x=  def list_ex(): x.append(20) def add_list(): x=[30,40] x.append(50) print (x) list_ex() print (x) add_list() print (x)
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text:
Pancreatoduodenectomy without Vascular Resection in Patients with Primary Resectable Adenocarcinoma and Unilateral Venous Contact: A Matched Case Study.
Pancreatic ductal adenocarcinoma (PDAC) is one of the most biologically aggressive neoplasms characterized by poor prognosis with a mortality rate which currently ranks fifth in the list of cancer-related deaths. Surgical management remains the primary treatment, but resection is possible only in 15 to 20% of patients . Approximately 65% of pancreatic tumors involve the pancreatic head. While patients with body or pancreatic tail cancer present usually with metastatic disease, lesions arising in the pancreatic head usually present with jaundice or symptoms related to duodenal obstruction.
Consequently, patients with pancreatic head tumors may obtain improved survival from early diagnosis and treatment. In these cases, whenever possible, an R0 resection margin is associated with a 5-year survival rate of 20% in some reports. Because the pancreatic head is anatomically closely related to major arteries and veins, in 40% of patients, cancer involves one or more major vascular structures at the time of diagnosis . The concept of borderline resectable pancreatic cancer  and the staging system proposed by the consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association [4, 5] underlines the close relationship between the critical visceral vasculature and the local spread of the disease. The primary portal-mesenteric axis en bloc resection during pancreatoduodenectomy (PD) is considered a safe approach in experienced high-volume centers with acceptable morbidity and mortality and favourable prognosis compared to unresectable disease. However, the benefit in terms of improved disease-free survival by this aggressive major surgical resection remains unproven.
The present study was designed to investigate the oncological outcome (local/distant recurrence rate) and patients' survival after a conservative approach on the portal-mesenteric venous axis (PMA) in an intraoperative ultrasound- (IOUS-) selected group of PDs, in patients with primary resectable with vascular contact- (prVC-) PDAC.
2. Materials and Methods
From January 2008 to December 2017, 433 pancreatic resections were performed at the General Surgery Unit of the University of Pisa, of which a total of 156 were PDs for PDAC: 135 without vascular resection (VR) and 21 with VR. Eighty-eight patients underwent a total pancreatectomy, of which 51 for PDAC and 14 VR.
In this period, in our institution, primary pancreatic resection was contraindicated only when metastatic disease and invasion of the superior mesenteric or celiac artery were identified by preoperative imaging. PMA infiltration was not considered a contraindication for primary resection.
An intraoperative ultrasound (IOUS) with high-frequency probe (12-5 MHz, Intraoperative Biplane, BK Medical APS, Peabody, MA, USA) in order to check the relationship between the tumor and the PMA and SMA and to exclude occult liver metastasis was routinely performed in all patients undergoing PD. In case of the US sign of infiltration of PMA, we proceeded with an en bloc resection of the tumor with the tract of the vein involved, while for cases with a cleavage plane between the tumor and the PMA detected by ultrasound, we peeled off the vein from the tumor through a macroscopic tumor-free plane.
Preoperative workup included anamnestic collection, physical examination, blood exams, abdominal ultrasound (US), computed tomography (CT), magnetic resonance (MRI), and, depending on the case, other diagnostic methods, such as contrast-enhanced ultrasound (CEUS), endoscopic ultrasonography (EUS), and positron emission tomography (PET).
Preoperative biliary drainage was performed when bilirubin blood level was higher than 20 mg/dl. Patients underwent neoadjuvant therapy, when considered locally advanced at the diagnostic imaging.
Decisions about clinical management involved a multidisciplinary consultation between surgeons, oncologists, radiologists, and radiotherapists. Patients' data were stored in a dedicated institutional database.
For the present study, the grade of PMA invasion and the types of PDAC regarding tumor resectability (resectable, borderline resectable, locally advanced, and metastatic disease) were assigned retrospectively according to the National Comprehensive Cancer Network (NCCN) classification system  and to the International consensus on the definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017 .
We identified a group of 40 patients with primary resectable disease with venous contact- (prVC-) PDAC, in whom, after checking the feasibility with IOUS, the vein had been peeled off the tumor without leaving macroscopic residual disease, avoiding a vascular resection (nvrPD group). We compared this group with a control group of 40 patients treated with a standard PD (sPD) for primary resectable without vascular contact- (prwVC-) PDAC. The control group was selected using a one-to-one case matched methodology from the prospectively collected institutional database, where each patient of the nvrPD group was matched with a patient operated for prwVC-PDAC, using the following criteria: age, tumor size, grading, stage, and adjuvant therapy.
In these two groups, we evaluated differences in perioperative surgical results, local/distant recurrence, and survival. Prospectively collected details regarding pre-, intra-, and postoperative course and follow-up of patients of the two groups were retrospectively analysed and compared.
Preoperative and operative data included age, sex, BMI, ASA score, and operative time. Postoperative data included the length of hospital stay, postoperative morbidity (according to the Clavien-Dindo classification) , reintervention rate, and 30-day mortality. The medical complications recorded were pulmonary or urinary tract infections, cardiac complications, and neurological complications. The surgical complications included intra-abdominal fluid collections, surgical site infections, postoperative pancreatic fistula, digestive, and biliary or intraperitoneal hemorrhage. Postoperative pancreatic fistula (POPF) was defined and classified using the 2016-Revised International Study Group on Pancreatic Surgery classification (ISGPSc) . Pathological data included the stage of pancreatic cancer, number of harvested lymph nodes, lymph node status, perineural space invasion, vascular space infiltration, vascular bed infiltration (medial pancreatic margin), and resection margin status.
Pathological data included the stage of pancreatic cancer according to the AJCC/TNM classification (8th edition) and the residual tumor classification (R0, free tumor margin > 1mm; R1, free tumor margin if <1mm or microscopic residual tumor; and R2; macroscopic residual tumor) [10, 11].
During the follow-up, data was collected on adjuvant therapy; local or systemic recurrence; the 1-, 3-, and 5-year overall survival (OS); and the disease-free survival (DFS) rate. The OS was defined as the length of time from the surgical resection of the pancreatic adenocarcinoma to the patient's death (last follow-up). Similarly, the DFS was defined as the time from the surgical resection to the diagnosis of recurrence (symptoms, radiological evidence, and/or pathological confirmation).
2.1. Statistical Analysis. For the data analysis, the [chi square] test was used to define associations between categorical factors and surgical groups. Continuous variables with normal distribution are expressed as the mean [+ or -] standard deviation (SD) and compared using Student's t-test, with a significance being set at p < 0.05. Variables with an abnormal distribution are expressed as the median and compared using the Wilcoxon test. Survival was compared using the Kaplan-Meier curves and log-rank test. The statistical analysis was performed using SPSS (Statistical Production and Service Solution for Windows, SPSS Inc., Chicago, IL, USA) and STATA version 13 (STATA Corp., TX, USA).
Demographic characteristics summarized in Table 1 showed no significant differences in clinical features between the two groups. The mean overall operative time (OT) was similar in both groups (435.9 [+ or -] 93.8 in the sPD group vs. 429.4 [+ or -] 86.1 in the nvrPD group, p = 0.75). Postoperative data (Table 2) showed no difference in the median length of postoperative stay between the two groups:15.0 days vs. 17.0 days for the sPD and nvrPD groups, respectively (p = 011). The overall postoperative complication rate was similar in both groups, occurring in 16 patients (40.0%) in the sPD group and in 22 patients (55.0%) in the nvrPD group (p = 0.18). Medical complications occurred in 10 cases (25%) and in 17 cases (42.5%) in the sPD and nvrPD groups, respectively (p = 0.10). Pancreatic fistula (according to the 2016-revised ISGPSc of POPF) developed in 3/40 patients (7.5%) in both groups: one grade B POPF (2.5%) and 2 (5%) grade C POPF in the sPD group and 3 (7.5%) grade C POPF in the nvrPD group; p = 0.55. Surgical complications occurred in 6 patients (15%) in the sPD group and in 5 patients (12.5%) in the nvrPD group (p = 0.75). The surgical complications in the sPD group were digestive hemorrhage (n = 2), bleeding associated with POPF grade C (n = 2), parietal hematoma (n = 1), and obstruction of the gastrointestinal anastomosis (n = 1). In the nvrPD group, surgical complications were digestive hemorrhage (n = 2) and bleeding associated with POPF grade C (n = 3). Digestive hemorrhage was treated with endoscopic intervention in all cases of both groups. Reintervention was required in 4 patients (10%) of the sPD group (2 grade C POPF, 1 parietal hematoma, and one gastrointestinal anastomosis obstruction) and in 3 patients (7.5%) of the nvrPD group (3 grade C POPF, p = 0.69). Postoperative mortality rate was 2.5% (1/40 cases) in both groups. Pathological findings are summarized in Table 3. No differences were reported between the two groups in terms of the stage of the disease, perineural and vascular bed infiltration. A mean of 28.4 [+ or -] 13.4 lymph nodes per patient was harvested in the sPD group versus 31.5 [+ or -] 14.1 in the nvrPD group (p = 0.32). The lymph nodes were positive in 29/40 cases (72.5%) in the sPD vs. 30/40 cases (75%) in the nvrPD (p = 0.80).
The median follow-up was 28.5 [+ or -] 23.2 months in the sPD group and 23.8 [+ or -] 20.8 months in the nvrPD group (p = 0.35). No patients in the two groups underwent neoadjuvant therapy because of primary resectable PDAC. In the sPD group, 21 patients (52.5%) vs. 20 patients (50%) in the nvrPD group received adjuvant therapy (p = 0.82). The disease-free survival (DFS) with the Kaplan-Meier method is shown in Figure 1. Isolated local recurrence was reported in 2/40 cases (5%) in both groups. No statistically significant difference in systemic progression or combined local and synchronous systemic disease rate was reported between the two groups: 17/40 cases (42.5%) in the sPD group vs. 18/40 case (45%) in the nvrPD group (p = 0.82) and 1/40 cases (2.5%) in the sPD group vs. 3/40 cases (7.5%) in the nvrPD group (p = 0.30, Table 4). Survival analysis using the Kaplan-Meier method is shown in Figure 2. The median survival was 22 months for the sPD group and 23 months for the nvrPD group (p = 0.80). No difference in the overall survival was observed between the two groups: 1-year overall survival rate was 76.3% in the sPD group vs. 70.0% in the nvrPD group; 3-year overall survival rate was 35.6% in the sPD group vs. 31.6% in the nvrPD group; and 5-year overall survival was 28.5% in the sPD group vs. 25.3% in the nvrPD group (p = 0.81).
The pancreatic head is closely related to major arteries and veins, which are involved at the time of diagnosis in 40% of pancreatic ductal adenocarcinoma [2, 12]. According to the National Comprehensive Cancer Network (NCCN) guidelines, pancreatic cancer with superior mesenteric vein (SMV) and/or portal vein (PV) involvement greater than 180 degrees is considered borderline resectable unless the portal venous flow can be restored . Several reports have shown similar short- and mid-term survival of patients with vein resection compared to patients treated with standard PD; specifically, Yekebas et al.  and Tseng et al.  did not report any difference in postoperative morbidity, mortality, and survival rate between the two groups. As a result of these reports, the surgical treatment in high-volume centers consists of mesenteric root mobilization and primary vascular resection en bloc, including cases of unilateral contact on preoperative imaging. The treatment includes all the true positive cases but overtreats many patients in whom histology of the excised specimen reveals only juxtavascular peritumoral inflammatory adherence rather than actual vascular infiltration . Although feasible and safe, vascular resection is associated with increased perioperative risks, with increased morbidity associated with venous reconstruction [16, 17]. In patients with jaundice, portal clamping may further impair liver function . The development of pancreatic fistula close to the suture line may promote thrombosis or pancreatic fistula-associated hemorrhage because the vascular resection and revascularization increase the likelihood of vessels being eroded by any pancreatic leak . Furthermore, in patients treated with a total splenopancreatectomy, the compromised gastric venous drainage may necessitate a subtotal or total gastrectomy with increased postoperative morbidity . Hence, some reports have raised doubts on the benefit of portal/ mesenteric vein resection and have indicated that patients do not obtain any survival benefit after PV/SMV/PMA resection [14,21,22]. In fact, Roch et al. reported that vascular resection increased the 90-day mortality and that the vessel wall invasion does not represent a specific prognostic factor of overall survival because patients with and without vein resection obtained comparable overall survival rates at 1, 3, and 5 years. Indeed, the same authors report a higher rate of recurrence in the PMA resection group, probably because survival in these patients is largely due to aggressive tumor biology . Zhou et al. in a meta-analysis including 19 studies found no differences in terms of overall survival between vascular and no vascular resection PDs. They also concluded that these patients' higher local recurrence did not materially contribute to poor survival, since this death was largely due to the systemic progression of the disease . Preoperative staging can provide useful information on the relationship between the pancreatic tumor and the vascular wall to assist in planning the surgical resection. Multidetector computed tomography (MDCT) has provided the most accurate assessment of vascular involvement showing excellent sensitivity (100%) and specificity (72%) and high positive predictive value (89%) . Al-Hawary et al. published a consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association on preoperative cross-sectional imaging evaluation of tumor involvement of PMA . The probability of vascular invasion is related to the contact of the tumor with the vessel. In a study by Springett and Hoffe, the probability of vascular invasion was increased to 40%, 80%, and 100% when the tumor had [less than or equal to] 180[degrees] contact, >180[degrees] contact, and 360[degrees] contact, respectively . Moreover, venous caliber change at imaging is related with venous wall invasion as reported by Nakao et al. who demonstrated an absence of venous invasion on pathologic examination of resected specimens in patients without a radiographic appearance of vascular involvement while vascular invasion was revealed by pathologic examination in 51%, 74%, and 93% of patients with radiographic unilateral portal vein narrowing, bilateral portal vein narrowing, and complete portal vein obstruction with venous collateral formation, respectively . Furthermore, the ability of CT to predict that vein resection is necessary approximates to 40% . For these reasons, if the borderline resectable tumor with PMA invasion necessitates vascular resection to achieve a potentially curative resection, the focal contact between the neoplasm and the vascular wall is best considered a "black zone," because at histopathological examination, the resected vessel is subsequently confirmed to be infiltrated by tumor in only 20-30% of cases . In this respect, the severe desmoplastic reaction induced by pancreatic cancer contributes to the difficulty in the differentiation between adhesion and true vascular invasion. Thus, in this subgroup of patients, primary vascular resection may not be necessary. This difficulty in preoperative evaluation is related to the radiological definition of the vascular contact that differs from the pathological examination of the resected specimen.
The objective of the present study was to evaluate if the dissection of the tumor from the PMA in prVC could have similar surgical and oncologic outcome of a standard PD allowing surgeons to manage this situation without performing a vascular resection. In this single-center experience, a series of 40 prVC-PDAC were retrospectively compared with a comparable group of prwVC-PDAC, using a case-matched methodology, treated with standard PD. The use of IOUS proved to be very useful in the management of this prVC group as it enabled the definition of the limit of the PDAC and enabled differentiation between PMA involvements by the tumor from an inflammatory peritumoral process, enabling US-guided peeling with the preservation of PMA. The reported literature supports the usefulness of intraoperative ultrasound specially in identifying resectable head pancreatic lesions without infiltration of PMA [28, 29]. In fact, the adenocarcinoma appears as a hypoechogenic mass at IOUS, the margins and size of the lesion are more clearly visible and the relationship between the tumor and the critical vessels can be better evaluated.
Our study has demonstrated comparable oncologic results between the sPD and the nvrPD groups. Significantly, local recurrence was not higher in patients who had preservation of the vascular wall. Moreover, according to Zhou et al. who reported data that indicates that systemic progression is the leading cause of patients' death , we observed that the most important factor influencing long-term survival was the disease progression represented by peritoneal spread or hepatic metastasis. In fact, the patients' survival seems to be related to the aggressive biological behavior of the tumor, rather progressive local disease, although adequate resection to achieve local control remains important, but does not influence materially patient survival. In our opinion, the execution of a standard PD without vascular resection in some of these patients reduces the operative time, the length of hospital stays, and the morbidity without compromising clinical oncological outcome and overall survival.
The present study has some limitations, the first being related to its retrospective nature which inevitably raises possible selection bias. Secondly, the results of the prVC group could be overestimated as we did not include patients who underwent tangential or end-to-end vascular resection. However, the study underlines the importance of the intraoperative evaluation with US to specifically assess the extent of vascular and indeed the presence of vascular involvement to avoid the need for vascular resection during PD. In addition, to the best of our knowledge, this remains the first series comparing prwVC-PDAC and "no vascular resection" prVC-PDAC in a relatively large cohort, although we admit that further studies are needed to confirm the results of the present study.
PD without VR is a surgical approach that can be considered safe and oncologically acceptable in selected patients with preoperative prVC-PDAC. The poor prognosis of this disease is related to the aggressive biology and systemic spread of the tumor, rather than its local control. The present study does not support the need for vascular resection in all patients with prVC-PDAC.
The data used to support the findings of this study are available from the corresponding author upon request.
All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.
Conflicts of Interest
The authors declare that they have no conflict of interest.
Prof. Luca Morelli, Dr. Raffaella Berchiolli, Dr. Simone Guadagni, Dr. Matteo Palmeri, Dr. Niccolo Furbetta, Dr. Desiree Gianardi, Dr. Matteo Bianchini, Dr. Niccola Funel, Dr. Giovanni Caprili, Dr. Luca Emanuele Pollina, Prof. Giulio Di Candio, Prof. Franco Mosca, Dr. Gregorio Di Franco, and Prof. Alfred Cuschieri are responsible for the study conception and design. Prof. Luca Morelli, Dr. Simone Guadagni, Dr. Matteo Palmeri, Dr. Niccolo Furbetta, Dr. Desiree Gianardi, Dr. Matteo Bianchini, Dr. Niccola Funel, Dr. Giovanni Caprili, Dr. Luca Emanuele Pollina, and Dr. Gregorio Di Franco are responsible for the acquisition of data. Prof. Luca Morelli, Dr. Berchiolli Raffaella, Dr. Simone Guadagni, Dr. Matteo Palmeri, Dr. Niccolo Furbetta, Dr. Desiree Gianardi, Dr. Matteo Bianchini, Dr. Gregorio Di Franco analysed and interpreted the data. Prof. Luca Morelli, Dr. Berchiolli Raffaella, Dr. Simone Guadagni, Dr. Matteo Palmeri, Dr. Niccolo Furbetta, Dr. Desiree Gianardi, Dr. Matteo Bianchini, Dr. Niccola Funel, Dr. Giovanni Caprili, Dr. Luca Emanuele Pollina, and Dr. Gregorio Di Franco drafted the manuscript. Prof. Luca Morelli, Prof. Giulio Di Candio, Prof. Franco Mosca, and Prof. Alfred Cuschieri are responsible for the critical revision of manuscript.
The study was supported by the ARPA Foundation (http:// www.fondazionearpa.it).
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Luca Morelli (iD), (1,2) Raffaella Berchiolli, (3) Simone Guadagni, (1) Matteo Palmeri (iD), (1) Niccolo Furbetta (iD), (1) Desiree Gianardi, (1) Matteo Bianchini, (1) Niccola Funel (iD), (4) Giovanni Caprili, (1) Luca Emanuele Pollina, (4) Giulio Di Candio, (1) Franco Mosca, (2) Gregorio Di Franco (iD), (1) and Alfred Cuschieri (5)
(1) General Surgery, Department of Surgery, Translational and New Technologies in Medicine, University of Pisa, Italy
(2) EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Italy
(3) Vascular Surgery Unit, Department of Cardio Vascular Surgery, University of Pisa, Italy
(4) Division of Surgical Pathology, University of Pisa, Italy
(5) Institute for Medical Science and Technology, University of Dundee, Dundee, UK
Correspondence should be addressed to Luca Morelli; email@example.com
Received 24 September 2018; Accepted 25 October 2018; Published 25 November 2018
Academic Editor: Alessandro Zerbi
Caption: Figure 1: Disease-free survival (DFS) of the sPD and nvrPD groups.
Caption: Figure 2: Overall survival (OS) of the sPD and nvrPD groups.
Table 1: Patient characteristics and operative data. sPD group (n = 40) Mean age, year (range) 68.0 [+ or -] 11.1 (42-86) Male, n (%) 25 (62.5%) Female, n (%) 15 (37.5%) Mean body mass index, 25.0 [+ or -] 4.1 (16.1-39.0) kg/[m.sup.2](range) ASA score, n (%) ASA I 1 (2.5%) ASA II 10 (25%) ASA III 24 (60%) ASA IV 5 (12.5%) Neoadjuvant therapy, 0 n (%) Mean overall operative 435.9 [+ or -] 93.8 (280-745) time, min (range) nvrPD group (n = 40) p value Mean age, year (range) 68.8 [+ or -] 11.0 (46-92) 0.76 Male, n (%) 23 (57.5%) 0.65 Female, n (%) 27 (32.5%) Mean body mass index, 28.8 [+ or -] 5.0 (14.7-43.6) 0.99 kg/[m.sup.2](range) ASA score, n (%) ASA I 0 ASA II 6 (15%) 0.49 ASA III 28 (70%) ASA IV 6 (15%) Neoadjuvant therapy, 0 1 n (%) Mean overall operative 429.4 [+ or -] 86.1 (300-700) 0.75 time, min (range) Table 2: Postoperative and pathological data. sPD group (n = 40) Median length of postoperative stay, days 15 (12-23) [Q1-Q3] Overall complications, number of patients (%) 16 (40%) Clavien-Dindo classification of postoperative complications Grade I 2 (5%) Grade II 7 (17.52%) Grade III 4 (10%) Grade IV 2 (5%) Grade V 1 (2.5%) Medical complications, n (%) 10 (25%) 2016 ISGPS POPF, n (%) 3 (7.5%) Biochemical leak 2 (5%) Grade B POPF 1 (2.5%) Grade C POPF 2 (5%) Surgical complications, n (%) 6 (15%) Reintervention, n (%) 4 (10%) Mortality 1 (2.5%) nvrPD group (n = 40) p value Median length of postoperative stay, days 17 (12-29.5) 0.11 [Q1-Q3] Overall complications, number of patients (%) 22 (55%) 0.18 Clavien-Dindo classification of postoperative complications Grade I 5 (12.5%) Grade II 10 (25%) 0.69 Grade III 3 (7.5%) Grade IV 3 (7.5%) Grade V 1 (2.5%) Medical complications, n (%) 17 (42.5%) 0.10 2016 ISGPS POPF, n (%) 3 (7.5%) 1 Biochemical leak 4 (10%) Grade B POPF 0 0.59 Grade C POPF 3 (7.5%) Surgical complications, n (%) 5 (12.5%) 0.75 Reintervention, n (%) 3 (7.5%) 0.69 Mortality 1 (2.5%) 1 Table 3: Pathological data. sPD group (n = 82) Stage, n (%) Ia 1 (2.5%) Ib 0 IIa 8 (20.0%) IIb 29 (72.5%) III 1 (2.5%) Perineural space infiltration, n (%) 27 (67.5%) Vascular space infiltration, n (%) 12 (30%) Vascular bed infiltrations, n (%) 3 (7.5%) Mean lymph node harvest, n (range) 28.4 [+ or -] 13.4 (10-84) Patient with positive lymph nodes, n (%) 29 (72.5%) Grading, n (%) G1 1 (2.5%) G2 33 (82.5%) G3 6 (15%) R-status, n (%) R0 37 (92.5%) R1 3 (7.5%) nvrPD group (n = 34) Stage, n (%) Ia 2 (5%) Ib 1 (2.5%) IIa 7 (17.5%) IIb 29 (72.5%) III 2 (5%) Perineural space infiltration, n (%) 33 (82.5%) Vascular space infiltration, n (%) 14 (35%) Vascular bed infiltrations, n (%) 5 (12.5%) Mean lymph node harvest, n (range) 31.5 [+ or -] 14.1 (9-69) Patient with positive lymph nodes, n (%) 30 (75%) Grading, n (%) G1 2 (5%) G2 29 (72.5%) G3 9 (22.5%) R-status, n (%) R0 36 (90%) R1 4 (10%) p value Stage, n (%) Ia Ib 0.79 IIa IIb III Perineural space infiltration, n (%) 0.12 Vascular space infiltration, n (%) 0.63 Vascular bed infiltrations, n (%) 0.46 Mean lymph node harvest, n (range) 0.32 Patient with positive lymph nodes, n (%) 0.80 Grading, n (%) G1 0.55 G2 G3 R-status, n (%) R0 0.69 R1 Table 4: Follow-up data. sPD group nvrPD group p value (n = 40) (n = 40) Adjuvant therapy (n, %) 21 (52.5%) 20 (50%) 0.82 Isolated local recurrence 2 (5%) 2 (5%) 1 (n, %) Systemic progression 17 (42.5%) 18 (45%) 0.82 (n, %) Local and systemic disease 1 (2.5%) 3 (7.5%) 0.30 (n, %)
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Clinical Study|
|Author:||Morelli, Luca; Berchiolli, Raffaella; Guadagni, Simone; Palmeri, Matteo; Furbetta, Niccolo; Gianardi|
|Publication:||Gastroenterology Research and Practice|
|Article Type:||Case study|
|Date:||Jan 1, 2018|
|Previous Article:||The Polymorphisms at PRSS1-PRSS2 and MORC4 Loci and the Risk of Post-ERCP Pancreatitis.|
|Next Article:||Persuasion, Adaptation, and Double Identity: Qualitative Study on the Psychological Impact of a Screen-Detected Colorectal Cancer Diagnosis.|

domain: literature


text:
The Colorado baker who triumphed in the Supreme Court over his right to refuse to bake a wedding cake for a same-sex couple on religious grounds is now suing the state over his refusal to bake a cake for a trans woman.
In June 2018, Autumn Scardino said she asked for a cake to celebrate the anniversary of her transition – with blue on the outside and pink on the inside – and was refused, NPR reported.
In June, regulators in Colorado ruled there was enough evidence to support a claim of discrimination and sent Scardino and Phillips to court-ordered mediation.
“The woman on the phone told me they do not make cakes celebrating gender changes,” Scardino wrote in her complaint.
“That’s a cake I can’t create for anybody,” Phillips said. “I know the Bible says that God created male and female and that we don’t get to choose that, and we don’t get to change that.
“And I don’t feel like the government has a right to compel me to participate in creating a cake that promotes that message,” he told Colorado Public Radio.
Phillips is suing the state seeking a permanent injunction to prevent anti-discrimination laws being enforced against him.
He is also seeking $100,000 in damages.
Colorado’s governor, John Hickenlooper, is named as the defendant in the case and has said that it’s expected the case will head to the Supreme Court all over again.
The verdict handed down in the same-sex wedding case did not clarify if refusing to provide goods and services to LGBTI people is a matter of free speech.
The decision comes after, in recent months, a New Zealand baker refused to make a wedding cake for a lesbian couple from Brisbane.

domain: sociology


text:
"Don’t bend; don’t water it down; don’t try to make it logical; don’t edit your own soul according to the fashion. Rather, follow your most intense obsessions mercilessly."
"To attain knowledge, add things every day. To attain wisdom, remove things every day."
— Tao Te Ching


text:
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A Counter-Strike: Source (CS:S) Forum Thread in the Customization category, submitted by aireX92. My best frag movie.Clanxa Xtreme Assassins. CS 1.6 | Professional [Frag Movie] Oldschool-style Frag Movie by Rodolfo Roth of Hard Pictures starring some of the worlds best Counter.We bring you the latest CS:GO. Cloud 9's run to the Major final was straight out of a hollywood movie. This week I revel in the best of. Counter-Strike has a.So I've recently found myself watching more frag movies than I have in the past and I'm just curious as to which edits you guys enjoy watching the. Best CS: GO.

domain: entertainment


text:
The occurrences of natural disasters are uncertain, but not totally random. Knowing what warning signs to look out for before a tragedy strikes can help you stay out of harm’s way.
Had you ever been hiking in the woods and seen a patch of trees bent into a J shape? Well, you might have escaped a disaster because that’s a sign of an impending landslide. Here the ground has been shifting slowly, making the trees grow strangely. Another sign of potential landslide is cracking in the ground, which can happen on the sidewalk, street, or dirt itself. Landslides occur on slopes though, so if you’re in a flat area, you’re probably safe.
If you want to try skating or just take a walk on a frozen lake, you should first make sure it’s safe. A quick look at the color can be a good first step to determine its safety. If it’s clear and blue, it’s probably safer than if it’s white or gray.
Dogs are good at telling you things, even if they can’t speak our language. So, if your dog is sniffing, licking or biting a particular part of your body more than usual, you’d better get it checked out. Dogs have such a powerful nose that they can sniff out evidence of cancer, and there have been plenty of cases that have proven it.
Lying on the grass and watching fluffy white clouds may be a peaceful way to kill time, but if you find yourself watching a wall of cloud, go to the shelter. This wall of cloud is lower than the rest of the thunderstorm and can be up to 5 miles long. If the cloud is rotating, it can cause a destructive tornado.
Be careful when you see a lot of dead fish or other dead animals on the beach, because the water might be poisonous. Chances are that a red tide is gathering in the water near the beach. When the water contains more toxic algae than normal, it’s called a red tide. The toxic algae can make the water reddish or brown, but sometimes the water’s color is normal. If you go into the water, you could develop respiratory symptoms, such as coughing and an itchy throat.
While avalanches are sudden, there are typically some warning signs you can look for or feel before one occurs. Do you hear a “whumping” sound as you walk on the snow? Does the ground feel hollow underfoot? Check around your feet for cracks in the snow. If there has been a heavy snowfall in the past 24 hours, significant temperature rise, or nearby avalanche activity, it should put you on red alert for a potential avalanche.
Generally, animals can sense an earthquake a few seconds earlier than humans, because they detect the initial micro waves that we can’t feel.
When a fire occurs, of course, you are usually able to see and often smell the smoke. But if you’re standing at a distance, look out for birds and mammals flying and running in your direction, and pay attention to whether the wind is blowing towards you. This could mean that you’re standing in the fire’s path and you need to evacuate immediately.
You might not know it but humans are 30 times more likely to be struck by lightning than attacked by a shark. If your hair starts standing on end and your jewelry starts buzzing, lightning is likely to strike very close to you. Get to shelter immediately, or if you can’t, squat down on the ground and make yourself a small target. Touch the ground as little as possible and leave the area when you can.
Usually, the ocean has a calming and pleasant sound that many people like to fall asleep to, but sometimes, it roars like a train. If you hear this unusual sound, it’s likely that a tsunami is coming towards you, so get away immediately.
If you’re walking on the beach along the Pacific coast, and the waterline starts receding, you may be in trouble. Don’t waste any time looking at the flopping fishes or pretty corals, run to high ground as fast as you can, because a tsunami may be coming.
When around bees, the most important thing to do is not threaten or hit them. However, bees are attracted to sweet smelling and bright things, so accidents can happen – People get stung. A bee will die after stinging mammals, but the dead bee releases pheromones that call on nearby bees to attack. So, if you get stung and you’re near a hive, you should run to shelter, covering your head and face as best as you can.
If you see an area of choppy water in the sea, where seaweed and debris seem to be moving away from the shore, a strange gap in the waves, or even just section of discolored water, it’s likely that a deadly rip current lies underneath. Rip currents, commonly mistaken for riptides, are very fast, powerful channels of water flowing away from the shore. Swimmers who are caught in a rip current should swim parallel to the shore until out of it.
This oceanic pattern occurs when the waves from two weather systems that are far from each other meet. Waves from one weather system continue despite the wind shifting. Waves from the other weather system run at an angle, creating a shifting, dangerous pattern. Such a state is called a cross sea, which can be incredibly dangerous for ships, surfers, and swimmers.
The deadliest mushrooms belong to the Amanita genus, which includes the destroying angel and the death cap. Both of them look pretty ordinary. The destroying angel is all white, while the death cap can be yellow, green, brown or tan or rarely white. Most Amanitas live near trees, so it’s best not to eat any mushroom growing near a tree unless you’re an expert at identifying them.
Have you ever heard the old saying “Red sky at night, sailor’s delight, red sky in the morning, sailor’s warning?” Does it have any truth in it? Well, it does a bit. A red sky at night means that the setting sun is sending its light through a high concentration of dust particles. This usually indicates high pressure and stable air coming in from the west. Basically then, good weather will follow. A red sunrise can mean that good weather has already passed and a low-pressure system and a storm are moving to the east.
Bulls are notoriously dangerous, but cows can also be dangerous. More people die each year from cows than sharks, so you should be attentive when around these animals. If you see a cow pawing at the ground or snorting, you should get something between the two of you, like a tree or a feeding trough.
A funnel cloud is a rotating cone of air that does not touch the ground, but the wind and the effects of the circulation may still have significant impact at ground level, causing extensive damage. If the funnel cloud reaches the ground, then it becomes a tornado. Strong tornadoes are one of nature’s most destructive forces.
Of course, one of the most famous warning signs in nature is the rattlesnake’s rattle. The snake uses the rattle to warn enemies and predators not to get too close. If you do, it will bite you and inject its venom. The venom is normally used for killing small mammals for food.
Volcanoes can be very cool to visit, but as we all know, they can be deadly, too. So how do you tell if a volcano is about to erupt? Well, there may be a small earthquake under the volcano. Plus, it could swell and release more heat and gas. However, these signs are hard for the average person to notice. Luckily, we have volcanologists who constantly monitor the signals using technology.

domain: geography


edit In March 2007, Shakur, already sought by police for parole violations and named on the city's most-wanted gang members list, was arrested by the Los Angeles Police Department for allegedly breaking into the home of an acquaintance and beating him in order. His gang member friends try to give him money and drugs right away so that he can delve right back into a life of illegal activity and crime. The things that are absent from the streets that Shakur sees were also absent from his life. In the absence of that positive reinforcement their organizational skills turn to forming a successful set that will have adequate numbers and sufficient weapons to launch an attack on gang rivals. Kershawn shot two teenagers who were standing in the front yard at a house party that was being thrown in the Rollin' 60's neighborhood and later that evening shot another teenager to death in a drive-by as the young man was walking down the street. Microeconomics research paper outline nursing career research paper outline! The reactions of his friends and family to his new attitude and outlook on life illustrate the reinforcement of social disorganization. Monster, is a former member of the. He was released from Pelican Bay after serving two-thirds of his 6-year sentence in August 2012. This illustration paints a picture of a neighbourhood that is rife with the characteristics of a socially disorganized environment.
In a subsequent fistfight between the two teenagers a new recruit to the ETG's, eager to make a name for himself, pulled a gun and fatally shot Tyrone. On the evening of June 15, 1975, the day of his sixth-grade graduation, Kody was initiated into the ETG's. But the gang members hes organizing with have not been taught how to organize themselves for a positive goal, like a school athletic team or a church choir or study group. 5, also in 2008, Shakur made his fiction debut with the publication. The social network that should have existed within the community as a source of strength and positive reinforcement was replaced by a social network within the gang community, spreading violence and drug use throughout a community weakened by lack of leadership and socially positive structures. In the article Kody stated that he was incredulous after hearing Knight's claim that Tupac died owing him money despite selling over 60 million USD worth of albums for Death Row Records, and that he knew that all of Tupac's possessions, including his home and. Washington's murder was blamed on the Hoover Crips (now known as the Hoover Criminals or Hoover Gang which started a war between the East Side Crips and the Hoovers. Later, after being released from prison, Shakur reflects on his neighbourhood that he grew up in and recognizes its shortcomings: I couldnt believe the drabness of the city.
Sanyika Shakur is a true survivor, considering everything that has taken place in his life he has managed to make something of himself from nothing. Kody Scott was born into the gang life weither he liked it or not. Born on 1963 in South Central Los show more content. Monster by Sanyika Shakur aka Monster Kody Scott Growing up in a world of gangs, death, and suffering Kody Scott also known as Monster Kody grew up in a life of struggle. From eleven years old Kody knew what he wanted a to be, a gangster.
When these institutions degrade and stop playing active roles in the lives of the citizens of a community, the organization and social responsibility of the community is lost and crime and negative behaviour can spread in their place. The ETG's opened fire on a group of approximately fifteen Brims, shooting several of them. He has been given no reinforcement from his family unit, a family where there is seemingly little or no structure, so he finds that structure and reinforcement, along with the promise of better things, in gang life. 2 3, shakur claimed to have reformed in prison, joined the. The social disorganization theory, formulated by Burgess, Shaw and McKay, proposes that delinquency and crime are the results of communal institutions like family, church, school and local government fail and stop being active structures within a community. Tyrone's older brother, a member of the Rollin' 60's, demanded that the ETG's hand over the new recruit to be punished by the 60's and to prevent a war between the two gangs.


text:
A hierarchical hollow SnO/SnO2 heterostructure anode surrounded by a dual carbon layer (DCL@SnO/SnO2), inner (host) and outer carbon layers, was successfully designed via a simple hydrothermal method with a single Sn precursor to achieving high-performance Li-ion batteries (LIBs) and Li-ion capacitors (LICs). The carbon nanotube (CNT)-based inner carbon host and an ultrathin outer amorphous carbon layer introduced at the SnO/SnO2 heterostructure had good elasticity and high electrical properties to prevent volume change and ensure fast Li-ion transport during cycling, respectively. Meanwhile, the SnO/SnO2 heterostructure comprising p-type SnO and n-type SnO2 facilitated further fast interfacial Li-ion transfer within the p–n SnO/SnO2 heterojunction anode via the acceleration effect induced by the built-in electric field (BEF). The resulting half cells LIBs consisting DCL@SnO/SnO2 anode shows a high reversible specific capacity of 902.1 mAh g−1 after 500 cycles at a current density of 1400 mA g−1. The specific capacity of 347.04 mAh g−1 was still maintained even at a high current density of 10 000 mA g−1. Moreover, the maximum energy and power density of 125 W kg−1 and 200 Wh kg−1, respectively, were achieved from the half cells LIC comprising DCL@SnO/SnO2 anode (LIC-DCL@SnO/SnO2).
ASJC Scopus subject areas
- Materials Science(all)

domain: chemistry


text:
So many of you left kind words on my morning post about wishing me well on my tests and doctor appointment today. I ended up getting back just in time to beat the regularly scheduled blog post and thought I would give you an update and not make you wait until tomorrow. I know you all hate waiting as I do.
Kalissa drove me over to Lacrosse….and what’s a trip to the doctor in Lacrosse without a picture of the bridge over the Mississippi. It’s kind of my tradition to take one.
Here we are. Although Kalissa couldn’t go to my appointment with me, it was nice to have her with. She happened to have an orthodontist appointment on the same day.
She stopped at Once Upon a Child and bought Carver summer clothes to kill the time waiting for me.
My first stop was to get a Chest CT scan. That took about 10 minutes and then it was on to get my PET scan.
EXACTLY one year ago today I sat in the same waiting room in the same chair watching this very same clock as Kramer was getting his PET scan. I’ll admit…it was a tough moment. As that’s the day we learned he only had a short while to live as his PET scan showed he was full of cancer.
I couldn’t help but wonder a bit what my result would be. How ironic that I’d have a PET scan exactly one year later.
Having a PET scan done isn’t hard…fun no, but not hard. Don’t be afraid of them is it comes your time to get one. It’s a simple IV injection, a nap (yes seriously a 45 minute nap) and then the scan.
The patient lies on this bed and the machine takes them into the tube. I got a strap around my head, chest and feet so I couldn’t move. I was in the tube for about 25 minutes.
After that, I went to the waiting room of my doctor to meet with her. I was early but she got me in right away.
Here are the results:
Nothing. I know that’s kind of frustrating…but seriously there was nothing.
In a previous Chest CT scan there was a tiny nodule in my lung they were following. It’s gone. People can get them from a cold..so it disappeared. I do have a new one in my right lower lung that is 1/2 cm. They aren’t concerned about it at all as it could easily disappear too.
The PET scan showed nothing. No cancer.
YET, my blood work shows cancer. So, what do we do? Here’s the plan:
I am being referred back to Mayo Clinic. They are going to see if they can do anything there. My insurance is an issue if I go there though as it’s “out of network”. We’ll see what they find out….likely nothing again…but we’ll see.
I will likely go through the icky diet and full body scan and will likely be treated blindy for thyroid cancer with another dose of radioactive iodine.
but…that’s all up in the air until Mayo has their turn at me.
I guess there is a name for a case like mine. It’s called Incomplete Biochemical Response. That means nothing shows up on imaging but I have an increasing thyroglobulin tumor marker.
So home I went with no real answers. It was all anticlimactic. I do have to say, as disappointing as it was to not know anything, I’ll take this news over the news I got with Kramer a year ago on this day. He was loaded with cancer…and feeling terrible.
I feel normal…I did talk to her about my medicine and we’re doing a little tweaking with that. I unexpectedly lost 12 pounds. If you’re diabetic, and you weren’t really trying to lose weight, that’s a whole thing. I do attribute much of it to change of lifestyle in general…but something we need to keep an eye on.
So on the way home I stopped at WalMart pharmacy. Remember all the trouble I had with getting my Jardiance three month ago….and it went from over $1100
to $260 for a 30 day supply
to $230 for a 90 day supply
to $150 for a 90 day supply….(read about that HERE)
Well today it cost me NOTHING. Go figure.
Once home I got a note from my doctor. I was to call to Mayo Clinic in Rochester and make an appointment. I went through a long process and finally got to the scheduler. She told me the first appointment was August 4th. Well that frustrated me to no end so I told her I wouldn’t accept that date. Instead I would call my doctor who referred me and have her office call to schedule the appointment for me and they would likely get a quicker appointment….and just like that, the a June 29th appointment opened up. AMAZING how that worked. I didn’t mean to be bitchy but seriously, I was put off by covid and my cancer more than doubled. What would the number do by waiting another 10 weeks. UGH.
From there it was a call to my insurance. Mayo Clinic is “out of my network” so there was a whole line of paperwork to get that approved too but it’s started.
So now we wait until the 29th….I now understand why my surgeon told me that thyroid cancer is a good one to get if you have to get a cancer but it really nickels and dimes a person to death.
I’m happy and feel well and think in the end…that’s really all that matters. I’ve waited to see doctors…I’ve waited for results….I can wait again.

domain: health


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Dr. James Hansen is the former NASA scientist who first testified to the US Congress about the dangers of greenhouse gases. 34 years ago this month, he told the August body that he was 99% sure that the rise in global average temperatures was caused by an accumulation of carbon dioxide and other artificial gases in the atmosphere as a result of human activity.
Of course, no one listened to Dr. Hansen then, and that is one of the reasons why we are today on the brink of a global climate catastrophe. To make matters worse, the reactionary soldiers of the U.S. Supreme Court are ready to send a legal thunder down this week, stating that the federal government has no business regulating carbon emissions under the Clean Air Act. But Hansen and several of his colleagues have anticipated the court’s forthcoming verdict and have written to the Danish Environmental Protection Agency with a proposal that they believe will save the day.
Together with Donn Viviani, who spent 35 years with the EPA before retiring, Hansen has filed a legal document with the EPA claiming that greenhouse gas emissions pose a danger to the climate and should be regulated as such under the Toxic Substances Control Act, a law passed in 1976 as part of a series of environmental regulations in the United States.
“Using TSCA would be a small step for [the US president] Joe Biden, but potentially a huge leap for humanity – as a first step towards getting the polluters to pay, “Hansen said according to a report from The Guardian. The TSCA, which was amended in 2016, allows the EPA to impose regulatory requirements on companies and enforce strict controls on certain substances. It has been used to curb chemicals including asbestos, lead in paints and PCBs.
It covers substances that pose “an unreasonable risk of harm to health or the environment.” Hansen and Viviani believe that this can be interpreted to allow for a phasing out of greenhouse gas emissions. “TSCA is like the ruby slippers [in The Wizard of Oz] – it can do almost anything. It can allow you to levy a tax on carbon and can handle the legacy of carbon emissions. It has almost international reach, as the USA is the largest market in the world and could also apply these measures to imports, ”says Viviani.
To support their claims, Hansen and Vivianid, along with several other people who are part of the petition, have filed “a mountain worth” of scientific studies showing the impact of greenhouse gases on the weather, resulting in forest fires, heat waves, severe drought, rising sea levels and increasingly acidified seas.
The United States has a recent history of trying to regulate carbon dioxide under existing environmental legislation, as Congress has often been reluctant to consider enacting laws to limit greenhouse gas emissions. Barack Obama was unable to get his climate legislation through the Republican-dominated Congress. He tried to use the Clean Air Act – another of the environmental achievements of the 1970s – to regulate carbon dioxide emissions from power plants, but under Trump the Terrible, that effort was reversed. This week, the US Supreme Court will decide whether the EPA should have CO2-regulating powers at all, but Hansen believes that the change to TCSA in 2016 provides a fresh basis on which to present the argument again.
“TSCA is different,” Hansen says. “It’s better than the Clean Air Act. CAA was a possible remedy for a rising CO2 fee because the Supreme Court of Massachusetts vs. EPA ruled that CO2 was a pollutant. However, there is a very strong suspicion that if CAA is used on that way, the current Conservative Supreme Court will overturn that decision, which they can not easily do with the TSCA, which was adopted by Congress and confirmed [in 2016] with bipartisan support. “
Some climate activists have criticized President Biden for what they see as a lack of action in the face of the climate crisis, despite prioritizing it in the early days of his presidency. The war in Ukraine and rising energy prices have led the White House to highlight new gas extraction as an alternative to Russian supplies. Obstructionism by Despicable Joe Manchin has also been a factor.
Viviani tells The Guardian, “President Biden is an empathetic man; we hope he is a brave man too. We hope he will use both his empathy and courage to pick up on this tool he has in TSCA and use it to give hope that a solution will be found for the many millions of young people, and indeed all of us. “Under the provisions of the TSCA, the EPA has 90 days to consider and act on the legal request.
In addition to Hansen and Viviani, the other petitioners include Lise Van Susteren, Professor of Psychiatry and Behavioral Sciences at George Washington University, John Birks, Emeritus Professor of Atmospheric Chemistry at the University of Colorado Boulder, Richard Heede of the Climate Accountability Institute, and the Climate Protection and Recovery Initiative.
For more on the petition of Hansen, Viviandi and others, watch this video by James Hansen and his colleagues, which was brought to the attention of Dan Allard.
How is it possible that the US Supreme Court could at all think to judge against constructive climate action? The answer is simple. The six so-called judges who pose as “conservatives” are men who were dieted throughout their legal careers by the Federalist Society, one of the many tentacles of Koch Industries, the conglomerate led by Charles Koch.
For 50 years, Koch has funded opposition to the New Deal, government regulation, the civil rights movement, the Woodstock generation, and almost every progressive initiative you can imagine. Much of the money Koch has invested in his vicious plans has been spent on protecting his God given the right to extract and burn fossil fuels.
These judges were anointed to the bench with the understanding that they would do everything in their power to protect the business model of their benefactor. They are not there to serve the Constitution or protect democracy. They’re there to protect Charles Koch’s business interests first and foremost, and that’s exactly what they intend to do.
When done, America will be a theocracy dominated by white men. Hansen and company may believe that the law on the control of toxic substances will prevent a perversion of climate initiatives, but they must keep in mind that what Congress adopts one day may be undone by an upcoming Congress another day.
Elections have consequences. And if the U.S. Congress sneaks right after the midterm elections this fall, there will be nothing left of America to preserve while the fire of conservatism sweeps through Congress and legally achieves what the treacherous troublemakers on January 6, 2021 could not.
We welcome Dr. James Hansen for working tirelessly to keep climate change at the center of people’s minds and praying that his and his colleagues’ efforts are enough to prevent America from slipping off track and becoming a nation that puts the fear of homosexuals ahead of effective climate action.
See our brand new E-bike guide. If you are curious about electric bikes, this is the best place to start your e-mobility journey!
Do you appreciate CleanTechnica’s originality and cleantech news coverage? Consider becoming a CleanTechnica member, supporter, technician or ambassador – or patron of Patreon.

domain: news


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Pros: All Stainless for easy cleaning. The Big Bite Augar is really amazing. The large meat tray is very nice.
Cons: The meat stomper is hollow plastic.
I purchased the LEM #22 Grinder late last fall and have been very happy with it. I have run about 800 lbs of meat through it so far and have not had any issues. It is very strong and very fast. The Big Bite Auger works as advertised and is a big improvement over my standard #22 open throat grinder. The meat pieces do not bounce on the auger threads until pushed. The threads grab the meat and immediately start pushing it forward to the knife and plate. When feeding meat it is more like pushing meat into a drain than stuffing meat into the throat. For the first grind I do not need the meat pusher. I do need the meat pusher when doing a second grind. The meat sometimes sticks to the side of the throat on the 2nd grind. The height of the grinder plate is very nice. I use 6" steam pans and they fit very well.
I have not tried stuffing with the stuffer tubes but I think the Big Bite Auger would do better than a conventional auger.
The meat pusher is hollow plastic and has a cheap feel to it. It would be handy if the unit would have a cord holder of some type.
Overall this is a very nice and very well built unit.

domain: food


text:
Anna Netrebko Brings Down the Metropolitan Opera as Lady Macbeth in Verdi's Classic
One would think that if Anna Netrebko announced a new role, it would be met with excitement. However, this wasn't the case when Anna said she would go out for Lady Macbeth. But in light of her performance in Verdi's classic, Netrebko proved she can transcend any role.
Being labeled a "crazy gamble," it's obvious why skeptics would think she couldn't take on the responsibilities of a dramatic soprano. But like her incendiary personality, her Lady Macbeth has been stirring up theater-goers of the Metropolitan Opera like a firestorm.
Michael Cooper at The New York Times recounted the minutes from Friday night's performance, acknowledging that Netrebko's "demented performance" was so exciting that it propelled "both artist and audience figuratively on the brink of madness."
The 43-year-old has since wanted to take on an arsenal of new roles, this being the first of the series. She wants to sing a more dramatic repertoire, an operatic repertory that includes Bellini's Norma, of which 'Trebko will open the Met's 2017–18 season.
Even Mr. Peter Gelb heralded the singer that he championed with his Opera in recent years. Praising her of her Macbeth performance, he said the singer was "at the top of her game."
Check out Cooper's review here. And needing no introduction, here she is below.© 2016 The Classical Art, All rights reserved. Do not reproduce without permission.

domain: celebrity


text:
We may also receive compensation if you click on certain links posted on our site. While compensation arrangements may affect the order, position or placement of product information, it doesn’t influence our assessment of those products. Please don’t interpret the order in which products appear on our Site as any endorsement or recommendation from us. Finder.com compares a wide range of products, providers and services but we don’t provide information on all available products, providers or services. Please appreciate that there may be other options available to you than the products, providers or services covered by our service. Browse a variety of coin offerings in one of the largest multi-cryptocurrency exchanges and pay in cryptocurrency. FTX exchange offers a range of cryptocurrencies, up to 10x leverage, access to global liquidity, no-fee debit cards for FTX users, fee-free first ACH deposit and benefits for FTT token holders. Copy the trades of leading cryptocurrency investors on this unique social investment platform. Since you are trading crypto CFDs and not actually purchasing the digital currency, you can profit from both rising and falling markets.
We provide excellent online services than any other professional web development and Digital marketing company in UAE, India. All functions of the portal (checking indicative prices / confirming trades) will be available when you log-in to your Binance account. Today, almost every country has its own currency, with the exception of countries with a common currency or countries that have adopted a foreign currency . Thus, there are worldwide more than 160 official currencies that can be traded on the currency market at constantly changing exchange rates. On the currency market, there is a larger trade volume than on the credit or the stock market.
Btc To Usd Converter
The recent crackdown dented Bitcoin’s infrastructure, which subsequently weighed heavily on the price of the coin. There have been positive headlines hitting the wires too – the US levies capital gains tax on cryptocurrencies, which implies a positive step. By exchanging BTC against fiat currencies (such as the U.S. dollar or Japanese yen) or using them as payment for goods and services, Bitcoin can be earned or received in various ways. BTC considers as the most popular cryptocurrency, and on the other side, USD is the most demanding fiat currency globally. The given all are fiat currency and the most widespread pairs in the market. While institutional money is a major positive for cryptocurrencies, the launch of a Bitcoin ETF would go a long way in rubberstamping its legitimacy.
- Data may be intentionally delayed pursuant to supplier requirements.
- First, in contrast to 2017 when retail money entered the crypto space, in 2020 it was big, institutional money flowing into the scene.
- Laws and regulations for foreign exchange should be amended if needed to cover crypto alongside traditional assets, the global stability watchdog said.
- BTC considers as the most popular cryptocurrency, and on the other side, USD is the most demanding fiat currency globally.
- Currency traders are familiar with the major currency pairs, and often a good number of the minor pairs.
- Going forward, cryptocurrency investors will particularly be buoyed by flexible, principle-based, and collaborative regulation efforts by the relevant agencies.
Founded in 2013, CoinMama lets you buy and sell popular cryptos with a range of payment options and quick delivery. Buy, sell and earn cryptocurrency with this user-friendly exchange and smartphone app. Instantly purchase a handful of leading cryptocurrencies with the SoFi app, which also insures your coins against potential hacks or theft. If you’re interested investing in any cryptocurrency, the potential of your investment depends heavily on the market. Despite today’s wild headlines, there’s no single cryptocurrency that guarantees a positive return. With AvaTrade, you do not need to create a wallet to trade cryptocurrency. Beyond fundamentals, BTCUSD also has an interesting technical picture worth a look at. At just above $30,000, Bitcoin has already done a 50% retracement off its all-time highs, with that level also being a 1.618 Fibonacci extension of the previous cycle that peaked in late 2017. The price has also been consolidating in the $30,000-$40,000 price range for a while now, and it is only a bit realistic to anticipate a breakout soon. Volatility will likely come sooner rather than later in either direction.
Usd To Btc
Bitcoin market price is updated every three minutes and is automatically displayed in USD. Signing up for an account involves providing your name, date of birth, address, email address, phone number, and other personal information. You’ll also be required to provide a bank account, an electronic payment service like PayPal, or both . To find more supportive info for their suggestions, experienced traders often check the market depth formed by the order book records. This indicator visually https://www.beaxy.com/ reflects how many customers are willing to buy or sell Bitcoin for a particular price. Instant Buy Buy crypto with your credit or debit card in a few clicks. Bitcoins and other cryptocurrencies like Etherium are relatively easy to use and can be converted into USD. Of course, anyone hoping to use cryptocurrency needs to be keeping track of their value. Rubix is one of the leading decentralized exchange platforms where one can buy, sell and exchange cryptocurrencies quickly and securely.
You can convert, purchase and sell cryptocurrency with ease, keeping track of rates through the convenient Rubix Conversion tool. Conversion rates are based on CoinDesk’s Bitcoin Price Index and the price indices of other digital assets. World currency prices are based on rates obtained via Open Exchange Rates. Some marketplaces enable you to load your bitcoins onto a debit card that automatically converts them to dollars. These points are just a few reasons why people prefer virtual currencies against traditional fiat funds. Mainly, crypto transactions are highly secured with hashing algorithms, simple in use, and are not regulated by a single entity . The answer is simple — the higher the trading volume is, the more people are supporting the current trend. Check live rates, send money securely, set rate alerts, receive notifications and more. Smartwebsolutions is website design and Digital marketing company IN DUBAI AND KERALA. We offer complete web-business solutions for all type of businesses of all sizes. We have developed more than 30+ websites in the past Three years and currently provide Search Engine Optimisation services to over 10 businesses.
Convert Bitcoin To Dollars
These percentages show how much the exchange rate has fluctuated over the last 30 and 90-day periods. These are the lowest points the exchange rate has been at in the last 30 and 90-day periods. These are the highest points the exchange rate has been at in the last 30 and 90-day periods. In ten years this value increased by million times and the last highest point the BTC has reached was nearly $62,000. See the Bitcoin exchange rate i.e. the current value of one bitcoin. Create a chart for any currency pair in the world to see their currency history. These currency charts use live mid-market rates, are easy to use, and are very reliable.
You have heard of beaxy exchange no? Where were you? 🤔
— $HOT-PROPHET (@DrCryptoTony) March 22, 2022
Yahoo Finance’s Jared Blikre examines the market action in the day’s final trading hour, volatility levels, Treasury yields, the U.S. dollar, sector actions, and cryptocurrency price actions. Our currency rankings show that the most popular Bitcoin exchange rate is the XBT to USD rate. There is no official ISO code for Bitcoins, although XBT is commonly used. While energy use by crypto miners is not yet a concern in India, the country has over 10 million crypto investors by some estimates. India is in the process of preparing regulations regarding cryptocurrencies and the situation is foggy as of now. In addition, various regulators in the UK, Spain and Singapore have tightened rules on crypto-asset promotion, which is causing a fall in the cryptocurrency market. The crypto market sell-off continues, with Bitcoin down once again to start the week. Finder.com is an independent comparison platform and information service that aims to provide you with the tools you need to make better decisions. While we are independent, the offers that appear on this site are from companies from which finder.com receives compensation. We may receive compensation from our partners for placement of their products or services.
Conversion Rates Bitcoin Btc To Us Dollar Usd
If you want to actually convert bitcoin to dollars, deposit them in a digital marketplace and sell them to an interested buyer. The digital marketplace will quickly and easily convert your bitcoins to dollars and transfer them to a debit card, bank account, or digital wallet of your choice. When you’re looking for a place where to buy Bitcoin or other virtual currencies, a robust crypto exchange platform will come in handy. When using cards online, people care most about the security of their operations and card data. So, when you found a Bitcoin trading platform, make sure it’s secure enough before making any operations. Cryptocurrencies have taken currency and digitalized it, allowing for the swift transfer of currency without the involvement of any third party. You can also use our Bitcoin price table above to check the latest Bitcoin price in major fiat and crypto currencies.
As a rule, verification takes a few minutes to provide necessary information and photos. We know people with the nickname, Satoshi Nakamoto, as the Bitcoin creators. But we shouldn’t forget that they have also created the first blockchain — the only kind of digital network where cryptocurrencies can operate. Even before BTC developers launched the first distributed ledger, the concept of blockchain was described by different computer scientists. Please note that technical indicators don’t provide a full representation of what’s happening in the cryptocurrency market. Before making the decision to buy or sell any cryptocurrency, you should carefully consider both technical and fundamental factors, as well as your financial situation. Natalie Arabian dropped out of college once she started making a lot of money from her crypto investments. The ultimate tools for crypto traders to maximize trading profits while minimizing risk and loss. Our trained team of editors and researchers validate articles for accuracy and comprehensiveness.
However, it doesn’t mean that you can not withdraw your digital funds when you need them. To cover the customers’ transactions, CEX.IO keeps the company’s funds on hot wallets. In our modern life, this new technology finds .1 btc to usd a lot of use cases outside the digital industry. The genesis of Bitcoin came during the 2008 global financial crisis, and initially, crypto was touted as the future of money, essentially as an alternative to fiat.

domain: finance


text:
The Chrysler brand and ABC’s “Jimmy Kimmel Live!” not only celebrated, but surprised Massachusetts nurse Florence Njoroge with a brand-new 2020 Chrysler Pacifica modified for wheelchair access by Vantage Mobility International. The acknowledgement took place during Kimmel’s weekly Health Care Hero segment, which pays tribute to those on the front lines of the COVID-19 crisis.
“We at VMI understand how important it is for families to have a safe and reliable vehicle that is accessible for every member of the family,” said Mark Shaughnessy, CEO of Vantage Mobility International. “Our core value is to never forget the challenges that our customers face, and to that end, we continue to partner with automakers such as Chrysler to ensure that those with mobility challenges have access to solutions that enable greater independence and make daily living activities just a little bit easier.”
The Health Care Hero nomination letter was submitted by Florence Njoroge’s son, Jayson, who recognized her as a hero for working as a geriatric nurse at a local nursing home and rehab care facility in Massachusetts. Jayson continued his letter by lauding Florence for her unending devotion to provide full-time care to his dad and her husband of 20 years, who has bravely been fighting ALS for the last decade.
Jayson wrote about his mother’s constant optimism and smile – while urging how a mobility vehicle would totally change their lives. He knew that an accessible vehicle would provide much-deserved normalcy, mobility and freedom to Florence, her husband and their three children.

domain: medical


After numerous attempts to sign other starters and rumors about acquiring another arm, the Mets have finally added another piece to their rotation.
A look at Manaea’s baseball journey so far
Manaeas’s major league journey started in 2013 when the Kansas City Royals selected him 34th overall in the Major League Baseball Draft. He quickly rose through the minor leagues before being dealt alongside Aaron Brooks to the Oakland Athletics in exchange for Ben Zobrist on July 28, 2015.
Manaea would make his major league debut for the green and gold the following year.
The left-hander finished his rookie campaign, pitching 144.2 innings across 25 appearances, 24 of which were starts, to a 3.86 ERA with a 1.189 WHIP and 124 strikeouts.
The Indiana native would take a step back in his sophomore campaign, pitching 158.2 innings across 29 starts to a 4.37 ERA with a 1.399 WHIP and 140 strikeouts.
Manaea would bounce back in 2018, pitching 160.2 innings across 27 starts to a 3.59 ERA with a 1.077 WHIP and 108 strikeouts. The left-hander also threw the first no-hitter for the Athletics since 2010 when he blanked the Red Sox on April 21.
The Indiana native would start 2019 rehabbing a shoulder injury that forced him to miss the tail end of the 2018 campaign, and despite initial timelines expecting him to be back by midseason, Manaea didn’t return until September.
In five starts to close the 2019 campaign, Manaea dominated, pitching 29.2 innings to a 1.21 ERA with 0.775 WHIP and 30 strikeouts alongside a ridiculous 358 ERA+.
Manaea would fail to replicate that success in his postseason debut when he started the 2019 American League Wild Card game against the Tampa Bay Rays.
The left-hander lasted just two innings, allowing four hits and four runs, although he did strike out five batters in what turned into a 5-1 loss for the green and gold.
The Indiana native struggled in the Covid-19 shortened 2020 campaign, pitching 54 innings across 11 starts to a 4.50 ERA with a 1.204 WHIP and 45 strikeouts.
Manea would bounce back in 2021, leading the American League in starts with 32 while pitching 179.1 innings to a 3.91 ERA with a 1.227 WHIP and 194 strikeouts.
That would turn out to be Manaea’s final campaign for the green and gold as on April 3, 2022, the Athletics traded Manaea and Aaron Holiday to the San Diego Padres for Adrián Martínez and Euribiel Angeles.
The Indiana native’s first season in the National League would not go to plan, as he pitched 158 innings across 30 appearances, 28 of which were starts, to a 4.96 ERA with a 1.297 WHIP and 156 strikeouts.
After the season, Manaea signed with the San Francisco Giants, where he got demoted to the bullpen after some early season struggles.
The 31-year-old finished the 2023 campaign, pitching 117.2 innings across 37 appearances, 10 of which were starts, to a 4.44 ERA with a 1.241 WHIP and 128 strikeouts.
Manaea opted out of his contract following the season and became a free agent.
What does this mean for the Mets?
Signing Manaea is a low-risk, high-reward situation for the blue and orange. The Mets hope the left-hander can revitalize his career in Queens and become a solid piece of their rotation.
The opt-out after the first year will also allow the Mets to easily trade him at the deadline if he has a massive first half, which is excellent for an organization that wants to improve its farm system.
The addition of Manaea does give the Mets five starting pitchers, but they may look to add another in an attempt to have some depth or for the potential to have a six-man rotation.


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"Thank you for taking what I did, and doing what I could have never imaged." - Rodney Mullen
We found an interview from The Berrics with professional skateboarder Rodney Mullen discussing resiliency, falling down, and picking yourself up again. He also talks about the gratitude he shares with the skateboarding community through the contributions of everyone, and the joy he feels when the next generation of skateboarders approach him
to thank him for doing what he did. Rodney in turn says, "thank you." "It comes from an ethos of sharing and feeling connected with people through what you do... and that's not something that's often taught."
"Skateboarding changes you in ways that you could never essentially try or go learn in a few sessions. It comes from years and years of getting back up. It changes you from inside." Rodney Mullen is often considered "The Godfather" of street skateboarding. He is credited with inventing a lot of the flip tricks that shaped the sport into what it is today. But he is quick to turn around the kudos by thanking his community for building upon his work and making the community as a whole stronger. "We all find this mutual sense of belonging in shaping a community by what we do. And what we do is we individuate ourselves... I take these elements and I help form myself to separate myself and give it back. And to the rest of the community, grow."
"I think there's something about skating that's special that way." Around 8:36 he talks about the uniqueness and individuality of skateboarders as athletes. "You are on your own. Not only are you on your own... you gotta go through adversity." Noting that skateboarders often lack the supportive "entourage" that comes with playing on a team, and are typically treated like criminals by authority figures. "There's something about that... it bakes into us on a deep level. That helps shape us."
What are your experiences with skateboarding? Does skateboarding help you to express yourself as an individual? Does skateboarding make you feel more or less connected with your community?

domain: psychology


text:
THE MYSTERIOUS BIBLE CODES
Based on Grant Jeffrey's new bestseller, The Handwriting of God,
this outstanding companion audio book explores startling and authoritative
discoveries that have been buried beneath the surface text of
the Hebrew Scriptures for over 3000 years. Now, Grant Jeffrey
brings you the real truth behind the Bible Codes by means of this
powerful and definitive audio series. With convincing documentation
this compelling presentation will demonstrate to even the most
skeptical mind the supernatural origin of the Scriptures. There
is a war raging for the souls and minds of humanity nd the main
battleground is the issue of biblical authority.
Only in this generation with high speed computers
could the Bible Codes truly be discovered revealing the names
of "Arafat" "PLO" "Shimon Peres"
"Peace Treaty" the "Oklahoma bombing" and
much more.No human writer could have known the significance of
these words in ancient times. Here's the audio that breaks new
ground from a Christian perspective in exploring the sacred mysteries
of the Bible and providing new evidence that the Bible is "without
error" and trustworthy despite the attacks on its authority.
Explore these fascinating Topics:
Astonishing New Bible Code Discoveries
The Christian Perspective on the Bible Codes
Jesus and His disciples' names revealed in the Old Testament
Is Christianity Credible?
Can We Still Trust The Bible?
This special audio edition will bring the Bible to life and re-awaken
your passion and excitement for Jesus Christ and the great truths
of the Word of God. This is a great faith-building and witnessing
Running time: 90 Minutes
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domain: library


Organization: Deposit Protection Fund of Uganda (DPF)
Duty Station: Kampala, Uganda
Reports to: Manager, IT Operations
Provide user and technical support and maintenance of the Fund’s IT infrastructure.
Deposit Protection Fund of Uganda Profile:
The Deposit Protection Fund of Uganda (DPF) is a Ugandan government agency that provides deposit insurance to depositors in Ugandan Banks, Credit Institutions and Microfinance Deposit-taking Institutions (MDIs).
Roles and responsibilities:
Maintain and prepare all paperwork for various IT activities.
Provide performance backup to retrieve data in case of emergency.
Assist staff to check and ensure resolution of computer issues.
Monitor computer operating systems.
Upgrade systems and escalate issues.
Ensure optimal performance and maintain records of service level agreements.
Documents issues and resolutions and track calls using current call tracking system and follow-up with users on open tickets.
Maintains technical documentation of networks, upgraded systems and associated architecture and IT standards and practices for IT systems acquisition, development and operations.
Maintains an inventory of software licenses, hardware equipment and applications deployed in all environments at the Deposit Protection Fund.
Conducts user acceptance testing of new and upgraded IT infrastructure.
Conduct technical reviews of own documents to achieve high quality and conformity to the Fund standards.
Performs general preventative maintenance tasks including patching and upgrades. on computers, laptops, printers, servers and any other authorized peripheral equipment.
Carries out evaluations of software or hardware and recommend improvements or upgrades.
Deals with hardware and application support queries and issues reported to the support desk and escalated issues which cannot be resolved internally but require external vendor assistance.
Resolves identified vulnerabilities on the Fund’s computing equipment (i.e. servers, workstations, laptops, tablets, smartphones, etc.).
Participates in testing of patches and vulnerability remediation solutions before application to production environment.
Conducts technical review of own documents to achieve high quality and conformity to the Deposit Protection Fund standards.
Manages network infrastructure devices such as firewalls, switches and wireless access points including installation, upgrades, and hardware refreshes.
Reviews alerts and notifications generated by the remote monitoring and management system and resolve accordingly.
Provides administration, support, and maintenance of the Fund’s IT Infrastructure and Security tools.
Performs other work-related duties as assigned, within your scope of practice.
System and process change requests.
IT infrastructure configuration documents and status reports
Technical investigation reports.
Periodic training needs assessments and quality reviews.
Acceptance Test Plans for business applications, testing schedules and reports.
Service Call updates, IT system incidents, applications and database status reports.
Technical documentation and reports e.g. IT Policies, Current Practices (MCPs), Standard Operating Procedures (SOPs) and Technical feature specifications for new systems.
A first-class or upper second-class bachelor’s degree in Computer Science, information systems/technology, engineering or other quantitative fields, from an accredited institution, is essential.
Professional certifications in relevant fields such as ITIL, CISSP, CCNA, CCNP MCSE Server Infrastructure, and other Microsoft and Cisco certifications are desired.
Knowledge and experience with UNIX/Linux/Windows server systems administration are desirable.
Knowledge or experience delivering mail, storage (SANs), NTP, VoIP, DNS, RADIUS, Web, Virtualization is desirable.
Knowledge or experience in server virtualization, Cisco Firewalls, Switches, Domain Name Services, and Active Directory Services is desirable.
Demonstrated proficiency in MS office packages is desirable.
Prior work experience is not a must.
How to Apply for Deposit Protection Fund Uganda Jobs – No Experience Graduate IT Operations Officer:
All suitably qualified and interested candidates are encouraged to apply online at the link below.
Deadline: 30th January 2020 by 5:00 pm.
NB: No employer should ask you for money in return for advancement in the recruitment process or for being offered a position. Please contact Fresher Jobs Uganda if it ever happens with any of the jobs that we advertise.


text:
Free Forum : Help and support to Forumotion users. Create and administrate a forum. Discover our guides, tutorials, tips on the Forumotion's Support Forum. Free Forum : Help and support to Forumotion users. Create and administrate a forum. Discover
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Free forum : Where the pimpin' PSPers come to unwind, have fun, and win some awesome prizes.
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A fun, friendly place to discuss just about everything.
Free forum : A Group of friends dedicated to PSP tagging and snagging! Contests, challenges, friends! No blank registrations please!
A free roleplaying, writing, blogging, and art community. Legends is welcoming, friendly, and has fair moderation. Come join the adventures, creativity, and fun!
roleplay, legends, lore, fantasy, games, battles, empires, #free, writers, gaming, romance, adventure, drama, stories, action, sci-fi, science, fiction, dragons, elves, centaur, writing, blog, blogging, contest, advertiseme
Say What You Want, When You Want BOOM SHAKALAKA! ! !
Free forum : The place to hang out and talk about the show and our other interests!
Free forum : We are a tagger & snagger friendly community. We are drama free at all time. Participation is a requirement.
Free forum : Gardening and social group
Free forum : Dedicated to the preservation, restoration and rebuilding of all Dynaco tube audio equipment.
Lost Message Board, Lost and General Chat about the show and everything else.
A place for gamers to talk about games and stuff.
Free forum : This forum is for those interested in the Zodiac Killer case.
zodiac, minutemen, francisco, serial, killer, unsolved, murder, ross, sullivan, fred, manalli, kaczynski, arthur, leigh, allen, richard, gaikowski, kjell, qvale, william, thoresen, weather, underground, speaking, knife, rope, fire
Free forum : Ass kickin, skate lickin, fishnet wearin, bruise comparin bitches on the internet. discussing things.
Naruto forum roleplay with free progression to get the character you want, T1 and free rules, constant updates, your own story, great community, great systems, great events.
A refuge for community, information and discussion .
Free forum : Private forum for Members of the Dobyns Rods Pro Staff
Chat etc for Sky Blues fans. Free forum : SkyBlues around the World
But Why Are The Sweets Gone?. But Why Are The Sweets Gone?
Free forum : Discuss bets, tips and general chat regarding gambling.
The forum for the Super Smash Bros Crusade fangame.
Free forum : A place for friends to gather for conversation and support
A Percy Jackson and the Olympians RPG. Free forum : Half-Blood Hill
d Removed on: 12/05/2016
Free forum : Offering The Best Tagger's Forum That's Just A little Different Than The Rest

domain: hobby