Thank you, Mark, for taking a chance on me, and seeing something within me that I often cannot see within myself.

This the before shot. Here's the after.

El día de hoy enviamos a nuestro case manager los documentos de la revalida profesional, básicamente fueron tres cartas de tipo referencia laboral, pero no como las que estamos acostumbrados aquí en Venezuela, para el caso de Australia las cartas deben seguir un patrón específico que VEA facilita el cual contiene una breve descripción de la empresa, la lista de actividades de forma detallada que se realiza dentro de ella  y en nuestro caso por ser del área informática, los software y hardwares manejados, en este aspecto amigos debemos armarnos de paciencia y ser un poco negociantes:

PACIENCIA: Por lo general cuando comienzas a elaborar las cartas de tus empleadores VEA te proporciona un formato o Pattern y usted debe comenzar a redactarla con los conocimientos de ingles que tenga, en este caso les recomendamos buscar lo siguiente: Modelos de carta de recomendación  y su equivalente de perfil de cargo, ambos en ingles (Gracias San Google), apelar a sus conocimientos de ingles y ayudarse con algún software de traducción como global link o power translator, haciendo un mix de estas cosas obtendrán su primera versión, no se preocupen si VEA se las devuelve con muchas correcciones, por lo general la primera no es la vencida, ni la segunda, ni la tercera, ni la cuarta, pero llega el momento en que de tanto corregir todos los errores desaparecen, esto es importante sobre todo cuando una palabra mal puesta puede costar la revalida; Ahhh un punto importante si conocen algún nativo o anglo parlante pídanle ayuda, es sumamente útil lastima que nosotros lo descubrimos después de mucha roncha.

Cuando ya tengan las versiones definitiva es cuando llega el momento de volverse UN POCO NEGOCIANTE, ya que por lo general al momento de ir al empleador y decirles yo quiero una referencia laboral pero que diga “ESTO” enseñándole los modelos aprobados por VEA puede que tu ex jefe se ponga suspicaz y justo en ese momento recuerdes porque C?ñ? te fuiste de allí, adicionalmente si no saben mucho de ingles miraran la carta como gallina mirando Sal, a uno de nuestros empleadores debimos entregarle la carta en ingles y su equivalente en español, el otro nos mandaba a cambiarla porque no le parecía la forma como estaba estructurada, ojo el contenido estaba bien pero simplemente no le parecía la estructura,…….. Pero DIOSSSS el carajo no entendía que eran REQUERIMIENTOS y eso que trabaja en el área de SISTEMAS y no entendía el concepto de REQUERIMIENTO, bueno en la villa del señor de todo se ve, ahora el tercer empleador no tuvo problemas ni con la estructura ni con el contenido, solo la tomo la leyó nos pidió que se la dejáramos un día para analizarla y listo! las firmo, en el caso de los otros dos (2) luego de llamadas, persecuciones, rezos, meditación, yoga, vudú y unos velones encendidos a maría lionza ….. Tuvimos la dicha de ver sus firmas en las cartas, al empleador actual no le solicitamos nada, ya que nuestro case manager nos indico que con los tres (3) empleadores anteriores era suficiente, además no sabemos que consecuencia podría traer a nivel de ambiente laboral que en la empresa se entere que uno de sus empleados esta levantando vuelo pa´ otro lado, eso se sentiría como un pre aviso pero sumamente largo…………… L

Lo cierto amigos es que entre el lleva y trae de VEA y la cacería  de los empleadores se nos fueron casi cuatro (4) meses y es así como llegamos al lunes 29 de septiembre de 2008 fecha en la que por fin mandamos las cartas, pero si creían que todo quedaba allí……….!!!! Pues NO, ;-) ahora comienza el COMPAS DE ESPERA un desesperante periodos de entre uno (1) y dos (2) meses en el cual el instituto correspondiente, en nuestro caso la ACS (Australian Computer Society)  efectúa la revalida, DIOSSSSSSS es desesperante y eso que solo llevamos un día de espera, afortunadamente todos los BLOG y artículos que hemos leído nos augura una importante oportunidad de ser aprobados, pero preferimos ver el papelito con el OK o lo que sea que dé la ACS para indicar que acepta la revalida, esperamos que no pase tanto tiempo y dentro de poco escribirles dándoles la buena nueva. Hasta una próxima oportunidad.

I admit it freely: the Airborne Company is my absolute favorite subfaction in COH. They're cool, they've got planes, guns, bombs and bitchin' recoilless rifles -- plus the ability to drop troops and AT anywhere on the map. Right behind Airborne on my list is Luftwaffe, which is pretty much Axis airborne. I mean, how badass are Fallschirmjagers? And who doesn't love the sight of Butterfly Bombs twirling gracefully to earth like leaves on a gentle autumnal wind? To say nothing of the sight of a Henkel circling the map, relentlessly pounding Allied armor.

Instead, in this week's expert Battle Report, the bold young SgtMorelloo picks Tank Hunters against the legendary Sepha, which is a pity because Sepha goes ALL infantry. Still, this is an excellent albeit blobby match -- and Morelloo gets credit for opening with a mildly effective Scout Car spam tactic.

The game begins with Sepha in the north and he opens with the standard 4 Rifle squads. Notice how he caps the high munitions point by his base -- spreading the squad very close to the civilian building so he can claim it first if a G43 Panzer Grenadier should rush his men. I'll be keeping a close eye on little stuff like this throughout the match; these are things you should try to incorporate into your game as matters of habit.

Would you like to know more? Of course you would! Click to read on.

Now the match develops with Morelloo's PGs and Scout Cars herding Sepha's Riflemen northward; however Sepha keeps his Rifles grouped closely together and the mass charge is too much for PGs, even in green cover. NOTE: Herein lies the weakness of Scout Car spam -- it means less G43 PGs, which in great enough numbers would have severely punished any such mass charge. Not discouraged by this setback, Morelloo attacks again en masse and forces Sepha to retreat. Knowing that the next few minutes of the game will cost him many Rifle casualties, Sepha chooses to build a Medic Tent right by the opening of his base -- a classic position on Langres. The hedgerow protects the tent from most enemy fire, while the exposed portion is small enough to be easily defended by any Riflemen at hand.

There's a few exchanges between Rifles and PGs/Scout Cars, followed by a massed Rifle charge from Sepha when the Scout Cars are being repaired. These skirmishes really show that Scout Cars simply offer too little firepower against massed Riflemen. The manpower is better spent on tough PGs that can take advantage of cover. I can see a case being made for multiple Scout Cars harrassing lone Rifle squads while they cap, but this never happened in this game. Why? Sepha kept his Riflemen together.

By now it's a solid 7 minutes into the game and Morelloo's first Armored Car hits the field. Unfortunately by this point Sepha has the CPs for Paratroopers and is floating more than 200 MUN. Sepha also teched to BARs, an excellent choice with so many Rifles on the field. BARs kill Scout Cars fast and do a number on ACs as well. They also help balance long-range firefights between G43 PGs and Riflemen who both have cover. You see just one such a firefight here, as the first AC moves to flank Sepha's position. Unfortunately massed BAR fire from units in cover prevent the AC from doing any meaningful damage before taking too many hits itself.

There's a few more skirmishes but the action continues to shift towards Morello's half of the map. One thing that caught my eye was a situation where two Rifle squads were garrisoned inside a building that gets rushed by 4 vetted G43/MP44 PG squads. Sepha quickly orders them to exit from the side of the building AWAY from the PG death blob, then retreats them. A more careless player might just order them to pop out and wind up with two Rifle squads in the midst of a buzzsaw of gunfire -- this is how easily whole squads die in COH if you're not concentrating.

Ultimately we know how a game between BAR Rifles/Paratroopers and G43/MP44 PGs will go. As good and versatile as American infantry is, getting hit by G43 Volley Fire and slowed, then surrounded by MP44 troops, is incredibly frustrating. Sepha loses multiple vetted Paratrooper squads this way, and Morello starts a nice recoilless rifle collection out of the remains.

Check out this charge by mixed-veterancy MP44 PGs against mixed-veterancy BAR Rifles in yellow cover. Despite the extra rounds the Rifles squeeze off with their longer range, the MP44s are just too lethal up close.

Sepha retreats again, but he maintains a clear upper hand in terms of manpower. The free Rifle squads reformed from the Medic Tent help immensely, and at one point a vetted G43 PG refuses to retreat -- very bad luck for Morelloo. Sepha offsets his heavy manpower upkeep with Supply Yard upgrades, which, by the way, make a clear impact in this match. This is how the game is decided; there's no clear turning point, Morello is just pushed back into his base repeatedly due to waves of Riflemen and several very painful Strafing Runs, which cost 5-7 PGs apiece.

By the time Morelloo's Jagdpanther comes out, the fighting is literally on his doorstep. Morelloo's puzzling choice of doctrine is probably what did him in. A Jagdpanther is practically worthless against massed BAR Rifles and can be eliminated in short order by a combination of Sticky Bomb/Paratroopers/57mm AT guns.

One point of amusement -- about 60% of the way through this match, Sepha's AT gun crew walks over a Teller mine and is insta-gibbed. Good stuff.

(Click screenshot at left to enlarge) One final point I wish to draw your attention to. Sepha, like all good players and all good real-life tactical leaders, can quickly study terrain and place his troops in a way to tackle all comers. Just check out this shot, in which Sepha rapidly fortifies a position to counter infantry and Morelloo's Jagdpanther. Any vehicle hit by the mine is within the AT gun's cone of fire. A Rifle squad garrisons a key building to prevent flanking, and can exit the building quickly to support the MG or throw a Sticky Bomb. The AT gun is back far enough to shift firing arcs if needed. Nice.

Seph (aka Sepha)
PROS:
- Good distribution of force in the early game (massing Rifles) saves him from being overrun by PGs and Scout Cars
- Good counter to ACs with BAR Rifles + Paratroopers with Recoilless Rifles
- Good Medic Tent placement yields 3 free Rifle squads
- Two superbly aimed Strafing Runs inflict heavy damage, one even kills a Scout Car
- Good situational awareness throughout the game

CONS:
- Kept retreating Paratroopers too late, resulting in loss of entire vetted squads and their expensive upgraded weapons

SgtMorelloo
PROS:
- Good situational awareness and unit preservation throughout the game
- Good use of focus fire and G43 Volley Fire to eliminate valuable enemy squads
- Good placement of Teller mines, but no M8s ever materialized to make them truly worthwhile

CONS:
- Scout Car spam yields mediocre results; helps keep Sepha on defensive early on, but can't seal the deal
- Scout Cars were not often used to capture territory or to OP high resource sectors
- Picked totally wrong doctrine given opponent's unit mix, which became apparent 30% of the way into the match
- Even going down the left side of the tree would've yielded Hetzers, which kill infantry far better than a Jagdpanther, and come much earlier

Conclusion:
SgtMorelloo's baffling doctrine choice was his biggest mistake. Luftwaffe probably would've been ideal, with Fallschirmjagers and FG42s and high-damage ambush giving the perfect anti-infantry boost. Butterfly Bombs would've restricted enemy movement. Early on, spending the 1st CP in Luftwaffe Ground Forces would've kept Scout Cars and ACs fully repaired most of the time, while freeing PGs for offensive action.

Sepha plays a solid infantry-heavy game and makes the unusual choice of dropping many Paratrooper squads, increasing his upkeep. He manages to make it work and takes full advantage of the Supply Yard upgrades. Nothing special here, except his nearly error-free play and the smart, intuitive tactics he employs at every turn. Not especially innovative, but impressive in its consistency.

Mechanism of no reflow.

Coronary  microvascualr plugging  is mainl  due to thrombus and atheromatous debri , myocardial  edema , microvascualr spasm may also contribute.

Where can it occur ?

• First described in cath lab, especially following primary angioplasty.
• It can very  well happen following thrombolysis in STEMI.

• Can occur in venous grafts.

How do you recognise no reflow?

In cath lab it will be self evident from the check angiogram. Some times it is less obvious and may  require, myocardail blush score, TIMI frame  count, contrast echocardiography, PET scan etc. In post MI a very simple method to recognise this entity could be the observation of persistent ST elevation in ECG .

Treatment.

                                 Extremely difficult. Almost every coronary vasodilator has been tried.(Nitrates, nicorandil, calcium blockers, etc).Success is less than 10%.  High pressure flushing with saline inside the coronary artery is advocated by some.Others believe it's dangerous to do it. So prevention is the key. Avoid doing PCI in complex, thrombotic lesions. Use thrombus suction device like export catheter(Medtronic). Distal protective devices are double edged devices , useful only in experienced hands.

 Unanswered question

What is the size of the particle (thrombotic and atheromatous  debri)  the   coronary microcirculation safely handle and push it into the coronary venous circulation and the coronary sinus for disposal ?

 If we can lyse the thrombus into micro particles by some mechanism and make it traverse the coronary circulation this complication of microvascuar plugging can be treated and prevented .

What is the final message ?

• No reflow is relatively common condition during emergency PCI done for ACS patients
• More common in complex thrombotic lesions.
• Can also  occur in STEMI
• Treatment is often vexing . In fact the treatment of this condition is so difficult , it can be termed  almost synonymously with "Failed PCI"
• Prevention is the key

• Thrombolysis is the specific treatment for acute myocardial infarction. ( Privileged few , get primary PCI))
• Failed thrombolysis occurs in significant number of patients ( 30-40%).
• Persistent ST elevation  120 minutes after thrombolysis is best indicator of failed thrombolysis.
• It has been a consistent observation  failed  thromolysis almost always occur in anterior or LAD myocardial infarction. 

In a simple study we have documented  patients  with inferior MI  rarely had persistent ST elevation and thrombolysis  has been  almost always successful ( Except in few patients associated lateral MI)

The mechanism of better thrombolysis in right coronary artery  is simple.The success of thrombolysis , apart from early time window , is directly correlated with pressure head  and the duration of contact between the thrombolytic agent and the thrombus. In right coronary circulation the  blood flow is continuous ,  occurs  both in systole and diastole that facilitates the maximum delivery of the thrombolytic agent . Further there is a favorable  pressure gradient  across RV myocardium  as the transmural occluding pressure across RV is considerably less then LV myocardium. 

This paper was presented in the  "Annual cardiological society of India scientific sessions"

at Chennai, Tamil Nadu.India December 2000

Click to down load PPT full presentation

                                    Ventricles are not made up off entirely myocytes. Apart from myocytes it contains specialised  purkinje cells , fibrocytes, interstitial cells and  some times primitive mesenchymal cells. Ventricular tachycardia can arise either in purkinje cells, the myocytes  or even the fibrocytes. The myocyte  VT  classically occur during ACS or post infarct VTs.They are  more often hemodynamically unstable and quickly degenerate into ventricular fibrillation. Myocardial VT is likely to be pulseless and require DC cardiversion frequently. Purkinje VTs are relatively less unstable. If VT arise proximally in the septum near the distal his, or in bundle branches (BBR) the VT is more stable.They  are likely to respond to be medical management.

What is the therapeutic implication of knowing  myocardial VT ?

                               In fact  ,simply knowing the cell of origin of VT is not suffice .The ionic currents inside the cell that trigger and sustain the VT is more important. There are few ionic circuits responsible for VT. Sodium , Intra cellular calcium, potassium , beta receptor mediated calcium current.If we know the individual ionic culpirit we can block that specifically  . Now we have multi purpose ion blockers  like amiodarone which acts like a broad spectrum antibiotic and terminates a VT.

                              So as of now there is no real purpose of breaking our head  in locating the cell  of origin  and the ions responsible for VT  at  the bed side ,( Researchers will do that for us !).  We have only few  antiarrhythmic drugs available in our crash cart  .Our job is to choose the optimal  drug  which will fit in for our patient. In electro physiology labs, radio frequency ablation is done .This is  nothing but shooting down the abnormal electrical  focus (Cluster of cells or a samll segment of myocardium).  In future,  a single abnormal  cell could be selectively neutralised with cell based therapy assisted by  nanopore robots !

The weirdest thing about this dream was that it had a narrator, as if I was still reading the book.  Somebody was explaining this whole thing to me.

It started out at a graduation party for the class valedictorian at her neighbor's house (which is darn close to how the actual book starts). A stranger pulls up and asks directions, winds up chatting with the Dad, and staying for most of the party. At some point he learns that the girl's mother had died when she was a lot younger.

A few hours and a few beers later, the father and the stranger step across the street, to the father's house. The house is almost exactly as I pictured the girl's house in the book - a rundown, dirty old shack with only two rooms. At this point, the way this dream is playing out, is I'm reading the words, which are evoking these images. Apparently, some of the pieces of the interior of the house that I pictured weren't exactly as the narrator/author/text of the book wanted me to picture them, so the dream cut to an image of a computer screen, where images were scrolling. A few were found that better fit the feel of the interior, and when they were selected, the dream went back to the inside of this house, now with different stuff in it, and the stranger and the father. 

Eventually they meander out to the back of the shack, which has a roofed-in porch that butts onto a small creek. At the edge of the porch there is a little stand with a big, dirty looking bowl and a jar next to it. The stranger doesn't know what yet, but he knows things just took a turn.

They wander up to the urn, and the father says, "Sometimes, during big moments like this, I like to resurrect her, so she's here with us." 

He then opens the jar, which by now the stranger has realized is an urn, and begins scooping out the ashes into the bowl with, I think, a garden spade. Producing a medicine dropper (but bigger... a turkey baster?) seemingly out of nowhere, the father fills the ashes with water from the creek thing, and turns the contents of the bowl a sort of milky looking mud, talking the whole time.

"I know this doesn't work. I just have this idea in my head that combining her with the Earth somehow makes her more alive. But, I guess it's not like she's going to crawl out from the bowl, you know?" Then he chuckles. The stranger reaches down to swat a mosquito from his leg and cuts his hand on the table, but not wanting to interrupt, says nothing.

Then, the dream gets kind of fuzzy. The weird ceremony is over, and the stranger starts scooping the ashes back into the urn, and the father sees blood in the ashes from the cut on the stranger's hand. He screams, thinking his wife is coming back to life, startling the stranger, who drops the spade into the creek, with the ashes still on it. Then my dream fixated on the urn and the bowl full of ashes while the father murders the stranger and then commits suicide, presumably with the spade he grabs out of the creek. 

Then, suddenly, I'm looking through the stranger's eyes, and I get up off the porch, go inside, close the door, shut off all the lights the father had turned on, lock the front door, run outside to my car, which is still parked across the street from the graduation party, which is still going on. All the party-ers are watching me as I climb in the drivers seat and speed off.  Then, the dream pans back to the party, and the car which is still parked outside the house, because obviously, the guy is dead. And then I woke up.

ANYWAY, I know this is already a long entry, but I wanted to talk a little about my job search seminar yesterday. First off, the first sentence I heard when I walked in was, "If you don't have a GED, you're not going to get a job." And thought, here we go again. The seminar was run by the same person who did my individual employment readiness counseling, so I knew it was going to be a disaster. 

But I learned some stuff. Turns out there's a sort of weird Government funded reverse employment agency in Leesville that trains you on computer/job/people skills, and then pays prospective employers to hire you for three months (usually the employer pays the agency). I jumped all over it since I used to work for an employment agency in Alaska. The presenter was an insuffrable woman who kept saying "CLICK IT ON" instead of 'click on it' when describing how to use her website.

Also, I learned more about this spouse preference thing. For all government jobs that are NAF (non-appropriated funds) they have a spouse preference program. This means that if I'm an army spouse, I get picked for the job above other qualified applicants. Sounds great, right?

It was designed by the military, of COURSE it isn't great, stupid! Sure, I get picked above random civilians, but I ALSO get picked above VETERANS. Yeah. Not only that, I'm not PERSONALLY eligible for spouse preference, because on my husband's travel orders, it lists me as coming from New York (long story), and him coming from Alaska. When I asked this question, she told me that it was designed for a married couple in which the military person has to PCS, and the spouse has to quit a job and move to a new place. Technically, since according to his orders we were separated anyway, this doesn't apply to me. 

It ALSO doesn't apply to another forlorn looking woman from Texas who just married her husband and moved here a few months ago. She's not on the orders, OBVIOUSLY, because they weren't married when he was issued them, so EVEN THOUGH she had to pick up her life and dump it in Leesville, she gets no preference. Considering how few jobs there are and how many spouses, I don't think either of us are getting hired anywhere soon.

To submit an application to an NAF position (you're gonna like this - it's so ARMY), you have to submit

1. The application
2. Your Resume
3. Your references, which must be on another sheet
4. A photocopy of your Driver's License
5. A photocopy of your College Degree
6. A photocopy of your High School Diploma or GED ("we can't assume that because you went to college that you graduated high school")
7. Your Spouse Preference Sheet
8. A photocopy of your Spouse's orders

So 8. 8 pieces of paper to apply for a NAF job. NOT ONLY THAT, but she told us that if, say the job requires that you type 40wpm, and it doesn't list your typing speed anywhere on your resume, you will not be called, even if you have ten years of clerical experience.

??!??!!

Look, the point is, I got a certificate for going.

How many certificates did YOU get yesterday? That's what I thought.

Chest pain is one the commonest presenting symptom  in any  hospital both as  an emergency  or non emergency. Reaching an accurate diagnosis is very important. The main  purpose of evaluation of chest pain is to recognise it as cardiac or non cardiac origin . Cardiac chest pain almost always means ischemic chest pain . That is called angina. (Of course there are few important causes for non ischemic cardiac chest pain which Will be discussed later). 

     Standard features of typical angina.

•    Typical angina
•    Atypical chest pain
•    Non cardiac chest pain** Non cardiac chest pain is not a diagnosis. Any physician (or a specialist)  should take some effort to localise it. (Muscle, nerve , pleura , anxiety  etc) . But  generally once these patients are ruled out of cardiac pain  they become less special and are simply referred back to their  family physician, only to return back  with  another cardiac  pseudo-emergency  in a different hospital . 

  Why we are diagnosing atypical chest pain liberally ?

                                       Currently  the patients as well as  the physicians  are   aware of the looming epidemic of CAD. The other major reason is lack of application of mind during clinical appraisal  and examination. Many of the patients with non cardiac chest pain  (Muscle, nerve , pleura )  are termed as atypical chest pain. Though some of the popular texts use atypical  chest pain  and non cardiac chest pain interchangeably , it is not  correct to do so. For example don't ever label a  patient with chest pain with chest wall tenderness as atypical chest pain and order a cardiac work up .It  is a poor model to  emulate , that consumes time and resources!.Instead they should be diagnosed a confident non cardiac chest pain  and dealt properly.

      

   

    

   

Once a patient is diagnosed  atypical chest pain what's next ?                                           

   It is also worthwhile to remember non anginal  chest pain can also be an emergrency and life threatening 

•  Pulmonary embolism
•  Pneumothorax
• Thoracic tumors
• Aortic aneurysm (Dissection and non dissection)  The list is not  exclusive

     Final message

      What do we really mean by  atypical chest pain ?  

      In reality we don't mean any thing !

This is one of the many activities that Nicholas enjoyed doing. He sat and played for at least 20 minutes. After 1.5 hours of their work period, the students sat on the carpet and Ms. Leigh read another story. The kids had a snack and then went off to PE.

It was a good morning. Fun to see Nicholas interact with the other students and teachers.

Logic would suggest , in this era of  stem cells and  nano medicine ,  every muscle fibre in ventricle is worth in gold !. So when the nature provides an  extra reserve of myocardium in the form of LVH one should welcome it , if otherwise not harmful.

Is LVH due to systemic hypertension beningn ?

Not really, LVH has been shown to be an independent cardiac risk factor. (The famous Framingham study)Further LVH can result in diastolic dysfunction and a risk of cardiac failure increases.

But in spite of these observations, an  astute clinician with considerable experience will appreciate , patients with LVH fare better during an acute coronary syndrome !

This has been a consistent clinical observation . (Shall we call it as class C . ACC /AHA evidence ? )

Is LVH  an asset during ACS ?

• A hypertrophied heart takes ischemic injury very easy , it doesn't really hurt much . Another possibility is that in  LVH myocytes are relatively resistant to hypoxia .
• Patients with LVH rarely show  significant wall motion defect following an STEMI.This is probably because the full thickness transmural necrosis is almost never possible even if extensive MI occurs.
• This is also reflected in ECG  as these patients   rarely develop q waves in  following STEMI .
• Persistent ST elevation and failed thrombolysis is very uncommon in pateints with LVH. 
• LVH provides  a relative immunity against development of cardiogenic shock . It requires 40% of LV mass destruction to produce cardiogenic shock.This can rarely happen in LVH. In a  long term analysis we have found none of the patient with LVH developed cardiogenic shock following STEMI.
• LVH patients  are also protected against development of free wall rupture.

 Concluding message

"Lack of evidence  does not make a fact a myth"

LVH , either pathological or physiological , has a hither to unreported beneficial effect .It acts as a myocardial  reserve and help limit the impact of STEMI .

Why is this apparent paradox ? What is basic differnce between UA and AMI ?

In STEMI there is a sudden & total occlusion of a coronary artery usually by a thrombus with or without a plaque .The immediate aim is to open up the blood vessel . Every minute is important as myocardium undergoes  a continuous process ischemic necrosis. So thrombolysis (or more specifically fibrinolysis should be attempted immediately) .The other option is primary angioplasty,  which will not be discussed here.

The thrombus in STEMI  is RBC &  fibrin rich and often called a red clot. Number of fibrinolytic agents like streptokinase, Tissue palsminogen activator,(TPA) Reteplace, Tenekteplace etc have been tested and  form the cornerstone of STEMI management.The untoward effect of stroke  during  thrombolysis  is well recognised , but usully the risk benefit ratio favors thrombolyis in most situations except in very elderly and previous history of stroke or bleeding disorder.

Unstable angina is a  close companion of STEMI . Many times it precedes STEMI often called preinfarction angina. During this phase blood flow in the coronary artery  becomes sluggish gradually,and patients develop  angina at rest .But unlike STEMI there is never a total occlusion and myocardium  is viable but ischemic,  and emergency salvaging of myocardium is not a therapeutic aim but prevention of MI becomes an aim. It is a paradox of sorts ,  even though thrombus is present in  UA ,  It has been learnt by experience thrombolytic agents are not useful in preventing an MI .

Why  thrombolysis is not useful in UA ?

1.In unstable angina  mechanical obstruction in the form of plaque fissure/rupture is more common than completely occluding thrombus. So lysis becomes less important.

2. Even if the thrombus is present , it is often intra plaque  or intra lesional and the  luminal  projection of thrombus is reduced  and hence thromolytic agents have limited area to act.

3.Further in UA/NSTEMI since it is a slow and gradual occlusion (Unlike sudden & total occlusion in STEMI) the platelets  get marginalised and trapped within the plaque .Hence in UA  thrombus is predominantly  white  . Often, a central platelet core  is  seen over which fibrin clot may also be  formed.

4.All available  thrombolytic agents act basically as a fibrinolytic agents,  and   so it finds   difficult to lyse the platelet rich clot.There is also a small risk of these agents lysing the fibrin cap and exposing underlying platelet  core and trigger a fresh thrombus.This has been documented in many trials( TIMI 3b to be specific) So if we thrombolyse in UA , there could be a risk of recurrent ACS episodes in the post thrombolytic phase.

5. UA is a semi emergency where  there is no race against time to salvage myocardium .Administering a  stroke prone thrombolytic agent tilts the risk benefit ratio against it.

6. Among UA, there is a significant group of secondary /perioperative UA   due to increased demand situations. Here there is absolutely no role for any thromolytic agents,  the  simple reason is , there is  no thrombus to get lysed. 

7.Many of the UA patient have multivessel CAD and might require surgical revascualarisation directly .

So fibrinolytic  agents are contraindicated in UA so what is the next step ?

A combination of aspirin, clopidogrel, heparin, glycoprotien 2b 3a antagonist formed the major therapeutic protocol in these patients.Even though these are called antiplalet agents some of them  like 2b/3a antagonist eptifibatide, tirofiban, and many times even heparin has a potential to dissolve a thrombus. So technically one can call these agents  as thrombolytic agents.

What are the unresolved issues

                                       Even though clinical trials have convincingly shown thrombolytic agents  have no use in UA .There is a nagging belief  THAT  there could  be group of patients  with UA , still might benefit from thrombolysis as total occlusions have been documented  in some cases with UA.This is  especially true in peri-infarction unstable angina (Pre & post) as there is a fluctuation  between total and subtotal occlusions ) .But bed side recognition of this population is very difficult.

Many would consider this issue as redundant now,  since  most of  these patients  are taken up for emergency revascularisations

A Eu (cadets) et à Vire (2e-3e-Dep), les sottevillais ont réalisé de belles performances.

A Eu, manche de Challenge de l'Espoir, les cadets sottevillais ont réalisé un beau tir groupé : Pierre Legagneur a pris la 4ème place (échappé en contre attaque) et Benoit Lemaitre a obtenu la 6ème place.

Il en a été de même aux 2 jours de Vire, où Jérome Chauvin, Gabriel Legagneur et Matthieu Planterose étaient engagés au sein d'une équipe de Seine Maritime. Après 3 courses difficiles, Jérome a obtenu la 9ème place au classement général final tandis que Gabriel a terminé 11ème. Deux belles places au classement général obtenues grâce à une 11ème et 12ème place respectivement pour Jérome et Gabriel lors de la première étape, puis notamment avec une 4ème place pour Gabriel lors de la deuxième étape et une 7ème place pour Jérome lors de l'ultime course.

Photographies de l'épreuve de Eu :

Tout d'abord, pour débuter l'été, une grande partie des effectifs sottevillais s'est retrouvée pour la cérémonie d'inauguration de la manifestation culturelle "Viva Cité" à Sotteville lès Rouen. L'occasion pour les jeunes et moins jeunes du club de se retrouver au coeur de la ville, tout en mettant en avant les couleurs du club.

Jérôme Chauvin a participé aux Championnats du Monde masters qui se déroulaient en Autriche. Pour sa première participation, le capitaine de route de l'ACS a obtenu de belles places aux épreuves de Coupe du Monde (7ème et 9ème) mais a dû se contenter de la 18ème place pour le Championnat du Monde, sur 186 coureurs au départ. Tout de même un très beau résultat pour le sottevillais, surtout au vu du déroulement de la course. Pour préparer ce grand rendez-vous, Jérôme n'avait rien laissé au hasard et la forme était bien présente, en témoignent ses beaux résultats (2ème à Gerponville et Aumale notamment) et ses nombreux kilomètres accumulés en échappée.

Pour Pierre Legagneur, il a aussi été beaucoup question de championnats. Tout d'abord sur piste, avec les Championnats de France qui se déroulaient à Hyères (Var) du 3 au 9 Juillet. Lors de la course aux points, le sottevillais a terminé 5ème de sa série et s'est donc qualifié pour la finale. Un finale au cours de laquelle il n'a pas pu réellement peser sur la course. Egalement engagé sur l'Américaine, Pierre, pourtant en bonne forme, n'a pu se qualifier pour la finale. Puis fin Août à Cusset (Allier) pour les Championnats de France de l'Avenir, sur route cette fois ci. Sur un parcours particulièrement éprouvant et forcément face à un plateau de qualité, le sottevillais a été malchanceux. En effet, le cadet première année de l'ACS a subi un ennui mécanique suite à l'une des nombreuses chutes qui ont émaillé la première partie de course. Retardé, Pierre n'a pu ré-intégrer ce qu'il restait du peloton. Fidèle à son comportement offensif, il a tout de même réussi à s'extirper du peloton, avant cet incident, pour effectuer quelques kilomètres en échappée. Avant cette sélection, le sottevillais avait notamment réalisé de très belles performances sur les courses du Trophée Madiot, en faisant la course en tête dans chacune des manches estivales.

D'autres beaux résultats sont également à souligner pour cet été. Gabriel Legagneur a obtenu la 8ème place de la finale chronométrée du Challenge de Normandie Juniors et la 8ème place au classement général final du Challenge. Il a aussi terminé 3ème à Woincourt, 4ème à Renazé (Mayenne), 5ème à Lisieux, et s'est imposé de très belle façon à Saint Martin de Landelles (Manche). Face à une opposition de premier ordre, avec 160 coureurs au départ - dont certains membres de l’équipe de France Juniors, Gabriel s’est imposé en solitaire après avoir lâché ses 2 derniers compagnons de fugue, issus d’une échappée initiale de 9 hommes. Avec ces beaux résultats, le junior sottevillais est passé tout près de sa sélection pour les Championnats de France de l'Avenir, et il participera prochainement à une manche du Challenge National Junior avec la sélection régionale. Matthieu Planterose a profité de sa bonne forme pour s'imposer en catégorie départementale à l'épreuve chronométrée de Saint Michel Tubeuf (Orne) et pour terminer 11ème et 1er Dep à Grainville la Teinturière. Valentin Douville a quant à lui obtenu la 4ème place à Breteuil sur Iton, juste derrière Aurélien Riquier, 3ème. Aurélien qui a justement réalisé de belles courses en Moselle, en obtenant notamment une belle 2ème place et en réalisant de bonnes places en 1ère catégorie (13ème et 20ème).

Enfin, du côté de l'école de cyclisme, de bons résultats sont également à noter, avec notamment la victoire de Jordan à Thuit Anger (résultats complets à voir sur le blog de l'école de cyclisme).

Après cet été bien chargé, place à la rentrée et à la fin de saison...

Quelques photographies pour illustrer cette période estivale :

Participation à Viva Cité

Matthieu en contre la montre

Valentin qui a obtenu une 4ème place

Gabriel qui mène le groupe de tête à Lisieux

Sur les routes de la région ou en Autriche, Jérôme est toujours à l'avant de la course

Matthieu qui se rapproche de la 3e catégorie

Gabriel en vainqueur à St Martin de Landelles

Pierre aux Championnats de France sur piste :

Pierre au départ du Championnat de France sur route

Pierre tente en vain de réintégrer le peloton après son incident mécanique

The "for the children" battlecry has been over-used so much these days, that this mother is wondering if we shouldn't just ban children next. Sounds heartless I know, but when special interest groups run ads using healthy kids that claim hot dogs gave them cancer, I see this as emotional blackmail. I see this as teaching children that it is perfectly acceptable to lie in order to try to manipulate others into doing what you want. I see this as exploiting children.

TV Ad Attacks Hot Dogs As Cancer Risk

But Actual Evidence Doesn't Measure Up To Pro-Vegetarian Sponsors' Claims

CHICAGO, Aug. 26, 2008

(AP) A new TV commercial shows kids eating hot dogs in a school cafeteria and one little boy's haunting lament: "I was dumbfounded when the doctor told me I have late-stage colon cancer."

It's a startling revelation in an ad that vilifies one of America's most beloved, if maligned, foods, while stoking fears about a dreaded disease.

But the boy doesn't have cancer. Neither do two other kids in the ad who claim to be afflicted.

© MMVIII The Associated Press.

Read the FULL STORY here.

So where's the FTC? Isn't there some regulation or law about "truth in advertising"? Or is that something that is ONLY applicable to businesses pushing an actual product?

What truth-in-advertising rules apply to advertisers?

Under the Federal Trade Commission Act:

• Advertising must be truthful and non-deceptive;
• Advertisers must have evidence to back up their claims; and
• Advertisements cannot be unfair.

What makes an advertisement deceptive?

According to the FTC's Deception Policy Statement, an ad is deceptive if it contains a statement - or omits information - that:

• Is likely to mislead consumers acting reasonably under the circumstances; and
• Is "material" - that is, important to a consumer's decision to buy or use the product.

Personally I don't believe non-profits, special interest groups or charities should be given an exemption on telling the truth. If anything they should be held to an even HIGHER STANDARD of honesty because of the way many of them are viewed, not to mention their tax-exempt status.

As an example, the American Cancer Society is the richest non-profit in the United States (don't you wonder how a "non-profit" can actually BE RICH?). Yet this same organization constantly claims to have no money for research into the very thing they are supposed to be researching. At the same time, they seem to have all the money in the world to advertise on TV and not tell the whole truth in their advertising. I've lost all respect for them and will never donate to them again because of this fact. They seem more interested in trying to get the people to live as they want them to instead of doing what they claim they are about..................researching the real causes (versus just accusing slight associations as absolute causes) and finding cures for cancer.

American Cancer Society: The World's Wealthiest "Nonprofit" Institution

Samuel S. Epstein M. D.

The American Cancer Society is fixated on damage control— diagnosis and treatment— and basic molecular biology, with indifference or even hostility to cancer prevention. This myopic mindset is compounded by interlocking conflicts of interest with the cancer drug, mammography, and other industries. The "nonprofit" status of the Society is in sharp conflict with its high overhead and expenses, excessive reserves of assets and contributions to political parties. All attempts to reform the Society over the past two decades have failed; a national economic boycott of the Society is long overdue.

The American Cancer Society (ACS) is accumulating great wealth in its role as a "charity." According to James Bennett, professor of economics at George Mason University and recognized authority on charitable organizations, in 1988 the ACS held a fund balance of over $400 million with about $69 million of holdings in land, buildings, and equipment (1). Of that money, the ACS spent only $90 million— 26 percent of its budget— on medical research and programs. The rest covered "operating expenses," including about 60 percent for generous salaries, pensions, executive benefits, and overhead. By 1989, the cash reserves of the ACS were worth more than $700 million (2). In 1991, Americans, believing they were contributing to fighting cancer, gave nearly $350 million to the ACS, 6 percent more than the previous year. Most of this money comes from public donations averaging $3,500, and high-profile fund-raising campaigns such as the springtime daffodil sale and the May relay races. However, over the last two decades, an increasing proportion of the ACS budget comes from large corporations, including the pharmaceutical, cancer drug, telecommunications, and entertainment industries.

© 2003 Cancer Prevention Coalition

Read the FULL STORY here.

Emotional extortion to push an agenda to force everyone to eat the way the movement wants and not allowing for the free will that God/dess gave us all.

Everyone is using "the children" today. MADD has been using them for decades. The anti-smoker/ing movement has been seriously using them for the last 5 years at least. The anti-obesity movement is using them just as vigorously now.

The step is obvious and it seems that the UK is bound, set and determined to take that step, in the process they are repeating history. Unfortunately they are fashioning their new world after a dictator they fought and won against. I just read something in the Telegraph that sent chills down my spine for it's resemblance to Hitler's Youth Movement.

Children aged eight enlisted as council snoopers

Children as young as eight have been recruited by councils to "snoop" on their neighbours and report petty offences such as littering, the Daily Telegraph can disclose.

By Martin Beckford, Sarah Graham and Betsy Mead

Last Updated: 1:00PM BST 06 Sep 2008

The youngsters are among almost 5,000 residents who in some cases are being offered £500 rewards if they provide evidence of minor infractions.

One in six councils contacted by the Telegraph said they had signed up teams of "environment volunteers" who are being encouraged to photograph or video neighbours guilty of dog fouling, littering or "bin crimes".

The "covert human intelligence sources", as some local authorities describe them, are also being asked to pass on the names of neighbours they believe to be responsible, or take down their number-plates.

Ealing Council in West London said: "There are hundreds of Junior Streetwatchers, aged 8-10 years old, who are trained to identify and report enviro-crime issues such as graffiti and fly-tipping."

Harlow Council in Essex said: "We currently have 25 Street Scene Champions who work with the council. They are all aged between 11 to 14. They are encouraged to report the aftermath of enviro-crimes such as vandalism to bus shelters, graffiti, abandoned vehicles, fly-tipping etc. They do this via telephone or email direct to the council."

© Copyright of Telegraph Media Group Limited 2008

Read the FULL STORY here.

There's a phrase in there that I wasn't familiar with "fly-tipping". According to Wikipedia:

Fly-tipping or dumping is a British term for illegally dumping waste somewhere other than an authorised landfill. It is the illegal deposit of any waste onto land, i.e., waste dumped or tipped on a site with no licence to accept waste.

Generally, I could agree with the concept here. After all, it IS the responsibility of everyone in the community to do their part to keep the community pleasant and clean. Anyone can call a number to report some wrongdoing. This is common knowledge and most people have no trouble finding the number if they really want to call something in for action to be taken.

What I find obscene about this is the fact that they are deliberately recruiting children, as young at 10 years old, using MONETARY rewards to get them to act as spies on their neighbors. That is just so Hitler-ish it must have Winston Churchill wondering why so many good people died fighting Hitler and his fascist rule.

We are coming full circle it seems and if we are not careful.........or rather, if we don't start putting a stop to the insanity NOW, we will find ourselves living in Hitler's dream world. I'll have another example of this tomorrow.

The one proposed by Medina is simple and most useful.

In this grading three segments

• Proximal main vessel
• Distal main vessel
• Branch vessel

Are given a code 0, and 1 if  lesion is present or absent .

This grading gives simple and fast method to label a bifurcatiuon lesion and to asssess the response to PCI. The only issue here is the individual  lesions are not graded , for example branch vessel ostium just involved about 20 % is not addressed . Further TIMI flow in these vessels may also be incorporated

How medina grading can be used to assess effectiveness of

angioplasty  ?

A patient with 1.1.1  after the treatment should revert back to 0.0.0.  if converted into 0.0.(.5) may indicate a residual side branch lesion  .5 shall indicate 50% residual lesion, .3 , 30% etc

What is the best management strategy for bifurcation lesions?

The topic has been discussed extensively for over a decade in various forums.

Though the lesions and intervention techniques  appear complex the basic concept is simple.

Following is the 8 point algorithm

1. Assess the bifurcation lesion accurately.

2. Apply the general rule and ask the first question whether PCI is neccessary at all ? if decided for PCI

3. Stent the main vessel.Protect the side branch.  

4. Dilate the side branch with a balloon.(KIss or through the struts) 

5. Very rarely,  if the side vessel is more significant and large  stent it and balloon the main vessel.

6. Use drug eluting stents with caution .

7. Resist the temptation of using two stents unless the situation demands and is absolutely required.

8. Never attempt to do bifurcation angioplasty during ACS as apart of primary angioplasty.( Unless you're extremely competent, even then aim of primary PCI is to salvage myocarium quickly , not to provide TIMI 3 flow in non IRA vessel.)

Dr.S.Venkatesan.Madras medical college.Chennai.

• Acton - Norah Gaughan Berocco vol.2
• Hexacomb Cardigan - Interweave Knits - Spring 08

Both are cropped style, perfect for spring/summer Melbourne weather and covering up against air-con on casual Friday in my office.

I am planning to knit Acton in Serenity - Patons Bamboo/Cotton in black and unsure about what to knit the Hexacomb Cardi in (thinking of a pale pink with a black or chocolate brown trim). But this brings me to the next exciting spring knitting announcements; new colours/yarns by Australian Country Spinners!

Eagle eyes on Ravelry spied some new colours and yarns in their LYS. I have yet to see them in the flesh (popped into Clegs yesterday but yarns have been pushed aside for the hat and fascinator displays for Spring Carnival).

• new Natural Cotton 100% undyed cotton in 8ply and 4ply in a range of subtle earthy colours (of course!) I quite like the pale green.
• new colours in 100% Bamboo, including some bright blue, orange & green and a black

I can't wait to see them in my hand. I might pop down to Wool Baa next weekend and have a looksie. There are also some great new supporting pattern books (although has anyone ever actually knitted a bikini?).

Wot's on the Needs

• Tiger's Eye Scarf - had a disaster with the Blue Bayou Mitred Stole, the yarn I chose (Live2Knit Elizabeth in Smoke) just did not work with the pattern. I spoke to the gift recipient, we logged onto Ravelry and I showed her some options. Yay a chance to do more lace. I have completed a couple of repeats and it is looking lovely
• Socks - almost finished Uneven Ribbing sock in Jigsaw Heirloom, which is looking great too.
• The Goth Mermaid Shawl is still on the needles, I just to bind off. Maybe tonight during dvd time.

Other Cool Stuff

• Yarn Magazine 11

The new issue of Yarn magazine appeared in my letter box last week. Whilst it is the best Australian knitting mag by far, the new editors have not quite got the stylish look and layout of the Barbara Coddington issues. They still look a bit amateurish. But aside from that criticism, the content is pretty good with a combination of reviews, patterns, interviews and instructional articles. Especially in love with the Rain Stole by Ailsa Daly. The article deconstructing the argyle was very informative. And the ads are always good (I never usually say that about ads. I watch mainly SBS and ABC and listen to RRR to avoid most ads) I can find out about new, small local yarn producers who I would prefer to support.

• Popknits -

Another new pattern that jumped straight onto my queue comes from another new online knitting magazines. We knitters are totally spoilt by the generous of spirit (and time) of people who produce these magazines (Yarn included!). Anyway...the pattern which fell into my queue is Gossamer Garden Stole (in the lace vein again!) by Lia Liang. Not a fan of the purple it is knitted in but I can see the beauty of the pattern. Also cool is Buttercup by Melissa Wehrle. Excellent stuff.

• Joy Gammon rocks - Danger Mouse jumper pattern on ebay. I just need a child now.

Copied from www.preventcancer.com

American Cancer Society:   The World's Wealthiest "Nonprofit" Institution

Samuel S. Epstein M. D.

• Conflicts of Interest
  - Mammography Industry
  - Pesticide Industry
  - Drug Industry
• Board of Trustees

The American Cancer Society is fixated on damage control— diagnosis and treatment— and basic molecular biology, with indifference or even hostility to cancer prevention. This myopic mindset is compounded by interlocking conflicts of interest with the cancer drug, mammography, and other industries. The "nonprofit" status of the Society is in sharp conflict with its high overhead and expenses, excessive reserves of assets and contributions to political parties. All attempts to reform the Society over the past two decades have failed; a national economic boycott of the Society is long overdue.

The American Cancer Society (ACS) is accumulating great wealth in its role as a "charity." According to James Bennett, professor of economics at George Mason University and recognized authority on charitable organizations, in 1988 the ACS held a fund balance of over $400 million with about $69 million of holdings in land, buildings, and equipment (1). Of that money, the ACS spent only $90 million— 26 percent of its budget— on medical research and programs. The rest covered "operating expenses," including about 60 percent for generous salaries, pensions, executive benefits, and overhead. By 1989, the cash reserves of the ACS were worth more than $700 million (2). In 1991, Americans, believing they were contributing to fighting cancer, gave nearly $350 million to the ACS, 6 percent more than the previous year. Most of this money comes from public donations averaging $3,500, and high-profile fund-raising campaigns such
as the springtime daffodil sale and the May relay races. However, over the last two decades, an increasing proportion of the ACS budget comes from large corporations, including the pharmaceutical, cancer drug, telecommunications, and entertainment industries.

In 1992, the American Cancer Society Foundation was created to allow the ACS to actively solicit contributions of more than $100,000. However, a close look at the heavy-hitters on the Foundation's board will give an idea of which interests are at play and where the Foundation expects its big contributions to come from. The Foundation's board of trustees included corporate executives from the pharmaceutical, investment, banking, and media industries. Among them:

• David R. Bethune, president of Lederle Laboratories, a multinational pharmaceutical company and a division of American Cyanamid Company. Bethune is also vice president of American Cyanamid, which makes chemical fertilizers and herbicides while transforming itself into a full-fledged pharmaceutical company. In 1988, American Cyanamid introduced Novatrone, an anti-cancer drug. And in 1992, it announced that it would buy a majority of shares of Immunex, a cancer drug maker.
• Multimillionaire Irwin Beck, whose father, William Henry Beck, founded the nation's largest family-owned retail chain, Beck Stores, which analysts estimate brought in revenues of $1.7 billion in 1993.
• Gordon Binder, CEO of Amgen, the world's foremost biotechnology company, with over $1 billion in product sales in 1992. Amgen's success rests almost exclusively on one product, Neupogen, which is administered to chemotherapy patients to stimulate their production of white blood cells. As the cancer epidemic grows, sales for Neupogen continue to skyrocket.
• Diane Disney Miller, daughter of the conservative multi-millionaire Walt Disney, who died of lung cancer in 1966, and wife of Ron Miller, former president of the Walt Disney Company from 1980 to 1984.
• George Dessert, famous in media circles for his former role as censor on the subject of "family values" during the 1970s and 1980s as CEO of CBS, and now chairman of the ACS board.
• Alan Gevertzen, chairman of the board of Boeing, the world's number one commercial aircraft maker with net sales of $30 billion in 1992.
• Sumner M. Redstone, chairman of the board, Viacom Inc. and Viacom International Inc., a broadcasting, telecommunications, entertainment, and cable television corporation.

The results of this board's efforts have been very successful. A million here, a million there— much of it coming from the very industries instrumental in shaping ACS policy, or profiting from it. In 1992, The Chronicle of Philanthropy reported that the ACS was "more interested in accumulating wealth than in saving lives." Fund-raising appeals
routinely stated that the ACS needed more funds to support its cancer programs, all the while holding more than $750 million in cash and real estate assets (3). A 1992 article in the Wall Street Journal, by Thomas DiLorenzo, professor of economics at Loyola College and veteran investigator of nonprofit organizations, revealed that the Texas affiliate of the ACS owned more than $11 million worth of assets in land and real estate, as well as more than 56 vehicles, including
11 Ford Crown Victorias for senior executives and 45 other cars assigned to staff members. Arizona's ACS chapter spent less than 10 percent of its funds on direct community cancer services. In California, the figure was 11 percent, and under 9 percent in Missouri (4):

Thus for every $1 spent on direct service, approximately $6.40 is spent on compensation and overhead. In all ten states, salaries and fringe benefits are by far the largest single budget items, a surprising fact in light of the characterization of the appeals, which stress an urgent and critical need for donations to provide cancer services.

Nationally, only 16 percent or less of all money raised is spent on direct services to cancer victims, like driving cancer patients from the hospital after chemotherapy and providing pain medication.

Most of the funds raised by the ACS go to pay overhead, salaries, fringe benefits, and travel expenses of its national executives in Atlanta. They also go to pay chief executive officers, who earn six-figure salaries in several states, and the hundreds of other employees who work out of some 3,000 regional offices nationwide. The typical ACS affiliate, which helps raise the money for the national office, spends more than 52 percent of its budget on salaries, pensions, fringe benefits, and overhead for its own employees. Salaries and overhead for most ACS affiliates also exceeded 50 percent, although most direct community services are handled by unpaid volunteers. DiLorenzo summed up his findings by emphasizing the hoarding of funds by the ACS (4):

If current needs are not being met because of insufficient funds, as fund-raising appeals suggest, why is so much cash being hoarded? Most contributors believe their donations are being used to fight cancer, not to accumulate financial reserves. More progress in the war against cancer would be made if they would divest some of their real estate holdings and use the proceeds— as well as a portion of their cash reserves— to provide more cancer services.

Aside from high salaries and overhead, most of what is left of the ACS budget goes to basic research and research into profitable patented cancer drugs. The current budget of the ACS is $380 million and its cash reserves approach $1 billion. Yet its aggressive fund-raising campaign continues to plead poverty and lament the lack of available money for cancer research, while ignoring efforts to prevent cancer by phasing out avoidable exposures to environmental and occupational carcinogens. Meanwhile, the ACS is silent about its intricate
relationships with the wealthy cancer drug, chemical, and other industries. A March 30, 1998, Associated Press Release shed unexpected light on questionable ACS expenditures on lobbying (5). National vice president for federal and state governmental relations Linda Hay Crawford admitted that the ACS was spending "less than $1 million a year on direct lobbying." She also admitted that over the last year, the society used ten of its own employees to lobby. "For legal
and other help, it hired the lobbying firm of Hogan & Hartson, whose roster includes former House Minority Leader Robert H. Michel (R– IL)." The ACS lobbying also included $30,000 donations to Democratic and Republican governors' associations. "We wanted to look like players and be players," explained Crawford. This practice, however, has been sharply challenged. The Associated Press release quotes the national Charities Information Bureau as stating that it" does not know of any other charity that makes contributions to political parties."
Tax experts have warned that these contributions may be illegal, as charities are not allowed to make political donations. Marcus Owens, director of the IRS Exempt Organization Division, also warned that "The bottom line is campaign contributions will jeopardize a charity's exempt status."

TRACK RECORD ON PREVENTION
Marching in lockstep with the National Cancer Institute (NCI) in its "war" on cancer is its "ministry of information," the ACS (6, pp. 306– 314). With powerful media control and public relations resources, the ACS is the tail that wags the dog of the policies and priorities of the NCI (7, 8). In addition, the approach of the ACS to cancer prevention reflects a virtually exclusive "blame-the-victim" philosophy. It emphasizes faulty lifestyles rather than unknowing and avoidable
exposure to workplace or environmental carcinogens. Giant corporations, which profit handsomely while they pollute the air, water, and food with a wide range of carcinogens, are greatly comforted by the silence of the ACS. This silence reflects a complex of mindsets fixated on diagnosis, treatment, and basic genetic research together with ignorance, indifference, and even hostility to prevention, coupled with conflicts of interest.

Indeed, despite promises to the public to do everything to "wipe out cancer in your lifetime," the ACS fails to make its voice heard in Congress and the regulatory arena. Instead, the ACS repeatedly rejects or ignores opportunities and requests from Congressional committees, regulatory agencies, unions, and environmental organizations to provide scientific testimony critical to efforts
to legislate and regulate a wide range of occupational and environmental carcinogens. This history of ACS unresponsiveness is a long and damning one, as shown by the following examples (6):

1. In 1971, when studies unequivocally proved that diethylstilbestrol (DES) caused vaginal cancers in teenaged daughters of women administered the drug during pregnancy, the ACS refused an invitation to testify at Congressional hearings to require the FDA (U. S. Food and Drug Administration) to ban its use as an animal feed additive. It gave no reason for its refusal.

2. In 1977 and 1978, the AC