group.
Changing the world on that scale has required us to also scale Oculus at warp speed. With our growth and product strategy, we've decided to establish new PC and mobile VR groups to be more focused, strengthen development and accelerate our roadmap. Looking ahead and thinking about where I'm most passionate, I've decided to lead the PC VR groupآ—pushing the state of VR forward with Rift, research and computer vision. As we've grown, I really missed the deep, day-to-day involvement in building a brand new product on the leading edge of technology.


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Please enter a number from 4 to 15.
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Authorization is hereby given to school officials to render emergency medical treatment for any serious injury or illness to my child in the event I cannot be reached at the time of accident or illness. I authorize emergency transportation of my child to a hospital if deemed necessary.
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I wish to apply for admission of my child to the St. Justin Summer School Program. The information stated above is true and correct to the best of my knowledge.


Dr. Kenneth Bahoora has been a treating physician in Nevada for 17 years. He graduated from Life University in Atlanta Georgia where he received his doctorate in chiropractic. He has extensive training and knowledge in exercise rehabilitation, nutrition & weight loss management. He provides wellness strategies for each individual patient, as he understands that each individual is unique in what is required for their health-care needs. He is credentialed, certified and received specialized training in accident reconstruction, spinal bio-mechanical engineering, spinal MRI interpretation, MRI physics, providing impairment ratings utilizing AMA Guides 5th & 6th Edition, examining and triaging the trauma patient and neurodiagnostic interpretation protocols. He lectures to doctors and the legal community on subjects including but not limited to trauma and injury protocols, spinal bio-mechanical engineering and crash dynamics and the trauma victim.
1st Chiropractor that treated us with respect, and actually listened to me. By listening to me, we learned I had more injuries than I was aware of. What an honor to be treated like a human being. They treat you like family here, and it's an honor to experience extraordinary service.
All of the chiropractors at this office are wonderful. Michelle and Dr. Bahoora in particular are outstanding. They take the time to speak with you and help tailor your treatment to your exact needs.
Professional and compassionate staff. In a city where you have to wonder about people's intentions, it's a relief to find a chiropractor that has your health as their first priority.
Very attentive staff. Down to earth doctor.
This company is a well oiled machine! They have the routines and exercises and staff all there to help at any time. Wonderful place and wonderful staff!
As a professional colleague and long time Las Vegas/Henderson resident, I've worked with many chiropractic offices over the years, but Dr. Bahoora and his office are stand outs in their field! You will not be treated like a number here. At Mountain West Chiropractic you'll receive outstanding, individualized treatment and well you'll notice that you're a person, not a number. When you go to Mountain West on Pecos, you will experience the ultimate in chiropractic healthcare. They provide cutting edge treatment and really work with you you achieve your individualized goals. We presented to Dr. Bahoora with some very difficult medical issues a and he reached out and set up a highly individualized treatment program to help us reach our goals. Both myself and my daughter have worked with Dr. Bahoora to improve our spine health. I had lingering, long term issues from a auto accident in 2012, and she has severe scoliosis. He helped us with a program designed to help improve the curve of her spine and we are both working to avoid surgery in the future. Dr. Bahoora is one of the few doctors trained in biomechanics. I believe we will be successful based on the positive results we continue to see, and his entire offices care and the interest they've taken in helping us succeed in overcoming our spine health issues. Can't wait to share before and after pictures!
Great staff and service. These guys are very professional and offer cutting edge chiropractic care.
Chiropractic has helped me in ways unimaginable. I was not a believer until I came to MWC. Dr. B is simply put....amazing! He has managed to get me back into shape so I am able to enjoy life again. If you follow his treatment plan - you will not regret one single minute of it. Dr. B and his Team know their 'stuff' and they are all amazing. The office staff is just as great too!! My experiences at this doctor's office have been wonderful and I would highly recommend you go and have them - "get your life 'back-in-line'".
Always an excellent experience each time I go to Mountain West Chiropractic in Henderson! Great doctors and great staff! Beautiful office and short waiting time. I also love that they accept walk-ins for days I don't have an appointment but need an adjustment. Two thumbs up all the way!
Outstanding service from personal and Dr. Ted.
Easy process each time is a good experience and have feel this is a great chiropractor practice, I don't trust many.
This place is just awesome. My spine was way out of alignment. When I saw how bad the x-ray was I worried it was even able to be corrected at all. More over I was sure we could do nothing about the pain. It only took a couple of treatments and lot of ice to start a healing process. It has been a few weeks now and I have only minimal pain and my spine is in much better alignment. I highly recommend you give this a try. Other places have the same machine with much less patient caring and much higher prices. Check it out. I am positive you will be as happy as I am. This is Unsolicited and I have absolutely no interest in the practice except to feel so much better.
I felt so comfortable and in great hands. I had such a traumatic experience but they made me feel I was in good hands and it's going be okay.
Everyone is so nice an respectful... It's an honor to have such great staff.
I am new to this office but from the moment I walked in I was treated like I was the only one there. The front staff is so friendly and helpful. Going out of their way to help me. The staff in the back is very caring and make sure you are comfortable all the way. Dr. B explained my x-rays in detail. I never even knew that I had some of the conditions he explained. He told me how he can help me and explained a treatment plan. I am really impressed by this office all around.
The staff here is awsome in every way. The therapy and ajustments that Dr.Bahorra administers help me to continue to be mobile pain killer free, and improving day by day. ALL the doctors here can make pain free pain relieving adjustments. I've had my neck , complete back and leg ajusted by them and they're really good about not causing discomfort to all ages and body types. To top it off they are very knowledgeable about how we as patients can maintain our mobility and push to stay health all around. Where else can you go where the Chiropractor will pull up your MRI, and pinpoint your issue, explain it to you, then go an adjust it on the spot!
I have some pain relief. Lots of questions and very thorough.I appreciate the prompt courteous staff. Very warm feeling facility. Another nice touch was, one of the practicing doctors, Rick noticed I was new to the facility and introduced himself.
I was very impressed with how thorough and very professional everyone was at the office. I have gone and gotten treatments from different chiropractor before but nothing like this. You are the best and I would recommend your facilities to everyone I know.
All of the chiropractors at this office are wonderful. Michelle and Dr. Bahoora in particular are outstanding. They take the time to speak with you and help tailor your treatment to your exact needs. The office staff is also very friendly which is always a plus.
First time ever going to a chiropractor! Amazing experience from when I walked in to when i walked out! Friendly, knowledgeable staff who made me feel extremely comfortable! I recommend!
very friendly and easy to talk to..comfortable..thanks.
I walked in and I wasn't greet by the front desk person whom name I didn't get. I stood there for about 4 minutes and finally she asked me if she can help me. I said yes I have a 3:15 appointment and she said ok go sit down. Almost 10 minutes later a lady named Sasha came out and asked me if she could help, I told her the same thing that I had an appointment and she looked me up in the computer, and gave me the paperwork took me in and soon after a gentle man named Cris walked in and everything from there was very nice and I love the place. When done and it was time to schedule my next appointment the same woman couldn't find me in the sistem; again mrs Sasha had to step in. Everything was great except for the way this Asian woman made me feel in the beginning and at the end. It makes me feel like she doesn't know what she's doing. I waisted some valuable time because of her . For me rest everyone made me feel very good and comfortable thank you.
I have been coming here for a year now and I have had nothing but the best service from the doctors and the staff!! They treat you the way a doctors office should treat you.
Highly Professional and Quality Services...Surgery/Drug-Free!!
Really took the time, talked with me and was truly engaging to understand my complaints.
Dr. Brennan really works with everyone. I noticed several of his patience today, getting help and answers. I had every question answered, including spending time to look up special answers about what might be of help to me, specifically. The entire staff is always a pleasure to work with.
I wanted to start the ideal protein diet. Met with Chris, very knowledgeable, very nice person and easy to talk to. Office is clean. Front desk person very polite and helpful. Very pleased with my experience there.
I am satisfied with the first visit. Dr. Brennan explained my X-rays to me and the course of action that was needed to be taken in order to get my body on the right track. The rest of the staff is helpful and friendly.
Excellent doc's who are very accurate and knowledgeable. Very professional. Great customer service and the techs are kind!! I started feeling better on my first appointment!
As a new chiropractic patient, the staff prepared me for each process involved at the office. Each time I am in, I'm greeted with friendly staff members and am treated with respect and kindness. As all of our time is important, Mountain West Chiropractic works to see that you begin your treatment as soon as your scheduled time. I will recommend this to my colleagues and friends.
I look forward to my visits with the amazing staff at Mountain West Chiropractic! The staff is friendly and the customer service is top notch! The therapists and Doctors really care and that absolutely helps in the healing process! Not to mention the amazing service you receive when entering to check in with Sara! I highly recommend Mountain West Chiropractic to all who suffer in chronic pain as well as injury recovery. I'm here for both.
The staff is extremely helpful and went above and beyond to make me feel welcome.
This is my 2nd experience using chiropractic after an injury in 2012. Hurt my lower back last week and couldn't sit/lie down so left work to seek out relief at Mountain West Chiropractic, one of the only providers on my PPO listing that returned my calls for an appt. Choice was based on location to my home in Green Valley. Assessment by nurse/tech 1st and reviewed pictorial of spine/major organs/nerves. I was impressed by empirical knowledge/information shared about how spine relates to rest of body. X-rays taken so I would get a baseline report and how my spine differs from its ideal shape/condition. Rec'd partial adjustment with return this past Wed. Rough wknd followed but pain managed through ice/ibuprofen and hydration. Pain subsided by Mon and returned to work but still unpleasant. Wed appt began with DC's review of x-rays, ID of issues, and treatment plan discussed. After full adjustment, ice/electrotherapy, and back stretching machine, I found 100% improvement in symptoms and demeanor WITHOUT OPIOID MEDS OR SURGERY! Staff is very professional, cost is reasonable, interventions highly effective and I do not get the sense that this provider is trying to take advantage of my ignorance or insurance benefits. I shared my experience with my co-workers and have been asked for and will give them a referral to Mountain West Chiropractic. Folks who suggest these DCs are "quacks" ought to weigh the pros/cons of chiropractic vs. addictive drugs/surgery.
When I first went to Dr. B I was a mess. After extensive therapy, I am pain-free. I wish I had found him years ago. My quality of life has grown all because of Dr. B and his treatment plan.
They have the best expertise team to assist you, to help you heal better and to make you feel the best as a patient!! I've been with other chiropractors in the past two years, but never felt so pampered, and loved like this place before. Thank you so much for caring!!!
I am feeling really great after my treatments! Everyone is so courteous and helpful!
I thought that providing the paperwork prior to the appointment was a great idea. No sitting in the office filling out paperwork. I did not expect to have a treatment, but I appreciate the integrated approach to treating my issues! I am looking forward to that point where I am able to do the things that I want to do physically!
Enjoy going for my treatment . I feel so much better when I go home. Everyone is so caring always ask if everything is ok with you. Thanks so much for what you all do every day.
I have always been treated with five star quality service. A lovely , friendly staff with excellence in timely and professional manors. I recommend Mountain West to all my friends and acuantences in the gym. the only suggestion I have is to have a place to set your chart wile waiting for your adjustment and it would keep in line the next up. Also this would help your staff to pick the next chart on possibly a hanging board that lets them get out and call the next Apt with no confusion.
The best. I have never gone to a chiropractor until now. Have to say #1 & the best. Everyone is helpful & respectful.
© Mountain West Chiropractic. All rights reserved.


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Pyrites, NY (View All Cities)
44.516, -75.185
ZIP (~200 yard radius)
Pyrites, NY
ZIP code 13677 is located in northern New York and covers a slightly less than average land area compared to other ZIP codes in the United States. It also has a slightly less than average population density.
The people living in ZIP code 13677 are primarily white. The number of people in their late 20s to early 40s is extremely large while the number of seniors is large. There are also a slightly less than average number of families and a slightly higher than average number of single parents. The percentage of children under 18 living in the 13677 ZIP code is extremely large compared to other areas of the country.
Male 2 5 2 5 2 3 3 4 2 2 5 0 0 2 2 1 1 0
Female 1 5 10 3 4 3 2 5 4 5 2 1 1 3 2 1 0 0
Total 3 10 12 8 6 6 5 9 6 7 7 1 1 5 4 2 1 0
Owner 0 5 3 7 1 5 1 0
Total 0 6 8 8 1 6 2 0
ZIP code 13677 has a small percentage of vacancies.
The majority of household are owned or have a mortgage. Homes in ZIP code 13677 were primarily built in 1939 or earlier.
As with most parts of the country, vehicles are the most common form of transportation to places of employment. Pedestrians and cyclists beware. The area has some of lowest percentages of commutes without a vehicle in the country. Compared to other ZIP codes in the country, 13677 has very few people that work at home. In most parts of the country, the majority of commuters get to work in under half an hour. The commute in 13677 is that short for a higher percentage of workers than almost anywhere in the United States. Many commuters should consider themselves lucky that they don't have a longer commute. It is very uncommon, compared to the rest of the US, for employees to have to travel more than 45 minutes to their place of employment.
Compared to other ZIPs, 13677 has a very small percentage of people that did not graduate high school.
Canton, NY


Cartoon Characters Smartphones Seamless Pattern Background Mobile Phone Communication Technology Faces Concept Element Flat Design Style. Vector Illustration Of Smartphone Lizenzfrei Nutzbare Vektorgrafiken, Clip Arts, Illustrationen. Image 119040247.


I am looking the market for my first road bike. I am planing to be using the bike, couple times per week for 1 - 2 hour rides, and maybe on the weekend some longer ones, around UK Yorkshire.
There are two things that I would like to know.
Is there significant difference, on how one road bike will handle uneven roads compared to others? Is there a way to know that from specs?
Also, I am looking to find a balance between performance and comfort. I know for a fact I wont be racing, but will taking long leisure rides on country side. If I where to choose between happy lower back, and 5/10 minutes faster within the hour, I could choose happy lower back. Again, I am not sure if there clues on the geometry of the bike that can help me spot the difference on this.
There is no substitute for riding a few different bikes to feel the difference.
To get to do this, you'll need to develop a relationship with a local bike shop (LBS). A good LBS will let you take a bike for a short ride, and some will hire a bike to you for a longer ride.
Explain what you want and what your budget is. Be up front that you're checking out your options, and you'll find your honestly repaid. Expect to pay more at an LBS than online, but that extra buys you a lot in future service, and bundled goods and services. Remember you'll need a helmet, shoes, and cycling clothes. Getting everything as a bundle will be cheaper overall.
While tires can help with rough surfaces, the overall geometry helps with your general comfort. Consider if you will be comfortable with drop bars or if you want flat bars.
A cyclo cross or touring bike may suit your purposes better than a top end race bike.
Good luck, and feel free to ask specific followup questions!
Tires can make a significant different in terms of comfort, especially on uneven roads. If you're comparing two different bikes, ask what is the largest tire that either one can handle.
I used to have a road bike where some 25mm tires rubbed on the front derailleur clamp (a tire labelled "25mm" is not always 25mm wide). With that bike I didn't have a choice - 25mm or 23mm tires was all I could use. Those narrow tires require high pressure and are uncomfortable.
Now I have a cyclocross bike that can use tires up to 40mm, and I'm currently running 35mm Schwalbe Kojak tires. It rolls as fast as any other road bike (I ride with a group, and coasting downhill behind other bikes, I can see that my bike isn't slower). But most of the impact and vibration from the road surface is absorbed by the tires.
There are some road bikes, such as the Specialized Diverge and the Norco Search, that work with tires up to 32mm (with fenders) or 35mm (without fenders). These are sometimes called "gravel bikes", intended to be rideable on gravel roads. Obviously they also work very well on paved roads.
You don't have to use wide tires -- but it's good to have the choice. You can try it out and see if you like it.
The one thing I always say to people in your situation is to remember that we have all been there. And the saving grace here is that by the time you get to buy your second bike, you will know exactly what to look for. With that in mind, you might want to think about limiting what you spend on your first bike.
For your suspension and comfort on uneven roads, I would urge you to talk to other cyclists in your vicinity. Are they riding "regular" road bikes? Or are they riding bikes like cyclocross (CX) bikes to take account of the imperfect surfaces? For example, I live in the New Forest and ride a couple of road bikes, one audax and one out-and-out racing bike, with no problem on the road surfaces down here. I have been up to Yorkshire a few times and the surfaces didn't particularly strike me as any worse than the surfaces I ride. I just think that people who are already riding these roads might be able to help you, I'm sure they'd be happy if you stopped them and asked (as long as you did so sensibly I suppose!).....I certainly wouldn't.
Within the road bike genre, there are obviously many different styles of bike. As I say, one of my bikes is an audax bike. Audaxes are road events that are long (can be hundreds of km), so whilst they are still road bikes, they're built so the rider will be comfortable in the saddle for several hours. They also take place in the winter, so bikes will usually have things like mudguards, also I fitted a rack to mine to go touring with panniers, so something like that may be an option for you.
But please, the single best piece of advice is to test the bike before you buy it.
Not the answer you're looking for? Browse other questions tagged road-bike frames beginner or ask your own question.
Why aren't sportive' 'bikes popular outside the UK?
Should I get a road bike?
Can I change my bike's frame?
What will the difference in speed be between an endurance geometry road bike and a race geometry road bike?


Based on the award-winning novel by Valerie Zinnati.
French born Tal (Agatha Bonitzer) has just moved to Jerusalem with her family and is confronted by the reality of the region's violence by a suicide bombing. Tal questions the morality of this act of terrorism and her brother, a soldier, puts this message into a bottle and throws it in the sea.
The message is the catalyst for a budding online friendship that develops between a young Israeli girl and a Palestinian boy (Mahmoud Shalabi) who lives with his mother (Hiam Abbass) in Gaza. They must endure an explosive situation that is not of their choosing at an age where young people are falling in love and taking their place in adult life. The challenge is whether their relationship might give them the strength to confront the harsh reality.


text:
The Galápagos shearwater (Puffinus subalaris) is a small shearwater. Until recently it was considered to be a subspecies of Audubon's shearwater, but it is actually one of two members of a very ancient lineage of the small Puffinus species, the other being, as indicated by mtDNA cytochrome b sequence data, the Christmas shearwater.

It is an endemic breeder of the Galápagos Islands, and is largely sedentary, although individuals are commonly seen as far as the Oaxacan coast of Mexico.

Description
The Galápagos shearwater has dark brown upperparts, undertail and underwing flight feathers, the rest of the underparts plumage being white. It sometimes has a dark collar. Both sexes are alike, as are the young after fledging.

It is a slender-bodied shearwater, about 29–31 cm long, with a wingspan of around 63 cm and weighs 123-225 g. The species closely resembles the tropical shearwater, although the latter is typically blacker and has a longer tail.

Behaviour
The Galápagos shearwater is a gregarious species and will feed at sea with other shearwaters and boobies. It flies low over the water and feeds on squid, fish and offal. It intersperses 4-10 stiff wing beats with shallow glides.

Reference

External links
 Galapagos shearwater photos

Puffinus
Shearwaters
Endemic birds of the Galápagos Islands
Galápagos Islands coastal fauna
Birds described in 1897
Taxa named by Robert Ridgway

redpajama_set_name: RedPajamaWikipedia


text:
The Global Debt Crisis
Return to Brookings Institution Press
Haunting U.S. and European Federalism
Edited by Paul E. Peterson and Daniel Nadler January 22, 2014
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Debt crises have placed strains not only on the European Union's nascent federal system but also on the federal system in the United States. Old confrontations over fiscal responsibility are being renewed, often in a more virulent form, in places as far flung as Detroit, Michigan, and Valencia, Spain, to say nothing of Greece and Cyprus. Increasing the complexity of the issue has been public sector collective bargaining, now a component of most federal systems.
The attendant political controversies have become the debate of a generation. Paul Peterson and Daniel Nadler have assembled experts from both sides of the Atlantic to break down the structural flaws in federal systems of government that have led to economic and political turmoil. Proposed solutions offer ways to preserve and restore vibrant federal systems that meet the needs of communities struggling for survival in an increasingly unified global economy.
Contributors: Andrew G. Biggs (American Enterprise Institute); César Colino (National Distance Education University, Madrid); Eloísa del Pino (Instituto de Políticas y Bienes Públicos, Madrid); Henrik Enderlein (Hertie School of Governance, Berlin); Cory Koedel (University of Missouri); Carlos Xabel Lastra-Anadón (Harvard University); Daniel Nadler (Harvard University); Shawn Ni (University of Missouri); Amy Nugent (Government of Ontario, Canada); James Pearce (Mowat Centre, University of Toronto, Canada); Paul E. Peterson (Harvard University); Michael Podgursky (University of Missouri); Jason Richwine (Washington, D.C.); Jonathan Rodden (Stanford Uni versity); Daniel Shoag (Harvard University); Richard Simeon (University of Toronto, Canada); Camillo von Müller (University of St. Gallen, Switzerland, and Leuphana University, Germany); Daniel Ziblatt (Harvard University)
Brookings Institution Press, January 22, 2014
Ebook ISBN: 9780815724179
Paperback ISBN: 9780815704874
Paul E. Peterson
Paul E. Peterson is Henry Lee Shattuck professor of government and director of the Program on Education Policy and Governance at Harvard University. He is a senior fellow at the Hoover Institution at Stanford University and editor-in-chief of Education Next.
Daniel Nadler
Danier Nadler is a visiting scholar at the Federal Reserve and a Ph.D. candidate in government at Harvard University.
Global Governance & Politics
The Federal Budget
What should be the top priority for Africa in 2023?
Aloysius Uche Ordu
Somalia's challenges in 2023
Vanda Felbab-Brown
The Houthis after the Yemeni cease-fire
Syria's dissolving line between state and nonstate actors
Steven Heydemann
Libya's hybrid armed groups dilemma
Stephanie T. Williams


Modern and functional, the White Samantha Chair by Go Home can be pulled up to any table. Mix with a variety of other Sofi and Samantha Chair colors to produce a unique seating arrangement.
Dimensions: 24.5" L x 19" W x 31.75" H · Seat height is 18".


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On Wednesday night we took 44 year 12 and 13 students to London to see the longest running West End Musical 'Les Miserables'.
Many of the students were moved to tears by the experience and we look forward to seeing some freshly inspired auditions for our School Musical.
We are pleased to announce the auditions for our annual Musical will take place in early January with more details to be released soon.


Jeffrey "Assassin" Campbell is a leader of a new generation of Jamaican dancehall artists who are hoping to elevate the genre by providing music with more lyrical depth.
"I try to maintain a certain level of integrity in the material," says Campbell from his home in Jamaica. "It is not all about the frivolous dancehall. We try to add substance to the mix rather than just all hype and entertainment." As in the States–where thug posturing in hip-hop has become a tired cliché–Jamaican dancehall's obsession with guns, violence and homophobia has threatened to stunt its growth.
Determined to flip this script, the 22-year-old deejay brings a conscious vision to his recent full-length debut, Infiltration, the first of a multi-record deal he signed with VP and Penthouse Records. Tracks like "Free at Last" echo themes found in classics like Peter Tosh's "400 Years"; using Martin Luther King's famous phrase as a jumping-off point, Campbell says his song gives voice "to the journey of black people."
Campbell's own path hasn't been easy. Growing up in Papine, Kintyre, a town east of Kingston, he believed that getting an education was the key to escaping the gang life that impacted many in his community. After attending Kingston's Camperdown High School, he planned to study journalism at the University of West Indies. While at Camperdown, he developed the talent that would earn him his nickname. "The name came from being involved in lyrical battles in the lunchroom," he explains.
The journey that would take Campbell beyond the lunchroom began in school, when he gave a song to his friend Briggy, whose uncle happened to be Spragga Benz. Spragga used Campbell's lyrics for his hit "Big Up All Di Shotta Dem."
Encouraged by his success as a ghostwriter, Campbell expanded what he calls his "recognizance mission" after graduating in 2000. He hooked up with esteemed producer Donovan Germain of Penthouse Records and charted the 2002 single "Ruffest and Tuffest." Having experienced regional recognition, Campbell is now ready to extend his operation worldwide.
Although he still plans to attend university, his focus with the release of Infiltration is to get his voice heard, and to help dancehall evolve. "On this debut album, we'll show we have the potential to move forward from this stage where we are at now," he declares.
De Tropix: M.I.A.'s backing vocalist takes her own hype to the next level.


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