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Perioperative Medicine | April 2019
Electromagnetic Interference with Protocolized Electrosurgery Dispersive Electrode Positioning in Patients with Implantable Cardioverter Defibrillators
Peter M. Schulman, M.D.; Miriam M. Treggiari, M.D., Ph.D., M.P.H.; N. David Yanez, Ph.D.; Charles A. Henrikson, M.D.; Peter M. Jessel, M.D.; et al Thomas A. Dewland, M.D.; Matthias J. Merkel, M.D., Ph.D.; Valerie Sera, M.D.; Izumi Harukuni, M.D.; Ryan B. Anderson, M.D., Ph.D.; Ed Kahl, M.D.; Ann Bingham, M.D.; Nabil Alkayed, M.D., Ph.D.; Eric C. Stecker, M.D., M.P.H.
From the Department of Anesthesiology and Perioperative Medicine (P.M.S., M.M.T., M.J.M., V.S., I.H., R.B.A., A.B., N.A.) and the Knight Cardiovascular Institute (C.A.H., P.M.J., T.A.D., E.C.S.), Oregon Health and Science University, Portland, Oregon; the School of Public Health, Oregon Health and Science University and Portland State University, Portland, Oregon (N.D.Y.); and Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (E.K.).
This article is featured in "This Month in Anesthesiology," page 1A.
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Submitted for publication April 7, 2018. Accepted for publication November 14, 2018.
Submitted for publication April 7, 2018. Accepted for publication November 14, 2018.×
Address correspondence to Dr. Schulman: Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code KPV12C, Portland, Oregon, 97239. schulman@ohsu.edu. This article may be accessed for personal use at no charge through the Journal Web site, www.anesthesiology.org.
Perioperative Medicine / Clinical Science / Cardiovascular Anesthesia / Technology / Equipment / Monitoring
Anesthesiology 4 2019, Vol.130, 530-540. doi:10.1097/ALN.0000000000002571
Editor's Perspective:
What We Already Know about This Topic:
Electromagnetic interference from monopolar electrosurgery may disrupt implantable cardioverter defibrillators.
Current management recommendations by the American Society of Anesthesiologists and Heart Rhythm Society are based on expert clinical opinion since there is a paucity of data regarding the risk of electromagnetic interference to implantable cardioverter defibrillators during surgery.
What This Article Tells Us That Is New:
With protocolized electrosurgery dispersive electrode positioning in patients with implantable cardioverter defibrillators, the risk of clinically meaningful electromagnetic interference was 7% in above-the-umbilicus noncardiac surgery and 0% in below-the-umbilicus surgery. In cardiac surgery, clinically meaningful electromagnetic interference with use of an underbody dispersive electrode was 29%.
Despite protocolized dispersive electrode positioning, the risk of electromagnetic interference in above-the-umbilicus surgery is high, supporting recommendations to suspend antitachycardia therapy when monopolar electrosurgery is used above the umbilicus.
With protocolized dispersive electrode positioning, the risk of electromagnetic interference in below-the-umbilicus surgery is negligible, implying that suspending antitachycardia therapy might be unnecessary in these cases.
With an underbody dispersive electrode, the risk of electromagnetic interference in cardiac surgery is high.
Background: The goal of this study was to determine the occurrence of intraoperative electromagnetic interference from monopolar electrosurgery in patients with an implantable cardioverter defibrillator undergoing surgery. A protocolized approach was used to position the dispersive electrode.
Methods: This was a prospective cohort study including 144 patients with implantable cardioverter defibrillators undergoing surgery between May 2012 and September 2016 at an academic medical center. The primary objectives were to determine the occurrences of electromagnetic interference and clinically meaningful electromagnetic interference (interference that would have resulted in delivery of inappropriate antitachycardia therapy had the antitachycardia therapy not been programmed off) in noncardiac surgeries above the umbilicus, noncardiac surgeries at or below the umbilicus, and cardiac surgeries with the use of an underbody dispersive electrode.
Results: The risks of electromagnetic interference and clinically meaningful electromagnetic interference were 14 of 70 (20%) and 5 of 70 (7%) in above-the-umbilicus surgery, 1 of 40 (2.5%) and 0 of 40 (0%) in below-the-umbilicus surgery, and 23 of 34 (68%) and 10 of 34 (29%) in cardiac surgery. Had conservative programming strategies intended to reduce the risk of inappropriate antitachycardia therapy been employed, the occurrence of clinically meaningful electromagnetic interference would have been 2 of 70 (2.9%) in above-the-umbilicus surgery and 3 of 34 (8.8%) in cardiac surgery.
Conclusions: Despite protocolized dispersive electrode positioning, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with surgery above the umbilicus were high, supporting published recommendations to suspend antitachycardia therapy whenever monopolar electrosurgery is used above the umbilicus. For surgery below the umbilicus, these risks were negligible, implying that suspending antitachycardia therapy is likely unnecessary in these patients. For cardiac surgery, the risks of electromagnetic interference and clinically meaningful electromagnetic interference with an underbody dispersive electrode were high. Conservative programming strategies would not have eliminated the risk of clinically meaningful electromagnetic interference in either noncardiac surgery above the umbilicus or cardiac surgery.
During a surgical procedure, the function of an implantable cardioverter defibrillator may be disrupted by electromagnetic interference, most frequently resulting from monopolar electrosurgery (often called "cautery").1–4 The potential for electromagnetic interference from electrosurgery depends on the power settings and set mode (i.e., monopolar or bipolar) of the electrosurgical unit, and the distance between the current pathway and the implantable cardioverter defibrillator.4 While bipolar electrosurgery is highly unlikely to cause electromagnetic interference,3 the more frequently used monopolar electrosurgery requires a dispersive electrode applied to the patient's skin to complete the electrical circuit, frequently referred to as "return pad." A new option uses an underbody electrode that is incorporated into a pad and placed directly on the operating table. Consequences of electromagnetic interference in patients with implantable cardioverter defibrillators include hemodynamically significant bradycardia or asystole in the pacing-dependent patient, inappropriate shocks or antitachycardia pacing in the patient with an implantable cardioverter defibrillator ("antitachycardia therapies"),5 direct damage to the implantable cardioverter defibrillator, and other, less common sequelae.1,2,6,7 Failure to prevent or mitigate the effects of electromagnetic interference might lead to patient injury and even increase mortality.5,8–12
Thus, for patients with implantable cardioverter defibrillators undergoing surgery, key recommendations from the American Society of Anesthesiologists (ASA),1 Heart Rhythm Society,2 and others13 include verifying whether the patient is pacing-dependent, ensuring the device is functioning properly, determining the likelihood of electromagnetic interference, and employing preventive strategies such as disabling antitachycardia therapy (i.e., so that the implantable cardioverter defibrillator cannot deliver shocks or antitachycardia pacing) and reprogramming the device to an asynchronous pacing mode (i.e., to prevent pacing inhibition) when necessary.
However, these recommendations are mainly based on expert opinion, case reports, and anecdotal experience since systematically collected data are lacking. The paucity of prospective data regarding the risk of electromagnetic interference has resulted in inconsistent or even contradictory practice recommendations. For example, although electrosurgery unit dispersive electrode positioning to direct the electrosurgery unit return current away from the pulse generator and leads is a key recommendation of both the ASA and Heart Rhythm Society, the ASA Practice Advisory states the literature is insufficient to determine the risk of electromagnetic interference using this approach.1 Furthermore, the Heart Rhythm Society Expert Consensus Statement states that implantable cardioverter defibrillator reprogramming might be unnecessary when monopolar electrosurgery is employed inferior to the umbilicus,2 whereas the ASA Practice Advisory recommends suspending antitachycardia therapy whenever monopolar electrosurgery is used, regardless of the surgical site.1 Additionally, neither practice recommendation offers guidance regarding the use of an underbody dispersive electrode.
Given conflicting expert consensus guidance and limited data, we performed a single center, prospective cohort study to rigorously estimate the occurrence of intraoperative electromagnetic interference from monopolar electrosurgery with protocolized positioning of a conventional electrosurgery unit dispersive electrode, and with use of an underbody dispersive electrode.
Consecutive individuals 18 yr of age and older with an implantable cardioverter defibrillator, undergoing elective surgery, were invited to participate if the use of intraoperative monopolar electrosurgery was planned. Individuals with an implantable cardioverter defibrillator manufactured by Medtronic (USA) or Boston Scientific (USA) were eligible for inclusion, regardless of the location of surgery. Because St. Jude Medical (USA) and Biotronik (USA) implantable cardioverter defibrillators cannot be programmed to a "monitor only" mode, individuals with a device by these manufactures were excluded if the location of surgery was above the umbilicus. Subjects undergoing surgery above the umbilicus were also excluded if they were pacing dependent because asynchronous pacing was necessary and precluded use of a ventricular tachycardia monitor zone. Individuals were also excluded if monopolar electrosurgery was not used, or surgery involving the implantable cardioverter defibrillator pulse generator pocket was planned.
The Institutional Review Board of Oregon Health and Science University (Portland, Oregon) reviewed and approved this study. Written informed consent was obtained from each participant. Between May 2012 and September 2016, 167 subjects were consented and enrolled. Once enrolled, subjects were classified into one of three groups based on surgery type and location; group surgery above the umbilicus were subjects undergoing noncardiac surgery superior to the umbilicus, group surgery below the umbilicus were subjects undergoing noncardiac surgery at the level of or inferior to the umbilicus, and group cardiac surgery were subjects undergoing cardiac surgery.
Preoperative Implantable Cardioverter Defibrillator Interrogation and Programming
Implantable cardioverter defibrillators were interrogated by specially trained and credentialed anesthesiologists or members of the electrophysiology service. Battery status, lead parameters, and arrhythmia log were recorded. Antitachycardia therapy was programmed off for participants in the surgery above the umbilicus and cardiac surgery groups. However, antitachycardia detection was kept on, in "monitor-only mode," so that sensed events could still be recorded. Antitachycardia settings were not changed for participants in the surgery below the umbilicus group. Pacing parameters (i.e., lower rate limit, pacing mode) were only changed if clinically indicated. If an asynchronous pacing mode was deemed clinically indicated, the patient was considered no longer eligible for study participation.
Intraoperative Management
The dispersive electrode was placed by the operating room nurse. A specific protocol (table 1 and fig. 1) was used to determine the dispersive electrode position and type. A conventional dispersive electrode was used for patients undergoing noncardiac surgery. The conventional dispersive electrode position was determined by the site of surgery and location of the patient's pulse generator, with the intention of diverting the current return pathway away from the implantable cardioverter defibrillator. The Megadyne (Mega Soft, USA) under body dispersive electrode was used for patients undergoing cardiac surgery. In all cases, the electrosurgery unit was utilized as clinically indicated with settings and duration of use left at the surgeon's discretion.
Electrosurgery Unit Dispersive Electrode Positioning
Electrosurgery Unit Dispersive Electrode Positioning×
Illustration of the protocolized position of electrosurgery unit dispersive electrode positioning. See also table 1.
Postoperative Implantable Cardioverter Defibrillator Interrogation and Programming
Implantable cardioverter defibrillators were reinterrogated and data were collected as previously described. All preoperative settings were restored (antitachycardia therapy was programmed back on) unless programming changes (i.e., lower rate limit, pacing output) were deemed clinically necessary.
Study Endpoints
The primary endpoints were (1) the occurrence of right ventricular lead electromagnetic interference from monopolar electrosurgery with protocolized electrosurgery unit dispersive electrode positioning for patients undergoing noncardiac surgery superior to the umbilicus (above the umbilicus group) and at or inferior to the umbilicus (below the umbilicus group); and (2) the occurrence of right ventricular lead electromagnetic interference from monopolar electrosurgery for patients undergoing cardiac surgery (group cardiac) when an underbody dispersive electrode was used. Secondary endpoints were the occurrence of clinically meaningful electromagnetic interference, defined as electromagnetic interference that would have resulted in the delivery of inappropriate antitachycardia therapy if the antitachycardia therapy had not been programmed off for patients in the surgery above the umbilicus or cardiac surgery groups, or electromagnetic interference that resulted in the delivery of inappropriate antitachycardia therapy for patients with surgery below the umbilicus.
Inappropriate antitachycardia therapy (i.e., due to a non–life-threatening arrhythmia, or physiologic or nonphysiologic oversensing) can have adverse consequences and might even increase mortality. Modern ("conservative") programming strategies attempt to reduce the risk of inappropriate and avoidable antitachycardia therapy by utilizing higher detection rates, longer detection durations, antitachycardia pacing, and algorithms that discriminate supraventricular tachycardia from ventricular tachycardia. Thus, we determined whether the occurrence of electromagnetic interference and clinically meaningful electromagnetic interference would have been further decreased if all implantable cardioverter defibrillators had been programmed to a conservative strategy (i.e., Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy8 or PainFree SmartShock Technology study14). Finally, we investigated the occurrence and the nature of implantable cardioverter defibrillator–related problems identified during preoperative implantable cardioverter defibrillator interrogation.
All intraoperative events recorded by the implantable cardioverter defibrillator were independently reviewed by two electrophysiologists blinded to surgery type. Each event was categorized as either a true arrhythmia or an electromagnetic interference. A third electrophysiologist adjudicated any discordant interpretations. Electromagnetic interference was further categorized as (1) not clinically meaningful (i.e., not sufficiently severe enough to trigger inappropriate antitachycardia therapy); (2) clinically meaningful (i.e., severe enough to trigger inappropriate antitachycardia therapy based on how the implantable cardioverter defibrillator was actually programmed preoperatively); or (3) clinically meaningful with conservative programming (i.e., severe enough to trigger inappropriate antitachycardia therapy if a programming strategy known to reduce the risk of inappropriate antitachycardia therapy had been employed).
Summary statistics were determined for all key characteristics evaluated for this study. Means ± SD are provided for quantitative characteristics, and frequencies (%) are provided for categorical characteristics. All summaries were stratified by study group (above the umbilicus, below the umbilicus, and cardiac). Estimates of dispersion were expressed as 95% CIs for each outcome. CIs were calculated using the Agresti–Coull method.15 Standard CIs and "exact" intervals16 are known to perform poorly when outcome probabilities are rare (small), even for moderate sample sizes.17 The Agresti–Coull CIs employ corrections to standard intervals and have superior coverage and precision.15 All CIs are two-sided. For sample size considerations, we planned to collect the maximal number of eligible patients between May 2012 and September 2016. Our objective was to estimate the occurrences with maximal precision.
Finally, it is plausible that a more closely spaced sensing and pacing electrode configuration might reduce the risk of electromagnetic interference.18 Thus, in exploratory analyses, we investigated whether implantable cardioverter defibrillators with a true bipolar lead configuration or implantable cardioverter defibrillators with an integrated bipolar lead configuration were associated with different risks of electromagnetic interference for each of the three groups. A true bipolar configuration uses two closely spaced electrodes near the distal end of the lead tip for pacing and sensing, whereas with an integrated bipolar configuration, the electrodes for pacing and sensing are more widely spaced, since the distal shocking coil is used in lieu of one of the dedicated lead tip electrodes.
We evaluated the dataset for missing data and determined the possible impacts (biases) were minimal given that we had complete data on 21 of 24 characteristics evaluated in this manuscript. Furthermore, of the three characteristics with missing data (i.e., anesthesia duration, lead type, shock), percentages missing were less than 5%, 4.2%, and 4.9%, respectively. Statistical analyses were performed using Stata version 15.1 (StataCorp LLC, USA).
During the study period, 167 patients were screened, of whom 144 (86%) met eligibility criteria. Figure 2 shows the flow of study participants from screening to assessment of the primary outcomes. Patient demographic characteristics are presented in table 2.
Demographic Characteristics of Study Population
Demographic Characteristics of Study Population×
Study flowchart displaying characteristics of cohort selection. ICD, implantable cardioverter defibrillator.
Device Characteristics
There were 79 Medtronic, 51 Boston Scientific, 9 St. Jude Medical, and 5 Biotronik implantable cardioverter defibrillators (table 3). There were 101 (70%) conventional implantable cardioverter defibrillators and 43 (30%) biventricular implantable cardioverter defibrillators. The implant duration of the generator and leads varied with a mean ± SD time of 32 ± 25 months (n = 141) and 51 (44) months (n = 138), respectively. Other than suspending antitachycardia therapy, no preoperative programming changes were deemed necessary in 126 of 144 (88%), thus these implantable cardioverter defibrillators were considered optimally programmed. Reprogramming was performed in 18 of 144 implantable cardioverter defibrillators (12%) to change the pacing mode (predominantly to turn off rate response), rate, output, or in one case the type of antitachycardia pacing (because of recent ventricular tachycardia). A preoperative problem was found in 8% (12 of 144), as follows: battery at elective replacement indicated (n = 3); inadequate safety margin for pacing on ventricular (n = 5) or atrial channel (n = 1); high right ventricular pacing threshold and failure of the atrial lead to capture (n = 1); high right ventricular pacing threshold (n = 1); and high right ventricular lead impedance (n = 1). Preoperative interrogation data were not available in 3.5% (5 of 144) of cases. In one case, an intraoperative device–related problem occurred (T wave oversensing).
Implantable Cardioverter Defibrillator Characteristics
Implantable Cardioverter Defibrillator Characteristics×
Primary and Secondary Endpoints
Outcome probabilities are presented in table 4 and in figure 3. The occurrence of intraoperative electromagnetic interference of any detected rate or duration was 20% (95% CI, 12.1 to 31.2) in noncardiac surgery above the umbilicus, 2.5% (95% CI, 0.0 to 14.4) in surgery below the umbilicus, and 68% (95% CI, 50.3 to 81.2) in cardiac surgery. When restricted to intraoperative electromagnetic interference that would only have been clinically meaningful based on actual preoperative programming, the occurrence of electromagnetic interference was 7% (95% CI, 2.7 to 16.2) in noncardiac surgery above the umbilicus, 0% (95% CI, 0.0 to 10.8) in surgery below the umbilicus, and 29% (95% CI, 16.5 to 46.7) in cardiac surgery. When restricted to intraoperative electromagnetic interference that would only have been clinically meaningful based on programming strategies known to reduce inappropriate therapies (i.e., if all implantable cardioverter defibrillators had been programmed to utilize high detection rates or long detection durations), the occurrence of electromagnetic interference would have been 2.9% (95% CI, 0.15 to 10.7) in noncardiac surgery above the umbilicus, 0% (95% CI, 0.0 to 10.8) in surgery below the umbilicus, and 8.8% (95% CI, 2.2 to 24.1) in cardiac surgery.
Primary and Secondary Study Outcomes by Surgical Procedure Location Group*
Primary and Secondary Study Outcomes by Surgical Procedure Location Group*×
Distribution and summary statistics (mean, standard error) of electromagnetic interference (EMI) in patients undergoing surgery above the umbilicus (A), surgery below the umbilicus (B), and cardiac surgery (C) groups. The left displays the occurrence of any intraoperative EMI, the center displays the occurrence of clinically meaningful intraoperative EMI (EMI that would have or did result in delivery of inappropriate antitachycardia therapy), and the right displays the occurrence of EMI had all implantable cardioverter defibrillators been programmed to a conservative strategy (Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy or PainFree SmartShock Technology study14).
Postoperative Characteristics
Postoperative interrogation demonstrated that all implantable cardioverter defibrillators withstood intraoperative electromagnetic interference without malfunction or occurrence of unanticipated programming changes.
Exploratory Endpoints
A true bipolar lead, as compared to an integrated bipolar right ventricular lead, was associated with a significantly lower occurrence of intraoperative electromagnetic interference in the noncardiac surgery above the umbilicus group (1 of 34 [3%] true bipolar vs. 11 of 33 [33%] integrated bipolar; P = 0.001); however, there were no differences for patients with surgery below the umbilicus (1 of 27 [4%] vs. 0 of 10 [0%]; P = 0.781) or in cardiac surgery (11 of 20 [55%] vs. 12 of 14 [86%]; P = 0.060). The occurrence of clinically meaningful electromagnetic interference or electromagnetic interference assuming conservative programming was not different for implantable cardioverter defibrillators with a true versus integrated bipolar lead for any of the study groups.
We conducted a large cohort study in a population of patients with implantable cardioverter defibrillators to evaluate the risk of intraoperative electromagnetic interference from monopolar electrosurgery. Our study was the first to determine the risk of electromagnetic interference with protocolized electrosurgery unit dispersive electrode positioning and the occurrence of clinically meaningful electromagnetic interference. Despite protocolized electrosurgery dispersive electrode positioning as recommended by the ASA and Heart Rhythm Society, we found an overall high risk of electromagnetic interference among patients who underwent noncardiac surgery above the umbilicus. The risk of electromagnetic interference among patients who underwent surgery below the umbilicus was negligible. The occurrence of electromagnetic interference was exceedingly high among patients who underwent cardiac surgery with an underbody dispersive electrode. The occurrence of clinically meaningful electromagnetic interference, which, although substantially lower than the overall occurrence of electromagnetic interference, was still as high as 7% for surgeries above the umbilicus, and 30% for cardiac surgery. Interestingly, we found that clinically meaningful electromagnetic interference would not have occurred for noncardiac surgeries below the umbilicus if all implantable cardioverter defibrillators had been programmed according to the conservative strategies of the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy or PainFree SmartShock Technology study.14 These programming strategies are now considered standard for all new implantable cardioverter defibrillators implanted for primary prevention based on multiple trials showing a lower risk of inappropriate shocks and improved outcomes.
The strengths of the current prospective study are the following: we prospectively stratified patients based on location and type of surgery into three groups; we only included surgeries that involved the use of monopolar electrosurgery; and we excluded interventional and endoscopic procedures that would have been unlikely to result in electromagnetic interference. Our study design differs from previous reports in several ways; therefore, the interpretation of our findings in the context of previous studies needs to account for these differences. In all prior studies evaluating the occurrence of intraoperative electromagnetic interference, the electrosurgery unit dispersive electrode was placed on the thigh or in an undefined "standard" position, without regard for the surgical site or location of the patient's pulse generator.19–24 Other complicating issues that make interpreting the risk of electromagnetic interference in these studies difficult include (1) lack of accounting for the use of bipolar rather than monopolar electrosurgery; (2) inconsistency in reporting the location of surgery (i.e., superior or inferior to the umbilicus); and (3) failure to exclude interventional and endoscopic procedures that typically do not require monopolar electrosurgery. Moreover, none of these previous studies evaluated the risk of electromagnetic interference with an underbody dispersive electrode.25
Gifford et al. reported electromagnetic interference occurrence for noncardiac surgery superior to the umbilicus ranging from 22% (upper extremity) to 50% (thorax or head/neck).22 In a subsequent study, Gifford et al. reported similar electromagnetic interference rates ranging from 15% (upper extremity) to 35% (head/neck) to 45% (thoracic).23 Friedman et al.24 reported similar electromagnetic interference rates (shoulder/upper extremity, 9%; head/neck, 43%; thoracic, 50%) to the two aforementioned studies by Gifford et al.22,23 Using the same surgery location categories, our figures of overall electromagnetic interference risk would have been overall slightly higher (upper extremity, 25%; head/neck, 35%; thorax, 61%). For surgery inferior to the umbilicus, all three of the aforementioned studies found an overall electromagnetic interference rate of 0%, while this figure was 3% in our study.
For noncardiac surgery above the umbilicus, we found an overall occurrence of electromagnetic interference of 20%. Thus, the average occurrence of electromagnetic interference in this group was lower than previously reported, a finding that might be attributable to our use of protocolized dispersive electrode positioning, or to the inclusion of cardiac surgery in previously reported thoracic surgery groups. Even though the occurrence of electromagnetic interference in surgeries above the umbilicus was lower than previously reported, it was still higher than we anticipated. It is conceivable that the true overall risk of intraoperative electromagnetic interference from monopolar electrosurgery is higher than may be inferred from previous reports due to the aforementioned limitations of these prior studies. Although very low, we were surprised to detect a nonzero frequency of electromagnetic interference in surgeries below the umbilicus, which may have occurred because, unlike some of the previous studies that excluded lower abdominal surgery in their "below the umbilicus" groups, we included lower abdominal surgery in this group.
For patients undergoing cardiac surgery with an underbody dispersive electrode, we found an electromagnetic interference occurrence of 68%. Since the surface area of this electrode is substantially larger than a conventional electrode, it is conceivable that this risk of electromagnetic interference might have been reduced by the use of a conventional electrosurgery dispersive electrode positioned according to a defined protocol.25
Interestingly, we determined that the risk of electromagnetic interference would have been substantially reduced in noncardiac surgery with programming strategies now frequently used to decrease the risk of inappropriate antitachycardia therapy among patients receiving implantable cardioverter defibrillators for primary prevention of sudden cardiac death. These findings suggest that the benefits of these conservative programming strategies might also extend to the perioperative setting.
Our study has limitations. The underbody dispersive electrode was only used in patients undergoing cardiac surgery. Therefore, we cannot draw conclusions about the risk of electromagnetic interference when this electrode is applied in other surgeries. We also did not randomize cardiac surgery patients to an underbody or conventional dispersive electrode. Furthermore, since monopolar electrosurgery was used at the discretion of the surgeon, the electrosurgical unit settings were not standardized.
In summary, our study demonstrated a substantial overall risk of intraoperative electromagnetic interference from monopolar electrosurgery for surgery above the umbilicus, despite protocolized placement of the dispersive electrode, and for cardiac surgery with the use of an underbody dispersive electrode. Understanding the true risk of intraoperative electromagnetic interference is important because evidence suggests that inappropriate antitachycardia therapy, whether antitachycardia pacing or shock, can cause adverse outcomes and even increase mortality.5,8–12 Furthermore, inappropriate antitachycardia therapy occurring intraoperatively may be especially serious because of the hemodynamic perturbations and physiologic stress often associated with surgery and anesthesia, and because a shock might cause unexpected patient movement.
While the risk of clinically meaningful electromagnetic interference was substantially lower than the overall risk of electromagnetic interference, it was still high enough to warrant recommending suspending antitachycardia therapy anytime monopolar electrosurgery is used in procedures above the umbilicus. Since the rate of clinically meaningful electromagnetic interference in this group would have been further reduced had all implantable cardioverter defibrillators been programmed to minimize inappropriate antitachycardia therapy (i.e., according to the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy or PainFree SmartShock Technology study,14 programming strategies that are often used in patients who have not yet experienced ventricular tachycardia or ventricular fibrillation), in the future as programming strategies continue to evolve, it may be worth reevaluating whether perioperative recommendations for implantable cardioverter defibrillator management can be modified accordingly. While it is hard to be confident that systems of care could be implemented to routinely ensure safe use of monopolar electrosurgery without implantable cardioverter defibrillator reprogramming for surgery above the umbilicus, it is possible that with promulgation of modern conservative programming strategies (and attention to patterns of electrosurgery use), the risk of electromagnetic interference could be substantially mitigated. Alternate strategies to mitigate the risk of electromagnetic interference are especially important for emergency situations when implantable cardioverter defibrillator or pacemaker reprogramming is often not possible, and magnet use is either impractical (i.e., prone surgery or magnet in surgical field) or not effective (i.e., pacing-dependent patients with an implantable cardioverter defibrillator). Our study also demonstrated that the risk of electromagnetic interference for surgery below the umbilicus was extremely low and without clinical relevance, which corroborates the findings of prior studies. This finding supports the recommendation of the Heart Rhythm Society that implantable cardioverter defibrillator reprogramming might be unnecessary when monopolar electrosurgery is employed inferior to the umbilicus, and may call for more nuance than the current recommendation from the ASA to suspend antitachycardia therapy whenever monopolar electrosurgery is used, regardless of surgical site. While the ASA recommendations may be appropriate for elective surgeries in centers with well-established protocols for implantable cardioverter defibrillator management, in the setting of urgent or emergent surgeries or when appropriate postoperative reprogramming cannot be guaranteed, the harms of preoperative implantable cardioverter defibrillator reprogramming for surgery inferior to the umbilicus could exceed the small potential benefits. Finally, we found the risk of electromagnetic interference with an underbody dispersive electrode was alarmingly high, and believe future studies to evaluate its use in patients with implantable cardioverter defibrillators are needed. We believe the results of our study can be used to better inform perioperative decision making, and guide future recommendations and advisories on the perioperative management of patients with implantable cardioverter defibrillators.
The authors wish to remember and express their deepest gratitude for the guidance, insights, and encouragement provided by Marc A. Rozner, Ph.D., M.D., during the design and conduct of the study. The authors would also like to thank Janna Higgins, M.S., Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, for her tireless dedication to recruiting participants and collecting device interrogation data. The authors would also like to acknowledge the outstanding contribution of Michael Kampp, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, for producing the illustration of the Electrosurgery Unit Dispersive Electrode positioning, and Marie Kane, M.S., Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, for her invaluable editorial assistance.
Supported by an unrestricted grant from Boston Scientific (Marlborough, Massachusetts).
American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: Pacemakers and implantable cardioverter defibrillators: An updated report by the American Society of Anesthesiologists Task Force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology. 2011;114:247–61. [Article] [PubMed]
Crossley, GH, Poole, JE, Rozner, MA, Asirvatham, SJ, Cheng, A, Chung, MK, Ferguson, TBJr, Gallagher, JD, Gold, MR, Hoyt, RH, Irefin, S, Kusumoto, FM, Moorman, LP, Thompson, A . The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: Facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm. 2011;8:1114–54. [Article] [PubMed]
Schulman, PM, Rozner, MA, Sera, V, Stecker, EC . Patients with pacemaker or implantable cardioverter defibrillator. Med Clin North Am. 2013;97:1051–75. [Article] [PubMed]
Robinson, TN, Varosy, PD, Guillaume, G, Dunning, JE, Townsend, NT, Jones, EL, Paniccia, A, Stiegmann, GV, Weyer, C, Rozner, MA . Effect of radiofrequency energy emitted from monopolar "Bovie" instruments on cardiac implantable electronic devices. J Am Coll Surg. 2014;219:399–406. [Article] [PubMed]
Powell, BD, Asirvatham, SJ, Perschbacher, DL, Jones, PW, Cha, YM, Cesario, DA, Cao, M, Gilliam, FR3rd, Saxon, LA . Noise, artifact, and oversensing related inappropriate ICD shock evaluation: ALTITUDE noise study. Pacing Clin Electrophysiol. 2012;35:863–9. [Article] [PubMed]
Schulman, PM. Nussmeier, N. Perioperative management of patients with a pacemaker or implantable cardioverter defibrillator UpToDate. Waltham, MA: UptoDate IncAvailable at: https://www.uptodate.com/contents/perioperative-management-of-patients-with-a-pacemaker-or-implantable-cardioverter-defibrillator. Accessed June 13, 2018..
Lau, W, Corcoran, SJ, Mond, HG . Pacemaker tachycardia in a minute ventilation rate-adaptive pacemaker induced by electrocardiographic monitoring. Pacing Clin Electrophysiol. 2006;29:438–40. [Article] [PubMed]
Moss, AJ, Schuger, C, Beck, CA, Brown, MW, Cannom, DS, Daubert, JP, Estes, NA3rd, Greenberg, H, Hall, WJ, Huang, DT, Kautzner, J, Klein, H, McNitt, S, Olshansky, B, Shoda, M, Wilber, D, Zareba, W ; MADIT-RIT Trial Investigators. Reduction in inappropriate therapy and mortality through ICD programming. N Engl J Med. 2012;367:2275–83. [Article] [PubMed]
Stempniewicz, P, Cheng, A, Connolly, A, Wang, XY, Calkins, H, Tomaselli, GF, Berger, RD, Tereshchenko, LG . Appropriate and inappropriate electrical therapies delivered by an implantable cardioverter defibrillator: Effect on intracardiac electrogram. J Cardiovasc Electrophysiol. 2011;22:554–60. [Article] [PubMed]
Veltmann, C, Borggrefe, M, Schimpf, R, Wolpert, C . Fatal inappropriate ICD shock. J Cardiovasc Electrophysiol. 2007;18:326–8. [Article] [PubMed]
Raitt, MH . Inappropriate implantable defibrillator shocks: An adverse outcome that can be prevented. J Am Coll Cardiol. 2013;62:1351–2. [Article] [PubMed]
Rozner, MA, Kahl, EA, Schulman, PM . Inappropriate implantable cardioverter defibrillator therapy during surgery: An important and preventable complication. J Cardiothorac Vasc Anesth. 2017;31:1037–41. [Article] [PubMed]
Healey, JS, Merchant, R, Simpson, C, Tang, T, Beardsall, M, Tung, S, Fraser, JA, Long, L, van Vlymen, JM, Manninen, P, Ralley, F, Venkatraghavan, L, Yee, R, Prasloski, B, Sanatani, S, Philippon, F ; Canadian Cardiovascular Society; Canadian Anesthesiologists' Society; Canadian Heart Rhythm Society. Society position statement: Canadian Cardiovascular Society/Canadian Anesthesiologists' Society/Canadian Heart Rhythm Society joint position statement on the perioperative management of patients with implanted pacemakers, defibrillators, and neurostimulating devices. Can J Cardiol. 2012;28:141–51. [Article] [PubMed]
Auricchio, A, Schloss, EJ, Kurita, T, Meijer, A, Gerritse, B, Zweibel, S, AlSmadi, FM, Leng, CT, Sterns, LD ; PainFree SST Investigators. Low inappropriate shock rates in patients with single- and dual/triple-chamber implantable cardioverter defibrillators using a novel suite of detection algorithms: PainFree SST trial primary results. Heart Rhythm. 2015;12:926–36. [Article] [PubMed]
Agresti, A, Coull, BA . Approximate is better than "exact" for interval estimation of binomial proportions. Am Stat. 1998;52:119–26.
Clopper, CJ, Pearson, ES . The use of confidence or fiduciary limits illustrated in the case of the binomial. Biometrika. 1934;26:404–13. [Article]
Brown, LD, Cai, TT, DasGupta, A . Interval estimation for a binomial proportion. Stat Sci. 2001;16:101–7.
Suresh, M, Benditt, DG, Gold, B, Joshi, GP, Lurie, KG . Suppression of cautery-induced electromagnetic interference of cardiac implantable electrical devices by closely spaced bipolar sensing. Anesth Analg. 2011;112:1358–61. [Article] [PubMed]
Cheng, A, Nazarian, S, Spragg, DD, Bilchick, K, Tandri, H, Mark, L, Halperin, H, Calkins, H, Berger, RD, Henrikson, CA . Effects of surgical and endoscopic electrocautery on modern-day permanent pacemaker and implantable cardioverter defibrillator systems. Pacing Clin Electrophysiol. 2008;31:344–50. [Article] [PubMed]
Fiek, M, Dorwarth, U, Durchlaub, I, Janko, S, Von Bary, C, Steinbeck, G, Hoffmann, E . Application of radiofrequency energy in surgical and interventional procedures: Are there interactions with ICDs? Pacing Clin Electrophysiol. 2004;27:293–8. [Article] [PubMed]
Hoyt, RH, Johnson, WB, Leiserowitz, A . Monopolar electrosurgery interactions with the implantable defibrillator Heart Rhythm. 2010;7:S246–7.
Gifford, J, Larimer, K, Thomas, C, May, P, Stanhope, S, Gami, A . Randomized controlled trial of perioperative ICD management: Magnet application versus reprogramming. Pacing Clin Electrophysiol. 2014;37:1219–24. [Article] [PubMed]
Gifford, J, Larimer, K, Thomas, C, May, P . ICD-ON Registry for Perioperative Management of CIEDs: Most require no change. Pacing Clin Electrophysiol. 2017;40:128–34. [Article] [PubMed]
Friedman, H, Higgins, JV, Ryan, JD, Konecny, T, Asirvatham, SJ, Cha, YM . Predictors of intraoperative electrosurgery-induced implantable cardioverter defibrillator (ICD) detection. J Interv Card Electrophysiol. 2017;48:21–6. [Article] [PubMed]
Kleinman, B, Ushomirsky, S, Murdoch, J, Loo, J, Radzak, J, Cytron, J . Unintended discharge of an ICD in a patient undergoing total knee replacement. Anesthesia Patient Safety Foundation Newsletter. 2017;32:10–1.
Link ID: 2513945
Link Type: podcast-article
Linked Multimedia Creation Date: 4/3/2019 8:00:56 PM
Multimedia Url: http://traffic.libsyn.com/anesthesiology/asa_03-06-19-vicki-edited.mp3?dest-id=227029
Multimedia Title: Podcast on Electromagnetic Interference in Implantable Defibrillators
Multimedia Filename: asa_03-06-19-vicki-edited.mp3?dest-id=227029
Multimedia Type: podcast
Multimedia Duration: 43:28
Peter M. Schulman, Miriam M. Treggiari, N. David Yanez, Charles A. Henrikson, Peter M. Jessel, Thomas A. Dewland, Matthias J. Merkel, Valerie Sera, Izumi Harukuni, Ryan B. Anderson, Ed Kahl, Ann Bingham, Nabil Alkayed, Eric C. Stecker; Electromagnetic Interference with Protocolized Electrosurgery Dispersive Electrode Positioning in Patients with Implantable Cardioverter Defibrillators. Anesthesiology 2019;130(4):530-540. doi: 10.1097/ALN.0000000000002571.
Visual Abstract
Commentary: Intraoperative Electrosurgical Electromagnetic Interference in Patients with Implantable Cardioverter Defibrillators: Is It Safe?
Podcast on Electromagnetic Interference in Implantable Defibrillators
Moderator: BobbieJean Sweitzer, M.D.
Participants: Peter M. Schulman, M.D. and G. Alec Rooke, M.D., Ph.D.
Articles Discussed:
Intraoperative Electrosurgical Electromagnetic Interference in Patients with Implantable Cardioverter Defibrillators: Is It Safe?
Initial Experience of an Anesthesiology-based Service for Perioperative Management of Pacemakers and Implantable Cardioverter Defibrillators
Sounds Impossible, but It's Knot
Stop Interfering! Intraoperative Management of ICDs
Hyperinsulinemic Normoglycemia during Cardiac Surgery Reduces a Composite of 30-day Mortality and Serious In-hospital Complications: A Randomized Clinical Trial
Cardiovascular Anesthesia
Technology / Equipment / Monitoring


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It's that exciting time of year, when temperatures are finally rising and summer vacations coming up. Everyone is planning a trip, whether you are planning a close-by local weekend getaway or a fun filled overseas trip, it's important to take your healthy and "live well" habits with you when you go.
I have made many switches to products that feel better in my life and when it comes to travel, choosing simpler products to take with me makes all the difference while I am away. Along with making simple choices in my diet, cleaning products and clothing, I have recently started using a different tampon too. No one wants to have their period on a summer vacation but it happens, and when it's that time of the month I use TampaxPure and Clean.
Tampax Pure and Clean offers women the trusted comfort and protection of Tampax with simple ingredients in a tampon they can really count on. In my experience, Tampax Pure and Clean is the best option for me because it has simpler ingredients and fits perfectly into my lifestyle. I am always sure to take them with me when I am going on a trip.
Tampax Pure and Clean tampons have a 100% cotton core, which is responsibly-sourced in the U.S. They are also free of dyes, fragrances and chlorine bleaching. And, like all of Tampax's amazing products they have the trusted protection including widthwise expansion and a LeakGuardTM Braid for built-in back up protection.
Bringing a work out set to keep up my exercise routine.
Carrying my own water bottle to stay hydrated and limit plastic use.
Buying or making my own organic snacks to have along the way to avoid processed food at the airport.
Downloading a nature sound app on my phone to help me get decent sleep while not in my own bed.
Taking an adult coloring book with me to help me relax and get off my phone.
I was also super pumped to learn that Tampax and Always are the only Feminine Care brands in Smart Label! You can find everything you need to know about the products, including ingredients and sustainability by using the SmartLabel app, by going to smartlabel.org, or visiting the Tampax and Always websites.
Tampax Pure and Clean is available at Target. To find out more, click here.


text:
'use strict';

const helper = require("../../helper.js");
const soajs = helper.requireModule('./index.js');
const requester = require('../requester');
const _ = require("lodash");
const assert = require("assert");

describe("Integration for inputmask", function () {

	let config = require('./config.js');
	let scenarios = require('./scenarios.js');

	config.packagejson = {
		"version": "1.0.0",
		"dependencies": {}
	};

	_.forEach(scenarios, function (scenario) {
		config.schema[scenario.u] = scenario.im;
	});

	const service = new soajs.server.service(config);

	before((done) => {

		service.init(() => {

			_.forEach(scenarios, function (scenario) {
				service[scenario.m](scenario.u, function (req, res) {
					req.soajs.log.info('Test:' + scenario.u + ' ' + scenario.m);
					let data = {};
					_.forEach(scenario.im, function (info, input) {
						data[input] = req.soajs.inputmaskData[input];
					});
					res.json(req.soajs.buildResponse(null, data));
				});
			});

			service.start(() => {
				done();
			});
		});
	});

	after((done) => {
		service.stop(() => {
			done();
		});
	});

	_.forEach(scenarios, function(scenario) {
		describe('Testing InputMask: ' + scenario.m + ' http://localhost:' + config.servicePort + "/", function() {
			_.forEach(scenario.tests, function(test) {
				let testDescription = 'Testing ' + scenario.m + test.u;
				if(test.p !== undefined) testDescription += ' post:' + JSON.stringify(test.p);
				if(test.desc !== undefined) testDescription += ' desc:' + JSON.stringify(test.desc);
				if(test.skip) {
					it.skip(testDescription, function(done) {
						done();
					});
				}
				else if(test.only) {
					it(testDescription, function(done) {
						requester(((scenario.m === 'delete') ? 'del' : scenario.m), {
							uri: 'http://localhost:' + config.servicePort + test.u,
							body: test.p,
							form: test.pf
						}, function(err, body) {
							assert.ifError(err);
							assert.deepEqual(body, test.r);
							done();
						});
					});
				} else {
					it(testDescription, function(done) {
						requester(((scenario.m === 'delete') ? 'del' : scenario.m), {
							uri: 'http://localhost:' + config.servicePort + test.u,
							body: test.p,
							form: test.pf
						}, function(err, body) {
							console.log(body)
							assert.ifError(err);
							assert.deepEqual(body, test.r);
							done();
						});
					});
				}
			});
		});
	});

});

redpajama_set_name: RedPajamaGithub


Cllr Steve Foulkes started the meeting at 6.15pm saying he was going to take three items of Any Other Business first as they were urgent. He was pre-warning people. He wanted a verbal update on the one day strike. Cllr George Davies had an announcement to make on housing funding and he wanted a quick verbal on issues about gas supplies in Leasowe and Moreton East, as well as a further future report on the lessons learnt.
Cllr Jeff Green said there was speculation surrounding the Serious Fraud Office investigation.
Cllr Steve Foulkes said he had not been informed that the situation had changed, although he was aware of some things.
He asked for declarations of interest.
Cllr Phil Davies declared an interest in item 12 as he was a trustee of the Wirral Food bank, however as he was not a Council appointed trustee, he asked Bill Norman for advice as to whether the interest was personal or prejudicial.
Bill Norman replied that in his opinion it was personal, not prejudicial.
Cllr Chris Meaden declared an interest in item 5 (Annual Children's Services Assessment 2011) because of her daughter's employment.


Our homemade barbecue dishes are already very affordable, but you can save even more with our daily specials that cost under $7!
If you enjoy our food, why not bring it to your next event? We offer catering for events with as little as 25 people to as large as 2,000 people.
Jack's Bar-B-Q has been Oklahoma City's home of legendary barbecue for over 45 years.
Come in and see what everyone's raving about!


Seattle is being terrorised by a string of mysterious killings. It's not long before Bella and the Cullens figure out its newborn vampires doing the killing, but who is behind it all and why are they coming for Bella and the Cullens?
With graduation approaching Bella has a choice to make, stay human or become a vampire and be with Edward forever. On top of all this Bella needs to decide who she wants to be with, who she loves, her werewolf best friend Jacob or her vampire boyfriend Edward.
This is the third book in the Twilight Saga. I had honestly forgotten how good this series is. I really enjoyed rereading it again. I love the love triangle between Bella, Edward and Jacob. To have two people madly in love with you must be so overwhelming.
Jacob is my favourite character. I just love everything about him, he's sweet and loving, protective and fun. I think Jacob and Bella would make a beautiful couple, I find myself really rooting for Jacob to be the one to win Bella's heart even though I know he won't.
Stephanie Meyer is a wonderful writer, this book is really well written, with fantastic characters and amazing descriptive writing. The pace is perfect, building you up throughout the whole story, leading you into the excitement.
The plot is interesting, captivations and gripping. It keeps you hooked throughout and once you've finished your desperate to read the next book in the series. A fantastic book and a 5-star series.


The annual Yorkes Classic is one of Australia's most prestigious surfing events, with some of our most talented surfers competing for thousands of dollars in cash and prizes. With the best and biggest waves available across the 'Bottom-End' of southern Yorke Peninsula over the October long weekend, the event has grown to become a major sporting attraction for both surfers and spectators alike. Locations, within Innes National Park, will be announced each day, depending on conditions. The Marion Bay Tavern will host the event prize giving and also keep you entertained for the weekend. Entry permits to Innes National Park are available from Yorke Peninsula Visitor Centre website or by calling, Or they can be purchased at the Natural Resource Centre as you enter Innes National Park.


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Posted by Alicia & filed under Giveaways, Knitting Patten, Local, Yarn. This post has 28 comments.


the entire declassified CREST archive is now available on the CIA Library website.
I'm amazed, I must say. Rarely do I encounter a blog that's both educative and engaging, and without a doubt, you've hit the nail on the head. The issue is something too few men and women are speaking intelligently about. I'm very happy I came across this in my hunt for something concerning this.
Spot on with this write-up, I absolutely feel this site needs a great deal more attention. I'll probably be returning to see more, thanks for the info!


text:
Q: Jfreechart get Mouse Co-ordinates I have been trying to get current Mouse Co-ordinates in a JfreeChart and found that the following solution was working partially
JFreeChart get mouse coordinates
I have been using OHLC Dataset to draw the chart and while I could get the RangeAxis properly (meaning in the subplot values), I couldn't make anything out of the value recieved for the X-Axis from the above example.
I am sure that I am receiving the values in some other format (not the displayed date format), anyone could point out what I am doing wrong?

A: Got it solved after few hours of experiment. Here is the code for a complete MouseMotionListener. Just added this to the chartPanel and voila! - it works!
The chartY returns proper value of Y-Axis and the dateString returns complete date. Tried it in an OHLC Chart and seems proper.
 MouseMotionListener mouselisten = new MouseMotionListener() {

    public void mouseDragged(MouseEvent e) {
        //
    }

    public void mouseMoved(MouseEvent e) {
        Point2D p = e.getPoint();
        Rectangle2D plotArea = chartPanel.getScreenDataArea();
        XYPlot plot = (XYPlot) chart.getPlot(); // your plot
        double chartX = plot.getDomainAxis().java2DToValue(p.getX(), plotArea, plot.getDomainAxisEdge());
        double chartY = plot.getRangeAxis().java2DToValue(p.getY(), plotArea, plot.getRangeAxisEdge());

        DecimalFormat dfT   = new DecimalFormat("00");
        GregorianCalendar gc = new GregorianCalendar();
        long lDte = (long)chartX;
        Date dtXX = new Date(lDte);
        gc.setTime(dtXX);
        String sDD  = dfT.format(Double.valueOf(String.valueOf(gc.get(GregorianCalendar.DAY_OF_MONTH))));
        String sMM  = dfT.format(Double.valueOf(String.valueOf(gc.get(GregorianCalendar.MONTH)+1)));
        String sYY  = dfT.format(Double.valueOf(String.valueOf(gc.get(GregorianCalendar.YEAR))));
        String dateString = sDD +"/"+ sMM +"/"+ sYY;

    }
};

redpajama_set_name: RedPajamaStackExchange


Few conservative writers out there find the spot where religion and politics truly do meet in a beautiful way like Mike Adams. Part of this is I'm sure because of his background as a former atheist.
Scott told me he had raised his kids in the church and believed in God although he had not been to church regularly in a number of years. He said he felt no guilt over his absence from church. After all, it was a weekend business that kept him from attending. And, besides that, he said he was leading a "moral life" without going to church.
...Life is full of uncertainty but without God two things really are certain: We will make a mess of our lives, and we will help others do the same.
Give the full article a read and don't hesitate to act on his concluding advice if you can.


text:
Eugene Weekly : Coverstory : 3.26.2009
Nesting Green Home & Garden Special Issue
Seasonal Salads What to plant for tasty greens year-round
Conserving Water, Anticipating Surprises A profile of Deborah Brady
Small Space, Big Tastes Ten herbs you can grow in your apartment
Eco-Paint the Town Environmentally friendly options
On the Wing Plants that attract birds and butterflies
2009 Spring Planting Guide
Not a Yolk
Backyard chickens produce
by Jessica Hirst
Maybe you like the idea of bestowing fresh eggs on your friends in exchange for all that zucchini they give you every summer, but you don't know the difference between a biddy and a brood. You want to take advantage of Eugene's city code that allows you to keep chickens, but you're just not sure where to begin.
Dark Brahma hen. Photo by art Bromage Through Wiki Commons
It turns out that getting started raising your own chicks might not be as daunting a task as it seems. And now that it's spring, chicks are available in stores.
"Chickens are easy to care for," says Down to Earth store manager Rachel Klinnert, who began raising her own chicks about a year ago. Klinnert says she had no experience caring for chickens before she started but that she's been able to learn as she goes with the help of books such as Storey's Guide to Raising Chickens by Gail Damerow.
To begin your adventure as a chicken owner, you'll need the following items: chicks, a large cardboard box (Klinnert used a refrigerator box), a heat lamp, pine chips, feed and special containers for food and water. Klinnert says she got her day-old chicks from Coastal Farm Supply for about $2 each. Coastal carries all the other supplies you'll need to get started, she says.
For the first eight weeks or so you'll need to be home every day to feed the chicks, clean their box and keep an eye on them. After that, says Klinnert, they "feather out" and are ready to go outside. You'll need to build a coop and keep it clean, but grown chickens are pretty low maintenance, she says.
The only downside to the endeavor might be the cost. Although it might seem like backyard chickens would be a money saver, the initial setup costs for two chicks could run anywhere between $60 and $80. And down the road, you'll still need to build a chicken coop. But with organic local eggs running $4.50 to $5 a dozen, that's not a bad deal.
Klimmert says that you can build a simple coop for minimal effort and cost. She recommends building a complete enclosure to keep the birds safe from neighborhood predators such as cats, dogs, raccoons, possums, hawks and owls.
Because Klinnert's chickens are in a safe environment, they're not stressed, so they're content and easy to have around, she says. "I love the noises that they make," she says. "It's great listening to the sound of chickens cooing, and they're pretty, sweet little animals. It's been a really good experience."
Of course, fresh eggs aren't bad either. A chicken lays approximately one egg every 36 hours, so two chickens will provide about a dozen eggs a week. A chicken will generally begin producing eggs after it's about 5 months old, says Klimmert. And as for the other stuff that comes out of chickens, it can be used to fertilize the garden.
Most importantly, though, fresh eggs will release you from any zucchini debt you might be in since your neighbor's windfall harvest last season.

redpajama_set_name: RedPajamaCommonCrawl


text:
More info on Stanford, California
Loyola, California
Los Altos, California
Los Altos Hills, California
Saratoga, California
Stanford, California: Wikis
— CDP —
Location in Santa Clara County and the state of California
Coordinates: 37°25′21″N 122°9′55″W / 37.4225°N 122.16528°W / 37.4225; -122.16528Coordinates: 37°25′21″N 122°9′55″W / 37.4225°N 122.16528°W / 37.4225; -122.16528
2.7 sq mi (7.2 km2)
0 sq mi (0.1 km2)
Elevation 75 ft (23 m)
Population (2000)
- Density 4,931.5/sq mi (1,849.3/km2)
PST (UTC-8)
- Summer (DST)
FIPS code
Stanford is a census-designated place (CDP) in Santa Clara County, California, United States. The population was 13,315 at the 2000 census.
Stanford is an unincorporated area of Santa Clara County and is adjacent to the city of Palo Alto. Stanford, California is a valid postal address, and has its own post office and ZIP codes: 94305 (campus buildings) and 94309 (post-office boxes). A popular site to see/hike in Stanford is the Dish.
The CDP of Stanford is mostly made up of Stanford University. Its resident population consists of the inhabitants of on-campus housing, including graduate student villages and the "Faculty Ghetto" of single-family homes owned by their faculty inhabitants but located on leased Stanford land. A residential neighborhood adjacent to the Stanford campus, College Terrace, featuring streets named after universities and colleges, including Oxford, Harvard,Yale and Columbia, is not part of the Stanford CDP but of the city of Palo Alto.
Stanford is located at 37°25′21″N 122°9′55″W / 37.4225°N 122.16528°W / 37.4225; -122.16528 (37.422590, -122.165413)[1].
According to the United States Census Bureau, the CDP has a total area of 2.8 square miles (7.2 km²), of which, 2.8 square miles (7.1 km²) of it is land and 0.04 square miles (0.1 km²) of it (1.44%) is water.
As of the census[2] of 2000, there were 13,314 people, 3,207 households, and 1,330 families residing in the CDP. The population density was 4,849.8 people per square mile (1,869.4/km²). There were 3,315 housing units at an average density of 1,207.4/sq mi (465.4/km²). The racial makeup of the CDP was 60.40% White, 4.90% Black or African American, 0.72% Native American, 25.57% Asian, 0.16% Pacific Islander, 3.65% from other races, and 4.60% from two or more races. 8.96% of the population were Hispanics or Latinos of any race.
There were 3,207 households out of which 17.9% had children under the age of 18 living with them, 38.7% were married couples living together, 1.8% had a female householder with no husband present, and 58.5% were non-families. 23.0% of all households were made up of individuals and 2.5% had someone living alone who was 65 years of age or older. The average household size was 2.22 and the average family size was 2.73.
The age distribution was 7.2% under the age of 18, 58.5% from 18 to 25, 23.7% from 25 to 45, 6.1% from 45 to 65, and 4.4% who were 65 years of age or older. The median age was 22 years. For every 100 females there were 118.0 males. For every 100 females age 18 and over, there were 119.4 males.
The median income for a household in the CDP was $41,106, and the median income for a family was $88,596. Males had a median income of $67,250 versus $56,991 for females. The per capita income for the CDP was $22,443. About 11.1% of families and 21.4% of the population were below the poverty line, including 11.6% of those under age 18 and 1.8% of those age 65 or over.
The area is strongly Democratic, with 54% registered with Democrats and 15% registered with the Republican Party.[3] In the state legislature Stanford is located in the 11th Senate District, represented by Democrat Joe Simitian, and in the 21st Assembly District, represented by Democrat Ira Ruskin. Federally, Stanford is located in California's 14th congressional district, which has a Cook PVI of D +18[4] and is represented by Democrat Anna Eshoo.
^ "US Gazetteer files: 2000 and 1990". United States Census Bureau. 2005-05-03. http://www.census.gov/geo/www/gazetteer/gazette.html. Retrieved 2008-01-31.
^ "American FactFinder". United States Census Bureau. http://factfinder.census.gov. Retrieved 2008-01-31.
^ Template:Cite url=http://www.sen.ca.gov/ftp/SEN/senplan/SD11.HTM
^ "Will Gerrymandered Districts Stem the Wave of Voter Unrest?". Campaign Legal Center Blog. http://www.clcblog.org/blog_item-85.html. Retrieved 2008-02-10.
San Francisco Bay Area portal
Santa Clara County, California
County seat: San Jose
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Bell Station | Casa Loma | Chemeketa Park | Coyote | Holy City | Loma Chiquita | Old Gilroy | Redwood Estates | Rucker | San Antonio Valley | Sargent | Sveadal
Alma | Lexington | Wrights
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Alamo • Albany • Alum Rock • Ashland • Bay Point • Blackhawk-Camino Tassajara • Brentwood • Cherryland • Clayton • Dixon • El Cerrito • El Sobrante • Half Moon Bay • Healdsburg • Hercules • Hillsborough • Lafayette • Larkspur • Millbrae • Mill Valley • Moraga • North Fair Oaks • Orinda • Piedmont • Pinole • San Anselmo • San Lorenzo • Stanford • Tamalpais-Homestead Valley • Windsor
Sub-regions
East Bay • North Bay • San Francisco Peninsula • Silicon Valley • South Bay
Categories: Census-designated places in California | Settlements in Santa Clara County, California | Stanford University | University towns in the United States
Hidden categories: Infobox Settlement US maintenance
Will Gerrymandered Districts Stem the Wave of Voter Unrest? - Campaign Legal Center blog: Will Gerrymandered Districts Stem the Wave of Voter Unrest?


text:
A Year of NC at the Movies
It's been a year since Rob Gray joined the crew at Numéro Cinq and took over the nascent NC at the Movies series. Only a year, but he has made himself a mainstay of the community. I originally set him up as a kind of duke or baron in my Internet kingdom. I said he could do what he wanted within his fiefdom. And he has made that slot unique, bizarre, macabre, exciting, erotic, stylish and always surprising and delightful. He has contributed dozens of short movies and movie commentaries. I don't know of another publication with a feature remotely like this. It's gone well beyond any editorial fantasy I might have had at the beginning.
Not only that, but as an editor with his own domain, Rob has brought in other exceptional movie commentators — Jon Dewar, Sophie M. Lavoie, and Megan MacKay. He has also contributed poetry, fiction and a complete screenplay to the magazine. And just last issue he started a new hybrid series of publications, coupling poets with critics in a single hybrid piece — see "Stray Dog Poetics" with poet Shane Rhodes and critic Rob Ross.
To acknowledge Rob's profound (and, yes, often exuberantly eccentric) contributions to NC, I've devoted 10 slots on the slider at the top of the page to some of my favourite pieces, including, yes, the ever popular Treevenge by Jason Eisener (the Christmas movie that proved to me the truly depraved nature of Rob Gray's mind) and Pedro Pires's Danse Macabre (which I adore — go figure).
I look at the list of movies and, momentarily, I bask in the glow of accomplishment — we really have created something unique and beautiful at NC.
One Response to "A Year of NC at the Movies"
Kim Aubrey says:
Congrats, Rob, on a year of terrific films and commentary!!
In Good Company — Invisible Stories: An inventory of every book on my desk, in three stacks and one upright row, on the night of September 14, 2012. The ecstasy of influence: A plagiarism, By Jonathan Lethem @ Harper's Magazine


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HomeNews10 indicted in deadly prison riot
10 indicted in deadly prison riot
July 26, 2013 Monica Land News, Statewide News, Top Stories 0
From The Mississippi Link Newswire
JACKSON – Ten additional individuals have been indicted in connection with the riot that occurred at the Adams County Correctional Center (ACCC) in Natchez, Mississippi on May 20, 2012, the FBI and the U.S. Attorney announced this week.
Catlin Carithers
The ACCC houses approximately 2,500 non-resident aliens who have been convicted of federal charges in the United States. During the riot, several correctional officers were assaulted.
Correctional Officer (CO) Catlin Carithers died as a result of injuries he received during these assaults.
Other COs were taken captive and held hostage for several hours by participants in the riot. Total damage to ACCC was estimated to be $1,305,142.
The following individuals are being charged with violating Title 18, U.S. Code, Section 1792—instigating, conniving, willfully attempting to cause, assisting, or conspiring to cause any mutiny or riot at a federal correctional facility:
Gerson Benavides, age 29
Adrian Romero-Carrera, age 27
Carlos Flores, age 40
Ruben Coronado-Licon, age 22
Ricardo Quintana, age 28
Margarito Munoz-Astello, age 36
Bertil James, age 38
Ian Jeffrey Reid, age 43
Haisam Ali, age 36
Raybell Granillo, age 28
Nine other inmates have been previously arrested and charged in connection with the May 20, 2012 riot at ACCC, and four of those inmates have been convicted.
The investigation into this incident is ongoing and more arrests are expected.
Adams County Correctional Center
deadly prison riot
Natchez Miss.
prison riot
Doctor: Dennis Farina was being treated for cancer
Emile Griffith, elegant boxing champ, dies at 75
Von Drehle Corp. locating to Adams County
February 20, 2013 Monica Land Statewide News 0
Officials from von Drehle Corporation said the company is locating manufacturing operations to Natchez. The company, which provides paper products to commercial and industrial consumers nationwide, will create at least 100 new jobs; make investments in additional converting equipment and subsequently install a paper machine.
Von Drehle has acquired the former Mississippi River Pulp facility, which closed its doors in November 2012. From its new Natchez location, von Drehle will manufacture paper products formerly produced by Mississippi River Pulp, as well as its own product lines. […]
Natchez casting call set for James Brown movie
September 17, 2013 Online Editor Entertainment, News, Top Stories 1
NATCHEZ, Mississippi — Actors and musicians looking to land a part in the upcoming James Brown movie to be filmed in Natchez will have their chance this weekend.
The Natchez Democrat reports Universal Pictures is scheduled to have a casting call for "Get On Up" Saturday at the Natchez City Auditorium.
The film will tell the story of the Godfather of Soul's life from his impoverished childhood to his evolution into one of the most influential figures of the 20th century… […]
Sheriff: Gang started prison riot in Adams County; one guard killed
May 24, 2012 Monica Land News, Statewide News, Top Stories 0
NATCHEZ – (AP) A gang fight in a prison for illegal immigrants quickly escalated into a riot involving as many as 300 inmates, some lashing out with sticks or homemade knives as the uprising […]


The Earth has spinning round in house for roughly four.5 billion years. But, kids, we're alive to witness The Masked Singer.
Fox's 44 percent Rotten Tomatoes-approved smash was again on Wednesday (January 16) to place 5 of the disguised, remaining ten celebrities on stage earlier than panelists Robin Thicke, Jenny McCarthy, Ken Jeong and Nicole Scherzinger, and make them sing for his or her anonymity. For added giggles, comic Joel McHale was thrown into the combination, as a result of that is apparently the place guesting on the X-Files reboot and Santa Clarita Diet will get you.
As for the competing celebs, the earlier two weeks noticed the departures of Pittsburgh Steelers large receiver Antonio Brown as Hippo and Tommy Chong as Pineapple. With such blinding star wattage now absent, the place will we go from right here? And who received the boot on evening three? Read on!
At this level, the panelists properly suspect that Deer is a NFL participant. And certainly, his efficiency of Florida Georgia Line's 2013 hit "Get Your Shine On" signifies that singing clearly isn't his most important occupation.
Following Deer's newest flip in entrance of a mic, Joel McHale searches deep for a optimistic remark. "It was the perfect track I've ever seen sung by a deer in a fuel masks," he pronounces. Don't fear, Joel -- solely 43 minutes left to go.
Also, let's not neglect that in 1989, after a protracted drought in his pop profession, Osmond's comeback Billboard Hot 100 chart hit "Soldier Of Love" was initially promoted with out revealing his identify or releasing an accompanying music video. Folks, Donny was the O.G. masked singer!
Anyway, Peacock expertly belts out "Counting Stars" whereas standing on a hydraulic carry 30 ft above the stage. He's received all of the agility of somebody who has -- oh, I don't know -- appeared on a number of seasons of Dancing With The Stars, maybe?
After relying closely on Auto-Tune to get via a rendition of Britney Spears' "Oops!…I Did It Again," Unicorn hears some sage knowledge from the panelists. "I nearly pooped a rainbow," Jenny McCarthy says.
With these clues, the panelists are nonetheless no nearer to determining whether or not the fur-covered, one-eyed creature is an athlete, a singer or a comic. A fiery efficiency of Gavin DeGraw's early-aughts anthem "I Don't Wanna Be" impresses Robin Thicke, who pronounces it's his favourite efficiency of the evening.
"None of the opposite singers went for some bit mountaintop notice on the finish, and he went all the best way to the highest," Robin says. Host Nick Cannon chimes in that he agrees.
Eliminated: Alas, the time has come for Deer to be shot, strapped to the roof of a rusty Toyota and pushed off the present. Before being unmasked, Robin appropriately surmises that it's former NFL quarterback and present Fox NFL Sunday co-host Terry Bradshaw beneath the antlers, given the 70-year-old's shoulder-shuffle whereas laughing.


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University of Toronto Quarterly
Eugene A. Forsey: An Intellectual Biography (review)
Roger Hutchinson
10.1353/utq.2006.0114
Eugene A. Forsey: An Intellectual Biography
Roger Hutchinson (bio)
Frank Milligan . Eugene A. Forsey: An Intellectual Biography University of Calgary Press. xiv, 318. $34.95
Frank Milligan has provided a rich and enticing portrait of Eugene Forsey as a creative intellectual, as an engaged social reformer and constitutional expert, and, more questionably, as a transitional figure in a Canadian society that had become less Christian and more secular by the time of his death in 1991. As a former director of museums in Alberta and New Brunswick, and as director of the Nantucket Historical Association and its properties, Milligan drew heavily on primary sources - lecture notes, unpublished manuscripts, and correspondence. In addition, he used Forsey's published works and secondary materials to explore the interactions among ideas, personalities, and the institutions of civil society and parliamentary democracy. As the note on the paperback cover promises, in this study of Forsey's religious and political beliefs 'Milligan unearths the philosophical underpinnings of many of Canada's early twentieth-century political, economic, religious, and social reform movements.' He also identifies the personal background and social factors shaping the life of this incisive, argumentative constitutional expert whose 1980 publication, How Canadians Govern Themselves, has been reissued four times with the last printing in 2003.
Forsey was born in Newfoundland and raised in Ottawa in a British Methodist home. He remained grounded in the beliefs and values of Christianity as his religious affiliations shifted among the Methodism of his youth, the United Church (after church union in 1925, and for the last three decades of his life as an active member of Église Saint-Marc, a French-language United Church in Ottawa), and Quaker (at Oxford until the Spanish Civil War made pacifism no longer a viable option), plus frequent attendance at Anglican services in Montreal and at Oxford.
The nature of his liberal, social justice-oriented Christian faith is suggested by his affinities with John Macmurray, King Gordon, Gregory Vlastos and R.B.Y. Scott, and by his active membership in the Student Christian Movement, the Fellowship for a Christian Social Order, and committees of the United Church such as the Montreal Presbytery Committee on Social and Economic Research.
He remained faithful to 'the authentic tradition of Canadian conservativism' (as he recalled in his biography, A Life on the Fringe) as his political affiliations changed from Conservative to CCF (he refused to join the NDP over its 'two nations' policy) to Liberal (when he agreed to sit as a Liberal in the Senate), to a growing uncertainty about which political party provided the best vehicle for his political and religious convictions.
His ideas about social reform and economic planning, the relationships among civil society, organizations, and the state, civil liberties, and the role [End Page 376] of organized labour both contributed to and were shaped by his involvement with the League for Social Reconstruction, the Canadian Civil Liberties Union, and the Canadian Congress of Labour (later the Canadian Labour Congress), and his experience as a university instructor at McGill, Carleton, and Waterloo.
Milligan does a good job of discussing the importance of Forsey's Christian faith. However, by picturing him as a transitional figure in a Canada that became less Christian and more secular, Milligan reflects the assumptions of the secularization theory of mainstream social science. An alternative perspective would involve stressing Forsey's respect for other religious views throughout his life, and his emphasis on the role of reasoned, factually based arguments when churches participate in public debates. Whether or not Forsey used explicitly theological language depended more on the audience than on whether a speech was early or late in his career. When addressing church groups he used the theological language appropriate for the occasion as well as reasoned, factually based arguments. His insistence that 'the churches should support what labour wants because that is what is in the interests of the whole community' did not represent, as secularization theorists suggest, the reduction of religion to politics or the transition from a religious to secular orientation. It represented a foretaste of the way citizens in a pluralistic society deliberate with one another as citizens and as members of 'those...


text:
import getpass
import logging
import sys
from pprint import pprint
from drf_client.connection import Api as RestApi

logging.basicConfig(stream=sys.stdout, level=logging.INFO)

logger = logging.getLogger(__name__)

username = input('Email? ')
password = getpass.getpass()

options = {
    'DOMAIN': 'http://127.0.0.1:8000',
    'API_PREFIX': 'api/v1',
    'TOKEN_TYPE': 'jwt',
    'TOKEN_FORMAT': 'JWT {token}',
    'USERNAME_KEY': 'username',
    'LOGIN': 'auth/login/',
    'LOGOUT': 'auth/logout/',
    'USE_DASHES': False,
}

c = RestApi(options)

ok = c.login(username=username, password=password)
if ok:

    # GET some data
    my_objects = c.org.get()
    for obj in my_objects['results']:
        pprint(obj)
        logger.info('------------------------------')

    logger.info('------------------------------')
    logger.info('------------------------------')
    # If the URL includes "-", add under parenthesis:
    # GET: /api/v1/someresource/some-path/
    my_object = c.someresource('some-path').get()
    pprint(my_object)
    logger.info('------------------------------')
    logger.info('------------------------------')

    payload = {
        'data1': 'val1',
        'data2': 'val2',
    }

    resp = c.someresource.post(data=payload)
    pprint(resp)

    logger.info('------------------------------')

    c.logout()


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text:
Jimmy Fallon Explains Ring Avulsion Injury [Video]
Home » Jimmy Fallon Explains Ring Avulsion Injury [Video]
Jimmy Fallon, the Tonight Show host and comedian, explained his ring avulsion injury to the late-night TV audience upon his return to the show on Monday, July 13. The gruesome injury has sidelined the Tonight Show host for more than two weeks and nearly cost the former Saturday Night Live (SNL) player his ring finger. Fallon's complicated injury required surgery and landed him in the Intensive Care Unit (ICU) of Bellevue Hospital in New York City for 10 days. The video clip of Fallon explaining his ring avulsion injury to the audience is located at the end of this article.
The comedian was forced to cancel a June 26 taping following an accident at home that resulted in his newsworthy injury. Fallon tripped over a rug in his kitchen and caught his wedding ring on the kitchen counter during his fall, which resulted in the host's mangled finger. Initially, the Tonight Show host believed he had broken his finger, but upon his arrival at the emergency room, he was quickly notified by the ER staff that his situation was very serious indeed. The Fever Pitch actor was promptly transferred to Bellevue Hospital and referred to a microsurgery specialist in an effort to save his traumatized digit.
It was during this time that Fallon was made aware of the severity and complexity of his injury. A ring avulsion can occur anytime a ring catches on a surface forcefully enough that the soft tissue and skin of the finger becomes torn or dislodged. The hospital staff explained that the severity of a ring avulsion can vary greatly. In some cases, the injury involves only mild bruising and contusions. In more severe cases, however, it can result in partial or total deglovement, which involves all the soft tissue and skin of the digit being ripped off similar to the removal of a glove. Moreover, in severe cases, amputation of the digit is often required. Given the severity of Fallon's injury, this scenario was a likely outcome.
Alas, the Tonight Show host lucked out, thanks to the efforts of the staff at Bellevue Hospital in New York City. In particular, the TV personality owed his good fortune to a skilled microsurgeon, who implanted a vein from the comedian's foot into his hand. The late-night host underwent six hours of surgery in order to repair the injury and spent 10 days in the ICU. As the comedian continues to recover, he is expected to regain the feeling in his hand over the next two months.
While ring avulsion injuries are more common than many might think, severe injury cases are relatively rare. However, many patients who suffer from similar injuries are not as lucky as Fallon. Case in point, according to a 2014 study published in the journal Hand, researchers evaluated the treatment outcomes for 33 patients who experienced similar ring injuries, which included avulsions as well as other less severe ring injuries, and found that nine of those cases resulted in amputations.
Medical experts have recommended common sense approaches for lowering the risk of such injuries including removing rings in dangerous work environments or hazardous situations (e.g. construction or factory work, using power tools, playing contact sports, etc.), wearing a ring on a chain, making a cut in the ring to provide an opening, and getting a ring tattoo in place of a traditional ring. Moreover, as a result of his injury and recent experience, Fallon has tweeted that he has a new idea for wedding bands. In fact, he is clamoring for jewelers around the world to contact him about his wedding ring concept.
Tonight Show host and comedian Jimmy Fallon explained his ring avulsion injury to the late-night TV audience upon his return to the show on July 13. The gruesome injury had sidelined the Tonight Show host for more than two weeks and nearly cost the former SNL player his ring finger. Fallon detailed his complicated injury, surgery, and 10-day ICU hospital stay for the viewers, who were relieved to see him back at work. As promised, watch the video clip of Fallon explaining his ring avulsion injury to the audience below.
Written and Edited by Leigh Haugh
Entertainment Weekly–Jimmy Fallon Almost Lost His Finger Because He Tripped Over a Rug
Health–How a Finger Injury Landed Jimmy Fallon in the Hospital for 10 Days
Sydney Morning Herald–Jimmy Fallon Reveals Nearly Losing a Finger in Ring Avulsion Injury
Fallon, injury, Jimmy Fallon, Ring Avulsion, tonight show
By Leigh Haugh
2 thoughts on "Jimmy Fallon Explains Ring Avulsion Injury [Video]"
Knot Theory (@knotheory) says:
Still a good ending since Jimmy Fallon got to keep his finger! Our design house creates silicone wedding rings to prevent ring avulsions like this. Let your loved ones know that they can find us at knotheory.com 🙂
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Editor's note: John Walters, Seven Days' next political columnist, will take over "Fair Game" in January.
Even as governor-elect Phil Scott appears to lean right in his early choices for top administration posts, he hewed a cautious, centrist line Tuesday morning in an interview with Seven Days.
Indeed. Scott brought up the issue of affordable housing unbidden, after discussing the overarching theme of his pending administration: affordability and economic opportunity. He was clear in making the issue a priority but noncommittal about how he would address it. Government grants, tax incentives, guided zoning, easing the permitting process?
"It's probably a combination of all of the above," he declared.
I think it's more about the process than the way you seek that — and I'm not artfully saying this — it's not about compromising our environmental goals, it's more about the process in the way. It's the bureaucracy that gets in the way sometimes. It's frustrating.
It's hard to know whether this was just his roundabout way of speaking or if he was being deliberately obscure. But the result was, one came away without a clear idea of his actual plans or agenda.
Nothing that you want to disclose?
Yeah. But there are some interesting concepts that we're contemplating. There are areas where we think that there can be some improvement. And I believe that we will be able to fulfill my promise of not raising revenue, or not, uhh, trying to limit the growth of the budget. I believe that we'll be able to accomplish that. But it's going to take some creative, a creative approach, which I think there's some opportunity.
He was equally vague about his legislative agenda ("There certainly are a number of areas.") and how he would use the levers of executive power to advance his agenda without legislative buy-in.
I believe that there will be some opportunity for us to provide for our citizens and protect them. I think it's essential that we do.
Asked if there had been any surprises in his role as governor-elect, Scott responded with a dose of humanity.
I don't think there have been any big surprises, but certainly your life is different. You're under more of a microscope, and your life is different in terms of having to schedule everything, and your life is scheduled for you, and trying to keep a personal life is challenging.
Even the spouses were talking about how difficult it is to get in because you have security, so you have a little disagreement with your significant other, and you have to learn that there's somebody else there, and it's going to happen. [chuckle] And getting comfortable with the fact is … interesting.
Finally, on a subject of special concern around Vermont racetracks, the Thunder Road SpeedBowl veteran expressed hope that he wouldn't have to completely give up his favorite spare-time activity — auto racing.
I'm negotiating that with my security as we speak. To be honest, it's been part of my life for a long time, and it would be — it's not the highest priority on my list, but if I could do a couple races, I would.
That'd sell a few tickets at Thunder Road. Wouldn't you pay to see a sitting governor tradin' paint with the boys?


I was sooo wrong when I thought the windows on the west side of the north tower were "tiny." I apologize to anyone I may have led astray and hopefully this brief video will help clear things up.
That is exactly what I was referring to which paints you into a corner.
Jim Fetzer Interviews Pablo Novi!


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Tag: La venda
Spain / by Sanjay (Sergio) Jiandani - March 28, 2019 5:36 pm
Spain: Miki to sing at Earth Hour concert in Madrid on Saturday
TVE, the Spanish national broadcaster, has revealed today that Miki will be its ambassador at the next Saturday's Earth Hour concert. The Spanish hopeful is set to perform his Eurovision…
Spain: TVE reveals commentators and spokesperson for Eurovision 2019
TVE, the Spanish national broadcaster, has confirmed the commentators and spokesperson for the forhcoming 2019 Eurovision Song Contest in Tel Aviv. Julia Varela and Tony Aguilar will be flying to…
Spain / by Sanjay (Sergio) Jiandani - March 7, 2019 12:10 am
Spain: Miki releases the official music video of 'La Venda'
TVE, the Spanish national broadcaster has released the official music video of the 2019 Spanish Eurovision entry 'La Venda'. The 2019 Spanish Eurovision hopeful Miki has released the official video…
Spain / by Sanjay (Sergio) Jiandani - March 4, 2019 12:30 pm
Spain: Miki flies to Israel to film postcard: official video premiere on 6 March
Miki, the 2019 Spanish Eurovision hopeful is flying to Israel today in order to film his Eurovision postcard. He will be premiering the official music video of his Eurovision entry…
Spain / by Sanjay (Sergio) Jiandani - February 16, 2019 2:00 pm
Spain: Fokas Evangelinos will be resposible for Miki's staging in Tel Aviv
TVE, the Spanish national broadcaster, has announced today that the internationally acclaimed Greek stage director Fokas Evagelinos will be responsible for Miki's staging at the forthcoming 2019 Eurovision Song Contest…
Spain: Miki films official music video of 'La Venda'
TVE, the Spanish national broadcaster has unveiled details on Miki's Eurovision entry's official music video along with a set of exclusive photographs from the shooting. The official music video of…