text:
Early outcome after sirolimus-eluting stent implantation in patients with acute coronary syndromes
Insights from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry
Pedro A Lemos, Chi-hang Lee, Muzaffer Degertekin, Francesco Saia, Kengo Tanabe, Chourmouzios A Arampatzis, Angela Hoye, Marco van Duuren, Giorgios Sianos, Pieter C Smits, Pim de Feyter, Willem J van der Giessen, Ron T van Domburg and Patrick W Serruys
Received February 12, 2003
Revision received March 15, 2003
Pedro A Lemos, MD*,
Chi-hang Lee, MBBS, MRCP*,
Muzaffer Degertekin, MD*,
Francesco Saia, MD*,
Kengo Tanabe, MD*,
Chourmouzios A Arampatzis, MD*,
Angela Hoye, MB ChB, MRCP*,
Marco van Duuren*,
Giorgios Sianos, MD*,
Pieter C Smits, MD, PhD*,
Pim de Feyter, MD, PhD*,
Willem J van der Giessen, MD, PhD*,
Ron T van Domburg, PhD* and
Patrick W Serruys, MD, PhD, FESC, FACC*,* (p.w.j.c.serruys{at}erasmusmc.nl)
↵*Reprint requests and correspondence:
Prof. Patrick W. Serruys, Thoraxcenter, Bd 406, Dr. Molewaterplein 40, NL-3015 GD Rotterdam, Netherlands.
Objectives This study evaluated the early outcomes of patients with acute coronary syndromes (ACS) treated with sirolimus-eluting stents (SES).
Background The safety of SES implantation in patients with a high risk for early thrombotic complications is currently unknown.
Methods Sirolimus-eluting stents have been utilized as the device of choice for all percutaneous procedures in our institution, as part of the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. After four months of enrollment, 198 patients with ACS had been treated exclusively with SES (64% of those treated in the period) and were compared with a control group composed of 301 consecutive patients treated with bare stents in the same time period immediately before this study. The incidence of major adverse cardiac events (MACE) during the first month was evaluated (death, nonfatal myocardial infarction [MI], or re-intervention).
Results Compared with control patients, patients treated with SES had more primary angioplasty (95% vs. 77%; p < 0.01), more bifurcation stenting (13% vs. 5%; p < 0.01), less previous MI (28% vs. 45%; p < 0.01), and less glycoprotein IIb/IIIa inhibitor utilization (27% vs. 42%; p < 0.01). The 30-day MACE rate was similar between both groups (SES 6.1% vs. control patients 6.6%; p = 0.8), with most complications occurring during the first week. Stent thrombosis occurred in 0.5% of SES patients and in 1.7% of control patients (p = 0.4). In multivariate analysis, SES utilization did not influence the incidence of MACE (odds ratio 1.0 [95% confidence interval: 0.4 to 2.2]; p = 0.97).
Conclusions Sirolimus-eluting stent implantation for patients with ACS is safe, with early outcomes comparable with bare metal stents.
Percutaneous intervention has been increasingly demonstrated to reduce the risk of adverse events in patients with acute coronary syndromes (ACS) (1,2). Several technical and medical advancements have contributed to improve the results of angioplasty in this population. However, patients with acute coronary disease still present a higher risk for early events than chronic stable patients, possibly owing to an increased propensity for thrombotic complications in the first days after the intervention (3–5).
Sirolimus-eluting stent (SES) implantation has been demonstrated to virtually abolish in-stent restenosis in elective patients with relatively simple lesions (6,7). Notably, the reduction of in-stent restenosis with SES was achieved without compromising the high acute success rates currently accomplished with bare stents. However, the impact of SES in unselected complex cases is presently not known. Sirolimus has been reported to decrease endothelial function in vitro (8)and to affect platelet physiology (9–11). Moreover, impaired local vascular healing with delayed endothelization and late fibrin persistence has not been ruled out after SES implantation (12,13). Therefore, evaluation of the safety of SES in patients with increased risk for early thrombotic events is warranted.
The aim of this study was to investigate the impact of SES implantation on the occurrence of early adverse events (30 days) in a consecutive series of unselected patients with ACS enrolled in the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry.
The RESEARCH registry
The SES (Cypher; Johnson & Johnson-Cordis unit, Cordis Europa NV, Roden, the Netherlands) received Conformité Européenne mark approval in April 2002, since then being commercially available for routine use in Europe. From April 16, 2002, it has been our policy to utilize the SES as the device of choice for every percutaneous coronary intervention performed in our institution, as part of the RESEARCH registry. The RESEARCH is a single-center registry conducted with the aim of evaluating the impact of SES implantation in the "real world" of interventional cardiology. All consecutive procedures were included, without any specific anatomical or clinical restriction. Additionally, a control group was formed by all patients treated with percutaneous interventions in the period immediately before this study. Therefore, the control and the RESEARCH groups are constituted by two sequential cohorts, primarily defined by the interventional strategy applied (conventional bare stent or SES implantation, respectively).
All procedures were performed according to standard interventional techniques except by the utilization of SES as the device of choice during the RESEARCH period (at the initiation of the RESEARCH registry, SES were available in diameters from 2.25 to 3.00 mm and lengths of 8, 18, and 33 mm). Glycoprotein IIb/IIIa inhibitors were given at the discretion of the operator.
The postprocedural antiplatelet regimen consisted of aspirin lifelong and clopidogrel 75 mg/day for one month (control group and patients treated with bare stent only) or three months (patients treated with SES). Prolonged clopidogrel prescription (six months) was recommended for patients treated with SES and at least one of the following characteristics: multiple SES (>3 stents), total stented length >36 mm, chronic total occlusion, bifurcations, and in-stent restenosis.
During the RESEARCH period, according to the actual SES utilization, three subgroups were a priori expected: 1) patients treated only with SES; 2) patients in whom both a SES and a non-SES device were utilized at the index procedure; and 3) patients treated without implantation of any SES. The specific reasons for nonutilization of SES were registered on a lesion-per-lesion basis.
The RESEARCH registry was designed with the primary objective of evaluating the effectiveness of SES implantation compared with the control population. Effectiveness in both groups was measured by the survival time during which patients remain free of major adverse cardiac events (MACE) after one year of follow-up. Additionally, the following secondary objectives have also been predefined: 1) short-term (30-day) safety in patients with ACS; 2) survival free of MACE at six-month follow-up; 3) cost-effectiveness analysis at six months and one year; 4) anginal status and medication usage at six months and one year; and 5) quality of life and work status at six months and one year.
In the present study, we report on the 30-day outcomes of patients with ACS treated with SES implantation compared with the control population. This study protocol was approved by the local ethics committee and is in accordance with the principles of Good Clinical Practice for Trials of Medicinal Products in the European Community and the Declaration of Helsinki. Written, informed consent was given by every patient.
ACS substudy: patient population
In the present report, we evaluated the 30-day outcomes of all 198 consecutive patients with unstable angina or acute myocardial infarction (MI) treated exclusively with SES during the first four months of the RESEARCH registry (from April 16, 2002 to August 15, 2002). This group represents 64% of all procedures performed in patients with ACS in the period (n = 311 patients). Patients receiving both bare stents and SES in the same procedure (32 patients; 10%) and those treated without SES implantation (81 patients; 26%) were not included in the present analysis. Among patients not included, nonutilization of SES was due to unavailability of an appropriate SES size (diameter or length) in 73% of cases, inclusion in another study in 5%, and impossibility to cross the lesion with the SES in 1%. In the remaining 21% of cases, SES was not utilized owing to a variety conditions related to the operator's personal choice or other "medical/technical issues" (for instance, balloon dilation instead of stent implantation in a small coronary branch, mechanical thrombectomy without stent implantation for vessels with a high thrombotic burden, or heparin-coated stents owing to contraindication for antiplatelet therapy). A control group was comprised of 301 consecutive patients with ACS treated with bare stent implantation during the last four months (from December 16, 2001 to April 15, 2002) before the initiation of the RESEARCH registry (94% of all patients treated in the period). Patients with unstable angina were categorized according to the Braunwald classification (14). Procedures performed in the first 24 h of an acute MI were classified as rescue or primary angioplasty, if preceded or not by (failed) intravenous thrombolysis, respectively. Patients treated after 24 h but before discharge of an episode of MI were classified as post-MI unstable angina (Braunwald class C).
End point definitions and follow-up
Major adverse cardiac events were defined as: 1) death; 2) nonfatal MI; or 3) repeat target lesion revascularization or target vessel revascularization. A definite diagnosis of MI required an increase in the creatine kinase level to more than twice the upper normal limit with an increased level of creatine kinase-MB (7). Target lesion revascularization was defined as any surgical or percutaneous re-intervention motivated by a significant luminal narrowing within the stent or in the 5-mm distal or proximal peristent segments. Target vessel revascularization was defined as any re-intervention driven by lesions located in the treated vessel even beyond the target lesion limits. Additionally, we analyzed the incidence of stent thrombosis, defined as any angiographically documented thrombotic occlusion (Thrombolysis In Myocardial Infarction [TIMI] flow grade 0 or 1) or flow-limiting thrombus (TIMI flow grade 1 or 2) occurring after the procedure (after removal of the guiding catheter) in an artery treated with angiographic success (TIMI flow grade 3 immediately after stent placement and percent in-lesion diameter stenosis ≤30%).
All procedures were performed in a tertiary cardiology center. As ruled by the local medical system organization, the majority of hospitalized patients treated in this tertiary facility were referred from other peripheral hospitals, to which they were discharged shortly after the procedure unless a periprocedural complication occurred and/or specialized surveillance was required. In total, patients have been referred from a group of 14 local hospitals. Postprocedure medical care was performed at the discretion of the site of origin. Cardiac enzymes were measured serially after the procedure for all in-hospital patients maintained in our hospital. In most of the peripheral hospitals, cardiac markers were not collected routinely, unless a postprocedure MI was suspected. For elective outpatient cases, it has been our practice to discharge the patients after a mean period of observation of 3 ± 1 h (unpublished data), provided no postprocedural complications had occurred (access site hemostasis was routinely performed with a femoral closure device whenever possible). As a result of these policies for in- and outpatient cases, serial cardiac markers were not available only for patients in whom the likelihood of postprocedure MI was judged to be low. Such policy has been supported by evidence from studies with large population cohorts showing that minor asymptomatic enzymatic elevation has no impact on either short- or long-term prognosis (15,16)and, therefore, is highly unlikely to influence the postprocedural medical conduct.
In-hospital outcome information was obtained by means of an electronic clinical database for patients maintained in our hospital after the procedure and by review of the hospital records for those discharged to secondary hospitals. During the follow-up, recordings of all repeat interventions (surgical and percutaneous) and re-hospitalizations were prospectively collected in a dedicated database. Long-term survival status was assessed by written inquiries to the Municipal Civil Registries at 30 days, 6 months, and 1 year after the procedures. Questionnaires were sent at six months and one year to all living patients with information regarding postdischarge anginal status, medication usage, and the occurrence of clinical events. Furthermore, a psychological questionnaire was sent and included forms with the Short Form-36 quality of life (17), the Hospital Anxiety and Depression Scale (18), and the Type D personality score (19). The referring physician and institutions as well as the general practitioners were directly approached whenever necessary for additional information. For patients who went abroad, an effort was made to contact the local civil registries of their new residencies. Patients lost to follow-up were considered at risk until the date of last contact, at which point they were censored.
Data management and statistical analysis
All consecutive procedures were included in the control group and in the RESEARCH, utilizing a dynamic registry design as previously described by Rothman and Greenland (20). For each patient, the time until the first MACE was computed (person-time). Any eventual repeat percutaneous intervention acts then as a new index procedure, and the person-time contributes again to the cohort. Therefore, a patient can contribute to one, two, or more person-time. This design is of particular interest in a study like the RESEARCH, which intends to evaluate two consecutive cohorts treated with coronary angioplasty. If re-entry is not allowed, the second group (in the present case, treatment with SES) is consequently emptied from cases with treatment for restenotic lesions. This design, therefore, permits the inclusion of patients with in-stent restenosis in both study periods, allowing the evaluation of the impact of each particular re-intervention on the subsequent outcomes. In view of the small applicability of this concept (person-time analysis) for short-term evaluations, no calculations with person-time units were performed in the current ACS substudy.
Discrete variables were presented as percentages and compared with Fisher exact tests. Continuous variables were presented by their means and standard deviations and compared with Student ttest or one-way analysis of variance. Cumulative survival and MACE-free survival were calculated according to the Kaplan-Meier method. The log-rank test was used to compare survival and MACE-free survival among the different groups. Multivariate independent predictors of 30-day outcomes were evaluated by logistic regression. All baseline and procedural characteristics presented in Table 1were tested, and a final multivariate model was constructed by backward deletion of the least significant variables. All tests were two-tailed, and a p value of <0.05 was considered as significant.
Baseline and Procedural Characteristics of Patients Treated With Bare Stents Versus Patients Treated With Sirolimus-Eluting Stents
Baseline and procedural characteristics
Clinical and procedural characteristics of the 499 patients included in the present report are summarized in Table 1. As compared with the control patients, patients treated with SES had more frequently primary angioplasty (95% vs. 77%; p < 0.01), more bifurcation stenting (13% vs. 5%; p < 0.01), less previous MI (28% vs. 45%; p < 0.01), and less glycoprotein IIb/IIIa inhibitor utilization (27% vs. 42%; p < 0.01) (Table 1). Also, peak creatine kinase-MB was lower for acute MI patients treated with SES (217 ± 236 U/l vs. 317 ± 256 U/l; p = 0.04) (Table 1). Procedural angiographic success was achieved in all attempted lesions in a similar proportion of cases in the SES and the control groups (96% vs. 97%, respectively, p = 0.48) (Table 1).
30-day outcome
The 30-day outcomes of the SES and control groups are shown in Table 2. Complete follow-up information was available for all patients in the SES group and for all except one patient in the control group (99.7%). There were no differences in the incidence of adverse events between patients treated with bare stents and those treated with SES (30-day MACE rate 6.1% vs. 6.6%, respectively; p = 0.8 by log-rank test), with most complications occurring in the first week after the procedure (Fig. 1). Stent thrombosis occurred in one patient (0.5%) in the SES group and in five patients (1.7%) in the control group (p = 0.4) (Table 2). We performed a multivariate analysis to determine independent predictors of MACE at 30 days. Figure 2shows the four significant predictors of 30-day MACE identified in the final model. The presence of multivessel disease (odds ratio [OR] 4.4 [95% confidence interval {CI}: 1.8 to 10.8]; p < 0.01), cardiogenic shock (OR 3.9 [95% CI: 1.2 to 12.8]; p = 0.02), and acute MI at presentation (OR 3.3 [95% CI: 1.4 to 7.6]; p < 0.01) were associated with an increased risk of MACE, while right coronary angioplasty (OR 0.4 [95% CI: 0.2 to 0.9]; p = 0.04) was related to a decrease in the odds of early adverse events. When forced into the model, SES utilization (OR 1.0 [95% CI: 0.4 to 2.2]; p = 0.97) did not predict the occurrence of adverse events, with virtually no influence on the predictive strength of the model (Fig. 3).
Cumulative major adverse cardiac events (MACE) rate (death, nonfatal myocardial infarction, or re-intervention) during the first month for control patients (bare stent) and patients treated with sirolimus-eluting stents (SES). Note that >50% of events occurred during the first week in both groups.
Multivariate independent predictors of 30-day major adverse cardiac events (MACE) rate (death, nonfatal myocardial infarction, and re-intervention) derived from the final logistic regression model. The odds ratios (OR) are shown on logarithmic scale together with their 95% confidence interval (CI).
Comparison of the strength (chi-square values) for the prediction of 30-day major adverse cardiac events (MACE) rate (death, nonfatal myocardial infarction, and re-intervention) of multivariate models. Model 1 is the final model selected in the logistic regression analysis and included the variables displayed in Figure 2. The forced inclusion of sirolimus-eluting stent (SES) utilization (Model 2) did not enhance the predictive strength of the model, as reflected by the negligible change in the chi-square values.
Incidence of Adverse Events at 30 Days in Patients Treated With Bare Stents Versus Patients Treated With Sirolimus-Eluting Stents
In this study, we analyze for the first time the impact of SES implantation on the early outcomes of patients with ACS. Compared with conventional bare stents, utilization of SES in unselected patients with acute MI or unstable angina was observed to be safe at 30 days, with similar rates of procedural success and early adverse events.
Patients treated with SES differed in some aspects from patients in the control group. Control patients presented more rescue angioplasty for failed thrombolysis (instead of primary angioplasty), which could have increased the risk of events in this group. Conversely, SES patients were more frequently treated for bifurcation lesions, a well-known risk factor for periprocedural complications (21,22). Moreover, glycoprotein IIb/IIIa inhibitors were less commonly used in patients treated with SES, which may have exposed these patients to a higher procedural risk (23). It seems unlikely that the lower utilization of glycoprotein IIb/IIIa blockers in this group could be explained by a lower risk profile perceived during the procedure because both the control and SES populations were equally composed predominantly of patients with acute MI or high-grade unstable angina, with no significant difference in their diabetic status. Nevertheless, after adjusting for baseline and procedural differences, the type of stent used, either bare or SES, was not significantly associated with the occurrence of early adverse events.
Recently, sirolimus has been reported to reduce endothelium-dependent relaxation in vitro in a porcine model, although the authors did not rule out an effect of the drug vehicle (8). Additionally, sirolimus has been reported to increase platelet aggregation and secretion in transplant recipients (11). However, recent studies have demonstrated that this drug efficiently blocks the synthesis of Bcl-3, a regulatory protein expressed when platelets adhere to collagen via integrin αIIbβ3(9,10,24). Regardless of these contradictory laboratory findings, SES was not associated with clinically relevant device-related complications in our series, with no modification of the risk profile for procedural failure or event occurrence.
Patients treated with SES presented a similar timing of postprocedural complications compared with control patients, with most events occurring in the first days after the procedure, a typical pattern previously reported after bare stent implantation (4,5). In this context, a relatively delayed hazardous effect of the drug leading to an increase in "late" thrombotic complications after the first week was not observed in our patients.
The present investigation suffers from the inherent limitations of a nonrandomized trial, which explains some unbalance in the baseline characteristics among the treatment groups. However, the study population is representative of the "real world" of interventional cardiology, with findings more readily applicable to daily clinical practice. Postprocedure cardiac markers were not collected routinely for all patients (available for 42% of control patients and 46% of patients in the SES subgroup [p = NS]). This was justified by the fact that high-grade enzymatic elevations, those with proven prognostic impact (15,16), rarely occur "unnoticed" in asymptomatic patients. When comparing patients with and without postprocedure enzymes collected, the 30-day death rate was 7.1% versus 0% (p < 0.001) and the re-intervention rate was 4.7% versus 0% (p < 0.001), reflecting the low-risk nature of patients for whom cardiac markers were not measured. Similarly, the relatively low frequency of utilization of glycoprotein IIb/IIIa inhibitors in our study reflects the current practice of administration of these drugs in several countries worldwide (25). Risk stratification was based mainly on clinical characteristics. Although laboratorial tests are known to add important prognostic information, the validated Braunwald classification for unstable angina applied in the present study provides a powerful clinical tool for individual risk assessment (14).
Sirolimus-eluting stent implantation for patients with ACS was safe, with early outcomes comparable to conventional bare metal stents. Maintenance of the excellent short-term results already achieved with the current techniques is crucial for the validation of SES as a useful strategy in the treatment of complex cases, such as those commonly found in daily practice. Further evaluation in the context of randomized trials is warranted to confirm the results observed in the present study.
major adverse cardiac events
Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital registry
sirolimus-eluting stent
Thrombolysis In Myocardial Infarction
Revision received March 15, 2003.
Lagerqvist B.,
Husted S.,
Kontny F.,
(2002) A long-term perspective on the protective effects of an early invasive strategy in unstable coronary artery disease: two-year follow-up of the FRISC-II invasive study. J Am Coll Cardiol 40:1902–1914.
Cannon C.P.,
Weintraub W.S.,
Demopoulos L.A.,
(2001) Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 344:1879–1887.
Hausleiter J.,
Kastrati A.,
Mehilli J.,
(2002) Predictive factors for early cardiac events and angiographic restenosis after coronary stent placement in small coronary arteries. J Am Coll Cardiol 40:882–889.
Thel M.C.,
(2000) Timing of and risk factors for myocardial ischemic events after percutaneous coronary intervention (IMPACT-II). Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis. Am J Cardiol 85:427–434.
Schuhlen H.,
Dirschinger J.,
(1998) Intracoronary stenting and risk for major adverse cardiac events during the first month. Circulation 98:104–111.
Degertekin M.,
Serruys P.W.,
Foley D.P.,
(2002) Persistent inhibition of neointimal hyperplasia after sirolimus-eluting stent implantation: long-term (up to 2 years) clinical, angiographic, and intravascular ultrasound follow-up. Circulation 106:1610–1613.
Morice M.C.,
Sousa J.E.,
(2002) A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 346:1773–1780.
Jeanmart H.,
Malo O.,
Carrier M.,
Nickner C.,
Desjardins N.,
Perrault L.P.
(2002) Comparative study of cyclosporine and tacrolimus vs. newer immunosuppressants mycophenolate mofetil and rapamycin on coronary endothelial function. J Heart Lung Transplant 21:990–998.
Pabla R.,
Weyrich A.S.,
Dixon D.A.,
(1999) Integrin-dependent control of translation: engagement of integrin αIIbβ3regulates synthesis of proteins in activated human platelets. J Cell Biol 144:175–184.
(1998) Signal-dependent translation of a regulatory protein, Bcl-3, in activated human platelets. Proc Natl Acad Sci U S A 95:5556–5561.
Babinska A.,
Markell M.S.,
Salifu M.O.,
Akoad M.,
Ehrlich Y.H.,
Kornecki E.
(1998) Enhancement of human platelet aggregation and secretion induced by rapamycin. Nephrol Dial Transplant 13:3153–3159.
Teirstein P.S.
(2001) Living the dream of no restenosis. Circulation 104:1996–1998.
Virmani R.,
Farb A.,
Kolodgie F.D.
(2002) Histopathologic alterations after endovascular radiation and antiproliferative stents: similarities and differences. Herz 27:1–6.
Scirica B.M.,
McCabe C.H.,
(2002) Prognosis in the thrombolysis in myocardial ischemia III registry according to the Braunwald unstable angina pectoris classification. Am J Cardiol 90:821–826.
Brener S.J.,
Ellis S.G.,
Schneider J.,
Topol E.J.
(2002) Frequency and long-term impact of myonecrosis after coronary stenting. Eur Heart J 23:869–876.
Kurlansky P.A.,
Traad E.A.,
Galbut D.L.,
Singer S.,
Zucker M.,
Ebra G.
(2002) Coronary bypass surgery in women: a long-term comparative study of quality of life after bilateral internal mammary artery grafting in men and women. Ann Thorac Surg 74:1517–1525.
Herrmann C.,
Brand-Driehorst S.,
Buss U.,
Ruger U.
(2000) Effects of anxiety and depression on 5-year mortality in 5,057 patients referred for exercise testing. J Psychosom Res 48:455–462.
Denollet J.,
Vaes J.,
Brutsaert D.L.
(2000) Inadequate response to treatment in coronary heart disease: adverse effects of type D personality and younger age on 5-year prognosis and quality of life. Circulation 102:630–635.
Rothman K.J.,
Greenland S.
(1998) in Modern Epidemiology, Cohort studies, eds Rothman K.J., Greenland S. (Lippincott, Williams & Wilkins Publishers, Philadelphia, PA), 2nd edition, pp 79–80.
Wilensky R.L.,
Selzer F.,
Johnston J.,
(2002) Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry). Am J Cardiol 90:216–221.
Zaacks S.M.,
Allen J.E.,
Calvin J.E.,
(1998) Value of the American College of Cardiology/American Heart Association stenosis morphology classification for coronary interventions in the late 1990s. Am J Cardiol 82:43–49.
Cura F.A.,
Bhatt D.L.,
(2000) Pronounced benefit of coronary stenting and adjunctive platelet glycoprotein IIb/IIIa inhibition in complex atherosclerotic lesions. Circulation 102:28–34.
Lindemann S, Tolley ND, Dixon DA, et al. mTOR and p38 MAP kinase differentially signal the translation of mRNAs in activated platelets (abstr). Circulation 2001;104:II223
Steg P.G.,
Goldberg R.J.,
Gore J.M.,
(2002) Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE). Am J Cardiol 90:358–363.
You are going to email the following Early outcome after sirolimus-eluting stent implantation in patients with acute coronary syndromes
Pedro A Lemos, Chi-hang Lee, Muzaffer Degertekin, Francesco Saia, Kengo Tanabe, Chourmouzios A Arampatzis, Angela Hoye, Marco van Duuren, Giorgios Sianos, Pieter C Smits, Pim de Feyter, Willem J van der Giessen, Ron T van Domburg, Patrick W Serruys


text:
Located in Mpumalanga, the Upper Vaal is a critical water source for downstream users and supplies water to the Gauteng city-region. A few towns, such as Ermelo, are found in the Upper Vaal catchment.
Size: 81 856 ha
The Vaal River flows from this water source area. The Vaal flows eastwards through to its confluence with the Orange River, forming the boundary between the Free State and Gauteng.
The Upper Vaal is critical for supplying water to South Africa's economic hub, the Gauteng city-region.
The Upper Vaal, together with the Northern Drakensberg, Maloti Drakensberg and Upper Usutu, supports more than 13 million people.
The Vaal River is a conduit for transferring water from the Tugela in KwaZulu-Natal and the Orange/Senqu Rivers to Gauteng.
The Vaal River further sustains many towns, including Sasolburg, on its way to its confluence with the Orange River.
It supplies water to Eskom used for cooling two of its coal-fired power stations.
Coal and gold mining
Large-scale cultivation
Leaking waste water treatment
Plantation/Woodlot 0.14%
Cultivation (dryland) 33.73%
There are currently no formally protected areas in Upper Vaal. The Upper Vaal currently has no (0%) formal protection.
Approximately 60% of the Upper Vaal water source area is in natural condition. However, up to 40% of the Upper Vaal is under cultivation for dryland crops such as maize. A range of critical biodiversity areas fall within the water source area and it is vital for sustaining downstream freshwater ecosystems.
COAL MINING, FARMING AND WATER SOURCE AREAS
Coal fields in Ermelo, Evander, the Highveld and Witbank overlap almost entirely with the Upper Vaal water source area. Nevertheless, it currently has no legal protection. Further, it is a critical agricultural area, with up to 40% under cultivation. Which legal mechanisms may be used to protect this water source area and associated agricultural resources from the impacts of coal mining?
65% of our wetlands are threatened and 48% are critically endangered.

redpajama_set_name: RedPajamaCommonCrawl


I picked this notebook up on the cheap today, and am going to use it at work for general notes. It's a bit nicer than the Spirax recycled paper one they supply us with.
This notebook is Big W's answer to the hardcover notebook market. It's branded "Ditto" which is Woolworths' home brand of stationery. It's not bad quality for $7.50 on shelf.
The cover is rather hard, keeping it tight and rigid. It comes in both red and black, however I have a small A6 black version, so I figured it'd be nice to try the red. After opening and inspecting it, the seems of the cover do lose colour slightly, and the red is not uniform across the whole cover – there are slight variations. What can you expect for $8?
The paper is a nice, 80gsm cream, with some fairly dark lines. I'm more a fan of lighter lines which don't break up the page as much, but for writing the dark ones are fine. The lines also don't go right to the edge of the page, which gives you a few interesting features; The edge of the notebook is white, not lined, and it helps keep your writing contained.
As you can see in the pen tests below, there is not very much bleed on the Sharpie and Sailor pens, and almost no show-through out the back.
All in all, this is a pretty neat, cheap alternative to an XL Moleskine or similar. I would highly recommend it to anyone looking for a more permanent, hard cover notebook.


Lock in a great price for NH Bratislava Gate One – rated 8.8 by recent guests!
Excellent room, beds large and comfortable, excellent bathroom. A big shopping mall is in front of the hotel, perfect! Croatian-speaking gentleman at the reception was very kind and welcoming. Wellness included in the price.
The SPA Center was good. The water could have been warmer. The room was clean and modern.
The room was very nice and clean, sauna was a bit too small but the swimming pool was nice.
One of the best buffet breakfasts I had, even though the scrambled eggs were a bit lukewarm.
The staff were very helpful and friendly, they added an extra bed to the room without any drama. Breakfast selection was good, Bar has old town prices but that's to be expected.
Friendly staff, nice location, clean and big rooms with nice bathroom.
It is super modern, everything is the latest technology....the sound from the TV is transferred to the restroom when you turn on the light to go to use the bathroom. The decor in the reception hallway is really cool. Parking is reasonable at 10 euro per night.
Rest of the week. Hotel SPA. Other guys and girls from hotel stuff.
Hey NH owner ! Good day ! This is your best NH we stayed in ( Shtuttgart , Zürich , Vienna ) nothing to compare ! All your hotels MUST be of Bratislava ' s standard . Wish you success .
NH Bratislava Gate One This rating is a reflection of how the property compares to the industry standard when it comes to price, facilities and services available. It's based on a self-evaluation by the property. Use this rating to help choose your stay!
Offering a spa area with an indoor pool, NH Bratislava Gate One is located next to the Avion Shopping Park and 1.2 mi from Bratislava Airport.
The beds are equipped with Italian mattresses Lineaflex that provide maximum comfort.
Slovak and international dishes can be enjoyed in the restaurant and lobby bar. The next bus stop is just 350 feet away. From there you can reach the center of Bratislava within 20 minutes. Private parking is available at an additional cost.
When would you like to stay at NH Bratislava Gate One?
The 21m2 - 40 m2 rooms offer amenities such as high-speed internet connection, air-conditioning, a safety deposit box, a flat-screen TV, a radio, a telephone, a mini-bar, coffee/tea making facilities and a bathroom with a bath tub or a shower, a hairdryer, slippers and a bathrobe. You can also enjoy a cup of coffee from the Nespresso machine. These rooms are located on the upper floors with views.
This air-conditioned suite offers a living area and a separate bedroom, high-speed WiFi, a spacious seating area, tea/coffee making facilities, a safety deposit box, a mini-bar, a flat-screen TV, a radio, a telephone and a bathroom with 2 washbasins, a bathtub, a shower, 2 toilets, a hairdryer, a bathrobe and a bidet. You can also enjoy a cup of coffee from the Nespresso machine.
Some of the rooms have an entrance to the terrace.
Includes high-speed internet, LCD TV, air conditioning, a minibar and a safe which can also accommodate a laptop. This spacious room has a king size bed.
These rooms offer high-speed internet connection, air-conditioning, a safety deposit box, a flat-screen TV, a radio, a telephone, a mini-bar, coffee&tea making facilities and a bathroom with a shower, a hairdryer and a bidet in some rooms. Additional beds can be added upon request.
These rooms offer high-speed internet connection, air-conditioning, a safety deposit box, a flat-screen TV, a radio, a telephone, a mini-bar, coffee&tea making facilities and a bathroom with a shower, a hairdryer and a bidet in some rooms. An additional bed can be added upon request.
These rooms offer high-speed internet connection, air-conditioning, a safety deposit box, a flat-screen TV, a radio, a telephone, a mini-bar, coffee&tea making facilities and a bathroom with a shower, a hairdryer and a bidet in some rooms. An additional bed can be added upon request. It offers even more space and fits up to four people.
The most comfortable rooms in Bratislava. From standard rooms to suites, we have it all. Whether you are travelling on business or leisure, our staff is ready to do everything to satisfy your needs and make your stay truly special.
House Rules NH Bratislava Gate One takes special requests – add in the next step!
NH Bratislava Gate One accepts these cards and reserves the right to temporarily hold an amount prior to arrival.
The front desk personnel was not so accommodating.
The receptionist did not communicate with the cleaners and the morning shift about us wanting to have late checkout. He was either playing dumb or he was actually dumb. We tried to explain we want to come back to the hotel and use the facilities, he said he will make not in the computer. He then rang us to check with us again and at the end made a complete mess of it as we were getting phone calls next day to check out ASAP. Also the parking was not letting us through although we checked with the receptionist and we were told the parking is till 2pm the next day but it wasn't.
Bed, shower, the content of minibar.
Small issue with the shower in 418. Water runs out of the shower a bit. Need to drop a towel down to keep the water from flowing in to the rest of the bathroom.
Great Location. Lots of space. The hotel is fantastic. Morning Boufe is out of the world. I recommend this hotel as its easy to access, park. You can shop at the mall right across the street!
The room itself was very unpleasant, no atmosphere. Loud noices in the bathroom from toillet flushing in other rooms (?). On checking in, the staff hoped I would like this particular room. Now I understand why. Also, on the second night, I was disturbed in my sleep due to loud noise in the next room. Staff took little action on my request. The breakfast is way too expensive: very standard, little choice, low quality food stuffs. The food in the restaurant is also of very average quality.
Restaurant is nice but food not so good and overpriced. The hotel is located in the suburbs, but the parking is not free.
NH Gate One is a very beautiful and modern hotel near the airport. Our room was really big and clear on the last level of this super nice building. Very comfortable room with big queen bed bed and LCD TV. Bathroom was very nice and clear with one semi transparent opal glass wall. Breakfast was good with some tasty food. SPA / Wellness zone is small but i think enought because i see only 3 other guest all the time. Staff is friendly. Wifi is free and free Nespresso Coffee in the room. 6-5 EUR to oldown with Bolt (ex-Taxify). Close to the Avion shopping park!
A few issues that I need to mention: 1. Parking is not for free, even through there is a lots of space in the garage (€10 per day). We thought guests are for free so we parked in the garage. However, we got charged€3 for 18 min! Weird, because you can park for free at the nearby shopping mall. 2. There was rather a weird odour when we entered the room (maybe not nicely smelling cleaning products??) After we opened the window, the smell was gone, luckily :) 3. Magazines in the room did not seem to be appropriate, also the painting above the bed portraying sperms entering the egg... Rather weird. 4. There were naked people (men) in the wellness area, including the pool... -_-. Not pleasant surprise. - _- 5. 5G Wifi in our room did not work during our stay. 6. Water from the shower was leaking all over the bathroom. Room 725.
Staff was friendly and polite. Room had a decent size and was well maintained. Bed was comfortable, we had a good sleep. 24/7 Gym is a big plus. We really enjoyed it in the morning. Close to the airport, shopping mall, Ikea and other big stores. Thank you.


BMW 3-Series (E90 E92) Forum > BMW E90/E92/E93 3-series General Forums > Regional Forums > USA - Mid-Atlantic > Walnut Blasting near Columbia,MD?
I did some searching on here about Walnut Blasting Services in the Baltimore County/Howard County Area but looks like the providers mentioned in the earlier threads no longer participate in these forums or provide the required services. Anyway, if someone has a recommendation for people who can do Intake Valve Cleaning / Walnut Blasting in the Howard County (Columbia,MD, Ellicott City,MD) or nearby areas, please do share the information. Thank you for reading.


This album of soothing lullabies will transform any environment into a calm, restful sanctuary. Instrumental arrangements performed by a small grouping of musicians offer slow and flowing melodies to calm and soothe. Smooth transitions provide a perfect backdrop for relaxing. A Kindermusik exclusive.


According to the latest report from KGI Securities analyst Ming-Chi Kuo, Apple will soon show us the Apple Watch Sport in new yellow and rose gold colors to match the style of the upcoming iPhone 6s and iPhone 6s Plus. Although the sales are expected to be lower that it was predicted earlier, the guys from Cupertino may still sell nearly 10 million smartwatch units.
As you probably know, the guys from Cupertino are currently working on the new version of watchOS for the Apple Watch. The next iteration of the operating system for Apple's wearable device will boast two serious improvements, namely, the ability to connect to known Wi-Fi hotspots without the iPhone and new push complications. Of course, Apple will add lots of stability, security and performance enhancements, but the two features mentioned above are surely the most awaited. The exact date of watchOS 2 release remains unknown. All we know is that it will be made available for public this fall.


text:
TileType = {}

TileType.Nothing = 0
TileType.Environment = 1
TileType.Floor = 2
TileType.Wall = 3
TileType.Ceiling = 4

redpajama_set_name: RedPajamaGithub


I have sensor gateway, V5 I believe which leads me to my first question.
My sensor gateway has an oled display, does that make it a 5 or do previous hardware ver. also have a display? I based the firmware update based on the displays (all but one had an oled, which mine does.
Here is my issue: it was working fine until I updated the firmware to v5.07. The unit was not displaying anything on the display and the unit becam un-responsive.
I first tried a warm reboot (pressed reset button for 5 seconds). When that didn't work, I did a factory reset.
After the factory reset I was able to logon however the display still was not working. I re-applied 5.07 and the display returns but when I get the logon screen and type the default factory password but I get an http 404 page can't be found. The current i/p address is the factory default.
Any assistacne would be greatly appreciated!
One another note. Even though the device won't let me login, I can ping it.
Also the online and sensor light are flashing slowly.
Can you do the factory reset once again please? It sounds like the process got interrupted.
Doing it now. Although, even when I do the factory reset the display does not display anything.
Like I said, I'm assuming I have version 5.
I'm now logged on and the firmware version is 2.08.
Hard ware version is 4.0.
I based the firmware update based on the fact I have an oled display. Is it possible I"m using the wrong firmware upate version.
And just so you know, this is will be the third time I have re-applied the update.
Which is the filename that you are using to update with?
Okay, looks like the wrong firmware version was loaded.
Can I try and put on the correct version to see if that resolves the issue?
You can give it a try, if you are still having issues after this please do let us know as we have not had any reports like this come in.
okay thanks. i did the v2.11 firmware update (for v4 hardware) and i'm able to configure to local i/p and the temp. seems correct. before when i did the update the display works but it would not let me logon after the update (v5 firmware).
it is showing v2.11as the current firmware however the sensor and online lights continue to blink slowly and the oled display still does not come up.
not sure what is going on. my bad for not loading the correct firmware in the first place.
I did and it didn't work. Unit becomes un-responsive after a period of time.
Not worth it. I just went ahead and purchased a new one for the website.
Is the base unit I purchased on you store V5 or V4?
I also completed a firmware upgrade to Factory_Hwver5_Fw_Release_5.7bin from 2.11 release, and also seeing 404 not found error. I have factory reset the device a number of times and clear my browser history but still seeing the same 404 error. Any further suggestions?
Probably you have the wrong firmware installed, since 2.11 is for gateway v4.


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noun: A giant in size, feats, stature, or (physical or intellectual) appetites.
After Gargantua, a voracious giant, the father of Pantagruel, in a series of novels by François Rabelais (c. 1490-1553). The son also has given a word to the English language: pantagruelian. Earliest documented use: 1571.
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Milan 09: Israeli designer Arik Levy will present Osmosis, a collaboration with rapid prototyping company .MGX by Materialise, in Milan later this month.
The crystal-inspired pieces will be shown at the Swarovski Crystal Palace exhibition at Via Savona 56 in Zona Tortona, from 22-27 April.
"Osmosis: Through the membrane of experiencing the transition from real to virtual, from solid to a metaphor, visual and emotional perception transforms.
The Osmosis from the urban landscape in to the installation space opens up a journey to the micro, macro expression of architectural products and techno-craft existence.
I keep on travelling between technology and art, design and reflection, engineering and light…Swarovski master cutter daily environment and magic. Searching for the exchange platform to experiment, explore and revile boundaries of both stone cutting metaphor as well as the semi permeable bridge to my own work.
.MGX by Materialise has collaborated with Arik Levy to create a ground-breaking new exhibition which will be revealed at the Swarovski Crystal Palace during the Salone Internazionale del Mobile in Milan.
The exhibition, entitled "Osmosis", will run from April 22 to 27th, and was inspired by the unique concept of crystal. The revolutionary .MGX rapid prototyping technologies enabled Levy to create an installation that travels between art and technology, design and engineering as well as reflection and light.
"With the natural process of crystallizing as a metaphoric base, and wanting to create formations that integrated the Chaton crystal cut, working with .MGX and 3D printing was evident. Only this technology permits the exploitation and visualization of these genetically modified sculpture formations. .MGX is my constant technology partner and it is this collaboration that allowed me to transform my ideas into reality", explains Levy.
Now in its eighth year, the Swarovski Crystal Palace aims to create signature interpretations of light and design using the emotive medium of cut crystal.
See all our stories from Milan in our special Milan 09 category.


text:
ACCEPTED

#### According to
Index Fungorum

#### Published in
Klotzschii Herbarium Vivum Mycologicum, Editio novo. Century no. 175 (1855)

#### Original name
Peronospora ochroleuca Ces.

### Remarks
null


text:
UCF Faces UConn in Semifinal Match
The American Championship Central
No. 1 UCF vs. No. 4 UConn
Thursday, Nov. 8 | 7 p.m.
Tickets | Watch | Live Stats
ORLANDO, Fla. (UCFKnights.com) – The one-seeded UCF men's soccer team will face four-seeded UConn in the semifinal match of the American Athletic Conference Tournament Thursday evening at 7 p.m. at the UCF Soccer Complex. This will be the second semifinal match of the evening as two-seeded SMU faces six-seeded Memphis at 4:30 p.m.
The game will be streamed live on the American Digital Network and live stats will also be available. Students get in free with a valid student ID. Tickets can be purchased here. For more information on the 2018 American Championship, visit the tournament central page.
The Knights are coming off their biggest win of the season thus far after taking down Cincinnati, 1-0 to secure a share of the regular season title and home pitch advantage for the Tournament. Louis Perez was a hero for the Knights after netting the lone goal in the 84th minute.
THE OPPONENT
UConn finished the regular season 10-4-2 overall and 3-2-2 in The American.
The Huskies lost their final two regular season matches after leading in the conference standings for the majority of the season.
In the meeting with the Huskies this season, UCF and UConn went to double overtime in the 0-0 draw.
Cal Jennings led all players with seven shots as the Knights compiled 19 in the 110 minutes.
UConn defeated Temple, 3-1 on Tuesday to advance to the semifinal match.
KNIGHT BITES
UCF earned three major award honors from The American announced Tuesday as Jennings was named Offensive Player of the Year, Louis Perez earned Midfielder of the Year, and Yannik Oettl was named Goalkeeper of the Year.
Coach Calabrese and his staff won Coaching Staff of the Year in just their second season.
UCF also grabbed seven All-Conference selections. Jennings, Perez, Yoni Sorokin, and Oettl were named First Team All-Conference, while Yanis Leerman earned Second Team All-Conference and All-Rookie Team accolades. Andres Hernandez Betancur was also named to the All-Rookie Team.
The Black and Gold earned their highest ranking in program history at No. 7 by the United Soccer Coaches (USC). This is the fifth straight week the Knights have made the top 20 and third straight week in the top 10.
In the most recent RPI, the Knights come in at 13th.
The Knights enter Thursday's match with an eight-match unbeaten streak. In that streak, UCF is 7-0-1.
Home pitch advantage is sure to play in UCF's favor as they boast a 7-1-2 record at the UCF Soccer Complex this season and 11-1-3 over their last two seasons.


text:
Home/Entertainment News/
Ellen Pompeo is "trying to focus on convincing everybody" that 'Grey's Anatomy' should end
After 18 seasons on ABC, Ellen Pompeo says she's ready for Grey's Anatomy to end. But not everyone agrees.
"I've been trying to focus on convincing everybody that it should end," the actress told Insider.
"I feel like I'm the super-naive one who keeps saying, 'But what's the story going to be, what story are we going to tell?'" she explains. "And everyone's like, 'Who cares, Ellen? It makes a gazillion dollars.'"
They're not wrong. Pompeo, who stars as Meredith Grey and is also a producer on the show, is one of the highest-paid actresses on TV following contract negotiations in 2017. She makes $575,000 per episode.
This isn't the first time she's expressed a desire to wind things down, though.
"I mean, I've been trying to get away for years," Pompeo told Entertainment Tonight earlier this year. "I have been trying. It's not because I haven't been trying. I have strong relationships at the network and they have been very, very good to me, and have incentivized me to stay."
"Miraculously, we keep coming up with ways to have a reason to stay and if there's a reason, that warrants it," she said.
Starz releases trailer for sixth season of 'Outlander'
'Parasite' Oscar winner Bong Joon Ho drafts Robert Pattinson for sci-fi project
Amazon forges an official title for its epic Tolkien series: 'The Lord of the Rings: The Rings of Power'
Sidney Poitier's cause of death revealed, all-star tribute to Harry Belafonte, and more
'Book of Boba Fett' co-star Rory Ross on living out his lifelong dream of being in that galaxy far, far away
Broadway to dim its lights tonight for Sidney Poitier
Gaspard Ulliel, award-winning 'Hannibal Rising' and 'Moon Knight' star, dead in ski accident at 37
In Brief: 'Game' over for Ellen at NBC; 'Picard' returning March 3, and more
Willem Dafoe to make his 'SNL' debut on January 29; Katy Perry will be musical guest
Fashion icon Andre Leon Talley dead at 73
Golden Globe Awards to be held on January 9
"I miss him" — Mario Cantone mourns '…And Just Like That' co-star Willie Garson
HBO Max releases teaser scene of John Cena in 'The Suicide Squad' spin-off 'Peacemaker'
Julianna Margulies addresses playing a lesbian on 'The Morning Show'
Jared Leto claims he was "only joking" about his gross 'Suicide Squad' gifts


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text:
Vickerman hailed as model legislator
January 27, 2021 hhnews207 News 0
Jim Vickerman
Senator from Tracy — a longtime voice for farmers, veterans — dies at age 89
Tracy farmer and dedicated lawmaker Jim Vickerman, who prided himself on putting "people before politics," died last Tuesday at McLaughlin Hospice House in Marshall.
Vickerman, who served residents of Minnesota's Senate District 22 (formerly District 28) for 24 years, was 89.
Former House Rep. Marty Seifert, who served with Vickerman in the Legislature for 14 years, called his former colleague a dying breed and said he wishes there were more politicians serving today like him.
"I really looked up to him as to what a good legislator should be," Seifert said. "He treated everybody fairly, he listened and tried to take care of the folks back home the best he could."
Serving in neighboring districts, Seifert, a Republican from Marshall, said he and Vickerman co-authored a number of bills together during their time in St. Paul, many pertaining to Lyon County and the surrounding area. Seifert said Vickerman was universally respected and was like a grandfather figure to many younger legislators.
"I was 24 when I got elected the first time, and he was always very kind to me," said Seifert. "I never heard him say a nasty or partisan word in the 14 years I served with him. He was just a model of what a good legislator should be. I wish we had more like him there today."
Seifert said moderate Democrats like Vickerman are few and far between in today's political climate.
"There are people who are nice, but he was the full package," said Seifert. "He voted his district, treated everyone with kindness, worked extremely hard and was really universally liked by everybody. I don't think you could find one person who would say a bad thing about Jim Vickerman. The guy was a class act."
A member of the DFL party, Vickerman was first elected in 1986. His most recent election victory came in 2006, when he defeated current District 22 Sen. Bill Weber of Luverne.


Onyx is a natural stone that is making its presence felt in the luxury design area. It is an extremely unique stone and it is renowned for its extreme elegance and vividness. Onyx is considered as a precious stone because of its rarity.


text:
from pytest_bdd import given, when, then
from model.contact import Contact
import random

@given('a contact list')
def contact_list(db):
    return db.get_list_contacts()

@given('a contact with <firstname>, <lastname>, <middlename>, <nickname>, <title>, <company>, <address>, <email2>, <email3>, <work_phone>, <home_phone>, <mobile_phone>, <fax>, <homepage>, <address2>, <phone2> and <notes>')
def new_contact(firstname, lastname, middlename, nickname, title, company, address, email2, email3, work_phone, home_phone, mobile_phone, fax, homepage, address2, phone2, notes):
    return Contact(firstname=firstname, lastname=lastname, middlename=middlename, nickname=nickname, title=title, company=company,
                   address1=address, email2=email2, email3=email3, home_phone=home_phone, work_phone=work_phone,
                   mobile_phone=mobile_phone, fax=fax, homepage=homepage, address2=address2, phone2=phone2, notes=notes)

@when('I add the contact to the list')
def add_new_contact(app, new_contact):
    app.contact.create(new_contact)

@then('the new contact list is equal to the old list with the added contact')
def verify_contact_added(db, contact_list, new_contact):
    old_contacts = contact_list
    new_contacts = db.get_list_contacts()
    old_contacts.append(new_contact)
    assert len(old_contacts) == len(db.get_list_contacts())
    assert sorted(old_contacts, key=Contact.id_or_max) == sorted(new_contacts, key=Contact.id_or_max)

@given('a non-empty contact list')
def non_empty_contact_list(db, app):
    if len(db.get_list_contacts()) == 0:
        app.contact.create(Contact(firstname="Marina", middlename="Ivanovna", lastname="Ivanova", nickname="PrettyGirl",
                           title="economist", company="OAO Dream-House", address1="Russia, Lenina 10",
                           home_phone="8889652", mobile_phone="9261234567", work_phone="3654578", fax="9871245",
                           email="mar@mail.ru", email2="marina@oao-dream-house.com", email3="marina_cool@dh.com",
                           homepage="www.dream-house.com", address2="Russia, Spb, Lenina 17", phone2="145", notes="Likes to swim"))
    return db.get_list_contacts()

@given('a random contact from the list')
def random_contact(non_empty_contact_list):
    return random.choice(non_empty_contact_list)

@when('I delete the contact from the list')
def delete_contact(app, random_contact):
    app.contact.delete_contact_by_id(random_contact.id)

@then('the new contact list is equal to the old contact list without the deleted contact')
def verify_contact_deleted(db, non_empty_contact_list, random_contact, app, check_ui):
    old_contacts = non_empty_contact_list
    new_contacts = db.get_list_contacts()
    old_contacts.remove(random_contact)
    assert old_contacts == new_contacts
    if check_ui:
        assert sorted(new_contacts, key=Contact.id_or_max) == sorted(app.contact.get_list_contacts(), key=Contact.id_or_max)

@given('a index of the edited contact')
def index_contact(non_empty_contact_list, random_contact):
    return non_empty_contact_list.index(random_contact)

@when('I edit the contact from the list')
def edit_contact(app, new_contact, random_contact):
    new_contact.id = random_contact.id
    app.contact.edit_contact_by_id(new_contact)

@then('the new contact list is equal to the old contact list with edited contact')
def verify_contact_edited(db, non_empty_contact_list, new_contact, index_contact, app, check_ui):
    old_lists = non_empty_contact_list
    new_lists = db.get_list_contacts()
    old_lists[index_contact] = new_contact
    assert sorted(new_lists, key=Contact.id_or_max) == sorted(old_lists, key=Contact.id_or_max)
    if check_ui:
        app.contact.check_ui_data(new_lists)


Sheet 1 General outline, frames, wheels, axles, axleboxes , bogie frames , coupoing rods, etc., valve gear details, guide yokes , crossheads and pony truck details .
Sheet 2 Cylinder details, smokebox , steam and exhaust connections , safety valve, lubricator and regulator, boiler feed pump, stay and eccentrics, diagram of pipe connections , ashpan fixing, f ire box bracket and cab footplate.
Sheet 3 Full boiler details with sections, combustion chamber, etc., backhead details, ashpan and grate.


Grayling Campground is a little tighter knit than Rainbow campground and sits just above the store and marina at Big Lake. There is a country store for most of your needs including boat rentals, ice, food and fishing gear. For boat rentals call 928-521-1387. Store hours are as follows; weekend:6:00am-6:00pm, all other days 8:00am-5:00pm. Check out some of the years best catches in the pictures under the glass at the register. You really can't miss when you get a campsite at Big Lake, virtually every amenity is available! Showers and a dump station are located just east of the Rainbow Campground. The Visitor Center is located just before you reach the Rainbow campground and there are often scheduled activities so check it out when you arrive.
Some campsites do not have a panorama if the campsite was occupied when I visited.