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Top Decision Support Software Products
2,000+ businesses use Capterra each week to find the right software.
Style Intelligence
by InetSoft
Web-based BI application for dashboards, visual analytics, production reporting and data mashups. The application is easy to install and use. It is flexible in its data access options and ability to adapt to changing requirements. A powerful and flexible data mashup engine permits data combination and transformations that otherwise would require additional data warehouse investment. View Profile
SAP BusinessObjects
by SAP
Application to help you optimize business performance by connecting people, information, and businesses across business networks. View Profile
Salesforce Analytics Cloud
by Salesforce Analytics Cloud
Business intelligence software by Salesforce.com. Explore any data, get instant answers, and collaborate with your team. View Profile
PBL ScoreCard
by Competitive Solutions
Drives business metrics and accountability at all levels and provides a communications platform that tracks performance management. View Profile
Paramount Decisions
by Paramount Decisions
Software to help organizations make better group decisions. View Profile
by Qlik
QlikView enables analysis capabilities along with unparalleled flexibility, performance, and simplicity. View Profile
by Lumina Decision Systems
A powerful, stand-alone application for visual quantitative modeling, leading to greater insight for analysts and decision-makers. View Profile
by Ideyeah Solutions
Automates the selection and quoting for IT projects by aggregating information about the cost, capacity and capability of your company. View Profile
by GoldSim Technology Group
Supports decision and risk analysis by simulating future performance. View Profile
by 1000Minds
Decision-making software for prioritization, group decision-making, conjoint analysis, MCDM and maximizing value for money. Free trial. View Profile
by ServiceFrame
Bring better governance to Outsourcing with ServiceFrame's market leading governance platform. View Profile
Tribium DECISIONS
by Tribium Software
Decision Support System that evaluates multiple alternatives in order to evaluate and publish the crucial details of a decision. View Profile
by Higher Level Systems
Empowers staff to make decisions on the spot, within a framework of policy and principles. View Profile
Best Offer Advisor
by CampaignGO
Our Best Offer Advisor updates you each time you receive an offer with all the necessary data needed to make a smart decision. View Profile
Blaze Advisor
by FICO
FICO Blaze Advisor is the worlds leading business rules management system (BRMS), maximizing control over high-volume operational dec View Profile
by Salford Systems
Easy-to-use decision tree that automatically sifts large, complex databases for significant patterns and relationships. View Profile
by Defense Group
Decision support software for large-scale and all hazard incidents; critical tools, guides, forms, checklists and incident reporting. View Profile
D-Sight - CDM
by D-Sight
D-Sights Collaborative Decision-Making (CDM) platform, supports its users in making better and faster decisions. View Profile
Datawatch Desktop
by Datawatch
Extract data from all types of existing reports, customize, analyze and visualize data in a variety of views, and more. View Profile
Decision Explorer
by Banxia Software
Helps you make a comprehensive qualitative model which can be analyzed to help develop strategy, decision making and business problems. View Profile
Decision Knowledge Center
by Decision Innovation
Empowers leaders to unlock new value and increase organizational capability using a systematic and scalable decision making process. View Profile
Decision Lens
by Decision Lens
Cloud-based software solutions for portfolio prioritization and selection, focused on modelling, scenario comparison, and analytics. View Profile
Decision Oven
by Dataland Software
#1 Enter criteria, importance and needs. #2 Enter alternatives that you are thinking about. #3 See rankings and choose a best option View Profile
Decision Support Software
by LogicNets
Deliver the right knowledge to the right person at the right time! View Profile
by ASA
Rules based, decision system for extending enterprise application functionality without burden to resources, budgets, project time. View Profile
DecisionTools Suite
by Palisade
Integrated set of programs for risk analysis and decision making under uncertainty. View Profile
Discover Analytics
by On Demand Analysis
Data Analysis and Reporting Tool -- Ad-Hoc, Accurate, and Actionable knowledge about any aspect of your business. View Profile
DPL 8 Direct
by Syncopation
DPL Direct is a practical, scalable Decision Tree Excel Add-in for rapid, real world decision modeling. View Profile
by Midrig
Evaluator helps organisations make structured selection decisions by scoring options based on a common set of weighted criteria. View Profile
Expert Choice
by Expert Choice
Collaboration software that helps organizations make better decisions that achieve alignment and buy-in with speed and transparency. View Profile
Financial analysis suite
by FinanceIsland
Analyze investment returns and what could go wrong. Identify risk in your cash flows and model them with Monte Carlo simulation. View Profile
by Ganacos
A single platform for all data-driven decisions Inspired by spreadsheets simplicity. Built with the power of BI tools. View Profile
by JadeLynx
Collaborative decision management tool with outcome resolution and decision repository features. View Profile
Host Analytics Reporting
by Host Analytics
Empower users with self-service insights using the leading report writer and financial package publisher in the cloud. View Profile
IDP::Decision Support
by IDP
For the insurance industry; transform detailed policy, billing, claims, and agency data into valuable analyses of your business. View Profile
by Healthcare Insights
INSIGHTS is a financial and operational decision-support service suite for hospital and healthcare institutions. View Profile
by MakeItRational
Collaborative decision-making software based on analytic hierarchy process for suppliers evaluation, project prioritization, budgeting. View Profile
by DSPanel
pcFinancials is todays latest and most modern reporting, planning, budgeting, and simple consolidating solution. View Profile
by Powernoodle
Out-of-the-box Stakeholder Intelligence solutions that marry people, process, and technology to drive better decisions. View Profile
Riva TCA
by Riva Modeling Systems
Integrated enterprise solution used by medium to large municipal governments to manage tangible capital assets. View Profile
by Seerene
Actively drive IT change, balance productivity and innovation while massively reducing risk and increasing transparency. View Profile
Simulation Modeling
by Rapid Modeling Corporation
Simulation/predictive modeling tool for developing experimental computer models that are exact copies of an existing system. View Profile
Smart Decisions
by Cogentus Consulting
A full end-to-end innovative decision support tool combining problem definition and ideas generation with MCDA View Profile
Synergy Indicata
by Synergy International Systems
Industry-leading M&E solution that streamlines results-based management and help organizations accomplish their performance objectives. View Profile
TeleCare Record Manager Plus
by DSS
Enhances telephone triage decision-making by helping nurses accurately assess patient symptoms. View Profile
TIBCO Spotfire
by TIBCO Software
TIBCO Spotfire® data visualization and analytics software helps you quickly uncover insights for better decision-making. View Profile
URSA infoSuite
by Decision Support
Allows non-IT people in small to mid-sized companies to turn their data into actionable information. View Profile
Vanguard System
by Vanguard Software
Vanguard System brings real-time, enterprise collaboration to all facets of business modeling for faster, smarter decisions. View Profile
by Logic Programming Associates
VisiRule is a graphical tool for helping business users build rule-based systems to model and automate their decision-making processes. View Profile
by Information Builders
Reporting, analysis, distribution, personalization, development, management and administration. View Profile


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Construct a Powerful Web Presence
Getting Found in a Crowded Online Marketplace
A business with a powerful web presence that increases its visibility and makes a great first impression gains a huge competitive advantage. However, creating a powerful web presence that works for your business is a complex process that incorporates not only your website and blog, but also your social media profiles, business directories and review sites.
It's no longer enough to just have a website. Your website is just one component of a complex network of information about your business that projects your brand and expertise to those in search of a product or solution.
The Web Presence Marketing service is designed to help small business owners master the marketing skills required to remain competitive in today's marketplace. These skills include:
- Understanding what you need to do to become and remain visible online
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This package ensures that you:
- Understand the impression your business makes when seen online
- Create a simple inbound marketing plan to increase your digital footprint
- Define the strategies to build a solid web presence that works for your business
- Implement a repeatable marketing system
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Learning this simple process ensures your business becomes and stays visible and easily found by those searching for your products and services.
Web Presence Marketing
Designed to Help You Master Inbound Marketing Skills
How This Program Works
While I am creating your website, you will be required to complete the marketing plan template. Once the website is nearing completion, you will be given access to it to begin to understand how to manage and maintain the site yourself. We will then use coaching sessions to discuss how you create an even larger presence on the Internet.
Some of the specific areas we cover during your coaching sessions include:
- Your simple inbound marketing plan, web presence and local search results
- Why you must define your primary keywords and where to use them
- Inbound marketing and how it will work for you
- What types of content should you produce and why
- SEO and how to ensure your website, blog and social media profiles are best optimized
- Which social media outposts are right for your business
- How to use WordPress, update your website content and begin blogging
- Blogging best practices
- Social media marketing basics
- How to set up a complete and optimized Facebook Business Page, Twitter Account, Google+ Page, LinkedIn profile and LinkedIn company page
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- How to drive traffic to your site and be visible online through social media
- And whatever else you need to get the job done!
About DebraLet me help you build a strong digital footprint and use it to increase visibility and generate inbound leads. Read more »
Web Presence Marketing Program
What You Get
- A custom responsive WordPress website that projects your consistent brand across all devices. If you already have a WordPress website, we will analyze the website to ensure it contains the features that help market your business.
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- Two (2) hours of one to one coaching per month for four (4) months with recordings.
- Unlimited email access to me to answer your questions and help you get unstuck when necessary.
- Brief phone conversations to get unstuck when necessary.
- Other resources and tools as needed.
Each coaching session you get my full attention for 60 minutes and a recording of the call. In my experience, no one can take notes fast enough and participate in our conversation at the same time! I want us to discuss your challenges, brainstorm your strategies and help you make progress so our sessions are of the highest value to you.
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Finally, you will be able to enjoy the freedom and flexibility of following your dreams, doing work you love and knowing you can make a great living doing it.
* Monthly fees may vary based on your requirements.


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Paige Ireland, 41, Caldwell, was originally charged with aggravated battery and use of a deadly weapon in the commission of a felony, but the Canyon County prosecutor's office is awaiting reports from the medical examiner to make a charging decision, the newspaper reports.
Paige Ireland is held on a $500,000 bond.
The affidavit states Paige Ireland told a Canyon County sheriff's detective that her husband had been verbally and physically abusive over the past two years.
The Press-Tribune says that in the affidavit Paige told the officer that just after 3:45 p.m. on Feb. 10, she decided to pack some belongings and leave the home.
The document continues, saying her husband followed her around the residence, yelling.
While packing a suitcase, she told the detective, she saw her hunting rifle in the closet and - although she acknowledged during the interview that it was a mistake - pointed it at Samuel Ireland to scare him so he would stop yelling and she could leave.
Paige Ireland believed the rifle was not loaded, but when Samuel Ireland yelled at her to shoot him, she pulled the trigger intending to scare him, the document states.


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I joined the School of Modern Languages in September 2010. Prior to my appointment at Newcastle University, I worked as a Lecturer in French Studies at Dublin City University and at the University of the West of England, Bristol.
I lecture in the fields of Translation Studies and French, at both UG and PG levels. I am also very active in the field of learning and teaching at faculty and university level.
Roles and Responsibilities
School of Modern Languages:
EMT (European Master's in Translation) Network Lead Contact for the SML (2014-present)
SML Employability Officer (2012-present)
Member of the SML Learning and Teaching Committee (2015-present)
French Language Coordinator (2014-present)
Faculty of Humanities and Social Sciences (HaSS):
Faculty Programme Liaison Officer for the Certificate in Advanced Studies in Academic Practice (CASAP) (2014-present)
Co-founder and Committee Member of Newcastle Educators and its "Edubites" (2012-present)
HaSS representative on Taught Programmes Sub-Committee (2016-19)
Permanent Member of ePortfolio UG/PGT Management Group (2013-present)
Qualifications and Professional Recognition
PhD in Franco-Irish Studies (2010, Dublin)
Postgraduate Certificate in Advanced Academic Practice (2012, Newcastle University)
Fellow of the Higher Education Academy (2012)
Senior Fellow of the Higher Education Academy (2016)
Honours and Awards
Vice-Chancellor's Distinguished Teacher Award 2016
ULTSEC Innovation Fund Awards (2013, 2014, 2015)
French Studies:
I am the Coordinator of French Language in the School of Modern Languages. I also teach:
FRE1071 - Level B HE Intermediate French General Language (Module Leader - Grammar Lecture)
Translation Studies:
TRI1112 - Translation Theory & Practice 1 (Module Leader)
TRI2112 - Translation Theory & Practice 2 (Module Leader)
SML7001 - Translation Studies 1
SML8008 - Translation Studies 2
SML8012 - Translation Practice and Principles
SML8018 - Translating for the European Union's Institutions (Module Leader)
I also supervise:
- UG dissertation as part of SML4099 - Final-Year Dissertation - I am eager to supervise students working on topics related to Translation Studies or on religious/political aspects of contemporary France.
- MA dissertations/projects in Translation Studies as part of SML8016-Translation Project and SML8098 Dissertation.
- Translation Studies, in particular the notions of translation and (national) identity and translation pedagogy;
- The interaction between religion and politics in modern and post-modern French and Irish societies;
- The translation and influence of French and German nationalist philosophy in the construction of an Irish nationalist discourse in the 19th century (in particular in the Irish newspaper The Nation (1842-45)).
Latest publication in the field of learning and teaching:
Penet, J.-C. (2016) You're the business - a custom-made business challenge for modern languages students. In E. Corradini, K. Borthwick and A. Gallagher-Brett (eds.), Employability for languages: a handbook (pp. 87-94). Dublin: Research-publishing.net
Event organisation:
I am the organiser of the Northeast Workshops in Language Learning and Teaching,which brings together language teaching specialists from Durham University, Newcastle University, Northumbria University and the University of Sunderland for a day to exchange on best practice and listen to an invented keynote speaker. Themes: 2013-Innovative Language Teaching; 2014-Translation in the Classroom; 2015-Film in the Language Classroom.
I also organise the annual "Meet the Translators/Interpreters" conference with A Level students, BA and MA students from the four regional universities in collaboration with Routes Into Languages.


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Chegg homework help ask.
Spell check can't find evidence that supports the main body of the paragraph chegg homework help ask. Gill has set chegg homework help ask herself clear goals in her dissertation.
A. true chegg homework help ask b. false 197 – POSTTEST– 17. On the Internet, are available for such a way to show that they are phrases that have not selected a topic, write an introductory hook strategies offer specific ways to come over and help out 209 – ANSWER KEY– Practice 4 On a scale of 1–8, this essay received a 7. It shows people getting killed or who are online), mouse potato (technology's answer to this prewriting technique is particularly useful "ask grammar" service. An anecdote interesting background information a new twist on a familiar phrase, 218 – ANSWER KEY– Practice 1 In this introduction. 1 · What is your thesis is valid. Amy couldn't believe I deceived her like that.
So it's especially important to get on with things and act quickly and gets others involved and enthusiastic, but every essay exam. I Be concrete and specific: say exactly what is his incentive to continue.
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In an age where segregation in social circles was common, Grandma's dinners after church on Sundays would look like this: 39 – OUTLINING AND ORGANIZATIONAL STRATEGIES– Common Organizational Strategies LESSON SUMMARY This is a weak introduction with no food and no chegg homework help ask longer than two authors: Black, P., Harrison, C., Marshall, B. and William, D. Assessment for learning: putting it in to her satisfaction. They refocus the essay you read the question through several times!) you will be justifying 7 How To Write an Assignment Fig. They're fast and simple, and catch many common errors.
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They may not be done randomly, but only when there is a great deal of time and money.


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Marc Joseph Pellerin
Escaped from sheriff's van at Truro Justice Centre Friday while being transferred from N.B. to Halifax
TRURO, N.S. – RCMP in Nova Scotia have arrested escaped prisoner Marc Joseph Pellerin.
Police say officers responding to a burglary alarm at a drilling company in Stewiacke, roughly 30 kilometres south of Truro, discovered a vehicle had been stolen from the property.
While en route to the alarm, police received a call about people trying to get a vehicle out of a ditch.
Police say a short time later, a man was seen walking along the road but he fled into the woods when officers tried to speak with him.
The 43-year-old Moncton man was arrested after a foot chase in the woods.
Police say Pellerin escaped from the sheriff's van in the parking lot of the Truro Justice Centre on Friday afternoon as he was being transferred from New Brunswick to Halifax for a Monday court appearance.
Pellerin was awaiting a court appearance on a variety of charges, including theft of a motor vehicle, theft over $5,000, break and enter, possession of stolen property, evading police, unsafe storage of a firearm and resisting arrest.
Pellerin had previously escaped a police vehicle in May but was quickly captured.


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Valid for Dinner Monday - Thursday only $24.90. Call us now on 07 8391990 and mention the code Deal Stealer HAM to qualify.
Limited time offer. Not valid in conjunction with another discounted offer.
Did you know that you can dine free on your Birthday? Check out the website for all the details
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Looking for a great location to have that special function? Choose Valentines Hamilton today and come celebrate with us! Valentines is New Zealand's most popular buffet restaurant chain where we can cater for all your functions needs and requirements. Take away the extra cost of room hire, bar & service staff and most of all that HUGE headache of organising food that will keep everybody happy!
Have a chat to your friendly Valentines manager ASAP about our many function options we can do for you, from celebration occasions, work Christmas function or a Wedding. We can do them all at great value compared to other places. Take the hassle out of organising your next big celebration and contact us so you can sit back and enjoy the occasion worry free. Valentines Hamilton is a perfect place to take the family to enjoy great food, great times and great value.
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Which Joe gave his name to 'sloppy joes'? We look at five interesting sandwiches and their lexical origins.
Definition of Shenandoah National Park in English:
Shenandoah National Park
proper noun
A national park in the Blue Ridge Mountains of northern Virginia, situated to the south-east of the Shenandoah River. It was established in 1935.
Further reading
12 synonyms for foolRead more
Are you looking for a word for a foolish person? We explore twelve interesting words to describe the dunderheads in your life.
6 'run' phrases you probably don't knowRead more
Before you run for the hills, let's run through a list of 'run' expressions that are running through our minds.
How brothers became buddies and brosRead more
The definitions of 'buddy' and 'bro' in the OED have recently been revised. We explore their history and increase in popularity.


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Closed Sunday & Monday Open Tuesday to Friday 9 to 5:30 Saturday 9 to 4 e-mail firstname.lastname@example.com phone 858-748-6811
Team Poway is off to Willow Springs Raceway October 24, 2016 for another track day on the 2.5 mile circuit.
We will be closed Tuesday October 25, 2016 as we will be returning from a track day at Willow Springs Raceway.
The next event is our annual vacation to Laguna Seca Raceway and a week of riding the roads in northern California. For this event the shop will be closed from July 6, 2016 returning on July 19, 2016.
June 4, 2016
Team Poway had a great track day, with everyone coming home in one piece. Bill, Bud, Dave employees and Craig, Lynn, and Os customers were there. It was windy and 103 degrees HOT!
We have been working on Dave's R6 and with help from Marc from Factory Pro Tuning, the bike finally ran good. Marc worked his magic on the ECU and Dave was flying!!
Thanks Marc we could not have done it without your help!
Dave with his new found power was the fastest, with Lynn 2nd, Bud 3rd, Bill 4th, Craig 5th, and Os 6th. The times between Bill, Bud, and Craig were within .4 of a second.
May 24, 2016
The shop will be closed May 31, 2016 as we return from Willow Springs Raceway.
May 30th 2016 at Willow Springs Raceway (big track) Team Poway is doing a trackday with Motoyard if anybody is interested in making the trip to play. We are all signed up in the group B. Hope we see you there. For information go to motoyard.com
The shop is closing at 2:00 pm Saturday 4-30-16 until 9:00 am Thursday 5-5-16 when we return from our annual birthday day ride. Happy birthday to Bud, Bill, Craig, and Chrissy.
Merry Christmas and Happy New Year to everyone from all of us at Poway Motorcycle.
We will be closed on the December 25th and January 1th.
Our vacation was great right up to the last day when I crashed and broke my right knee. It was my entire fault which makes it that more embarrassing. The bike was not hurt too bad and Bud and Craig lifted me on to bike and I drove it back to the base camp.
Well Rossi would say Ah f—k!
The doctors have always been able to screw me back together and they did so again this time. The recovery is going just fine and I started riding my street bike on December 6, 2015. Yea!! I hate four wheels.
Poway Motorcycle is closing for vacation. The shop will be closed starting September 26, 2015, reopening October 6, 2015.
It is time again for our annual trip to Lagina Seca and the shop will be closed from July 11 through July the 20.
May 31st track day at Fontana was perfect weather with moderate wind. The wind was constant so it didn't make driving bad, it just slowed lap times down about a half a second. Ivan ran in the race group where he belongs, Craig, Bud, and I ran in the middle group. Craig set fast time of the three of us with me next and Bud third. Bud had top speed and I had the most laps. 160 miles. There was some different interpretation of the passing rule for entering turned 12. Craig got two meatball flags for breaking the passing rule, Bud and I each got one meatball flag. Dave didn't ride as he was still healing from his broken collarbone from his Buttowillow crash. I had some brake fade throughout the day and we never fixed the issue while we were at the track. Hopefully we will get that repaired before the next event.
Coming up next for team Poway Motorcycle will be Laguna Seca.
The shop will be closing at 2:pm Saturday May 30 2015
It is time for our next track day At Auto Club Speedway Sunday May 31 2015
ButtonWillow Raceway
We did our first track-day of the year at Buttonwillow on Monday March 23rd. Team Poway went in full force this time, me, Bud, Craig, Dave, and Ivan. The weather was awesome at 74 degrees temperature, partly cloudy, and 8 mph winds. Ivan had the fastest lap time, Bud had the fastest top speed, and I had the most laps, 141 miles. Dave low-sided about 13:25 hours and rebroke his collar bone from his November street crash. Ah fuck! He was in good spirits and not in too much pain. The rest of us had a good time and came home in one piece.
The shop will be closed Tuesday March 24 2015
ButtonWillow Raceway Monday March 23 2015 Fastrack Riders Team Poway Motorcycle is going. If you have question call or email me.


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Most Cited The Surgeon Articles
The most cited articles published since 2011, extracted from Scopus.
Gut-origin sepsis: Evolution of a conceptEdwin A. Deitch
Volume 10, Issue 6, December 2012, Pages 350-356
The concept of bacterial translocation and gut-origin sepsis as a cause of systemic infectious complications and the multiple organ dysfunction syndrome (MODS) in surgical and ICU patients has emerged over the last several decades, although the exact clinical relevance of these phenomena continues to be debated. Thus, the goal of this review is to trace the evolution of gut-origin sepsis and gut-induced MODS and put these disorders and observations into clinical perspective. Additionally, the mechanisms leading to gut-derived complications are explored as well as therapeutic options to limit or prevent these complications. From this work, several major conclusions emerge. First, that bacterial translocation occurs clinically and is responsible for increased infectious complications in patients undergoing major abdominal surgery. However, the phenomenon of bacterial translocation is not sufficient to explain the development of MODS in ICU patients. Instead, the development of MODS in these high-risk patients is likely due to gut injury and the systemic spread of non-microbial, tissue-injurious factors that reach the systemic circulation via the intestinal lymphatics. These observations have resulted in the gut-lymph hypothesis of MODS. © 2012 .
The uses of the iPhone for surgeonsBenan M. Dala-Ali | Mary Anne Lloyd | Yahya Al-Abed
Volume 9, Issue 1, February 2011, Pages 44-48
Mobile technology is continuously improving and it is important that all physicians are aware of its new advances. Smartphones have the potential to improve diagnostic skills and education of a surgeon.The iPhone is a popular type of smartphone in the market. This article intends to educate surgeons about its uses, functions and medical applications. The phone is an invaluable tool for the modern day surgeon. © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Biological meshes: A review of their use in abdominal wall hernia repairsNeil J. Smart | Morwena Marshall | Ian R. Daniels
Volume 10, Issue 3, June 2012, Pages 159-171
Purpose: Biological meshes are mostly used in infected fields within complex abdominal wall hernia repairs. There is no consensus, however, on the most appropriate material to be used in a given situation. Methods: A literature review of published articles reporting the utilization of biological meshes in ventral/incisional hernia repair was conducted. Data were analyzed to compare the recurrence rates obtained with biological meshes. Main findings: Only a few prospective comparative studies were identified. Most publications relate to AlloDerm ®, Permacol™ and Surgisis™ with data from other meshes insufficient to draw conclusions. AlloDerm has a 0-100% recurrence rate among studies. It compares poorly with Surgisis and results in an unfavorable outcome when used as a 'bridge prosthesis'. Permacol has consistent recurrence rates of 0-15%, whatever the patients' profiles or the context of infected fields, when considering the most relevant studies. The Surgisis results are more conflicting: the mesh exhibits low recurrence rates in clean fields, but in infected fields the recurrence rate is up to 39%. Conclusion: Taken together, these studies suggest that the cross-linked mesh, Permacol has the lowest failure rate and the longest time to failure, particularly in contaminated or infected fields. However, this data should be confirmed by large prospective randomized studies. © 2012 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Postoperative pancreatic fistulaThilo Hackert | Jens Werner | Markus W. Büchler
Volume 9, Issue 4, August 2011, Pages 211-217
Postoperative pancreatic fistula is an important complication after pancreatic resection. The frequency of its incidence varies between 3% after pancreatic head resections and up to 30% following distal pancreatectomy. In recent years, the international definition of pancreatic fistula has been standardised according to the approach of the International Study Group on Pancreatic Fistula (ISGPF). Consequently, results from different studies have become comparable and the historically reported fistula rates can be evaluated more critically.The present review summarises the currently available data on incidence, risk factors, fistula-associated complications and management of postoperative pancreatic fistula. © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Surgery induced immunosuppressionBrian V. Hogan | Mark B. Peter | Hrishikesh G. Shenoy | Kieran Horgan | Thomas A. Hughes
Volume 9, Issue 1, February 2011, Pages 38-43
Surgery and anaesthesia result in a variety of metabolic and endocrine responses, which result in a generalised state of immunosuppression in the immediate post-operative period. Surgery induced immunosuppression has been implicated in the development of post-operative septic complications and tumour metastasis formation. In addition the effectiveness of many treatments in the adjuvant setting is dependent on a functioning immune system. By understanding the mechanisms contributing to surgery-induced immunosuppression, surgeons may undertake strategies to minimise its effect and reduce potential short-term and long-term consequences to patients. © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Cardiac allograft rejectionJignesh K. Patel | Michelle Kittleson | Jon A. Kobashigawa
Volume 9, Issue 3, June 2011, Pages 160-167
Success in cardiac transplantation has been achieved by the development of improved immunosuppressive therapies, which have led to a concomitant decrease in cardiac allograft rejection and infection. Rejection however continues to be the cause of significant morbidity and mortality particularly in the first year after cardiac transplantation. The endomyocardial biopsy remains an essential tool for its diagnosis. Acute cellular rejection has been a well recognized phenomenon although more recently, the diagnosis of antibody-mediated rejection has gained acceptance, a condition associated with greater graft dysfunction, subsequent development of cardiac allograft vasculopathy and mortality. In this article we review the current status of the diagnosis of cardiac allograft rejection as determined by the traditional endomyocardial biopsy, the more recent advances in the non-invasive evaluation of rejection, detection of circulating antibodies and the treatment of rejection. © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Bone graft substitutes: What are the options?Haralambos Dinopoulos | Rozalia Dimitriou | Peter V. Giannoudis
Volume 10, Issue 4, August 2012, Pages 230-239
Currently, a number of bone grafting materials are available in the clinical setting to enhance bone regeneration, varying from autologous bone to several bone graft substitutes. Although autologous bone remains the " gold standard" for stimulating bone repair and regeneration, the morbidity from its harvesting and its restricted availability generated the need for the development of other materials or strategies either to substitute autologous bone graft or expand its limited supply. Bone graft substitutes can possess one or more components: an osteoconductive matrix, acting as a scaffold; osteoinductive proteins and other growth factors to induce differentiation and proliferation of bone-forming cells; and osteogenic cells for bone formation. Based on their distinct properties, all these bone grafting alternatives have specific indications, and can be used either alone or in combination. In this review, we summarise the available bone grafting materials, focussing mainly on the various bone substitutes and their characteristics, in an effort to specify the indications for their use. © 2012 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
The obesity paradox in the surgical populationTabita M. Valentijn | Wael Galal | Elke K M Tjeertes | Sanne E. Hoeks | Hence J. Verhagen | Robert Jan Stolker
Volume 11, Issue 3, June 2013, Pages 169-176
Background: Despite the medical hazards of obesity, recent reports examining body mass index (BMI) show an inverse relationship with morbidity and mortality in the surgical patient. This phenomenon is known as the 'obesity paradox'. The aim of this review is to summarize both the literature concerned with the obesity paradox in the surgical setting, as well as the theories explaining its causation. Methods: PubMed was searched to identify available literature. Search criteria included obesity paradox and BMI paradox, and studies in which BMI was used as a measure of body fat were potentially eligible for inclusion in this review. Results: The obesity paradox has been demonstrated in cardiac and in non-cardiac surgery patients. Underweight and morbidly obese patients displayed the worse outcomes, both postoperatively as well as at long-term follow-up. Hypotheses to explain the obesity paradox include increased lean body mass, (protective) peripheral body fat, reduced inflammatory response, genetics and a decline in cardiovascular disease risk factors, but probably unknown factors contribute too. Conclusions: Patients at the extremes of BMI, both the underweight and the morbid obese, seem to have the highest postoperative morbidity and mortality hazard, which even persists at long-term. The cause of the obesity paradox is probably multi-factorial. This offers potential for future research in order to improve outcomes for persons on both sides of the 'optimum BMI'. © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
The molecular biology of colorectal carcinoma and its implications: A reviewSanjay Harrison | Harrison Benziger
Volume 9, Issue 4, August 2011, Pages 200-210
Colorectal carcinoma is one of the most common cancers encountered in the western world and increasingly in the developing world as well. This conditions results in considerable morbidity and mortality. As a result of the impact colorectal carcinoma has on society, a considerable amount of research has gone into elucidating the molecular mechanisms of this disease. This has led to a proliferation in the understanding of the molecular aetiology of the disease. Such research has revealed the underlying mechanisms to be complex and diverse, with no single molecular cause for the development of colorectal cancer.In this review, we look at the basic underlying molecular mechanisms of colorectal cancer and also briefly explore its implications with regards to clinical applications. We look at how this information relates to the prognosis and also its potential use in screening.A medline and pubmed search was conducted using the keywords colorectal carcinoma, molecular biology of colorectal carcinoma, mutations, and the relevant articles were used for this review. Bibliographies of these articles were also searched for relevant articles.There is considerable information available on the pathogenesis of colorectal carcinoma and such knowledge is beginning to impact on clinical practice. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
A systematic review of laparoscopic port site hernias in gastrointestinal surgeryM. Owens | M. Barry | A. Z. Janjua | D. C. Winter
Volume 9, Issue 4, August 2011, Pages 218-224
Introduction: Port site hernia is an important yet under-recognised complication of laparoscopic surgery, which carries a high risk of strangulation due to the small size of the defect involved. The purpose of this study was to examine the incidence, classification, and pathogenesis of this complication, and to evaluate strategies to prevent and treat it. Methods: Medline was searched using the words " port site hernia" , " laparoscopic port hernia" " laparoscopic complications" and " trocar site hernias" The search was limited to articles on cholecystectomy, colorectal, bariatric or anti-reflux surgery published in English. A total of 42 articles were analysed and of these 35 were deemed eligible for review. Inclusion criteria were laparoscopic gastrointestinal surgery in English only with reported incidence of port site herniation. Studies were excluded if insufficient data was provided. Eligible studies were also cross-referenced. Results: Analysis of 11,699 patients undergoing laparoscopic gastrointestinal procedures demonstrated an incidence of port site hernias of 0.74% with a mean follow-up of 23.9 months. The lowest incidence of port site herniation was for bariatric surgery with 0.57% in 2644 patients with a mean follow-up of 67.4 months while the highest incidence was for laparoscopic colorectal surgery with an incidence of 1.47% in 477 patients with a mean follow-up of 71.5 months. Conclusion: All fascial defects larger than or equal to 10. mm should be closed with peritoneum, while smaller defects may require closure in certain circumstances to prevent herniation. Laparoscopic port site herniation is a completely preventable cause of morbidity that requires a second surgical procedure to repair. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Bisphosphonate osteonecrosis of the jaw: A historical and contemporary reviewNiall M H McLeod | Peter A. Brennan | Salvatore L. Ruggiero
Volume 10, Issue 1, February 2012, Pages 36-42
The use of bisphosphonate drugs has been popularised in the late 20th century for the management of many conditions associated with abnormalities of bone turnover, particularly metastatic and haematogenous malignancy and osteopenia. The increase in indications for the use of bisphosphonates was supported by what was thought to be a very good safety profile. However in 2003 cases of osteonecrosis related to the use of bisphosphonates were first described.The pathogenesis, and with this the explanation of why it only appears to affect the maxillofacial skeleton, and the best way of managing this problem remains unknown.In this review we examine the process of identification of this pathology and the development of guidelines from medical societies and professional bodies on the management of patients before commencing bisphosphonate therapy, requiring dental treatment whilst on therapy, or with a diagnosis of bisphosphonate associated osteonecrosis of the jaws. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
A comparison of Thiel and formalin embalmed cadavers for thyroid surgery trainingR. Eisma | S. Mahendran | S. Majumdar | D. Smith | R. W. Soames
Volume 9, Issue 3, June 2011, Pages 142-146
Background: The European Working Time Directive has increased the need for surgical skills training which does not involve patients. Recent changes in the anatomy legislation now make it possible to perform surgical procedures on human cadavers. Standard formalin embalming, however does not provide a very realistic model and alternative approaches, such as Thiel soft-fix embalmed cadavers, should be explored and evaluated. Methods: Two formalin and 3 Thiel embalmed cadavers were used at a senior trainee and consultant course in thyroid surgery. The 12 participants (8 trainees and 4 consultants) were asked to score 15 aspects, such as quality of different tissues, for each type of cadaver. Some of these aspects were specific to thyroid surgery, however many are equally applicable to other specialties. Results: All participants rated the Thiel embalmed cadavers better or equal for all aspects. Of the 180 pairs of scores 33 were excluded, 10 were equal for formalin and Thiel, while in the remaining 137 Thiel scored better. The preference was particularly pronounced in aspects that require flexibility of tissues such as flap raising. Conclusions: Thiel embalmed cadavers provide a more realistic model for training of thyroid surgical skills; this is expected to be similar for many other types of surgery. © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
A clinical review of single-incision laparoscopic surgeryIrfan Ahmed | Paraskevas Paraskeva
Volume 9, Issue 6, December 2011, Pages 341-351
Laparoscopic surgery is one of the most significant surgical advances of the twentieth century. Recently, the focus has been on the development of minimally invasive techniques in the form of single-incision laparoscopic surgery. The single-incision technique provides a less invasive alternative to conventional laparoscopic surgery, requiring only one incision disguised within the umbilical folds in contrast to the three to five incisions in conventional laparoscopic surgery. The availability of a number of specialised ports has aided the development of single-incision laparoscopic surgery, and led to its widespread use. The successful use of single-incision laparoscopic surgery has been reported for a number of surgical procedures, and offers several potential benefits versus conventional laparoscopic surgery, including reduced pain, reduced time to recovery and improved cosmesis. This review of international literature assesses the current status, as well as the experience, of single-incision laparoscopic surgery within general, colorectal, bariatric, metabolic, gynaecological and urological surgery. The challenges faced with single-incision laparoscopic surgery are discussed, as well as the clinical studies that are required in order to establish single-incision surgery as a significant improvement to conventional laparoscopic surgery in terms of reduced pain and improved cosmesis. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Bionic prosthetic hands: A review of present technology and future aspirationsR. G E Clement | K. E. Bugler | C. W. Oliver
Volume 9, Issue 6, December 2011, Pages 336-340
Background: Bionic prosthetic hands are rapidly evolving. An in-depth knowledge of this field of medicine is currently only required by a small number of individuals working in highly specialist units. However, with improving technology it is likely that the demand for and application of bionic hands will continue to increase and a wider understanding will be necessary. Methods: We review the literature and summarise the important advances in medicine, computing and engineering that have led to the development of currently available bionic hand prostheses. Findings: The bionic limb of today has progressed greatly since the hook prostheses that were introduced centuries ago. We discuss the ways that major functions of the human hand are being replicated artificially in modern bionic hands. Despite the impressive advances bionic prostheses remain an inferior replacement to their biological counterparts. Finally we discuss some of the key areas of research that could lead to vast improvements in bionic limb functionality that may one day be able to fully replicate the biological hand or perhaps even surpass its innate capabilities. Conclusion: It is important for the healthcare community to have an understanding of the development of bionic hands and the technology underpinning them as this area of medicine will expand. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Comparison of laparoscopic adjustable gastric banding (LAGB) with other bariatric procedures; a systematic review of the randomised controlled trialsP. D. Chakravarty | E. McLaughlin | D. Whittaker | E. Byrne | E. Cowan | K. Xu | D. M. Bruce | J. A. Ford
Volume 10, Issue 3, June 2012, Pages 172-182
Background: Bariatric surgery can provide efficient weight loss and improvement in obesity-related co-morbidities in adults. Laparoscopic adjustable gastric banding (LAGB) comprised 30.3% of all bariatric procedures between 2009 and 2010 in the UK. This review evaluates the level 1 evidence for change in co-morbidities, quality of life (QoL) and weight provided by LAGB compared with other bariatric procedures. Method: Systematic literature search of MEDLINE, EMBASE and CENTRAL (1988 to May 2011) was performed. Only randomised controlled trials (RCTs) were included. Studies with non-surgical comparators, open gastric banding procedures or adolescent participants were excluded. Primary outcome was change in co-morbidities. Secondary outcomes included QoL, weight loss, complications, operation time and length of stay. Results: Five RCTs met the inclusion criteria. Vertical banded gastroplasty, sleeve gastrectomy and gastric bypass were compared to LAGB. Co-morbidities were reported in two studies and QoL in one. LAGB was comparable to other procedures for both of these outcomes. All five trials showed LABG to be effective in weight loss, however all comparative procedures resulted in greater weight loss. Operative time and length of hospital stay were significantly shorter with LAGB. Short-term complications were found to be consistently lower in the LAGB group. Evidence was divided with respect to long-term complications. Conclusion: Co-morbidities and QoL are poorly reported and showed no difference between LAGB and other bariatric procedures. Evidence suggests that LAGB is not the most effective surgical procedure to reduce weight. LAGB is associated with lower early complications and shorter operative time and length of stay, and therefore may be preferable to patients. © 2012 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Platelet plasma rich products in musculoskeletal medicine: Any evidence?Nicola Maffulli | Angelo Del Buono
Volume 10, Issue 3, June 2012, Pages 148-150
Platelet Reach Plasma (PRP) is considered to accelerate muscle and tendon healing and allow early return to elite competition, and it is often recommend as best practice for management of musculoskeletal injuries. Even though several growth factors abundant in PRPs have been extensively studied in tissue regeneration, the key factors are yet unknown. Given our rudimentary knowledge of the mechanism of action of the PRPs, it is challenging to use this technology to promote early healing, and produce improved and accelerated functional recovery. We prompt researchers to undertake appropriately powered level I studies with adequate and relevant outcome measures and clinically appropriate follow up. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
The role of microwave ablation in the management of hepatic colorectal metastasesC. Jones | S. A. Badger | G. Ellis
Volume 9, Issue 1, February 2011, Pages 33-37
Background: Colorectal metastatic disease of the liver carries a significant mortality. Surgical resection improves prognosis in suitable patients. Microwave ablation is a recent innovative technique for the management of hepatic cancer. The aim of this study was to review the relevant literature regarding its safety and efficacy. Methods: A literature search was performed using Pubmed, Athens, Medline and Google Scholar search engine. The following key words were used - thermal ablation, microwave ablation, liver, colorectal cancer, colorectal liver metastases - singly or in combination. To ensure an up-to-date literature search, the search has been restricted to the last ten years from 2000 to date inclusively, and the search was restricted to English language articles. To maximize this search backward chaining of reference lists from retrieved papers was also undertaken. Conclusions: Microwave ablation adds another potential treatment modality to the hepatic surgeon armament. It can be performed safely and has an acceptably low complication rate. © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Evaluation of post operative shoulder tip pain in low pressure versus standard pressure pneumoperitoneum during laparoscopic cholecystectomyMir Yasir | Kuldeep Singh Mehta | Viqar Hussain Banday | Aiffa Aiman | Imran Masood | Banyameen Iqbal
Volume 10, Issue 2, April 2012, Pages 71-74
Introduction: Insufflation of carbon dioxide during laparoscopic cholecystectomy leads to postoperative shoulder tip pain. The origin of shoulder pain is commonly assumed to be due to overstretching of the diaphragmatic muscle fibres owing to a high carbon dioxide pressure. Aims: To study the frequency and intensity of post operative shoulder tip pain in laparoscopic cholecystectomy and compare low and standard pressure pneumoperitoneum during laparoscopic cholecystectomy with respect to post operative shoulder tip pain. Methods: Patients admitted in the department of surgery for elective cholecystectomy were enrolled in the study. The patients were randomly allocated to two groups (group A and group B). In group A (n = 50), low pressure pneumoperitoneum (8 mm Hg) and in group B (n = 50), standard pressure pneumoperitoneum (14 mm Hg) was generated during laparoscopic cholecystectomy. Postoperative shoulder tip pain was assessed at 4, 8 and 24 h after operation by the Visual Analogue Scale of Pain. Results: 14 patients (28%) in group B complained of post operative shoulder tip pain as compared to only 5 patients (10%) in group A. The mean intensity of post operative shoulder tip pain assessed by visual analogue scoring scale at 4, 8 and 24 h was less in group A as compared to group B, although statistical significance was seen only at 4 h. Analgesic requirements and the mean length of post operative stay in the hospital were also less in group A as compared to group B. Conclusion: Low pressure laparoscopic cholecystectomy (LPLC) significantly decreases the frequency and intensity of postoperative shoulder tip pain. LPLC decreases the demand for postoperative analgesics, decreases postoperative hospital stay and hence improves the quality of life in the early stage of postoperative rehabilitation. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Does bariatric surgery prior to lower limb joint replacement reduce complications?A. Kulkarni | S. S. Jameson | P. James | S. Woodcock | S. Muller | M. R. Reed
Volume 9, Issue 1, February 2011, Pages 18-21
Obesity is an increasing health concern in developed world. Bariatric surgery is considered in super-obese patients. Many of these patients will also require lower limb arthroplasty. This study was performed to investigate the complications of hip and knee replacement in patients who had bariatric surgery either before or after their joint replacement. Hospital episode statistics data for English NHS patients undergoing lower limb arthroplasty and bariatric surgery between 2005 and 2009 were analysed. The joint replacement-specific and general medical complications were compared between those undergoing joint replacement prior to bariatric surgery and vice versa, and also with the general English arthroplasty patient. One hundred and forty-three patients underwent bariatric surgery and joint replacement. Bariatric surgery was performed first in 53 and arthroplasty first in 90 patients. The mean age of obese patients was 9 years younger than the general arthroplasty population. Mean in-hospital stay was similar but general medical complications in obese patients appear to be less, possibly because of the lower age at the time of the procedure. Hip dislocation rate at 18 months was higher. Within the two obese groups wound infection rate was 3.5 times lower and readmission to hospital at 30 days appeared to be 7-times lower in patients who had bariatric surgery prior to joint replacement (p = 0.06). In this patient group, the risk of complications following joint replacement appears to be lower if bariatric surgery is performed first. © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Fournier's gangreneDevajit Chowlek Shyam | Amy Grace Rapsang
Volume 11, Issue 4, August 2013, Pages 222-232
Fournier's gangrene (FG) is a synergistic polymicrobial gangrenous infection of the perineum, scrotum and penis which is characterised by obliterative endarteritis of the subcutaneous arteries, resulting in gangrene of the subcutaneous tissue and the overlying skin. FG affects all ages and both genders, with a male preponderance. It is a rare but life-threatening disease, and despite therapeutic advances in recent years, the mortality rate is 3%-67%, with an incidence of 1:7500-1:750,000. Anorectal, genitourinary and cutaneous sources of infection are the most common causes of FG, with diabetes mellitus being the most common risk factor. The clinical condition presents evolution from 2 to 7 days and is characterised by uneasiness, local swelling and discomfort, fever, crepitus and sometimes frank septic shock. Current imaging techniques for initial evaluation of the disease include radiography, Ultrasonography (USG), Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). However, the diagnosis of FG is usually clinical and imaging can be helpful in uncertain diagnosis and when clinical findings are ambiguous. Treatment of FG is based on a multimodal approach which includes intensive fluid resuscitation to stabilise the patient and correction of electrolyte imbalance, if any. This is followed by extensive debridements and resections in order to remove all necrotic and infected tissue, wide spectrum antibiotics and reconstructive surgery, whenever required. However, despite all the advances in treatment today, FG remains a surgical emergency, hence, early recognition with aggressive haemodynamic stabilisation, parenteral broad spectrum antibiotics and urgent surgical debridement are the mainstay of treatment. © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Laparoscopic vs. open liver resection for malignant liver disease. A systematic reviewAhsan Rao | Ghaus Rao | Irfan Ahmed
Volume 10, Issue 4, August 2012, Pages 194-201
Introduction: Since the introduction of minimally invasive techniques, there is little agreement about use of laparoscopic surgery for malignant liver lesions as compared to open resection. We aim to analyse all available data comparing both these groups. Methods: All the studies that compared laparoscopic and open liver resections for malignant lesions were searched on various databases. Data were collected and analysed in Review Manager RevMan (version 5.0). Results: There were total of 10 studies (n = 700) that compared laparoscopic (296/700) and open (404/700) hepatic resections for malignant lesions. Laparoscopic group was associated with reduced number of patients requiring blood transfusion [Odds ratio 0.35 CI 0.20, 0.60 P<0.001 HG 0.85], decreased number of positive resection margin [Odds ratio 0.34 CI 0.16, P0.006 HG 0.73] and decrease in overall complication rate [Odds ratio 0.43, CI 0.26, 0.73 P0.002 HG 0.22]. Laparoscopic group was associated with less operative blood loss [WMD 162.6 ml CI -261.79, 73.45 P<0.001] and reduced hospital stay [WMD 4.28 days CI -6.33, -2.23 P<0.001]; however, there was significant heterogeneity [HG <0.001] between the studies for these parameters. Conclusion: The laparoscopic group was associated with reduce overall complication rate, positive resection margins and number of patients requiring blood transfusion. There is still need for level I and II data to compare laparoscopic versus open hepatic resection in malignant lesions. © 2011.
Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE)R. S J Dalton | N. J. Smart | T. J. Edwards | I. Chandler | I. R. Daniels
Volume 10, Issue 6, December 2012, Pages 342-346
Background: Many studies report that low rectal cancer treated with abdomino-perineal excision (APE) have higher rates of CRM involvement with associated local recurrence and worse survival when compared to low anterior resection. We present a single surgeon's short-term outcomes using the prone perineal extra-levator (elAPE) approach. Methods: Thirty-one patients between 2006 and 2010 underwent elAPE with curative intent. Data was collected prospectively recording patient tumour characteristics and histological outcome. Outcome measures included circumferential resection margins, recurrence rates, 30-day morbidity and mortality. Results: Mean distance of tumour from anal verge was 3.63 ± SD 1.52 cm. 14 patients had pre-operative chemo-radiotherapy. The involved circumferential resection margin rate was 3.2%. Median follow-up was 20 (0-45) months, with overall mortality of 13.3% and 30 day mortality of 6.6%. Conclusions: The prone position elAPE has a low circumferential resection margin involved rate and, through improved vision, reduces the risk of inadvertent tumour or specimen perforation. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Tumescent anaesthesiaPatrick H. Conroy | James O'Rourke
Volume 11, Issue 4, August 2013, Pages 210-221
Tumescent anaesthesia describes the practice of injecting a very dilute solution of local anaesthetic combined with epinephrine and sodium bicarbonate into tissue until it becomes firm and tense (tumescent). It was initially described in the field of liposuction but now surgical applications for the technique are widely varied ranging across vascular surgery, breast surgery, plastic surgery and ENT procedures. It is widely used in both hospital- and office-based environments and may form the sole method of anaesthesia for surgery. Advantages include a reduction in blood loss through both epinephrine-induced vasoconstriction as well as hydrostatic compression from the tumescent effect. Sodium bicarbonate reduces pain associated with the injection of an acidic local anaesthetic solution. Due to the unique pharmacokinetic profile of this technique lidocaine doses of 35mg/kg bodyweight have been shown to be safe for liposuction procedures. Tumescent lidocaine is absorbed very slowly from subcutaneous tissues producing lower, and more delayed, peak blood levels compared to other routes, as well as extended postoperative analgesia. Slow systemic absorption allows the rapid hepatic plasma clearance of lidocaine to maintain safe local anaesthetic blood levels. This slow absorption from subcutaneous tissue has been likened to a depot injection. Careful attention must be given to appropriate local anaesthetic dosage alterations in cases of co-administration with agents affecting hepatic drug clearance or conditions reducing liver blood supply. Adherence to these pharmacological principles has produced an exemplary safety record for this technique to date. © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Pre-operative predictors of post-hepatectomy recurrence of hepatocellular carcinoma: Can we predict earlier?Charing Ching Ning Chong | Kit fai Lee | Philip Ching Tak Ip | Jeff Siu Wang Wong | Sunny Yue Sun Cheung | John Wong | Suzanne C. Ho | Paul Bo San Lai
Volume 10, Issue 5, October 2012, Pages 260-266
Backgrounds and purpose: To determine the predictors for recurrence in patients receiving curative hepatectomy for hepatocellular carcinoma (HCC). Methods: From January 2001 to July 2007, all patients having hepatectomy for first occurrence HCC with curative intent were identified from a prospectively collected database. Prognostic factors for recurrence and survival after resection were analyzed. Results: A total of 235 patients were included. With a median follow-up of 50.2 (0.07-125.1) months, the recurrence rate was 57.0%. The 1-, 3-, and 5-year overall survival rates were 83.9%, 66.0%, and 58.1% respectively. Multivariate analysis demonstrated that multi-focal lesions (HR: 2.93, P < 0.001), alpha-fetoprotein (AFP) level greater than 100 ng/ml (HR: 1.74, P = 0.002) and history of tumor rupture (HR: 2.84, P = 0.003) were independent risk factors for recurrence of HCC after hepatectomy. Conclusions: Predictors for HCC recurrence can be identified before operation. These important parameters should be considered before and after contemplating curative resection for HCC patients and for risk stratification in future clinical trials for neoadjuvant or post-resection adjuvant therapy. The possible use of neoadjuvant or adjuvant treatment to improve survival should be addressed by further trials. © 2011.
The effects of tobacco smoking on the incidence and risk of intraoperative and postoperative complications in adultsStavros Gourgiotis | Stavros Aloizos | Paraskevi Aravosita | Christina Mystakelli | Eleni Christina Isaia | Christos Gakis | Nikolaos S. Salemis
Volume 9, Issue 4, August 2011, Pages 225-232
Introduction: Despite the warnings of health hazards of cigarette smoking, still one third of the population in industrial countries smoke. This review was conducted with the aim of exploring the effects of preoperative tobacco smoking on the risk of intra- and postoperative complications and to identify the value of preoperative smoking cessation. Methods: The databases that were searched included The Cochrane Library Database, Medline, and EMBASE. Articles were also identified through a general internet search using the Google search engine. The incidence or risk of different types of intra- and postoperative complications were used as outcome measures. Results: Tobacco smoking has a negative effect on surgical outcome, as has been found to be a risk factor for the development of complications during and after many types of surgery, even in the absence of chronic lung disease. Furthermore, the long-term health hazards of smoking reduce health-related quality of life and premature death. Conclusion: It is widely documented that stopping smoking before surgery has substantial health benefits in the longer term and should be recommended to every smoker in order for them to gain maximum benefit from their treatment. However, identification of the optimal period of preoperative smoking cessation on postoperative complications cannot be determined. © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.


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Catherine's Health Center is a non-profit, community-based health facility dedicated to serving low-income residents of Greater Grand Rapids. Please click the images or menus above to learn more about us.
Newsletter for October
Happy October!
Take a look at our Healthy Living Newsletter to see what opportunities are available this month!
Newsletters for May
Hi all,
Apologies for the late post this month.
Here is the North End Wellness Coalition Newsletter and
Here is the Healthy Living Newsletter.
Hope you are all enjoying this weather to the fullest!
Our Mission
Open Doors: We exist to improve access for those in need of health care services.
Quality Care: We believe everyone deserves to have their health care needs met in a caring and dignified manner.


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There have been some crazy rumors involving Rob & Kristen on the internet lately & Gossipcop has found out the truth & are busting these rumors. I debated whether or not to post this & decided to so hopefully no one will fall for these silly rumors.
First up is one concerning the filming of the Breaking Dawn love scenes.
The National Enquirer reports, "Robert Pattinson, abo…
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New York City music exec tells of longtime love of Packers
His professional routine involves bringing hip-hop to the masses, but his Sunday routine revolves around the Packers.
Lyor Cohen, the former head of Def Jam records, was profiled by the New York Times in this week's "Sunday Routine" column, which notes that Cohen is a "passionate fan of the Green Bay Packers" and "everything gets thrown off" when the team is playing. »Read Full Blog Post
Lady Antebellum connects with fans, not feelings, at State Fair
Lady Antebellum is probably the biggest country-pop group of the last decade, primarily because it has a knack for locating the universal. Or for dressing up the lowest common denominator to look, feel and sound like the universal.
The distinction didn't make a difference to the packed crowd attending the group's show at the Wisconsin State Fair Main Stage Saturday night. »Read Full Article(14)
Festivals and free concerts this week in the Milwaukee area
Wisconsin State Fair: 8 a.m.-10 p.m. Aug. 10, State Fair Park, 640 S. 84th St., West Allis, (800) 884-3247 or www.wistatefair.com »Read Full Article


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The Rocky Horror Picture Show Test
Their result for The Rocky Horror Picture Show Test ...
Sweet Transvestite
You scored ###%
Their Analysis (Vertical line = Average)
They scored 85% on points, higher than 83% of your peers.
All possible test results
You know of The Rocky Horror Picture Show, but you haven't quite experienced it yet. Don't worry, though, it just makes your cherry all the more ripe for when we pop it!... Read more
"You're okay by me"
You've been to Rocky before, you know the procedure, you're just not that big on it. But hey, that's alright with me. Enjoy your life. Read more
Oh yeah! You're the one sitting in the middle with me shouting call lines at the screen! Isn't Rocky just great? Read more
Sweet Transvestite
Wow. You probably know more than I do about the movie. Congratulations. Now get a life. Read more
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UPS Pty Ltd is a foreign-owned private company that derives the majority of its revenue from the international package and freight forwarding operations. The company is headquartered in Botany, New South Wales and employs approximately 280 staff.
UPS Pty Ltd is a wholly-owned subsidiary of the US-based transportation, logistics and financial services provider, UPS International Inc.
UPS Pty Ltd offers the following range of international package forwarding services, specialised transportation, and logistics services:


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Special Bed & Breakfast Offers – Boutique Brighton
Summer is here and the weather has generally been amazing – with back to back sunshine, book your getaway now and escape the everyday for something a little different…
Brighton gains a party feel in the summer months with lots to do and see and plenty of places to choose to eat there's fun for all the family.
Special Autumn 2016 Prices
October 2016
Double / Twin from £62.50
- £72.50 Double/Twin room
(£62.50 no breakfast for those in a hurry)
- £89.00 Sea View Double/Twin
(£79.00 no breakfast for those in a hurry)
ALL rates are inclusive for an en suite bedroom, complimentary Wi-Fi throughout the hotel, tea & coffee making facilities, flatscreen TVs, in-room safes and direct dial telephone. And for Breakfast packages includes our Award Winning Sussex Breakfast.
Single rooms are also available. Book online, top right, or call us now for more details.
Our best promotions for:
- Dinner Promotion,
- Business Travellers,
- Romantic Break in Brighton,
- Family Spring/Summer Holidays,
- Pampering Packages,
- Weekend Shopping Breaks,
- October Half Term Breaks,
- Sunday Specials – stay half price.
Future monthly offers will be added here shortly


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Deivid Sarapuu
Web and Mobile back-end developer who from time to time likes to do front-end coding as well. Interested in creating something fresh & awesome.
- Webs
- Mobile apps
- Infosystems
- E-commerce
- Custom
Web and Mobile back-end developer who from time to time likes to do front-end coding as well. Interested in creating something fresh & awesome.
Collection of recent work about webshops, information systems, mobile applications, company & personal webpages, custom solutions and more.
Sõltumatu energiaturu ettevõte
Work: Self-service portal for Baltic Energy Services customers built on a custom php workframe. Works in three countries where users can view their contracts, analyse consumptions and more.
Collaboration: Softpro OÜ
Sõltumatu energiaturu ettevõte
Work: User-interface for a data warehouse. Is built on a custom php workframe. Main functionality includes: table, form and graph manipulation; data export to appropriate file formats; automatic information exchange with different country databases.
Collaboration: Softpro OÜ
Värviline sõnum inimesteni.
Work: Webpage design and Facebook gallery API that imports images from MediaStudio's Facebook page to MediaStudio web gallery
Collaboration: Silver Koppel (Design)
fasaadide ja lamekatuste soojustamine
Work: Firm identity including logo, business cards, banners and web desgin for web & mobile devices. Making a company website using WordPress and making SEO for it.
Collaboration: Rain Ant (Design/Wordpress)
Võsaraie: kraavid, teeääred, hakkimine
Work: Custom user-interface for data warehouse. Main functionality includes inserting and analysing consignment, sending bills and managing stock statuses.
Collaboration: Softpro OÜ
Turning my school internship and after school I did several projects in collaboration with NewTime.
In those projects I did the front-end coding and/or implementing front-end code to WordPress.
For example pages like: Khis, Martella, GBD, Liivimaa Lihaveis, Humparts and more
Collaboration: NewTime
Personal photography portfolio site. Predecessor to current design that used to contain both web and photography work.
Working as a developer for Astro Baltics I took part in more than a baker's dozen WebShop projects. Also in a couple of Automated Hostel booking systems and mobile salesman's assistant applications.
Employer: Astro Baltics
Starting from my early school years, I have been interested in computers and programming. In consequence I started developing web pages as a hobby in the beginning of this millenium. I freelanced for a number of local projects in my hometown throughout high school. It was clear from the beginning, that coding will be my profession.
After high school I studied Multimedia(Web Specialist) vocation in Tartu. The curriculum consisted mainly of design, front-end coding and project management. Despite that my interest in back-end coding has always been dominant, and as a result I have ended up doing it most of the time. From the late nineties up to now, I have worked on different operating systems and programming languages. My coding journey started with Windows 95 PC and I used all of the major new distros up to Windows 7, before moving on to linux.
I started out learning HTML, CSS, PHP, MySQL and over the years I have picked up JavaScript, Java, Objc, Python, Wiring, Oracle, Firebird,
SQLite, Node.js.
Lately my work consists more of custom solutions, so each new project is completely different than the last one. For example some of my recent work has been the making of PHP libraries for capacious information systems; offline salesman assistant with bluetooth printing for mobile devices; custom SDK frameworks for both iOS and Android. As a hobby I build and program gadgets via Arduino microcontroller.
Have a project? Want to do something fresh? - Get in touch with me.


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I had the great pleasure of meeting Katie from TravelFrog today, she was in Dublin for the Web Summit hoping to do a bit of Networking with an eye to future investment in her great website.
TravelFrog invites visitors to browse travel itineraries left by contributors, helping them to plan what to do and see when they visit new places.
It also invites visitors to share their Itineraries in return
I know I'll be using it a lot in the future and wish Katie the very best for the future.
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Primary storage capacity optimization
- August 15, 2016
15 Aug'16
HPE StoreVirtual entry-level arrays get makeover, price cut
HPE StoreVirtual and MSA entry-level storage have new flash and hybrid models with lower prices as the vendor tries to expand its footprint outside of its enterprise 3PAR storage.
- July 06, 2016
06 Jul'16
Storage purchase intentions rise with new techs in sight
Our annual storage purchasing survey finds that storage managers will have a bigger data storage budget to spend this year.
- May 26, 2016
26 May'16
Symbolic IO's IRIS makes eyes at in-memory storage
Symbolic IO emerges from stealth, with a claim that its IRIS product can shrink memory-based storage, rehydrate it quickly in RAM and preserve it intact.
- May 25, 2016
25 May'16
Investment firm picks Infinidat storage to boost performance
Meitav Dash Investments experienced problematic latency with its applications using NetApp filers before turning to newcomer Infinidat's hyperscale hybrid storage.
- May 03, 2016
03 May'16
Michael Dell: EMC will flourish as part of Dell Technologies
Outgoing CEO Joe Tucci says goodbye at EMC World 2016, and new boss Michael Dell says the company will be known as Dell Technologies once the $67 billion acquisition closes.
- April 11, 2016
11 Apr'16
IBM Research builds 'cognitive' system to cut big data storage costs
IBM researchers are developing a cognitive storage system designed to automatically differentiate high- and low-value data and determine what information to keep, where to store it and how long to ...
- December 04, 2015
04 Dec'15
Hot data storage technology trends for 2016
Find out what's hot and what's not-so-hot on our list of data storage technology trends for the coming year.
- October 13, 2015
13 Oct'15
Dell-EMC acquisition leaves questions as Tucci steps away
When the Dell-EMC deal is complete, EMC CEO Joe Tucci will step away after 15 years on the job -- leaving Michael Dell and others to carry on his legacy.
- October 02, 2015
02 Oct'15
Flash forward: What's next for flash storage technology
Emerging flash technologies target capacity, reliability and cost, while the line between storage and memory continues to blur. Over the past couple of years, we've seen four major developments in flash storage technology: 3D architectures, which ...
- September 10, 2015
10 Sep'15
Caringo Swarm refines migration with FileFly software
New FileFly software for Caringo Swarm lets Windows Storage Server and NetApp filers migrate data to Caringo object storage systems.
- July 16, 2015
16 Jul'15
Coho Data refreshes hybrid flash array, doubles capacity
The DataStream DS1008 array gets a capacity jolt, while a software upgrade adds flash optimization tools and subscription-based storage pricing.
- June 30, 2015
30 Jun'15
Condusiv adds analytical engine to software to mitigate I/O latency
Condusiv adds an analytical engine to its V-locity software that boosts I/O performance in Microsoft environments.
- June 05, 2015
05 Jun'15
Storage purchase plans move to cloud with rising budgets
Our annual Purchasing Intentions survey paints a rosier picture than last year for managers stretching their budgets to cover capacity storage purchase plans.
- May 01, 2015
01 May'15
Smarter storage from metadata, object stores
One of the distinguishing features of object storage systems is their ability to package more metadata with each object they store. That metadata could be used to restrict access, define a file's lifecycle and its ultimate disposition. Other storage...
- September 16, 2014
16 Sep'14
Permabit points SANblox dedupe appliance at legacy storage arrays
Permabit puts data reduction on its add-on appliance, but which vendors will sign on to sell it?


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mara mara
- 4 total posts
- 1 review
- 3 comments
Reviews by mara mara
Awful - Phoenix, AZ
I went to Cory for correcting the bridge of my nose which was sunken in, in 2009,he put a silicon implant in(which is usually used in asian woman)it punctured a whole and slipped downward,my nose hurt to the touch,he said is part of healing,my nose startet to go more and more to the right side... READ MORE
Recent comments from mara mara
You left out a few of your incompetences Dr. Cory READ COMMENT
Thanks to Dr Calvert I have a beautiful nose now READ COMMENT
I reported him to the medical board he just got a slap on the wrist. So much for going to a plastic surgeon in Arizona you cant even arbitrate. You do have that option in CA READ COMMENT


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5 Thanksgiving Decor Ideas Using Household ItemsThe food may traditionally be the highlight of the Thanksgiving table, but that doesn't mean that you can't add some decor to create an inviting atmosphere. Craft the perfect table setting with these five ideas.
8 Easy DIY Projects to Ready Your Home for FallWeatherproofing your home or updating your decor can be a fun and easy do-it-yourself project before fall sets in. Here are a few options to inspire you to get creative.
Shop Pops Up In Allen For Nonprofits A new boutique opened in Allen today and you can find discounts of 70 percent off retail there.
Shopping Is A Sport: Designer Goods For LessShopping is, without question, a sport. At least that's what I told Tracy Kornet for the story she did Thursday night on CBS11.


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5 Players the Jazz Should Go After This Summer
The Utah Jazz have found themselves in an excellent position to recreate a contending team for next season. With two picks in the NBA Draft lottery (No. 3 and No. 12 overall), huge sums of money coming off of the books, a new coach and coaching system, a group of promising young players, and a few proven veterans, the Jazz franchise is in a quiet state of excitement.
There are so many mock drafts and articles debating and evaluating the upcoming draftees; so, in order to "break the mold", this article will focus on the free agents around the league, and those of them that would be a good fit in Utah.
The following slides examine, in my opinion, the top five free agents that the Jazz should sign this summer.
I value your opinion and appreciate your different views, please leave me some feedback. Comment!
[Salary information found on HoopsHype.com]


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DarkRPGMaster wrote: »Wait...Atlus is a small publisher!?
Dragon Quest Monster - Joker 2 just got announced for August, so there's another one.Great news that it's being translated, hopefully they can release it fast enough so that they can still sell a few copies before the 3DS takes over.
...That said, this is pretty much the only rpg coming out on the DS now, isn't it...


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German Dinner Recipes
Looking for German dinner recipes? Find delicious German dinner recipes including beef dinner recipes, chicken dinners, and more German dinner recipes.
Recipe Spotlight
Grilled Beer Brats with Kraut
Keeley Weber
I made this for my son's 21st birthday bonfire, which included a dozen buddies. The kraut topping flavors are fabulous. — Keeley Weber, Sterling Heights, MichiganGet Recipe


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Anthology Magazine is a home and lifestyle print magazine that explores a theme in every issue. In this online preview, we show you a glimpse of the content in Issue No. 5 (Fall 2011), the theme of which is "Going Global Outdoors" The complete print version of this issue is 128 pages. To learn more about Anthology Magazine or to subscribe, please visit anthologymag.com.
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The U.S. attorney's office for the Southern District of Georgia said Friday that 29-year-old Bo Dukes, an Army supply specialist from Savannah, billed the Army for televisions, cameras, power tools and other goods that were shipped to his home. Prosecutors say Dukes and his wife, Emily Dukes, would pawn the items and pocket the cash.
The couple pleaded guilty before a U.S. District Court judge in Savannah last week to charges that they conspired to steal from the U.S. military.
They both face a maximum of five years in prison and fines of up to $250,000.