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Dietz, Rob
By: Dietz, Rob, Rob Dietz, Daniel W ONeill
It's time for a new kind of economy
We're overusing the earth's finite resources, and yet excessive consumption is failing to improve our lives. In Enough Is Enough, Rob Dietz and Dan O'Neill lay out a visionary but realistic alternative to the perpetual pursuit of economic growth—an economy where the goal is not more but enough.
They explore specific strategies to conserve natural resources, stabilize population, reduce inequality, fix the financial system, create jobs, and more—all with the aim of maximizing long-term well-being instead of short-term profits. Filled with fresh ideas and surprising optimism, Enough Is Enough is the primer for achieving genuine prosperity and a hopeful future for all.
"Humans seem to be intent on confirming the argument of biologist Ernst Mayr that higher intelligence may be a lethal mutation. But the grim prognosis is not inevitable. This lucid, informed, and highly constructive book shows that with the will to act, solutions can be found to build a steady-state economy geared to meeting human needs."
"Rob Dietz and Dan O'Neill bring clarity and style to their impassioned and meticulous analysis, offering the way to a better quality of life and a sustainable future for all."
—Kate Pickett, Professor of Epidemiology, University of York; cofounder, The Equality Trust; and coauthor of The Spirit Level
"Dietz and O'Neill create a remarkable vision—a world with enough prosperity and happiness for everyone, not just for a few. This book will restore your hope in the future and give you specific things you can do to help!"
—Thom Hartmann, internationally syndicated talk show host and author of twenty-four books
Published by: Berrett-Koehler Publishers Details Related titles
Chapter 1. Have You Had Enough?
A person who knows that enough is enough will always have enough.
LAO TZU (SIXTH CENTURY B.C.E.)
A game of checkers offers very little insight into how to solve the world's intertwined environmental and social problems, or so I thought. In one particular game, my opponent opened with a series of reckless moves, placing checker after checker in harm's way. When I jumped the first one and swiped it off the board, I briefly wondered if I was being lured into a trap. But it was just a fleeting thought. After all, my opponent was only five years old.
I was playing against my daughter. She had just gotten home from her kindergarten class, and I was giving her a few strategy pointers from my limited bag of tricks. Her moves showed some modest improvement, but after a while, we both lost interest in the game. Besides, there are other fun things you can do with checkers, like seeing how high a tower you can build. At first, we were fast and free with our stacking—we even plopped down two or three checkers at a time. But as the tower grew, we changed our approach. With the light touch and steady hands of a surgical team, we took turns adding checkers one by one to the top of the stack. By this point, our formerly straight tower had taken on a disconcerting lean. On our final attempt to increase its height, the mighty checker tower reached the inevitable tipping point and came crashing down to earth. Like a reporter interpreting the scene, my daughter remarked, "Sometimes when things get too big, they fall."
Chapter 2. Why Should Enough Be the Goal?
Anyone who believes exponential growth can go on forever in a finite world is either a madman or an economist.
KENNETH BOULDING 1
To appreciate why an economy based on enough is worth striving for, it is useful to examine the failings of an economy that forever chases more. It's no secret that the dominant economic philosophy of modernity is more—more people and more production, more money and more consumption. Employees try to earn more income, business managers try to report more revenue on the balance sheet, and politicians try to ensure that the economy churns out more goods and services. On the surface, more seems like a good idea. For an employee, more money can mean financial security; for a business manager, more revenue can result in a promotion; and for a politician, more national income can generate votes in the next election. But if you dig beneath the surface, you begin to uncover the fatal flaws of more.
One person who has dug deeply is Jack Santa-Barbara. The story of his career serves as a personal case study for choosing enough instead of more. After earning a doctorate in psychology and working in academia for a while, he founded Corporate Health Consultants (CHC), a company with a mission to reduce stress on working people and help them improve their mental health. His company succeeded in both achieving its mission and turning a considerable profit. But money was never the motivation for Santa-Barbara. He says, "I've taken on work in my career only because I thought it was useful and interesting," a sentiment that's supported by his determined pursuit of other interests.2
Chapter 3. How Much Is Enough?
This extraordinary ramping up of global economic activity has no historical precedent. It's totally at odds with our scientific knowledge of the finite resource base and the fragile ecology on which we depend for survival.
TIM JACKSON 1
Determining how big the economy can grow with respect to the biosphere is a problem of scale, and scale is a concept that confounds many people. I met one such confounded person during a bike trip along the Chesapeake and Ohio Canal. The C&O Canal cuts a narrow path for 185 miles through the leafy, rock-strewn countryside of Maryland. After its completion in 1850, barges loaded with coal, timber, and food floated down the canal from the hills of Maryland into the heart of Washington, D.C. For seventy-four years, mules walked the towpath, pulling the barges, until competition from railroads and relentless poundings from floods put the canal out of business.2
But the C&O has lived a good life in its post-commerce years as a recreational respite from the hustle and bustle of Washington and other nearby towns. Along with its noteworthy scenery, the canal's route wanders through the tumultuous history of the American Civil War. It includes such destinations as Harpers Ferry, where the abolitionist John Brown seized the federal arsenal, and Antietam, one of the bloodiest battlefields of the war. This rich history helped the C&O attain its status as a National Historical Park and avoid being swallowed by the urban sprawl that radiated from the national capital after World War II.
Chapter 4. What Sort of Economy Provides Enough?
It is not enough simply to attack the progrowth orthodoxy; we must have an alternative vision.
HERMAN DALY 1
Students in college economics courses occasionally express their frustrations, and when they do, it can be both loud and public. Each fall at the University of Pennsylvania, home of the Wharton School of Business, students enrolled in Economics 101 participate in a curious ritual that can fairly be described as loud and public. The night before the first midterm exam, students abandon the library early, even though you'd expect them to linger among the dusty rows of books for one last look at their production-possibility frontiers and supply-and-demand curves. It doesn't take a reconnaissance team to track down the missing students—they can be found hanging out on the Junior Balcony and grassy field of the lower Quad.
More and more students make their way to the Quad as the hour approaches midnight. A nervous energy begins to pulse through the crowd, and windows open in the dorm rooms above, so that residents can get a good look at the gathering horde. A minute before midnight, an unsettling quiet descends on the students as they take a collective inward breath. Then the quiet is broken by a countdown, much like the one in Times Square on New Year's Eve. Ten, nine, eight, seven, …
Chapter 5. Enough Throughput
Limiting Resource Use and Waste Production
The Earth has no way of registering good intentions or future inventions or high hopes. It doesn't even pay attention to dollars, which are, from a planet's point of view, just a charming human invention. Planets measure only physical things—energy and materials and their flows into and out of the changing populations of living creatures.
DONELLA MEADOWS 1
Whether a mansion in Monaco, an apartment in Argentina, or a cottage in Cambodia, every household has a measurable metabolism. Materials, from trash cans to ceiling fans, from apple pies to French fries, flow into the household from external sources. Each household also obtains supplies of energy, such as electricity, sunshine, and natural gas, from the outside world. Members of the household consume the materials and use the energy to support their lifestyles. And finally, the household completes the metabolic process by expelling wastes to the environment through carbon dioxide emissions, wastewater discharge, and trash disposal. This metabolism, the flow of materials and energy and the emission of wastes, can be called the throughput of the household.
Chapter 6. Enough People
Stabilizing Population
I've never seen a problem that wouldn't be easier to solve with fewer people. The same problem becomes harder, or ultimately impossible, when more people are involved.
SIR DAVID ATTENBOROUGH 1
An unusual house sits in a typical middle-class neighborhood in the suburbs of Atlanta. Fifty homes that look like an early 1970s vision of the American dream line the neighborhood's shady cul-de-sacs. The mass-produced houses sit on parcels carved out of the forested red-clay slopes typical of Georgia's Piedmont region. These houses mostly look alike, since they share the same cultural and architectural roots, but the very last house at the end of the street stands out. It's a custom job with unusual coffee-colored brickwork, small built-in courtyards for rock gardens, and a design that still strikes most observers as being modern. It is the home of a Chinese-American family, and the youngest of the family's four children was my best friend when I was a kid.
It was obvious, even to a second-grader, that David's house was different on the outside, but I also noticed something different the first time I saw the inside. On the wall of the study, the room where we spent time discussing crucial matters such as Halloween costumes and the best design for a bicycle seat (banana or standard?), was a row of framed photos of U.S. presidents, from Lyndon Johnson to Jimmy Carter. Now that's an odd choice for a wall decoration, especially in a home adorned with scrolls, sculptures, and pottery from the Far East. Even odder was that each photo had a hand-written message and signature on it.
Chapter 7. Enough Inequality
Distributing Income and Wealth
Among the new objects that attracted my attention during my stay in the United States, none struck me with greater force than the equality of conditions. I easily perceived the enormous influence that this primary fact exercises on the workings of the society.
ALEXIS DE TOCQUEVILLE (1835) 1
In 1897 two tremendously influential artists were born in the American South. One lived a life of poverty, died in his forties among the ashes of his burned-down house, and remained anonymous until years after his death. The other lived into his mid-sixties, garnered international fame, and accumulated plenty of money and prestigious awards.
If you have a name like Blind Willie Johnson, then you just might be a blues musician. In the life stories of blues artists, it's hard to separate myth from fact, but according to a mishmash of sources, Johnson was raised by his father and stepmother, both of whom had a mean streak. When Johnson was seven years old, his father beat his stepmother when he caught her with another man. In a ghastly moment of revenge, she picked up a handful of lye and threw it into the face of her attacker's son.2 Blind as a result of this violent act, Johnson turned to religion and gospel music. He went on to preach and perform on street corners. He played a soulful slide guitar while singing with a gravelly bass voice "that could grind glass."3 He caught the attention of Columbia Records and recorded a set of songs between 1927 and 1930. Despite his musical talents, he lived his whole life in poverty. When his home burned down in 1945, he had nowhere else to go, so he remained among the ruins. In the open air, he fell ill and died.4
Chapter 8. Enough Debt
Reforming Monetary and Financial Systems
Even the apparently simple question of where money comes from is hard to answer. It's not the government printing press; money really originates when banks make loans. And since they charge interest for those loans, part of the endless-economic-growth model is in place right from the beginning—without the growth, you can't pay off the interest.
BILL MCKIBBEN 1
In the early 1990s when financial derivatives were taking off in the world of securities trading, one of Wall Street's rising stars, John Fullerton, was taking off on a flight bound for Tokyo. It was his inaugural trip as the manager of J. P. Morgan's commodities investment business in Asia, and it was a heady time. He was young—in fact, he was the second-youngest person ever to have become a manager at the renowned bank—and, as he remembers it, he was "running with the big dogs."2
When the flight got under way, he smiled to himself as he unfolded a copy of the New York Times. In addition to the demands of his rising career, he faced the demands of having a two-year-old and an infant at home. The first-class seat seemed like a luxury, but it was nothing compared to the luxury of being able to relax in peace with a newspaper. He should have felt like a million dollars, but instead he had an uneasy sense that he was in the wrong place. The fact that it was Father's Day weekend undoubtedly played a role. As they might say in the financial industry, leaving his family behind on that particular weekend had a "deflationary effect" on his excitement about his new job. But something else also troubled him.
Chapter 9. Enough Miscalculation
Changing the Way We Measure Progress
[T]he gross national product does not allow for the health of our children, the quality of their education, or the joy of their play. It does not include the beauty of our poetry or the strength of our marriages, the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage, neither our wisdom nor our learning, neither our compassion nor our devotion to our country; it measures everything, in short, except that which makes life worthwhile.
ROBERT F. KENNEDY (1968) 1
"Almost heaven, West Virginia, Blue Ridge Mountains, Shenandoah River …" I was in a backwoods bar late one evening with three friends, when one of them dropped a quarter in the jukebox and selected John Denver's "Country Roads." The four of us, already on our third round of beer, began singing along. Soon enough, the other five or six patrons in the bar had joined our chorus. It would have been a typical scene in this particular bar, located in rural Virginia alongside the very Blue Ridge Mountains referenced in the song, except for one oddity. My three friends, Sonam, Tchewang, and Jigme, hailed from the Himalayan kingdom of Bhutan. It was quite a sight to see the solemn, bearded faces of the locals across the bar singing their hearts out with the three Himalayan visitors. When the song was over, all of us, Bhutanese and Americans, raised our beer bottles in a salute to happy times and the universal appeal of music.
Chapter 10. Enough Unemployment
Securing Meaningful Jobs
Ultimately society, not the economy, determines how many people are out of work.
BLAKE ALCOTT 1
Deb Wren is the ideal employee, and her work ethic is one reason why. She grew up on a dairy farm where hard work was the norm, and she routinely helped with chores during her school years. Although she left home to attend college, farm life left a strong impression on her, so after earning her degree, she returned to the family farm to work alongside her father. Wren's warmth and positive attitude shine through, even as she describes her struggles tending a herd of cows in the frozen winter of upstate New York.
"It was so cold, and we had fifty or sixty new calves—a huge number for our small operation. We were doing our best to keep them warm and well fed. It was aggravating, because calves generally don't know what they're doing. But the heifers were even more of a problem. We'd spend the first two hours each morning milking them, and some of them had frostbitten teats—they were hard, scarred, and sore, and the cows would kick like crazy."2 Considering days like that, a nice, warm office might sound appealing, but Wren looks back on those times with fondness; she thinks that farm work strengthened her bond with her family and helped her develop a healthy appreciation of animals and the outdoors.
Chapter 11. Enough Business as Usual
Rethinking Commerce
Business is the economic engine of our Western culture, and if it could be transformed to truly serve nature as well as ourselves, it could become essential to our rescue.
KARL-HENRIK ROBÈRT 1
What's the most influential book that takes a critical view of the environmental excesses of business? There's an argument to be made for Henry David Thoreau's Walden, Rachel Carson's Silent Spring, and E. F. Schumacher's Small Is Beautiful, but our award goes to The Lorax by Dr. Seuss. Seuss created a fanciful landscape and populated it with a technicolor forest of Truffula Trees, a menagerie of curious critters, and two main characters—a clever entrepreneur named the Once-ler and a tenacious environmentalist called the Lorax.2 In part, the book's influence is due to Dr. Seuss's legendary rapport with children (and adults who stubbornly cling to a childlike sense of wonder). His eccentric illustrations, lyrical rhymes, and inventive language give the book staying power, but its influence also stems from its universal storyline—a storyline that resonates with readers who have observed the downsides of modern business practices.
Chapter 12. Enough Materialism
Changing Consumer Behavior
In rich countries today, consumption consists of people spending money they don't have to buy goods they don't need to impress people they don't like.
CLIVE HAMILTON 1
The stuff lying around in the workshop reveals that someone has been working on two distinct projects: building a wooden cabinet and repairing a bicycle. The warm smell of sawdust competes with the earthy odor of grease, and the tools of both the carpenter and the bike mechanic stake their claims on the workbench. Cardboard boxes of scrap lumber fight with crates of old bike parts for territory on the floor. For both projects (or any other conceivable project), there's a bin containing several rolls of duct tape. And keeping guard over this scene are sanders and saws, wrenches and routers, and pliers and planes arranged on the racks and shelves that line the walls.
Even though it's been decommissioned for years, I can still see my dad down there, thumbing through drawers of nuts, bolts, and spare parts to find just the right doohickey to solve some mechanical mishap. It's the workshop he kept in the basement of our house, and by any measure, it was overstocked. The tool usage rate was minuscule. Sure, he knew how to use (and even how to find) every item down there, but he had stuff you'd hardly ever need. He was clearly a tool addict. He'd buy an oscillating, pump-action, hot-glue demagnetizer if he could find a reason to justify the purchase.
Chapter 13. Enough Silence
Engaging Politicians and the Media
A voice is a human gift; it should be cherished and used, to utter fully human speech as possible. Powerlessness and silence go together.
MARGARET ATWOOD 1
During the summer before my final year in college, I worked as an intern for America's largest labor union, the American Federation of Labor and Congress of Industrial Organizations. Ironically, the AFLCIO hired my services for less than minimum wage. Despite the low pay, it turned out to be a great summer, especially after I learned which bars in downtown Washington, D.C., offered free tacos at happy hour. At my first day on the job, I learned (perhaps not too surprisingly) that the AFL-CIO cares a great deal about how members of Congress view a variety of labor issues. In fact, my boss told me that my top task each day was to comb through newspapers and collect articles about unions and the politics of labor. This was at a time just before the Internet held sway, so I would literally skim through a stack of newspapers and cut and paste the relevant articles onto sheets of paper. Then I would file the pasted articles in folders to be read by the union leaders.
Chapter 14. Enough Unilateralism
Changing National Goals and Improving International Cooperation
On a visit to Leningrad some years ago, I consulted a map to find out where I was, but I could not make it out. From where I stood, I could see several enormous churches, yet there was no trace of them on my map. When finally an interpreter came to help me, he said: "We don't show churches on our maps." … It then occurred to me that this was not the first time I had been given a map which failed to show many things I could see right in front of my eyes. All through school and university I had been given maps of life and knowledge on which there was hardly a trace of many of the things that I most cared about and that seemed to me to be of the greatest possible importance to the conduct of my life.
E. F. SCHUMACHER (1977) 1
The United States, with less than 5 percent of the world's population, emits about 18 percent of the world's total output of greenhouse gases.2 The five largest coal users, China, the United States, India, Russia, and Japan, consume 77 percent of the world's coal production.3 In the twenty-first century, when a single nation's consumption habits can produce global consequences, unilateral economic decisions can be downright dangerous. Aggressive competition, especially among the wealthiest nations, for control of critical resources like land, water, and oil could prove disastrous. The last thing we need is a race to wring the final fragments of growth out of an already overgrown global economy.
Chapter 15. Enough Waiting
Taking Action to Start the Transition
[H]ere's the deal: forget that this task of planet-saving is not possible in the time required. Don't be put off by people who know what is not possible. Do what needs to be done, and check to see if it was impossible only after you are done.
PAUL HAWKEN 1
According to Greek mythology, Helios, the sun god, lights the earth each day by driving his fiery chariot across the sky. He has made the trip from sunrise to sunset nearly nine hundred thousand times while the Parthenon has stood atop the Athenian Acropolis. This ancient temple has survived for more than two thousand years because it was conceived and constructed with durability in mind. The architects developed a timeless design, and the builders delivered a strong foundation and support structure. The same principles apply to creating a lasting economy: start with a good blueprint, construct a strong economic foundation, and build well-crafted policy pillars on top of it.
As described in Part I of this book, the social and environmental challenges of our times call for a new economic blueprint. The business-as-usual approach of chasing perpetual growth is failing. It is not sustainable on a finite planet, and it is damaging the natural systems upon which the economy depends. It is also not solving the problems of unemployment, poverty, and inequality. Nor is it improving the well-being of those who already have enough material wealth. To address these issues, we need a new economic structure designed for stability instead of growth.
Safe Enough to Soar
Why People Don't Believe You…
Hello, My Name Is Awesome
Up Is Not the Only Way
How You Learn Is How You Live
How to Change Minds: The Art of Influence without Manipulation
Execution IS the Strategy
What is a Child?
What is Psychotherapeutic Research?
Change Is Everybody's Business
Identity Is Destiny
Dietz, Rob, Rob Dietz, Daniel W ONeill
Berrett-Koehler Publishers


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Princess Bride by William Goldman has been reviewed by Focus on the Family's marriage and parenting magazine.
As a child sick with pneumonia, William Goldman's father read him a book titled The Princess Bride, which inspired Goldman's love of reading. Grown up and with a writing career and a son of his own, Goldman gives a copy of this fictional book to his son as a birthday present — only to realize his father had been skipping whole chapters, thinking they would be boring for a 10-year-old.
Goldman sets out to write an abridged version of The Princess Bride, leaving only the exciting parts so that his son can enjoy it, too. This idea runs throughout the book, occasionally interrupting the narrative with comments about the publishing industry, Goldman's childhood memories and his personal life.
Buttercup is a beautiful young girl who lives on a farm in the fictional European country of Florin. After several years, she realizes she's in love with Westley, the quiet farmhand who has served her father for many years. Upon professing her love, Westley makes plans to move to America, in order to make enough money and have enough land to provide for Buttercup as his wife. Not long after he leaves, however, Buttercup learns that the Dread Pirate Roberts captured Westley's ship — and the Dread Pirate Roberts takes no prisoners.
The King of Florin is very old and his health declining. His son, Prince Humperdink, makes plans to marry and, eventually, have a son who will take his place. At first, he plans to marry the princess from the neighboring country of Guilder, but upon learning the princess is bald, he decides to marry a girl from Florin — any girl, so long as she has hair.
Hearing of Buttercup's beauty, Humperdink finds her on her father's farm and demands that she marry him. Buttercup, emotionally stunted since Westley's death, stresses that she does not and will never love Humperdink, but agrees to marry him, rather than risk death by denying the prince.
Buttercup spends the next few years at princess school, growing in beauty and knowledge. The evening after she is officially introduced to the people of Florin, she is kidnapped by three men: a devious Sicilian plotting war; a quiet Spaniard seeking vengeance against the man who killed his father; and a giant Turk who, for all his strength, is gentle.
The reader quickly learns that the trio has been hired to frame Guilder for Buttercup's murder, thereby starting a war between Guilder and Florin. The Spaniard, Inigo, and the Turk, Fezzik, don't want to hurt Buttercup, but both of them have their reasons for following Vizzini: He's smart, and neither one of them can figure out how to get what they want without him.
Despite Vizzini's best-laid plans to get Buttercup to Guilder undetected, a man in black follows the trio. This man bests Inigo in fencing, defeats Fezzik in a test of strength and tricks Vizzini into poisoning himself. The man in black treats Buttercup cruelly at first as they run from Humperdink, an excellent hunter who pursues Buttercup as soon as she is discovered kidnapped.
The man in black turns out to be Westley, alive after all. He explains how he had befriended Roberts, who eventually retired and gave Westley the title of "Dread Pirate Roberts." His pirate ship waits to take them away from Florin and into their new lives together, but Humperdink catches them before they can escape.
Buttercup chooses to return to Humperdink rather than die with Westley, insisting that the prince return Westley to his ship. Humperdink agrees, but instead brings Westley to his Zoo of Death, a four-level subterranean zoo that houses all manner of animals the prince likes to hunt. Westley is tortured in the zoo for months. He is eventually placed on a machine that sucks life out of its victims, and painfully, he dies.
As Buttercup, Humperdink, and the rest of the country continue making plans for the royal wedding, Buttercup begins to regret leaving Westley. He had risked everything to find her, but she had left him anyway. Since his death, she hadn't allowed herself to truly feel anything, but soon realizes she never stopped loving Westley. She tells Humperdink that she'd rather die than marry anyone but Westley.
Humperdink lies to Buttercup and assures her that he will send messengers to Westley in order to bring him back to Florin. The reader learns that Humperdink had hired Vizzini to kidnap Buttercup in the first place in order to start the war with Guilder, and since that failed, he plans to murder Buttercup after the wedding. During this time — between Westley's death, Humperdink's plotting and the idea that true love will not win the day — the author offers several lengthy passages about the unfairness of life.
Without Vizzini, Inigo can't formulate a plan to find the six-fingered man who killed his father. In despair, he turns to drink. The day of Buttercup and Humperdink's wedding, Fezzik finds Inigo and nurses him back to health. Fezzik explains that Count Rugen, Humperdink's confidant, is the six-fingered man whom Inigo has sought for 20 years. Inigo, knowing he can't make a plan on his own, searches for Westley, the man in black who outwitted Vizzini. He and Fezzik storm the Zoo of Death, only to find Westley (at this point, only recently) dead.
Undeterred, Inigo and Fezzik take Westley to Miracle Max, an out-of-work sorcerer who can temporarily raise people from the dead. They ask for a one-hour spell — just enough time to stop the wedding and kill Count Rugen — but Max, a little rusty on making miracles, realizes after they leave that the spell will only last for 45 minutes.
In spite of the time constraints, the three defeat the 100 men guarding the palace; Inigo kills Count Rugen, at last; Westley rescues Buttercup, although by now she is technically married to Humperdink; and Fezzik finds a way for them to escape. When the spell wears off, Westley prays for the strength to keep living. He declares he will never die, even as he begins to fade again, with Humperdink hot on their trail. S. Morgenstern's narrative ends here, but Goldman adds how he thinks the story ought to end, repeating again that life is not fair.
God is mentioned occasionally, as a being that exists and has power over their world, but not necessarily one that demands their worship.
When Inigo expresses his discomfort at having to kill Buttercup, Vizzini tells him that God kills girls, so they shouldn't feel guilty. In a dream in which Buttercup and Humperdink are married, Humperdink calls their child a gift from God.
While preparing to torture Westley on the machine, Count Rugen says the Serpent in the Garden of Eden was the embodiment of pain. When Humperdink suggests that Westley might not return, Buttercup responds by saying she believes he'll return as surely as she believes in love and believes in God.
While waiting for Westley to save her from marrying Humperdink, Buttercup kneels at her bed and thinks of him, as if praying to Westley.
Count Rugen is convinced that the opposite of death is pain, rather than life. Several passages are influenced by Jewish culture, particularly in the interactions with Miracle Max and his wife. When Miracle Max's spell wears off and Westley starts dying again, he prays to a being he calls the Lord of Permanent Affection to stay alive.
Buttercup's parents are portrayed as constantly arguing. The sick king has little authority beyond his title, and his wife generally speaks for him. Humperdink uses his political influence to plot wars and hunt in exotic places. Vizzini views other people as lesser beings and treats his followers — Inigo and Fezzik — with derision and cruelty. When Inigo's father is killed, Yeste, a friend of the family, takes care of Inigo for two years.
In a way, Goldman himself has the strongest authority role in the story, as he uses the supposed abridgement to tell (or not tell) the story in the way he wants it told. In a few places, Goldman interrupts the story in order to warn younger readers (anticipating their parents' explanation of difficult passages) not to listen to their parents, that what he says is more trustworthy.
The following words appear in the text: h---, d--n, b--ch, and s---. Miracle Max calls Inigo a spick, which is a derogatory term for a Spaniard. God's name and Christ's name are used in vain a few times.
Vizzini and Westley both slap Buttercup. When Buttercup insults Humperdink, he pulls her by the hair from the room. Buttercup is knocked out after she tries to escape so they can make better time to the cliffs of insanity.
When Fezzik is first learning to fight, he accidentally breaks his father's jaw. In Inigo's first duel with Count Rugen, the count slashes Inigo's face, leaving him permanently scarred. In their final duel, Inigo returns the favor, and also threatens to cut out Count Rugen's heart. Other fights occur throughout the book. Humperdink kills several animals.
The prince and the count torture Westley, such as pouring boiling oil on his hands and putting him in a machine that sucks the life out of him.
Westley and Buttercup's first kiss is not described, but the reader is told it was the best kiss of all time.
Introductions: This version of the book includes two introductions, one for the 30th anniversary, and an earlier one for the 25th anniversary of the book. Both include references to the actors and other people involved with the making of The Princess Bride the movie, and also speaks of S. Morgenstern as if he were a real person and Florin as a real place. Goldman also gives more details about his personal life in the introductions, including negative comments about his ex-wife and their overweight son, as well as an encounter with a younger woman that almost resulted in an affair. These additional sections aren't necessary to read, but they help the reader understand the unconventional format of the story itself.
Buttercup's Baby: This version of the book includes an epilogue — the abridged first chapter to what we are told is S. Morgenstern's sequel to The Princess Bride, entitled Buttercup's Baby. Like the rest of the book, Goldman interjects once in a while to explain why he removed certain passages. A lengthy note before Buttercup's Baby explains why Goldman only abridges the first chapter. This section includes a scene where Buttercup and Westley are having sex, but the act is implied rather than described.
Women: The main narrative takes place in medieval times, and female characters, especially Buttercup, are treated more like objects rather than human beings with inherent rights and dignity.
Suicide: In a flashback, Inigo remembers his father, Domingo, and their friend Yeste arguing. Yeste takes out a knife and jokingly threatens to kill himself if Domingo doesn't agree with him. When Buttercup realizes she's in love with Westley, she declares she'd rather kill herself than marry Humperdink. When Westley doesn't rescue her and she does end up marrying Humperdink, she returns to Humperdink's chambers with the intent of killing herself, but Westley is there to stop her.
AdventureRomanceFairy Tale

redpajama_set_name: RedPajamaCommonCrawl


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For a very long time I wanted to take a painting class. I had the opportunity to take a class tonight. This is what we made. I honestly felt mine was the worst one of the class, but I'm okay with that. It was relaxing and fun. I will try again in the near future!
Maryanne Christiano-Mistretta is an author and award-winning journalist. Her latest book, "The Gypsy Smiled" can be purchased on Amazon: https://www.amazon.com/Gypsy-Smiled-Maryanne-Christiano-Mistretta-ebook/dp/B074VC7MT9
Tagged: art for beginners, inspiration, inspirational, painting for beginners, sunflower painting, trying something new
West Orange Arts Council Event
Maryanne Christiano-Mistretta and Carol Black-Lemon, artist
As a journalist, I'm usually covering stories on the weekend. Today was the first Saturday I had free in a long time. I looked up NJ Events and saw that the West Orange Arts Council was having a Mother's Day Shopping Boutique event. For those in the area, it's happening again tomorrow (Sunday, May 6, 2018) from 1 to 5 p.m. at 551 Valley Road, West Orange, New Jersey.
This event was so cool, I just had to blog about it! Check out all the links and maybe you can guess which artists I purchased from. It was a tough choice!
Carol Black-Lemon (www.blacklemonart.com) has original paintings, plus handmade jewelry.
Vivienne O'Neill (https://www.etsy.com/shop/vivienneoneill) has unique handmade fashion accessories, home furnishings, and all-natural beauty items, including natural soap made with goat's milk.
JDenaro (https://shop.aboutfacejdenaro.com/) is a fashion designer who has unique t-shirts, pillows and much more.
Sheila N. Kibutu (http://www.shiiscollection.com/) has incredible jewelry.
Sheila N. Kibutu, jewelry artist
I hope you enjoyed checking out all the artist's websites and remember to buy local whenever you can! ❤
For more information on the West Orange Arts Council, go here: http://www.woarts.org/
Tagged: art in new jersey, arts, black lemon, carol black-lemon, handmade jewelry, inspiration, jdenaro, New Jersey, new jersey artists, sheila n. kibutu, shii's collection, things to do in new jersey, vivienne o'neill designs, west orange arts council, west orange new jersey
'Pat DiNizio Way'
Pat DiNizio Way (photo by Maryanne Christiano-Mistretta)
Scotch Plains Township Ceremoniously Unveils 'Pat DiNizio Way' in Honor of Late Smithereens Frontman
By Maryanne Christiano-Mistretta
(Artical originally appeared in Scotch Plains Monthly)
Smithereens fans, friends, family, and township officials gathered on April 17, 2018, at Montague Avenue, at the corner of Westfield Avenue, for the official Pat DiNizio Way street unveiling
Pat DiNizio, frontman for The Smithereens passed away December 12, 2017, at the age of 62. He was a proud resident of Scotch Plains.
"It's a little bittersweet for us. Obviously, we'd rather have him than the sign," said Paul "Paulie" J. Smith, who grew up in Scotch Plains with DiNizio. "It's very heart warming for the town we grew up in to give him recognition. It's emotional he's not here anymore. Deep inside he'd feel touched and honored. He was humble, he'd be a little embarrassed about the recognition."
Jim Babjak, Smithereens guitarist agreed. "He'd say, 'Don't make a big deal of it' on one hand, but he'd be winking; Pat would be very honored."
Babjak performed a Smithereens song, "Life is So Beautiful" prior to the street unveiling. He also gave a heartfelt speech, ending with, "He was a real trooper, he kept playing to the very end."
Severo Jornacion, Smithereens bassist, who was able to fly in from L.A., said, "Of all places Pat lived in his life, Scotch Plains was his favorite." He reminisced about the places in Scotch Plains that Pat took him to, like Alfonso's Pizzeria, Stage House Tavern, and even the local Quick Check.
Band members Dennis Diken and Mike Mesaros weren't there, but Babjak read emotional messages from them, as well as a heartrending letter from DiNizio's daughter, Elisabeth.
Musician Rick Winowksi, who played in Pat's other band, The Scotch Plainsmen, performed a poignant song he wrote in honor of DiNizio.
Mayor Al Smith said the he "got emails from all over the country. Best thing we could do is have a street named after him."
Township Manager Al Mirabella said, "I wish we weren't here. I wish Pat was here. I'm glad you are here to honor Pat. Pat was a real fan of Scotch Plains and we're a real fan of his."
Bill King, fan and friend, said "We're still mourning. His voice is so full of emotion reflected in his songs. One thing was evident; how much he loved his mom."
After each speaker at the podium shared their memories of Pat, there were cheers and tears from the audience. It was truly a moving event. After the unveiling Antoinette DiNizio, Pat's mom, made an appearance. She proudly spoke about her beloved son to the many who approached her.
Fan Frank Lima, who spearheaded the event, said, "Pat's one of the greatest songwriters. I'm sad the whole thing had to happen. I'm glad to get the whole ball rolling. [Regarding the street naming]."
The Smithereens sold millions of records/CDs of melodic pop alternative hits like "A Girl Like You," "Only a Memory," "Behind the Wall of Sleep," and "Blood and Roses."
For more information on The Smithereens, visit the official website at: officialsmithereens.com.
To see original article, including more photos by Maryanne Christiano-Mistretta, visit: https://rennamedia.com/scotch-plains-township-ceremoniously-unveils-pat-dinizio-way-in-honor-of-late-smithereens-frontman/
Maryanne Christiano-Mistretta is the author of "On the Guest List: Adventures of a Music Journalist" available on Rebel Press: https://www.rebelpress.com/product/on-the-guest-list/
Tagged: Al Mirabella Scotch Plains, Antoinette DiNizio, Dennis Diken, dennis lords, dennis lords pharoah, entertainment, Frank Lima, jim babjak, Mayor Al Smith, Mayor Al Smith Scotch Plains New Jersey, Mike Mesaros, music, musicians from new jersey, New Jersey Musicians, Nick Clemente, Nick Clemente The Mylars, pat dinizio, Pat DiNizio Way, scotch plains new jersey, Severo Jornacion, the smithereens


Mesa Verde Apartments is a beautiful new construction family affordable housing development comprised of ninety (90) residential units in San Diego, CA. Come take a look at our one, two, and three bedroom apartment homes that are uniquely designed with the amenities in mind for you including. Take advantage of all the community amenities we offer at Mesa Verde such as a 1,600 square foot community room including a multipurpose room, community kitchen, laundry facility and computer lab.
Mesa Verde Apartments is located in a prime location with close proximity to essential neighborhood community amenities including public parks, trails and open space, neighbor serving commercial and retail, employment centers, schools, medical and healthcare facilities, and grocery/pharmaceutical stores.


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Q: Refresh Div in real time for all users at the same time? I need to know how I can refresh a div in real time for all users at the same time?
I have searched and searched for days and still haven't found a solid answer to this other than AJAX but when I try to find an example (even a simple example would do) so I can understand it, all i found was using AJAX to refresh a Div for one user (client side)!
is this a top coding secret that is kept from newbies like me or noone really knows the answer?
I even found the same question was asked on stackoverflow but again all the answers were "AJAX". okay lets say we are going to use ajax, but all the examples, tutorials are about refreshing a div for one user Not all the users!
Could someone point me in a right direction please? any examples, tutorials would be appreciated.
EDIT:
One example of what i mean is the timers on penny auctions! the timers and the highest bidder will be shown at the same time to all the users! there is no delay and even if there is its only a few milli seconds.

A: You can refresh your data with setting a refresh time. Like described here:
http://matthewaprice.com/simple-jquery-ajax-auto-refreshing-div/
Hope this will answer your question :)
*Edit; never mind just read you also read about refreshing option. My bad, did overread that.

A: I would suggest starting with a single user Ajax script and then expanding on that. You could create an ajax script that on the client side asks the server "Anything to tell the users?" Every 5 seconds or so. The server could then check a database if there is something to inform the users.
Like this, all users are polling every 5 seconds for updates and when you do have something to say, it will be displayed with an 5 second margin for all users if the polling works. The server controls the time, the client just polls.
After getting the message to show to the users from the server, refreshing the div should be trivial, something like $('#TheDiv').html("<p>" + yourservermessage + "</p>");.

Edit after comments: if performance or other issues demands it, using a synced option like web sockets might be prefereable. For those, check out http://socket.io/ and this related SO question. It does get a little more complicated compared to traditional polling though.

A: I maybe old school here but an iframe with a meta refresh wouldn't do the job ?

A: Use Websockets, there are good librarys for that already online
http://socketo.me/api/namespace-Ratchet.html
or
http://socket.io/

redpajama_set_name: RedPajamaStackExchange


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You are here: Home / Announcements / Bay Area Federation launches multi-year $7.6m. Teen Initiative
Bay Area Federation launches multi-year $7.6m. Teen Initiative
March 15, 2018 By eJP
Screenshot: Jewish Community HS of the Bay
The Jewish Community Federation of San Francisco, the Peninsula, Marin and Sonoma Counties (the Federation) has launched its Jewish Teen Education and Engagement Initiative, a five-year, $7.6 million endeavor.
The Initiative was designed with 1:1 match funding by the Jim Joseph Foundation, in the context of the national Jewish Teen Education and Engagement Funder Collaborative and will include five components:
Innovation Accelerator to scale, expand, and diversify innovative programs for teens with grant funding to a cohort of nonprofit organizations, entrepreneurial training, and coaching;
Professional Development to support well-trained, high caliber Jewish educators, widely recognized as the key to successfully engaging teens;
Experimentation Micro-Grants to pilot and test new program ideas;
Information Hub to provide a centralized resource for teens, parents, and the community; and
Scholarships to create incentives for teen participation in immersive experiences and Israel travel.
Additional support for and partnership in this work comes from The Jewish Federation and The Jewish Community Foundation of the East Bay.
The Federation's board of directors has approved $2 million in grants to community partners to be disbursed over three years. Of these grants, nearly $1.2 million were awarded as part of an Innovation Accelerator to organizations poised to scale, expand and diversify innovative program offerings. Programs in the Innovation Accelerator will participate in cohort-based learning on entrepreneurial methods and mindsets, guided by UpStart, a San Francisco-based incubator for Jewish community innovation.
The Teen Initiative's first set of grants include:
BBYO – San Francisco/Marin Expansion and Enrichment Initiative ($145,000)
Camp Tawonga – Teen Year-Round Engagement & Leadership Development Program ($150,000)
Congregation Emanu-El – The Gathering ($150,000)
The Contemporary Jewish Museum (CJM) – Museum Teen Council ($125,000)
JCC of San Francisco – Teen Arts Immersion Program (TAIP) ($125,000)
Jewish Youth for Community Action (JYCA) and Peninsula JCC – Peninsula-JYCA ($150,000)
Oshman Family Jewish Community Center – FACST-Fun, Active, Community Service for Teens ($150,000)
NCSY – Jewish Student Union (JSU) Culture Clubs ($150,000)
Camp Ramah in Northern California/Ramah Galim ($25,000)
Jewish LearningWorks ($745,000)
Filed Under: Announcements Tagged With: Engaging Jewish Teens, federation impact, Jim Joseph Foundation, UpStart


Since September of 1984, the East Lansing Educational Foundation's (ELEF) mission has been to "enhance excellence in public education by raising and distributing private resources for the benefit and enrichment of all students." ELEF's president, Mindy Emerson said, "Strong schools, which maintain high standards and opportunities, are a hallmark of a successful city when attracting new businesses and residents. ELEF wants that tradition of excellence to continue in the face of perpetually dwindling state funding." The organization began when one of East Lansing's first public schools, Bailey Elementary School, was scheduled to close. In order to memorialize the school, members of the East Lansing Bailey Neighborhood Association decided to donate leftover funds raised by the Bailey Parent Council, thus beginning the East Lansing Educational Foundation. "The foundation supports supplemental opportunities, which in turn support a strong East Lansing community," said Emerson. Today, the educational foundation develops enrichment programs, fosters the development of alumni relations and helps to fund equipment and facilities, which are not otherwise funded for East Lansing schools. This year the ELEF celebrated 25 years of service to the East Lansing community. Donations totaling over $400,000 have enhanced performing arts, student leadership and curricular excellence programs across the district. Each fall and spring, teachers throughout the district are encouraged to apply for various grants, which benefit all areas of K–12 curriculum. The ELEF would not be possible without the strong community support that they receive. "We have a strongly–committed hard–working group of volunteers serving on our governing board," stated Emerson. With a dedicated team of volunteers, the ELEF is able to continue to raise money for the district with their various events. These include a September football tailgate to welcome new kindergarten families, a May golf outing and an awards dinner to honor graduating seniors. Emerson said, "The donations by our citizens have had, and will continue to have, impact now and for future generations of students of the East Lansing Public Schools." If you are interested in volunteering with the East Lansing Educational Foundation, contact Emerson at elefmindy@gmail.com.
A senior at Michigan State University pursuing a career in communications and public relations, Danielle enjoys cooking, traveling and all Middle Eastern food.


Little Snow, young Inuit, tries to capture a bird from the depths for, according to tradition, to pass into the world of aldulthood. But as the girl catches the bird, she falls into the bottom of a fjord so extraordinary as disturbing, that of Giant Dwarf, an ogre who has the power, by a simple sneeze, to change at will size. An initiatory tale for young and old.


3 bedroom Property For Sale with 3 bedrooms and 2 bathrooms and an indoor area of 800 square meters. This stand-alone Property is located in Lat Phrao , it was completed in 2012 Oct. It is available for sale for a price of ฿22,990,000 and you can but the Property freehold.
3 bedroom Property For Sale with 3 bedrooms and 5 bathrooms and an indoor area of 350 square meters. The Property is part of the gated estate community THE WINGS - NAKNIWAT18 in Lat Phrao, Bangkok, Lat Phrao , it is scheduled for completion in 2018 Dec. It is available for sale for a price of ฿14,500,000 and you can but the Property freehold.
BK-37536 is a 200 square meter 3 bedroom Property with 3 bedrooms and 2 bathrooms that is available For Sale., It belongs to the Sena Niwet 1 Village development in Bangkok, Lat Phrao and was completed in 2005 May. The Property can be bought with a freehold ownership title for a sales price of ฿15,000,000 (฿75,000/Sq.M).
Find 3 bedroom Property For Sale in Lat Phrao.


text:
Prevalence of typical circle of Willis and the variation in the anterior communicating artery: A study of a Sri Lankan population
K Ranil D De Silva1, Rukmal Silva1, W.S.L Gunasekera2, RW Jayesekera3
1 Department of Anatomy, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka
2 Department of Anatomy, National Hospital of Sri Lanka, Sri Lanka
3 Department of Anatomy, Faculty of Medicine, Colombo, Sri Lanka
Date of Submission 04-May-2009
Date of Decision 21-May-2009
Date of Acceptance 18-Jun-2009
Date of Web Publication 8-Oct-2009
K Ranil D De Silva
Department of Anatomy, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda
Objective: To determine the extent of hypoplasia of the component vessels of the circle of Willis (CW) and the anatomical variations in the anterior communicating artery (AcomA) in the subjects who have died of causes unrelated to the brain and compare with previous autopsy studies. Materials and Methods: The external diameter of all the arteries forming the CW in 225 normal Sri Lankan adult cadaver brains was measured using a calibrated grid to determine the occurrence of "typical" CWs, where all of the component vessels had a diameter of more than 1 mm. Variations in the AcomA were classified into 12 types based on Ozaki et al., 1977. Results: 193 (86%) showed "hypoplasia", of which 127 (56.4%) were with multiple anomalies. Posterior communicating artery (PcoA) was hypoplastic bilaterally in 93 (51%) and unilaterally in 49 (13%). Precommunicating segment of the posterior cerebral arteries (P1) was hypoplastic bilaterally in 3 (2%), unilaterally in 14 (4%), and AcomA was hypoplastic in 91 (25%). The precommunicating segment of the anterior cerebral arteries (A1) was hypoplastic unilaterally in 17 (5%). Types of variations in the AcomA were: single 145 (65%), fusion 52 (23%), double 22 (10%) [V shape, Y shape, H shape, N shape], triplication 1 (0.44%), presence of median anterior cerebral artery 5 (2%), and aneurysm 1 (0.44%). Conclusion: The occurrence of "typical" CW in autopsy brains was rare. Further studies would be necessary to determine if these anatomical variations could predispose to cerebral ischemia and premature stroke in the Sri Lankan population.
Keywords: Anterior communicating artery, anatomical study, circle of Willis, hypoplasia, ischemic stroke
De Silva K R, Silva R, Gunasekera W, Jayesekera R W. Prevalence of typical circle of Willis and the variation in the anterior communicating artery: A study of a Sri Lankan population. Ann Indian Acad Neurol 2009;12:157-61
De Silva K R, Silva R, Gunasekera W, Jayesekera R W. Prevalence of typical circle of Willis and the variation in the anterior communicating artery: A study of a Sri Lankan population. Ann Indian Acad Neurol [serial online] 2009 [cited 2019 Jul 18];12:157-61. Available from: http://www.annalsofian.org/text.asp?2009/12/3/157/56314
Ischemic stroke in young adults (aged 15-45 years) is proportionately more common in India (15-30%) [1] and in Sri Lanka (34%), [2] in contrast to (3−5%) [3] in the West, the etiology of the majority of strokes in young adults in Sri Lanka is unexplained. [4],[5]
The circle of Willis (CW) plays an important role in cerebral hemodynamics as a collateral anastomotic channel, and presence of an intact CW should be more effective in facilitating cross flow compared to situations where there are deficiencies in the CW. There is a close correlation between a low capacity CW and an increased risk of stroke, [6],[7],[8],[9] collateral ability of the CW be best used when an emergency supervenes, depending on the presence and the size of the luminal caliber of its component vessels. [10],[11],[12]
Many studies have repotted a wide range in variation in the anatomy of the CW and the anterior communicating artery (AcomA) among normal individuals, [13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] hypoplasia of the component arteries of the CW has been studied in India. [17],[21],[26],[27] Hypoplasia of the component arteries of the CW and the anatomical variations of the AcomA has not been previously studied in Sri Lanka and the aim of this cadaveric study was to assess the extent of hypoplasia (diameters <1 mm) of component vessels of the CW; namely the internal carotid arteries (ICAs), precommunicating part of the anterior cerebral arteries (A1), AcomA, precommunicating part of the posterior cerebral arteries (P1), and posterior communicating arteries (PcoA); and the anatomical variations of the AcomA in subjects who have died of causes unrelated to the brain and compare with previous autopsy studies.
225 brains were obtained after ethical approval from medicolegal autopsies on individuals, aged between 18 and 73 years, who had died of causes unrelated to the brain and whose brains demonstrated no gross macroscopic evidence of cerebrovascular disease . The brains were removed from the cranial cavity and fixed in 10% formaldehyde. Blood was carefully washed out from the CW with isotonic saline. The arteries comprising the CW together with the basilar artery with minute branches arising from the main vessels were then carefully removed from the base of the brain. The external diameters of A1, AcomA, PcoA, and P1 were measured using a stereomicroscope equipped with a micrometer-calibrator (Leica). The equipment was standardized according to the manufacturer's specifications. The measurements were performed three times on each segment, by the first author and the calculated average was recorded as the value, line diagrams, and photographic records made, a vessel was recorded as absent only when it was not detected following examination under the dissecting microscope. In the present study, "typical" CW was defined if all of the component vessels of the CW were present, origin of the vessels forming the CW was from its typical source and the size of a component vessel more than 1 mm in diameter. [18] Hypoplasia was defined if a component vessel/s of the CW were less than 1 mm in diameter. [18]
Variations in the AcomA were classified into 12 types: single, one point fusion, long fusion, double, V shape, Y shape, H shape, N shape, triple, plexiform, presence of median anterior cerebral artery, and aneurysms; based on Ozaki et al., 1977 [23] and compared with studies. [18],[22],[23],[24],[25],[26] Macroaneurysm of the AcomA were recorded with line diagrams and photographs.
In the present study, 'typical circles' were found only in 32 (14.2%) of the brains. 193 (85.8%) showed hypoplasia, of which 127 (56.4%) were with multiple anomalies. The most frequent site of anomaly was in the posterior half of the circle (70%). There were no instances where any of the component vessels were completely absent.
361 component arteries of the CW were hypoplastic, 255 (70%) posteriorly, and 106 (30%) anteriorly. PcoA was hypoplastic bilaterally in 93 (51.5%), unilaterally in 49 (13.5%), 24 on the left, and 25 on the right side of the CW. P1 was hypoplastic bilaterally in 3 (1.6%), unilaterally in 14 (3.8%), 8 on the left, and 6 on the right side of the CW. AcomA was hypoplastic in 91 (25%). A1 was hypoplastic unilaterally in 15 (4.1%), 5 on the left and 10 on the right side of the CW.
Variations in the AcomA are indicated in [Table 1] and [Figure 1]A−E. Hypoplasia of the AcomA was seen in 91 (25.07%) of the specimens. One (0.44%) macroaneurysm, 25 mm in diameter, was identified arising from the AcomA in a 21-year-old female whose cause of death was homicide [Figure 2].
Hypoplasia of the component arteries of the CW has been reported in anatomic studies ranging from 0.7 % [19] to 80.6%, [20] and the proportion of 85.8% observed in the present study, appears to be the highest observed in a population. The prevalence of the 'typical circle', the "normal" textbook polygon ranges from 4.6% [28] to 72.2%. [19] A possible reason for the wide range may be the diversity in nomenclature and the criteria used to define hypoplastic vessels. There is little unanimity in nomenclature and quantitative measurement of the diameters of all the component vessels of 'circle', which has not been measured in several studies and have relied up on rough estimations of the vessel diameter in determining the anomalies of the CW rather than actual measurements. Vessels have been described as 'thread-like', 'string-like', 'minute', and 'very small' without regards to measured diameter.
In the present study, typical configuration was found only in 14.2% of the brains compared to 26.8%, [17] 53.2%, [21] and 45.2% [26] of studies conducted in India and 52.3% in the US. [18] Quantitative measurement of the actual external diameter of all the component vessels of the CW and specimens has been done routinely in the present study. It is believed that Sri Lankans have a common origin from India. The wide range in the prevalence of typical configuration between Indian and Sri Lankan studies, warrants further studies to ascertain influence of genetic, racial, regional, environmental, hemodynamic factors, or a combination of any of them.
The minimum threshold diameter for supplying collateral flow through CW, as assessed by transcranial color-coded duplex ultrasonography (TCCD) and carotid compression tests, was compared with their unfixed postmortem anatomy lies between 0.4 and 0.6 mm. The PcoA threshold diameter for collateral function was slightly higher than the AcomA threshold diameter, possibly due to greater length of PcoA. [29] In the absence of studies showing how far the postmortem arterial diameters of fresh or fixed brains are equal to in vivo diameters and the effect of absence of perfusion pressure and possible postmortem shrinking of the arterial wall, in the present study we defined vessels less than 1 mm in diameter as "hypoplastic" or "string-like".
The most frequent site of abnormal diameters was seen in the posterior half of the circle, and the 70% proportion in the present study is similar to other reported series, [6],[18],[19],[20],[21],[26],[30] this may be related to the embryological development of the posterior half of the CW, where the basilar and the ICAs anastomose during development of the cerebral arteries.
Reported incidence of absent arteries in the CW in normal brains leading to an incomplete circle range from 0.6% [18] to 17%. [23] In the present study of 225 autopsies, a vessel was considered absent only when it was not visualized despite careful examination under the dissecting microscope and there were no such instances observed. A meticulous examination is needed to demonstrate small twigs forming the CW. This is dependent upon proper collection of samples, careful removal of the brain and the CW and thorough examination under the dissecting microscope for torn arteries before a vessel is classified as absent. The presence even of small vessels may be important for potential collateral channels.
The state of the circle becomes important in determining the adequacy of the brain circulation. The possibility of by-passing or shunting effects in occlusion of one of the cerebral vessels and the adequacy of recovery or lack of recovery after vascular occlusions may be explained in part by variations in the anatomy of the circle of Willis. [11] A rapid, high reperfusion strongly increases survival in the ischemic penumbra, inhibiting the growth of the core region.
It has been reported that in Asians, the incidence of intracranial atherosclerosis in anterior circulation stroke is much higher than Caucasians. [31] Prevalence of posterior circulation stroke among Asians has been reported much higher compared to the West. [32],[33],[34] The average age of patients in the developing countries with stroke is 15 years younger than in developed countries. [35] The reasons for these differences are not well-understood and role of anatomy and the pathology of the cerebral arteries in the pathogenesis of cerebrovascular diseases in different ethnic or racial groups are far from clear. There exist several postulates as to the underlying reasons for the anatomical variation of the CW: amplitude of the neck movements, [36] hemodynamic factors, [15],[37] postnatal development, [38] and genetic factors. [39]
The findings of the anomalies of the AcomA in the present study, studies conducted in India [21],[26] and from those of more diverse populations, [18],[19],[21],[22],[23],[24],[25],[26] reported in the literature appears to be similar and is possibly due to embryonic development.
In the absence of studies showing relationship between functional in vivo diameters and postmortem arterial diameters of fixed brains, we used an arbitrary diameter of 1 mm of component vessels of the CW as hypoplastic. We did not measure the narrowest part of the arteries; these parts probably may determine collateral ability.
The present study reveals that high incidence of hypoplastic vessels (193 of 225; 86%) and with multiple anomalies (127 of 225; 56.4%), in the CW in the Sri Lankan population, whether it acts in combination with arteriosclerotic changes and/or changes in of food habits and/or genetic difference between normal and anamalous type of cerebral arteries, would contribute to premature strokes in young adults warrants further investigations.
This study was supported by Hiran Tillekeratne Research Fund, University Grants Commission, and Research Grant from the University of Sri Jayewadenepura. We wish to thank Dr. LBL De Alwis and Dr. Ananda Samarasekera, Judicial Medical Officers, for granting permission to inspect the samples, Mr. A. Dais for photography, and Mr. RAD Ratuwithana for data entry.
1. Anand K, Chowdhury D, Singh KB, Pandav CS, Kapoor SK. Estimation of mortality and morbidity of strokes in India. Neuroepidemiology 2001;20:208-11.
2. Gunatilake SB, Gunatilake HC. Young strokes: An increasing problem. Oral presentation, 104 th Anniversary Academic Sessions of the Sri Lanka Medical Association, Sri Lanka. 1991 March: 25.
3. Blecic S, Bogousslavsky J. Stroke in young adults. In: Barnett HJ, Mohr JP, Stein BM, Atsu FM, editors. Stroke-path physiology, diagnosis and management. 3 rd ed. New York: Churchill Livingstone; 1998. p. 1001-12.
4. Seneviratne BI, Ameratunga B. Strokes in young adults. Br Med J 1972;3:791-3.
5. De Silva KRD, Gamage R, Wewelwala CC, Gunarathna D, Kittner SJ, Sirisena D, et al. Young strokes in Sri Lanka: An unsolved problem. J Stroke Cerebrovasc Dis.2009; 14:304-308.
6. Fetterman GH, Moran TJ. Anomalies of the circle of Willis in relation to cerebral softening. Arch Pathol. 1941; 32: 251-7.
7. Alpers BJ, Berry RG. Circle of Willis in cerebral vascular disorders. Arch Neurol. 1963;8:398-402.
8. Battacharji SK, Hutchinson EC, McCall AJ. The circle of Willis: The incidence of developmental abnormalities in normal and infracted brains. Brain. 1967; 90: 747-58.
9. Henderson RD, Eliasziw M, Fox AJ, Rothwell PM, Barnett HJ. Angiographically defined collateral circulation and risk of stroke in patients with severe carotid artery stenosis. Stroke 2000;31:128-32.
10. Mull M, Schwarz M, Thron A. Cerebral hemispheric low-flow infarcts in arterial occlusive disease: Lesion patterns and angiomorphological conditions. Stroke 1997;28:118-23.
11. Miralles M, Dolz JL, Cotillas J, Aldoma J, Santiso MA, Gimenez A, et al. The role of the circle of Willis in carotid occlusion: Assessment with phase contrast MR angiography and transcranial duplex. Eur J Vasc Endovasc Surg 1995;10:424-30.
12. Shomer DF, Marks MP, Steinberg GK, Johnstone IM, Boothroyd DB, Ross MR, et al. The anatomy of the posterior communicating artery as a risk factor for ischemic cerebral infarction. N Engl J Med 1994;330:1565-70.
13. Barboriak DP, Provenzale JM. Pictorial review: Magnetic resonance angiography of arterial variants at the circle of Willis. Clin Radiol 1997;52:429-36.
14. Hillen B. The variability of the circle of Willis: Univariate and bivariate analysis. Acta Morphol Neth Scand 1986;24:87-101.
15. Hillen B. The variability of the circulus arteriosus (Willisii): Order or anarchy. Acta Anat (Basel) 1987;129:74-80.
16. Krabbe-Hartkamp MJ, Van der Grond J, de Leeuw FE, de Groot JC, Algra A, Hillen B, et al. Circle of Willis: Morphological variation on MR angiograms. Radiology 1998;207:103-11.
17. Vare AM, Bansal PC. Arterial Pattern at the base of the human brain. J Anat Soc India 1970;19:71-9.
18. Alpers BJ, Berry RG, Paddison RM. Anatomical studies of the circle of Willis in normal brain. Arch Neurol Psychiat 1959;81:409-18.
19. Fawcett E, Blachford JV. The circle of Willis. An examination of 700 specimens. J Anat and Physiol 1905;40:63-70.
20. Riggs HE, Rupp C. Variations in form of circle of Willis. Arch Neurol. 1963;8:8-14.
21. Reddy DR, Prabhakar V, Rao BD. Anatomical Study of Circle of Willis. Neurology India 1972;20:8-12.
22. Puchades-Orts A, Nombela-Gomez M, Ortuno-Pacheco G. Variation in form of Circle of Willis: Some anatomical and embryological considerations. Anat Rec 1976;185:119-23.
23. Ozaki T, Handa H, Tomomoto K, Hazama F. Anatomical variations of the arterial system of the base of the brain. Arch Jap Chir 1977;46:3-17.
24. Fujimoto K, Tanaka O. Morphological examination of the circulus arteriosus cerebri humani (circle of Willis) I. Anterior and posterior communicating arteries. Acta Anatomica (Nippon) 1989;64:481-9.
25. Eftekhar B, Dadmehr M, Ansari S, Ghodsi M, Nazparvar B, Ketabchi E. Are the distributions of variations of circle of Willis different in different populations? - Results of an anatomical study and review of literature. BMC Neurol 2006;6:22.
26. Kapoor K, Singh B, Dewan LI. Variations in the configuration of the circle of Willis. Anat Sci Int 2008;83:96-106.
27. Tandon PN. Epidemological study on subarachnoid haemorrhage in India (1972-75). ICMR.1987; 1-34.
28. Fisher CM. The circle of Willis: Anatomical variations. Vasc Dis 1965;2:99-105.
29. Hoksbergen AW, Fulesdi B, Legemate DA, Csiba L. Collateral configuration of the circle of Willis: Transcranial color-coded duplex ultrasonography and comparison with postmortem anatomy. Stroke 2000;31:1346-51.
30. Kamath S. Observations on the length and diameter of vessels forming the circle of Willis. J Anat 1981;133:419-23.
31. Moossy J. Pathology of cerebral atherosclerosis. Influence of age, race, and gender. Stroke 1993;24:I22-3; I31-2.
32. Lee JH, Han SJ, Yun YH, Choi HC, Jung S, Cho SJ, et al. Posterior circulation ischemic stroke in Korean population. Eur J Neurol 2006;13:742-8.
33. Bogousslavsky J, Melle GV, Regli F. The Lausanne stroke registry: analysis of 1000 consecutive patients with first stroke. Stroke 1988;19:1083-92.
34. Moulin T, Tatu L, Crιpin-Leblond T, Chavot D, Bergθs S, Rumbach T. The BesanΗon stroke registry: An acute stroke registry of 2500 consecutive patients. European Neurology 1997;38:10-20.
35. Truelsen T, Bonita R, Jamrozik K. Surveillance of stroke: A global perspective. Int J Epidemiol 2001;30:S11-6.
36. Lazorthes G, Gouaze A, Santini JJ, Salamon G. The arterial circle of the brain (circulus arteriosus cerebri). Anatomia Clinica 1979;1:241-57.
37. Milenkovic Z, Vucetic R, Puzic M. Asymmetry and anomalies of the circle of Willis in fetal brain. Microsurgical study and functional remarks. Surg Neurol 1985;24:563-70.
38. Stehbens WE. Etiology of intracranial berry aneurysms. J Neurosurg 1989;70:823-31.
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[Figure 1], [Figure 2]
1 Cerebrovascular MRI: a review of state-of-the-art approaches, methods and techniques
Matthew Ethan MacDonald,Richard Frayne
NMR in Biomedicine. 2015; 28(7): 767
2 Assessment of the Circle of Willis with Cranial Tomography Angiography
Ayse Karatas,Gokmen Coban,Celal Cinar,Ismail Oran,Aysun Uz
Medical Science Monitor. 2015; 21: 2647
3 Function of circle of Willis
Zvonimir Vrselja,Hrvoje Brkic,Stefan Mrdenovic,Radivoje Radic,Goran Curic
Journal of Cerebral Blood Flow & Metabolism. 2014;
4 Acute stroke: Basic concepts and use of imaging for clinicians
Authors of Document Castillo, M., Alvarez, H.
JBR-BTR. 2013;
5 result 2 Document Display with 64-detector MDCT angiography of cerebral vascular variations
Authors of Document Hamidi, C., Bükte, Y., Hattapoǧlu, S., (...), Gümüş, H., Bilici, A.
Source of the Document Surgical and Radiologic Anatomy. 2013;
6 A comprehensive study of the anatomical variations of the circle of Willis in adult human brains
Authors of Document Iqbal, S.
Source of the Document Journal of Clinical and Diagnostic Research. 2013;
De Silva K R
Silva R
Gunasekera W
Jayesekera R W
Anterior communicating artery
anatomical study
circle of Willis
hypoplasia
Article in PDF (198 KB)
Article Figures


text:
Shareholder Wins M&A Advisor Award
Amy Moss
Corporate, Securities & Finance
Texas Lawyers Newsmakers: Week of Jan. 13, 2020
Chamberlain Hrdlicka in Houston has announced that shareholder Amy Moss was named among The M&A Advisor's 18th annual M&A Advisor Award winners for her leadership in the acquisition of Garvin Industries Inc. by Southwire Co. The matter was selected by the publication as the M&A Deal of the Year in the $25 million to $50 million category at an awards dinner held Nov. 19 in New York City. Additionally, Moss was named as a finalist in the following categories: Industrials Deal of the Year ($10 million to $50 million); and Corporate/ Strategic Deal of the Year ($25 million to $50 million).
"Since 2002, we have been honoring the leading M&A transactions, companies and dealmakers. Chamberlain Hrdlicka was chosen from over 500 participating companies to receive the award." said Roger Aguinaldo, founder of The M&A Advisor, in a statement. "Chamberlain Hrdlicka represents the best of the M&A industry in 2019 and earned these honors by standing out in a group of very impressive candidates."
Moss counsels public and private companies in a broad spectrum of corporate transactions, with an emphasis on mergers and acquisitions, restructurings, private placements and public offerings. Her clients include venture capitalists, private equity funds, entrepreneurs, startups and emerging technology companies. She earned her undergraduate degree from Arizona State University and her law degree from the Vanderbilt School of Law.
"We are proud of Amy for her many contributions to our firm, including this successful result on behalf of her client, and are thankful to The M&A Advisor for the well-deserved recognition," said Wayne Risoli, managing shareholder at Chamberlain Hrdlicka, in a statement issued by the firm. "The M&A Advisor compiled an impressive list of honorees for this year's awards, and we are grateful to be included."
Subscribers may access the online version of the article here.
Amy Moss - Newsmaker in Texas Lawyer_ 01 13 2020.pdf


The 35yo actress told the courts today she intends to plead guilty. She is not represented by a lawyer and the case has been adjourned to July 1. The charge was over an accident that happened on 12 April when she reportedly knocked over a stationary motorcycle while turning into the carpark of her apartment. She may be jailed up to six months and/or fined up to S$1,000 for the offence.
2. One door closes, hopefully another opens?
Did you read our retrenchment stories on Double Negative and also the one from the Oil & Gas industry?
Hope they find better jobs soon! More here.
3. Free life and personal insurance coverage for our men!
The Ministry of Defence (Mindef) and Ministry of Home Affairs (MHA) will provide free life and personal insurance coverage for both full-time and operationally ready national servicemen with effect from 1st July. The scheme applies to servicemen in the Singapore Armed Forces (SAF), Singapore Police Force (SPF) and Singapore Civil Defence Force (SCDF).
4. Bring your Wellingtons to Bangkok!
If you're heading for Bangkok, be sure to pack your rain gear! Heavy rain yesterday brought traffic to a standstill in some parts of the city. Some schools and businesses even had to close. Weather forecasts update that rainy seasons with more rain and thunderstorms are coming, so consider yourselves warned!
Hello Kitty's lead designer tells the origin story of the British schoolgirl. Remember how the world went cray last year when it was revealed that Hello Kitty is not actually a cat, but a British girl? There's more.
The lead designer was actually puzzled why people thought Hello Kitty is a cat. Ermmm… Moving on… Did you know Hello Kitty had a mouth back in the 1980s? And they're gonna roll out more Kitty relatives after introducing Paul, Daniel's father. They're working on Daniel's mother and his twin brother.


text:
Q: HAML template error with no UTF characters: ActionView::Template::Error (incompatible character encodings: ASCII-8BIT and UTF-8) I'm getting this error, but only on production, and only when editing a specific record. It doesn't happen in development, and it doesn't happen for any other record. Not only that, but there are no UTF characters in the template, no UTF characters in en.yml, and the record also has no UTF characters either! I can view/show the record fine.
272 <158>1 2017-10-16T16:57:50.349003+00:00 host heroku router - at=info method=GET path="/users/26/edit" host=www.host.net request_id=6d8d22cc-3050-4628-85a4-f660991b4ce3 fwd="99.99.99.99" dyno=web.1 connect=4ms service=442ms status=500 bytes=1733 protocol=https
145 <190>1 2017-10-16T16:57:50.345615+00:00 host app web.1 - F, [2017-10-16T16:57:50.344992 #4] FATAL -- : [6d8d22cc-3050-4628-85a4-f660991b4ce3]
228 <190>1 2017-10-16T16:57:50.345696+00:00 host app web.1 - F, [2017-10-16T16:57:50.345626 #4] FATAL -- : [6d8d22cc-3050-4628-85a4-f660991b4ce3] ActionView::Template::Error (incompatible character encodings: ASCII-8BIT and UTF-8):
173 <190>1 2017-10-16T16:57:50.346033+00:00 host app web.1 - F, [2017-10-16T16:57:50.345973 #4] FATAL -- : [6d8d22cc-3050-4628-85a4-f660991b4ce3]     55:           .input-group
150 <190>1 2017-10-16T16:57:50.346035+00:00 host app web.1 - [6d8d22cc-3050-4628-85a4-f660991b4ce3]     56:             - us = Country.find_by code: 'US'
237 <190>1 2017-10-16T16:57:50.346036+00:00 host app web.1 - [6d8d22cc-3050-4628-85a4-f660991b4ce3]     57:             =cf.collection_select :country_id, [us] + Country.all, :id, :name, {prompt: t('company.country')}, class: 'form-control'
146 <190>1 2017-10-16T16:57:50.346037+00:00 host app web.1 - [6d8d22cc-3050-4628-85a4-f660991b4ce3]     58:             .input-group-addon.required *
143 <190>1 2017-10-16T16:57:50.346038+00:00 host app web.1 - [6d8d22cc-3050-4628-85a4-f660991b4ce3]     59:   .card-header= t 'company.financials'
118 <190>1 2017-10-16T16:57:50.346039+00:00 host app web.1 - [6d8d22cc-3050-4628-85a4-f660991b4ce3]     60:   .card-block
119 <190>1 2017-10-16T16:57:50.346040+00:00 host app web.1 - [6d8d22cc-3050-4628-85a4-f660991b4ce3]     61:     .card-text
145 <190>1 2017-10-16T16:57:50.346087+00:00 host app web.1 - F, [2017-10-16T16:57:50.346035 #4] FATAL -- : [6d8d22cc-3050-4628-85a4-f660991b4ce3]
259 <190>1 2017-10-16T16:57:50.346213+00:00 host app web.1 - F, [2017-10-16T16:57:50.346100 #4] FATAL -- : [6d8d22cc-3050-4628-85a4-f660991b4ce3] app/views/companies/_edit.haml:58:in `block in _app_views_companies__edit_haml___3739913582972992033_70135683358520'

The HAML is
      .input-group
        - us = Country.find_by code: 'US'
        =cf.collection_select :country_id, [us] + Country.all, :id, :name, {prompt: t('company.country')}, class: 'form-control'
        .input-group-addon.required *

Countries does not have any UTF characters except for 'Saint-Barthélemy' and 'São Tomé and Príncipe'. However I can still edit other records and list all countries fine.
I tried the solutions in

*

*ActionView::Template::Error (incompatible character encodings: UTF-8 and ASCII-8BIT) (I'm not using request.)

*incompatible character encodings: ASCII-8BIT and UTF-8 (I have no UTF in the template.)

*Error: Incompatible character encodings: UTF-8 and ASCII-8BIT (I set NLS_LANG=AMERICAN_AMERICA.UTF8.)

None of them worked. I also tried
  class Application < Rails::Application
    config.encoding = "utf-8"

I am using Heroku, Postgres, HAML, and Rails 5.0.6.

A: I hooked up my local server to the production database and tried to edit the record. I commented out whole sections with -# until it loaded and narrowed it to .description field, which definitely wasn't what was in the error message. I used the web debugger to print out the field
>>  @user.company.description
=> "... world\xE2\x80\x99s largest ..."
>>  @user.company.description.encoding
=> #<Encoding:ASCII-8BIT>

And I saw it was not UTF-8 encoding. (But strange that it will display it in #show fine. I tracked the problem to a custom type
class Company < ApplicationRecord
  @@encrypted_fields = [:name, :phone, :address1, :address2, :ein, :bank, :url, :description]
  @@encrypted_fields.each do |ef|
    attribute ef, :encrypted

class EncryptedType < ActiveRecord::Type::Text
  # called when loading from DB
  def deserialize(value)
    value.decrypt.force_encoding('utf-8') unless value.nil?

I added .force_encoding('utf-8') after it decrypts and it works now.


text:
AT1 receptor antagonists—beyond blood pressure control: possible place in heart failure treatment
John McMurray
CRI in Heart Failure, Wolfson Building—Room 363, University of Glasgow , Glasgow G12 8QQ, UK
Professor McMurray email: j.mcmurray{at}bio.gla.ac.uk
http://dx.doi.org/10.1136/heart.84.suppl_1.i42
The renin-angiotensin system (RAS) plays an important role in heart failure, and renin angiotensin aldosterone blockade has been shown to be of benefit in its treatment. The effectiveness of angiotensin converting enzyme (ACE) inhibitors has been well established in major trials including CONSENSUS 1, SOLVD, and V-HeFT-II.1-3More recently, the benefits of the aldosterone antagonist spironolactone have been demonstrated in the RALES trial.4
RAS blockade has also been of benefit in patients who have sustained a myocardial infarction, complicated by either left ventricular systolic dysfunction or by clinical signs of acute heart failure. This has been well documented in clinical trials, in particular SAVE, AIRE, and TRACE.5-7
Given the huge success of ACE inhibitors, it is not surprising that there is hope that angiotensin II type I (AT1) receptor antagonists might also have an important role in these patients. In assessing the potential role of AT1 antagonists there are three questions that need addressing:
Are AT1 antagonists better than placebo?
Are AT1 antagonists better than ACE inhibitors?
Should they be used in combination with ACE inhibitors?
Better than placebo?
No randomised, placebo controlled clinical trial has, to date, prospectively tested the hypothesis that AT1 antagonists are superior to placebo in terms of morbidity and mortality end points in congestive heart failure (CHF); in reality, this question would have been redundant should AT1 receptor antagonists have been shown to be superior to ACE inhibitors. However, following the results of the ELITE-II trial (see below) this question has now become an extremely important one to answer.
We do have one study which showed that, compared to placebo, an AT1 antagonist can improve exercise tolerance in CHF in a dose dependent manner (fig 1).8 This study randomised men and women with mild to moderately severe heart failure and reduced left ventricular systolic function to either placebo or to different doses of candesartan cilexetil, 4 mg, 8 mg, and 16 mg.
Mean change from baseline to last value in total exercise time (bicycle ergometry) among patients with CHF treated with placebo or candesartan cilexetil 4–16 mg for ⩽ 12 weeks (intention to treat population, n = 807).
There was an increase in exercise tolerance with active treatment that appears to be dose dependent, with the 16 mg dose significantly improving exercise time, compared to placebo (p < 0.05) (fig1).
There is a need for a large outcomes study that will show that AT1 antagonists improve prognosis. Originally designing such a study was seen as an ethical challenge; now in the light of ELITE-II, it is an ethical imperative.
Better than an ACE inhibitor?
"Better" can mean two things: more efficacious or superior tolerability. These are really two sides of the same coin. A treatment cannot be efficacious if it is not well tolerated and therefore taken by the patient.
TOLERABILITY
If AT1 antagonists are as effective as ACE inhibitors and better tolerated, there could be a substantial public health benefit to be gained. AT1 antagonists do not cause cough and do not seem to cause more of any other adverse effect than ACE inhibitors. They are, therefore, almost certainly better tolerated than ACE inhibitors.
In the ELITE-I study 21% of captopril treated patients discontinued treatment because of an adverse event (excluding death) compared to 12% of losartan treated patients (p = 0.002).9 The results from ELITE-II confirm this finding.10
In addition, the SPICE trial found that candesartan cilexetil was well tolerated by heart failure patients who were ACE inhibitor intolerant.11 Eighty three per cent of patients remained on active treatment at 12 weeks compared to 87% of placebo assigned patients (difference not significant).
In theory, AT1 antagonists may be more efficacious than ACE inhibitors as they will block the action of angiotensin II generated through non-ACE pathways. In addition, there may be potential benefits of hyperstimulating the unblocked AT2 receptor.
However, unlike AT1 antagonists, ACE inhibitors increase bradykinin. For some time the effects of bradykinin have been considered to be negative; it produces cough and may enhance noradrenaline (norepinephrine) release, but there are reasons to believe that bradykinin may also have positive effects. It increases vasodilation, promotes the release of fibrinolytic factors and leads to growth inhibition.
ELITE-I and RESOLVD
Until very recently, there were only two small studies that came to very different conclusions regarding the comparative efficacies of ACE inhibitors and AT1 antagonists: the ELITE-I trial, comparing losartan and captopril; and the RESOLVD pilot trials, comparing candesartan cilexetil to enalapril.9 12 The ELITE-I study reported that CHF patients treated with losartan had a lower mortality than patients treated with captopril. The RESOLVD study did not support these findings (fig 2). These contradictory results can be explained by the fact that these two trials were designed to examine tolerability rather than mortality and were not large enough to prove, with confidence, whether AT1 antagonists have superior efficacy to ACE inhibitors.
Mortality results from ELITE-I and RESOLVD pilot appear to be contradictory.
ELITE-II
Recently data have become available from ELITE-II, the first large, definitive study which explores the effect of angiotensin receptor antagonists on outcome in patients with heart failure.10 ELITE-II was designed to confirm the finding of ELITE-I that losartan was more effective than captopril. The patients in the study were an average of 71 years old, with mild to moderate heart failure, reduced ejection fractions (average 31%), receiving standard treatment with diuretics, digoxin and, in up to 25% of cases, β blockers.
Over 3000 patients were randomised to the same treatments as in ELITE-I: captopril 50 mg three times daily or losartan 50 mg daily. It was an event driven trial with a target number of deaths of 510. The anticipated follow up was two years, although it was one and a half in practice. The primary end point was all cause mortality and the secondary end point was sudden death or resuscitation from cardiac arrest. The principal tertiary end point was all cause death or all cause hospitalisation.
There was no significant difference in all cause mortality between the two groups (table 1). The hazard ratio was 0.88 in favour of captopril, and there was approximately 12% risk reduction in all cause mortality in the captopril group compared to the losartan group, although this was not significant (p = 0.16).
Losartan heart failure survival study: ELITE-II study end point summary
The secondary end point also showed no significant difference between the two groups. Similarly, the tertiary end point also revealed no significant difference between the two treatments with a hazard ratio of 0.94 (p = 0.21).
The only significant difference in outcome between the two groups was that more patients had to be withdrawn from captopril treatment because of adverse effects. The ELITE-II investigators concluded that losartan was clearly not superior to captopril and that ACE inhibitors should therefore remain the first line treatment of choice for patients with chronic heart failure. Indeed, comparison of ELITE-II with historical data from a trial comparing an ACE inhibitor with placebo (and therefore, indirectly, allowing us to compare losartan with placebo) shows that ELITE-II cannot even confirm that losartan is superior to placebo (table 2).
Comparison of ACE inhibitor (ACE-I) and AT1-receptor blocker (ARB) trials in heart failure/left ventricular dysfunction
In combination with ACE inhibitors?
There are theoretical reasons to suggest that ACE inhibitors and AT1 antagonists should be used in combination. If angiotensin receptor antagonists give better and more complete RAS blockade, and there are positive non-angiotensin II effects of ACE inhibitors, the optimum treatment may be to use both treatments together.
In a small study, 33 patients with severely symptomatic heart failure who were receiving full conventional treatment, including a large dose of ACE inhibitor,13 were randomised to receive either placebo or losartan on top of full conventional treatment, for six months. The two primary end points were improvement in exercise time, and improvement in New York Heart Association (NYHA) functional class.
The results showed that adding an angiotensin receptor antagonist to an ACE inhibitor significantly improved exercise tolerance in these patients (p < 0.02) (fig 3). In addition, NYHA classification also showed a significant improvement with the addition of losartan (p < 0.01). Clearly, this improvement will make patients feel much better and will improve their clinical status.
Effect of combination treatment with an ACE inhibitor plus losartan on exercise tolerance and NYHA functional class.
RESOLVD PILOT
The RESOLVD pilot study explored the effect of combination treatment on left ventricular remodelling.12 Patients with heart failure tend to show progressive left ventricular enlargement, which correlates with a poor outcome. Patients received either combination treatment with candesartan cilexetil and enalapril, or enalapril or candesartan monotherapy.
Left ventricular enlargement occurred in the enalapril group. In the combination treatment groups progressive left ventricular enlargement was retarded or even reversed. However, there was no significant difference in mortality between the two groups. A sufficiently large trial is needed to provide definitive data on morbidity and mortality.
NORMAL LEFT VENTRICULAR SYSTOLIC DYSFUNCTION
Patients with heart failure and normal left ventricular dysfunction are generally neglected. There may also be an important role for RAS blockade in these patients who tend to be hypertensive, often have diabetes, and frequently have ventricular hypertrophy. It is hoped that RAS blockade would improve the outcome for this type of patients.
It is hoped that many of the remaining questions regarding the role of AT1 receptor antagonists in the management of cardiovascular disease will be answered by a number of ongoing studies.
HEART FAILURE STUDIES
There is a programme of three trials called CHARM.14The first of these is a study looking at patients with heart failure, who have a low left ventricular ejection fraction and who are intolerant of ACE inhibitors. These patients are randomised to placebo or to candesartan cilexetil. This component of the CHARM programme is particularly important as it is the only remaining trial that will explore whether there is a role for angiotensin receptor antagonist monotherapy in patients with heart failure. As a result of its increased importance in defining the place of this new class of drugs in heart failure, the sample size of this component trail has recently been increased.
There are also two large studies designed to address the issue of combination treatment in heart failure: Val-HeFT15 and the second of the three trials in the CHARM programme. The final study in CHARM will compare candesartan cilexetil and placebo in heart failure patients with normal systolic function.
POST-MYOCARDIAL INFARCTION STUDIES
There are also two large ongoing postinfarction trials looking at the effectiveness of angiotensin receptor antagonists: OPTIMAAL and VALIANT.16 17 OPTIMAAL compares losartan and captopril in over 5000 high risk, post-myocardial infarction patients. The VALIANT trial has three treatment groups: valsartan monotherapy, captopril monotherapy and a combination arm. Importantly, the study is powered to test for both superiority of one treatment over another, and to identify non-inferiority. That means that it will be possible to say whether the AT1 antagonist is more effective or as effective as the ACE inhibitor.
Trial acronyms
AIRE: Acute Infarction Ramipril Efficacy
CHARM: Candesartan in Heart failure: Assessment of Reduction in Mortality and Morbidity
CONSENSUS-1: Cooperative North Scandinavian Enalapril Survival Study
ELITE: Evaluation of Losartan In The Elderly
OPTIMAAL: Optimal Therapy In Myocardial infarction with Angiotensin II Antagonist Losartan
RALES: Randomised Aldactone Evaluation Study
RESOLVD: Randomised Evaluation Of Strategies for Left Ventricular Dysfunction
SAVE: Survival And Ventricular Enlargement
SOLVD-T: Studies of Left Ventricular Dysfunction-Treatment
SPICE: Study of Patients Intolerant of Converting Enzyme inhibitors
TRACE: Trandolapril Cardiac Evaluation
VALIANT: Valsartan In Acute Myocardial Infarction
Val-HeFT: Valsartan in Heart Failure Trial
V-HeFT-II: Vasodilator Heart Failure Trial II
I would like to thank Dr John Norrie and Dr Colin Berry for the analysis in table 2.
The CONSENSUS Trial Study Group
(1987) Effects of enalapril on mortality in severe congestive heart failure: results of the co-operative north Scandinavian enalapril survival study (CONSENSUS). N Engl J Med 316:1429–1435.
OpenUrlPubMedWeb of Science
The SOLVD Investigators
(1991) Effect of enalapril on survival in patients with left ventricular ejection fractions and congestive heart failure. N Engl J Med 325:293–302.
Cohn JN,
Johnson G,
Ziesche S,
(1991) A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 325:303–310.
Pitt B,
Zannad F,
Remme WJ,
(1999) The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized aldactone evaluation study investigators. N Engl J Med 341:709–717.
Pfeffer MA,
Braunwald E,
Moye LA,
(1992) Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. N Engl J Med 327:669–677.
The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators
(1993) Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. Lancet 342:821–828.
The Trandolapril Cardiac Evaluation (TRACE) Study group
(1995) A clinical trial of the angiotensin-converting enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 333:1670–1676.
Riegger GA,
Bouzo H,
Petr P,
(1999) Improvement in exercise tolerance and symptoms of congestive heart failure during treatment with candesartan cilexetil. Symptom, Tolerance, response to exercise trial of candesartan cilexetil in heart failure (STRETCH) investigators. Circulation 100:2224–2230.
Segal R,
Martinez FA,
(1997) Randomised trial of losartan versus captopril in patients over 65 with heart failure (evaluation of losartan in the elderly study, ELITE). Lancet 349:747–752.
Poole-Wilson P,
(2000) Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the losartan heart failure survival study ELITE II. Lancet 355:1582–1587.
Granger CB,
Ertl G,
Kuch J,
(2000) Randomised trial of candesartan cilexetil in the treatment of patients with congestive heart failure and a history of intolerance to angiotensin-converting enzyme inhibitors. Am Heart J 139:609–617.
McKelvie RS,
Yusuf S,
Pericak D,
(1999) Comparison of candesartan, enalapril, and their combination in congestive heart failure; randomised evaluation of strategies for left ventricular dysfunction (RESOLVD) pilot study: The RESOLVD pilot study investigators. Circulation 100:1056–1064.
Hamroff G,
Katz SD,
Mancini D,
(1999) Addition of angiotensin II receptor blockade to maximal angiotensin-converting enzyme inhibition improves exercise capacity in patients with severe congestive heart failure. Circulation 99:990–992.
Swedberg K,
Pfeffer M,
Granger C,
(1999) Candesartan in heart failure—assessment of reduction in mortality and morbidity (CHARM): rationale and design. CHARM-programme investigators. Journal of Cardiac Failure 5:276–282.
Tognoni G,
Glazer RD,
(1999) Rationale and design of the valsartan heart failure trial: a large multinational trial to assess the effects of valsartan, an angiotensin-receptor blocker, on morbidity and mortality in chronic congestive heart failure. Journal of Cardiac Failure 5:155–160.
Dickenstein K,
Kjekshus J
(1999) Comparison of the effects of losartan and captopril on mortality in patients after acute myocardial infarction: the OPTIMAAL trial design. Am J Cardiol 83:477–481.
McMurray J,
Neuhart E,
Held P,
(1999) Clinical trials with angiotensin II receptor antagonists in heart failure and myocardial infarction. Br J Cardiol 6:566–576.


Fresh back from the Learning Technologies 2016 show in London, Sergey talks about the show, the LMS vendors, the little innovation he noticed among new elearning vendors and the future.
Sergey won the silver award for most innovate product (www.branchtrack.com). Congratulations, Sergey.


* High sensitivity to alcohol and small sensitivity to Benzine .
They are suitable for alcohol checker, Breathalyser.
Open the serial monitor of Arduino IDE. Write down the value of R0 – this is required for the next sketch example. Please write down the R0 after the reading stabilizes.
Replace the R0 below with value of R0 tested above . Expose the sensor to any one of the gases listed at the start.


Agile Tour 2014 Bengaluru will be hosted as ScrumMasters' UnConference, an exclusive avenue for ScrumMasters to converge, discuss, play and learn form the community. The ScrumMasters' UnConference would focus on deep dive sessions, team based learning to focus on common challenges faced by the ScrumMasters' in their day to day work.
These conferences are aimed at active and future ScrumMasters.