Registry. Cardiac catheterization. Percutaneous coronary intervention. Structural heart interventions.
To present the annual report of the Working Group on Cardiac Catheterization and Interventional Cardiology on the activity data for 2017.
Data were voluntarily provided by Spanish centers with a catheterization laboratory. The information was introduced online and was analyzed by the Steering Committee of the Working Group on Cardiac Catheterization and Interventional Cardiology.
In 2017, data were reported by 107 hospitals, of which 82 are public. A total of 154 218 diagnostic procedures (138 448 coronary angiograms) were performed (2.2% increase vs 2016). The use of intracoronary diagnostic techniques significantly increased, especially that of pressure wire (23.2% vs 2016, n = 7003). In 2017, the number of percutaneous coronary interventions rose to 70 928 (3.2% increase), of which 21 395 interventional procedures were performed in the acute myocardial infarction setting. A total of 105 529 stents were implanted, of which 90.3% were drug-eluting stents (6% increase). Radial access was used in 85.7% of diagnostic procedures and in 88.4% of interventional procedures. The number of transcatheter aortic valve implantations continued to increase (28.2% increase, n = 2821), as did the number of left atrial appendage closures (14.8% increase, n = 582) and percutaneous mitral valve repair procedures (14.1% increase, n = 270).
Diagnostic and therapeutic procedures in acute myocardial infarction increased in 2017. The use of the radial approach and drug-eluting stents also increased in therapeutic procedures. The number of structural procedures rose significantly compared with previous years.
As is the case each year, one of the fundamental tasks of the Steering Committee of the Working Group on Cardiac Catheterization and Interventional Cardiology is the collection of activity data from Spanish catheterization laboratories to prepare the annual registry. This work, which has been carried out uninterrupted since 1990,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 allows an overall view of changes over time in interventional cardiology and helps to detect opportunities for improvement.
The growth and diversification of the registry has paralleled the increase in such activity in the different units of the country; this year, new variables have been introduced to account for recently developed techniques and procedures, in both percutaneous coronary interventions and structural interventions, and those that are outdated have been simplified or modified. Data are submitted on a voluntary basis via an online database to facilitate participation. Data cleaning was performed by the members of both the steering committee and the working group, given that the preliminary results were presented at the annual meeting of the working group, which took place in Gijón, Spain, on June 7th and 8th, 2018.
The value of our registry of annual activity lies in its ability to reveal the degree of implementation of percutaneous techniques both in Spain itself and in relation to the international setting, as well as to evaluate and compare the development of interventional cardiology in the different autonomous communities. Even with the limitations of a voluntary activity registry,27 the free availability of the data promotes understanding of the actual distribution of resources and the trends in the use of diagnostic and therapeutic procedures. Therefore, these data serve as a reference to guide interventions to improve health care in multiple ways, via research, prevention, treatment, and resource distribution. Moreover, the combined effort of the interventional cardiology field to record its activity exemplifies, besides its transparency, its commitment to continuously improving a health care system that is defined by its equity and universality.
This article represents the 27th report on interventional activity in Spain and collects activity from both public and private centers corresponding to 2017.
In the present registry, data were collected on the diagnostic and cardiac interventional activity of most Spanish hospitals in 2017. Data collection was voluntary and was not audited. Anomalous data or data that deviated from the trend observed in a hospital in recent years were referred back to the responsible researcher from the center for reassessment. Data were collected via a standard electronic questionnaire that could be accessed, completed, and consulted through the website of the Working Group on Cardiac Catheterization and Interventional Cardiology.28 The data were analyzed by the Tride company, in conjunction with a member of the committee. The data were compared with those obtained in previous years by the working group steering committee. The results are published in this article, but a preliminary draft was presented as a slideshow at the working group's annual meeting.
As in previous years, the population-based calculations for both Spain and each autonomous community were based on the population estimates of the Spanish National Institute of Statistics up until July 1st, 2017, as published online.29 The Spanish population was estimated to have increased to 46 534 047 inhabitants (Figure 1). As in recent years, the number of procedures per million population for the country as a whole was calculated using the total population.
A total of 107 hospitals performing interventional activity participated in this registry; most of these centers (n = 82) were public (Appendix). This number effectively reflects the activity in Spain, with most of the volume concentrated in centers with public funding. Note that the number of centers reporting their data has remained stable in recent years, allowing sufficiently reliable comparisons with data from previous years. There were 225 catheterization laboratories: 142 (63.1%) were exclusively for cardiac catheterization, 57 (25.3%) were shared rooms, and 26 (11.5%) were hybrid rooms.
A nominal record of active interventional cardiologists was requested, with 477 such personnel in the 107 centers (413 of them accredited). Of the total number of interventional cardiologists recorded, 88 (18.4%) were women. Of the nursing staff, there were 679 registered nurses and 94 radiology technicians.
In 2017, 154 218 diagnostic studies were performed, a number similar to that recorded in 2016 (154 362), indicating that such activity has plateaued. Of these procedures, 138 448 (89.7%) were coronary angiograms (2.3% more than in 2016) and 10 332 diagnostic studies (6.7%) were performed on valvular patients. There was a significant increase in the radial approach, used in 85.7% of all diagnoses made this year (an 11.5% increase vs 2016).
The average number of diagnostic studies was 3311 procedures per million population in Spain; in terms of coronary angiography, the Spanish average was 2974 per million, slightly higher than that registered in 2016 (2912). The distribution by autonomous community of coronary angiograms per million population is shown in Figure 2. Regarding the diagnostic activity by center, 69 centers performed more than 1000 coronary angiograms (2 more than in 2016) and 20 performed more than 2000 (similar to the previous year).
Regarding intracoronary diagnostic techniques, there was a marked increase–23.2%–in the use of the pressure guidewire vs 2016 (7003 cases in 2017 vs 5686 in 2016). The gradual decrease in the use of intracoronary ultrasound in favor of optical coherence tomography in recent years stopped in 2016 and even reversed in 2017, with a 6.1% increase. However, the use of optical coherence tomography, whose popularity has grown considerably since its introduction, seems to have stagnated in the last 2 years, with a slight annual increment of 1.3% in 2017. The changes in intracoronary diagnostic techniques in recent years are shown in Figure 3.
Figure 3. Changes in the numbers of the different intracoronary diagnostic techniques. OCT, optical coherence tomography.
A total of 70 928 percutaneous coronary interventions (PCIs) were reported in 2017, which is 3.2% higher than the 68 695 PCIs in 2016. The changes in PCI over time are shown in Figure 4. There were 1524 PCIs per million population (vs 1478 in 2016 and 1466 in 2015). PCIs numbered 13 966 in women and 16 068 in those older than 75 years of age. The PCI/coronary angiography ratio remains at 0.5, similar to that of 2016.
Figure 4. Changes in the number of percutaneous coronary interventions between 2008 and 2017.
Regarding complex interventions, there was a notable increase in procedures performed on the left main vessel, with a total of 3661 (3439 in 2016), which comprised PCI of the unprotected left main trunk in 84%. Procedures recorded as involving multivessel disease accounted for 23% of all procedures (30% in 2015 and 24.8% in 2016). Lesions considered by operators as chronic total occlusions numbered 2346 (3.3% of all PCIs), and 6645 bifurcation lesions (9.3% of all PCIs) were addressed. However, this figure must be taken with caution, given that the response percentage was low among the different centers and there is a risk of underestimation. Finally, the number of restenosis interventions fell to 2812 (3191 in 2016). The progressive decrease in recent years in this procedure parallels the greater use of drug-eluting stents, as shown below.
As with diagnostic activity, the radial approach predominates in PCIs and reaches levels placing Spain at the forefront of this field, with 88.4% of interventional procedures performed via radial access (82.6% in 2016). The changes over time since its introduction in 2003 are shown in Figure 5, from an equal standing with the femoral approach in 2010 to its current dominance.
Figure 5. Changes in the number of diagnostic and interventional procedures involving the radial approach since 2003.
The distribution by community of the 1524 PCIs per million population in Spain is shown in Figure 6. Regarding the distribution per hospital in 2017, 25 centers performed more than 1000 angioplasties (3 more than in 2016), 49 performed between 500 and 1000, and 20 centers performed less than 250 PCIs. This year, 66% of the centers reported the immediate outcome variables: a successful outcome without complications was reported for 94.8%; 1% reported severe complications (death, acute myocardial infarction [AMI], or the need for urgent cardiac surgery); and only 0.3% reported intraprocedural death.
Implanted stents numbered 105 529 in 2017, which was a slight increase vs 2016 (104 628 stents). The stent/procedure ratio was 1.5 (1.6 in 2016). A noteworthy finding is the 6% increase in the percentage of drug-eluting stents implanted vs the total number of stents, reaching 90.3% (95 253) vs 84.4% (88 344) in 2016. When the use of drug-eluting stents was analyzed by community (Figure 7), a generalized increase was observed. Notably, most communities were above the Spanish average, with these stents already comprising 98% of all stents implanted, a by no means insignificant number. The number of procedures with bioabsorbable devices has plummeted, with 529 such procedures in 2017 (0.5% of the total) vs 1610 in 2016 (1.5%). The number of procedures with dedicated bifurcation stents also fell (210 cases [0.2%] vs 240 in 2016), as well as those with self-expanding stents, with only 37 cases (0.04%). There was a slight increase in the number of procedures involving polymer-free stents (4754 [4.5%] vs 3368 [3.2%] in 2016).
Figure 7. Use of drug-eluting stents by autonomous community.
The first notable finding in this section is the increase in the use of plaque modification devices for both rotational atherectomy, which reached its highest level in the last 10 years with 1324 reported cases (1171 in 2016 and 1262 in 2015), and laser atherectomy, currently performed in a small number of centers but with almost triple the number of procedures vs the previous year (58 in 2017 vs 21 in 2016). The use of special balloons, such as the cutting balloon, fell slightly to 2096 (2446 in 2016) due to the progressive increase in the use of the scoring balloon: 1931 (1520 in 2016). The use of drug-eluting balloons also slightly increased (2664 this year vs 2575 in 2016).
In 2017, there was a significant increase in the implantation of short-term circulatory assist devices during complex coronary interventions. The use was reported of 1129 intra-aortic balloon pumps (vs 984 in 2016), 68 extracorporeal membrane oxygenators (vs 40 in 2016), and 106 Impella devices (vs 59 in 2016).
Regarding other coronary intervention procedures, there was a significant increase in the number of septal ablations (96 in 2017 vs 67 in 2016) and, to a lesser extent, in coronary fistula closures (33 in 2017 vs 26 in 2016).
The recent trend for an increase in the number of PCIs in AMI continued with a 3% increment (21 395 interventions in AMI in 2017 vs 20 588 in 2016). This increase is due to the higher number of primary angioplasties, 7.4% more than in 2016 (17 785 vs 16 554), representing 83.1% of all PCIs in AMI. In accordance with the definitions of the European clinical practice guidelines,30 the treatment option "facilitated angioplasty", currently not indicated, has been withdrawn. Regarding the pharmacoinvasive strategy, 937 rescue PCIs after fibrinolysis administration were recorded (4.7% of the total number of AMI procedures), as well as 1726 delayed or elective PCIs (8% of the total number of AMI procedures).
Primary PCIs accounted for 24.7% of all angioplasties. The average number of primary PCIs per million population in Spain was 382 (356 in 2016 and 337 in 2015). Regarding the rate of primary angioplasty by autonomous community (Figure 8), there was a generalized increase, although it was especially marked in Extremadura, Galicia, Aragon, Region of Murcia, and Castile-La Mancha. However, there may be a bias because some hospitals may not have introduced their data; these figures should thus be taken with caution. The number of centers performing more than 300 primary PCIs decreased (from 28 in 2016 to 21 in 2017) due to an increase in centers performing between 200 and 300 (22 in 2017 vs 18 in 2016), whereas the number of centers performing fewer than 50 primary PCIs decreased from 25 in 2016 to 21 in 2017. Additionally, the number of centers with a 24-hour AMI team increased this year, from 82 in 2016 to 88 in 2017.
Figure 8. Primary angioplasties per million population, Spanish average and total by autonomous community in 2016 and 2017.
In terms of the technical aspects of AMI treatment, the use of the radial approach, in line with the above results, increased by 13% and was applied in 87% of PCIs in AMI. The same occurred with the use of drug-eluting stents to treat infarction, which reached 92% (85% in 2016). The use of abciximab as adjuvant treatment during PCI decreased by 3.6% vs last year (it is used in 17.2% of cases). Finally, the number of procedures using thrombus extractor devices fell slightly, from 34% in 2016 to 32% in 2017.
In 2017, 481 valvuloplasties were recorded in adults, 52% on the aortic valve, 43% on the mitral valve, and 5% on the pulmonary valve. The tendency continued for an increased number of isolated aortic valvuloplasties, not related to the implantation of a transcatheter aortic valve prosthesis, with 252 procedures in 2017 (231 in 2016). Success was achieved in 249 patients (98.8%); 3 cases with complications were reported, all of them severe aortic insufficiency. In contrast, the number of mitral valvuloplasties continued to decrease, with 202 reported this year (233 in 2016). The technique was successful in 196 patients (97%) and there were 6 cases of severe mitral regurgitation, with no cases of cardiac tamponade, stroke, or death.
After a marked increase in the number of procedures vs the previous year, transcatheter aortic valve implantation is now one of the main protagonists in structural heart interventions. Thus, in 2017, 2821 procedures were recorded vs 2026 in 2016 (a 28.2% increase), which represents an average of 61 procedures per million population (vs 43 in 2016). If this growth is assessed by autonomous community (Figure 9), there was a substantial increase in all communities vs 2016, with Cantabria, Galicia, the Principality of Asturias, Community of Madrid, Castile and León, the Chartered Community of Navarre, and the Basque Country above the Spanish average. Transcatheter aortic valve implantations were performed in 1625 patients older than 80 years (57.6%) and most patients had a contraindication to surgery or high surgical risk (61% vs 63.3% in 2016), with a slight increase vs the previous year in the percentage of patients with intermediate risk (20% vs 17.5%); no indication was specified for the remainder. Regarding the type of prosthesis used, the expandable balloon valve was used in 1248 cases (44.2%) and 1291 cases involved a self-expanding valve (45.7%); in 282 procedures, the type of valve used was not specified. The most frequently used access route was the transfemoral route (2484, 88% of cases), followed by the transapical (n = 73), representing a fall vs the previous year (2.5% of cases vs 3.8% in 2016). Regarding the in-hospital outcomes, 147 major intraprocedural complications (5.3%) were reported; 0.4% (12 cases) required conversion to surgery (urgent conversion in 10 of them). Death was reported during hospitalization in 13 cases (0.5%). A total of 280 patients (10.1%) required definitive pacemaker implantation (a reduction of 2% vs 2016). Nine cases of mitral "valve-in-valve" procedures were reported, as well as 6 in the tricuspid position (vs 2 in 2016).
Figure 9. Transcatheter aortic valve implantations per million population. Spanish average and total by autonomous community in 2016 and 2017.
Regarding the treatment of paravalvular leaks, there was an increase in the closure of aortic leaks, with a total of 72 in 2017 (vs 49 in 2016). However, the closure of mitral leaks decreased, with 118 cases in 2017 vs 138 in 2016. Five cases with complications were reported.
In 2017, 582 cases of left atrial appendage closure were performed, a 14.8% increase vs 2016 (496 cases) (Figure 10). Therefore, it is another of the burgeoning techniques. It should also be noted that significantly fewer complications (tamponade, embolism, or death) were reported than in the previous year (1% in 2017 vs 4.5% in 2016). The closures were performed with a disc-and-lobe device in 399 patients (69% of the total) and with a 1-piece device in 117 (20% of the total); in the remaining cases, the type of closure was not specified.
Figure 10. Changes from 2015 to 2017 in atrial appendage closure and percutaneous mitral valve repair procedures.
Another noteworthy finding is the significant increase in percutaneous valvular repair with the MitraClip system in 2017 (Figure 10). The registry recorded 270 cases of mitral valve repair (232 in 2016, a 14.1% increase), with a total of 374 clips (number of clips per procedure, 1.4). The following indications were reported: 67.3% functional mitral regurgitations, 20.2% organic, and 12.2% mixed. Regarding the outcomes, the mitral regurgitation was reduced to grade 1 in 132 patients (63%) and to grade 2 in 68 (32%); no improvement was achieved in only 4 cases (1.1%). The procedure is safe, with complications reported in only 4 patients. In 2017, the MitraClip system was used for the first time for the compassionate treatment of tricuspid regurgitation, with success in all cases.
There were 38 cases of endovascular aortic repair and 24 of renal denervation (33 in 2016). In 2017, new variables were included to reflect all of the newly introduced techniques. Thus, the first procedure with a coronary sinus reducer device was performed and the first 3 interventions with the V-Wave device. Previously omitted techniques were included, such as interventional procedures in pulmonary thromboembolism (89 cases reported in 20 centers) and balloon pericardiotomy (49 cases reported in 16 centers).
The most noteworthy finding in this section is the significant growth in the number of permeable foramen ovale closures, from 201 cases in 2016 to 284 in 2017, a 29% increase. No major complications or implant failures were reported with this technique. The number of interatrial communication closures slightly increased vs last year (294 in 2017 vs 271 in 2016); there were 8 cases of failure without major complications. There were 25 patent ductus arteriosus closures (37 in 2016) and 11 ventricular septal defect closures (21 in 2016). A total of 22 pulmonary valvuloplasties were performed (29 in 2016) and a pulmonary valve was implanted in 32 cases (31 in 2016), with a success rate of 94%.
The activity recorded in 2017 clearly reflects the changes over time in interventional cardiology in Spain and allows us to envisage the future path for this field. PCI activity has shown slow but steady growth and a clear qualitative leap, whose strongest indicator is the increase in all intracoronary diagnostic techniques and the high percentage of radial access. In structural heart interventions, the overall number of techniques implemented in recent years has increased and the significant jump in the number of procedures has reduced the previous prevailing gap with neighboring countries in this field.
With regard to coronary diagnostic activity, the greater use of intracoronary diagnostic techniques stands out, as already mentioned. Particularly relevant is the more than 20% growth in the use of the pressure guidewire, which nowadays is a fundamental tool for decision-making in the catheterization laboratory, supported by the excellent results obtained both in chronic patients and in the setting of AMI.31, 32 In addition, the increased use of nonhyperemic indices, which facilitate and expedite the procedure and have recently been validated in 2 large studies,33, 34 may have contributed to this marked growth. Another important finding is the increase, for the second year in a row, in intracoronary ultrasound, which seems to parallel the increase in percutaneous treatment of the coronary artery.
Another notable finding in the annual activity data is the growth in structural heart interventions, especially in transcatheter aortic valve implantation. The irrefutable evidence in favor of this technique and the expansion of its indication to intermediate-risk patients38, 39, 40 have favored a dramatic increase, from 43 implants per million population in 2016 to 61 in 2017. These figures place the rate per million population above the recently published European average,41 although still at a distance from countries such as France, Germany, and Switzerland. Another procedure showing significant growth is percutaneous mitral valve repair, mostly in patients with functional mitral valve regurgitation and high surgical risk, in line with the good clinical results observed for this indication in terms of improved functional class and cardiac remodeling.42 Left appendage closure, as indicated for patients with high risk of bleeding and contraindication to anticoagulation, also grew significantly, from 492 implantations in 2016 to 582 in 2017. In terms of structural heart disease outcomes, a significantly lower number of complications and more successful procedures have been reported this year across the board.
The activity collected in 2017 shows a slow but steady increase in the number of diagnostic and therapeutic coronary procedures, as well as a significant qualitative leap in intracoronary diagnostic techniques, particularly the use of the pressure guidewire. The dominance of the radial approach and the progressive increase in primary angioplasty as a treatment for AMI are clear indicators of the quality of Spanish interventional activity. There has been a marked increase in the number of procedures for structural heart disease, both in transcatheter aortic valve implantation and in atrial closure and percutaneous mitral valve repair, which moves Spain closer to European standards.
The Steering Committee of the Working Group on Cardiac Catheterization and Interventional Cardiology would like to thank the directors of the cardiac catheterization laboratories throughout Spain, all of those responsible for data collection, and all of our peers whose work and enthusiasm ensure fair and first-rate patient care.
10. Hernández JM, Goicolea J, Durán JM, Auge JM. Registro de actividad de la Sección de Hemodinámica y Cardiología Intervencionista del año 2000. Rev Esp Cardiol. 2001;54:1426-38.
11. Hernández JM, Goicolea J, Durán JM, Auge JM. Registro de actividad de la Sección de Hemodinámica y Cardiología Intervencionista 1990-2001. Rev Esp Cardiol. 2002;55:1173-84.
12. Hernández JM, Goicolea J, Durán JM, Auge JM. Registro de actividad de la Sección de Hemodinámica y Cardiología Intervencionista (1990-2002). Rev Esp Cardiol. 2003;56:1105-18.
22. García del Blanco B, Rumoroso Cuevas JR, Hernández Hernández F, Trillo Nouche R. Registro Español de Hemodinámica y Cardiología Intervencionista. XXII Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2012). Rev Esp Cardiol. 2013;66:894-904.
23. García del Blanco B, Rumoroso Cuevas JR, Hernández Hernández F, Trillo Nouche R. Registro Español de Hemodinámica y Cardiología Intervencionista. XXIII Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2013). Rev Esp Cardiol. 2014;67:1013-23.
24. García del Blanco B, Hernández Hernández F, Rumoroso Cuevas JR, Trillo Nouche R. Registro Español de Hemodinámica y Cardiología Intervencionista. XXIV Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2014). Rev Esp Cardiol. 2015;68:1154-64.
25. Jiménez-Quevedo P, Serrador A, Pérez de Prado A, Pan M. Registro Español de Hemodinámica y Cardiología Intervencionista. XXV Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2015). Rev Esp Cardiol. 2016;69:1180-9.
26. Serrador Frutos A, Jiménez-Quevedo P, Perez de Prado A, Pan M. Registro Español de Hemodinámica y Cardiología Intervencionista. XXVI Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2016). Rev Esp Cardiol. 2017;70:1110-20.
27. De la Torre Hernández JM, Edelman E. From Nonclinical Research to Clinical Trials and Patient-registries: Challenges and Opportunities in Biomedical Research. Rev Esp Cardiol. 2017;70:1121-33.
28. Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología. Registro de Actividad SHCI. Accessed 30 Jun 2018. Available at: http://www.registroactividadshci.es.
29. Instituto Nacional de Estadística. Cifras oficiales de población resultantes de la revisión del Padrón municipal a 1 de enero. Resumen por comunidades autónomas. Población por comunidades y ciudades autónomas y tamaño de los municipios. Accessed 1 Jul 2017. Available at: http://www.ine.es/jaxiT3/Tabla.htm?t=9681&L=0.
30. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of the acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39:119-77.
31. Smits PC, Abdel-Wahab M, Neumann FJ, et al. for the Compare-Acute Investigators. Fractional flow reserve-guided multivessel angioplasty in myocardial infarction. N Engl J Med. 2017;376:1234-44.
32. Van Nunen LX, Zimmermann FM, Tonino PA, et al. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial. Lancet. 2015;386:1853-60.
33. Götberg M, Christiansen EH, Gudmundsdottir IJ, et al. Instantaneous wave-free ratio versus fractional flow reserve to guide PCI. N Engl J Med. 2017;376:1813-23.
35. Barbato E, Dudek D, Baumbach A, Windecker S, Haude M. Current trends in coronary interventions: an overview from de EAPCI registries. EuroIntervention. 2017;13:Z8-Z10.
36. Stone G, Sabik J, Serruys P, et al. Everolimus eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375:2223-35.
37. Valgimigli M, Gagnor A, Calabró P, et al. Radial versus femoral access in patients with acute coronary síndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015;38:2465-76.
38. Leon MB, Smith CR, Mack MJ, et al. PARTNER 2 Investigators. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609-20.
39. Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic valve replacement in intermediate-risk patients. N Engl J Med. 2017;376:1321-31.
40. Jiménez-Quevedo P, Serrador A, Pérez de Prado A, Nombela-Franco A, Biagioni C, Pan M. Selection of the best of 2016 in interventional cardiology: expansion of TAVI indications to intermediate-risk patients. Rev Esp Cardiol. 2017;70:218-9.
41. Dudek D, Barbato E, Baumbach A, Windecker S, Haude M. Current trends in structural heart interventions: an overview of the EAPCI registries. EuroIntervention. 2017;13:Z11-3.
42. D'Ascenzo F, Moretti C, Marra WG, et al. Meta-analysis of the usefulness of MitraClip in patients with functional mitral regurgitation. Am J Cardiol. 2015;116:325-31.
43. Saver JL, Carroll JD, Thaler DE, et al. for the RESPECT Investigators. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017;377:1022-32.


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I am not a fan of this president one bit, but please please for the love of god, do NOT boo during the Hall of Presidents.
You are booing at a robot, not a real man. You look silly, you look petty, you look crazy. He doesn't even look that real.
We need this original attraction to survive this presidency and not give Disney a reason to replace it with Great Moments with Rocket Raccoon.
I'd like to think more decorum than that. After all, last several Presidents had more than their share of haters but no booing so hopefully folks realize it's as stupid as you say.
No, people booed W and Obama.
I think the whole idea is dumb. You are booing a robot.
Guess not at my audiences. But yeah, I can see it, just wishing folks had more sense.
I concur. As someone who doesn't like Trump, I say don't boo, its just not classy.
If you must send a message, then stay outside and cheer the muppets instead. They don't mind if you Boo - as long as you boo King George; plus the guest visit count is the metric Disney execs are going to be looking at.
Trump's speech is innocuous, but it's also more dramatic and interesting than Bush or Obama's presentation. If he gets boos, it'll have a totally different connotations. It won't be boring.
I think 45 would be much better suited filling in for Zazu in the now defunct Enchanted Tiki Room - Under New Management show. Similar look, tone and they both scream and threaten.
WDI did several obvious things to prevent "audience feedback."
1: There is a big bust of Walt Disney right at entrance of the theater with a poster indicating how Walt envisioned the Hall of Presidents to honor the office.
2: The new show starts out by talking about Walt's vision for a president attraction. By heavily emphasizing Walt it subconsciously sends a message not to act like a fool in the attraction.
3: There is not much opportunity to boo because of no breaks in the script. The last show said "Ladies and Gentlemen: President Barack Obama" before he started speaking. In the new show Trump starts speaking right after George Washington with no break for applause or boo's. The narrator also starts speaking right after Trump stops.
I saw the show today and there was a security person at the theater entrance doors as well as two security people in the theater, one on either side, as well as what looked like a security manager standing in the back. There was a round of applause after the show and nobody seemed to mind Trump being in it.
I give credit to both Disney and the president for putting aside their differences and doing whats right. HOP has always been a great attraction that I would say is Disney doing what Disney does best: bringing people from all races and political agenda's together. Remember Clinton got impeached and Bush started a very controversial war where a lot of people got killed. All presidents have had to make decisions that many people don't agree with and they are still all represented.
Zazu was the wise-of-heart hornbill from the Lion King. You might be thinking of Iago Rob.
The only time I ever booed a president in HOP was Hoover once, and even then it was a pretty quiet one (loud enough for my family to hear). Sure enough, my father gave me a look afterwards.
I agree completely with the poster's comments. However, on the thought of why one would boo a robot...we are a passionate people and some of us have strong political opinions, more so than ever before. People boo and shout at their TV screens all the time, as if the entity on the other side can hear them. Of course we are in private and not sitting in a theater with dozens of other people.
But here is the representation of a man that has caused tremendous emotions. It's even his voice you hear speaking directly to you. That is going to upset people who perhaps before entering, think they have a grasp and can handle it. As theme park enthusiasts, we all know and understand protocols and behaviors and would NEVER do this. But I think it is without uncertainty, going to happen.
Thanks for the scoop "The Man".
I understand the emotion that Trump brings out into people, but we need to be realistic. Its an attraction and a good one at that.
My fear is that Disney will use this as an excuse to get rid of this quasi educational attraction and replace it with something stupid and IP driven.
Thanks James - That is correct. Iago - the screaming and yelling Gilbert Geoffrey voiced villain from Aladdin.
I'll say this, every president from 1 to 45 has elicited anger or some other negative emotion from somebody. If people studied their history and held the same microscope up to all the others as they do to Trump, there would be at least a few reasons somewhere for booing every last one of them. The difference now I think is that a lot more people are incapable of checking their emotions, confusing the virtual world of the internet news sites, message board and social media outlets...with the real world that has real human beings who aren't just a name on a screen, and actual consequences and laws of cause and effect.
Everyone is entitled to their opinion and has freedom to express it, but acting like a child and having no self awareness or regard for those around you is not going to help your cause. If anything it only reinforces an image of a fool whose political arguments are probably equally as foolish, regardless of what side you are on.
To the self important, emotionally immature adult who feels compelled to have an outburst in the HOP like a toddler would in a restaurant, just know this. People who gave their left arm to enjoy Disney with their family frankly don't give...in the words of Clark W. Griswold...a frog's fat a** what you or anyone else thinks about Donald Trump or Obama or whoever else, but they do care that their precious time and very expensive vacation is being disrupted by the likes of you. Nobody likes what you are doing and nobody wants to listen to you. Politics has a time and a place like everything else, and the park isn't the time or the place. Drop it and have some fun, or just go home and let the rest of us enjoy ourselves.
Well said, by Derek Potter above. To "protesters", no one gives a crap about your opinion and no one should have to have it shoved down their throats -- especially not on vacation. Grow up and keep it to yourselves.


text:
Ex-White House lawyer Craig to face trial soon
The accusations against Craig tied allegations of illegal lobbying for the government of ex-Ukrainian President Viktor Yanukovych
Gregory Craig, former White House Counsel
Ex-lawyer of the White House of Barack Obama's time Gregory Craig will stand before the jury that may convict him to five years in jail. He is accused of the number of crimes within Robert Mueller's investigation on Russia's election meddling, as Bloomberg reports.
That time he was a partner of Skadden Arps Slate Meagher & Flom LLP and he was asked to prepare a report concerning that time Ukrainian pro-Russian regime, violating FARA law, which demands from the officials to report on their cooperation with the foreigners.
The accusations against Craig tied allegations of illegal lobbying for the government of ex-Ukrainian President Viktor Yanukovych. The investigation figured out that in 2012 Paul Manafort, President Donald Trump's former campaign chairman, asked Craig to make a report to deny the criticism of the prosecution of politician Yulia Tymoshenko by the Ukrainian government.
Related: Rudy Giuliani calls the U.S. Department of Justice to investigate Mueller's probe against Russia, Trump
Due to this, Craig is accused of lying to the government about his lobbying activities and no registration of the Ukrainian government as the agent. The prosecution works proving that Crage lied and withheld information about the extent of his work for the Ukrainian government.
As we reported earlier, U.S. federal judge of Virginia State found Paul Manafort guilty in fraudulence and sentenced him to 47 months imprisonment.
As it was reported, President Donald Trump's former campaign chairman Paul Manafort has been found guilty on eight counts of financial crimes. After a 16-day trial, Manafort was found guilty of five tax fraud charges, one charge of hiding foreign bank accounts, and two counts of bank fraud. The jury was unable to reach a verdict on the remaining 10 counts, and the judge declared a mistrial on those charges.
Related: Mueller warns of Russian meddling in 2020
Paul Manafort is charged with laundering money and evading taxes over ten years of cooperation with former Ukrainian leaders. Previously, an investigation team released over 300 documents, which reveal the details of Manafort's cooperation with the currently disbanded Party of Regions - the-then pro-presidential and ruling political force in Ukraine.
Later Manafort was sentenced to 7,5 years imprisonment, as a result of court hearings on his case.
Manafort Russia's interference in U.S. presidential election in 2016 Robert Mueller Craig

redpajama_set_name: RedPajamaCommonCrawl


text:
Planned Parenthood is Targeting Baby Girls in the Womb
Kidnapped Catholic Priest Gets a Hero's Welcome in His Homeland
Trump Administration to Terminate Obama's Climate Plan
By Cathy Ruse, JD, The Daily Signal, Oct. 9, 2017
Planned Parenthood wants you to think they are the champion of women. But if they achieve their goals, there may not be very many women left to champion.
Last year, Indiana passed a law that banned sex-selective abortion — the killing of unborn babies based on their sex. But last week, a federal district judge granted a permanent injunction against that law, at Planned Parenthood's request.
The ruling gives abortionists in Indiana the legal right to kill girl babies just because they are girls.
The case is Planned Parenthood of Indiana v. Commissioner of Indiana State Department of Health, but it could fairly be captioned: Planned Parenthood vs. Little Girls.
In the United States, only a handful of states have laws against sex-selective abortion. Planned Parenthood fights them wherever they appear.
It goes without saying that it's not the little boys whose lives are in peril from this abhorrent practice. It's the little girls. This is borne out by social science data from all over the world.
Modern abortion politics has done strange things to our culture. Women and children are natural allies for feminists, but abortion politics has made them enemies.
The first American feminists didn't see it that way.
Susan B. Anthony, a leader in the women's suffrage movement, denounced abortion. Elizabeth Cady Stanton, another early suffragist and an abolitionist, said, "When you consider that women have been treated as property, it is degrading to women that we should treat our children as property to be disposed of as we see fit."
And yet treating children as property to be disposed of as we see fit has become the litmus test in today's feminist movement.
When legislators in Arkansas enacted a ban on sex-selective abortions earlier this year, a prominent civil rights advocate blasted the measure as preventing women from "obtaining abortions that they want for whatever reason."
Help us champion truth, freedom, limited government and human dignity. Support The Stream »
Planned Parenthood also attacked the measure, giving aid to the practice of keeping boy babies while discarding girl ones.
And yet, women's rights activists continue to allow Planned Parenthood to claim the mantle of feminism for itself.
In 1988, Kate Michelman, former head of the National Abortion Rights Action League, told The New York Times: "Abortion is the guarantor of a woman's right to participate fully in the social and political life of society."
What an utterly un-feminist sentiment.
No woman should have to abort her child to participate fully in society. If a pregnant woman or mother can't participate, then something's wrong with society. Let's change society. Isn't that the truer feminist response?
Our politics have become so warped that the words "abortion" and "women's rights" are often used synonymously. If you're against abortion you're called "anti-woman." If you want to stop giving free tax dollars to abortionists then you're "waging war on women."
Our legal system, too, has become so warped that abortionists are allowed to stand in the place of women in court, as if their interests are identical.
Justice Clarence Thomas spoke of this "jurisprudential oddity" in his dissent in Whole Women's Health v. Hellerstedt last year: "Ordinarily, plaintiffs cannot file suits to vindicate the constitutional rights of others. But the Court employs a different approach to rights that it favors," he said wryly. "The Court has erroneously allowed doctors and clinics to vicariously vindicate the putative constitutional right of women."
Abortionists like Kermit Gosnell and Leroy Carhart sell abortions to women. One customer, Karnamaya Mongar, was dead hours after entering Gosnell's squalid clinic. Surely his interests were never synonymous with hers.
The attorney general in Indiana has vowed to appeal the ruling and to defend the ban on sex-selective abortion. The nation's abortion giant will of course keep fighting it.
The looming question for the feminist movement is: Will you stand against the selective elimination of women in the womb?
Cathy Ruse, JD, currently serves as Senior Fellow for Legal Studies at the Family Research Council.
She was Chief Counsel to the Constitution Subcommittee in the House of Representatives where she had oversight of civil rights and human rights issues, as well as religious freedom and free speech matters which came before the House.
Mrs. Ruse served for several years as the chief spokesperson on human life issues for the U.S. Catholic Bishops. She was co-host of the cable television program Legal Notebook, and has made national and international media appearances, including PBS' Firing Line, CNN's Crossfire, and Fox News' The O'Reilly Factor, among many others. Her writing has been published in the Wall Street journal, USA Today, The Christian Science Monitor, the Washington Times, and other national and regional newspapers and publications. In 1997 Wired magazine called Mrs. Ruse "one of the most influential opinion shapers in the country."
Mrs. Ruse served as legal director of Family Research Council in the mid-1990s and was legal counsel and program director for the National Law Center for Children and Families, a law firm devoted to strengthening and defending laws against pornography.
In 2004 she and her husband, Austin Ruse, received the John Paul II Award for Advancing the Culture of Life from the Institute for the Psychological Sciences. In 2006 they received the Defender of Life Award from American Collegians for Life.
stream.org/planned-parenthood-targeting-baby-girls-womb/


The Site Manager allows FileZilla client users to store information about their FTP sites.
The Site Manager command is located under the File menu. You can also press Ctrl+S or Command+S.
Use the New Folder button to introduce or add folders.
In the right panel, you have 4 tabs to enter some needed, and much optional, information about the selected site on the left.
Port: Only if it differs from the standards.
Protocol: Enter the type of FTP server you will connect to (such as FTP or SFTP).
Encryption: Whether, and how, the FTP connection should be encrypted.
Anonymous: You can't enter a username and password. In this case, the username is always "Anonymous".
Normal: You have to enter a username and, if required, a password.
Ask for password: FileZilla asks you the password during logon, and it remembers the password during the session.
Account: Selecting this enables the "Account" field in the bookmark's settings. This logon type is for FTP only; SFTP does not have support for it.
Key file: Selecting this enables the use of ssh keys for authentication. This logon type is for SFTP only. You must specify the private key file here, and the server must have your public key.
User: The user ID to use when connecting.
Key file: Required when using "Key file" logon type.
Servertype : allows you to make a special selection for this FTP target. Most sites will work fine with the Default value, however some will require SFTP.
Bypass proxy : Allows to bypass any proxy server.
Time Offset : Allows to adjust the times displayed for files. See the server time offset page for more information.
Specifies in more detail how transfer may take place.
Specifies the character set used to communicate with the targeted FTP site.
Once you've configured your site, select it and click Connect.
This page was last edited on 29 March 2019, at 09:56.


Does anyone have any old photos of West Norwood High Street from the 1950's/1960's that might show my old house number 77 next door to Trings the corn chandler come grocers.
I mean personal type photos that you may have in your possession not the ones I can find on the net or in books and the like or the ones at the local archives centres; I have all them or have seen them.
I would be most grateful for a copy if you have any, I lived there for 18 years and never took a photo (shame on me) sadly the properties are no longer there, they were pulled down in 1966 when we were made to move out.
Sorry Ken, no photos, but I did go to West Norwood Girls school in Gypsy Road in 1951. I lived in Herne Hill.
I too went to gypsy road school but it was the infants school and not until I was 5 that was in 1953.
You must have had some journey from Herne Hill to gypsy road, did you walk or was you really posh and got a bus?
Just turned 62, not sure that's young though, as my children all call me the old man or old moaner mainly.
Yes I remember the Jewish Orphanage, many's the time we were chased by the boys from there after we made fun of them, never got us though, well not me anyway.
Well I have the big 70 this year Ken. I wonder if that lovely Jewish orphanage building is still there and, if so, what it is used for now. May go and 'Google' it later.
Just Googled the orphanage - it has been pulled down. Such a shame, it was a very impressive looking building too.
Google up "Lambeth Landmark" look on the right hand side and under places pick out West Norwood then click on images and have a nice long look at the photos on there, I think there is one or two of the Jewish Orphanage on there.
You can also look see what they have for Herne Hill as well.
Thanks Ken, I'll have a play on that site later today. Thank you.
Had a look at Lambeth Landmark Ken - great photos on there of Herne Hill - loads of Brockwell Park where I used to play when I was a child, plus the Lido there. Thanks for the tip.
Hi Ken, born in Eden Rd, W. Norwood 1939, went to Gipsy Rd, School c1952. Had lots of Jewish Ophanage school mates ! Sorry no photo's only memories.
Cant recall 77 High St, but I worked when left school for Nye the Builder in High St. Used Crisp Bros cycle shop, Live on the Bloomhall Estc1940's, Etc, Etc,.
Hi there Norwood. I lived in Herne Hill - just off Milkwood Road from 1948 until I went to do nurse training in Croydon in 1958. Been living here on the East coast now for 39 years.
I am presently in Upper Norwood Ken, and our local library usually has a number of old postcards of Norwood. I could always ask there if they know of any local photographic records next time I'm passing.
Hi Norwood. Yes, it was the Gipsy Road school - didn't really like it much there and do remember Osbourn. During WW2, I was living in Yorkshire (born there), so no, wasn't evacuated thank goodness. I also knew a few Jewish orphans and also wonder what became of them.
"Yes" got these OK many thanks.
That would be nice of you, i do understand that they have some cabinets in that libarey that may have photos in, BUT i would only be interested in the one(s) that show 77 Norwood High Street, as i have most (or seen most) of the High Street views.
Sure, that's fine I understand Ken. Certainly don't mind taking a look for you. I will be up by the library on Wednesday, so will post a reply then.
Seems as if you were there or there about's before I was born, I do remember Nye and we were always over Cripoos with our bikes.
Hi Ken, did your brother or sister get any "group" photo at Gipsy Rd School. I never did ? My dealings with Cripoos, was motorcycles, I use to race at the Crystal Palace. I lived in Durning Rd, I wonder if I knew your sweet heart ? I married Barbara 1961 who lived in Gipsy Rd Gardens. Nice chatting Bob (why did I call myself "norwood" ?
No photos I am sorry to say, the brothers and sister that went to that school at the same time as you were Sidney, Donald, George, Alan and Louisa Rhoades.
My girl friend from about 1961 lived in the fist house (or the second) in Bloomhall Road, looking at Google maps it was number 15 or 17 but as regards her name, sadly I can't remember.
Not sure if you have looked at Gipsy Road School on Friends Reunited but there are some old boys and girls listed on there that you may remember. I am listed on there but it is not quite right because I only went to the "infants" part of Gipsy Road.
No Norwood, sorry but no photos. The cycle track brings back memories because our neighbour Peter Brotherton used to practice there and went to cycle for Great Britain in the Olympics in Melbourne. Yes, used to go to Brockwell Park Lido regularly too - oh happy days!
I was born in 1948 and went to Gipsy road infants about 1953 until 1955 then I went to Salter's Hill junior school up until about 1959 then on to Tulse Hill comprehensive.
Yes I do remember a lady keeper in Norwood park, their hut was next to the sweet kiosk near the paddling pool if I remember right? We used this park all the time and used to climb over the cinder pitch when the gate was locked.
I also remember the H.H track that you spoke of at Herne Hill because we went there for our Sports day at school.
We were at the Lido at Brockwell park as I remember all summer (well it seemed like it) but we only went when we could afford it.
As for Tannoy's I also worked there for Mr Fountain and his firm, but only for about 3 or 4 months when I first left school in 1963 then I went to work for the GPO and stayed there 40 years.
Just spoke to my sister and she has a photo of Gipsy road school BUT it was taken in the play ground and it only has girls in it as the school was spilt at that time.
Hi Ken, so sorry but silly me forgot the library is closed all day Wednesday. I did look in the window as they have a lot of their local postcard scenes platered over them. it would seem they only have pictures of Crystal Palace and Upper Norwood on show, however, I will get up there again tomorrow, as I want to got in and ask if they could find anything in the archives relating to your old address. Will post again tomorrow.
Some of you may be surprised to hear that Norwood Park has had a good deal of cash spent on it of late, they have built a new playground as well as lots of new equipment for the kids. And there is a One o'clock club too. They have closed down the old paddling pool, and may eventually remove it.
If anyone wants pictures, let me know, I'm only a stone's throw away from there.
Thank you for doing that for me, I also think that they may only have photos of Upper Norwood and Crystal Palace, but it may still be worth a try.
By the way I live in Ashford Kent and if there is anything local you want me to have a look at for you please just ask and I will have a look for you.
Hi Ken, I have been speaking with the local archivist at Upper Norwood Library one Mr. Savage, who was most helpful. He says he knows they have some info and images on West Norwood and he is going to look through everything they hold. I will be contacting him again on Friday.....gives him chance to have a proper look, so he can let me know if he turns anything up.
Other than that he suggests contacting Lambeth archives at the Minet Library, who hold images of West Norwood. They have their own mail address which you can find by googling.......I will go off and have a look over that next. Perhaps you may also wish to give them a try.........if you haven't all ready? Good luck, hope something turns up.
I have already been to the Minet Lib and they don't have any as far as i can tell by what i have seen, BUT you never know if you have seen all there is to be seen at those places do you?
Lets hope Mr. Savage comes up trumps.
Oh what a shame Ken. It's true, there may be other archives as yet unseen. Keep your fingers crossed for tomorrow then Ken. I will.
Hi Jen, I was born a five minute walk from Norwood Park, paddled in the pool just after the war, it was quite deep then, they made it shallow later. We had wonderful winters using old "air-raid" shelter roofs as sledges about 10 of us could sit on one and slide down the snow down salters hill (on the grass) that is !
Spoke to Mr. Savage again Ken and as you will have guessed he could not find any image of your particular address. Apparantly most of the buildings/properties, which were on that part of the high street and fell between the numbers of 61 - 79 Norwodd High Street, have now been taken over by a branch of Travis Perkins, the builders merchants.........which is ironic really, as my youngest son has worked for them for the past 8 years, as a driver.
He also mentioned googling Lambeth Landmark......but I see from a thread above you are familiar with it all ready.
He did mention that if you put Norwood high st in the search box it would probably throw up a half dozen images of the lower end, odd numbers. Maybe you have all ready tried that too?
One point of his research into this over the past couple of days, he was anxious to relate was that back in 1892 Number 77, where you lived, had been a Cat's meat dealer or cat food business, which he discovered in a Trade/Town Directory. The proprieter was one Robert Dove.
Sadly that's all I have been able to discover Ken........but never say never, something may turn up yet.
That's what I keep telling myself in my hunt for pics of my paternal grandparents.
Thank you very much for trying to help me I think your very kind in doing it, I have used the Lambeth Landmark that you speak of and although it's a great place for photos of Norwood sadly not 77.
Yes your right about it being pulled down (in 1966 it was) and the timber yard was put up some time later but it wasn't Travis Perkins at first, we had to move from 77 to Clive Road at that time.
I have also tried the "search box" thing but no luck for my old house, and your right about the "Cats meat man" my mum and dad moved there in about 1939 taking over the house from some of the Doves family, but they (the Doves) moved next door to number 75 and still run the cats meat trade from there for a few years.
Once again thank you Jen and if I can be of help to you (in any brick walls you may have come up to) please just ask.


text:
Another STOCK Act Update
by John Wonderlich Feb 6, 2012 12:44 pm
Since the STOCK Act is presumably going to see House floor consideration this week, we're continuing to follow the bill very closely.
We've got two main criticisms of the Senate-passed version of the STOCK Act, in addition to the Senate's failure to pass an e-filing requirement.
First, the Senate version requires anyone downloading the data behind the new reporting to create a login. We can't see any legitimate reason to require a login for downloading data. As we've noted before, Data.gov permits access to bulk downloads without a login, and such a requirement adds nothing of value. At its worst, it intimidates reuse and adds cost and a burden for public oversight. At its best, requiring a login for bulk downloads… Well, I can't think of anything good to say about it. (See the bottom of page 13 of the pdf.)
Second, the bill mandates that records be destroyed after 6 years. This is such a bizarre requirement that I think it's partially the result of a drafting error. Financial disclosures, whether they're the yearly declarations, or the new financial transaction disclosures, are valuable historical documents. They should continue to be available online for decades after they're filed, and at an absolute minimum, the House should remove the requirement that they be destroyed after 6 years, and instead require that NARA get copies of all the filings for safekeeping.
Finally, we've got a new suggestion for improving the disclosure requirements. The new financial transaction reporting requirements apply primarily to stock trades. But if 15K in stocks presents enough of a potential conflict of interest to require reporting, shouldn't real estate purchases and sales be disclosed in real-time as well? Congress has had one scandal after another about real estate (think of Hastert or Dodd), and the Boxer amendment about mortgage terms passed in the Senate. Members buying or selling real estate should be required to disclose the transaction as it occurs.
Tags: STOCK Act


CHICAGO, March 21, 2019 /PRNewswire/ -- According to the new market research report "Reporter Gene Assay Market by Reagents & Assay kits (Luciferase, Green Fluorescent Protein, â-glucuronidase, â-galactosidase), Application (Gene Regulation, Protein Interaction, Cell Signalling Pathways), End Users, Region - Global Forecast to 2024", published by MarketsandMarkets™, the Reporter Gene Assays Market is expected to reach USD 2.6 billion by 2024 from an estimated USD 1.6 billion in 2019, at a CAGR of 10.1%.
The major factors driving the growth of this market include increasing funding for cell-based research, growing applications of gene expression, and a rising preference for cell-based assays.
On the basis of product, the market is broadly split into reagents and assay kits. The assay kits segment is expected to account for the larger share of the Reporter Gene Assays Market in 2019. The large share of the assay kits segment can be attributed to their repeated use in gene expression studies and signaling pathway analysis during gene transcription or translation levels. Assay kits are preferred over standalone reagents in cases where a validated protocol for assay development is available. Assay kits not only save time but also offer technological advantages, easy availability, and greater convenience.
Browse in-depth TOC on "Reporter Gene Assays Market"
Based on application, the Reporter Gene Assays Market is segmented into gene regulation, protein interaction, cell signaling pathways, and promotor structural & functional analysis. In 2019, the cell signaling pathways segment is expected to grow at the highest CAGR during the forecast period. The high growth rate of this segment is attributed to its importance in several cellular functionalities (such as cell differentiation, cell fate determination, and cell growth) and advanced applications of cell signaling in life science sectors (such as biotechnology, molecular biology, and microbiology).
North America is expected to account for the largest share of the Reporter Gene Assays Market in 2019, followed by Europe. The large share of North America in the global market can be attributed to the growing academic and government investments in genomics and proteomics research; rising demand for cell-based assays in research; increasing focus on cell-based therapeutics; and rising focus of stakeholders on research projects involving proteins, associated biomolecules, and genes.
The prominent players in the Reporter Gene Assays Market are Thermo Fisher Scientific (US), Bio-Rad Laboratories (US), Merck (Germany), PerkinElmer (US), Promega Corporation (US), Biotium (US), Abcam plc (UK), Danaher Corporation (US), Geno Technology (US), Genecopoeia, Inc. (US), InvivoGen (France), PromoCell (Germany), Becton, Dickinson and Company (US), Biotium, Inc. (US), Canvax (Spain), LI-COR, Inc. (US), System Biosciences, LLC (US), Indigo Biosciences, Inc. (US), BioThema (Sweden), Takara Bio Inc (US), BioAssay Systems (US), Cell Biolabs, Inc. (US), BPS Bioscience, Inc (US), Biosynth AG (Switzerland), and Cayman Chemical (US).


4. Choose "Select a project" and enter a project name in the below box. Click next.
1. Click "Create Billing Account". You will receive $200 of credits per month, so you shouldn't have to worry about ever being charged.
2. Create a name for your billing project and press continue. Fill out your payment info.
1. In the window, you will be offered to enable your APIs. Press Next.
2. You will see a new window with your API key in the box. Copy the key to be able to use it and press Done.


If you want to go fishing, you could go learn how to fish. Or, if you are ready to pay, you could hire fishing charters. But, like anything else, before you book, make sure you are getting exactly what you want. Once in the boat, there is little you can do but go along.
If the price quoted for a charter sounds too good to be true then it probably is. Check the credentials and license of the captain. Ask if the captain is a member of the local guides association; if he is not, find out why. Tell the agent that you are on a budget and ask about any hidden or extra costs. You should be certain about the total amount you will pay and the services you will get in return.
Word of mouth is a tried and tested way of choosing the best fishing charter. You can also research online or you can talk to other tourists who may have been on a trip. The fishing charter company may not necessarily be at fault in any untoward incident. If the situation has been dealt with quickly and satisfactorily, the company is probably good.
When you charter a boat for fishing, you should check out the amenities available onboard. But even if you get a boat which promises a lot, it is the captain who runs it. Talk to the captain and check his license. Find out how he deals with the crew on board.
Go check out International Game Fish Association for more information!


text:
Millennials are making money by investing in the future.
Maya Kachroo-Levine
If you invest $30,000 in three specific stocks, you could triple your money in 10 years.
At least that's what acclaimed financial analyst Malcolm Berko wrote in his advice column last year.
The stocks you'd have to invest in, he said, are Raytheon, General Dynamics, and Lockheed Martin — three defense companies. In other words, what he's saying is: You could triple your money in 10 years, but you'd be capitalizing on the U.S. revving up its defense spending.
But here's the thing: Some investors, especially millennials, aren't concerned with only the returns.
Image via iStock.
As a generation, millennials want to put their money into stocks that are good for the world.
They've seen firsthand how much can change in 25 years. They've seen technology move at warp speed, lived through major policy shifts, and watched the world's population grow. They know they can effect change in the next 25 years — and they know we need change.
Millennials are also more apt to distrust financial institutions. As a generation, they had to enter the workforce amid record high unemployment rates, stagnant wages, and larger student debt bills than any previous generation. That's why many millennials want to take financial matters into their own hands.
In the next several decades, an estimated $30 trillion will be passed down from baby boomers to younger generations. That means $30 trillion of the world's assets could be reallocated into humanitarian endeavors.
In addition, by 2020, millennials will comprise 46% of the workforce, and as they become the primary earners, they will have an even greater effect on investing in this country.
In fact, they may well be the first generation that considers making the world a better place along with investment returns.
And it makes sense if you think about it: This is the generation that was promised a return on investment on their college tuition and instead got stuck with a massive bill and waning job prospects. The world they grew up in taught them to put less stock into promised returns and care more about tangible value.
But there is a smart way for millennials to invest in making the world a better place. It's called impact investing.
Impact investing essentially means putting money into causes that effect social change, explains Adam Connaker, an associate at The Rockefeller Foundation, a foundation that is working to solve the world's biggest and most entrenched challenges through innovative finance mechanisms.
"You have a right as an investor, no matter your size, to ask what impact your investments are having in the world," says Connaker.
If the projects do well, the investors see good returns on their investments. It proves altruism and making money on your investments are not mutually exclusive.
Eric Letsinger, founder and CEO of Quantified Ventures, says we are witnessing the largest transfer of wealth in our country's history, while simultaneously seeing government funding for health, social, and environmental programs dry up. As a result, impact investing will likely get a huge boost from millennial investors thanks to inherited and newly accumulated wealth.
Many of these impact investing projects allow members of a community to invest in public works that will improve their own neighborhoods. For example, Jason Anderson, president and CEO of Neighborly Securities, worked on a deal in Burlington, Vermont, that encouraged residents to invest in public projects like building sidewalks, rehabilitating bike paths, and improving waterfront access to Lake Champlain.
Photo via Garrett Brinker/Neighborly.
"We've talked to resident investors up in Burlington who told us that the main reason they invested in the issuance was because they commute to and from work on that bike path every day," says Anderson. "Because of their investment in the city, they can have a direct impact on that rehabilitation project."
Putting money into city-centric or environmental initiatives allows investors to directly affect the future of our communities.
Letsinger says that in 2016, they worked on an environmental impact bond with DC Water. The project financed green infrastructure as an alternative to building large concrete tunnels for Washington, D.C.'s water utility.
"If the project succeeds, it presents a win-win to both the investors and DC Water: The investors earn a higher return than they would have on a standard municipal bond from DC Water, and DC Water has then proven that green infrastructure is highly cost-effective," explains Letsinger.
In addition to the high returns for investors, the DC Water investment helped create green jobs and improve neighborhoods, and the success of this project will have future implications when it comes to making cities more environmentally friendly.
Because many millennials are a generation that would rather see green infrastructure go up in their neighborhood than watch their bank balance go up on a computer screen, they're the first generation that could make impact investing the norm.
If the millennial generation commits to investing in causes, it could change how we see money.
In fact, Letsinger says that most of the impact investors his company works with are millennials. Working with clients who are motivated not just by making money but by improving the world for future generations allows impact investing firms to target niche causes in various communities around the world.
He also says 2017 was a particularly good year for impact investing, which bodes well at such an early stage. He means that the returns on investment were good — but also that they saw more interest among people looking to make a difference.
With impact investing, "values and returns can coexist, allowing investors to fight climate change, produce more affordable housing, and develop clean energy," says Anderson.
If this trend continues, 20 years from now, financial advisers might be primarily offering environmental causes to invest in, rather than defense stocks.
Putting some savings into investments is something most people either already do or are going to do in the coming years. That doesn't need to change — what can change is where we put that money.
We can no longer rely on our government to fund the social and environmental efforts needed to improve our society and planet as a whole. This financial shift to impact investing will allow us to pool our money with other people who also want to create positive change. As a result, it can happen on a larger scale than we ever thought possible. Plus, as an added bonus, you'll likely find you can do well for yourself while simultaneously doing good in the world.
For more than 100 years, The Rockefeller Foundation's mission has been to promote the well-being of humanity throughout the world. Together with partners and grantees, The Rockefeller Foundation strives to catalyze and scale transformative innovations, create unlikely partnerships that span sectors, and take risks others cannot — or will not.
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Greenleaf Returns, Self-Righteous but as Necessary as Ever
Jouelzy
black church
Greenleaf review
Greenleaf season 2
black church and gays
Merle Dandridge as Grace Greenleaf and Lynn Whitfield as Mae Greenleaf (OWN)
Last season, OWN premiered the church-family drama Greenleaf. I caught the previews between commercials for Tyler Perry's soap opera, If Loving You Is Wrong, and made a mental note that it might be worth checking out, if only to see whether it veered left into Perry melodramatic land. Then I promptly forgot about it.
Thankfully, Netflix's trending list reminded me to check out the first season. I had an hour to spare, so I put the first episode on. In the end, I gave up my whole weekend, because once you start, you can't stop—Greenleaf is that good and that addictive. Then, just as I started to wonder what I would watch now, like the Lord blessing Job, turns out I had caught up just in time for last night's season 2 premiere.
The book of Job is a running theme throughout Greenleaf, as peril befalls the family that oversees a megachurch (Calvary) and lives under one roof of a small mansion in the suburbs of Memphis, Tenn. The series features masterly performances by Lynn Whitfield, who plays Mae, the Greenleaf matriarch, and Merle Dandridge, who plays Grace Greenleaf, the prodigal daughter who has returned after 20 years to upend a family full of deep secrets.
Grace was once a powerful preacher in her family's church and a favorite of the parishioners, and when she finally returns to the pulpit, she gives a rousing sermon based on Job 3:26. Job has cursed his life and lamented, "I have no peace, no quietness; I have no rest only turmoil" (NIV).
Grace's sermon goes on to be the most profitable service for Calvary, where the theology walks the line of prosperity preaching led by Greenleaf patriarch Bishop James (played by Keith David), who is charmingly sly in fitting the holy word into his materialistic needs.
The high drama, methodically paced out, is what pulls you into Greenleaf. It's also frustrating to watch every member of the holier-than-thou Greenleaf clan use Grace as the scapegoat, though their indignant self-righteousness helps the show to craftily address complex issues that we face daily and commonly sweep under the rug.
The show juxtaposes the use—or, really, the manipulation—of the Bible and Christianity to excuse one's actions, or lack thereof. The son, Jacob, is caught in his affair with Bishop's assistant; his wife forgives him in order to keep Grace from stopping his ascent into pastorhood, because infidelity isn't a boulder on that path.
Grace's main mission was to uncover the decades of abuse by her Uncle Mac, Bishop's right hand and legal counsel. The sexual abuse led to her sister Faith's suicide. Mac's ability to cover up and get away with his indiscretions belies a tangled web of efforts by the Greenleafs to ascend and profit from their church. Bishop isn't so upright after all.
The downfall of Mac, which causes the saintlike facade of the Greenleaf family to come undone, falls squarely on Grace's shoulders. Mae delivers some of the best lines here, dripped in Southern charm and biblical shade. Grace could be the one person to take her on, but she always demurs to her mother. That the push toward Christian forgiveness can be twisted to keep a beaten woman silent, while the mother of an abused daughter so believes in the sanctity of her church that she forgives everyone's silence and not only continues as a member but also works for the church, is what keeps Greenleaf intriguing and keeps it inspiring important discussions.
Going into season 2, I am most excited to see the development of the relationship between the daughter Charity; her musical director, Carlton; and her husband, Kevin. Carlton is openly gay and his partner, Reggie, will be attending church with him. It's easy to dismiss this as the cliché church storyline, but then there is Charity's husband, who is doing battle with his own sexuality, though he has never acted on it. In this second season, Charity, who has claimed acceptance of all people because "we're all humans," is super close to Carlton and his husband, to the derision of the church deacons. But she is refusing to work with her husband, Kevin, on any level.
It's a precarious way to highlight how we box in men's sexuality and the lack of of self-acceptance. Charity appears to be accepting and acknowledges that you cannot pray the gay away, but in reality, she's not willing to talk to or hear Kevin out at all. And yet she's running into the arms of Carlton and Reggie.
We notoriously respect the talents but not the humanity of black gay men, and as the deacon board makes noise about Carlton's marriage, it will be great to see Greenleaf do what it does best: allow the self-righteous to pull back the rug and tackle the underbelly of the black family and church's symbiotic ways.
YouTuber, author and feminist, a #SmartBrownGirl who loves tacos, culture and critical thought. You can find Jouelzy on YouTube at the intersection of pop culture, history and politics.


Nanomaterials hold promise as multifunctional diagnostic and therapeutic agents. However, the effective application of nanomaterials is hampered by limited understanding and control over their interactions with complex biological systems. When a nanomaterial enters a physiological environment, it rapidly adsorbs proteins forming what is known as the protein 'corona'. The protein corona alters the size and interfacial composition of a nanomaterial, giving it a biological identity that is distinct from its synthetic identity. The biological identity determines the physiological response including signalling, kinetics, transport, accumulation, and toxicity. The structure and composition of the protein corona depends on the synthetic identity of the nanomaterial (size, shape, and composition), the nature of the physiological environment (blood, interstitial fluid, cell cytoplasm, etc.), and the duration of exposure. In this critical review, we discuss the formation of the protein corona, its structure and composition, and its influence on the physiological response. We also present an 'adsorbome' of 125 plasma proteins that are known to associate with nanomaterials. We further describe how the protein corona is related to the synthetic identity of a nanomaterial, and highlight efforts to control protein–nanomaterial interactions. We conclude by discussing gaps in the understanding of protein–nanomaterial interactions along with strategies to fill them (167 references).