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Home > January 2015 - Volume 78 - Issue 1 > Evaluation and management of blunt traumatic aortic injury:...
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Evaluation and management of blunt traumatic aortic injury: A practice management guideline from the Eastern Association for the Surgery of Trauma
Fox, Nicole MD; Schwartz, Diane MD; Salazar, Jose H. MD; Haut, Elliott R. MD; Dahm, Philipp MD; Black, James H. MD; Brakenridge, Scott C. MD; Como, John J. MD; Hendershot, Kimberly MD; King, David R. MD; Maung, Adrian A. MD; Moorman, Matthew L. MD; Nagy, Kimberly MD; Petrey, Laura B. MD; Tesoriero, Ronald MD; Scalea, Thomas M. MD; Fabian, Timothy C. MD
Journal of Trauma and Acute Care Surgery: January 2015 - Volume 78 - Issue 1 - p 136–146
doi: 10.1097/TA.0000000000000470
BACKGROUND Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST.
METHODS A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair.
RESULTS Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines.
CONCLUSION There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.
From the Department of Surgery (N.F.), Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey; Department of Surgery (D.S.), The Johns Hopkins Bayview Medical Center; Department of Surgery (J.S.O., E.R.H.), The Johns Hopkins School of Medicine; Department of Vascular Surgery and Endovascular Therapy (J.H.B.), The Johns Hopkins Hospital and Johns Hopkins Medical Institutions; and Department of Surgery (R.T., T.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Urology (P.D.), Malcom Randall VAMC, University of Florida College of Medicine; and Department of Surgery (S.C.B.), University of Florida Health Science Center, UF Health Shands Hospital, Gainesville, Florida; Department of Surgery (J.J.C.), MetroHealth Medical Center; and Division of Acute Care Surgery (M.L.M.), Cleveland Clinic Lerner College of Medicine, Cleveland; and Department of Surgery, Wright State University, Boonshoft School of Medicine, Dayton, Ohio; Department of Surgery (D.R.K.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (A.A.M.), Yale University School of Medicine, New Haven, Connecticut; Department of Surgery (K.N.), Cook County Trauma Unit of Stroger Hospital, Chicago, Illinois; Department of Surgery (L.B.P.), Baylor University Medical Center, Dallas, Texas; Department of Surgery (T.C.F.), The University of Tennessee Health Science Center, Memphis, Tennessee.
Submitted: July 7, 2014, Revised: August 3, 2014, Accepted: August 4, 2014.
T.M.S. and T.C.F. should be noted as co-senior authors.
These practice management guidelines were presented at the 26th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 15–19, 2013, in Scottsdale, Arizona.
Address for reprints: Nicole Fox, MD, Trauma, Critical Care, Emergency Surgery, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ 08103; email: fox-nicole@cooperhealth.edu.
PICO Question 1
Identification of References
Outcome Measure Types
Data Extraction and Methodology
Results for PICO Question 1
Qualitative Synthesis
Quantitative Synthesis (Meta-analysis)
Grading the Evidence
Using These Guidelines in Clinical Practice
Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. For patients who survive to hospital arrival, 50% will die within 24 hours. This significant mortality rate is related to the high incidence (40%) of severe associated injuries. The primary mechanism associated with BTAI is motor vehicle crashes (70%); however, BTAI also occurs as a result of motorcycle crashes, falls from height, auto versus pedestrian, and thoracic crush injuries.1 The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines (PMGs) on this topic published in 2000.2 The literature search for the previous guideline ended in 1997. During the past 15 years, there have been rapid advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST.3
The GRADE framework is used by more than 70 international societies and organizations worldwide. It provides a systematic and transparent framework for clarifying questions, determining outcomes of interest, summarizing evidence, and moving from evidence to recommendations. Within GRADE, evidence is rated across studies for specific clinical outcomes that are important to patients. Recommendation strength and direction are based on evidence quality and the balance between outcomes and patient values and preferences.
There are several issues identified as relevant to this PMG update. Advances in technology and changes in practice occurred since the publication of the last guideline that affected the evaluation and management of BTAI. Areas of focus include the choice of diagnostic radiologic imaging, type of operative repair (open vs. endovascular), and timing of operative repair (immediate vs. delayed).
The objective of this guideline was to evaluate the choice of diagnostic imaging (chest computed tomography [CT] with intravenous contrast vs. conventional catheter-based angiography), type of surgical intervention (endovascular vs. open), and timing of surgical intervention (immediate vs. delayed) for patients with BTAI. The Population (P), Intervention (I), Comparator (C) and Outcome (O) questions are defined as follows:
In patients with suspected BTAI (P), should CT of the chest with intravenous contrast (I) be used versus conventional catheter-based angiography (C) for the identification of clinically significant BTAI (O)?
In patients with BTAI (P), should endovascular (I) repair be performed versus open repair (C) to minimize risk of mortality, stroke, paraplegia, and renal failure (O)?
In patients with BTAI (P), should timing of repair be delayed (I) or immediate (C) to minimize risk of mortality, stroke, paraplegia, and renal failure (O)?
With the assistance of an informationist, a search of the National Library of Medicine and the National Institutes of Health MEDLINE database was conducted using PubMed (www.pubmed.gov) with citations published between 1998 and 2013. We used the "related articles" function to broaden the search and scan all citations for relevance. In addition to the electronic search, we manually searched the bibliographies of recent reviews and articles. Articles were limited to those in the English language involving human subjects. Letters to the editor, case reports, book chapters, and review articles were excluded. These articles were reviewed by the committee chair, and the final reference list of 60 citations was distributed to the remainder of the study group for review. Of these, 51 articles were felt to be appropriate for the construction of these guidelines and included in the construction of tables of the summary of findings.
Per the GRADE approach, outcomes were chosen by the committee and rated in importance from 1 to 9, with scores of 7 to 9 representing critical outcomes. For PICO Question 1, the following outcomes were considered by the committee members: identification of clinically significant aortic injury, rapid diagnosis of aortic injury, complications associated with invasive procedures, cost, and patient transport. For PICO Questions 2 and 3, the following outcomes were considered by committee members: mortality, paraplegia, stroke, acute renal failure, length of stay, and cost. Not all of these criteria were deemed "critical" by the committee for the decision-making process within the GRADE framework. Therefore, the critical outcome for PICO Question 1 was determined to be the identification of clinically significant aortic injury. The critical outcomes for PICO Question 2 were mortality, stroke, paraplegia, and renal failure. The critical outcomes for PICO Question 3 were mortality, stroke, paraplegia, and acute renal failure.
A systematic review of the MEDLINE database using PubMed was performed with the search terms angiography, blunt aortic injury, blunt thoracic aortic injury, computed chest tomography, and CTA limited to dates from 1998 to 2013. Studies reporting total and false positives as well as total and false negatives for the use of CT with intravenous contrast and aortography were included for further review. Results for the sensitivity and specificity of both diagnostic tests were not pooled because of intrinsic limitations of the study of diagnostic test accuracy in different settings such as increased heterogeneity, nonstandardized designs, quality of testing, and incomplete confirmatory testing (intraoperative findings) in every patient. Six articles contained the necessary information to construct Forest plots for sensitivity and specificity and were deemed appropriate for the construction of the guideline.
A similar systematic search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed. Search terms included traumatic aortic injury, blunt aortic injury, blunt aortic trauma, endovascular aortic repair, and open aortic repair. Additional references were identified by using two previously published meta-analyses that reported on studies published from 1990 to December 2010.4,5 Articles were reviewed by the committee chair, and the final reference list of 40 citations was distributed to the remainder of the study group for review. Of these, 38 articles were felt to be appropriate for the construction of these guidelines. One article that reported results on an analysis of a large national administrative database was ultimately excluded because of having a methodology significantly different from the rest of the studies.6 When comparing open versus endovascular repair, a total of 37 studies reported the outcome of mortality, 21 reported incidence of paralysis, and 12 reported incidence of stroke. With regard to renal failure, the available literature did not provide sufficient or consistent measurements across the studies, specifically if the onset of renal failure occurred before or after surgical intervention. Therefore, this outcome was not able to be included in the meta-analysis.
A similar systematic review of the MEDLINE database was performed using search terms blunt aortic injury, traumatic aortic injury repair, immediate repair of blunt thoracic aortic injury, and delayed repair of blunt thoracic aortic injury limited to dates from 1998 to 2013. No randomized trials comparing delayed versus early repair have been performed for BTAI. A final list of seven articles was reviewed by the study group. The outcomes of interest were mortality (reported in all studies), stroke (one study), paraplegia (three studies), and renal failure (three studies).
For PICO Questions 2 and 3, the data for each included article were pooled, and relative risks (RRs) were calculated as measures of effect for dichotomous outcomes using Review Manager (RevMan, Cochrane Collaboration, version 5.2). Potential heterogeneity exists because of population differences as well as different types of surgery performed and how patients are defined. We examined these differences across studies to assess the clinical and methodological heterogeneity. For the meta-analysis, we used RevMan to calculate the Q statistic, and then the I2 statistic (%) was used to determine the proportion of variation between studies attributable to heterogeneity and categorized as "low" (25–49%), "moderate" (50–74%), or "high" (74–100%). We also used the χ2 test for heterogeneity and examined the confidence intervals (CIs) for overlap, with decreasing overlap representing increasing heterogeneity. All studies were analyzed using a random-effects model. Tables with summary of findings were constructed using GRADEpro (GRADE Working Group, version 3.2).
In patients with suspected BTAI (P), should CT of the chest with intravenous contrast (I) be used versus conventional catheter-based angiography (C) for the identification of clinically significant injury (O)?
Conventional angiography was considered the criterion standard for the diagnosis of BTAI for decades. During the past 20 years, however, CT of the chest with intravenous contrast has evolved as a valid screening and diagnostic modality for BTAI because of its availability, rapidity, and ability to diagnose additional intra-thoracic injuries. In the BTAI PMG published by EAST in 2000, the committee made a Level II recommendation stating that "computed tomography of the chest is a useful diagnostic tool for both screening and diagnosis of BTAI. Spiral or helical computed tomographic scanners have an extremely high negative predictive value and may be used alone to rule out BTAI. When these scanners are used, angiography may be reserved for patients with indeterminate scans."2 Since the original EAST PMG publication, rapid advances in CT technology occurred with the evolution of helical, spiral, and multigated CT scanners. Nine studies of relevance to this PICO question published after 1997 were identified. Six of these studies contained adequate information to formulate Forest plots of sensitivity and specificity (Fig. 1).
In 1998, Fabian et al.7 evaluated 494 patients; 71 had a diagnosis of BTAI. Sensitivity and negative predictive value were 100% for CT versus 92% and 97%, respectively, for aortography. Also in 1998, Demetriades et al.8 identified 9 of 112 trauma patients with BTAI. CT scan identified eight of these injuries. The single injury not identified on CT was a brachiocephalic intimal tear on which the CT images did not include the area of injury. Melton et al.,9 Parker et al.,10 and Dyer et al.11 in separate investigations with a total of 1,802 patients and 64 cases of BTAI found CT sensitivity to be 100%. In 2006, Bruckner et al.12 analyzed the results of 206 patients who underwent CT followed by aortography. A total of 16 patients had a diagnosis of BTAI; CT failed to identify one injury. The authors noted that this single false-negative scan was performed in 1997 on an older-generation scanner. The aortic injury subsequently identified with aortography was subtle and managed nonoperatively. Overall sensitivity of CT in the study of Bruckner et al. was 95%, and the negative predictive value was 99%.
It is important to note that this PICO question does not address the screening chest x-ray (CXR). This topic was well outlined in the 2000 EAST PMG on BTAI, and the literature on screening CXR has not changed significantly since that time (although we have not conducted an exhaustive systematic review of the topic for this update). Any patient with suspicious findings on CXR or those injured by significant deceleration or acceleration mechanisms should undergo further workup.2 Since cases of BTAI occur in patients with a normal CXR finding, any clinical suspicion of BTAI should be pursued further regardless of mechanism or CXR findings.
Forest plots of sensitivity and specificity were constructed for both CT and aortography. Six studies directly compared CT and aortography. The Forest plots indicate that the sensitivity of both tests is very high. Overall specificity is lower for CT as compared with aortography, indicating that there may be a higher number of "false-positive" results when using CT scan. It must be noted that according to the Cochrane Review Handbook for Systematic Reviews of Diagnostic Test Accuracy, "the statistical aspects of a systematic review of diagnostic test accuracy are more challenging than reviews of interventions."13 The RevMan statistical program used for this PMG does not pool sensitivity and specificity, calculate weights for Forest plots, or provide measures of heterogeneity.
With the use of the GRADE framework for evaluating the data specifically related to the outcome of identification of clinically significant injury, no serious risk of bias, inconsistency, indirectness, imprecision, or publication bias was found. Therefore, the overall quality of evidence was low. Per GRADE methodology, if sensitivities and specificities are similar for the diagnostic tests in question, then the preference for one modality over the other may come from the availability of one modality over the other, ease of use, and the value of other secondary information obtained from the diagnostic test.13
Within the GRADE framework, once the overall quality of evidence across studies and outcomes is determined, the guideline panel formulates a recommendation that considers the following: quality of evidence, patients' values and preferences, and cost/resource use. Despite the overall quality of evidence being low, the panel considered that most patients would place a high value on identification of clinically significant BTAI. The sensitivity of CT of the chest is comparable with aortography. There are also a higher number of "false positives" with CT of the chest, indicating that this screening modality may potentially identify minimal aortic injuries not identified on aortography. Furthermore, CT of the chest with intravenous contrast has the advantage of being readily available, less invasive, being less time consuming, and allowing for identification of other intrathoracic injuries. All of these factors resulted in the formulation of a strong recommendation by the committee. Within the GRADE framework, a strong recommendation implies that most individuals would want the recommended course of action, and only a small proportion would not.
In patients with suspected BTAI, we strongly recommend the use of CT scan of the chest with intravenous contrast for diagnosis of clinically significant BTAI.
In patients with BTAI (P), should endovascular (I) repair be performed versus open repair (C) to minimize mortality, stroke, paraplegia, and renal failure (O)?
The first acute repair of aortic rupture was reported in the 1950s by DeBakey et al. For decades, open repair of aortic injuries was considered the standard of care. In 1997, Kato et al.14 published the first case report of endovascular stent graft repair of BTAI. Three of 10 patients in this case series had a traumatic aortic aneurysm treated with an endovascular stent. By 2007, there were 284 cases of BTAI treated with endovascular stent grafts from 62 centers reported in the literature. Advances in technology and training paradigms occurred in tandem with the introduction of endovascular stents as a treatment modality for BTAI and resulted in a rapid shift in management of this injury. Early use of stent grafts to repair traumatic aortic injuries was considered "off label." However, in 2012, the Medtronic Valiant Thoracic Stent Graft with the Captivia Delivery System was approved by the Food and Drug Administration for the treatment of BTAI.15 To our knowledge, this is the only Food and Drug Administration–approved device for BTAI.
In 2011, the Society for Vascular Surgery (SVS) released clinical practice guidelines for endovascular repair of traumatic thoracic aortic injury. The society proposed a weak recommendation in favor of endovascular repair. The SVS used GRADE to develop its recommendations. The review included 7,768 patients from 139 studies (1990–2009), but the authors did not limit eligibility criteria based on study design.16 Therefore, 112 studies included were case series (noncomparative), and 27 were comparative observational studies. The overall quality of evidence was determined to be "very low." The group placed the highest value on the same outcomes chosen for this PMG: mortality, stroke, and paraplegia. Overall mortality was lower for patients who underwent endovascular repair versus open repair (9% vs. 19%). The risk of paraplegia was also lower for endovascular repair as compared with open (3% vs. 9%), and there were no differences in the incidence of stroke between the two groups.
To our knowledge, there are no randomized studies comparing open (OR) versus endovascular (TEVAR) repair of blunt thoracic aortic injury. For the purposes of this guideline, studies that reported results on only one kind of approach (TEVAR or OR) were excluded, and only articles with comparative reports of both approaches were included in the final analysis. Forty-five comparative studies (1997–2013) were identified, and 37 were ultimately included in the construction of the evidence profile (Fig. 3).17–52 Mortality data were available in all of the identified studies, and overall mortality was lower for endovascular as compared with open repair (8% vs. 19%). Rates of paraplegia were available in 12 of the 37 studies, and the incidence of paraplegia was also lower for endovascular versus open repair (0.5% vs. 3%). Rates of stroke were available in 21 of 37 studies, and the incidence of stroke was slightly higher in the endovascular group as compared with open (2.5% vs. 1%).
Endovascular repair is now performed more commonly than open repair in patients with BTAI. The 2008 study by American Association for the Surgery of Trauma (AAST) demonstrated that 65% of the patients were treated with endovascular stent grafts in 2007 as compared with 0% in 1997.28 Experience and training in endovascular repair have steadily increased, with a resultant decrease in exposure to open repair. One of the primary concerns with endovascular repair in earlier studies was the reported high rate of device-related complications. In the AAST series, 32 device-related complications developed in 25 patients (20%). Although the most common complication was endoleak (14%), other complications included access-vessel injuries, occlusion of the left subclavian or left common carotid artery, and late migration and thrombosis of the stent graft.28 During the past 5 years, however, reports demonstrate that the rate of device-related complications has decreased significantly. In 2014, Azizzadeh et al.52 published the follow-up results of 82 consecutive patients who underwent endovascular repair for BTAI. Average time to follow-up was 2.3 years, and the incidence of device-related complications was 2.4%. All patients should be evaluated preoperatively for the appropriateness of endovascular repair because there are contraindications to endovascular repair. These include aortic diameter less than 15 mm, involvement of tear into midarch requiring coverage of the left common carotid artery, and left vertebral origin on the aortic arch with an uncollateralized posterior inferior communicating artery. It is also important to note that if TEVAR is used, the treating center must have the ability to convert to open repair if necessary.
Long-term follow-up of patients who have endovascular stent grafts placed is required to monitor longevity and status of the graft. There was insufficient literature to make an evidence-based recommendation on the frequency of follow-up. In their 2011 guidelines, the SVS did not provide a recommendation for long-term evaluation and stated that the follow-up of patients after TEVAR "remains in evolution." The RESCUE trial, published in 2013, defined its follow-up protocol as follows: "a CTA or magnetic resonance angiogram at 1, 6, and 12 months and annually thereafter for 5 years. Multiple view chest x-rays will also be acquired at 1, 3, and 5 years to assess for device integrity."53 This remains an area in which further research is necessary.
Thirty-seven studies were included in the meta-analysis. Endovascular repair was associated with reduced mortality rates, with an RR of 0.56 (95% CI, 0.44–0.73). Of note, the I2 statistic was 0%, falling into the "low" heterogeneity category, indicating that the studies are comparable. Endovascular repair was associated with comparable stroke rates, with an RR of 1.48 (95% CI, 0.67–3.27). The I2 was 0%, indicating that the studies are comparable. Endovascular repair was associated with significantly reduced paraplegia rates, with an RR of 0.36 (95% CI, 0.19–0.71). The I2 was 0%, indicating that the studies are comparable (Fig. 2).
With the use of the GRADE framework for evaluating the data specifically related to the outcome of mortality, no serious risk of bias, inconsistency, indirectness, imprecision, or publication bias was found. The evidence could not be upgraded, and therefore, the overall quality was low. For the outcome of stroke, no serious risk of bias, inconsistency, indirectness, imprecision, or publication bias was found, and the evidence could not be upgraded. The overall quality of evidence for this outcome was low. For the outcome of paraplegia, no serious risk of bias, inconsistency, indirectness, imprecision, or publication bias was found. The evidence for this outcome was upgraded for a strong association, and the overall quality of evidence was moderate. An evidence profile was constructed using the Gradepro software by importing the data from RevMan (Fig. 3).
Despite the overall quality of evidence being low (mortality, stroke) to moderate (paraplegia), the panel considered that most patients would place a high value on a less invasive procedure that carries a significantly lower risk of blood loss, mortality, and paraplegia and a comparable risk of stroke. The panel also considered the fact that endovascular repair is performed more frequently than open repair, resulting in decreased experience with and training in open repair. In addition, initial concerns regarding a high rate of device-related complications seem unfounded as the current literature suggests that complication rates are low and continue to improve as technology evolves. All of these factors resulted in the formulation of a strong recommendation by the committee. Within the GRADE framework, a strong recommendation implies that most individuals would want the recommended course of action, and only a small proportion would not.
In patients diagnosed with BTAI, we strongly recommend the use of endovascular repair in patients who do not have contraindications to endovascular repair.
In patients with BTAI (P), should timing of repair be delayed (I) or immediate (C) to minimize mortality, stroke, paraplegia, and renal failure (O)?
The risk of rupture of contained BTAI is highest within the first 24 hours of injury. For this reason, immediate repair of BTAI was advocated and considered the standard of care for decades. In the 2000 PMG, a Level II recommendation was made for prompt repair unless patients "have more immediately life threatening injuries that require intervention such as emergent laparotomy or craniotomy, or if the patient is a poor operative candidate due to age or co-morbidities."2
For the purposes of this PMG, seven comparative studies (1997–2013) were identified, and all were included in the construction of the evidence profile. The 2004 study by Hemmila et al.54 reported data on two separate subsets of patients, a population from their own institution and a population from the National Trauma Data Bank. Mortality data were available in all studies, and overall mortality was lower for delayed repair versus immediate repair (9% vs. 21%). Rates of paraplegia were reported in four studies and were significantly lower for delayed repair as compared with immediate repair (0.6% vs. 5.5%). Incidence of stroke was evaluated in one study and was lower in the delayed group (7% vs. 9%). There was no difference in the incidence of renal failure (reported in three studies) between the two groups (9.3% delayed vs. 8.6% immediate)
In 1998, Fabian et al.7 prospectively evaluated the use of antihypertensive therapy in patients with BTAI. Of 71 patients with BTAI, 75% received a regimen of β-blockers with or without nitroprusside. They found that no in-hospital ruptures occurred in the delayed management or nonoperative management groups. The use of an antihypertensive regimen decreases aortic wall stress and tension and significantly reduces the risk of aortic rupture. Before this investigation, it was demonstrated that 12% of patients with BTAI sustained in-hospital aortic rupture. The success of anti-hypertensive regimens in preventing rupture has resulted in the practice of delayed repair of BTAI in both high- and low-risk patients. Any patient with BTAI should be immediately started and maintained on an antihypertensive regimen to prevent aortic rupture. These regimens are used to maintain the systolic blood pressure within a "normal" range, generally less than 120 mm Hg.
Delayed repair of BTAI was traditionally reserved for high-risk patients with major associated injuries or severe comorbidities. However, following publication of the 1998 article by Fabian et al., the use of antihypertensive regimens became widespread, and delayed repair was extended to low-risk trauma patients. In the 2009 AAST prospective study, 35% of patients overall underwent delayed repair.55 This was also the only one of the six comparative studies used to construct this PMG, which stratified patients in the early and delayed repair groups by the presence/absence of major extrathoracic injuries.56,57 The benefits of delayed repair in terms of mortality (22% early vs. 3% delayed), paraplegia (3% early vs. 0% delayed), and renal failure (38% early vs. 29% delayed) for patients with major extrathoracic injuries are significant. Incidence of stroke was not evaluated in this study. The mortality benefit of delayed repair (14% early vs. 8% delayed) was still present in patients without major extrathoracic injuries, although not as significant. In patients without major extrathoracic injuries, rates of paraplegia (1% early vs. 3% delayed) and renal failure (6% early vs. 8% delayed) were higher in the group that underwent delayed repair. The authors partially attributed the higher complication rate in the early repair group without major extrathoracic injuries to a higher rate of early deaths in this group. In light of the clear survival benefit associated with delayed repair, the authors advocated delayed repair in "all patients irrespective of risk factors."
Patient at a high risk of aortic rupture, based on clinical suspicion, imaging characteristics, and/or grade of injury should not be considered for delayed repair. This would include patients with Grade 3 and 4 injuries, which are defined as BTAI with pseudoaneurysm (Grade 3) and BTAI with active extravasation (Grade 4). In addition, clinical or radiographic evidence of pseudocoarctation may be an indication for urgent repair.
It is important to note that the role of medical management alone (without surgical or endovascular treatment) for "minor" BTAI was discussed and considered by the committee. Although this is an important issue, at this time, there is insufficient evidence to formulate a recommendation on this topic. It remains an area for further research.
Seven studies were included in the meta-analysis. Delayed repair was associated with reduced mortality rates, with an RR of 2.07 (95% CI, 1.03–4.15). Of note, the I2 statistic was 51%, falling into the "moderate" heterogeneity category. The risk of stroke with delayed repair was lower but was evaluated in only one study, with an RR of 1.36 (95% CI, 0.29–6.34). Delayed repair was associated with significantly reduced paraplegia rates (evaluated in four studies), with an RR of 5.90 (95% CI, 1.51–22.97). The I2 was 12%, falling into the "low" heterogeneity category, indicating that the studies are comparable. Rates of renal failure were comparable (evaluated in three studies), with an RR of 0.87 (CI 0.42–1.79). The I2 was 59%, falling into the "moderate" heterogeneity category (Fig. 4).
With the use of the GRADE framework for evaluating the data specifically related to the outcome of mortality, no serious risk of bias, inconsistency, indirectness, imprecision, or publication bias was found. The evidence was upgraded for a strong association, resulting in the overall quality of evidence being moderate. For the outcome of stroke, no serious risk of bias, inconsistency, indirectness, or publication bias was found. However, the evidence was downgraded for imprecision, and the overall quality was very low. For the outcome of paraplegia, no serious risk of bias, inconsistency, indirectness, imprecision, or publication bias was found. The evidence was upgraded for a very strong association, and the overall quality was high. For the outcome of renal failure, no serious risk of bias, inconsistency, indirectness, imprecision, or publication bias was found. Therefore, the overall quality of evidence was low. An evidence profile was constructed using the Gradepro software by importing the data from RevMan (Fig. 5).
The overall quality of evidence ranged from very low (stroke) to high (paraplegia). However, the panel considered that most patients would place a high value on BTAI repaired in a delayed fashion because it results in decreased mortality and paraplegia. Rates of renal failure were nearly identical. The panel discussed the fact that the patients who benefit the most from delayed repair are those who have major associated injuries. These patients clearly require resuscitation and treatment of immediately life-threatening injuries before aortic repair. The data are not as clear for patients without associated injuries who have no reason to undergo delayed repair. The panel does not advocate delaying repair of BTAI (e.g., until the following weekday morning) merely for surgeon convenience. Although the studies included in the evidence profile demonstrated decreased incidence of mortality, stroke, and paraplegia with delayed repair, it should be noted that the reason the majority of patients in these studies underwent delayed repair was because they had associated life-threatening injuries and/or a requirement for further resuscitation. Only one study evaluated the effect of delayed repair in a select group of patients without major associated injuries, and the number of patients in this group was small (n = 108). It is important to consider that in that group of patients, the benefit of delayed repair was only related to mortality. The incidence of paraplegia and renal failure in this subset of patients was higher. The consideration of these factors resulted in the formulation of a conditional recommendation by the committee. Within the GRADE framework, a conditional recommendation implies that the majority of individuals would want the recommended course of action but many would not.
In patients diagnosed with BTAI, we suggest delayed repair. It is critical that effective blood pressure control with antihypertensive medication is used in these patients.
These guidelines represent a detailed summary and comprehensive overview of the literature regarding the evaluation and treatment of BTAI. They are meant to inform the decision-making process and not replace clinical judgment. Patients with BTAI have a high mortality rate. The literature available for review strongly supports the use of CT of the chest with intravenous contrast for the identification of clinically significant injury and the use of endovascular repair of BTAI in patients without contraindications. The literature available for review supports delayed repair of BTAI in patients with the caveat that effective antihypertensive regimens must be used between the time of diagnosis and definitive repair.
In summary, we propose three important and evidence-based recommendations regarding BTAI, which were formulated using the GRADE methodology. First, we strongly recommend CT of the chest with intravenous contrast for the identification of clinically significant BTAI. Second, we strongly recommend the use of endovascular repair in patients with BTAI who do not have contraindications to endovascular repair. Finally, we suggest the use of delayed repair in patients with BTAI and emphasize that effective blood pressure control with antihypertensive medication must be used in these cases.
N.F. and E.R.H. conceived the study.
N.F. created the PICO questions. T.M.S. and T.C.F. assisted with finalizing the PICO questions. All listed authors with the exception of Ms. Seal and P.D. voted regarding the outcomes of interest for these PICO questions.
N.F. and D.S. performed the entire literature search, read all of the abstracts, and selected the articles for review. N.F., D.S., E.R.H., J.H.B., S.C.B., J.J.C., K.H., D.R.K., A.A.M., M.L.M., K.N., L.B.P. and R.T. reviewed and summarized the selected articles.
N.F. and J.H.S. extracted the data from the selected articles. J.H.S. and N.F. entered the extracted data into the RevMan and GRADEpro programs and evaluated the results for recommendations. P.D. assisted with data analysis and the RevMan and GRADEpro software programs.
N.F., D.S. and E.R.H. wrote the manuscript. T.M.S. and T.C.F. contributed equally to this work as senior mentors and should be noted as cosenior authors. E.R.H. reviewed this article for methodological content and made critical revisions to the final draft. All authors participated in the critical review of all versions of this article.
We thank the Eastern Association for the Surgery of Trauma and the EAST foundation for the opportunity to write this article and the detail-oriented peer review of this article by the guidelines committee.
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21. Azizzadeh A, Charlton-Ouw KM, Chen Z, Rahbar MH, Estrera AL, Amer H, Coogan SM, Safi HJ. An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries. J Vasc Surg. 2013; 57 (1): 108–114.
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23. Botta L, Russo V, Savini C, Buttazzi K, Pacini D, Lovato L, La Palombara C, Parlapiano M, Di Bartolomeo R, Fattori R. Endovascular treatment for acute traumatic transection of the descending aorta: focus on operative timing and left subclavian artery management. J Thorac Cardiovasc Surg. 2008; 136 (6): 1558–1563.
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26. Chung J, Owen R, Turnbull R, Chyczij H, Winkelaar G, Gibney N. Endovascular repair in traumatic thoracic aortic injuries: comparison with open surgical repair. J Vasc Interv Radiol. 2008; 19 (4): 479–486.
27. Cook J, Salerno C, Krishnadasan B, Nicholls S, Meissner M, Karmy-Jones R. The effect of changing presentation and management on the outcome of blunt rupture of the thoracic aorta. J Thorac Cardiovasc Surg. 2006; 131 (3): 594–600.
28. Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, Hemmila MR, O'Connor JV, McKenney MO, Moore FO. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma. 2008; 64 (3): 561–570.
29. Di Eusanio M, Folesani G, Berretta P, Petridis FD, Pantaleo A, Russo V, Lovato L, Di Bartolomeo R. Delayed management of blunt traumatic aortic injury: open surgical versus endovascular repair. Ann Thorac Surg. 2013; 95 (5): 1591–1597.
30. Doss M, Balzer J, Martens S, Wood JP, Wimmer-Greinecker G, Fieguth HG, Moritz A. Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience. Ann Thorac Surg. 2003; 76 (5): 1465–1469.
31. Durham CA, McNally MM, Parker FM, Bogey WM, Powell CS, Goettler CE, Rotondo MF, Stoner MC. A contemporary rural trauma center experience in blunt traumatic aortic injury. J Vasc Surg. 2010; 52 (4): 884–889.
32. Feezor RJ, Hess PJ Jr, Martin TD, Klodell CT, Beaver TM, Lottenberg L, Martin LC, Lee WA. Endovascular treatment of traumatic thoracic aortic injuries. J Am Coll Surg. 2009; 208 (4): 510–516.
33. Geisbüsch P, Leszczynsky M, Kotelis D, Hyhlik-Dürr A, Weber TF, Böckler D. Open versus endovascular repair of acute aortic transections—a non-randomized single-center analysis. Langenbecks Arch Surg. 2009; 394 (6): 1101–1107.
34. Jonker FH, Giacovelli JK, Muhs BE, Sosa JA, Indes JE. Trends and outcomes of endovascular and open treatment for traumatic thoracic aortic injury. J Vasc Surg. 2010; 51 (3): 565–571.
35. Kasirajan K, Heffernan D, Langsfeld M. Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and nonoperative management. Ann Vasc Surg. 2003; 17 (6): 589–595.
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41. Lebl DR, Dicker RA, Spain DA, Brundage SI. Dramatic shift in the primary management of traumatic thoracic aortic rupture. Arch Surg. 2006; 141 (2): 177–180.
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44. Moainie SL, Neschis DG, Gammie JS, Brown JM, Poston RS, Scalea TM, Griffith BP. Endovascular stenting for traumatic aortic injury: an emerging new standard of care. Ann Thorac Surg. 2008; 85 (5): 1625–1629.
45. Mohan IV, Hitos K, White GH, Harris JP, Stephen MS, May J, Swinnen J, Fletcher JP. Improved outcomes with endovascular stent grafts for thoracic aorta transections. Eur J Vasc Endovasc Surg. 2008; 36 (2): 152–157.
46. Ott MC, Stewart TC, Lawlor DK, Gray DK, Forbes TL. Management of blunt thoracic aortic injuries: endovascular stents versus open repair. J Trauma. 2004; 56 (3): 565–570.
47. Pacini D, Angeli E, Fattori R, Lovato L, Rocchi G, Di Marco L, Bergonzini M, Grillone G, Di Bartolomeo R. Traumatic rupture of the thoracic aorta: ten years of delayed management. J Thorac Cardiovasc Surg. 2005; 129 (4): 880–884.
48. Riesenman PJ, Farber MA, Rich PB, Sheridan BC, Mendes RR, Marston WA, Keagy BA. Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury. J Vasc Surg. 2007; 46 (5): 934–940.
49. Rousseau H, Dambrin C, Marcheix B, Richeux L, Mazerolles M, Cron C, Watkinson A, Mugniot A, Soula P, Chabbert V, et al. Acute traumatic aortic rupture: a comparison of surgical and stent-graft repair. J Thorac Cardiovasc Surg. 2005; 129 (5): 1050–1055.
50. Tong MZ, Koka P, Forbes TL. Economic evaluation of open vs endovascular repair of blunt traumatic thoracic aortic injuries. J Vasc Surg. 2010; 52 (1): 31–38.
51. Yamane BH, Tefera G, Hoch JR, Turnipseed WD, Acher CW. Blunt thoracic aortic injury: open or stent graft repair? Surgery. 2008; 144 (4): 575–580.
52. Azizzadeh A, Ray HM, Dubose JJ, Charlton-Ouw KM, Miller CC, Coogan SM, Safi HJ. Outcomes of endovascular repair for patients with blunt traumatic aortic injury. J Trauma Acute Care Surg. 2014; 76: 510–516.
53. Khoynezhad A, Azizzadeh A, Donayre C, Matsumoto A, Velazquez O, White R. Results of a multicenter, prospective trial of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Vasc Surg. 2013; 57: 899–905.
54. Hemmila MR, Arbabi S, Rowe SA, Brandt MM, Wang SC, Taheri PA, Wahl WL. Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair? J Trauma. 2004; 56 (1): 13–23.
55. Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, Hemmila MR, O'Connor JV, McKenney MO, Moore FO. Blunt traumatic thoracic aortic injuries: early or delayed repair—results of an American Association for the Surgery of Trauma prospective study. J Trauma. 2009; 66 (4): 967–973.
56. Estrera AL, Gochnour DC, Azizzadeh A, Miller CC, Coogan S, Charlton-Ouw K, Holcomb JB, Safi HJ. Progress in the treatment of blunt thoracic aortic injury: 12-year single-institution experience. Ann Thorac Surg. 2010; 90 (1): 64–71.
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Blunt aortic injury; traumatic aortic injury; blunt aortic trauma
Journal of Trauma and Acute Care Surgery78(1):136-146, January 2015.
Blunt aortic injury
traumatic aortic injury
blunt aortic trauma
Blunt aortic injury, traumatic aortic injury, blunt aortic trauma
Articles in PubMed by Nicole Fox, MD
Articles in Google Scholar by Nicole Fox, MD
Other articles in this journal by Nicole Fox, MD
EAST Practice Management Guidelines
An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma
Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma
Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage
The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA)
The splenic injury outcomes trial: An American Association for the Surgery of Trauma multi-institutional study
Copyright © 2019 by the American Association for the Surgery of Trauma


The Washington New Church School believes that reading throughout the summer vacation keeps student sharp and ready for the next school year. Besides, it is so much fun to read!
Students grades 3rd – 8th have required summer reading. Below are the parameters, lists and report forms for each grade.


A beautiful starry night paired with the finest of delicacies is the perfect combination for a splendid evening. Spend that evening with Golden Sarovar Portico at the in-house terrace restaurant- Shosha.
Shosha is no less than a paradise for food lovers in Amritsar. It checks all the required boxes for a hangout place. Conceptualized in a Hinglish, casual theme this restaurant in Amritsar serves Indian delicacies fused with the flavors of the west. Our outstanding barbeque and grill options prove to be a delicious treat for your palate. We also serve exotic beverages and cuisines from all over the world to provide our guests with a wholesome experience. We put extra efforts to ensure that your visit to our restaurant is delightful.
We at Golden Sarovar Portico believe that first, we taste with our eyes, then with our tongue, thus we give utmost importance to the presentation aspect of the food served at Shosha. Our menu is a special a la carte and has a wide range of cuisines to choose from.


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« ON A CRITICAL SUPREME COURT | Main | ON POLITICAL STRESS IN EMERGING MARKETS »
ON GOOGLE UNPLUGGING BROWSER SYNC
Must say that like many other geeks and early adopters, I was surprised and very disappointed to learn from Lifehacker, that Google is suspending support and development of it's popular Google Browser Sync extension software for the next version of the Firefox 3 browser to be launched next Tuesday. Lifehacker posted a reply to a user query from the Google team responsible for the product:
"Thanks for trying out Google Browser Sync and for all of your feedback. It was a tough call, but we decided to phase out support for Browser Sync. Since the team has moved on to other projects that are keeping them busy, we don't have time to update the extension to work with Firefox 3 or to continue to maintain it.
For those of you who want to continue to use Firefox 2, we'll maintain support for old versions of Google Browser Sync through 2008. After that, we can recommend a few other products that scratch a similar itch. We hope that one of them works for you:
Mozilla Weave [labs.mozilla.com] from Mozilla Labs—Offers bookmark and history synchronization across computers.
Google Toolbar for Firefox [toolbar.google.com]—Store your bookmarks online and access them from any computer online.
Foxmarks Bookmark Synchronizer [addons.mozilla.org]—Synchronizes your bookmarks across all computers where it is installed.
The Google Team"
Like many Firefox users, I find Google Browser Sync to be the single-most useful extension I use on Firefox, since it allows automatic syncing of not just bookmarks, but my passwords, usage history, and browser states across several computers, both Windows and Macs. It's been a "Thriller" product for me since day one, despite occasional problems as the product evolved within Google.
If this news is true, I'm going to forgo using FireFox 3.0 into 2009, even though it's supposed to be a much faster and more stable browser. I know there are other potential alternatives for this functionality, including the Fennec initiative by Firefox developer Mozilla, but I prefer getting this service from Google than anyone else.
It's especially puzzling that Google think this software is not critical to continue to support given that it's long-term strategic mission is to get hundreds of millions of users around the world comfortable doing their computing off the cloud, less tethered to specific computers and devices.
In fact, Google Browser Sync seems to be the perfect customer facing device to propagate the work it's doing with Google Gears, which is a set of emerging Google technologies allowing tons of Google and third-party applications to run on multiple computers even when the user do not have an internet connection. Nik Cubrilovic has a great post today on TechCrunch describing where that effort is at Google to date.
If anything, Google should be expanding it's investment in Browser Sync, and making every effort to make the technology less geeky and more appealing and obvious in it's benefits to mainstream users.
All this is especially ironic given that competitors like Yahoo! are pulling out all the stops to become the daily "starting point" on the internet for hundreds of millions of users around the world.
Google already is the starting point with it's Search application, and services like Browser Sync were starting to act as the glue bringing the disparate computers together for every user, starting to do things on the internet every day. And they didn't even think of it is a starting point. User habits were changing to just expect that their computing environment would be the same as they flit from machine to machine, all using Google services. What other Google product or service could be more important to invest in than that?
Other companies like Apple are also hoping to be glue together the browsing experience for it's users across both Macs and Windows, and into it's iPhone and iPod Touch hand-held devices, using it's Safari browser as the conduit.
Microsoft is also working on similar strategies on the multiple incarnations of it's Live platform initiatives.
But these solutions are vertically focused on a given company's hardware and software. Google is uniquely positioned to be a cross-platform, and potentially cross-browser provider of this unifying functionality. Technically, the task is not a trivial one, given that it requires tying together many standard and non-standard, proprietary and non-proprietary technologies to make a seamless user experience possible across computers and hand-helds. Again, this seems to be totally aligned with Google's long-term strategic focus.
I like many geeks, am hoping that Google re-considers it's strategy with Google Browser Sync. Here's hoping that Google has a strategy to continue to bring Browser Sync like functionality to future browsers and platforms to the masses, even if it's with a whole different name and approach.
Saturday, June 14, 2008 in Gripes, History of Technology, Old Tech Used New Ways, Personal, Reviews, Software, Technology: Unintended Consequences, Web/Tech, Wireless, Wished for Feature/Service | Permalink
I do not use the product you mentioned. I use Google personal history through their Google tool bar. They already know enough about me so how does it matter if they also know what I am clicking.
I find my own clickstream data stored at Google very useful. I can always go back to it and search it and it is accessible from any computer and from any place. It does require Google toolbar installation while I am recording the personal clickstream data.
Firefox history also stores exact same data but it is slow to load and search once there is long enough history stored there.
I do however agree with you on the point that Google should support Firefox more then they are doing it. They are a web based company and browser is the application people use to access it.
Posted by: Javed Alam | Saturday, June 14, 2008 at 01:44 PM
Discontinue Browser Sync Suddenly = Worst Possible Press for Google
Google revealed less than a week before Firefox 3 release they will not update the Google Browser Sync (GBS) extension for Firefox 3, leaving thousands of users with a choice: Upgrade to FF3 or keep GBS.
I am *beginning* to doubt Google, and for a very loyal follower, that could be a problem. Years ago, Yahoo used to be a leading service with many great features. Before that Lycos and AltaVista had a good share of the market. Each one lost market share when they failed to support users and keep up in the quickly moving internet application development and public
perception marketplace.
Google has remained on top now because they are good. And they remain good. They keep up. They develop more. Their applications are more innovative. And they are responsive. Responsive? Well. . .
The discontinuance of GBS has put doubt in the minds of thousands, if not a million users: Will Google do this to another product I rely on? I'm asking that question, and I use Gmail, GBookmarks, GHistory, GNotebook, GDocs, GCalendar, and many more.
If this new policy of Google, to abandon users with little or no warning, continues, then I need safer alternatives. I may find alternatives, but will they be better? I suspect in some cases, they will not. I started using Google products because they were good, not because they were Google. I only tried them because they were Google.
I point out something that Google may have failed to take into account: Google said the team that had developed GBS had "moved on to other projects." That is because they could.
They built a good product. The users had little trouble with it. It didn't require massive amounts of support. THE USERS USED IT, THEY LIKED IT, AND IT WAS GOOD.
The world has moved along a bit further, and Firefox has evolved. GBS needs to be updated. They could make it good like it was. So users will use it, they will like it and it will be good. Isn't that the Google Way? Or is that being discontinued too?
Google may have lost more than just a little bit of image. Time will tell. So will the actions Google takes with GBS. I still hope they update it. The work now will be worth more to Google in the future than it costs now. The worth is continued loyalty. The cost of abandoning GBS is the insertion of doubt.
If Google supports the users now while other alternatives are still in development it could be a positive move. If they fail to try, they fail not only the users, but the ideals of Google itself.
Posted by: Eric Powell | Sunday, June 22, 2008 at 02:09 PM

redpajama_set_name: RedPajamaCommonCrawl


The surprising wallpaper is segment of Marque Siege Auto has dimension x pixel. You can download and obtain the Marque Siege Auto images by click the download button below to get multiple high resolutionversions. Here is important information about Siege Bebe. We have the resource more wallpaper about Siege Bebe. Check it out for yourself! You can get Marque Siege Auto and see the in here.


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305 GW of solar power capacity installed worldwide / ICRE8
305 GW of solar power capacity installed worldwide
Globally, solar power capacity has reached 305 gigawatts (GW) thanks to the 50 per cent rise in solar capacity added in 2016 spurred largely by China and the U.S. increasing demand.
Across the world there is now 305 GW of solar capacity, an increase from just 50 GW in 2010.
In 2016 alone the total amount of solar PV capacity reached more than 76 GW, up from 51.2 GW in 2015.
According to the latest figures from SolarPower Europe, China and the U.S. led the solar surge, with both nations nearly doubling the amount of solar added in 2015.
James Watson, Chief Executive of SolarPower Europe, said: "In order to meet the Paris [climate agreement] targets, it would be important if solar could continue its rapid growth. The global solar industry is ready to do that, and can even speed up."
Asia's solar market share reached in excess of 66 per cent last year in 2016, while demand in the U.S. was more than double that of Europe.
In 2016, China was the world's largest solar market, adding a remarkable 34.2 GW an increase of over 125 per cent compared to the previous year.
The U.S. added an estimated 14 GW of solar, up from 7.3 GW in 2015, while in Japan and India 8.6 GW and 4.5 GW of solar additions were added respectively.
The UK currently leads Europe for solar growth with 29 per cent of new capacity, despite a significant drop in installations after the government cut subsidies, followed by Germany with 21 per cent and France with 8.3 per cent.
While early 2016 saw Europe reach the milestone of 100 GW of solar power capacity, growth soon slowed and now stands at around 104 GW.
The solar industry in Europe is calling on the European Union (EU) to set more ambitious renewable energy targets in order to spur growth in the sector.
At present, the EU has committed to increasing renewable energy use by 27 per cent by 2030.
Alexandre Roesch, Policy Director at SolarPower Europe, said: "We need to build a major industrial project around solar and renewables. To start with, increasing the 2030 renewable energy target to at least 35 per cent will send a strong signal that Europe is back in the solar business".
Michael Schmela, Executive Advisor and Head of Market Intelligence at SolarPower Europe, stated that in Southern European countries solar power could generate around €0.03 per kilowatt hours (kWh) in 2017 to 2018, unmatched by any other technology.
He went on to say that to achieve this "we need a reliable governance system to steer investment into solar power plants".
Original location


Well, looks like Mad Men withdrawal has set in, everyone. It's only been a month or so and I'm having a hard time with it.
From an outsider's perspective, Sterling Cooper appears to be half circus, half perfect-place-to-work. Afternoon drinks get the creative juices flowing, people don't hold back opinions, and everyone there is charming, in their own little way. You'd work there, right? Honestly, if I could carry Roger Sterling around in my pocket for the rest of my working life, I'd be a happy lady.
There's a lot to learn from this show, so we've gathered some Mad Men gifs for advice on nailing your next interview.
1. You got the call!
Somebody wants you. Or at least was intrigued enough by your resume that they'd like to meet the personality that goes along with it. Keep your cool. When they ask about your availability to interview, pretend you don't have an excessive amount of free time in your schedule. And if you actually don't? Even better. A company wants someone who is also wanted elsewhere.
2a. On Interview Eve, get a good night's sleep..
2b. ..followed by an excellent breakfast the next morning.
People don't realize, but getting enough sleep, especially the night before an interview is crucial. You're sharper, quicker with answers, you don't fumble, and you look alive. In this interview, you may only be representing yourself, but if you're hired you'll be representing the company, and they want someone who can take care of themselves.
Maybe Don's not the best example here.
3. Arrive within the Goldilocks window of time.
Don't arrive late, but don't arrive too early. Five minutes is perfect. Any earlier and you'll spend an awkward amount of time with the receptionist, not to mention you'll rush (and annoy) your interviewer.
Your pulse might be going a mile a minute, but keep that to yourself throughout the interview. Speak clearly and deliberately. Don't eagerly throw your answer in their face, let it roll off the tip of your tongue. Gives you time to really think about what you're saying.
Notice the workspace, notice what the people wear, what they're talking about, and what's important to this company. Context clues. Are the walls blank or covered with posters? Do they have the latest and greatest technology? Be aware of your interviewer's personality. Blanket advice can't be given as far as how to interact in an interview – you have to read the signs. If the person across the table from you is very professionally dressed and speaks formally, you're expected to do the same. If they're a little more casual or easygoing, you can let your personality show a little bit more. Don't push it– it's still an interview, and it still dictates your future at the company, but it means they're probably very interested in the type of person you are as much as the type of worker you are.
6. Show 'em what you got.
And if it's orange juggling, best of luck to you. No matter how the interview has gone up until this point, keep your confidence level high. Be proud of your work, and make sure to explain it well.
If you need to meet with several people and your smile died after Person 2, keep up appearances. Be just as friendly as you were with your original interviewer. They all probably have a say in this decision, otherwise you wouldn't be meeting with them.
A solid handshake will do. A "thank you" will also do. And a follow-up email reaffirming your interest in the position will mandatorily do.
9. If it went well, postpone the Happy Dance.
Not in the elevator. Not even in the parking lot. This also applies to any sort of victory phone call. You don't know who you're sharing an elevator with, and there's a fine line between confidence and arrogance.
10. Don't harumph if you don't hear back immediately.
Interviewing is a long process sometimes. However, if they promised you a call "either way," and if they didn't follow through, you're welcome to politely inquire.
So there you have it. Surely, this doesn't cover everything, but it's an excellent place to start. You can survive the interview process until Mad Men's return next year.
Such a simple solution to make something positive out of something negative. Every job seeker needs to know how to make their own lemonade when they don't get the job.
There is a plethora of advice available on how to "get the job." But what happens when you've taken all the proper steps and you still don't get the call asking you when you can start? Rejection is disappointing, but turning a negative into a positive is the best thing you can do to move forward.
Express gratitude: After hearing back from the hiring manager, thank them for their consideration. Asking for feedback can help you gain insight into whether there were any particular skills or examples of work that would have had a more positive impact. Check out "How to Ask Why You Didn't Get the Job" for advice on this tricky conversation.
Don't be defensive: It's easy to get offended and flash your defensive side, but conducting yourself in the most professional manner possible when you don't get the job can leave the door open and won't damage your reputation (remember, it's a small world).
Utilize the experience and feedback: Think of rejection as a chance to improve. This is a great time to refine your resume, portfolio and job expectations.
Remember, you will bounce back, and thinking of this temporary setback as a learning experience can make you a better job candidate, and ultimately, a better employee.
Virgo (August 22-September 23) Virgo is an Earth sign ruled by the planet Mercury. Sometimes stubborn, Virgos are notorious for over-complicating situations and limiting their capability to move forward. Also known for analytic minds and excellent memories, Virgos are highly intelligent and precise.
If you are searching for a job: You may feel doubtful and unsure if the position you're interviewing for is a good fit for your skills and personality. Ask the interviewer as many questions as you need to in order to fully understand what the job entails. Your first interview is not the place to seem fussy and inflexible. Succinctly communicate your interest in the position and how your skills are applicable for the job.
If you are hiring: After interviewing all possible candidates, put your excellent analytic skills to work evaluating each job seeker's skills and experience. Don't get caught up on small details. Once you make your hiring decision, act quickly to ensure that your potential new hire has not taken another position.
Exude Overconfidence – Give your prospective employer a good dose of you… only to the 100th power. Be sure you talk only about yourself; don't ask questions that relate to the position and the company. Pepper the conversation with words like "guru," "super-creative," and more! You'll have them escorting you to the parking lot in no time!
Be Completely Unprepared – Resume? Portfolio? Bah, who needs them? If you want to completely botch your chances of a promising future, go ahead and fill in the blanks of your resume in pen. (Bonus points if you're in the lobby right before your interview.) Be sure to exclude any relevant and competitive skills. To really seal the deal, leave out your portfolio pieces that showcase the exact skills they were looking for.
Of course, these are only a few things you can do to sabotage your chances of getting the next great gig. If you're serious about real interview advice on landing your dream job, give CM Access a call – we'll point you in the right direction!
Creative hiring managers are using video conferencing not only for internal meetings, but also for the interview process…and it's paying off for both companies seeking talent and job seekers.
We're offering time-strapped hiring managers and job seekers an alternative to the traditional interview. To shorten the time to hire, CM Access has embraced video conferencing to quickly bring candidates and hiring companies together. No schedules to juggle or travel expenses to incur, while the job seeker gains a job and the hiring company quickly adds a talented team member to hit the ground running.
Keep it Professional – Since you're not in an office setting, it's easier to become slack about your level of professionalism. Keep in mind you're not chatting with a friend. This is a job interview, so prepare as you would for any face-to-face meeting – with a sharp, polished and professional appearance and attitude. Don't take any wardrobe risks with "business in the front, party on the bottom." You may shift in your seat and give your potential employer a shot of your pajama pants they will likely not forget.
The Setting –You've combed your hair and you're dressed to impress, but does the interviewer really need to know that you're sitting in your bedroom with laundry hanging on your treadmill? Be sure to create a professional-looking background, free of clutter and without any hidden surprises lurking or interrupting (that means no barking dogs, lingering cats or children barging into the room!
Practice Makes Perfect – Even if you're an interview pro, the camera can add to your nerves and throw you off your A-game. Enlist a friend to help you rehearse to ensure that you feel comfortable when it comes to the real interview. For the most realistic eye contact, don't look at your screen but at the camera. Be sure you keep your movement minimal – try to avoid talking with your hands, fixing your hair or fidgeting.
You can also check out a great video from Time, "How to Ace a Job Interview on Skype," to help get you prepared for your video. Now that you have some tips to get you "ready for your close-up," will your next interview be virtual?
Thanks to Kermit and Seth, we now know that pizza is not a vegetable – Really!?…Really!
Funny, you would think the whole "pizza-not-being-a-vegetable" discussion would be a common sense issue, but as you heard, apparently it's not so clear cut to everyone. Since it appears common sense topics may not be as obvious to some, we'd like to review a few of the top mistakes and misconceptions that can hurt your chances for getting the interview and the job.
"It doesn't matter how I dress for an interview" – Come on, you're not going out on a Friday night with friends or going to the gym. It's an interview for a job, so show them you're serious.
No one will look at my Facebook page (or read my Tweets or view my YouTube videos from college) – Really? Think again. Come on folks, we've said it before, do we really need to say it again? If you don't want a potential employer seeing it, then do not post it on the Internet!
"I'm too busy to do any networking" – Hmmm, your current career and your future career can be greatly influenced by your ability to stay connected. Networking is not only a great way to stay in touch with colleagues and peers, but to meet new ones. It's also a great way to share ideas and compare notes on the latest industry trends. With sites like LinkedIn, networking is at your fingertips.
You've reviewed the resumes and portfolios, completed the phone screens, and now it's time to start scheduling face-to-face meetings with the marketing, creative and interactive candidates you believe are qualified for the job.
So how do you conduct a successful interview? Just follow the tips below on what to do, but before that, take a look at this video clip (courtesy of Miranda) of what NOT to do. You'll thank us… The Interview from Hell.
Be prepared – Review the candidate's resume once again and keep it in front of you.
Manage the time – Have an agenda and schedule for each interview. Be sure to provide them to any team members participating in the process as well.
Set the tone – After introducing yourself and thanking the candidate for coming in, be sure to explain the interview process and provide a brief overview of the company and the position.
Actively listen – And take good notes.
Observe – In addition to listening, observe the candidate's body language and how they present themselves.
Steer clear of inappropriate questions – Be sure you understand best hiring practices and avoid questions that are inappropriate or even illegal.
Sell the position – Be sure to present the position, your company and what you have to offer in a positive light.
Check out this article for tips on avoiding the "open mouth, insert foot" style of interviewing. We can't say it enough — be prepared. Being too casual in conversation, attire, and attitude is not going to impress your potential employer. Don't go there!


For over seven decades, our customers turned to us to enhance their image with a variety or full service uniform rental and facility service programs. Over the years our customers have been able to experience first hand our philosophy here at Arrow Uniform, one that seems to be harder and harder to come by today. Arrow operates under a few simple principals driven down from the owners of our company, "Exceed your Customer's Expectations" and "Put your Customer First"! While others have built their business model around a corporate structure based on increasing stockholder value, we founded these simple principals that are still near and dear to the Andris family today, and a key component of our "Core Ideology".
Over the past decade, Arrow Uniform has been asked by many of our satisfied customers to take our service first philosophy and manage their entire national program, copy exact in states we traditionally did not offer coverage. Arrow Uniform was up to the challenge, and has put together national management programs second to none. Visit our National Account Management page to learn more about our national programs.


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TOP CHEF CANADA, DEBUTS SEASON 10 ON SEPTEMBER 26 AT 10 P.M. ET/PT ON FOOD NETWORK CANADA
Top Chef Canada, Season 10 Key Cast. (L-R): Janet Zuccarini, Mark McEwan, Eden Grinshpan, David Zilber, Chris Nuttall-Smith, and Mijune Pak. Photo Credit: Mike Ford / Food Network Canada. (CNW Group/Corus Entertainment Inc.)
TORONTO, August 17, 2022 – Food Network Canada's esteemed culinary competition, Top Chef Canada, returns for a milestone 10thseason featuring fiery new challenges, a roster of exceptionally talented chefs, and the title of Canada's Top Chef on the line. A Top 20 overall specialty entertainment program in spring '21*, this season, dubbed Top Chef Canada X makes its debut on September 26 at 10 p.m. ET/PT on Food Network Canada.
Top Chef Canada welcomes acclaimed chef, fermenter and co-author of the best-selling book The Noma Guide to Fermentation, David Zilberto the judging panel. Since 2004, David has worked in some of the top kitchens around the globe. Most recently, he was the head of the Fermentation Lab at the revolutionary three-Michelin-star restaurant Noma in Copenhagen, ranked as the top restaurant in the world. Joining David at the judging table is the returning cast: chef and cookbook author Eden Grinshpan as host, along with judges Mark McEwan, chef and owner of The McEwan Group, powerhouse restaurateur Janet Zuccarini, food writer and personality Mijune Pakand renowned food journalist and critic Chris Nuttall-Smith.
Top Chef Canada X is a monumental season featuring chefs from across the country, including the first-ever competitor hailing from the Yukon. In addition to the title of Canada's Top Chef, the winner will earn the largest reward in Top Chef Canada history: a cash prize of $100,000 provided by Royale Tiger Towel, a luxury Lexus NX, brand-new kitchen outfitted by KitchenAid, an exclusive farm-to-table adventure courtesy of Glad, and a $10,000 cash prize from DoorDash.
The professional chefs hoping to secure the title of Canada's Top Chef are:
Martine Bauer, 36, Toronto, Ont. (Pompette)
Tawnya Brant, 39, Ohsweken, Ont. (Yawékon)
Kimberly Conway, 29, Charlottetown, P.E.I. (Brickhouse Kitchen & Bar)
Joachim 'Jo' Hayward, 32, Toronto, Ont, (Wynona)
Chris Irving, 40, Whitehorse, Yukon (Private Chef & Consultant)
Camilo Lapointe-Nascimento, 25, Montreal, Que. (Menu Extra)
Deseree 'Dez' Lo, 45, Vancouver, B.C. (Marine Drive Golf Club)
Vaishnav 'Vish' Mayekar, 30, Vancouver, B.C. (Pepinos & Caffe La Tana)
Lindsay Porter, 36, Edmonton, Alta. (The Common)
Trevane 'Tre' Sanderson, 27, Toronto, Ont. (Vela)
Monika Wahba, 32, Toronto, Ont. (Maha's Restaurant)
Visit foodnetwork.ca for full biographies and exclusive cast videos.
This season promises to reflect on the past nine seasons of the beloved competition series known for showcasing the country's best chefs and shining a light on the diverse cuisines Canada offers. Throughout the episodes, fans will recognize Quickfire Challenges reimagined from the past, such as the Culinary Skills Race. The chefs will also be challenged to push the boundaries of creativity with a vegan feast and even a trip to the Caribbean, with unexpected twists along the way.
During this season's fast-paced challenges, culinary personalities and icons joining the Top Chef Canada judging panel as guest judges and tasters include:
Dale McKay (Top Chef Canada Season 1 winner, Ayden Kitchen & Bar – Saskatoon, Sask.)
Andrea Nicholson (Top Chef Canada Season 1 and 5 competitor, Butchie's – Whitby, Ont.)
Adrian Forte (Top Chef Canada Season 8 competitor and cookbook author)
Danny Smiles (Top Chef Canada Season 3 finalist, Auberge Willow Inn – Hudson, Que.)
The Beaches (Juno award-winning musicians)
Gail Simmons (Judge, Top Chef)
George Mendes (Veranda – New York City, N.Y.)
Marcus Samuelsson (Red Rooster – Harlem, N.Y.)
Dwayne De Rosario (Author & Canadian Soccer Legend)
Alvin Leung (Bo Innovation – Hong Kong)
Amanda Cohen (Dirt Candy – New York City, N.Y.)
Cheryl Hickey (Host, ET Canada)
Ricardo Larrivée (Judge, Wall of Bakers, Café RICARDO – Quebec)
Dylan Benoit (Host, Fire Masters, Carnivore – Cayman Islands)
Daniel Boulud (DANIEL – New York City, N.Y.)
Kerryann Burnett (The Lobster Pot – Cayman Islands)
An impressive roster of sponsors join the competition with impactful brand partnerships all season long. A grand prize sponsor for the first time, Royale Tiger Towel paper towel provides Canada's Top Chef with a $100,000 cash reward. The brand is also stocked in the locker room and at the chefs cooking stations, assisting them with a tidy prep area each week. In a Quickfire Challenge, Royale Tiger Towel paper towel takes the stress out of the mess, awarding the winner with a $5,000 prize.
Lexus returns as the official vehicle of Top Chef Canada, as a grand prize sponsor for the third season in a row. This year's winner will drive away with the Lexus NX valued at over $55,000. The vehicle is also featured in-show where the judges and chefs arrive to Elimination Challenges in luxury, experiencing the exclusive features the Lexus NX has to offer throughout the season.
KitchenAid outfits the entire Top Chef Canada kitchen, with top of the line countertop and major appliances to help take the chefs' culinary creations to the next level. As a grand prize sponsor, Canada's Top Chef will be awarded with their own stunning kitchen of KitchenAid appliances valued at approximately $16,400. KitchenAid is known for colour, so the Quickfire Challenge tests the chefs' ability to incorporate colourful ingredients in their dish. The Quickfire Challenge winner will take home $5,000 courtesy of KitchenAid.
As the chefs chop, peel and dice their way through each challenge, the new compostable drawstring bags from Glad are provided to ensure proper waste-sorting. At each chef's cooking station Glad compostable bags and recycling bags will be featured throughout the season. In addition, the brand contributes to the grand prize, awarding the winner with a unique farm-to-table experience valued at $10,000.
Ensuring that the chefs keep track of time throughout each challenge, DoorDash sponsors the digital clock in the Top Chef Canada kitchen. Additionally, the brand sponsors the iconic Restaurant Wars Challenge, taking on the added task of handling the rush of delivery and takeout orders on top of the dining room service, and with a $5,000 prize at stake. In an Elimination Challenge that will provide the chefs with an opportunity to showcase their breadth of skill, a vegan feast is sponsored by Becel and Violife, featuring their line of plant-based products. The winner with the best progressive tasting menu will be awarded a $5,000 prize courtesy of Becel and Violife. A new twist is raising the stakes on Top Chef Canada X like never before. For this intense mystery challenge, two chefs must create a standout dish highlighting one ingredient – Avocados From Mexico. The winning chef will be rewarded with a $3,000 cash prize courtesy of Avocados From Mexico.
The award-winning winery Campo Viejo joins as the season's official wine sponsor, stocking the pantry and locker room with bottles of their premium wines made from the Rioja winemaking process. As Campo Viejo's wines are best shared with friends and family, a Quickfire Challenge will task the chefs to impress special guests with a delicious dish for a $5,000 prize courtesy of Campo Viejo. A perfect pairing for a great meal, Canadian sparkling water sponsor Montellier will also be featured in the chefs' locker room this season and at the judges' table. In a flavour-balancing showdown, the brand will also provide a $5,000 prize for the chef that can best utilize opposing ingredients in a Quickfire Challenge.
Visit foodnetwork.ca for an exclusive look at the upcoming 10th season and companion content including full chef bios and compilations. In addition, foodnetwork.ca behind-the-scenes scenes content with the host and judges and an introduction to get to know our new judge David Zilber.
Top Chef Canada is the homegrown version of the hit Emmy® Award-winning NBCUniversal Series Top Chef and is produced by Insight Productions (a Boat Rocker company) in association with Food Network Canada. Executive Producers are John Brunton and Mark Lysakowski, Executive Producer and Showrunner is Eric Abboud, and Series Producer is Daniel Klimitz. For Food Network Canada, Marni Goldman is Executive in Charge of Production, Krista Look is Vice President of Original Lifestyle Content and Lisa Godfrey is Senior Vice President of Original Content and Corus Studios, Corus Entertainment.
*Source: Numeris PPM Data, SP21 (Jan4-May30/21) – confirmed data, Total Canada, CDN SPECIALTY COM ENG – excluding sports stations, 3+ airings, A25-54 AMA(000)
Competitions • 1 min read •
Bocuse d'Or Americas: The winner of 2022
After a fierce competition, the United States has been crowned the winner of Bocuse d'Or Americas 2022.…
Joel Gudheimsson • 28 Jul 2022


Share what you're going through with your LO (little one) during Leap 9, please!
The first week was no different, sleeping through, napping well but we're in the middle of it now just past the storm cloud and she wakes up 2-3 times a night, inconsolable, standing up in the crib, and won't settle until my husband or I will rock her to sleep. Last night she woke 10pm, 1.30am and 4.30am - almost like sleep cycles! I'm knackered, my husband will be travelling next week and will have to deal with her alone.
Daytime is manageable, a few tantrums but otherwise very playful and sweet. It's the sleep... It's hard when you get so used to them STTN and then bam! back to like a newborn. She also has a cold and a cough so these combined probably make her so difficult nighttime.
I'm really struggling. For 2 1/2 weeks so far she's standing up screaming in the night for 1-3 hours at a time, then sleeps for up to 1 hour then screams again for another hour and repeat. I've tried sitting next to her in her cot, picking her up and even co-sleeping but it makes no difference.
In the day she's very clingy and wants to BF ALL the time.
How long is this supposed to last and when is the worst of it?
Fingers crossed for all of us that it passes soon!
18 month sleep regression / night separation anxiet??!
Who has Next to me Chico bed?


On a day that's all about hearts, we must thank David and Amy Bond and Judith Wanichek Adams for opening theirs.
The Bonds are the young couple from Negaunee who shared the story of their search for David's birth mother in a two-part story that appeared in The Mining Journal Thursday and today.
Adams is the birth mother who was found in that search.
All three, for the sake of helping others, were open to talking about the emotions behind such an important effort.
From a 2014 perspective, the world in which Milwaukee resident Judith Wanichek gave birth as an unmarried teen seems a bit like the dark ages. But in 1970, it was called "getting in trouble" and few options were available to young women like her, who were often shunned.
As much as young Judy wanted to keep her son, she loved him so much, she did what she thought was best for him and relinquished custody to a couple ready to provide a good home for him.
David was lucky to have a wonderful pair of adoptive parents in that couple, Bill and Jo-Ann Bond.
For the next 43 years, Judith wondered what had happened to her son. And David sometimes wondered, too.
With great determination, Amy Bond in October started a search to find her husband's birth mother. The breaks went her way and amazingly, she was able to do just that, bringing much joy to not just the Bonds, but to Judith, who now lives in Indiana.
Of course, not every search will have a happy ending. Some birth parents do not want to be found.
We certainly want those wishes to be respected.
However, we encourage anyone involved in adoption to consider transparency, to allow medical history, most especially, to be shared with children who are adopted.
We thank adoptive parents for offering a good life to a child whose birth parents are unable to care for him or her. Adoptive parents make an amazing difference in this world.
We also thank birth parents who want to give their child a great growing-up situation, something they cannot provide, for whatever reason.
Indeed, the sign of being a great parent – be it birth or adoptive – is putting the needs of your child first. That's what Judith did. That's what Jo-Ann and Bill Bond did.
We thank David, Amy and Judith for sharing a truly heart-touching story this Valentine's Day.


Discussion in 'Embedded Systems and Microcontrollers' started by corsair, Mar 26, 2010.
For my project I am building a mini-weather station, and a part of it includes using a thermal-resistance transducer and a PIC18F4550. For the moment, I do not have the thermometer, but my professor said that I can use a 10k Ohm potentiometer to simulate/calibrate it.
You'll want to read Chapter 21 in the PIC18F4550 datasheet. The pins in the PIC's port 'A' (RA0, RA1, etc) which are connected to the switches and the J_ADC connector have alternate names/applications, e.g RA0=AN0, RA1=AN1 etc (see the pin diagram in the datasheet) so you will be physically connecting to those pins in their roles as AN0, etc. The ADC conversion data will be generated and controlled by the ADC registers as described in TAble 21-2 of the datasheet. Its pretty complicated, but you should be able to find some examples online that will help.
So, after having done this, I'm going to you guys for help.
Right now, I have a 10k Ohm potentiometer hooked up to AN0, VDD, and GND. In addition, I have a 7-segment display so that I can see the temperature.
Anyways, that's my attempt at this temperature probe. Thanks in advance for the help!
Just wait for some time, if you need help understanding the code, I will try to explain it to you.


If you haven't already noticed, I'm a big believer in layering my glitter with sparkles and topping all of that with flakies. Because more is more, right? Well, at least as far as I'm concerned, it is!
Don't Get Elfed Up is a gorgeous glass-fleck polish from China Glaze's Cheers! Holiday Collection. It's a dark teal that flashes blue with a glint of purple at extreme angles. I wish the purple flash was more visible in person, but sadly, it's stronger in the bottle. The formula on this was great. Three easy coats and done, great application!
Moonlight the Night is one of two glitters in the China Glaze House of Colour Collection for Spring 2016. It's an opalescent glitter in teal with translucent glitter in coralish pink and purple. There's a good range of glitter colors in here, and I really love the bright flash of the coral.
To finish off that layering, I used one coat of The Uptown by Color Club. It's a purple jelly with flakies that flash through the rainbow. The red and green flashes are the most brilliant, making this a really fun shade to wear. One coat of clear followed by a coat of Seche Vite, and this mani was good to go. And I'm definitely wearing it for another day!