The over all population of Gabriel Leyva Solano (Zapotillo Dos) is 1222 persons, 623 of them are male and 599 of them are female.
The population of this place consists of 513 minors and 709 adults, with 72 of them being 60 years and older.
296 inhabitants of the location Gabriel Leyva Solano (Zapotillo Dos) in Mexico live in indigenous households. 88 of the citizens 5 years and older, speak an indigenous language. The count of people who only speak an indigenous language without having knowledge of the Spanish language is 0 people, while 85 as well speak Spanish.
A legal claim on health care and social insurance benefits have 860 citizens of Gabriel Leyva Solano (Zapotillo Dos).
In Gabriel Leyva Solano (Zapotillo Dos) exist about 270 households.
Of these households 271 are common houses or apartments, 70 are without floor and about 35 consist of one room only.
220 of the normal households have sanitary installations, 217 are connected to the public water supply, 250 have access to electricity.
The economic situation allows 4 households to own a computer, 80 own a washing machine and 233 households are equipped with one ore more televisions.
Besides the 51 analphabets aged 15 or older, about 10 minors between 6 and 14 are not visiting a school.
45 inhabitants of the population of 15 years and older did not visit a school and 407 persons did not finish the school. 173 visited only the 6 years lasting primary school, 139 visited and finished the college or similar scholar institutions.
A total of 52 aged 15 to 24 years visited a school, the medium time school is visited through the whole population is 7 years.
Do You know the places close to Gabriel Leyva Solano (Zapotillo Dos) ?


Resolved, That (a) at any time after adoption of this resolution the Speaker may, pursuant to clause 2(b) of rule XVIII, declare the House resolved into the Committee of the Whole House on the state of the Union for consideration of the bill (H.R. 4) to reauthorize programs of the Federal Aviation Administration, and for other purposes. The first reading of the bill shall be dispensed with. All points of order against consideration of the bill are waived. General debate shall be confined to the bill and shall not exceed one hour equally divided and controlled by the chair and ranking minority member of the Committee on Transportation and Infrastructure. After general debate the bill shall be considered for amendment under the five-minute rule. The bill shall be considered as read. All points of order against provisions in the bill are waived.
(b) No amendment to the bill shall be in order except those printed in part A of the report of the Committee on Rules accompanying this resolution and amendments en bloc described in subsection (e).
(c) Each amendment printed in part A of the report of the Committee on Rules shall be considered only in the order printed in the report, may be offered only by a Member designated in the report, shall be considered as read, shall be debatable for the time specified in the report equally divided and controlled by the proponent and an opponent, shall not be subject to amendment, and shall not be subject to a demand for division of the question in the House or in the Committee of the Whole.
(d) All points of order against amendments printed in part A of the report of the Committee on Rules or amendments en bloc described in subsection (e) are waived.
(e) It shall be in order at any time for the chair of the Committee on Transportation and Infrastructure or his designee to offer amendments en bloc consisting of amendments printed in part A of the report of the Committee on Rules not earlier disposed of. Amendments en bloc offered pursuant to this subsection shall be considered as read, shall be debatable for 20 minutes equally divided and controlled by the chair and ranking minority member of the Committee on Transportation and Infrastructure or their designees, shall not be subject to amendment, and shall not be subject to a demand for division of the question in the House or in the Committee of the Whole.
(f) At the conclusion of consideration of the bill for amendment the Committee shall rise and report the bill to the House with such amendments as may have been adopted. The previous question shall be considered as ordered on the bill and amendments thereto to final passage without intervening motion except one motion to recommit with or without instructions.
Sec. 2. Upon adoption of this resolution it shall be in order to consider in the House the bill (H.R. 3144) to provide for operations of the Federal Columbia River Power System pursuant to a certain operation plan for a specified period of time, and for other purposes. All points of order against consideration of the bill are waived. The amendment printed in part B of the report of the Committee on Rules accompanying this resolution shall be considered as adopted. The bill, as amended, shall be considered as read. All points of order against provisions in the bill, as amended, are waived. The previous question shall be considered as ordered on the bill, as amended, and on any further amendment thereto, to final passage without intervening motion except: (1) one hour of debate equally divided and controlled by the chair and ranking minority member of the Committee on Natural Resources; and (2) one motion to recommit with or without instructions.
(b) the Chair may at any time declare the House adjourned to meet at a date and time, within the limits of clause 4, section 5, article I of the Constitution, to be announced by the Chair in declaring the adjournment.
Sec. 4. The Speaker may appoint Members to perform the duties of the Chair for the duration of the period addressed by section 3 of this resolution as though under clause 8(a) of rule I.


The Toledo Buddy Walk® has grown exponentially over the last 15 years and Renee Canfield, Executive Director of the Down Syndrome Association of Greater Toledo (DSAGT), hopes 2016 will be no exception.
While Renee has been working with nonprofits for years, last year she experienced her first Buddy Walk®. In reflecting on last year's event, Renee shared with us how much she enjoyed, "the way our families connected with each other. Usually it's parents, siblings, grandparents, cousins, aunts, uncles, friends, friends of friends, teachers and more. I think that is what amazed me last year. The network of support reflected at the Buddy Walk®. There's nothing like it." The team camaraderie is also a key part of the Toledo Buddy Walk® culture, with many groups bringing their own t-shirts and signs to celebrate their loved one with Down syndrome.
Participants at this year's walk are in for a fun-filled day of celebration. Music and dancing, carnival style games, a photo booth, free pizza provided by Little Caesars, mascots, and a few new surprises are in store for this year's event. Additionally, DSAGT has secured a new location for the walk, which will be held at Fifth Third Field, home of the beloved Toledo Mud Hens! As in the past, there will also be a family resource fair with information about local services. With all of the different activities, there will be something for everyone to enjoy!
DSAGT serves a wide region, including counties in Ohio and Michigan, and the walk is the perfect time for many families in both states to reunite. While families may not see each other throughout the year, Renee says, "Everyone always comes back for the Buddy Walk®." Not only is this a time to reconnect with old friends, but it provides ample opportunities for new families to become connected as well. Renee says the walk is, "a time of celebration and togetherness for individuals in the community with Down syndrome and the people whose lives they touch." With the shared feelings of togetherness, it is no surprise that families return year after year.
DSAGT has a goal of raising $50,000 for the 2016 Toledo Buddy Walk®. Funds raised from the walk help the organization provide valuable programming to its service area for activities like: teen and adult dances, outings and life skills programs, First Steps Baby Group, a Lending Library, and family support groups/outings. The walk helps keep programs local families count on running.
To show your support for DSAGT and the 2016 Toledo Buddy Walk®, please visit their fundraising site at http://www.ds-stride.org/toledobuddywalk. To learn more about DSAGT, please visit http://www.dsagt.org.


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FW Academy
'How To Not Be A D***head': What Women In Sport Can Teach Men
Three female sports stars open up about 'the moment they knew' their lives had changed forever and what male sports stars can learn from women.
By Emily Brooks
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On Friday morning, 100 women and men gathered around decorated tables in a decorated ballroom to listen to three decorated female sports stars open up about 'the moment they knew' their lives had changed forever. The event was held by Future Women and the ICC T20 World Cup in Sydney's CBD; the sports stars were cricketer Alyssa Healy, Collingwood Magpies AFLW player and retired netballer Sharni Layton, and para-triathlon world champion Lauren Parker; and the answers we expected to receive are the answers sports stars are so good at giving. Vulnerable but guarded, scripted enough to seem off the cuff. The type of answers that appear to say so much, but upon second listen, say nothing at all.
They were not the answers we heard on Friday morning.
When an audience member asked the three panellists what women sports stars could teach male professional athletes, Healy jumped to her microphone: "How to not be a dickhead!" The room erupted with laughter and applause and Layton responded with "I love this chick". Healy continued: "I feel really lucky that I grew up in the generation I did. We had to fight for a lot of stuff, it wasn't just handed to us. And so, to go out on a night on the piss and throw everything away is just ridiculous to me." As women's sport grows in both popularity and scrutiny, Healy believes female sports stars will not be free of scandals, "but I think we're more realistic as people about what we're throwing away. And that's something hopefully they [male athletes] can learn."
Layton believes professional codes like the AFL and NRL – particularly, the men's leagues – have "gone too far and too professional" that the players are no longer able to have lives. "These athletes, they don't have life balance," Layton said. The former Australian Diamonds captain said sports leagues need to "come back a bit" and allow players to live their lives so that they can appreciate life in a holistic sense, but also gain perspective on the game. "I try to tell [this to] the AFLW girls, which is just so funny, because they're like, 'We want to be full-time professionals' and I'm like, 'Noooooo. Don't do it.' Because the thing I love most about football is playing part time because you get your life and sport as well. So yes, [women] do need more money to be able to support that training and to recover, but to be able to work and have a life outside of that is, holistically, so much better for you as a human being – and that's what the male athletes lack at the moment. Just that life perspective."
The inequities that appear to be problems holding women in sport back – the lack of funding, the lower pay, the smaller crowds, the coinciding smaller commercial deals – have been flipped on their heads by the women they're impacting and repositioned as a force for good. A force, maybe, for change. An approach to the game they hope their male counterparts – who are often thrust into stardom around the time they can have their first legal drink – adopt. As the commercial success of the women's leagues begins to (and should) change for the better, it is a humble mindset and holistic perspective they hope the young women coming through the ranks will maintain.
"To be able to work and have a life outside of that is, holistically, so much better for you as a human being – and that's what the male athletes lack at the moment. Just that life perspective."
But you're probably wondering about 'the moment I knew' moments: Healy was a "reluctant athlete" whose love of cricket was driven by a desire to escape problems off the field. She became a professional cricketer, almost by accident. For Layton, "netball chose me" but she was carried by her goal-oriented persona. And after writing down each goal, and achieving every single one of them, she feel "empty". The success was supposed to mean everything but she felt nothing. After months of regular breakdowns, she was sent to a psychiatrist and discovered she had depression. She soon realised it wasn't something she couldn't "fix", but something she could learn to live with. "It's not about being fixed. It's who you are," she told the crowd. She has since retired from netball, and makes time to give back to herself. Speaking about it honestly is now something that drives her. For Parker, she was a swimmer who became a triathlete who began competing in Ironman championships professionally. While on her final training for the Port Macquarie Ironman on April 18, 2017, she was involved in an accident leaving her paralysed from the waist down. Her entire life changed "in a split second". She spent six months in hospital, she worked through rehab, she continued to push herself, and she is now a Para-triathlon World Champion. Finding para-triathlons, she said, saved her.
"Always believe in yourself, because if you don't have that belief in yourself then you won't reach those goals that you have set," Parker told the room. "For me, if I hadn't believed in myself that I could make it, that I could overcome what I've overcome, then I wouldn't have become world champion… It is important for younger kids to know that there is no such thing as 'can't'. And to always have that belief in yourself and to never give up on your dreams." As the room sat in awe, Layton leaned over to Parker and said, "I have a question." Parker has had a "rougher trot" than "the rest of us", and no doubt has bad days. How does she get through them?
"I do have those days, and a lot of days that are a struggle. I put it down to the support I have around me, and the amazing team around me, because I wouldn't be able to do it without them," Parker said. "It's hard to start the day and get up in the morning and know that I can't walk, that I can't do the things that I used to be able to do. But I just have to get over that. You know there's nothing I can do about that. I just need to move forward, and just get on with it. But yeah, pretty much every day is a struggle being in a wheelchair. Everyday life is a struggle."
She has a red feather tattooed on her arm that means strength, vitality and health, and another tattoo that says 'Forever Strong' in Maori. "I've got a friend who is Maori that gave me those words the week I had my accident and they really meant a lot to Brad and I… I got them tattooed on my arm as a reminder to always have that belief in myself, and you know, that gives me strength. And when I'm in a race or having a down day, I can just look at my arm and get that reassurance to be strong and that helps me every time in every circumstance."
As the panel discussion came to its end, the three women had discussed their most vulnerable moments, their advice to younger women, their hopes for the future of sport. Healy had laughed at Layton's "cute" enthusiasm for her upcoming wedding, warning her it gets worse but "It's a beautiful day…" After listening to Parker's grueling 7 day a week training schedule, Layton and Healy started "to feel like I'm not an athlete". They had learned as much about each other, as we had learned about each one of them. "When I was growing up, sports people were put on a pedestal, so I am loving sick sitting in the middle of these two incredibly, authentic, genuine human beings who are being completely themselves today," said Layton. "Because I remember watching the Olympics or the Commonwealth Games or whatever it was and you'd get all the cliche answers and I was like, 'I am never going to fit into that world'… Now, whenever I go out into the community and see kids, I say, 'I am still a human just like you. If you work your ass off, you can be what I have done too.' So it doesn't matter who you are, what your personality is, what your values are – actually, values do come into it because you need to train hard – but it's about embracing who you are as a human." And as young women around the country can now see these honest women, and believe they can one day be them, I was reminded of another phrase as well. It was one comedian Dave Chappelle once told Oprah: "Success takes you where character cannot sustain you." These women have had the time to build their characters before the public eye caught sight of them. And this morning, it appeared they still had character in spades.
Hopefully, young women can hold onto that.
The T20 World Cup is aiming to break the 20-year attendance record for a women's sporting fixture, by getting over 90,000 people to the MCG for the final in March. Purchase your tickets and support the movement here.
If you or someone you know is seeking support and information about mental health or suicide prevention, contact Lifeline on 13 11 14 or the Suicide Call Back Service on 1300 659 467.
womeninsport
Best Of Future Women
Ash Barty Talks Chasing Dreams, Grand Slams And Staying True To Yourself
By Natalie Cornish
'We're 100% In This Or Not At All': Zara Madrusan On Running Melbourne's Best Bars With Her Husband
'Females In Sport Are More Realistic About Where They've Come From': Cricketer Alyssa Healy
'Without A Feminist Marriage, I Couldn't Do What I Do': Kristine Ziwica
Just A Thought: Amie Frydenberg On Letting Guilt Go
By Jamila Rizvi
Amie Frydenberg On Combatting The Juggle, Guilt And Being Called 'Darling'
By Helen McCabe
Just A Thought: The New Gender Pay Gap Stats Will Make You Eyeroll
'Being Known Helps, What You're Known For Matters': Uber's Comms Directors On Reputation, Authenticity & Saying Sorry
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redpajama_set_name: RedPajamaCommonCrawl


One sentence in the Thursday Dispatch article "Dann scandal leads to donation limits" left me puzzled.
"Dann could be sanctioned by the Ohio Elections Commission for campaign spending, including outlays from his transition account."
There should be absolutely no question about former Attorney General Marc Dann being sanctioned, especially after the way he skirted the intended purpose of this money.
At the least, it was unethical, especially using $12,000 to buy dinnerware from his wife's business.
I don't know the extent of his lawbreaking but, in my opinion, Dann and his wife should both spend some time behind bars for stupidity and arrogance.
Then maybe they could feast on prison food off that new dinnerware.


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Well, there you have it, folks! Season 7 of Castle has officially come to an end, and what an end it was! Our beloved team of Terri Edda Miller and Andrew W Marlowe penned last night's episode, "Hollander's Woods." Along with veteran director Paul Holahan, the team we have affectionately come to know as MilMar delivered a season finale that was satisfying in so many ways.
We hope you enjoyed last night's episode and will join us tonight on Stana Talk Radio to share your thoughts on "Hollander's Woods." Here are our discussion questions:
1. What did you think about the episode overall? What were some particularly powerful moments or elements that stood out to you for one reason or another?
2. It was widely known that when AWM and Terri wrote this episode they didn't know if this would be the season or series finale. Had this been the series finale would you have been satisfied with that ending? Why or why not?
3. Though there was no major cliffhanger, we know that Beckett is facing a crossroads in her career. Will she continue on to become Captain of her own precinct or will she decide to go the political route and run for state Senate? What are your predictions for KBC in S8? What would you most like to see happen? What's best for the series?
4. Though many fans are sad to see AWM and Terri Edda Miller leave the Castle team, there is a lot of excitement over the new show-running team of Terence Paul Winter and Alexi Hawley (who returns to Castle after a stint with The Following). How do you feel about these behind-the-scenes changes? What do you think it might mean for S8 of Castle (and possibly beyond)?


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Aitraaz (2004) | Akshay Kumar, Kareena Kapoor, Priyanka Chopra, Amrish Puri, Paresh Rawal, Annu Kapoor, Suresh Bhagwat,
Aitraaz (2004) | Hindi Movie | 6.6/10 | Synopsis : A man is accused of sexual harassment by his former lover and he has
Aitraaz
SYNOPSIS : A man is accused of sexual harassment by his former lover and he has to prove his innocence in order to restore his dignity.
STAR CAST : Akshay Kumar, Kareena Kapoor, Priyanka Chopra, Amrish Puri, Paresh Rawal, Annu Kapoor, Suresh Bhagwat, Kamal Chopra, Firoz Irani, Dinesh Lamba, Anil Nagrath, Juliette Navis, Preeti Puri, Vivek Shauq, Upasna Singh
GENRE : Drama | Romance | Thriller
DIRECTOR : Abbas Alibhai Burmawalla RATINGS : 6.6/10
RELEASE : 12 Nov 2004 RUNTIME : 2hour 40min
Naiyya
India - Hindi Hulchul
Movie - 26 Nov 2004
India - Hindi Hatya: The Murder
Movie - 15 Oct 2004
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© 2018 Scratchu.com | Contact Us | Privacy | Terms ✉ Aitraaz (2004) | Akshay Kumar, Kareena Kapoor, Priyanka Chopra, Amrish Puri, Paresh Rawal, Annu Kapoor, Suresh Bhagwat, Kamal Chopra, Firoz Irani, Dinesh Lamba, Anil Nagrath, Juliette Navis, Preeti Puri, Vivek Shauq, Upasna Singh - Aitraaz (2004) | Hindi Movie | 6.6/10 | Synopsis : A man is accused of sexual harassment by his former lover and he has to prove his innocence in order to restore his dignity....


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Graphic Stories Cyprus 2020: End Results
Category: Academic
The 6th Conference on Graphic Design and Visual Communication in Cyprus, Graphic Stories Cyprus, was held with great success in Nicosia on 6-8 March 2020.
Graphic Stories Cyprus is the only established, independent, annual conference in the field of visual communication and applied arts covering their full range, namely graphic design, illustration, typography, visual arts, semiotics, animation, photography, multimedia design, internet and web design, calligraphy and design in general.
The 6th Graphic Stories Cyprus included eleven (11) lectures, five (5) creative workshops and one (1) international poster exhibition featuring designers from Cyprus and abroad. During this 6th event, special attention was paid to the multifaceted activities aimed at covering and expressing all visual arts and their creators, with the special theme of the conference being its connection to the Cultural Heritage and Tradition through the international poster contest entitled Cultural Heritage, One World, One Future. The Conference on Graphic Design and Visual Communication in Cyprus, Graphic Stories Cyprus, has been selected as one of Europe's best festivals by the European Festivals Association (EFA) and has been awarded the European Quality Stamp EFFE Label for the period 2019-2020.
The conference is addressed to all the creators of visual communication, applied and visual arts, professionals or students, graphic designers, web designers, illustrators, photographers, animators, 2D/3D designers, printmakers, creative agencies, advertisers, marketers, associates as well as those interested in getting to know the profession of visual communications designer.
The 6th Graphic Stories Cyprus hosted 11 lectures by major Cypriot and foreign designers, covering a wide range of Applied Arts, Visual Communication and Design. Mr Stavros Kyprianou, a journalist with the Cyprus Broadcasting Corporation, made the opening speech at the conference, while Mrs Maria Miltiadou, Head of National Programs and Public Relations at the Youth Board of Cyprus, addressed the event.
Andreas Panayi, student at the Department of Multimedia and Graphic Arts of TEPAK, talked about the visual identity that he designed for the 6th GSC. Lakis Argyrou, a professional with years of experience in Communication and Public Relations, presented the necessary steps for a successful professional networking. Web designer and co-founder of Lightblack, Michalis Vassiliou, talked about website design, implementation and promotion. Ioannis Fetanis, a social designer, presented his professional journey from internal search to multidimensional reality.
The importance of Infographics in print and electronic media was presented by the designer Zoe Katsigianni, while Panos Constantopoulos, designer of Infographics and Director of the gr design magazine talked about the relationship between documentary journalism and personal opinion. Vassia Kalozumi from the creative studio Corn, presented the creative international course of their office. In the search of a new manifesto for the humanist typefaces in a post-trend fashion world, was the title of the speech by the designer and founder of Parachute Typefoundry, Panos Vasileiou. Marios Tavellis and Chris Trimbach, guest speakers from Kemanes Printshop, spoke about color management. Math Studio founder and photographer Marios Theologis talked about advertising photography, portrait photography and nude art photography.
During this creative three-day event, four (4) workshops were held, offering accumulated and professional level knowledge and experience in relation not only to modern practices but also to traditional applications of the visual arts and design. Photorealistic Digital Illustration was the subject of the workshop by Costis Papatheodorou, while Panos Constantopoulos and Zoe Katsigianni introduced the participants of their workshop, to the secrets of Infographics design. Experimental typography and editorial design were the subject of the workshop by Ioannis Fetanis, while Katerina Pantela highlighted the details and design features of designing for animation. At the same time, one (1) children's workshop with the theme of Cultural Heritage, a world, a future was held by the illustrator Panayiota Michael.
Cultural Heritage, One World, One Future is the title of the exhibition that includes the 50 distinguished artworks of the 4th International Poster Competition organized by Graphic Stories Cyprus. The posters of the exhibition came from a corresponding international competition that attracted 570 designers from 27 countries. The exhibition hosted at the Bank of Cyprus Cultural Foundation in Faneromeni also features the posters of eleven (11) invited prominent designers. At the same time, the poster with the theme of the exhibition, which was created at the art poster workshop held last November, at American University Emirates, Dubai, is also hosted. The workshop was attended by 20 students from AUE University and was implemented under the direction of Angeliki Athanasiadi and Andrea Panayi at the invitation of the University's graphic design professor, Dr Arafat Al-Naim.
The theme of the competition Cultural Heritage, One World, One Future and the corresponding exhibition aims to highlight and promote the value of Cultural Heritage and the importance of diversity in relation to the common future of all the people on earth. Contestants were invited to visualize their thoughts, ideas and concerns about the value of Cultural Heritage and to answer the question of how our cultural diversity can be our strength, to enhance our sense of belonging to a common world and share a common future.
The inauguration of the exhibition was held on Friday, March 6, 2020, by Nicosia's City Councilor Mr. Chrysanthos Fakas, on behalf of the honorable Mayor of Nicosia, Mr. Constantinos Yiorkatzis. The Bank of Cyprus, together with the Greek font company Parachute Typefoundry, offered the prizes of a total value of 2500 euros. The awards were presented by Nicosia's City Councilor Chrysanthos Fakas, the founder of Parachute Typefoundry, Panos Vassiliou and the internationally renowned graphic designer and partner of Graphic Stories Cyprus, Mr Charis Tsevis.
The winners of the competition by category were: Constantinos Hayes, Cyprus High School and Technical School students, Carilla Karahan from Turkey in the International Visual Communication Students category, Michaella Michail in the higher education visual communication Students of Cyprus category. In the international category for professional visual communication designers, the competition had 2 winners who shared the 1st place: Adonis Papadopoulos from Cyprus and Gerasimos Choraitis from Greece. The commemorative prizes of the competition were provided by OXRA Design Company and designer Christos Grigoriadis.
Graphic Stories Cyprus was organized in cooperation with the Bank of Cyprus and is under the auspices of the Cultural Services of the Ministry of Education and Culture of the Republic of Cyprus and the Municipality of Nicosia. Bank of Cyprus and the Greek company Parachute Typefoundry offered the prizes of the international poster competition.
TAGS: Cyprus, Graphic Stories Cyprus
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Due to most of my work being contracted by marketing agencies who need to outsource their WordPress development, I can't maintain an online portfolio of all my projects. Some sites are under NDA and some clients don't want their clients to know they are outsourcing. With that said, here are some projects that I have developed and am allowed to share. All the projects listed are custom WordPress themes unless otherwise noted.
I also formerly co-ran Whirl Sites, a WordPress-website-as-a-subscription service. I designed and developed most of the themes we used, and I planned, developed, and executed the backend membership, updates, and maintenance systems.


We've got great jobs for people just starting their careers, looking for a flexible second job or continuing to work after retirement. At KFC, what you do matters! If you want a fun, flexible job and be part of a winning team, find out now why Life Tastes Better with KFC. Apply today!


and dancers who've been there, for advice.
Issues with your teacher can't be resolved if you keep your feelings bottled up inside. "The first thing to do is talk with a parent or guardian," says Dr. Kate Hays, a sports and performance psychologist. Tell him or her how you're feeling in class and why. Does the teacher give you too many or not enough corrections? Do you feel the teacher yells at you? Are hurtful comments being made? Hash out the situation together.
Ask a friend whether she's noticed the teacher picking on or ignoring you. "One of my classmates tries to joke about always being put in the back corner in dances, but I know it's a sensitive subject for her," Forderkonz says. If your friend agrees with how you feel, ask if she can be with you when you talk to your parents. Having a witness to bolster your account will show them your situation is serious.
Once you've talked out your feelings with your parents, consider speaking directly with the teacher. If your conflict is relatively minor, that might be the simplest way to fix classroom issues. "One of my preteen students felt picked on in class," says Angela Bates Majewski, of Angela Bates Dance Academy in Newtown Square, PA.


Security cameras are installed in the Haverhill Public Library to protect the safety and security of people, the building, and its contents, while protecting individuals' right to privacy. Only authorized Library staff may view recordings.
Video recording cameras will be used in public spaces of the Library to discourage criminal activity and violations of the Library's Code of Conduct. The recording of audio is restricted under the Electronic Communications Privacy Act and will not be used.
Cameras may be installed in outdoor and indoor places where individuals lack a reasonable expectation of privacy. Examples include public common areas of the library such as parking lots, entrances, seating areas, service desks, and areas prone to theft or misconduct. Cameras will not be installed in areas of the Library where individuals have a reasonable expectation of privacy such as restrooms or private offices. Cameras will not be positioned in areas where patrons' viewing, listening, or personal account information may be easily monitored.
Because security cameras are not constantly monitored, staff and public should take appropriate precautions for their safety and for the security of personal property. Neither the Haverhill Public Library nor the City of Haverhill is responsible for loss of property or personal injury.
Recorded data is confidential and secured in a controlled area. Video recordings will typically be stored for no longer than 30 days. As new images are recorded, the oldest images will be automatically deleted.
Video data will be made available to law enforcement officials or agencies upon written request, and with approval of authorized Library staff. The Library shall retain a copy of the request. Recorded data will be accorded the same level of confidentiality and protection provided to library users by Massachusetts law and the Library's policies with respect thereto. Access is also allowed by law enforcement when pursuant to a subpoena, court order, or when otherwise required by law.
Patrons who experience a crime such as theft of personal possessions while at the Library must submit a report to law enforcement. Members of the public will not be granted access to recorded data; this access must be requested, in writing, by law enforcement.
In situations involving banned patrons, stored still images may be shared with staff Library-wide. Shared images may remain posted in restricted staff areas for the duration of the banning period. The general public will not have access to this information.
A breach of this policy may result in disciplinary action up to and including dismissal. Any library employee who becomes aware of any unauthorized disclosure of a video recording and/or a potential privacy breach has a responsibility to immediately inform the Director of the breach.
A copy of this policy may be shared with any patron or staff member upon request. The policy is also available on the Haverhill Public Library website.
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The Library disclaims any liability for use of the video data in accordance with the terms of this policy, given that the library is a public facility and the security cameras shall be limited to those areas where patrons and/or staff have no reasonable expectation of privacy.
The Board of Trustees of the Haverhill Public Library will review the Security Camera policy and regulations periodically and reserves the right to amend them at any time. The Board authorizes the Library Director to waive regulations under appropriate circumstances, specifically during emergencies when response time is critical. The Library Director is the chief person empowered to make decisions regarding the use of the security cameras. The Library and the Board of Trustees reserves the right to consult legal counsel in matters involving warrants or subpoenas seeking access to security footage.


Fans of Game of Thrones will instantly recognise the iconic island of Dragonstone, which has become a key location in season 7 of the blockbuster TV show.
But what they may not realise is just how easy it is to get to from Plymouth - it's just a ferry and a car ride away.
Currently home to Daenerys Targaryen and her 'Hand' Tyrion Lannister, the imposing island is actually called Gaztelugatxe, and is situated in Northern Spain - just 80 miles away from the port Santander.
And Brittany Ferries flagship ferry the Pont Aven sails weekly to Santander from Plymouth, meaning you don't need to fly - either by plane or on one of Daenarys' dragons - to get there.
'Gaztelugatxe' actually translates to Castle Rock - but, unfortunately, the imposing castle featured in the TV series is CGI.
Still, the island itself is rather impressive - and it is linked to the mainland by a very impressive bridge, which King of the North Jon Snow walked across in Season 7.
And let's face it, who wouldn't want to walk in Jon Snow's footsteps.


The best interest of the University and its employees will be served only if the needs of our students and the community we serve are met in the most serviceable and effective manner. For many of our customers the telephone will serve as the primary, and in some instances, the only source of service fulfillment, with those individuals representing the business operation of the University.
Therefore, it is of utmost importance that all employees subscribe to the principle that customer service is of utmost importance and will "go the extra mile" to assure their 100% satisfaction.


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Me2B
People vs. Adtech
‹ It's 2013. Why are we still in login hell? • A way to get CBS after all ›
Daily Outline
August 6, 2013 in Broadcasting, Business, infrastructure, Internet, Journalism, Links, Photography, Places, problems, Quote, Technology | Permalink
Britt Blaser's flying stories. The dude is a terrific writer who has lived to tell, and tell well. He should do that more often. Speaking of which, I interviewed him for this podcast.
How 24 Tiny Satellites Could Change Business Forever. By Nate Hindman and Joe Epstein. Subhead: "Skybox doesn't want to see pictures of Earth from space just for kicks. It wants to scour the globe for information that will remake industries." It's about Skybox, to which I gave $100 in its Kickstarter campaign. Don't have the t-shirts yet. (Not needing them either. I just noticed for the first time that t-shirts were a perk.) And I look forward to my fifteen minutes.
Libraries don't have to be a thing of the past – just look at Melbourne's. By Anita Sethi in The Guardian. Subhead: "Taking a close look at some of the most glorious of the world's public libraries, from Australia to England, is a reminder of just how vital they are the world over."
The New Yorker channels The Onion with Shouts & Murmurs:
Even More New Features of Your Gmail Inbox! By Ethan Kuperberg.
Amazon Founder Says He Clicked on Washington Post By Mistake. By Andy Borowitz. Also by Andy: Boehner Urges Republicans To Rest Up for Meaningless Votes Ahead.
Personal data and independence
The Independent Purchase Decision Support Test, by Adrian Gropper, M.D. Pull quote: " What I need is an Agent that's independent of my 'provider' institution EHR and communicates with that EHR using the Stage 2 guidelines without any interference from the EHR vendor or the 'provider'. It's my choice who gets the Direct messages, it's my choice if I want to ask my doctor about the alternatives and it's my doctor's choice to open up or ignore the Direct messages I send." (EHR is Electronic Health Record.)
Your data is your interface. By Jarno Mikael Koponen in Pando Daily. Pull quote: "Before solving the 'Big Data' we should figure out the 'small' personal part. Algorithms alone can't make me whole. Different services need my continuous contribution to understand who I really am and what I want. And I believe that apps and services that openly share their data to provide me a better user experience are not far off."
Jarno is also the father of Futureful (@futureful) which Zak Stone of Co.Exist (in Fast Company) in says "hopes to bring serendipitous browsing back to the web experience by providing a design-heavy platform for content discovery." Just downloaded it.
The rebirth of OMNI — and its vibe. Subhead: Glenn Fleishman on the imminent reboot of the legendary science and science fiction magazine. In BoingBoing. Two bonus links on the OMNI topic:
The almost-complete OMNI archive
Jeff Bezos buys the Washington Post. This is either wonderful for journalism or horrifying. By Sarah Lacy in Pando Daily. Pull quote: "John Doerr…described an entrepreneur with uncommon focus and discipline around what the customer wants. I guess the future of the Post will ride on who Bezos sees as 'the customer' and what's in his best interest."
Donald Graham's Choice, by David Remmick in The New Yorker.
Here's Why I Think Jeff Bezos Bought The Washington Post. By Henry Blodget in Business Insider. Pull-quote:
First, I'd guess that Jeff Bezos thinks that owning the Washington Post will be fun, interesting, and cool. And my guess is that, if that is all it ever turns out to be, Jeff Bezos will be fine with that. This is a man who invests in rockets and atomic clocks, after all. He doesn't necessarily make these investments for the money. Or bragging rights. Or strategic synergies.
Second, I'd guess that Jeff Bezos thinks that there are some similarities between the digital news business and his business (ecommerce) that no one in the news business has really capitalized on yet.
The Natives Are Feckless: Part One Of Three. By Bob Garfield in MediaPost. Pull-quotage:
Well done, media institutions. You have whored yourselves to a hustler. Your good name, such that it remains, is diminished accordingly, along with your trustworthiness, integrity and any serious claim to be serving the public. Indeed, by bending over for commercially motivated third parties who masquerade as bona fide editorial contributors, you evince almost as little respect for the public as you do for yourself.
There's your native advertising for you. There's the revenue savior being embraced by Forbes, the Atlantic, The Washington Post, The Guardian, Business Insider and each week more and more of the publishing world.
According to the Pew Research Center for the People and the Press, sponsored content of various kinds was a $1.56 billion category in 2012 and growing fast.
Future of TV might not include TV. By Shalini Ramachandran and Martin Peers in The Wall Street Journal. It begins, "Predicting that transmission of TV will move to the Internet eventually, Cablevision Systems Corp Chief Executive James Dolan says 'there could come a day' when his company stops offering television service, making broadband its primary offering." And wow:
In a 90-minute interview on Friday, the usually media-shy 58-year-old executive also talked about his marriage, his relationship with his father Chuck and his after-hours role as a singer and songwriter. He said his rock band, JD & the Straight Shot, toured with the Eagles last month.
Mr. Dolan said that on the rare occasions he watches TV, it is often with his young children, who prefer to watch online video service Netflix, using Cablevision broadband.
He added that the cable-TV industry is in a 'bubble' with its emphasis on packages of channels that people are required to pay for, predicting it will mature 'badly' as young people opt to watch online video rather than pay for traditional TV services.
Making TVs smart: why Google and Netflix want to reinvent the remote control. By Janko Roettgers in Gigaom.
Hulu, HBO, Pandora coming to Chromecast. By Steve Smith in MediaPost. Pull-quote: "A battle over content clearly is brewing between Google and Apple. Apple TV has recently expanded its offerings of content providers to include HBO Go, Sky TV, ESPN and others. The two companies are pursuing different delivery models as they try to edge their way onto the TV. Apple TV is a set-top box with apps, while Chromecast relies on apps that are present on mobile devices to which the dongle connects."
Setting TV Free. By yours truly in Linux Journal.
Standards, Monopoly and the Quantified Self. In which Phil Windley unpacks Why the Quantified Self Needs A Monopoly, by Matt Asay in ReadWrite. I have a comment under Phil's post.
We Need a New Church Committee: It's time for a basic re-evaluation of intelligence operations. By Yochai Benkler in the New Republic.
World innovation clusters. In MIT Technology Review. Leaders are (in descending order by $ investment):
Skolkovo/Innovation City
Tech City London
Amazon "Upends" Another Industry Sector: Grocery. Are You Next? By Alistair Barr in The River.
Mobile POS Systems More Popular WIth SMBs. By Mark Walsh in MediaPost.
The Mobile Wallets Flying Under the Radar. By Chuck Martin, in MediaPost.
Dear Hotels: Quit Being A-Holes. By yours truly in Linux Journal.
A Tipping Point Against The Copyright Monopoly Regime Is A Lot Closer Than You Think. By Rick Falkvinge in TorrentFreak.
Handbaskets to hell
Is Facebook a Public Utility? Yes, says Filmmaker Cullen Hoback. By Paul Detrick in Reason I like Cullen's movie Terms and Conditions May Apply, but I think we dilute the meaning of Public Utility by calling Facebook one.
Other Agencies Clamor for Data N.S.A. Compiles. By Eric Lichtbau and Michael S. Schmidt in The New York Times.
Copyright, Click Wrap and the Fourth Circuit Court, by Raving Lunacy.
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Academics>
We are the only university where a world-renowned design college, a rigorous liberal arts college, an exceptional performing arts college, and many legendary graduate colleges and programs come together. Our 10,000 students study across our colleges, breaking down walls between disciplines with the goal of designing a better, more just world.
Learn more about the colleges that make up our progressive university.
From the moment you enter Parsons, consistently ranked one of the top design schools in the world, your conception of design will be challenged and expanded. While here, you'll learn to apply new perspectives and critical thinking while mastering established fields of design or advancing emerging ones.
Designed for fiercely independent scholars, our progressive liberal arts college is where immersive intellectual exploration meets real autonomy. The reading- and writing-intensive programs at Lang are grounded in scholarly development and deep critical thinking. With a flexible and diverse curriculum, you have the freedom to explore exactly what is relevant to you and find your own academic path.
The College of Performing arts is made up of three renowned schools: the School of Jazz and Contemporary Music, Mannes School of Music, and the School of Drama. While here, you can expand the limits of your artistry, taking advantage of the opportunity to draw on different artistic disciplines. Alongside prominent faculty, you reinvent tradition, engage with social issues, and develop entrepreneurial skills with which to pursue sustainable career opportunities after graduation.
The New School for Social Research has a legendary history, upholding the university's long-standing tradition of challenging orthodoxy, promoting public debate, and cultivating academic rigor. Studying and working alongside prominent faculty, you will develop new perspectives and bring new ideas into the world in the areas of social sciences, philosophy, and historical inquiry.
Our graduate, professional, and adult bachelor's programs connect theory to real-world practice, training you to address civic life, create new forms of culture, and respond to contemporary challenges around the world. Whether you're studying at the Milano School of Policy, Management, and Environment; the School of Media Studies; the Julien J. Studley Graduate Programs in International Affairs; or the Creative Writing MFA program, you can pursue your academic, professional, and civic aspirations while studying and working alongside a network of professionals.
Imagine an intimate, atelier-like environment in which to study classical artistic traditions, explore new creative methods, and develop convention-defying designs. At Parsons Paris, guided by Parsons' signature curriculum, you will work side by side with undergraduate and graduate students from around the world. Discover how Paris' unique features — its heritage brands, place at the center of European industry, new technologies, and social innovation — can enrich your work and relevance as a global designer.
With courses and programs delivered by expert faculty practitioners from colleges across the university, Continuing and Professional Education makes The New School's progressive approach to education accessible to learners of all ages. We offer pre-college and college students opportunities to explore creative disciplines. We help early professionals fast-track their careers or shift to new ones with specialized certificate programs. And through our executive education programs, we equip leaders and entrepreneurs with the design skills and approaches they need to find transformative solutions for global business challenges.


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The Institute of Contemporary Art, Miami presents a major performance of "Trisha Brown: In Plain Site." Trisha Brown, a founding figure of the American modern dance movement, and her renowned choreography has inspired generations of dance creators into the 21st century.
The four performances will highlight a selection of seminal dance pieces by Brown, which builds upon the significance of artist Donald Judd's collaborations and support of his contemporaries, echoing SoHo's artistic community of the 1970s and '80s. Donald Judd designed the stage sets for two of Brown's acclaimed works: Son of Gone Fishin' (1981) and Newark (Niweweorce) (1987).
Trisha Brown (b. 1936, Aberdeen, WA; d. 2017, San Antonio, TX) was a groundbreaking American choreographer and dancer whose avant-garde work and experiments in pure movement challenged a generation's perceptions of performance. Prior to establishing the Trisha Brown Dance Company in 1970, Brown was a founding member of the Judson Dance Theater with Yvonne Rainer, as well as the improvisational Grand Union. Throughout her career, Brown collaborated with leaders in music, theater, and the visual arts, including visual artists Donald Judd, Robert Rauschenberg, and Elizabeth Murray, and musicians Laurie Anderson, John Cage, and Alvin Curran, among others.
Thursday, April 26, 2018: 6:30pm
Friday, April 27, 2018: 1pm and 6:30pm
Saturday, April 28, 2018: 1pm
Tickets are $20 each
Member tickets are $10 each
"Trisha Brown: In Plain Site" is presented as part of ICA Performs, ICA Miami's program dedicated to showcasing major experimental time-based work and interdisciplinarity in contemporary art.
Major support for this season of ICA Performs, featuring Trisha Brown: In Plain Site, is provided by David Herro and Jay Franke.
ICA Performs


Our aim is to serve your every need when it comes to tax returns and all that comes with them.
You will always deal with a qualified tax adviser with experience of working in the accounts and taxation profession since 2002.
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Research Article| Volume 110, ISSUE 5, P1424-1433, November 1995
PDF [988 KB]PDF [988 KB]
Improved airway healing after lung transplantation
An analysis of 348 bronchial anastomoses
Hiroshi Date, MDa (by invitation)
Hiroshi Date
Elbert P. Trulock, MDb (by invitation)
Elbert P. Trulock
Joseph M. Arcidi, MDa (by invitation)
Joseph M. Arcidi
Sudhir Sundaresan, MDa
Sudhir Sundaresan
Joel D. Cooper, MDa
Joel D. Cooper
G.Alexander Patterson, MDa
G.Alexander Patterson
DOI:https://doi.org/10.1016/S0022-5223(95)70065-X
Previous ArticleCombined lung and liver transplantation in patients with cystic fibrosis: A 4 1/2-year experience
Next ArticleInhaled nitric oxide fails to confer the pulmonary protection provided by distal stimulation of the nitric oxide pathway at the level of cyclic guanosine monophosphate
We evaluated various clinical factors to identify predictors of airway complication after lung transplantation. Two hundred twenty-nine consecutive single (n = 110) and bilateral (n = 119) lung transplants were done between September 1988 and August 1994. These 348 bronchial anastomoses were retrospectively analyzed. Airway complication that necessitated clinical intervention affected 33 anastomoses (9.5%) in 29 patients (12.8%). Satisfactory healing was achieved in 22 of these patients by conservative therapy such as one or a combination of dilation, stent, and laser. There were five deaths (2.2%) attributable to airway complications. One patient had an early postoperative death unrelated to airway complication and one patient has a recalcitrant bronchus intermedius stricture. Complication occurred more often in single-lung than in bilateral lung transplants (16/110, 14.4%, versus 17/238, 7.1%; p < 0.05). The use of a mattress suture (21/153, 13.7%) was associated with more frequent complications than was simple interrupted suture (8/122, 6.6%) or figure-of-eight suture (4/73, 5.5%) (p < 0.05). For patients in whom airway complications subsequently developed, the duration of postoperative mechanical ventilation was greater than that for those in whom an airway complication did not develop. The prevalence of airway complications as our program evolved was evaluated by separating the 229 transplants into three groups: phase I, the first 77 transplants; phase II, the next 76 transplants; and phase III, the most recent 76 transplants. The airway complication rate per anastomosis was significantly lower in phase III (5/126, 4.0%) than in phase I (12/110, 10.9%; p < 0.05) and phase II (16/112, 14.3%; p < 0.01). The majority of airway complications are successfully treated and rarely fatal. The recent reduction in prevalence of airway complications is likely a result of better maintenance immunosuppression and rejection surveillance. (J THORAC CARDIOVASC SURG 1995;110:1424-33)
In the early days of clinical lung transplantation, dehiscence of the bronchial anastomosis was a frequent source of mortality.
Veith FJ
Kamholz SL
Mollenkopf FP
Montefusco CM
Lung transplantation 1983.
Improvements in patient selection, lung allograft preservation, surgical technique, postoperative care, and immunosuppression have reduced the prevalence of airway complications. Experienced centers have recently reported the prevalence of airway complications to be in the range of 7% to 14%.
Shennib H
Massard G
Airway complication in lung transplantation.
Ann Thorac Surg. 1994; 57: 506-511
Griffith BP
Magee MJ
Gonzalez IF
Anastomotic pitfalls in lung transplantation.
J THORAC CARDIOVASC SURG. 1994; 107: 743-754
In our center airway complications represent aninfrequent source of mortality.
Cooper JD
Patterson GA
Trulock EP
the Washington University Lung Transplant Group
Results of 131 consecutive single and bilateral lung transplant recipients.
The optimum techniques of bronchial anastomosis and of perioperative and postoperative treatment of transplant recipients remain controversial and vary from one center to another. This retrospective review of our experience was conducted to evaluate various clinical factors and identify those that might be associated with the development of bronchial anastomotic complications in a group of single (SLT) and bilateral sequential (BLT) lung transplant recipients.
PATENTS AND METHODS
Between September 1988 and August 1994, 229 SLTs (n = 110) and BLTs (n = 119) were done in 226 patients at Barnes Hospital. These 348 anastomoses were retrospectively reviewed and evaluated in December 1994 with a minimum follow-up of 120 days. En bloc double-lung transplants (n = 8) were not included in this study.
Donor lungs were harvested by the technique we have previously described.
Sundaresan S
Trachiotis GD
Aoe M
Donor lung procurement: assessment and operative technique.
Ann Thorac Surg. 1993; 56: 1409-1413
All donors were pretreated with systemic heparin and the pulmonary artery bed was flushed with modified Euro-Collins solution after prostaglandin E1 (500 μg) administration directly into the pulmonary artery.
All transplants were done with the use of previously described techniques.
Pasque MK
Kaiser LR
Haydock DA
Triantafillou AN
Improved technique for bilateral lung transplantation: rationale and initial clinical experience.
Calhoon JH
Grover FL
Gibons WJ
Single lung transplantation: alternative indications and technique.
The donor bronchus was shortened to two rings proximal to the upper lobe takeoff. In our most recent 217 cases anastomoses were conducted in the following sequence: bronchus, pulmonary artery, left atrium. In the first 12 SLTs in our experience, the bronchial anastomosis was done last. The technique used for bronchial anastomosis has evolved with time. Until September 1991, an end-to-end anastomosis with simple interrupted 4-0 Vicryl polyglactin 910 sutures (Ethicon, Inc., Somerville, N.J.) was done in most cases. We then adopted a telescoping technique in most cases whenever the difference in bronchial size between the donor and the recipient was significant (see latter part of Results section). The anastomosis was constructed with 4-0 Prolene polypropylene (Ethicon) or polydioxanone (PDS, Ethicon) sutures as described by Griffith and associates
or with a figure-of-eight technique asdescribed by Calhoon and colleagues.
We continued to use end-to-end anastomoses with simple interrupted or figure-of-eight sutures when donor and recipient bronchi were of an equal size and for a small-caliber left bronchial anastomosis. Direct bronchial artery revascularization was not used. Some form of bronchial anastomotic coverage was used in all but four anastomoses. Early in our experience a pedicled flap of omentum was used routinely. Pericardial fat was later used in a small number of cases but the majority of anastomoses were covered with donor and recipient peribronchial fat and nodal tissue. Patients received methylprednisolone 500 to 1000 mg intravenously at the time of reperfusion.
Standard immunosuppression consisted of azathioprine (2 mg/kg), cyclosporine, steroid, and antilymphocyte antibody. Cyclosporine was given as a continuous infusion (3 to 6 mg/hr) in the early postoperative period, followed by enteral administration when tolerated. The dose was adjusted to obtain a blood level in the high therapeutic to slightly supratherapeutic range. Until 1991 routine therapy with steroids was withheld during the early postoperative period. Subsequently methylprednisolone 0.5 mg/kg per day intravenously was administered for 3 days, followed by oral prednisone 0.5 mg/kg per day. Induction cytolytic therapy was used in most patients. The first six patients received OKT3. Toxicity of this agent prompted routine use of Minnesota antilymphocyte globulin (15 mg/kg per day intravenously) until July 1992 when that agent was no longer available. After a 6-month interval when no cytolytic therapy was used for induction, ATGAM lymphocyte immunoglobulin/antithymocyte globulin (Upjohn Co., Kalamazoo, Mich.) 15 mg/kg per day intravenously was used routinely.
Flexible fiberoptic bronchoscopy was frequently used to monitor donor airway viability and integrity of the bronchial anastomosis. Patients routinely underwent initial bronchoscopic evaluation before they were taken from the operating room and again immediately before extubation. Routine surveillance bronchoscopies with bronchoalveolar lavage and transbronchial lung biopsies were done at 2 to 3 weeks and 2, 3, 6, and 12 months, and annually thereafter. Bronchoscopy was done on other occasions dictated by clinical parameters such as dyspnea, hypoxemia, decline in pulmonary function test result, radiographic infiltrate, or unexplained fever.
For purposes of this review, an airway complication was defined as a finding of significant dehiscence that necessitated extended chest tube drainage or other surgical intervention or a finding of stenosis or malacia that necessitated dilation, debridement, laser therapy, or stent placement. Partial dehiscence, mucosal necrosis, or slough detected by bronchoscopy was not considered an airway complication when satisfactory healing occurred without further intervention.
Various clinical factors were evaluated to identify predictors of airway complication. Factors evaluated were recipient factors (age, sex, diagnosis, previous preoperative steroid history, current preoperative steroid use), donor factors (age, sex, arterial oxygen tension [Pao 2] at fraction of inspired oxygen [Fi o 2] 100% and 5 cm H2O positive end-expiratory pressure, ischemic time), operative factors (type of transplant, side of transplant, requirement for cardiopulmonary bypass, type of bronchial anastomosis, suture technique, suture material, type of wrapping), and postoperative factors (Pao2 at Fi o 2100%, mean systemic pressure, mean arterial pressure, cardiac output, peak airway pressure: all measured on arrival in the intensive care unit). Other postoperative factors included used of continuous intravenous prostaglandin E1infusion during the first 24 postoperative hours, percentage of allograft perfusion measured by quantitative ventilation-perfusion nuclear scintigraphy within the first 12 postoperative hours, duration of mechanical ventilation, early maintenance steroid use, number of 3-day bolus methylprednisolone course given as therapy for suspected acute rejection within the first 30 days, total dose of bolus methylprednisolone given within the first 30 days, the first day of bolus methylprednisolone given, type of induction cytolytic therapy, transbronchial biopsy-proven A2 or greater acute rejection within the first 30 days, cytomegalovirus status, and biopsy-proven cytomegalovirus pneumonia within the first 90 days.
The prevalence of airway complications during different stages of our program was evaluated by separating the 229 transplants into three groups: phase I, the first 77 transplants; phase II, the next 76 transplants; and phase III, the most recent 76 transplants. All parameters noted previously were evaluated among the three phases.
Predictors of airway complications were analyzed by multivariate analysis. Significance was sought among three phases with use of a x2 test for onparametric data and analysis of variance and the Tukey honest significant difference multiple comparisons procedure for parametric data. Data are expressed as mean plus or minus 1 standard deviation. Statistical significance was accepted at the 95% confidence level, p < 0.05.
Airway complication
Significant dehiscence affected 15 anastomoses in 12 patients 15.7 ±10.7 days (4 to 38 days) after transplantation. Five patients, including two patients who underwent retransplantation, died of this complication. In another five patients, chest tube or mediastinal tube placement, or both, to achieve complete reexpansion of the lung permitted satisfactory closure of the leak. Although a stricture ultimately developed in one patient, it was successfully managed by subsequent dilation. In one patient, a silicone-rubber stent was placed 26 days after transplantation with a satisfactory result. In one patient, sudden death of unknown cause occurred 3 days after chest tube placement.
Significant stenosis occurred in 18 anastomoses among 17 patients 105.2 ±86.7 days (24 to 385 days) after transplantation. All but one case were successfully managed by conservative therapy such as one or a combination of dilation (17 patients), stent (11 patients), and laser (4 patients). One bilateral lung recipient had complete obstruction of the bronchus intermedius, which could not be adequately treated.
In summary, airway complications that necessitated clinical intervention occurred in 29 patients (12.8%) and 33 anastomoses (9.5%). Conservative therapy resulted in excellent improvement in 22 patients. There were five deaths (2.2%) attributable to airway complications.
Evaluation of clinical factors
Various clinical factors were evaluated by comparing the cases of the 315 anastomoses that healed without complication (group I) with the cases of the 33 anastomoses that necessitated clinical intervention (group II).
Recipient factors (Table I) and donor factors (Table II) were not significantly different between the two groups.
Table IRecipient preoperative factors
Group I: no complication (n = 315)
Group II: complication (n = 33)
p Value
Age (yr) 42.8 ± 11.7 44.6 ± 12.1 NS
Sex NS
Male 157 (49.8) 15 (45.5)
Female 158 (50.2) 18 (54.5)
Diagnosis NS
Obstructive 176 (55.9) 19 (57.6)
Restrictive 27 (8.6) 4 (12.1)
Septic 72 (22.9) 6 (18.2)
PVD 40 (12.7) 4 (12.1)
Remote steroid history NS
Yes 221 (70.2) 23 (69.7)
Preop. steroid use NS
No 231 (73.3) 21 (63.6)
Values in parentheses indicate percentage. NS, Not significant; PVD, primary pulmonary hypertension, Eisenmenger's syndrome.
Table IIDonor factors
Female 94 (29.8) 6 (18.2)
Pao 2 (mmHg) 470 ± 80 494 ± 63 NS
Ischemic time(min) 314 ± 93 291 ± 102 NS
Values in parentheses indicate percentage. Pao 2 was measured with Fi o 2 100, 5 cm H2O positive end-expiratory pressure. NS, Not significant.
Data from analysis of operative factors are shown in Table III. Anastomotic complications occurred more often in SLT than in BLT (16/110, 14.4%, versus 17/238, 7.1%; p< 0.05). Mattress suture (21/153, 13.7%) was associated with more frequent complications than was simple interrupted suture (8/122, 6.0%) or figure-of-eight suture (4/73, 5.5%) (p < 0.05). No correlation was found between transplant side, use of cardiopulmonary bypass, anastomosis type (end-to-end versus telescope), suture material, or type of wrapping and the subsequent development of an airway complication.
Table IIIOperative factors
Airway complication rate
Operation type < 0.05
SLT 16/110 (14.4)
BLT 17/238 (7.1)
Side NS
Right 17/174 (9.8)
Left 16/174 (9.2)
CPB NS
Yes 12/102 (11.8)
No 21/246 (8.5)
Anastomosis type NS
End-to-end 11/158 (7.0)
Telescope 22/190 (11.6)
Donor into recipient 13/102 (12.8)
Recipient into donor 9/88 (10.2)
Suture technique < 0.05
Simple 8/122 (6.6)
Figure-of-eight 4/73 (5.5)
Mattress 21/153 (13.7)
Suture material NS
PDS polydioxanone 20/243 (8.2)
Vicryl polyglactin910 10/93 (10.8)
Prolene polypropylene 3/12 (25.0)
Wrapping NS
Omentum 10/112 (8.9)
Peribronchial tissue 17/194 (8.8)
Pericardial fat 5/36 (13.9)
Intercostal muscle 0/2 (0.0)
None 1/4 (25.0)
Values in parentheses indicate percentage. NS, Not significant; CPB, cardiopulmonary bypass.
Postoperative factors in the intensive care unit (ICU) are summarized in Table IV. Patients in whom airway complications subsequently developed had required longer postoperative mechanical ventilation than those without airway complications (12.9 ±18.4 days versus 5.5 ±20.5 days, p < 0.01). Among 289 anastomoses subjected to mechanical ventilation for less than 7 days, 22 (7.6%) complications were observed. In contrast, among 59 anastomoses subjected to mechanical ventilation for longer than 7 days, 11 (18.6%) complications were noted (p < 0.01). Pao 2, mean arterial pressure, mean pulmonary artery pressure, cardiac output, and peak airway pressure were not significantly different between the two groups. Use of prostaglandin E1 and the percentage of pulmonary perfusion to the anastomosis side did not correlate with the subsequent development of airway complications.
Table IVPostoperative factors (ICU)
Pao 2 (mmHg) 346 ± 153 317 ± 152 NS
BP (mm Hg) 79.6 ± 11.0 83.9 ± 10.6 NS
PAP (mm Hg) 23.3 ± 6.4 24.5 ± 5.1 NS
CO(L/min) 4.7 ± 1.4 4.7 ± 1.0 NS
PGE1 NS
No 101 (32.1) 8 (24.2)
Perfusion scan (to anastomosis) (%) 58.0 ± 20.5 64.9 ± 17.5 NS
Peak airway pressure (cm H2O) 31.1 ± 5.7 31.2 ± 6.3 NS
Mechanical ventilation (days) 5.5 ± 9.9 12.9 ± 18.4 <0.01
Values in parentheses indicate percentage. PaO 2, arterial pressure, pulmonary artery pressure, cardiac output, and peak airway pressure were measured 1 hour after the patient was admitted to ICU. PaO 2, Arterial oxygen tension with Fi O 2 100%;NS, not significant; BP, mean arterial pressure; PAP, mean pulmonary artery pressure; CO, cardiac output; PGE1, prostaglandin E1.
Other postoperative factors regarding immunosuppression, rejection, and cytomegalovirus infection are shown in Table V. There was no significant difference between the two groups with respect to any of these factors.
Table VPostoperative factors (immunosuppression, rejection, cytomegalovirus)
Postop. steroid use NS
From day 1 173 (54.9) 19 (57.6)
From day 4-7 133 (42.2) 12 (36.4)
From day 21 9 (2.9) 2 (6.1)
Courses of MPD <30 days 1.9 ± 1.0 1.9 ± 1.1 NS
MPD given <30 days (gm) 2.4 ± 1.3 2.6 ± 1.5 NS
First bolus MPD (day) 5.7 ± 4.1 4.6 ± 2.8 NS
Cytolytic therapy NS
ALG 160 (50.8) 18 (54.5)
ATG 128 (40.6) 6 (18.2)
OKT3 5 (1.6) 1 (3.0)
None 22 (7.0) 8 (24.2)
A2 rejection or greater NS
< 30 days*
Yes 105 (34.7) 6 (22.2)
Recipient/donor CMV status NS
N/N 62 (19.7) 5 (15.2)
P/N 68 (21.6) 8 (24.2)
N/P 91 (28.9) 9 (27.3)
P/P 94 (29.8) 11 (33.3)
CMV pneumonia <90 days † NS
*Data obtained from the patients who survived more than 30 days.
†Data obtained from the patients who survived more than 90 days.
Values in parentheses indicate percentage. NS, Not significant; MPD, methylprednisolone (Upjohn); ALG, antilymphocyte globulin; ATG, antithymocyte globulin (Upjohn); OKT3, monoclonal antibody to the CD3 receptor on lymphocytes (Ortho Pharmaceutical Corp., Raritan, N.J.); CMV, cytomegalovirus; N, negative; P, positive.
Prevalence of airway complications with evolution of transplant program
The prevalence of airway complications in different phases of our series is summarized in Table VI. The airway complication rate was significantly reduced to 4.0% in phase III from 10.9% in phase I and 14.3% in phase II.
Table VIChronologic prevalence of airway complications
PhaseIII
Period 1988.5-1991.7 1991.8-1993.3 1993.4-1994.8
No. of transplants 77 76 76
Single/bilateral 42/35 40/36 28/48*
No. of anastomoses 110 112 126
Airway complication 12/110 (10.9) 16/112 (14.3) 5/126 (4.0)†
*p < 0.05 (versus phase I).
†p < 0.05 (versus phase I), p < 0.01 (versus phase II).
Values in parentheses indicate percentage.
We speculated that this recent decrease in airway complications might be a result of various changes in technical and clinical management practices over time. We therefore reevaluated all the clinical factors listed in Table I, Table V. Factors that changed significantly among the three phases are shown in Table VII. All other factors were not significantly different among the three phases.
Table VIIChronologic change of clinical factors
I vs. II
I vs. III
II vs. III
Preop. steroid use <0.001 <0.001 NS
Yes 6 (7.8) 22 (28.9) 32 (42.1)
No 71 (92.2) 54 (71.1) 44 (57.9)
Anastomosis type* <0.001 <0.001 NS
End-to-end 92 (83.6) 25 (22.3) 41 (32.5)
Telescope 18 (16.4) 87 (77.7) 85 (67.5)
Suture technique* <0.001 <0.001 NS
Simple 88 (80.0) 18 (16.1) 16 (12.7)
Figure-of-eight 18 (16.4) 22 (19.6) 33 (26.2)
Mattress 4 (3.6) 72 (64.3) 77 (61.1)
Suture material* <0.001 <0.001 NS
PDS polydioxanone 33 (30.0) 94 (83.9) 116 (92.1)
Vicryl polyglactin 910 72 (65.5) 11 (9.8) 10 (7.9)
Prolene polypropylene 5 (4.5) 7 (6.3) 0 (0.0)
Wrapping* <0.001 <0.001 <0.001
Omentum 98 (89.1) 14 (12.5) 0 (0.0)
Peribronchial 0 (0.0) 77 (6.9) 117 (92.9)
Pericardial fat 8 (7.3) 20 (17.9) 8 (6.3)
Intercostal muscle 2 (1.8) 0 (0.0) 0 (0.0)
None 2 (1.8) 1 (0.9) 1 (0.8)
PGE1 <0.001 <0.001 NS
Yes 30 (39.0) 69 (90.8) 68 (89.5)
No 47 (61.0) 7 (9.2) 8 (10.5)
Postop. steroid use <0.001 <0.001 <0.001
From day 1 3 (3.9) 48 (63.2) 68 (89.5)
From day 4-7 63 (81.8) 28 (36.8) 8 (10.5)
From day 21 11 (14.3) 0 (0.0) 0 (0.0)
Courses of MPD (<30days) 2.2 ± 0.9 2.4 ± 0.9 1.5 ± 0.9 NS <0.001 <0.001
MPD given <30 days(gm) 2.7 ± 1.1 2.9 ± 1.3 1.9 ± 1.3 NS <0.005 <0.001
First bolus MPD (day) 3.9 ± 2.1 4.3 ± 2.1 8.3 ± 5.2 NS <0.001 <0.001
Cytolytic therapy <0.001 <0.001 <0.001
ALG 69 (89.6) 53 (69.7) 0 (0.0)
ATG 0 (0.0) 9 (11.8) 74 (97.4)
OKT3 6 (7.8) 0 (0.0) 0 (0.0)
None 2 (2.6) 14 (18.4) 2 (2.6)
A2 rejection or greater <30 days NS <0.001 <0.05
*Data were obtained per anastomosis. All the other data were obtained per transplant.
Values in parentheses indicate percentage. NS, Not significant; PGE1, prostaglandin E1; MPD, methylprednisolone; ALG, antilymphocyte globulin; ATG, antithymocyte globulin; OKT3 monoclonal antibody to the CD3 receptor on lymphocytes.
Significant technical change occurred between phase I and phase II. In phase I, the standard technique was an end-to-end anastomosis with simple interrupted 4-0 Vicryl polyglactin 910 sutures followed by bronchial omentopexy. In phase II, a telescoping anastomosis with modified mattress 4-0 PDS polydioxanone sutures followed by wrapping with peribronchial nodal tissue was commonly used. No significant technical change was made between phase II and phase III except that omentopexy was completely abandoned in phase III. Preoperative steroid use and postoperative prostaglandin E1 infusion were significantly increased in phase II compared with their use in phase I. However, there was no difference between phase II and phase III.
Postoperative immunosuppression and rejection monitoring were changed significantly between phase II and phase III. Low-dose corticosteroid administration from day 1 along with induction cytolytic therapy with antithymocyte globulin was routinely used in phase III. Rejection therapy by bolus injection of methylprednisolone was mainly based on histologic (transbronchial lung biopsy) evidence rather than empiric clinical diagnosis (such as fever, cough, shortness of breath, decrease of Pao 2) in phase III. As a result, course of methylprednisolone and total dose of methylprednisolone given within 30 days were significantly decreased and the first bolus methylprednisolone dose was significantly delayed in phase III compared with that in phases I and II. Biopsy-proven A2 or greater rejection within the first 30 days was documented in more recipients in phase III than in phases I and II. This is because of the increase in biopsy procedures in phase III. The number of early transbronchial lung biopsies done was 67 in phase I, 104 in phase II, and 151 in phase III. The prevalence of A1 or greater rejection per biopsy procedure was unchanged among the three phases.
Historically, poor bronchial healing was a major problem after lung transplantation.
Without reconnection of the bronchial arterial circulation, airway viability is exclusively dependent on vascular supply by retrograde collateral flow from pulmonary to bronchial circulation. On the basis of favorable results from a number of laboratory investigations,
Lima O
Peters WJ
Effects of methylprednisolone and azathioprine on bronchial healing following lung autotransplantation.
J THORAC CARDIOVASC SURG. 1982; 83: 418-421
Morgan E
Goldberg M
Ayabe H
Ferdman A
Improved bronchial healing in canine left lung reimplantation using omental pedicle wrap.
A comparison between cyclosporin A and methylprednisolone plus azathioprine on bronchial healing following canine lung autotransplantation.
routine use of bronchial anastomotic omentopexy and avoidance of high-dose perioperative corticosteroids were thought to be key strategies for the first successful series of human lung transplants.
Toronto Lung Transplant Group
Unilateral lung transplantation for pulmonary fibrosis.
N Engl J Med. 1986; 314: 1140-1145
However, recent studies have demonstrated that omentopexy is no longer essential and that modest early doses of postoperative corticosteroids do not impair airway healing.
Shafers HJ
Haverich A
Wagner TOF
Wahlers T
Alken A
Borst HG
Decreased incidence of bronchial complications following lung transplantation.
Eur J Cardiothorac Surg. 1992; 6: 174-179
Miller JD
DeHoyos A
for the University of Toronto
Washington University Lung Transplant Programs
An evaluation of the role of omentopexy and of early perioperative corticosteroid administration in clinical lung transplantation.
Inui K
Schafers HJ
Aoki M
Bronchial circulation after experimental lung transplantation: the effect of long-term administration of prednisone.
Alternative techniquessuch as telescoping anastomosis
and direct bronchial revascularization
Daly RC
Tadjkarimi S
Khaghani A
Banner NR
Yacoub MH
Successful double lung transplantation with direct bronchial artery revascularization.
Couraud L
Baudet E
Martigne C
Bronchial revascularization in double lung transplantation: a series of 8 patients.
Ann Thorac Surg. 1992; 53: 88-94
McGregor CGA
Routine immediate direct bronchial artery revascularization for single-lung transplantation.
have been reported with low rates of airway complication.
The ideal techniques of bronchial anastomosis and perioperative and postoperative treatment of transplant recipients are controversial and vary from one center to another. However, results appear similar even when different techniques are used. We have previously reported no difference in the prevalence of bronchial anastomotic complications from a concurrent series of patients who underwent transplantation at Washington University and the University of Toronto.
Patients who underwent transplantation at the University of Toronto had mattressed anastomoses wrapped with local nodal tissue and received routine perioperative steroids. Patients who underwent transplantation at Washington University had end-to-end anastomoses wrapped in a pedicled flap omentum and did not receive routine early perioperative corticosteroids.
Having a large number of airway anastomoses for analysis, we were provided with an opportunity to review each of these factors in our own group of patients. The technique of bronchial anastomosis is undoubtedly important. Our experience did not show a significant difference in the airway complication rate between end-to-end and telescoped anastomoses. It should also be noted that there was no difference whether the donor or recipient bronchus was intussuscepted. However, in this series the modified mattress suture used for a telescoping anastomosis was associated with a significantly greater rate of complications (13.7%). Griffith and associated
has reported a similar complication rate (12%) with use of this technique. When figure-of-eight suture was used for a telescoping anastomosis, the prevalence of airway complication was only 3.1%. A modified mattress suture technique more readily achieves the desired intussusception and it avoids the potential creation of an obstructing flange of invaginated cartilage (Fig. 1).
Fig. 1A, Modified mattress suture. This technique holds rings of smaller airway to mucosal surface of larger airway to avoid potential for obstruction of flange of invaginated cartilage. However, no strength is given between two overlapped cartilages. B, Figure-of-eight suture. Firm strength is given between two overlapped cartilages although it is more difficult to achieve telescoping.
However, no strength is given between the overlapped cartilages. On the other hand, figure-of-eight suture gives firm strength between the overlapped cartilages although it is somewhat more difficult to achieve complete telescoping. Our current policy is as follows. When the bronchial size is equivalent, we use end-to-end anastomosis either by simple interrupted or figure-of-eight sutures. For a small left bronchial anastomosis, we recommend simple interrupted suture. When the discrepancy in bronchial size is obvious, we use a telescoping technique either by figure-of-eight sutures when it is easy to achieve an intussusception or by a modified mattress suture technique when it is somewhat more difficult to achieve a telescoped result.
There was no difference in the airway complication rate among the types of bronchial wrapping. A prospective randomized study recently reported by Khaghani and colleagues
Al-Kattan K
Wrapping the anastomosis with omentum or an internal mammary artery pedicle does not improve bronchial healing after single lung transplantation: results of a randomized clinical trial.
J Heart Lung Transplant. 1994; 13: 767-773
has demonstrated that the prevalence of bronchial anastomotic complications after SLT is not affected by wrapping the anastomosis with either omentum or an internal mammary artery pedicle. Our current standard is wrapping the anastomosis with peribronchial nodal tissue because this is easy to achieve and eliminates any direct contact between the bronchial and pulmonary artery anastomosis.
It is interesting that none of the preoperative recipient factors evaluated was a predictor of airway complication. Although high-dose preoperative corticosteroid therapy may compromise bronchial healing, in our experience modest doses of preoperative prednisone do not affect airway integrity. Of note was that preoperative steroid use did not compromise airway integrity. This is the same conclusion that the San Antonio group has previously reported.
Postoperative low-dose corticosteroid administration also did not increase airway complications, which confirms previous reports from the San Antonio
and Hannover
groups.
It is interesting that airway complications were more commonly observed in SLT recipients. With two bronchial anastomoses, BLT has a twofold risk of airway complication compared with SLT. Furthermore, the transplanted lung receives more pulmonary artery perfusion than the native lung in SLT, whereas both lungs are equally perfused in BLT. Yet we have previously reported that patients receiving SLT because of pulmonary fibrosis and primary pulmonary hypertension have a longer requirement for mechanical ventilation as a result of allograft dysfunction.
Davis Jr, RD
Manley J
Differences in early results after single-lung transplantation.
This may compromise collateral bronchial flow in these allografts in comparison with that in bilateral grafts in which allograft dysfunction is less commonly encountered. This may explain why SLT bronchial anastomoses were complicated more commonly than BLT anastomoses (14.4% versus 7.1%). The relationship between allograft dysfunction and airway complications is further suggested by the fact that airway complications were much less commonly encountered in patients who received ventilator support for fewer than 7 days (7.6%) in comparison with patients who received ventilator support longer than 7 days (18.6%). We do not believe that mechanical ventilation in and of itself predisposes to an increased prevalence of airway complications. Indeed, Yokomise and colleagues
Yokomise H
Cardoso PFG
Kato H
The effect of pulmonary arterial flow and positive end-expiratory pressure on retrograde bronchial mucosal blood flow.
have previously demonstrated that positive end-expiratory pressure augments retrograde collateral bronchial mucosal flow.
We acknowledge that this explanation for the differences in airway complications between SLT and BLT is speculative and impossible to confirm in this retrospective review. A more practical explanation is also available. It is possible that the bias of our transplant program directors was to treat airway problems in SLT recipients more aggressively than the same problems in BLT recipients. Although this may be true, the fact remains that clinically significant airway complications occurred more frequently in SLT than BLT recipients.
We observed a significant reduction in the airway complication rate to 4% during phase III. Major technical changes evolved between phase I and phase II but not between phase II and phase III as already described. Postoperative immunosuppression and rejection monitoring changed significantly between phase II and phase III. In phase III, low-dose corticosteroid administration from day 1 along with induction cytolytic therapy with antithymocyte globulin was routinely used and rejection therapy by bolus injection of methylprednisolone was mainly based on histologic rather than clinical diagnosis. These observations suggest that the recent improvement in airway healing is likely a result of better maintenance immunosuppression and rejection surveillance. Fujimura and associates
Fujimura S
Kondo T
Handa M
Histologic assessment of bronchial anastomotic healing in canine lung transplantation.
have reported that lung allograft rejection is closely connected with wound healing of the bronchial anastomosis in canine lung transplantation. We think it is important to give timely but not excessive methylprednisolone for the treatment of acute rejection because pulmonary-to-bronchial collateral flow would be impaired by infection as well as by rejection.
The Harefield group
and Bordeaux group
have both reported successful bronchial artery revascularization for en bloc double-lung transplantation with tracheal anastomosis. Although we do not dispute the value of revascularization in that procedure, we remain unconvinced regarding its benefit in patients undergoing SLT and indeed BLT. Daly and McGregor
from the Mayo Clinic have reported a small series of patients who underwent revascularization as part of a SLT procedure. We believe that this represents an additional technical challenge that is not necessary in the vast majority of patients and completely impractical in patients undergoing BLT. We await with interest the long-term follow-up results in these patients to determine whether such revascularization will have any impact on the ultimate development of bronchiolitis obliterans syndrome, as has been proposed.
Indeed, in the most recent 100 successive transplants conducted at our center, we have had only one death attributable to airway dehiscence. We believe that increasing experience, meticulous surgical technique, and rigorous postoperative care have significantly lessened the prevalence of airway complication after pulmonary transplantation.
We acknowledge the assistance of Mary Ann Kelly in preparation of the manuscript and statistical advice from Richard B. Schuessler, PhD.
Dr. Walter Klepetko. (Vienna, Austria).
This paper summarizes the current status of a long and outstanding surgical development, which has brought the problem of bronchial anastomosis down from being the most crucial one in lung transplantation to the reported remarkable figure of 4%. We all have to be indebted to the author's group and especially to Dr. Cooper and Dr. Patterson for their continuous work in the field.
It is fascinating to observe how the importance of several factors that were believed to be so crucial in the early period has changed. Lung transplantation without omental wrapping was considered previously to be simply impossible. Nowadays this technique is hardly used anymore. In addition, the former assumption that early postoperative use of steroids could severely compromise bronchial healing has been changed into the beneficial concept of immediate postoperative application of steroids quite uniformly.
This paper nicely demonstrates that healing of the airway depends on two major factors. Correct surgical technique is one of them. It is obviously less important which particular technique, end-to-end or telescope, is applied, as long as the surgeon has become experienced and familiar with it. It is also pointed out that not every technique should be applied in every anatomic situation. For instance, the telescoping technique in the presence of very small airways seems to be a poor option. On the other hand, adequate bronchial microcirculation plays a major role in prevention of bronchial problems and depends on a multitude of factors. This is shown nicely in this study by the fact that prolonged ventilation was associated with a higher prevalence of problems. Perioperative management, therefore, becomes crucial for microcirculation, and not the least important factor is efficient prevention, diagnosis, and treatment of rejection.
In our own experience of about 120 lung transplantations, the worst case of severe impairment of microcirculation occurred in a patient after BLT. At bronchoscopy, severe, almost complete, ischemia was present as far down as to the segmental bronchial orifices of the lower lobes. Despite the severity of the situation, we were able to treat the patient successfully with Y-shaped silicone stents extending into the upper lower lobe carina on the left and down the intermediate bronchus on the right side. After 6 months one stent was lost and the patient underwent successful retransplantation. The patient is still alive 4 years after that procedure.
In light of these considerations, I would like to ask the authors three questions. First, could they give us more details about their postoperative regimen of heparinization and prostaglandin E1administration? Second, the authors mentioned in the manuscript that they are now accepting moderate doses of preoperative steroids. I would like to ask what they understand concerning the moderate dose and what the highest dose of steroids was that they ever accepted. Finally I would like to address a question to Alec Patterson. Looking back at the more than 10-year period during which the technique of bronchial anastomosis has significantly developed, what, in your opinion, was the initial benefit of omental wrapping? Was it simply a mechanical effect that prevented catastrophe or was it truly beneficial for the bronchial microcirculation?
In the early several cases we used low-dose heparin systemically, but in the rest of the cases we used low-dose heparin, 5000 units every 12 hours, subcutaneously, to prevent thrombotic complications after the operation. We currently use prostaglandin E1routinely, unless significant hypotension becomes a problem.
Concerning preoperative use of steroids, we currently accept up to 20 mg prednisone daily. On occasion patients require acute augmentation of steroid therapy because of an exacerbation of the underlying disease. We still accept these patients, expecting that they are at increased risk of poor bronchial healing.
Dr. Alec G. Patterson (St. Louis, Mo.).
I would like to initially congratulate Dr. Date for a great presentation and Dr. Klepetko for his kind remarks. For those of you who do not know, Dr. Klepetko has developed and now directs one of the most successful lung transplant programs in Europe.
I do not know precisely what the benefit of omental wrapping was in those early days, although I think it had two important benefits. First, it revascularized the ischemic bronchus. Dr. Joel Cooper showed that nicely in a series of canine experiments years ago. I also think that it provided security and protection from mediastinal sepsis in those few patients who did have some bronchial dehiscence. In those days the preservation that we used was terrible. We purposely made the donor lung atelectatic, heparinized the donor, removed the lung without the use of any flushing solution, kept it immersed in cold saline solution, and then placed it in the recipient while making no attempt to keep it cold during the suturing. Given that, it is remarkable to me that any of those transplants worked, and it is no surprise that the donor pulmonary-to-bronchial collateral circulation was deficient in some of those cases.
Dr. Hans-Joachim Schäfers (Hannover, Germany).
The current prevalence of airway complications, in the range of 4%, certainly indicates that one of the major arguments of isolated lung transplantation versus heart-lung and domino transplantation is now an argument of the past. In a similar time frame, since 1988 up to the beginning of this year, we have in our lung transplant program done a total of 140 isolated lung transplants. We have observed airway complications in 13 of 210 anastomoses at risk, for a prevalence of 6.2%. Initially the prevalence was rather high, which prompted us to institute a protocol directed at improving bronchial microcirculation. This was indicated by experimental data, part of which was presented at the meeting of this Society 3 years ago. The patients were given steroids, heparin, and prostacyclin beginning in the immediate postoperative phase. In addition, as suggested by the San Antonio group, donor and recipient airways were kept short, which allowed us to omit omentopexy. End-to-end anastomosis with simple interrupted sutures has been the main approach, with telescoping of the bronchi used only for size discrepancy.
Following this concept, we have observed a prevalence of airway complications of only 4%, that is, 8 complications in the most recent 198 grafts at risk. We have, interestingly, observed a change in the type of complications. Rather than having ischemia right at the site of the anastomosis, we have had problems limited to the lobar bronchi, especially the intermediate bronchus. If one excludes those isolated lobar complications, the prevalence would only be 2.5%.
In the past 2 years we have used parenchyma-sparing resection for the treatment of stenosis rather than stenting. The results have been excellent in the most recent 4 patients.
My questions to the authors are as follows. Have they had a similar trend of ischemia occurring not so much on the anastomotic site itself but extending especially into the intermediate bronchus? Do they have any experience with resection of bronchial stenosis? Finally, what do they think the reasons are for the higher prevalence of airway complications in SLT?
We have also seen several patients in whom stenotic changes developed within the bronchus intermedius. These have been difficult to treat with conventional silicone-rubber stents. We have also seen malacia with intact mucosa. In these patients we have used a self-expandable metallic stent instead of a silicone-rubber stent and are pleased with the results. We have not used surgical resection to correct bronchial stenosis.
As concerns the reason SLT is associated with more complications than BLT, it is possible that the collateral circulation in the parenchyma of the SLT is not as good as that of the BLT. We have observed that, as a result of allograft dysfunction, the postoperative course of SLT for fibrosis or pulmonary hypertension is more complicated than that for BLT. BLT has theoretically a twofold risk of airway complication; however, if we calculate the airway complication per anastomosis, we find that SLT does have more complications than BLT.
☆From the Division of Cardiothoracic Surgerya and Respiratory and Critical Care Medicine,b Washington University School of Medicine, St. Louis, Mo.
☆☆Read at the Seventy-fifth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass., April 23-26, 1995.
★Address for reprints: G. Alexander Patterson, MD Division of Cardiothoracic Surgery, Washington University School of Medicine, One Barnes Hospital Plaza, Suite 3108 Queeny Tower, St. Louis, MO 63110.
★★0022-5223/95 $5.00 +0
♢12/6/67385
DOI: https://doi.org/10.1016/S0022-5223(95)70065-X
© 1995 Mosby, Inc. Published by Elsevier Inc. All rights reserved.


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Can your employees follow all the procedures, wear all the personal protective equipment (PPE), obey all the rules and still get injured? Of course. This is why effective leaders identify the need to influence employees to do more than what is required.
Companies expect adherence to rules, policies and procedures. If the employee doesn't comply, it is, unfortunately, common to administer disciplinary measures. Discipline, however, rarely motivates an individual to want to do more.
What is the average level of performance you receive from your employees on a scale of one to 10? Ten represents a superstar performer who always goes above and beyond. Five represents someone who does the minimum necessary (i.e., behavior expected to remain employed). A one is someone who isn't even showing up for work. What would you rank the average level of performance in your work group, team or company?
Certainly there are some who might fall below expectations and there are those who have the internal drive to do more. But what works to motivate one person's discretionary effort is not guaranteed to positively influence another. Incentives often backfire and rewards are hardly frequent or appealing enough. Motivation isn't that simple.
1. What do you want the person to do? This needs to be defined in behavioral terms, not results. Rather than suggesting someone to "be safe," what precisely do they need to do to be safe? Similarly, if you want an engaged work force culture, what would you see them do or hear them say that suggests they are engaged?
4. What happens if they don't do what you would like them to do? Negative consequences are designed to stop specific behavior, not start it. Sure, negative consequences may prompt behavior, but not always the desired ones. Punishing employees for not wearing their required PPE doesn't guarantee they will comply. The behavioral change might result in the punished employee keeping a lookout for the enforcer, rather than always wearing the PPE.
Policing safety has proven to be a less-than-perfect method of improving injury performance and often promotes under-reporting. Becoming an effective coach with answers to these important questions can leverage a manager's or supervisor's influence to make significant gains in both injury reduction and the safety aspect of company culture. Coaching skills improve all areas of performance, not just safety but also quality and productivity. The benefits to the organization impact almost every area of human performance and are one of the most effective tools to move the culture from have-to to want-to thinking.