I bought GBTC etf for 2k which uses crypto but sold for loss of 1k after a month.
there will always be something that comes along that people think is the bees knees. We won't know what until it comes along. Then some inevitably will get sucked into it for either fear of missing out or wanting to get rich quick. They will have been warned by others who've seen enough crazes come and go, but some portion won't listen and will dive in anyway thinking the rest of us are old fogies who don't know that the future is here (mutual funds are your grandfather's investment, right?).
I'll stick with my boring old no-load, low cost index mutual funds.
Even though there will be some who've had bad luck with crypto who will share their stories with others when the next craze comes along, it's all to easy to say "This time is different."
Last edited by arcticpineapplecorp. on Wed Dec 05, 2018 4:49 pm, edited 1 time in total.
Real estate is the closest thing?
Collectibles?, maybe, if you have the right expertise /knowledge in the right area (high end watches, rare coins, stamps, banknotes, vintage cars, art..) Not really a feasible "build wealth strategy", more like a "I have too much wealth already and need to spend it on something".. I have collected many things, and sold many for a neat profit over the years, but it takes a lot of time, research, effort and patience to buy low, hold and sell high.. and the occasional success are canceled out by the many losses or simple break even sales.
guns, ammo and liquor? Only if you are a complete pessimist dooomsday prepper..
Crypto is just vaporware, over-hyped nothing, backed by nothing, stabilized by no government or central bank, paying no dividends, worth only whatever the next person is willing to pay for it.
FWIW many old magic the gathering cards are worth far more than they were in the initial mid 90s boom. LIke 20x.
Every couple of decades they take a significant run and we will rehash arguments about the cost of a suit costing roughly the same amount of Gold in 1900 as it does now. Then they tank and the discussion subsides for another 20-30 years.
Bitcoin and foreign stocks all had their run on this forum.
Last edited by J G Bankerton on Wed Dec 05, 2018 5:07 pm, edited 1 time in total.
Yes, earlier this year an Alpha Black Lotus sold for over $87,000.
You mean staying away from ~half of the World's stock market for no good reason ?
Read Mr. Bogle's reasons to avoid foreign. I have 10% foreign, never mined a coin.
Read Mr. Bogle's reasons to avoid foreign.
Is Mr. Bogle wiser than the market ?
There are reasons why an individual US-based investor may be better off by reducing his share of foreign stocks below its capitalization weighted level, but it is highly dubious if that could ever amount to a large reduction.
Mr. Bogle's reasons might have been valid 100 years ago, but today other developed markets are as stable as the US. The risk of a socialist revolution in Switzerland is probably lower than the risk California seceding from the Union.
That is better than most of the other cryptocurrencies. For instance Ether fell from $1422 to $103, a loss of more than 92 percent.
I am sure that the interest in Bitcoin will return if the price recovers.
What is happening in France as I type was one of the reasons mentioned by Mr. Bogle. I see foreign has more staying power than coin though.
I blew it back in the day. I crunch numbers for SEIT for free. BTC was a few cents then and didn't make economic sense for me to mine because of the cost of electricity.
I ran my old collection through XIRR in Excel with latest TCG market prices and it indicates roughly a 15% CAGR. Ironically, that's using the "buy and hold" technique, though I kinda forgot about them over the last 20 years.
This is true. I got board with stocks and now invest in cigars. Not ordinary cigars but humidor queens that are destem to be passed from humidor to humidor at ever increasing prices. If I don't smoke too many.
I predict that the current love of avocados for toast and guacamole is going to continue. Due to inside information I have about soil and weather conditions where these fruits are grown, I predict their supply will go down while demand continues to rise. People all over the world will start to do anything to get their avocado fix and avacados will start to trade on the black market and in the fruit trade underworld. Avacados will be worth their weight in platinum. THERE WILL BE MONEY TO BE MADE!
My advice is to get in now any way you can. Buy avacado futures, learn to grow them in your basement, anything! And you can thank me later.
People all over the world will start to do anything to get their avocado fix and avacados will start to trade on the black market and in the fruit trade underworld.
My cigars contain an addictive drug, nicotine. Investing in addictive products has proven to never fail.
FIRE is a popular topic, which i think jives well with the general frugality of your median BH.
In the future, it wouldn't surprise me to see a UBI (universal basic income) in certain Scandinavian countries, and I think that will be a hot topic of discussion, not so much the political aspect but what that means for retirement and FIRE. Many philosophical implications.
Keep this quiet; Bolivars will be a Habanos Edicion Limitada in 2018.
I don't see much about peer to peer lending these days either.
What's next? Possibly international socks doing really well and posters asking if they should invest? The luxury watch bubble bursting?
the total income to date... has amounted to approximately one and a half million pounds sterling in the Swiss francs and Venezuelan bolivars in which for reasons of prudence--they continue to be the hardest currencies in the world--we convert all our takings.
Bolivars are fiat money. You should have been in Petros.
Editors in Wikipedia wrote: The petro, or petromoneda, launched in February 2018, is a cryptocurrency developed by the government of Venezuela. As of August 2018 it does not appear to function as a currency. Announced in December 2017, it is supposed to be backed by the country's oil and mineral reserves, and is intended to supplement Venezuela's plummeting bolívar fuerte currency, as a means of circumventing U.S. sanctions and accessing international financing. On August 20, 2018 the bolívar soberano (Sovereign Bolivar) was introduced, with the government stating it would be linked to the petro coin value.
A fiat currency backed by a cryptocurrency. Best of both worlds.
I am honestly surprised that Bitcoin has held up as well as it did. It stayed around $6k for several months. I wonder where the bottom will be now that it has begun to fall again?
Are you saying guacamole is not addictive?
Crypto currency will make a come back when it can be generated for less than the cost of electricity. Maybe.
I remember hearing of Bitcoin when it was pennies a Bitcoin, I researched getting a mining rig but it was too expensive. It's a minor regret of mine.
Episode 289 of planet money there's a guy who talks about how he used to buy them when they were cheap, but has sold many now that it's at $14. He said he made about $5k.
He had a few thousand then. I wonder how many he has now! At 20,000, those few thousand were worth 60MM.
Not in my area of New Jersey. I don't know about the Hipsters in Jersey City. They funny.
I remember hearing of Bitcoin when it was pennies a Bitcoin, I researched getting a mining rig but it was too expensive.
I had a machine with 8 GPU and 12 CPU, it sucked 1500 watts, the max from a 110 outlet. I built it to look for extra terrestal communication with SETI. It cost $250 a month in electricity. I did this in the dead of winter, it was the only way to keep the machine cool. It was for science and keep the house warm. I should have crunched a few coin but why for a few cents?
It can be fun to speculate or to try to make a quick buck mining, but most arguments for crypto in the long-run either conflate it with "Blockchain" as a technology, or devolve into far-fetched hypotheticals about the black market and impending government collapse. The best real argument I've seen for an "intrinsic value" is as an alternative to other forms of cash transfers.
Assume you were a new merchant dealing in $10 transactions (e.g., fast casual restaurants or most day-to-day retailers). Card processors like PayPal will charge you 2.9% + 30 cents to do a transaction, or about ~$0.59 per transaction. I think there is an argument for crypto if it allowed you to do the same thing *substantially* cheaper (in order to compensate for the added volatility of exchange rates, the delay in the transaction clearing, and the hassle of converting back to dollars).
Right now, the cost of a Bitcoin transaction is about ~$0.17. You can make of that what you will, but my sense is that the price was hyperinflated last year, and the current price is probably closer to a point it has at least some hypothetical utility.
The Tobacco cabal is moving in on the marijuana business along with the Beer industry. Just stick with the addictive stocks we have and know.
TLDR: I'm not feeling a lot of FOMO.
I couldn't agree with you more. The few companys that will profit from this industry will be the ones we already know.
It can take 90 seconds or longer for the chain to crunch a transaction. It will get longer and longer as time goes by. That would not fly in the retail world. BTC is for hiding money and doing illegal things. That is what keeping it alive. The drug cartels hold billions in BTC.
Marijuana is not patentable and once it is totally legal, and not cash only, the big boys of tobacco and alcohol will crush the startups like the cockroaches they are.
My kid was mining Bitcoins with his gaming computer while at school all day when they were going for $10/ea. Boy I wish I had dropped a couple grand on them as speculation but at the time it seemed even more ridiculous than it does now.
do own the URL for bitbitter.com, perhaps now is the time for me to launch my blog and tell stories such as this.
Eventually Bitcoin will go back to its actual and original value, which is nothing.
I wonder how that question followed from the first sentence.
I mean, what makes you think that crypto currencies was "most likely to compete" with Bogleheads?


text:
Adult: Coronary| Volume 158, ISSUE 1, P141-151, July 2019
The impact of the radial artery or the saphenous vein in addition to the bilateral internal mammary arteries on late survival: A propensity score analysis
Francesco Formica, MD
Francesco Formica
Address for reprints: Francesco Formica, MD, Clinica Cardiochirurgica, Ospedale San Gerardo, ASST Monza, Via G.B. Pergolesi 33, 20052 Monza (MB), Italy.
Cardiac Surgery Unit, ASST San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Stefano D'Alessandro, MD, FECTS
Stefano D'Alessandro
Gurmeet Singh, MD, FRCSC
Division of Cardiac Surgery, Department of Critical Care Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
Ana Maria Ciobanu, MD
Ana Maria Ciobanu
Emergency Department, IRCCS Humanitas Hospital, Milan, Italy
Luigi Amerigo Messina, MD
Luigi Amerigo Messina
Statistics and Quality Health Service, ASST San Gerardo Hospital, Monza, Italy
Salvatore Scianna, MD
Salvatore Scianna
Mario Moscatiello, MD
Mario Moscatiello
Open ArchivePublished:January 10, 2019DOI:https://doi.org/10.1016/j.jtcvs.2018.12.078
Previous ArticleCommentary: Minimally invasive direct coronary artery bypass: Reawakening of a sleeping beauty?
Next ArticleCommentary: Radial artery and bilateral mammary arteries in coronary artery bypass grafting: How much is too much?
Long-term survival benefits of full arterial revascularization with radial artery (RA) used in addition to bilateral internal mammary arteries (BIMA) compared with saphenous vein (SV) used in addition to BIMA has not been clearly defined.
We retrospectively analyzed 660 3-vessel coronary artery disease subjects who received BIMA in addition to either RA (n = 206) or SV (n = 454) grafting in a period between June 1999 and November 2017. After propensity score matching, we obtained 190 matched pairs for analysis.
In the matched population, in-hospital mortality occurred in 4 patients (1%), with 2 deaths (1.1%) in the BIMA + RA group and 2 deaths (1.1%) in BIMA + SV group (P > .99). The median follow-up time was 9.2 years (interquartile range, 5.6-13 years) with a maximum follow-up time of 18.5 years. There was not a significant difference in long-term survival between the 2 groups over the follow-up period. Survival at 5, 10, and 15 years were 94.8 ± 1.7%, 83.7 ± 3.1%, and 78.6 ± 3.9% in the BIMA + RA group and 96.2 ± 1.4%, 85.1 ± 2.9%, and 80.4 ± 3.6% in the BIMA + SV group (stratified log-rank P = .78). Cox proportional hazard regression model was used to estimate that the use of RA in addition to BIMA did not affect the late mortality (propensity score adjusted hazard ratio, 1.05; 95% confidence interval, 0.62-1.79; P = .83).
In a relatively small population of triple-vessel coronary artery disease, the use of RA as a third arterial conduit with BIMA did not confer a long-term survival benefit.
bilateral internal mammary arteries
total arterial myocardial revascularization
CABG
BIMA (bilateral internal mammary arteries), CABG (coronary artery bypass grafting), CI (confidence interval), CPB (cardiopulmonary bypass), CxA (circumflex coronary arteries), ECMO (extracorporeal membrane oxygenation), HR (hazard ratio), IABP (intra-aortic balloon pump), IQR (interquartile range), PS (propensity score), RA (radial artery), RCA (right coronary artery), SMD (standardized mean difference), SV (saphenous vein)
Comparison of survival probabilities in matched patients who underwent BIMA and RA versus BIMA and SV CABG.
In triple-vessel disease coronary patients who underwent coronary surgery, radial artery used in addition to the bilateral internal mammary arteries did not confer better long-term survival compared with use of the saphenous vein.
Long-term survival in triple-vessel coronary patients who underwent coronary artery bypass grafting surgery with BIMA with either radial artery or saphenous vein is comparable. Further longer-term studies with larger cohorts of patients are needed to show whether the radial artery should be preferred to saphenous vein as a third conduit to use in addition to the BIMA.
See Commentaries on pages 152 and 154.
Coronary artery bypass grafting (CABG) is still recommended for patients with 3-vessel coronary artery disease
Sousa-Uva M.
Neumann F.J.
Ahlsson A.
Alfonso F.
Banning A.P.
2018 ESC/EACTS guidelines on myocardial revascularization.
Eur J Cardiothorac Surg. 2019; 55: 4-90
and total arterial myocardial revascularization is advocated for patients younger than 60 years old
Hillis L.D.
Smith P.K.
Anderson J.L.
Bittl J.A.
Bridges C.R.
2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
J Thorac Cardiovasc Surg. 2012; 143: 4-34
or in patients with reasonable life expectancy of at least 15 to 20 years.
Tatoulis J.
Total arterial coronary revascularization—patient selection, stenoses, conduits, targets.
Ann Cardiothorac Surg. 2013; 2: 499-506
Multiple arterial grafts improve long-term survival compared with single left internal mammary artery grafting or percutaneous coronary intervention.
Locker C.
Bell M.R.
Frye R.L.
Multiple arterial grafts improve survival with coronary artery bypass graft surgery versus conventional coronary artery bypass grafting compared with percutaneous coronary interventions.
J Thorac Cardiovasc Surg. 2016; 152: 369-379.e4
Shi W.Y.
Hayward P.A.
Rosalion A.
Newcomb A.E.
Fuller J.A.
Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies.
Radial artery (RA)
Caputo M.
Zakkar M.
Bryan A.
Angelini G.D.
Are three arteries better than two? Impact of using the radial artery in addition to bilateral internal thoracic artery grafting on long-term survival.
Buxton B.F.
Is a third arterial conduit necessary? Comparison of the radial artery and saphenous vein in patients receiving bilateral internal thoracic arteries for triple vessel coronary disease.
Eur J Cardiothorac Surg. 2016; 50: 53-60
or gastroepiploic artery,
Formica F.
Ferro O.
Greco P.
Martino A.
Gastaldi D.
Paolini G.
Long-term follow-up of total arterial myocardial revascularization using exclusively pedicle bilateral internal thoracic artery and right gastroepiploic artery.
Eur J Cardiothorac Surg. 2004; 26: 1141-1148
Colagrande L.
Corti F.
Right gastroepiploic artery graft: long-term clinical follow-up in 271 patients--experience of a single center.
J Card Surg. 2006; 21: 539-544
Suma H.
Tanabe H.
Takahashi A.
Horii T.
Isomura T.
Hirose H.
Twenty years experience with the gastroepiploic artery graft for CABG.
in addition to bilateral internal mammary arteries (BIMA), have been reported as conduits alternative to saphenous vein (SV) to effect complete myocardial revascularization. Several meta-analysis and review articles
Gaudino M.
Puskas J.D.
Di Franco A.
Ohmes L.B.
Iannaccone M.
Barbero U.
Three arterial grafts improve late survival: a meta-analysis of propensity-matched studies.
Yanagawa B.
Verma S.
Mazine A.
Tam D.Y.
Jüni P.
Impact of total arterial revascularization on long term survival: a systematic review and meta-analysis of 130,305 patients.
Int J Cardiol. 2017; 233: 29-36
Martinez-Gonzale B.
Reyes-Hernandez C.G.
Quiroga-Garza A.
Rodriguez-Rodriguez V.E.
Esparza-Hernandez C.N.
Olizondo-Omana R.E.
Conduits used in coronary artery bypass grafting: a review of morphological studies.
Ann Thorac Cardiovasc Surg. 2017; 23: 55-65
Schwann T.A.
El Hage Sleiman A.K.
Yammine M.B.
Tranbaugh R.F.
Engoren M.
Bonnell M.R.
The incremental value of three or more arterial grafts in CABG: the effect of native vessel disease.
Ann Thorac Surg. 2018; 106: 1071-1078
described the RA as the third-most commonly used arterial conduit in addition to BIMA in patients who underwent CABG. Preference for the RA over the right gastroepiploic artery is because of the relative technical ease of harvesting. Recent guidelines consider the use of the RA conduit reasonable when grafting the right coronary artery (RCA) with critical stenosis (≥90%) or circumflex coronary arteries (CxA) with severe stenosis (≥70%).
Aldea G.S.
Bakaeen F.G.
Pal J.
Fremes S.
Head S.J.
Sbik J.
The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting.
Ann Thorac Surg. 2016; 101: 801-809
These anatomical restrictions likely account for the lack of RA conduit adoption, and the historically low number of patients analyzed in various published studies. Moreover, recent randomized trials have reported conflicting midterm angiographic results of RA compared with SV graft.
Collins P.
Webb C.M.
Chong C.F.
Moat N.E.
Radial Artery Versus Saphenous Vein Patency (RSVP) Trial Investigators. Radial artery versus saphenous vein patency randomized trial: five-year angiographic follow-up.
Deb S.
Cohen E.A.
Singh S.K.
Une D.
Laupacis A.
Fremes S.E.
Radial artery and saphenous vein patency more than 5 years after coronary artery bypass surgery: results from RAPS (Radial Artery Patency Study).
J Am Coll Cardiol. 2012; 60: 28-35
Gordon I.R.
Hare D.L.
Matalanis G.
Horrigan M.L.
Comparable patencies of the radial artery and right internal thoracic artery or saphenous vein beyond 5 years: results from the Radial Artery Patency and Clinical Outcomes trial.
J Thorac Cardiovasc Surg. 2010; 139: 60-65
Whether full arterial revascularization with the RA used in addition to BIMA for 3-vessel coronary disease is associated with better midterm and long-term survival compared with SV used in addition to BIMA has not been clearly defined. In this study, we sought to evaluate the early and the long-term survival in patients with 3-vessel coronary disease who underwent CABG either with BIMA and the RA, or BIMA and the SV, to verify the effect of the RA as a third arterial conduit.
The local ethical committee approved the Bilateral Internal Mammary Artery Plus RA--Long-Term Survival Analysis (BIMARS) study (approval: deliberation 836, June 8, 2017). Individual patient consent was waived. We retrospectively analyzed prospectively collected clinical data from the surgical registry at the San Gerardo Hospital, University of Milano-Bicocca (Monza, Italy) between June, 1999 and November, 2017. Of the 3750 patients who underwent isolated CABG during the study period, 2129 patients received at least 3 distal anastomoses. Among them, 660 (31%) received BIMA in addition to either RA (n = 206) or SV (n = 454) grafting. Figure 1 shows a Consolidated Standards of Reporting Trials diagram illustrating the patient selection algorithm.
Figure 1Consolidated Standards of Reporting Trials diagram of study population. CABG, coronary artery bypass grafting; RA, radial artery; BIMA + RA, Bilateral internal mammary arteries and additional use of radial artery; BIMA + SV, bilateral internal mammary arteries and additional use of saphenous vein.
To be included, all subjects had at least 3-vessel coronary artery disease with 3 or more distal grafts performed. Patients with concomitant SV and RA (n = 65) grafting or with concomitant SV on diagonal branch (n = 10) were excluded from the analysis.
In our series, the RA was used to graft the RCA with a critical stenosis (≥90%) or the CxA with a severe stenosis (≥70%). The RA was used as a "Y" free graft connected to the left internal mammary artery or anastomosed to the ascending aorta. The right internal mammary artery was used either as pedicle graft or as "Y" fashion free graft from the left internal mammary artery.
Terms, Data Collection, and Study End Points
Early mortality, or procedural mortality, was defined as any death within 30 days of CABG, whether occurring during hospitalization, or after discharge. Late death was defined as death occurring after 30 days from surgery. Follow-up information was obtained from the Local Regional Institutional Health Database System. All-cause mortality was used to assess long-term outcome. All-cause mortality is the most robust and unbiased index because subjective or biased clinical documentation/assessment is avoided.
Lauer M.S.
Blackstone E.H.
Young J.B.
Topol E.J.
Cause of death in clinical research: time for a reassessment?.
The following preoperative variables were included in the model: gender, age, surgical era (1999-2008 and 2009-2017), diabetes mellitus (oral or insulin therapy), smoking history (previous or current), dyslipidaemia, chronic obstructive pulmonary disease, previous cerebrovascular events (transient ischemic attack or stroke), paroxysmal and permanent atrial fibrillation, redo surgery, body mass index, creatinine, New York Heart Association functional class, Canadian Cardiovascular Society functional class, peripheral vascular disease, carotid artery disease, chronic congestive heart failure, unstable angina, recent myocardial infarction (within 90 days), left main disease (>50%), left ventricle ejection fraction, percutaneous coronary intervention, timing of surgery (urgent or emergent), European System for Cardiac Operative Risk Evaluation-II and Society of Thoracic Surgeons mortality score.
Perioperative and postoperative data collected included: aortic clamp time, cardiopulmonary bypass (CPB) time, number of distal grafts, mode of surgery (off-pump CABG, conventional CPB, or miniaturized CPB), modality of CPB weaning (without inotropes, with inotropes, assisted with intra-aortic balloon pump [IABP] or assisted with extracorporeal membrane oxygenation [ECMO]), reoperation for bleeding, blood transfusion, new-onset cerebrovascular event, prolonged ventilation (>48 hours), acute kidney injury, need for renal therapy replacement, creatinine peak, perioperative myocardial infarction, creatine-kinase myocardial band peak, pneumonia, inotrope requirement, need for IABP, duration of IABP, low cardiac output, need for ECMO, duration of ECMO, deep sternal wound infection (wound infection without sternal split, mediastinitis, sternal split without infection), and new-onset atrial fibrillation.
Descriptive statistics for categorical variables are reported as frequency and percentage; continuous variables are reported as mean ± standard deviation.
A propensity score (PS) was generated for each patient from a multivariable logistic regression model to reduce the effect of potential confounding pretreatment variables. A multivariable logistic regression model was generated with treatment type as a dependent variable. The resulting PS for each patient represented the probability of being in the BIMA + RA or BIMA + SV group. The goodness of fit of the method was evaluated using the Hosmer-Lemeshow test (P = .76) and the model achieved good discriminative power with a receiver operating curve resulting in an area under the curve of 0.75 (95% confidence interval [CI], 0.68-0.83).
Two pairs of matched patients (BIMA + RA or BIMA + SV) were obtained using the greedy-matching algorithm to implement nearest-neighbor 1:1, with a caliper width of 0.2 standard deviation of the logit of the PS, without replacement.
Austin P.C.
Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies.
Pharm Stat. 2011; 10: 150-161
Pretreatment variables selected in the PS-matched patients were compared using the standardized mean difference (SMD) to assess the quality of the matching. The SMD represents the difference in mean between the 2 groups in units of standard deviation. A rule of thumb suggests a meaningful covariate balance between the 2 groups when the SMD is <10%.
Collins G.S.
Le Manach Y.
Comparing treatment effects between propensity scores and randomized controlled trials: improving conduct and reporting.
Austin A.C.
Propensity-score matching in the cardiovascular surgery literature from 2004 to 2006: a systematic review and suggestions for improvement.
To measure the treatment effect in the matched population, the Wilcoxon signed rank test was used for continuous data, whereas the McNemar test with odds ratios and 95% CI was used to compare categorical postoperative outcome. Overall survival was estimated using the Kaplan–Meier method and was expressed as percentage. The Kaplan–Meier method was used to draw survival curves and calculate 5-, 10-, and 15-year survival statistics. The stratified log rank test was applied to compare the equality of the survival curves in the matched population.
Statistical primer: propensity score matching and its alternatives.
Long term outcome was all-cause mortality.
We used the Cox regression model stratified on the matched pairs to estimate the unadjusted and adjusted hazard ratio (HR) and 95% CI of long-term mortality during follow-up between the 2 groups. We also applied the Cox regression model to regress the outcome on 2 variables, the treatment and the estimated PS.
A 2-tailed P value < .05 was always considered to indicate statistical significance. All statistical analysis was performed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp, Armonk, NY) and Stata/MP 15.1 (StataCorp, College Station, Tex).
After PS matching, 2 groups of 190 subjects were obtained. Preoperative variables before and after matching are presented in Table 1. Before matching, patients in group BIMA + RA were older, had fewer men, were more frequently diabetic (oral medication), more often presented with chronic congestive heart failure, had a higher Society of Thoracic Surgeons mortality score, and fewer distal anastomosis. After matching, the 2 groups were comparable for all preoperative variables (Figure 2).
Table 1Baseline covariate distribution between bilateral internal mammary arteries with use of radial artery and bilateral internal mammary arteries and use of saphenous vein in the unmatched and matched population
Unmatched population
Matched population
BIMA + RA (n = 206)
BIMA + SV (n = 454)
Propensity score 0.38 ± 0.17 0.27 ± 0.12 0.629 <.0001 0.35 ± 0.14 0.35 ± 0.13 0.039 .62
Male sex 174 (84.5) 425 (93.6) −0.252 <.0001 165 (86.8) 167 (87.9) −0.029 .75
Age, y 61.4 ± 8.9 59.6 ± 6.7 0.195 .01 60.7 ± 6.7 59.5 ± 6.4 0.085 .13
Era of surgery (1999-2008) 105 (51) 234 (51.5) 0.009 .89 100 (52.6) 105 (55.3) −0.050 .60
Era of surgery (2009-2017) 101 (49) 220 (48.5) 0.011 .87 90 (47.4) 85 (44.7) 0.053 .62
NIDDM 47 (22.8) 67 (14.8) 0.192 .01 38 (20) 31 (16.3) 0.088 .35
IDDM 3 (1.5) 10 (2.2) −0.062 .52 3 (1.6) 3 (1.6) 0 > .99
Hypertension 177 (85.9) 375 (82.6) 0.095 .28 163 (85.8) 161 (84.7) 0.03 .77
Ex-smoker 58 (28.2) 145 (31.9) −0.084 .14 52 (27.4) 55 (28.9) −0.035 .94
Current smoker 37 (18) 56 (12.5) 0.146 .15 33 (8.7) 32 (8.4) 0.014 .93
Dyslipidemia 149 (72.3) 305 (67.2) 0.115 .18 136 (71.6) 137 (72.1) −0.012 .90
COPD 13 (6.3) 27 (5.9) 0.015 .85 9 (4.7) 6 (3.2) 0.065 .42
Previous TIA 8 (3.9) 16 (3.5) 0.019 .97 4 (2.1) 5 (2.6) −0.027 .94
Previous stroke 1 (0.5) 2 (0.4) 0.006 .97 1 (0.5) 1 (0.5) 0 >.99
PAF 9 (4.4) 10 (2.2) 0.106 .25 6 (3.2) 7 (3.7) −0.026 .77
Permanent AF 1 (0.5) 1 (0.2) 0.038 .25 0 (0) 0 (0) 0 −
Redo surgery 2 (1) 2 (0.4) 0.054 .41 1 (0.5) 2 (1.1) −0.054 .56
BMI 26.5 ± 3.4 26.2 ± 0.088 .29 26.5 ± 3.2 26.5 ± 3.7 −0.031 .76
Creatinine, mg/dL 0.95 ± 0.25 0.97 ± 0.23 −0.09 .27 0.94 ± 0.23 0.96 ± 0.23 −0.062 .51
NYHA class 1.3 ± 0.5 1.3 ± 0.49 0.018 .82 1.29 ± 0.54 1.26 ± 0.48 0.047 .61
CCS class 2.3 ± 0.8 2.5 ± 0.8 −0.195 .02 2.34 ± 0.81 2.37 ± 0.88 −0.038 .71
Peripheral arteriopathy 19 (9.2) 27 (5.9) 0.113 .12 12 (6.3) 14 (7.4) −0.036 .68
Carotid disease 24 (11.7) 35 (7.7) 0.123 .10 17 (8.9) 14 (7.4) 0.049 .68
Chronic congestive heart failure 13 (6.3) 11 (2.4) 0.16 .01 7 (3.7) 8 (4.2) −0.022 .79
Unstable angina 26 (12.6) 94 (20.7) −0.243 .01 24 (12.6) 26 (13.7) −0.032 .76
Recent MI 50 (24.3) 144 (31.7) −0.173 .05 45 (23.7) 44 (23.2) 0.012 .90
Left main disease 54 (26.2) 124 (27.3) −0.025 .76 51 (26.8) 51 (26.8) 0 >.99
LV EF, % 55.3 ± 8.8 56.5 ± 7.4 −0.135 .09 55.9 ± 8.3 56.5 ± 8 −0.06 .53
Previous PCI 16 (7.8) 46 (10.1) −0.088 .33 13 (6.8) 11 (5.8) 0.039 .67
Urgent surgery 12 (5.8) 29 (6.4) −0.024 .78 11 (5.8) 9 (4.7) 0.045 .64
EuroSCORE II 0.91 ± 0.52 0.83 ± 0.72 0.111 .23 0.87 ± 0.53 0.8 ± 0.6 0.09 .86
STS score mortality 0.71 ± 0.83 0.54 ± 0.63 0.258 .001 0.63 ± 0.49 0.61 ± 0.83 0.02 .81
Distal anastomosis 3.08 ± 0.27 3.2 ± 0.48 −0.435 <.0001 3.09 ± 0.28 3.11 ± 0.33 −0.076 .50
Categorical variables are reported as frequency and percentage; continuous variables are reported as mean ± standard deviation. BIMA + RA, Bilateral internal mammary arteries and additional use of radial artery; BIMA + SV, bilateral internal mammary arteries and additional use of saphenous vein; SMD, standardized mean difference; NIDDM, non–insulin-dependent diabetes; IDDM, insulin-dependent diabetes; COPD, chronic obstructive pulmonary disease; TIA, transitory ischemic attack; PAF, parossistical atrial fibrillation; AF, atrial fibrillation; BMI, body mass index; NYHA, New York Heart Association; CCS, Canadian Cardiovascular Society; MI, myocardial infarction; LV, left ventricle; EF, ejection fraction; PCI, percutaneous coronary intervention; EuroSCORE, European System for Cardiac Operative Risk Evaluation; STS, Society of Thoracic Surgery.
Figure 2Covariance balance plot (Love plot) before and after propensity matching for patients who underwent CABG with BIMA + RA or BIMA + SV. STS, Society of Thoracic Surgeons; NIDDM, non–insulin-dependent diabetes; CGHF, chronic congestive heart failure; EuroSCORE, European System for Cardiac Operative Risk Evaluation; PAF, parossistical atrial fibrillation; BMI, body mass index; AF, atrial fibrillation; TIA, transitory ischemic attack; NYHA, New York Heart Association; COPD, chronic obstructive pulmonary disease; IDDM, insulin-dependent diabetes; PCI, percutaneous coronary intervention; LV EF, left ventricle ejection fraction; MI, myocardial infarction; CCS, Canadian Cardiovascular Society.
Perioperative Data
Off-pump CABG was more common in the BIMA + RA group. The number of distal anastomoses was significantly higher in BIMA + SV subjects (Table 2). Graft target distribution is summarized in Table 3. RA was anastomosed to the RCA in 160 patients (84.2%) and to the CxA in 30 (15.8%). In the BIMA + SV group, the RCA was grafted in 183 patients (93.7%) and CxA in 7 (3.6%). RA was used as "Y" free graft in 16 patients (8.4%). The right internal mammary artery was used as "Y" free graft in 21 patients (11%) in the BIMA + RA group and in 26 patients (13.7%) in the BIMA + SV group (Video 1).
Video 1Total arterial myocardial revascularization operation in a 71-year-old patient using bilateral internal mammary arteries and radial artery. A Y-shape graft was constructed between the right internal mammary artery (free graft) and the left internal mammary artery. The right internal mammary artery was used to revascularize the first and second obtuse marginal branches with sequential anastomosis; the left internal mammary artery was used to graft the left anterior descending artery; finally, the radial artery was applied to graft the posterior descending artery. The operation was performed using cardiopulmonary bypass and cross aortic clamping. Video available at: https://www.jtcvs.org/article/S0022-5223(19)30005-4/fulltext.
Table 2Intraoperative data in the matched population
Mean aortic clamp time 75.4 ± 20.6 75.9 ± 18.9 .82
Mean CPB time 97.4 ± 23.9 99.9 ± 24.6 .33
Mean anastomosis 3.09 ± 0.28 3.11 ± 0.33 .50
OPCABG, n (%) 18 (9.5) 2 (1.1) <.0001
Conventional CPB, n (%) 160 (84.2) 178 (93.7) .31
Miniaturized CPB, n (%) 12 (6.3) 10 (5.3) .72
Weaning off CPB 172/190 188/190 .42
Without inotropes, n (%) 172 (100) 185 (98.5)
With inotropes, n (%) 0 (0) 1 (0.5)
IABP, n (%) 0 (0) 1 (0.5)
ECMO, n (%) 0 1 (0.5)
BIMA + RA, Bilateral internal mammary arteries and additional use of radial artery; BIMA + SV, bilateral internal mammary arteries and additional use of saphenous vein; CPB, cardiopulmonary bypass; OPCABG, off-pump coronary artery bypass grafting; IABP, intra-aortic balloon pump; ECMO, extracorporeal membrane oxygenation.
Table 3Grafted distribution in the BIMA + RA and BIMA + SV group in the matched population
LIMA on LAD, n (%) 190 (100) 183 (96.3)
RIMA on:
LAD, n (%) 0 (0) 7 (3.7)
CX, n (%) 160 (84.2) 176 (92.6)
RCA, n (%) 30 (15.8) 7 (3.7)
RA on:
CX, n (%) 30 (15.8) –
RCA, n (%) 160 (84.2) –
SV on:
CX, n (%) – 7 (3.6)
RCA, n (%) – 183 (93.7)
RA free graft, n (%) 16 (8.4) –
RIMA free graft, n (%) 21 (11) 26 (13.7)
BIMA + RA, Bilateral internal mammary arteries and additional use of radial artery; BIMA + SV, bilateral internal mammary arteries and additional use of saphenous vein; LIMA, left internal mammary artery; LAD, left anterior descending artery; RIMA, right internal mammary artery; CX, circumflex coronary artery; RCA, right coronary artery; RA, radial artery; SV, saphenous vein.
Early Outcomes
In the unmatched patients, 30-day mortality occurred in 5 patients (0.7%) with 3 deaths (1.4%) observed in the BIMA + RA group and 2 deaths (0.4%) in the BIMA + SV group. In the matched subjects, 30-day mortality occurred in 4 patients (01%), with 2 deaths (1.1%) in the BIMA + RA group and 2 deaths (1.1%) in BIMA + SV group (P > .99). After matching, there were not any significant differences between the 2 groups regarding the other postoperative variables analyzed. Postoperative outcomes of the unmatched and matched populations are reported in Table 4.
Table 4Postoperative data of unmatched and matched population
OR (95% CI)
McNemar test.
Reoperation for bleeding, n (%) 4 (1.9) 10 (2.2) .82 0.87 (0.27-2.83) 4 (2.1) 2 (1.1) .41 2.02 (0.36-11.47)
Blood transfusion, n (%) 73 (35.4) 129 (28.4) .07 1.38 (0.97-1.96) 68 (35.8) 58 (30.5) .27 1.12 (0.82-1.94)
Stroke, n (%) 0 (0) 3 (0.6) .28 – 0 (0) 2 (1.1) .15 –
Prolonged ventilation (>48 h), n (%) 24 (11.7) 57 (12.6) .74 0.91 (0.55-1.52) 23 (12.1) 23 (12.1) >.99 1 (0.54-1.85)
Pneumonia, n (%) 5 (2.4) 15 (3.3) .54 0.72 (0.26-2.03) 5 (2.6) 7 (3.7) .55 0.70 (0.22-2.26)
Acute kidney injury, n (%) 0 (0) 1 (0.2) .50 – 0 (0) 0 (0) – –
Mean creatinine peak, mg/dL 0.90 ± 0.22 0.93 ± 0.21 .11 – 0.89 ± 0.22 0.91 ± 0.24 .40 –
AF, n (%) 48 (23.3) 94 (20.7) .45 1.16 (0.78-1.72) 40 (21.1) 41 (21.6) .90 0.96 (0.59-1.58)
Discharged with AF, n (%) 5/48 (10.4) 5/94 (5.6) 1/40 (2.5) 2/41 (5.1)
SR after amiodarone, n (%) 38/48 (79.2) 78/94 (86.7) 35/40 (87.5) 35/41 (89.7)
SR after electrical cardioversion, n (%) 3/48 (6.3) 4/94 2/40 (5) 1/41 (2.6)
Spontaneous cardioversion, n (%) 2/48 (4.2) 3/94 (3.3) 2/40 (5) 1/41 (2.6)
Perioperative MI, n (%) 6 (2.9) 16 (3.5) .68 0.82 (0.31-2.13) 6 (3.2) 7 (3.7) .77 0.85 (0.28-2.58)
CK-MB 23.9 ± 51.9 27.1 ± 54.6 .48 – 24.4 ± 54 29.9 ± 70.3 .39 –
Inotropes, n (%) 63 (30.6) 136 (30) .87 1.03 (0.72-1.47) 55 (28.9) 61 (32.1) .50 0.86 (0.55-1.33)
Low cardiac output, n (%) 1 (0.5) 4 (0.9) .58 0.54 (0.06-4.94) 1 (0.5) 1 (0.5) > .99 1 (0.06-16.10)
Postoperative IABP, n (%) 5 (2.4) 22 (4.8) .14 0.48 (0.18-1.30) 5 (2.6) 8 (4.2) .39 0.61 (0.19-1.91)
ECMO, n (%) 0 (0) 3 (0.7) .24 – 0 (0) 2 (1.1) .15 –
ECMO time (d) - 2 (1.4) – – – 2 (1.4) – –
MOF, n (%) 3 (1.5) 2 (0.4) .16 3.34 (0.55-20.14) 2 (1.1) 1 (0.5) .56 2.01 (0.18-22.36)
DSW infection, n (%) 6 (2.9) 10 (2.2) .58 1.33 (0.47-3.71) 6 (3.2) 4 (2.1) .52 1.51 (0.42-5.46)
Wound infection 4 (1.9) 8 (1.8) 4 (2.1) 3 (1.6)
Mediastinitis 1 (0.5) 0 (0) 1 (0.5) 0 (0)
Sternal split without infection 1 (0.5) 2 (0.4) 1 (0.5) 1 (0.5)
Mean IABP duration, d 2.2 ± 1.6 2 ± 0.5 .84 – 2.2 ± 1.6 1.7 ± 0.7 .58 –
Mean ICU length of stay, d 1.2 ± 0.8 1.3 ± 1.1 .39 – 1.2 ± 0.7 1.2 ± 0.8 .66 –
Mean hospital length of stay, d 6.3 ± 3.3 6.6 ± 5.7 .39 – 6.2 ± 3.1 6.2 ± 3.9 .92 –
30-d mortality, n (%) 3 (1.4) 2 (0.4) .16 3.34 (0.55-20.14) 2 (1.1) 2 (1.1) >.99 1.00 (0.13-7.17)
BIMA + RA, Bilateral internal mammary arteries and additional use of radial artery; BIMA + SV, bilateral internal mammary arteries and additional use of saphenous vein; OR, odds ratio; CI, confidence interval; AF, atrial fibrillation; SR, sinus rhythm; MI, myocardial infarction; CK-MB, creatine-kinase myocardial band; IABP, intra-aortic balloon pump; ECMO, extracorporeal membrane oxygenation; MOF, multiorgan failure; DSW, deep sternal wound; ICU, intensive care unit.
∗ McNemar test.
Long-Term Outcomes
In the unmatched patients, survival at 5, 10, and 15 years were 93.1 ± 1.9%, 82 ± 3.1%, and 75.1 ± 4.2% in the BIMA + RA group and 97.2 ± 0.8%, 86.4 ± 1.9%, and 80.7 ± 2.5% in the BIMA + SV group (log rank P = .10; Figure 3, A). In the matched groups, the overall median follow-up time was 9.2 years (interquartile range [IQR], 5.6-13 years) with a maximum follow-up time of 18.5 years. The estimated mean time until death was 15.6 ± 0.3 years (95% CI, 15.06-16.24). The median follow-up time was 9.2 (IQR, 5.6-11.9) years in the BIMA + RA patients and 9.3 (IQR, 5.5-14.4) years in the BIMA + SV patients. Survival at 5, 10, and 15 years were 94.8 ± 1.7%, 83.7 ± 3.1%, and 78.6 ± 3.9% in the BIMA + RA group and 96.2 ± 1.4%, 85.1 ± 2.9%, and 80.4 ± 3.6% in the BIMA + SV group (stratified log rank P = .78; Figure 3, B). Late death among the matched population was modeled using Cox regression analysis. The 15-year unadjusted HR showed that the use of RA did not affect late mortality (HR, 1.07; 95% CI, 0.63-1.82; P = .78). The PS adjusted HR showed that the use of the RA was not associated with late mortality (adjusted HR, 1.05; 95% CI, 0.62-1.79; P = .83) (Figure 4).
Figure 3Comparison of survival probability in patients who underwent BIMA + RA versus BIMA + SV in unmatched population (A) and matched population (B). CABG, Coronary artery bypass grafting; BIMA + RA, bilateral internal mammary arteries and additional use of radial artery; BIMA + SV, bilateral internal mammary arteries and additional use of saphenous vein; CI, confidence interval.
Figure 4Survival probability, propensity score adjusted Cox regression analysis between BIMA + RA and BIMA + SV groups. CABG, Coronary artery bypass grafting; BIMA + SV, bilateral internal mammary arteries and additional use of saphenous vein; BIMA + RA, bilateral internal mammary arteries and additional use of radial artery; HR, hazard ratio; CI, confidence interval.
The major finding of this study was that in a matched population who underwent isolated CABG with BIMA and the RA, the additional use of the RA as a third arterial conduit was associated with long-term survival comparable with that of patients who underwent CABG surgery with BIMA and the SV. Late survival was not statistically different between the 2 groups in the unadjusted and adjusted analyses. The clinical benefit of the RA for full arterial revascularization is recognized but widespread dissemination has lagged. In recent meta-analysis of 1036 patients, Gaudino and colleagues
Biondi-Zoccai G.
Sedrakyan A.
Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery.
reported a lower incidence of cardiac events, repeat revascularization, myocardial infarction, death from any cause, and a higher rate of 5-year patency in RA graft compared with SV graft. The meta-analysis reported also data from randomized trials, such as the Radial Artery Versus Saphenous Vein Patency trial and the Radial Artery Patency Study trial, which have both reported superior angiographic graft patency of the RA compared with the SV at 5 years postoperatively, and angiographic results from the Radial Artery Patency and Clinical Outcome trial, for which no differences were found in terms of 5-year patency between the RA and the SV. These conflicting data might explain why the RA is still not widely accepted as an arterial conduit in CABG, although recent data from large retrospective studies
Joyce L.D.
Burkhart H.M.
Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass graft surgery: analysis of 8622 patients with multivessel disease.
Medalion B.
Mohr R.
Ben-Gal Y.
Nesher N.
Kramer A.
Eliyahu S.
Arterial coronary artery bypass grafting is safe and effective in elderly patients.
have shown that multiple arterial grafts improve late survival. Despite the observed benefits of BIMA grafting, routine use of this strategy is applied in only approximately 4% of coronary patients in Canada,
Mastrobuoni S.
Gawad N.
Price J.
Chan V.
Mesana T.G.
Use of bilateral internal thoracic artery during coronary artery bypass graft surgery in Canada: the bilateral internal thoracic artery survey.
7% to 10% in the United States,
Iribarne A.
Goodney P.P.
Flores A.M.
DeSimone J.
Di Scipio A.W.
Austin A.
National trends and geographic variation in bilateral internal mammary artery use in the United States.
and 12% in Europe.
Kappetein A.P.
Dawkins K.D.
Morice M.C.
Mack M.J.
Russell M.E.
Current percutaneous coronary intervention and coronary artery bypass grafting practices for three-vessel and left main coronary artery disease. Insights from the SYNTAX run-in phase.
The observed lack of frequent multiple arterial conduit usage, despite clinical benefits reported in the literature, explains the conflicting data on comparisons of the RA or SV used in addition to BIMA in terms of long-term survival. In fact, to the best of our knowledge, most of the studies have analyzed relatively small groups of patients.
Because the operations for the patients in the study occurred over a period of 18 years, we considered it appropriate to divide the subjects into 2 eras (1999-2008 and 2009-2017) to verify if any differences in patient selection, surgical techniques, surgeon's learning curve, and surgeon's preference could affect the results. No differences between the 2 eras were reported for early and late outcomes.
In this study, long-term survival between the 2 groups was comparable and our results are consistent with other recent reports. Di Mauro and colleagues
Di Mauro M.
Iacò A.L.
Varone E.
Bilateral internal thoracic artery on the left side: a propensity score-matched study of impact of the third conduit on the right side.
published an 8-year survival of 91.9 ± 2.9% for patients who received BIMA + RA CABG compared with 95.6 ± 0.9% for patients who received BIMA + SV CABG (P = .12), without any observed differences between groups. The patients were not matched and the RA group (n = 87) was strongly unbalanced compared with the SV group (n = 590).
Mohammadi and colleagues
Mohammadi S.
Dagenais F.
Voisine P.
Dumont E.
Charbonneau E.
Marzouk M.
Impact of the radial artery as an additional arterial conduit during in-situ bilateral internal mammary artery grafting: a propensity score-matched study.
reported similar long-term results (median follow-up of 8 years) between BIMA + RA and BIMA + SV patients. In that study, in which 249 matched pairs of patients were analyzed, the investigators were unable to show any differences even when BIMA + RA patients were stratified according to the severity of the stenosis of the coronary target. The authors attributed the lack of long-term survival difference to small sample size, low burden of preoperative risk factors, and that all patients had received BIMA to graft the 2 most important myocardial territories.
Recently, Grau and coworkers
Grau J.B.
Kuschner C.E.
Johnson C.K.
Ferrari G.
Zapolanski A.
Brizzio M.E.
The effects of using a radial artery in patients already receiving bilateral internal mammary arteries during coronary bypass grafting: 30-day outcomes and 14-year survival in a propensity-matched cohort.
published data on 183 matched pairs of patients who underwent CABG with either BIMA + RA with or without SV or BIMA + SV. They observed that potential long-term survival benefit could be shown with the use of RA after 10 years (HR, 0.25; 95% CI, 0.06-0.97; P = .04), whereas at 10 years no differences were reported. In that study, the investigators incorporated the SV graft in the RA group, rendering the BIMA + RA group inhomogeneous in terms of total arterial revascularization strategy, with 152 distal anastomoses performed with the SV. Additionally, despite the application of time segment Cox regression analysis, the positive long-term survival trend over 14 years in BIMA + RA with or without SV should be cautiously interpreted, because after 10 years, the number of patients at risk were progressively reduced.
Similar conclusions were reported by Benedetto and colleagues.
They reported comparable long-term survival (up to 17 years) in 275 matched pairs of patients who underwent CABG with either BIMA + RA with or without SV or BIMA + SV. To our knowledge, that is the largest matched series published regarding use of the RA in addition to BIMA. In that study, as in the series published by Grau and colleagues,
some of the patients in the RA group received a SV graft (14%). Therefore, the BIMA + RA group could not be considered homogeneous in terms of revascularization strategy. However, the survival curve comparisons between the BIMA + RA and BIMA + SV groups showed no differences when the patients with SV graft were excluded from the analysis and only those subjects who received total arterial revascularization were analyzed. On the contrary, Shi and colleagues
recently published a relative large series of 262 matched pairs of patients showing a long-term survival advantage of RA compared with SV grafting at 15 years (P = .02). Moreover, in the separate analysis of a comparison of the groups according to the territory target (RCA), patients with RA had better 15-year survival (P = .004).
Although in our study we examined a relatively small number of patients, the strength is that the BIMA and RA group represent a total arterial myocardial revascularization strategy that was compared with a mixed arterial strategy. In our study we observed that the use of the RA was not associated with early negative results and did not increase the operative risk and late negative results. However, the effect of the RA graft on in-hospital mortality could not be evaluated using logistic regression because of the very low number of death events (n = 4).
The incidence of deep sternal wound infections, which is recognized to be associated with BIMA harvesting, was extremely low. This is likely explained by the low incidence of insulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, obesity, and reoperation for bleeding.
We found no significant difference in terms of distal anastomoses between the 2 groups. In all patients, we aimed to obtain a complete myocardial revascularization to avoid the negative effect of incomplete revascularization on late survival.
Patel N.N.
Fiorentino F.
Long-term survival after off-pump versus on-pump coronary artery bypass graft surgery. Does completeness of revascularization play a role?.
Omer S.
Cornwell L.D.
Rosengart T.K.
Kelly R.F.
Ward H.B.
Holman W.L.
Completeness of coronary revascularization and survival: impact of age and off-pump.
However, we acknowledge that each patient had passed the surgeon's "eyeball test" for RA usage, and some of those patients with an indication to more than 3 distal anastomosis received a SV graft because of the reluctance by some surgeons to perform sequential anastomosis with the RA.
The mean age of the patients in this study was approximately 60 years, with 76.8% younger than 65 years. This distribution of age is in line with the recent publications.
The use of RA in addition to BIMA is a preferred coronary revascularization strategy in young patients, although it was difficult to find a univocal message in terms of long-term clinical benefit for RA conduit in the literature. However, considering that some authors have reported a trend toward improved long-term benefit of RA after 10 to 12 years,
it is reasonable to expect a significant long-term benefit of BIMA + RA after 20 years. Data are lacking in the literature at this time with respect to such prolonged follow-up.
In our cohort, the role of 2 mammary artery conduits to effectively revascularize two-thirds of the myocardium might explain the lack of long-term survival benefit observed with use of the RA compared with the SV. In our clinical practice, the RA is considered a third arterial conduit, and is therefore used to graft the third most clinically significant myocardial territory. Thus, as theorized by Benedetto and colleagues
and Mohammadi and colleagues,
the superiority of the RA compared with the SV is not yet demonstrable in long-term survival in patients whose 2 most predominant myocardial territories were grafted with 2 mammary arteries. Furthermore, the site of a right coronary lesion might have a different effect on late survival depending on whether the stenosis is localized either in the proximal segment or in one of the terminal branches of the RCA, or in the case of a totally occluded RCA perfused from the left system. Unfortunately, we have no data regarding the grade of stenosis of the right and CxA and we acknowledge that this variable might affect the eligibility of patients for either the RA or SV use. There is strong evidence that grade of stenosis <75% might negatively affect the patency of the RA and therefore this arterial graft should be considered preferably when the grade of coronary stenosis is >90%.
However, we have not ignored the potential longer patency or the RA compared with the SV and surgeons should attempt to achieve a total arterial myocardial revascularization with BIMA and the RA for patients at low perioperative risk, and with a prolonged life expectancy. Longer follow-up might highlight a significant benefit of use of the RA over the SV.
Study Limitation
This study is limited in its retrospective nature. PS analysis strongly mitigates this limitation but does not eliminate the bias of surgeon's choice of conduit. The decision to use BIMA revascularization, or a BIMA + RA strategy, is highly dependent on operator preference.
The sample size is another limitation of this study due to the relatively small number of patients. However, it is comparable with previously reported single-center studies.
Another limitation of this study is the lack of data regarding the grade of stenosis of the right and CxA. Unfortunately, we cannot include this variable in the PS model and this means caution must be used in interpreting our results in terms of long-term survival in the BIMA + RA subjects. Long-term survival data are not reinforced by angiography, preventing verification of any eventual linear correlation between patency of either the RA or the SV and survival. In our country, as well as in most European countries, the high cost of angiographic procedures, along with associated risks, limits the indications for use of postoperative coronary angiogram to clinically important reasons. Moreover, it is difficult to obtain consent from asymptomatic patients to undergo postoperative angiography.
It would have been interesting to observe the grade of coronary target lesion, the freedom from new angina, new myocardial infarction, new reoperation, and causes of late death, but we were able to analyze only the cumulative survival for all-cause mortality as an objective and unbiased end point.
In a relatively small population of patients with triple-vessel coronary artery disease, the use of the RA as a third arterial conduit with BIMA did not negatively affect early outcome and conferred a long-term survival benefit comparable with that with the use of the SV. Further longer-term studies are required to show whether the use of the RA offer better long-term survival than the SV as a third graft in addition to BIMA.
The authors thank Giorgia Pavan for her tireless and high-value contribution during the correction and writing of the article.
eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlMGE0YTgyOGZiZTE0ZTVhMjk4NDkxYWM1Mzk5ODMzYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1MjM4NDM5fQ.ifopL6cNJQ2PL7xYVyS-EXsuB-wkhK4LAJpE0vAKWb2aWEOmTBXk0-K6G0i2zHan1Cd0oSiGvnkd86bR9KrHXdvBPgw5Ow6AyU9WubLfluf4DG9GUhAhRq_scj6Zb7Fxc9uajC5Xz-ovgUj1kurdHcR1JrHXkvmOBfTSaR-_5rVXZ2tn9WH4IFUwWx9CL08B7R-rSjiPiqq4sWfiZ07K-a-xlb8dEulBvd3xphUF7Aki7GpU9FPsydKrUg-0CsM1ohJMMFr2CXwb0cq5sk9VFBpdQPSz3MYUApmA9y8uB5rf97IU-X8hX3rOjKftwltZrHWj3eWJzre_T_Gahw5Hog
Total arterial myocardial revascularization operation in a 71-year-old patient using bilateral internal mammary arteries and radial artery. A Y-shape graft was constructed between the right internal mammary artery (free graft) and the left internal mammary artery. The right internal mammary artery was used to revascularize the first and second obtuse marginal branches with sequential anastomosis; the left internal mammary artery was used to graft the left anterior descending artery; finally, the radial artery was applied to graft the posterior descending artery. The operation was performed using cardiopulmonary bypass and cross aortic clamping. Video available at: https://www.jtcvs.org/article/S0022-5223(19)30005-4/fulltext.
Received in revised form: December 16, 2018
Received: July 6, 2018
This study was funded by the University of Milano-Bicocca Fund for Research; Fondi di Ateneo per la Ricerca, F.A.R., grant number: 2017-ATE-0613.
© 2019 by The American Association for Thoracic Surgery
Commentary: Arteries and veins: Choices abound
The evolution of coronary artery bypass grafting (CABG) surgery continues. Whether to conduct the operation on-pump or off-pump continues as an active debate.1,2 The choice of conduits—whether arterial or venous—remains a highly investigated and active area of clinical research.3 For good reason, cardiothoracic surgeons do not remain static. The desire that resides within all of us who perform CABG to improve the operation is robust.
Commentary: Radial artery and bilateral mammary arteries in coronary artery bypass grafting: How much is too much?
Long-term outcomes after coronary artery bypass grafting (CABG) largely relate to complete revascularization and graft patency. Recent changes in guidelines have advocated for the additional use of arterial grafting. In the 2018 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines, the radial artery (RA) is preferable to the saphenous vein (SV) in those with high-grade stenosis (class I level of evidence: B) and bilateral internal mammary arteries (BIMA) in those not at high risk for sternal infection (Class IIa level of evidence: B).

redpajama_set_name: RedPajamaCommonCrawl


text:
Жуко́вське сільське поселення () — муніципальне утворення у складі Зубово-Полянського району Мордовії, Росія. Адміністративний центр — село Жуковка.

Населення
Населення — 475 осіб (2019, 573 у 2010, 660 у 2002).

Склад
До складу поселення входять такі населені пункти:

Примітки

Поселення Зубово-Полянського району

redpajama_set_name: RedPajamaWikipedia


text:
By Jim Ludes On October 9, 2015 In Featured Slide, Opinion Tags Humanities, NEH, Senator Pell
The Hill: Legislating as it Once Was: The NEH Turns 50
The Following op-ed was published originally on the Congress Blog of The Hill, the Capitol Hill newspaper.
Legislating as it Once Was: The NEH Turns 50
Elizabeth Francis and James M. Ludes
Fifty years ago, President Lyndon Johnson signed legislation creating the National Endowment for the Humanities and the National Endowment for the Arts. It was not fast-tracked legislation, rather it was the result of determined effort by Senator Claiborne Pell of Rhode Island and his allies in the House and Senate. In a day and age of political paralysis, sequester, and government shut-downs, when many Americans question whether government can ever accomplish anything, it's useful to revisit the process Pell used to pass the legislation into law.
Senator Pell began, simply, with the idea that the U.S. government should support both the arts and the humanities in this country. Then, using the convening power of the Senate, he assembled the most important, leading voices on the issue. Over two weeks of testimony in February of 1965, Senator Pell brought scholars and artists before his subcommittee, university presidents, like Barnaby Keeney of Brown University, and union leaders followed, as did administration officials and other members of the Senate.
He gave these experts and stake-holders a platform from which to be heard, and then he did something radical.
He listened.
Senator Pell did not begin with a ten-point plan and a speech. There was no org-chart hidden away with authorities established and structures determined.
He listened and he worked to accommodate the concerns he was hearing.
He did not draw lines in the sand. He did not posture.
He did not pre-judge any of the big issues facing his subcommittee. For example, he did not begin with a conviction about whether the arts were part of the humanities.
He listened to the people who cared passionately on both sides of that debate.
He did not begin with a firm view of whether the new foundation should be independent or part of an existing federal agency.
In the end, Senator Pell earned truly bipartisan support for the legislation. Democrats with names that resonate still today supported the bill: Bayh, Dodd, Kennedy, McGovern, Mondale, and Muskie. But there were others, too, who voted for the legislation: Republicans like George Murphy of California, Jacob Javits, John Tower and even Barry Goldwater.
Why? There's no single answer. But there is one common answer: because Claiborne Pell listened.
Time and again, whenever the legislation seemed to be in trouble, Pell and his staff—especially Livingston Biddle who played such an important role and would later become chair of the National Endowment for the Arts—showed a remarkable ability to listen, to understand what was important to others, and to accommodate those priorities in the legislation.
Listening and accommodating were the twin elements of Senator Pell's approach to creating legislation. This was not sausage being made, as the old adage goes, it was a master's class on legislating. It's a lesson lost on too many of today's members of the House and Senate.
The National Endowment for the Humanities, fifty years-on, has made our democracy healthier, our scholarship richer, and our public dialogue more reflective. Through the creation of the state humanities councils, also driven by Senator Claiborne Pell who listened and heard a need for the humanities to reach local communities, the National Endowment for the Humanities has a direct and immediate impact, ensuring widespread access to history, heritage, and civic engagement. This is the legacy of a legislator and an approach to legislating that prized listening over winning. That's how you create institutions that, half-a-century later, remain true to their original mission. It's how you get things done in Washington. It's a lesson we'd be well served to remember.
In a broader sense, the public's engagement with the humanities supports listening, critical thinking, and reflective dialogue by all of us. These skills are essential for informed consent in a democracy. As we celebrate the 50th anniversary of the NEH, we affirm the importance of public support for the humanities to create a political community where we listen and accommodate to solve the great issues of our time, just as Senator Pell did 50 years ago.
Elizabeth Francis is the Executive Director of the RI Council for the Humanities. James Ludes is Vice President for Public Research and Initiatives as well as Executive Director of the Pell Center at Salve Regina University. Together with the University of Rhode Island Libraries these institutions created the Pell Humanities Initiative, celebrating the NEH 50th anniversary and honoring Senator Claiborne Pell's commitment to the humanities in the health of the nation by showcasing the vital contributions of the humanities in our society today. The views expressed here are their own.
Laudato Si': Pope Francis and the Challenge of the Environment
Bringing the Story of America's Opioid Crisis to the Screen with Danny Strong
Quick Hit: The President's Strategy for ISIL Assessed
Rhode Island Students Awarded 2019 Pell Medal for Excellence in U.S. History
Previous: Picks of the Week: Cybersecurity Awareness Month at the Pell Center
Next: Picks of the Week | The Long Game


text:
Man arrested over Hay River 'targeted shooting'
A file photo of the Hay River RCMP detachment in August 2019. Sarah Pruys/Cabin Radio
RCMP say a man has been arrested in connection with what police earlier called a "targeted shooting" that took place in Hay River on Monday.
The shooting took place in Hay River's downtown late on Monday evening. On Wednesday evening, RCMP said an adult male was in custody and charges were pending.
According to police, the victim of the shooting remains in hospital in Edmonton.
An RCMP statement suggested at least one police dog had been involved in the arrest, alongside officers from the Hay River detachment and the NWT's major crimes unit.
"The NT RCMP appreciates that this incident, coupled with recent events in Saskatchewan, has caused concern for the community of Hay River," said Insp Dean Riou, officer in charge of NWT RCMP's south district, referring to the killing of 10 people and wounding of 18 others in Saskatchewan's James Smith Cree Nation and the nearby village of Weldon. Both suspects in those crimes are now reported to be dead.
Riou said the investigation into the Hay River shooting continued and asked anyone with information to contact the town's detachment at (867) 874-1111.


In the course of the evening, we will examine the history and polity of the United Church of Christ, discuss the life and program of our church, explore questions of faith and theology and provide information concerning how one becomes a church member. We'll be meeting in the Upper Lounge.
Please contact the church office at (920) 733-7393, to express your interest or for additional information.


Basra Pearl is a hard object naturally produced in the soft tissue of a living shelled mollusk. The beauty of this amazing gem has astonished the jewel lovers worldwide since centuries. Pearl is also known for its astrological benefits that it provides its wearer with. Moon, the lord of zodiac sign Cancer governs the pearl gem whose position in a horoscope distinguishes the different impacts of pearl. Basra pearls are different types of pearl which got its name from the city Basra, in Iraq. Buy Basra pearl Online and are rare kind and found in the Arabian Gulf. To buy Basra Moti online, contact Brahma Gems which is a trusted name and deals in lab certified, 100% natural Basra pearl.
As per Indian astrology, the pearl is connected with the favorable planet Moon. Wearing the stone enables in strengthen Moon in the person's horoscope and blesses them with calmness, mental balance, positivity, and good health.
Vedic astrology recommends Moti Ratna for Kark Rashi.
Ascendants of Leo, Aries, Scorpio, Sagittarius, and Pisces can also wear Pearl gemstone to gain good results.
Pearl gem carries a powerful, centuries-old name for its high aesthetics, different mystical qualities and remedial abilities. This gemstone is notably featured in the ancient texts of India, Rome, China, and Egypt. From Cleopatra to Angelina Jolie. Forever worn as a sign of class and style throughout the centuries. Rated as the queen of gems, the stone is labeled by different names in different countries and cultures such as 'Tarak Ratna' or 'Chandra Ratna' in Hindi.
Bears Anger - According to the Vedas - Moon controls sentiments. Therefore, the stone is often prescribed to individuals who find trouble in managing their rage. Wearing the stone exhibits such individuals to stay relaxed, confident and certain.
Brings Certainty in Thoughts - Astrologers understand that wearing pearl benefits individuals in the professions where low concentration, high confidence, and better self-expression is extremely needed. Success in creative and artistic pursuits are regarded as some important benefits of wearing Moti gemstone.
Increases Maternal Relationship - Since Moon is connected with the parent or the nurturer in the Vedic astrology, wearing Chandra Ratna - Moti serve the well-being of a person'smother and increase their respective bonding.
Better Eyes, Skin & Heart - According to the ancient texts, wearing real Pearl profits the person to get support from water-borne illnesses. It is said that the positive energies of Pearl stimulate the water balance in the body and thereby helps the wearer to gain clean youthful skin, bright eyes, and robust circulatory system.
Pearl price changes with the quality and extent of the stone. The quality of the stone is usually determined by the factors such as its type, color, surface perfection, lustre and shape. The availability and request of specific type and colors also create a variation in the Moti Ratna price in the global market.
Quality - Usually, the less and shorter are the fault, higher expensive is the pearl. Because of its natural composition, secondary flaws don't create a meaningful value exception. A Pearl with dazzling brilliance merits a greater value, on the other hand, dull and opaque pearl are valued cheaply.
Color - The price of the pearl is higher for the white gemstones with a but rosy overtone. Creamy golden sea or the Tahitian black pearl cost too rests on the higher side due to its dark exotic color. The proximity of yellowish and greenish overtone might produce a decline in the pearl's overall cost.
Weight - Size carries a great impact on the pearl per carat. Big size pearls are costly compared to a similar smaller pearl as it uses a lot of time in its creation. Therefore, the bigger the bigger the pearl the more its cost.
Presently, Pearl cost in Indian rs begins from Rs 1000 per carat ($15 approx.) and can go up to Rs 2 lakh per carat ($3075 approx.) and above.
Why 90 % of the people are not getting results from pearl (Moti)?
Pearl gemstone is exceptionally good to control anger and spread positivity in the wearer's mind. However, most of the times, you do not see positive results after wearing it. Let's find out why!
Is it real? The market is flooded with fake gemstones. There are dealers out there who sell fake gemstones at their original price. So, the chances are, that the pearl (Moti) you're currently wearing might be not the real one. A fake stone won't work, no matter what you do.
Is it Heated? There are stones that are original amethyst, however, they are heated. Heating is basically done to improve the color or clarity of the gemstone. Always get your gemstone from a trusted gemstone dealer.
The quality of a natural pearl relies immensely on its origin, body color, surface texture, glow, and shape.
Origin- The top quality pearls are sourced from the coast of South India, Japan, Myanmar, Mexico, Sri Lanka, and Venezuela. The stone also found in the Basra city of Persian Gulf are deemed the most worthy due to their immense rare and strong historical importance. South Sea pearls from India, 'Kahil Moti' from Sri Lanka, Mikimoto Pearls and Akoya Pearls of Japan are comparatively less precious, however, quite popular in the gems and jewelry industry.
Color- Pearl body color and inferences rely on the type of Mollusc that allows them. The lighter and brighter is the Pearl color, the more relevant is the gemstone. Normally, a pure white Natural Pearl with a bit of rosy overtone is known to be the premium quality. Cream colored pearl is considered as the second most preferred choice. Due to the different color, the deep golden and black pearl stone are known to be very rare and valued accordingly.
Lustre - Pearl is formed of layers of a tough natural material known as Nacre that creates a facade shine when light reaches through its layers. A perfect quality Pearl with thick nacre layer frequently presents a glowing lustre and are viewed as entirely helpful. In contradiction, the normal-quality pearl with bad nacre seems too white, simple and pale in the display.
Finishing - According to the Pearl masters, the small dots and the detailed spot on Pearl's cover proof its actual origin. Theses spots emerge from the ends and jerks happened inside the Mollusc's body throughout the Pearl formation. The appearance of fewer surface defects and blemish signifies a higher quality and a more expensive pearl.
Shape - Pearls are simple organic gemstones, so can happen in any potential appearance which presents this gemstone both fascinating and one-of-a-kind. Commonly, the round and near-round Pearl are unique and considered most worthy. Pearl in balanced shape is forever favored over the ones in baroque shapes.
Pearls are really delicate and with proper care and cleaning, it can maintain their luster for years. While purchasing pearls, pick these with thick nacre to assist them to withstand wear over time.
Keep them away from household chemicals such as hairspray, cosmetics, perfume, alcohol and other harsh chemicals, which can create blemishes and stains and dull their luster over time. To avoid these effects, pearls should be the last item put on when dressing and the first item removed after returning home.
The stones carry a natural material called conchiolin. In time, this metal will dry out and high temperatures will destroy it. Water, fewer times, carry acid which might dissolve the aragonite crystals making, up the layers of nacre. So, wash and dry your pearl jewelry gently after you wear it.
Wash cultured pearls in very mild, soapy water and nothing else. Wipe them with a soft cloth before storing them.


text:
Ehlers accentuating the positive
Yankees prospect nabs Class A Advanced Offensive Player of the Year kudos
(Joy R. Absalon/MLB.com)
By Kevin T. Czerwinski / MLB.com | November 29, 2006 6:20 AM
The number that stood out the most about Cody Ehlers heading into the 2006 season was 248.
That would have been a great figure had it been the number of RBIs he had driven in through his first two professional seasons. It would have been a fantastic number if it was his hit total over those two years as well.
Put a decimal point in front of that number, though, and you get Ehlers' batting average in his first two seasons after being drafted by the Yankees out of the University of Missouri in 2004 (11th round). So when the 2006 season rolled around, not too many folks were paying attention to the Oklahoma native when he suited up for Tampa in the Florida State League.
But they're paying attention now after Ehlers put together a spectacular season on the Class A Advanced circuit, putting himself squarely on New York's prospect map and showing the type of promise that has folks in the Bronx eager to see what he'll do for an encore. Ehlers put together a career season, batting .298 with an FSL-leading 106 RBIs.
Ehlers also had 18 homers, was third in hits (148) and slugging percentage (.487) and first in doubles (38) and extra-base hits (57). For his efforts, he was tabbed as MiLB.com's Class A Advanced Offensive Player of the Year.
And all it took to turn around what was slowly becoming a mediocre career was a better outlook and approach. It sounds simple but only because Ehlers made it look that way.
"You know, maybe I caught a few people off guard this year," said Ehlers, an FSL All-Star. "But the ones that count, like myself, my parents and my coaches, they knew what I was capable of. Last year (2005), I had a decent year, but I didn't do everything I was capable of doing. I learned a lot of positive and negative things last year.
"I just started to focus on the positive and minimize the negative. Just use your head because baseball is such a mental game. If you lose your head, things can snowball in a hurry. Last year, I never had a really negative outlook, but I had some rough times as far as hitting was concerned. And when things aren't going your way, your average is going to suffer."
So Ehlers decided it was simply time to focus on remaining consistent. He also seems to have come to terms with the fact that at this point in his career, he's not going to be a big-time power hitter. Ehlers has finally made the adjustment to a wooden bat and has become a gap threat as a result. Look no further than his extra-base hit total for proof.
He also got stronger as the season progressed, hitting .346 with 20 RBIs in August. And left-handed pitching didn't seem to provide much of a problem for him, either. He hit .316 (37-for-117) against southpaws with a homer and 20 RBIs.
"I've turned into a gap guy with occasional power," said Ehlers, who hit 18 homers as a senior at Missouri. "I have a natural loft on the ball and it tends to go out if I square up right on it. I'm just looking to get stronger and more experienced now. If I do that, I don't see why I can't hit 20 home runs next year and become a 25- to 30-home run guy every year. It will come with my development."
Ehlers also believes that he has "the whole Yankee thing" figured out now, too. He's thrilled at being in a winning system and having such a wonderful array of Hall of Famers and coaches with whom to work. But he's aware that despite the recent success of Melky Cabrera and Robinson Cano, getting promoted in the New York system sometimes can be more difficult than with other organizations.
"If you can succeed in the Yankees organization, though, you can succeed in any organization," said Ehlers, who figures to start next season at Double-A Trenton. "Of course, you'd be foolish not to be positive and believe in yourself. You have to play and think like you should be in the Major Leagues, whether you're with the Yankees or the Devil Rays.
"It's just a matter of getting out there and letting things fall into place. That's the best way to look at it."
And everything certainly fell into place for Ehlers this season.
Kevin Czerwinski is a reporter for MLB.com. This story was not subject to the approval of the National Association of Professional Baseball Leagues or its clubs.


text:
SA'S BLACK FILM FESTIVAL
CARVER LIBRARY INTRODUCES SABIFF WITH LOCAL BLACK INDIE FILM SHOWCASE
San Antonio, TX -- The Carver Library is proud to introduce the launch of the San Antonio Black International Film Festival (SABIFF). SABIFF will present a local Black independent film showcase featuring a range of indie film and video projects by native San Antonians. A full day of activities from film screenings, Q&A from directors, and film industry-related panel discussions will begin at 10:30 am and run until 6:00 pm on Saturday, February 23, 2019 at the Carver Library located at 3350 E. Commerce Street, San Antonio, Texas. This event is free and open to the public.
A group of community filmmakers and movie enthusiasts began meeting at the Carver Library in the fall of 2018, with the purpose to create a Black independent film festival in the Alamo City. Birthed from mutual interests, the San Antonio Black International Film Festival was born under the umbrella of Forward Progress, Inc., a 501c3 arts and entertainment organization founded by DeaAnna Brown that "encourages creative dreamers to become authentic artists." The mission of SABIFF is to expose audiences in San Antonio and beyond to the myriad of narratives and diverse images of Diaspora peoples.
The goal is to present a variety of video/filmmakers and film professionals of color to
audiences through their film products, genres, panel discussions, lectures, andtraining. The Carver Library, a staple on the Eastside presents the first of many more SABIFF film festivities to come.
Local filmmakers and their films to be showcased include: Cedric Thomas Smith presenting his award winning film "Melissa", Ada M. Babino will screen her documentary "I Don' Been Through The Snake's Skin & Come Out Clean," Aundar Maat and Born Logic Allah will show their film Malcolm X, as well as director Dat Mayne DeeWayne, presenting Free Word, and music video presentations. A community forum on the importance of Black film along with a panel discussion that goes behind the scenes to unveil the professionals and talent involved in film production.
"Black History month is a perfect time to introduce SABIFF to the community," comments Ada M. Babino, filmmaker and a founder of SABIFF. The team behind SABIFF plans to exhibit a more extensive film festival in October that will present films throughout the Diaspora as well as relevant film panel discussions. Babino went on to say, "far too often films by, for and about African peoples are limited to audiences who attend film festival screenings. Our goal is to bring diverse images, stories, and genres to audiences open to learning, viewing, and entertainment in the process."
"We're extremely happy to continue SA's African American film legacy which has largely been forgotten," said D.L. Tilford Grant, the branch manager for the Carver Library who has partnered with SABIFF as a supportive venue. The branch named after African American scientist George Washington Carver, has a collection of over 55 thousand volumes including music, CD's, videos, and audiobooks that specialize in African American studies.
Carver Library San Antonio Film Festival
SABIFF
Carver Library
San Antonio Black Film Festival


text:
home >interviews >world attention on somalia's young
World Attention Focused on Somalia's Young
CNN, September 29, 1992
HILARY BOWKER, Anchor: Audrey Hepburn recently returned from a tour of Somalia as goodwill ambassador for the United Nations Children's Fund, or UNICEF. Earlier today, here in London, she talked to CNN about what she saw.
AUDREY HEPBURN, UNICEF Goodwill Ambassador: I thought I was prepared because I too have seen television and read the articles and seen the photographs, but nothing can prepare you for reality. What, what - is basically an abstraction when you see it on the written page, on the printed page becomes horrifying reality. Flying in to - to Somalia and just seeing hundreds and hundreds of graves around every settlement around, every village. Along the roads, dead animals, walking phantoms - and children who are only just alive in many cases, and I sort of marveled at the fact that they are. Too many people dying. The irony is that now the rains have come which, of course, the country needs, but the death toll has doubled because they are not properly housed, they have little shacks made of two or three twigs, we've flown in a lot of tarpaulin, but it - we don't have enough, so children are being snuffed out now by the wet and cold. And as you probably realize, few people die just of starvation, and that's true, but children usually die because of chills, because of coughs, measles - and yet, because they're so frail, they just disappear slowly.
BOWKER: The world's attention has been focused now on Somalia for several months, and aid has been getting through. Is it enough?
Ms. HEPBURN: No. We need much, much more, but I don't want to discourage people by saying that because they are being very generous, the governments are being very generous, and things are getting better, and reaching people, because, as you know, there's total anarchy in that it's a country without a government, without any kind of infrastructure, barely in ruins, having had four years of the most atrocious civil war. That - it's a little bit better, but we need a lot, lot more, we need funds, we have the organization and the ways to get it there, but everybody needs funds, not just UNICEF, so does the Red Cross and CARE and all the other agencies.
BOWKER: You mentioned that you don't want to discourage people, has there been a problem, do you think, of compassion fatigue?
Ms. HEPBURN: I don't believe in compassion fatigue, I think every human being is filled with compassion. They are fatigued, just as a mother with too many children who must take care of them when they're sick, you become very tired. I don't think - if somebody can give, if they know the situation, would ever not give, I don't believe it exists.
BOWKER: Audrey Hepburn was talking to CNN about her recent trip to Somalia as goodwill ambassador for UNICEF.
previous • menu • next


text:
Hoseynabad (, also Romanized as Ḩoseynābād; also known as Ḩoseynābād-e Zarand and Husainābād) is a village in Khoshkrud Rural District, in the Central District of Zarandieh County, Markazi Province, Iran. At the 2006 census, its population was 1,688, in 392 families.

References

Populated places in Zarandieh County


The new Ruff earwarming Winter-Wear. Our Beanie won the Red Cone Award for its great features as the reversible Brim. Brim up for normal homo sapiens and brim down if you are a cone head. This way it gives you more headroom.
You like your beanie more "Slouch" style, than you can leave the brim down too. So a maximum of ways to wear this great Knit Beanie.
We plastified our great Retro Logo and stuck it to both sides of the brim so there is no way in not showing Ruff support.


text:
Particularly in the current climate, things are changing rapidly. Consensus national information for trainees is available through the websites below.
Rota changes
ARCPs
Academy of Medical Royal Colleges
Working within limits
Medical Royal Colleges
Your own medical royal college will have information too
Royal College of Anaesthetists
Faculty of Dental Surgery
Royal College of Emergency Medicine
Royal College of General Practitioners
Faculty of Intensive Care Medicine
Royal College of Obstetrics & Gynaecology
Faculty of Occupational Medicine
Royal College of Ophthalmologists
Royal College of Paediatrics and Child Health
Royal College of Pathologists
Faculty of Pharmaceutical Medicine
Royal College of Physicians of London
Faculty of Public Health
Royal College of Radiology
Faculty of Sexual and Reproductive Health
Faculty of Sport & Exercise Medicine


text:
40th Anniversary Campaign
International Visitor Leadership Program
Custom Programs & Services
2020 Signature Event
E-Talk-About Series: The European Response to Covid-19 and Implications for Transatlantic Relations
May 5, 2020: 5:00 pm - 6:00 pm
« Armed Conflict and Pandemic in Ukraine: Insight from an IVLP Alum
Innovative Collective Action »
In our next E-Talk-About event, Former White House Special Advisor and Senior Foreign Service Officer. Molly Montgomery joins the San Diego Diplomacy Council for a discussion of how Covid-19 is affecting Europe. She will discuss the European response to the current crisis and the impact it will have on transatlantic relations, trade negotiations, Brexit, and other issues. This event will take place over Zoom on May 5th from 5-6pm PDT.
Ms. Molly Montgomery is currently a Vice President with Albright Stonebridge Group's Europe practice. Prior to this position, she served as Special Advisor to the Vice President for Europe and Eurasia, where she advised Vice President Mike Pence on strategy, policy development, and engagement toward Europe. Ms. Montgomery also served as Deputy Director of the Office of Eastern European Affairs at the U.S. Department of State, where she helped to lead the U.S. response to the crisis in Ukraine and developed strategies to fight corruption, spur democratic and market-oriented reforms, and increase energy security throughout the region. Her career in the U.S. Foreign Service spanned 14 years.
Ms. Montgomery holds an M.P.A. in International Relations from the Woodrow Wilson School at Princeton University and a B.A. in Political Science and History from Stanford University. She is a recipient of the Thomas R. Pickering Foreign Affairs Fellowship, a graduate of MIT's Seminar XXI program, and a term member of the Council on Foreign Relations. Ms. Montgomery is a non-resident fellow in the foreign policy program at the Brookings Institution, where her work focuses on Central and Eastern Europe and the Western Balkans.
Click here to register in advance.
Events, Upcoming Events
E-Talk About
4305 University Avenue, Suite 510, San Diego, CA 92105
619.291.8105 | Contact Us
© 2021 San Diego Diplomacy Council | Privacy Policy
We are a non-profit organization and a registered 501(c)(3)
Find Out More About The Global Leadership Youth Program!Register Today
San Diego Diplomacy Council
Join our mailing list and learn about our opportunities to connect with the world!


Meuillon, Raymond De a French preacher and theologian, was born about 1235 in Dauphiny. After having declared to adhere to the rules of St. Domninic at the Convent of Sisteran, he was elected in 1264 general preacher of that order, and some time afterwards he was nominated definitor. In 1278 he was commissioned to go to England to suppress the too liberal discourses of some Dominicans, accused of irreverence to the memory of St. Thomas. After having accomplished the mission assigned to him, Raymond gave an account of his journey to the assembled chapels in Paris in May, 1279. The delinquents were condemned, and the priors authorized to punish vigorously whosoever should attempt new excesses. As a reward for his zeal, Raymond was nominated definitor for a second time. Some years after he was introduced to the secular Church in the capacity of a bishop. In 1289 Raymond was promoted archbishop of Embrun. He died June 29, 1294. Raymond de Meuillon's writings may be divided into two distinct categories, viz. his statutes and his dogmatical books. L'Histoire Litteraire analyzes them both. His dogmatical books have been translated into Greek. The only copy of this version, once kept in the Monastery of St. Germain- des-Pres at Paris, is now in the imperial library of St. Petersburg, with a great number of other manuscripts of his. See Le Catalogue des MSS. Bibl. imper. by M. Edouard de Muralt, and the valuable article of M.V. Le Clerc in L'Histoire Litteraire.


text:
«Любовь моей жизни» (, ) — японская мелодрама 2006 года режиссёра Кодзи Кавано. Основана на одноимённой дзёсэй манге  .

Сюжет
Итико — восемнадцатилетняя девушка, она учится в университете и подрабатывает в музыкальном магазине. Она живёт вместе со своим отцом, который работает переводчиком английских романов на японский язык. Её мать умерла семь лет назад. Итико познакомилась с Эри, и они влюбились друг в друга. Когда Итико решила признаться отцу в том, что она лесбиянка, отец шокирует её ответным признанием. Оказывается, он — гомосексуал, а её мать тоже была лесбиянкой. Они оба хотели вырастить ребёнка и для этого поженились, хотя оба имели однополых партнёров. Отец же Эри намного более сдержано принимает свою дочь-лесбиянку. Связанная семейными обязательствами, Эри вынуждена разорвать отношения с Итико. Однако в конце концов они находят свой путь в жизни и снова оказываются вместе.

Актёрский состав

См. также
 юри — жанр манги и аниме, изображающий женские гомосексуальные отношения.
 Лесбийские отношения в кинематографе

Ссылки

Фильмы-мелодрамы Японии
Фильмы на лесбийскую тематику
Экранизации манги


Vaccination and protection with drugs against certain contagious diseases is carried out depending on the relevant Assessment of Safety and Risk statement for employees exposed to infectious diseases at work and in work situations where employees could transfer infection to other.
under the Administrative Procedure Act (GAPA), there is a eur 200 fine for failure to respond within specific time limits to invitations by health inspectors and for unjustifiable absence.
Doctors are required to check the person being vaccinated and his/her medical records to identify any potential risk of permanent deterioration in the person's health as this could constitute a reason to suspend the vaccination.
illness or a medical condition deemed to be incompatible with the vaccine.
An acute disease or a febrile condition is not considered to be a reason for a vaccine exemption under this Act. In such cases, vaccination is only postponed. If the doctor administering the vaccination finds reasons for a vaccine exemption as per the first paragraph of this Article, he should file an application for an exemption, and this should be technically justified and explained. All health records of the aforementioned person must be included in the application for a vaccination exemption.
An application for a vaccination exemption may be filed by the physician administering the vaccination, the recipient of the vaccination, the parents or the guardians of the recipient.
All applications for vaccination exemptions must be sent to the Ministry of Health.
The Commission considering applications for suspension of vaccination may request additional documentation or further medical examinations, if necessary.After completion of the process and within 90 days from receipt of the vaccination suspension application, the Commission hands down its expert opinion on whether or not there are grounds for suspension of vaccination, and sends it to the Health Minister.
Any person whose health is damaged by compulsory vaccination, as evidenced by serious and lasting reduction of vital functions, shall be entitled to compensation.
If the aforementioned person dies as a result of compulsory vaccination, his or her spouse or partner with whom he or she lived in a consensual union, their children and/or parents are entitled to compensation.
Damage in this context does not include damage caused by incorrect administration of the vaccine or from the inadequate quality of the vaccine as specified by the Slovenian regulations governing medicines.
When damage to a person's health or death of said person is caused by improper handling of the vaccine by medical personnel or by inadequate quality of the vaccine, proceedings should be filed in the civil courts against the manufacturer of the vaccine.
The amount of the compensation is still specified in tolars (previous Slovenian currency); the amount in euros (15 million tolars is approximately 60.000 euros) is therefore not clear.
As of present date, there have only been two cases of compensation awarded in Slovenia: two nurses for damage caused by the Hep B vaccine.
Unvaccinated children in Slovenia: currently kindergartens and schools cannot legally demand that children be vaccinated. Doctors are however obliged to sign a health certificate stating that the child is fit for school or specifying if s/he has any allergies but vaccination status is considered to be private.
Those who practise and believe in allopathic medicine do not like to talk about side effects of vaccines. They are usually reluctant to record them or to investigate further. Paediatricians usually assure parents that the vaccine they will administer has no serious side effects, which of course is far from the truth. The package insert is not given to parents unless they ask for it (very rare). Even then they usually try to hand out the short version on a leaflet and not the original package insert. When side effects do occur, doctors usually dismiss them as coincidence and rarely report them. Reporting is only available to doctors or medical institutions, not to individuals or patients.


CONSUMERS HAVE AN INSATIABLE APPETITE FOR NEW PRODUCTS, OFTEN DESIRING DESIGNS THAT ARE CONTEMPORARY, AESTHETIC, FUNCTIONAL AND TECHNOLOGICALLY ADVANCED.
PREMIER PRODUCT DESIGN Ltd. IS A DESIGN COMPANY THAT PUTS ALL THE ABOVE CRITERIA INTO ITS DESIGNS, USING THE LATEST COMPUTER SOFTWARE TO PRODUCE HIGH QUALITY PRODUCT DRAWINGS, IMAGES AND ANIMATIONS THAT CAN BE USED IN THE MANUFACTURING INDUSTRY, PRESENTATIONS AND ADVERTISING.
PREMIER PRODUCT DESIGN LTD. IS CURRENTLY A DORMANT COMPANY AWAITING CLIENTS. AS SOON AS SUFFICIENT CUSTOMERS COME FORWARD THE COMPANY CAN BEGIN TRADING. IF YOU REQUIRE A DESIGNER PLEASE FEEL FREE TO CONTACT US VIA THE CONTACT US PAGE.
PLEASE FEEL FREE TO BROWSE OUR WEBSITE; YOU MAY SEE SOMETHING OF INTEREST.
PLEASE USE INTERNET EXPLORER FOR OPTIMUM QUALITY, OTHER BROWSERS NOT TOTALLY COMPATIBLE.


text:
Q: Composer classmap and loading files with non-standard extensions When loading files through the composer classmap functionality is it possible to load PHP files that have non-standard extensions such as myFileName.stub or myFileName.foo ?
At present it seems not to be loading them.

A: Composer will currently include files with the following extensions:
.php
.inc
.hh
The last one is for HHVM stuff.
Relevant lines from the class map generator here:
https://github.com/composer/composer/blob/master/src/Composer/Autoload/ClassMapGenerator.php#L62
https://github.com/composer/composer/blob/master/src/Composer/Autoload/ClassMapGenerator.php#L76
So, looks like you'll need a custom map generator...

redpajama_set_name: RedPajamaStackExchange


text:
Q: How to update all the installed software in Ubuntu without using any PPA? I've got many softwares installed. But when the new version is released I'm not getting notified from the application that an update is available.
And I found that in most of Ubuntu applications the Update option is not available. I should wait for the next release for an updated version of the software. I've been updating Mozilla using the packages available from their PPA.
In ubuntu is there any way to update the softwares without using any PPAs?
Please don't recommend Build from source method since I don't like to do all those weird stuff like configuring the things manually etc.

A: if you installed softwares from USC, then you will get updates for that software automatically. In case of Firefox, firefox update is provided as a security update and also as a critical update since it is default browser in Ubuntu. But you cannot get a update of firefox immediately when it is released because it takes some times to build package for it and optimize it for Ubuntu. That's why you could not get updated firefox when it is released. For other software if there is a update then update manager will surely notifies you. BTW you can also use Ubuntu Tweak to manage ppa and get updated software if Update manger failed to do so.....

A: AFAIK there are very few portable apps that provide updates within the app but I don't think it will work for ubuntu as a whole as software installation is a privileged process. You should see How to make sure apt-get has the latest version of Software and understand ubuntu release process. So, unless freeze exception OR backported you may never get the latest software in ubuntu if that is what you want. This is probably why PPA and custom repositories comes to place.
If application itself states its supporting through PPA I don't think there is any harm on going that route. Softwares like google-chrome, opera etc also provide custom repositories from their own systems so you will be up-to date. As already stated there are other custom repositories as well such as medibuntu getdeb etc.
The only other option is building from source.
P.S. Firefox will get latest updates directly from the repositories and you donot need the ppa.

A: You might be interested in requesting Ubuntu Backports.  Starting in 12.04, there's a script called requestbackport in the ubuntu-dev-tools package that can be used to request software updates for stable releases that are available in later releases.  Please note that not all software will qualify for a backport.

A: Update options in Ubuntu come in 5 flavors:
Distributions
Get the newest stable distribution.
Built-in repositories
Everything from main to multiverse.  If you need a newer version try a PPA
PPAs
A lot of interesting projects have PPAs(kind of like semi-official custom repositories)
Custom repositories
Medibuntu for instance
Source
Compile the package yourself
They all have advantages and disadvantages, but it seems to me your question is asking to install a newer package without a repository, ppa, or source.  These are your only normal options.

A: In your case, its better to use rolling release distros like Chakra, PCLOS, Linux Mint Debian as they get frequent updates to core and apps and you never have to re-install. Ubuntu goes for stability and thus the apps are kept at their stablest version, however PPA makes updates a breeze.