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Date: October 11, 2012
With New Maruti Alto 800 Getting Launched on 16th October 2012 and Existing Alto Carrying Discounts of Rs. 31,000 - Lets Compare New Alto with Old Alto 800
1. Engine and Power
« Present Maruti Alto Delivers 47 BHP of Power at peak torque of 63 NM
« New Alto 800 to come with peak power of 49 BHP and torque of 69 NM
Change : New Alto 800 is going to be powerful than Existing Alto
2. Body Dimensions
« Present Alto has Length - 3495mm, Width - 1475mm, Height - 1460, Wheel Base - 2360 mm, Boot Space - 117 Lit
« New Alto 800 has Length - 3395mm, Width - 1490mm, Height - 1475, Wheel Base - 2360 mm , Boot Space - 177 Lit
Change : New Alto is shorter in length against Existing Alto - but will have slightly more shoulder room and bit taller than Existing Alto and most important bigger boot space
3. Fuel Efficiency
« Big Factor - Existing Alto delivers mileage of 19.7 Kmpl
« New Alto 800 will deliver mileage of 22.5 Kmpl + as per expected ARAI benchmarks and over 30 Km/kg of CNG
4. Body Looks
Major Factor. New Alto 800 is smart with angular headlights and looks much more modern and stylish against Present Alto both from front and tail. The Front theme seems like any other modern era car, side looks been inspired from Swift and stylish tail lights adds on the beauty of the car
5. Interiors and Features
« Existing top End Alto Lxi comes with Power Steering and Auto Fuel Lid Opener apart from AC
« New Alto 800 expect to have Power Steering, Front Door Power Window, Better Quality Dashboard and Seats along with Optional Airbags in top End Lxi Model.
6. Color Options
Existing Alto comes in 6 color options, New Alto 800 expect to come in 7 color choices
Existing Alto has attractive 31,000 Cash Discount. However - observing the host of changes in New Alto - one quote comes to mind - \" When Patterns are Broken, New Worlds Emerge. \"
New Maruti Alto 800 going to be :-
« More Powerful with higher torque
« Stylish adding a charm. Infact the complete body design and feel has been redesigned
« Highly Fuel Efficient
« Better Interiors and quality with Silver finish on steering wheel and door handles adds elegance
« Added Features as per wishlist of Entry Segment Buyer
Maruti is going to break the pattern of its flag ship but traditional looking car into a style statement.
Our recommendation is to go with New Alto 800 adding on a modern era car to your family
New Alto 800 Pictures of Interiors and Exteriors
Connect with Author on:- Google


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Editors' Note: The "Download Now" link directs you to the iTunes App Store, where you must continue the download process. You must have iTunes installed in order to open the link, and you must have an active iTunes account to download the application. This download may not be available in some countries.
|Other Games
Publisher's Description+
What's new in this version:
1. Greater amount of data to support.2. Fixed few users can not enter the room bug.3. Now data transfer is more secure.

subset: commoncrawl


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March 14, 2010
By Brian Davis, Assistant Media Relations Director
KNOXVILLE, Tenn. - On a rainy Sunday afternoon at Lee Softball Stadium in Tennessee Invitational action, the No. 19 Lady Vol softball team (18-5) utilized a nine-strikeout performance from freshman pitcher Ivy Renfroe and three RBIs each from freshman right fielder Kat Dotson and sophomore third baseman Jessica Spigner to roll past Liberty (10-6), 10-0 (5 inn.).
Renfroe was outstanding over four no-hit frames of relief, tying her career-high with nine K's and improving to 9-1 on the season. Sophomore Cat Hosfield started the contest, permitting two hits in a single inning of work while walking one and striking out one.
Dotson was perfect in going 2-for-2 at the plate and hammered her first collegiate home run to go along with three RBIs and two runs scored. Spigner posted a 1-for-2 effort with three RBIs, while senior catcher Tiffany Huff was 2-for-3 with two RBIs. Senior first baseman Erinn Webb also blasted her second home run of the campaign and knocked in two tallies while going 1-for-3 at the dish.
After a quick top of the first where Hosfield worked around a lead-off walk and ended the frame with a strikeout of Liberty shortstop Kelly Strickland, Tennessee junior center fielder Kelly Grieve (2-for-2, three runs) got a UT scoring chance started with a one-out single to center in the bottom half. Dotson stepped into the box, and on a 1-2 count, blasted her first collegiate home run to deep right for a quick 2-0 lead. The occurrence marked the 12th time this season that the Lady Vols struck pay dirt during the initial inning.
A base hit on a sharp bouncer off the bat of third baseman J'Nae Jefferson and an Amber DePasquale bunt single put two Liberty runners on base with none out in the top of the second. That ended Hosfield's time in the circle as Renfroe entered and immediately imposed her will, striking out first baseman Kaylee West, catcher Keely McMillon and second baseman Cassie Hendrix in order to leave the LU duo stranded.
The Lady Vol lead reached three runs leading off the bottom of the second as Webb drove a Tiffani Smith offering to deep right for her second HR of the campaign. A walk by sophomore shortstop Ashley Andrews, an infield single off the bat of Chavanne and a wild pitch placed runners at second and third with still no one out. Grieve drew a walk to pack the bags and Dotson then coerced a free pass to force in a tally to make it 4-0, Tennessee. After blasting what would have been a sure grand slam just foul, Spigner ripped a two-RBI single to left. On the very next pitch from Smith, Huff knocked in a pair of runs on a base knock to left as UT nabbed an 8-0 advantage and ended the stay in the circle for Liberty's starter as Katie Warrington entered in relief. Following a botched Lady Flame fielder's choice and a groundout to second, Webb delivered an RBI via a bouncer to second as Huff crossed the dish with the Big Orange's ninth run. The frame finally came to a conclusion on an Andrews fly out to right, but in all, 11 Lady Vols came to the plate in scoring seven runs on the benefit of four hits and three walks in the inning.
Renfroe continued her mastery of the Lady Flames in the top of the third, improving her consecutive strikeout count to five with K's of left fielder Danielle Howard and right fielder Jenny Law. A bouncer to third by Liberty designated player Ashley Bensinger made it six in a row retired by UT's 5-10 right-handed pitcher.
The hit parade continued for UT with one out in the third as consecutive singles from Grieve and Dotson set the stage for a Spigner sacrifice fly to right center as the Tennessee lead expanded to 10-0.
From there it was all Renfroe as the freshman hurler struck out the last four Liberty batters of the contest to up her count to a career-high tying nine K's as Tennessee prevailed, 10-0 (5 inn.).
No. 19 UT wraps up the Tennessee Invitational at Lee Softball Stadium against Campbell on Sun., March 14th, at approximately 6 p.m. Check out Tennessee Invitational Tournament Central through utladyvols.com at http://www.utladyvols.com/sports/w-softbl/spec-rel/tennw-invite.html for Gametracker live stats of every game.


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2 figures omitted
Hepatitis C virus (HCV) infection is a major cause of liver disease and hepatocellular carcinoma in the United States.1,2 Of the estimated 2.7-3.9 million persons with active HCV infection, most were born during 1945-1964 and likely were infected during the 1970s and 1980s, before the advent of prevention measures.3 Nationwide, rates of acute, symptomatic HCV infection declined during 1992-2005 and then began to level.4 Declines also were observed in rates of newly reported HCV infection in Massachusetts. Although these declines were evident among reported cases overall in Massachusetts during 2002-2006, an increase was observed among cases in the 15-24 year age group. In response to this increase, the Massachusetts Department of Public Health (MDPH) launched a surveillance initiative to collect more detailed information on cases reported during 2007-2009 among this younger age group and to examine the data for trends through 2009. This report describes results of both efforts, which revealed continued increases in rates of newly reported HCV infection among persons aged 15-24 years. These cases were reported from all areas of the state, occurred predominantly among non-Hispanic white persons, and were equally distributed among males and females. Of cases with available risk data, injection drug use (IDU) was the most common risk factor for HCV transmission. The increase in case reports appears to represent an epidemic of HCV infection related to IDU among new populations of adolescents and young adults in Massachusetts. The findings indicate the need for enhanced surveillance of HCV infection and intensified hepatitis C prevention efforts targeting adolescents and young adults.
MDPH currently uses an electronic data system for disease surveillance. All positive laboratory results indicating HCV infection are reportable to MDPH. A positive laboratory result on a previously unreported case prompts a case report form to be sent to the health-care provider (e.g., clinician) ordering the test. This one-page form collects information on demographics, symptoms, and risk history. In accordance with CDC case definitions, HCV infection cases are classified as either confirmed (i.e., positive by an anti-HCV antibody assay with a nucleic acid test [NAT] result confirming active infection) or probable (i.e., positive antibody test result with confirmatory NAT either not conducted or not reported to MDPH). For this analysis, all confirmed and probable cases of HCV infection were included.
In 2006, anecdotal information received from community-based partners about HCV infection cases among adolescents and young adults prompted a review of state surveillance data. Although an overall decline in rates of newly reported HCV infection (from 181 to 128 cases per 100,000 population) was observed during 2002-2006, an increase (from 65 to 102 cases per 100,000 population) was observed among persons aged 15-24 years. At the time, 75% of 2005 surveillance reports for cases among persons in this age group lacked risk history; therefore, the sources of infection were unknown. Beginning in 2007, MDPH sent HCV infection case report forms (CRFs) to reporting clinicians to collect additional information when a report of newly identified HCV antibody (anti-HCV) positivity among persons aged 15-24 years was received. Clinicians also were sent reminders to fill out CRFs if more than 30 days had passed from the date the form was sent and a completed form had not yet been received by MDPH.
During 2002-2009, rates of newly reported HCV infection (confirmed and probable) among persons aged 15-24 years increased from 65 to 113 cases per 100,000 population. The number of confirmed cases of HCV infection reported in Massachusetts was further examined by age and compared for the years 2002 and 2009. The data shifted from a unimodal age distribution in 2002 to a bimodal age distribution in 2009, with the latter showing substantially more reports of HCV infection among adolescents and young adults compared with the earlier period.
During 2007-2009, MDPH received 1,925 reports of new cases of HCV infection among persons aged 15-24 years. Of these, 1,026 (53%) were classified as confirmed cases of HCV infection; the remainder were classified as probable. Although some clustering of cases was observed in urban areas, cases were reported from all areas of the state, including large metropolitan areas, suburban areas of Boston, smaller cities, and rural areas. Cases occurred with nearly the same frequency among men and women.
Of the 1,925 CRFs sent to reporting sources for completion, 1,448 (75%) were returned to MDPH, providing details of 802 confirmed and 646 probable cases. Of those returned, 252 (17%) CRFs did not have sufficient information to assess risk, and of these, 148 (59%) contained no risk data.
Of the total 1,448 CRFs returned, 1,357 (94%) included information on race. Of these, 1,052 (78%) indicated cases among persons who were white, 37 (3%) who were black, and 21 (2%) who were Asian; four indicated cases among persons who were American Indian/Alaska Native, and two indicated cases among persons who were Native Hawaiian or other Pacific Islanders. Ninety-four CRFs indicated cases in persons reported as being of unknown race, and 147 indicated "other" or multiple race categories. Of 1,154 (80%) cases with ethnicity information, 98 (8%) were among persons identified as Hispanic. Eight percent of the 1,448 cases with completed CRFs were among persons who were homeless or incarcerated.
By far, the most common risk identified was IDU. Of 1,196 cases with a reported risk history, 860 (72%) were in persons who reported current or past IDU; of these, 719 (84%) reported injecting drugs during the preceding 12 months. In addition, 445 (34%) reported some history of intranasal drug use. All but 34 of the cases for which intranasal drug use was listed also indicated IDU. Of the 719 cases for which IDU during the preceding 12 months was reported, 615 (85%) were among persons who reported heroin use, 220 (29%) cocaine use, seven (1%) methamphetamine use, and 31 (4%) use of other drugs, including opiates other than heroin (categories are not mutually exclusive because more than one drug could be reported). Additional commonly reported potential exposures included "other" blood exposures (24%) (further detail is missing for most cases for which this was reported; for those cases with this information included, a majority of "other" exposures listed were related to IDU), tattoos (23%), and a history of incarceration (20%); however, most cases involving these exposures were among persons who also were exposed through IDU.
Reported by: Shauna Onofrey, MPH, Daniel Church, MPH, Patricia Kludt, MPH, Alfred DeMaria, MD, Kevin Cranston, MDiv, Massachusetts Dept of Public Health. Geoff A. Beckett, MPH, Scott D. Holmberg, MD, John W. Ward, MD, Deborah Holtzman, PhD, Div of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Deborah Holtzman, CDC, 404-718-8555, firstname.lastname@example.com.
CDC Editorial Note: The Massachusetts surveillance data indicate an increase in HCV infection cases among adolescents and young adults during 2002-2009. These cases were primarily among non-Hispanic white residents in urban, suburban, and rural communities. Although calculating an incidence rate from the surveillance data or determining the duration of infection for persons who tested positive for anti-HCV antibody is not possible, the findings suggest that most persons aged 15-24 years with HCV infection likely acquired their infections within a few years of being tested and reported. Although similar increases in human immunodeficiency virus (HIV) infection were not identified for this age group, increases in reports of HCV infection among injection drug users might be a harbinger of increases in IDU-associated HIV.
Other states have indicated similar increases in HCV infection among adolescents and young adults. For example, in 2008, New York reported an increase in HCV infection among persons aged <30 years in suburban Buffalo.5 Since that time, surveillance data have indicated continued transmission and possibly new activity in other areas of New York (Elena Rizzo, New York State Department of Health, personal communication, 2011).
During the period when increases in HCV infection were being observed, Massachusetts experienced a concomitant increase in heroin use among adolescents and young adults. Data from MDPH-funded substance abuse programs showed a rise in the percentage of admissions (for all drug use) among persons aged 15-24 years, from 19% in 2002 to 23% in 2008.* Furthermore, the percentage of program clients who reported needle use when admitted increased from 29% in 2002 to 38% in 2008 among persons aged 15-24 years, whereas the percentage among all other age groups during this same period remained relatively constant at approximately 30%. Although the occurrence of IDU-associated HCV infection has been documented for decades, the recent epidemic in reported cases among adolescents and young adults and its apparent association with increases in drug injection and sharing of injection equipment in this population is a disturbing trend. Law enforcement data suggest this trend might be occurring in other states. During 2002-2009, the estimated average annual number of heroin initiates in the United States increased from 100,000 to 180,000.† Law enforcement reporting from the Great Lakes, Mid-Atlantic, New England, New York/New Jersey, Southeast, and West Central regions also suggests that heroin use is increasing, particularly among younger users.‡
Addressing the epidemic of HCV infection among adolescents and young adults presents unique challenges in terms of education, outreach, and other interventions. Studies have shown that the incidence of HCV infection among injection drug users aged <30 years ranges from 10 to 37 cases per 100 person-years.6,7 Moreover, among adolescents and young adults who inject drugs, HCV positivity has been associated with duration and frequency of injection.6 Adolescents and young adults might be more likely to share drug equipment because of the nature of their social networks, which are characterized by trust and sharing.6 The nature of these interactions must be taken into account when developing educational materials. Adolescents and young adults are likely to have participated in other risky behaviors before initiation of injecting and might have multiple physical, mental, and emotional health needs.8 The recent Institute of Medicine report on viral hepatitis and liver cancer noted that younger injection drug users might be at highest risk for seroconversion in the years immediately following initiation of injection practices.2
The findings in this report are subject to at least four limitations. First, the surveillance data only include information for persons who have access to and obtain serologic testing and thus might underrepresent the number of persons with HCV infection. This also might explain, in part, the demographic patterns that were observed. Second, efforts by MDPH to raise awareness of the increase in case rates among this age group might have contributed to an increase in testing and reporting of cases after 2007. Although data were not available to ascertain whether this actually occurred, and if so, what the magnitude of such an effect might have been, increases in the case rate among adolescents and young adults in Massachusetts were evident in the years before 2007 and, in fact, were more pronounced. In addition, recent research on injection drug users showed that, although persons aged 18-24 years had the highest rate of being tested for HIV, they had the lowest rate of HCV testing despite national recommendations for counseling and screening of injection drug users.9,10 Third, differences by county of residence could not be determined because of infrequent recording of residence information on laboratory results not accompanied with a matching CRF. Finally, differences in testing and reporting by county might also exist. Further studies are needed to better characterize the population groups that are at increased risk and those persons who are infected with HCV. Health-care providers need to be encouraged to ask about risks for HCV infection, especially IDU, and to screen patients at risk.
One important outcome of this study is that CDC, in collaboration with state and local health departments, is examining HCV surveillance data to determine whether similar trends are occurring in other reporting areas. In addition, MDPH and CDC are conducting an in-depth investigation of the causes of HCV transmission among adolescents and young adults in Massachusetts to recommend and implement targeted prevention measures.
This report highlights the important role of surveillance for HCV infection and reporting of all laboratory tests positive for HCV, along with the capacity to collect data of sufficient quality for meaningful analysis of trends in transmission and disease. By 2010, 43 states (including Massachusetts) and the District of Columbia required reporting of all laboratory tests indicative of HCV infections.§ However, despite the laboratory reporting requirement, most states have limited resources dedicated to surveillance of viral hepatitis and lack capacity to investigate reported cases and forward reliable data to CDC for national reporting. The Institute of Medicine noted this deficiency in public health surveillance as a major weakness in the prevention of viral hepatitis and liver cancer and recommended federal assistance for states to effectively conduct surveillance for all forms of hepatitis C.2
This report also strongly indicates the need for expanded and intensified hepatitis C prevention efforts targeting adolescents and young adults. The Institute of Medicine notes that multicomponent, comprehensive risk reduction programs are likely to be the most successful at addressing HCV infection prevention needs of persons who use illicit drugs. Some interventions that could be implemented include access to sterile syringes and drug preparation equipment through syringe exchange services, expanded school-based education that includes viral hepatitis prevention messages, expanded harm reduction programs directed toward young drug users, entry to drug treatment for young injection drug users, and access to comprehensive health services that include HCV testing and linkage to care.
This report is based, in part, on contributions by Massachusetts local health departments.
In the United States, hepatitis C virus (HCV) infection is an important cause of morbidity and mortality, especially in its chronic form. Persons who inject drugs are at greatest risk for HCV infection.
What is added by this report?
The Massachusetts surveillance data indicate an increase in cases of HCV infection among adolescents and young adults (i.e., persons aged 15-24 years) during 2002-2009. The increase in case reports appears to represent an epidemic of HCV infection related to injection drug use in this age group.
What are the implications for public health practice?
This report highlights the essential role of surveillance for HCV infection and reporting of all laboratory tests positive for HCV, along with the collection of case data sufficient to assess disease burden and transmission patterns. This report also strongly indicates the need for expanded and intensified hepatitis C prevention efforts targeting adolescents and young adults.
*Additional information available at http://www.mass.gov/dph/masschip.
†Additional information available at http://oas.samhsa.gov/nsduh/2k9nsduh/2k9resultsp.pdf.
‡Additional information available at http://www.justice.gov/ndic/pubs38/38661/index.htm.
§Additional information available at http://www.cste.org/dnn/programsandactivities/publichealthinformatics/statereportableconditionsqueryresults/tabid/261/default.aspx.
Hepatitis C Virus Infection Among Adolescents and Young Adults—Massachusetts, 2002-2009. JAMA. 2011;305(24):2511-2513. doi:
© 2017


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"Death is not more certainly a separation of our souls from our bodies than the Christian life is a separation of our souls from worldly tempers, vain indulgences, and unnecessary cares."
Related quotes
"I don't believe taking your own life is wrong nor it's a lowest thing you can do for your own gain. If taking other people lives isn't worse than this, then who the hell who am I suppose to complain this to? Death? I certainly don't think he care about stealing."
"Difficult to believe with all this disease, how have faith when fear is state, driven by fate of mass corruption, destruction. Who will save us now, this is no time to bow"
"I've died many deaths, but I'm still not dead. I've lived may lifes, inside my head. Reality is but a broken thread, A dream I dreamt while awake in bed."


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Before I go, just wanted to share with you the first sketch challenge I completed yesterday over at 365 Cards.
Hope you are all enjoying the start to a brand new week. Things are warming up here and loving that spring is just around the corner.Love when stamps say it all.


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Follow Harriet on Twitter
About Harriet
- The Poetry Foundation's blog for poetry and related news.
- More about Harriet
- Contributors
- Archive
Visual Poetics 04
"Boiling C"
by Kelly Mark
Kelly Mark is a productive, conceptual artistic, working in a diverse variety of media. She has made art entirely out of stolen butter-knives; she has used pencils to completely overpaint sculptures through the act of drawing; and she has released a CD, recording 1000 planned, but as yet unbegun, tasks that she must accomplish. She has even produced a suite of videos, in which she performs the same sequence of quotidian activities on an urban street, doing so in a synchronized choreography at the same time and in the same spot over the course of a month so that when she plays each recording simultaneously, side by side, she appears, uncannily, to be occupying a plurality of timeframes all at once, without anyone noticing.
Mark has also produced elaborate, pictorial drawings, generated through the use of Letraset stencils. Even though practitioners of visual poetry have often used this medium to create typographic abstractions, Mark has demonstrated some of the potential for this artform in the context of a gallery. Some of the work (like "Boiling C," for example) does suggest the figuration of an actual object, but in most cases her work takes delight in the formal traits of type itself, without allusion to any external referent. The "drawings" vary in scale from the size of a page to the size of a wall, and the images often display a byzantine intricacy, since the aggregation of letterforms almost always begins to disappear into their collective twists and expressive swirls.
Mark has even used Letraset stencils to draw "chains" of graffiti, all of which stretch and contort across walls in ateliers, twisting around lightbulbs and mouldings, like a long narrative or a long signature, in which the letters themselves parade and cavort without making any sense to their readership. All of her Letraset drawings exhibit an abstract, gestural intensity, suggesting the kind of flourishes and arabesques, made as if by brushstrokes, despite the fact that the artist has had to rub each letter onto the surface through a process of painstaking application. I might suggest that her artwork has resuscitated some artistic interest in a medium that (because of computerized typographics) has lately fallen into quaint disuse among the exponents of visual poetry….
Comment (1)
I've never heard of Kelly Mark, but love these sculptures & drawings. Thanks for pointing our her work.
Posted in Uncategorized on Wednesday, December 19th, 2007 by Christian Bök.


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Begum Mahmooda Salim Khan
From Wikipedia, the free encyclopedia
Begum Mahmooda Salim Khan (1913–2007) was an early pioneer woman social activist of Pakistan, especially active in promoting women's rights and their access to better educational and health facilities. She briefly remained Pakistan's first woman cabinet minister during the General Ayub Khan regime, between 1962 and 1967,[1] before quitting politics and returning full-time to public service.
She died on 17 June 2007 aged 94 years.


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Steak is one of the only foods that comes with a really sharp knife, which makes it the perfect choice if your date is a pumpkin with no face yet. Carve into this Groupon.
Choose Between Two Options
$35 for a prix-fixe meal for two ($73.75 total value)
- Shrimp cocktail appetizer or dessert ($11.95 value)
- Choice of two entrees from chicken chardonnay, 7-ounce filet or spicy grilled pasta with shrimp ($49.90 value)
- Two glasses of house wine ($11.90 value)

$69 for a prix-fixe meal for four ($147.50 total value)
- Two shrimp cocktail appetizers or desserts ($23.90 value)
- Choice of four entrees from chicken chardonnay, 7-ounce filet or spicy grilled pasta with shrimp ($99.80 value)
- Four glasses of house wine ($23.80 value)

Red River Steakhouse
Red River Steakhouse's chefs know more than how to cook a steak; they also know exactly which steaks to cook. They start with prime cuts of USDA choice-grade midwestern beef, charbroiling the fine red meat at 1,200 degrees and sealing in the savory juices. The steak is paired with the customer's choice of soup, salad, or another delicious side, such as herb mashed potatoes or vegetables du jour. It's topped with a pad of steakhouse butter, which slowly melts on its way to the table. The steakhouse also prepares a selection of seafood, poultry, and pasta, such as teriyaki-style Ahi tuna, as complements to their signature dishes.
Customer Reviews
Fort Wayne
305 E Washington Center Rd
Fort Wayne, IN 46825
+12604840411Get Directions


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The Neutrino Division is home for Fermilab scientists and staff, and users from academic institutions around the world, operating and analyzing neutrino experiments and designing new ones.
Mission Statement
- Host a world-leading program of neutrino experiments
- Operate the current program : NOvA, MicroBooNE, Minerva, MINOS+, LArIAT
- Coordinate and execute a new international program of short and long-baseline neutrino experiments
- Provide support to the neutrino user community to participate in all aspects of this program
- Ranges from technical expertise in design, project management, operations, etc. to arranging office and meeting spaces
Studying Neutrinos
The subatomic particles called neutrinos are among the most elusive in the particle kingdom. Scientists have built detectors underground, underwater, and at the South Pole to measure these ghostly particles that come from the sun, from supernovae and from many other celestial objects.
Neutrinos fill the whole universe, with about 10 million of them per cubic foot, and most of them zip straight through the earth, and through particle detectors, without leaving a trace. Because they almost never interact with matter, only massive and sophisticated experiments can catch and measure the properties of neutrinos.
In addition to measuring neutrinos from the sky, physicists on earth use powerful accelerators to produce neutrino beams containing billions of neutrinos, of which a tiny fraction can be measured by detectors placed in the beam line. At Fermilab, the DONUT accelerator-based neutrino experiment led in 2000 to the discovery of the tau neutrino, the third of the three known types of neutrinos.
The NuMI beamline and the Booster Neutrino beamline deliver high intensity neutrino beams to Fermilab experiments such as MINOS+ and MINERvA, and for two new neutrino experiments MicroBooNE and NOvA.
Why Neutrinos are Important
- Particle Physics has made great progress in the last half century probing the quark half of the fundamental particles. We are now in a position to propose doing similar for the neutrinos. The mixing between the 3 neutrino generations is starting to look very different to its quark counterpart. We don't know why but it is probably important. Neutrinos may hold the key to understanding why the fundamental particles exist in 3 generations.
- Neutrinos are the real oddities of the fundamental particles (only interact Weakly, ultra small, but non-zero masses). Science often advances when studying the oddities (C.F. understanding life processes in general by studying life around deep sea vents)
- Neutrinos may only interact Weakly, but they are the most abundant particle in the universe with a pivotal role in the evolution of our universe
- A difference between how the neutrino types mix and how the antineutrino types mix is postulated to be the reason why matter dominates over anti-matter in our universe (i.e. why we exist)
PIP-II and Producing Neutrino Beams
The PIP II project will enable a large increase in the power of Fermilab's proton beams. This, in turn will produce more powerful neutrino beams. See the animation below to see how this happens.
Animation: Fermilab/Sandbox Studio
- Last modified
- 07/15/2015
- email Fermilab


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In a world where you can pick and pluck generic pieces up from the internet and other places to produce your website – often for free – there's increasingly a place for a bespoke web solution.
Ironically, such a tailor-made result can be cheaper, iteratively produced towards a final product, rather than being prescribed at the beginning of how it will look/feel/be.
This realisation by 10-year old Wellington web solutions company 3Months has seen it change tack, so much so that "we've essentially walked away from content management systems," says its client relationship manager, Nick Rowney.
A content management system (CMS) is a website feature such as the ability to upload a photo, add a page, change detail. Fully loaded CMS systems can look like the obvious answer, but often a customer will only use 20% of its potential.
The alternative, which has become more apparent as the web has aged, is that a one size model doesn't fit all. In fact, often the need to be able to add something different to a generic template is more difficult and time consuming and costly than starting from scratch with a purpose built solution.
A bespoke (as opposed to a CMS-oriented or driven model) website, is not just about the website. It is for a client who understands that the requirements need to be answerable to a business case, vision, and know what they're hoping to achieve and who understand their clients' needs.
3Months uses and Agile methodology, with every job being a journey, where adaptation rather than a set development path is called for.
Even a 3 year project can be split into phases, the "idea being it forces a business to really understand what they're trying to achieve, and lessens their risk," says Rowney.
"It forces the business to prioritise the site's requirements, and to understand the business value attached. Instead of viewing a website as a standalone part of the business, the bespoke approach puts the client in the position of a customer. "You need to understand where your customers are, what they look like, where they hang out," he says.
"We want to have our own area of bespoke web development," says Rowney, who had an extensive movie industry background before morphing into a client engagement role at 3 Months. "We don't take every customer on, our approach may not be suitable for some businesses."
Some web development companies built a website and walk away, but the fast moving world of the internet means websites need to keep up to date to take advantage of new opportunities.
"3Months believes in becoming your web partner, so we are always looking for new solutions for our clients," he says. Apple's iPhone and iPad are changing peoples' perceptions of what is possible over the net; they're game changers. The use of smart phones and location based sensors, and the mobile web we see as the future."
Rowney says that just as the internet is only for those who can afford it, for those technically and financially savvy people who will use mobile technology, "it is the sweet spot for the next lot of internet businesses."


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Member Since: January 22, 2011
Country: United States
I have Windows 7 and I finally (sort of) got this thing working. I tried every driver I could find on the net (at least twice, probably). Several of the more recent drivers (like the one posted by Mitch) seem to work with my ARM7 board. I couldn't get anything to work well with my 8051 in Windows 7 though. I finally used a virtual machine and some older drivers to get it to work. I still have to replug before each load cycle though.
No public wish lists :(


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We hear Konkona Sen Sharma and her husband Ranvir Shorey are going to head for a divorce very soon. Their marital relationship is beyond repair, and thus they have taken the decision to split away. In a recent event, both were seen separately arriving at the event, and they even sat far away from one another. When Ranvir was asked why are they maintaining a distance, he snapped that both of them are not conjoined twins so can sit separately.
But right now, we guess differences which cant be reconciled has cropped up in between Konkana and Ranvir. This March, they became the proud parents of their first child Haroon too. Konkana was heard saying to some of her close friends that she wants to get a divorce. Konkana tried hard to reconcile with her hubby, but nothing is working out in between them. Konkana cant go beyond a certain limit, and right now, both of them behave like chalk and cheese, and so its very natural that the pair can no longer live under the same roof.
A close source divulged, that Ranvir Shorey is not a great man to live with, however the actress tried her best to adjust with all problems till date, and wanted to be in the relationship. Konkana's friend say that she has still not given up hopes completely, and is making a final try to live with Ranvir. It was in 2007, Konkana started dating Ranvir, and in 2010 they got married privately on September 3rd. And in 2012 March, Konkana gave birth to Haroon in a hospital in the South of Mumbai.
Konkana debuted in the Hindi movie "Indira" way back in 1983 when she was a child. However it was the English movie "Mr and Mrs Iyer" in 2002, an English flick, with which Konkana rose to fame. Some of her popular flicks include "Page 3", "Omkara", "Traffic Signal", "Life In A…Metro", "Wake Up Sid".


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rumpleforeskin (30-10-2010)
[QUOTE=dailydoggy;525257]jesus have sex with it and be done ya spending more effort and dosh on it than trying to get a bunk up..[/QUOTE
only cleaning it regular due to the car being stood up for 6 years until i got my hands on it hence the respray needed and arches,interior etc need to be done and its a project car at the end of the day.would be just as happy to use turtle wax on it but hate dirty cars and all of mine are cleaned every week anyway like i have always done but just like ag products as its easier to work with and gets results
AG clean wheels is ok, but i preffer bilberry wheel cleaner, it goes further its cheaper and is really easy to use
if you're a waxaholic vics concours is the best wax ive used below the £50 mark,
pinnacle signature 2 is also very good, if budget allows raceglaze 55 is a awesome preformer in the looks and durability stakes
My car is almost Black looking in certain light conditions, I use a mixture of waxes depending on how long I have to spend cleaning the car.
I also have to clean & polish the missus X3 and 2 motorbikes.
I have found good results with AutoGlym, zymol, Maguires, Crystal Glow, & BMW own natural care polish.
The most I've spent on any product so far is £16, the BMW polish is good value at £9.99 IMO.
Before discovering the above products I used to use Turtle Wax, but thats now been given to my lad to polish his push bike.
Lots of peeps say my cars & bikes are the cleanest in our close & I have one of the cleanest cars at work, just goes to show that you don't have to spend big bucks to get a nice shine & admiring glances.
Having said that I see the Collinite 915 Marque D'Elegence + free Microfibre is not too expensive at £23.50 inc P&P, on good old Flea-bay. ...........might have to put that on my Xmas list
i used turtlewax high gloss on mine its fuss free goes on easy comes off easy got a best buy in autoexpress as well, no swill marks no white s**t left behind, i havent used clay but its far superior to autoglym super resin, autoglym are good on some things but not others, when i went to santa pod i was advised not to buy a autoglym bag for this reason, cant recomend the highgloos enough though its only a fiver a tub aswell, mines shappire black
It depends what your after and it's a MINEFIELD!! I'm an old guy and was well set in my ways. Wash the car with Zipwax and polish with whatever I had in the shed. It was only after I studied some of the detailing techniques that I discovered the secret to the best finish possible and that is...preparation. Just claying a car will give a smooth glass like finish. Further' to use a DA polisher with a fine finishing polish will take it to the next stage of 'bling' and remove most of the swirls. It's then up to the individual what glaze and or wax/sealant they use but if that preparation is done properly the results will be better than anything you have witnessed before.
full paint correction and sealed with gloss it.
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Avenging Angel
7 Fans
A preacher-turned-bounty hunter (Kevin Sorbo) returns to his small town after a three-year absence to avenge the death of his wife and daughter. Once home, he finds that their murderers now have great power over the community. Maggie: Cynthia Watros. Col. Cusack: Wings Hauser.
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- Goof (revealing mistake): After the preacher shots the sheriff at the squatter's camp, one of the men from the town is shown holding a gun and the barrel can be seen to be plugged.


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SECOND UPDATE (4:57 p.m.): From Morgan State: "Morgan State University Vice President of Student Affairs Kevin Banks and Director of Athletics Floyd Kerr will hold a press conference, Thursday, January 9 at 11:00 a.m. at Rm. 316 of the MSU Student Center to introduce the Bears head football coach. "
UPDATE (3:54 p.m.): An individual with knowledge of the situation confirms Hull's hiring. An announcement is expected on Wednesday night and an introductory news conference is expected to be scheduled for Thursday afternoon on campus.
The original post is below.
Former Maryland wide receivers coach Lee Hull has accepted the head coaching position at Morgan State, effectively ending his six-year tenure with the Terrapins, according to Pete Roussel of Coaching Search.
Had Hull not been offered the job, for which he was reportedly one of three finalists, Maryland would have needed to decide on his future with the program. Hull's contract, obtained via an open-records request, expired on Dec. 31. This season, he made a base salary of $133,875 with $41,592 in incentives, the second-lowest salary of the team's positional assistant coaches.
After Maryland declined to renew the contract of offensive line coach Tom Brattan, Hull was left as the only holdover from Ralph Friedgen's tenure. A former wide receiver at Holy Cross and in the Canadian Football League, Hull began his coaching career at the high school level in Massachusetts before scoring his first college job in 1998 at his alma mater. After five seasons at Oregon State (2003-07), where Maryland Athletic Director Kevin Anderson was previously stationed as the assistant athletic director, Hull came to Maryand in 2008 and has been the wide receivers coach ever since.
The Morgan State job was vacated when Donald Hill-Eley was relieved of his duties following a 5-7 season, and the program announced the formation of a university-wide search committee. Turns out, the Bears didn't have look far, remaining in-state in choosing Hull.
This now leaves Maryland with three open positional coaching positions to fill this offseason. Two — Hull and defensive line coach Greg Gattuso — left after accepting head coaching gigs, while Brattan was simply not retained. Interviews are ongoing for these jobs, though no names have trickled out yet.


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ITEM: 1FMRRNC • 0.167 kgCA$65.00
Youth revitalizing neck cream concentrated with hydrolyzed quinoa increases elasticity for firmer, more lifted neck. Retinol reduces lines and wrinkles while olive squalane and hyaluronic acid locks in hydration for supple, smooth skin. Niacinamide brightens and evens skin tone. Collagen boosting, age corrective cream for a more youthful neck.
NEWRetinol Restorative Neck Cream


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Need a nice knob!
I've recently got a quad gang Alps RK27 pot, but farnell sell over 1000 knobs and I'm rather overwhelmed by the sheer number of knobs... :o
All I want is a nice metal knob, that fits... would I be right in assuming it need to be around 20mm high?
FWIW: Datasheet here: http://avpg2.homepage.t-online.de/PD...114_10KDX4.pdf
EDIT: If it had rubber rings on it, that would be nice also... :)
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Dog loses $10 million in inheritance
Jun 25, 2008
Leona Helmsley, infamously nicknamed "the Queen of Mean," held a soft spot for Trouble, her white Maltese. The New York court system didn't share Helmsley's canine affection, it seems. In a settlement between Helmsley's grandchildren and the New York State Attorney General's Office, the court cut Trouble's inheritance from $12 million to $2 million.
But Trouble isn't down and out. Carl Lekic, the 9-year-old dog's caretaker and general manager of a Helmsley hotel in Florida, said $2 million would be "enough money to pay for the dog's maintenance and welfare," according to an affidavit. Lekic says the money will cover Trouble's annual expenses: $100,000 for full-time security, $8,000 for grooming, and $1,200 for food—not to mention the $60,000 Lekic receives every year as a guardian fee.
The court treated Helmsley's two grandchildren better than Trouble. Originally cut out of her will "for reasons which are known to them," the grandchildren will together receive $6 million in the settlement.
Photo by Stockbyte/Getty Images.
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Click a South Pittsburg
mattress retailer on the map or in the list below to find out more information,
including brands they carry, current mattress promotions, consumer reviews, store location details, and more.
Mattress Stores Near South Pittsburg, TN (3 found nearby) Expand search to 50 miles
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Mattress Shoppers: See a store in our area mattress info that's been closed or renamed? Know another mattress store near , TN that should be included on this map? If so, please let us know about it! Your feedback can be sent to: storefinder [at] goodbed [dot] com.
Mattress Retailers: See outdated store details for one of your mattress stores near , TN? Claim your store profile here. Have a mattress store in the area that's not listed on GoodBed yet? Add a new store profile here.


text:
Brooklyn GinMADE BY BROOKLYN GIN IN WARWICK, NEW YORK
Brooklyn Gin is made with only fresh, hand-cut citrus peel and juniper berries, cracked by hand to preserve the super-flavorful essential oils. This method requires a lot of manual labor, but it's apparently worth it, because the result is fresh, vibrant, citrus-forward flavor.
The folks at Brooklyn Gin buy their produce from local Brooklyn markets and make the neutral base spirit with 100% corn grown in upstate New York. It takes them three days to make just 300 bottles. Now that's small-batch!
tip of the tongue
Gin is almost always mixed into a cocktail, but Brooklyn Gin also tastes great by itself. The gorgeous bottle honoring our favorite borough is especially gift-worthy.
Did you know?
Gin can be infused with a wide variety of botanicals, but it MUST contain juniper berries, which are responsible for that distinct, piney, gin-y flavor.
40% alcohol by volume. Comes in a 750ml bottle.
- vegan.


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Lori Zimmer
Lori Zimmer is a New York based writer, with a passion for sustainable design, eco-tourism and art. She has written for Ecouterre, Inhabitots, ArtSlant, Patrick McMullan Mag, Flavorpill, WhiteHot and ArtFetch. She received her MA in art, media and business at FIT. In her free time, she writes an art and art history guide called Art Nerd New York and curates shows often focused on artists who use found or recycled materials.
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text:
Title: Winter Landscape Jigsaw Puzzle
About: Daniel or Denis van Alsloot (Dutch: Denijs van Alsloot) (c.1570–c.1626) was a Flemish Baroque painter. Winter Landscape is one of his most famous paintings. It was painted in 1610 using oil on panel.
Puzzle of the day on: 16-Feb-2012
Image Credit: Denis van Alsloot
Copy/Paste the HTML code below to link to this puzzle from your website or blog.


text:
... Feb 2013
Hi, gr8 job!! I love the laminated picture idea! How did you type the Dr. Dee on top?
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Re: a little more complex list operation
On 3/27/03 at 6:49 AM, nmoore at physics.umn.edu (Nathan Moore) wrote:
>Suppose I have the list,
>data = {{x1,y1},{x2,y2},{x3,y3}}
>and I want to produce the result (for fitting/plotting)
>data2 = {{f[x1],g[y1]},{f[x2],g[y2]},{f[x3],g[y3]}}
There are a number of ways to do this. For example
or equivalently
I am sure there are many other ways I haven't thought of yet as well. Mathematica provides a fairly rich set of tools to manipulate lists.


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I am extremely, extremely demotivated. For the past two days all I have thought about is withdrawing from my programme. There is nothing driving me to continue. No prospect of getting a high paying job, living overseas, travelling the world. Nothing.
Somebody motivate me.
Also, my Renner look alike got married after a 12 year relationship with his (now) wife. I give up.


text:
Junior Malik Smith hit a career high eight 3-pointers to lead Florida International to a 69-54 victory over Arkansas-Little Rock in a second-round Sun Belt Conference Tournament game Saturday night in Hot Springs, Ark.
FIU, the fourth seed, will play No. 1 seed Middle Tennessee in the Sun Belt semifinals. Middle Tennessee advanced by beating Louisiana-Lafeyette 81-66.
Smith finished with 25 points, four short of his career high, in making 8-of-10 field-goal attempts, all from beyond the 3-point arc.
He was one 3-pointer short of the conference tournament single-game record of nine set by Jacksonville's John Knox in 1997.
The Panthers (17-13), who advanced to Sunday evening's tourney semifinals, led for all but a brief period at the start of the game when UALR jumped in front 3-0. The Panthers responded with seven consecutive points to take the lead for good.
FIU led 34-26 at the half and maintained a double-digit advantage for much of the second half. The Panthers, who had more 3-point attempts (26) than 2-point tries (23), led by as many as 20 points late in the game.
The Trojans (17-15) struggled with their shooting, hitting only 30.6 percent overall (15 of 49) and making only three of their 18 3-point attempts. John Gillon led them in scoring with 16 points.
Both teams had problems with their ball-handling and wound up with 21 turnovers each.


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Recent Posts
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Daily Archives: October 18, 2013
New Ryse: Son of Rome story trailers, screenshots released
Microsoft Game Studios has two new trailers for Crytek's upcoming action title Ryse: Son of Rome. One of the videos gives a two-minute overview of the main character, Roman legionnaire Marius Titus, who is on a quest of revenge against the barbarians who killed his family. The other details the story behind a special weapon gifted to Titus by his father, the Damocles dagger, which is said to come from a centurion who returned from Hades to take vengeance on the corrupt generals that left him to die. Damocles' tale is especially eye-catching.
Deadly Premonition: The Director's Cut: Ultimate Edition now on PSN
A new version of Deadly Premonition: The Director's Cut has launched on PSN for PS3, the Ultimate Edition. This release features all of the content from the original Director's Cut as well as all post-launch downloadable content. The extra packs add seven trait-boosting suits and outfits, three new rides that enhance performance (and one that adds drifting), a vehicle skin, and the Real Estate pack that allows York to purchase a home and settle down in Greenvale.


text: First donation of the day! Madison Police Officers take the donations to the kids in our area less fortunate Leap for Kenny! entering to win tickets to Kenny at Lambeau Field they like the police car toy cash donations to help buy toys for the kids! thanks for your generosity how about this police car more toy donations Leap for your Seats with Kenny Chesney keep Leaping for Kenny Leap for your Seats thanks for your toy donations!! John found his new favorite magazine ooo nice centerfold it's Bacon! more toys for the kids! Chief Hellenbrad of Marshall helping out with the Toy Drive Deputy supporting the Toy Drive too! more Leaps for Kenny Leap for your Seats for Kenny with Star Country! Lindsay from AnchorBank awww more toys - wow what a cool radio car! nerf ball too! guys from Proscapes in Sun Praire came out to donate toys Thanks Jim, GM of Madison's Blain's Farm & Fleet, for all the help with the broadcast! Photo 1 of 1 Continue Gallery


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Bassmaster Elite Series pro Steve Kennedy went fishing on his week off.
Give him credit: He left his bass rig at home. This was a family-and-friends saltwater trip to Florida, a world away from competitive bass fishing.
The Kennedys packed their RV, hitched their 25-foot Boston Whaler to it, and drove from their Auburn, Ala., home to Cape San Blas for a week of fun, sun and fishing on the Gulf of Mexico.
If they'd stayed at home, the Kennedys would have been less than an hour away from the next Bassmaster Elite Series competition, May 5-8 on West Point Lake out of LaGrange, Ga. But now they will have a drive of about five hours — swinging through Auburn, of course, to swap boats.


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> Nexzett Kristall Klar Windshield Washer Fluid Concentrate 250 ml
Nexzett Kristall Klar Windshield Washer Fluid Concentrate 250 ml
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Nexzett Kristall Klar Windshield Washer Fluid Concentrate 250 ml
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February 29, 2016
I have had a bad experience with the wiper blades on my Mercedes ML and GL chattering and making much noise in the process. I read on the MBWorld.org forums that this product is equivalent to the MB product. As recommend on the bottle, I have added 25ml of this product to the washer reservoir hoping it will help quell the chattering. Since I live in Northern Michigan and need to have winter fluid for freeze protection, the forum suggests just adding this to the 1Z Einszett blue washer mixture. Time will tell if it does the job.
As compared to MB 35ml bottle, this is more economical.
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December 26, 2010
Its works and cleans the windshield real well but it freezes in the winter .. Thats is the only downfall to this .... Its smell nice
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July 31, 2008
This is the best wiper fluid additive I have ever used. No wiper streaks, no white residue, and 1 blast can remove a recently expired bug with ease. I polish my windows weekly with the 1Z glass polish. A perfect pair. Not to mention it smells great!
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Great idea. Easy to store, eliminates streaking and blade vibration. Cost effective when measure oz. to oz. Also, some products have stronge vapors that enter cabin, this does not have irratating fumes. Give it a try. I am going to order the 1z glass polish as well b/c rain x is to toxic in odor.
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text:
Interconnected Smokes
When the snow stops I want to get 3 interconnected smoke alarms. But ahead of time I want to get started with the wiring. I figure each with a wall mount 10" or so below the ceiling.(and 3ft. away from ceiling fans) For wiring I plan to start w/ a separate 15a circuit then 14/2 in and 14/3 out from the first alarm, then 14/3 between the rest. If this is correct then I want to know what the basic wiring configuration is???? Thanks in advance.
Generally we use black and white for power and the red for the interconnect lead which will be clearly labeled on the smokies.
It would be better to mount the smokes on the ceiling than on the walls.
Smoke will rise to the ceiling and will need to build down until it reaches the detectors if mounted on the wall. Ceiling mounts will give a faster alert to smoke than wall mounts giving you increased time to get out safely.
I see no need for a separate circuit though. Is there a reason for this?
While we're on that subject is the radon system supposed to be on a separate 15a circuit??
Back to the smokes--So wiring wise 1 to 1 black, wht, and red all the way through?????
As for the ground, just twist, wire nut, and stick them in the back of the box.
Thanks everyone for all the info!
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Concept Corvette App Projects Speed Data In Front Of Driver's Eyes [CES 2014]
Chevrolet is demonstrating a Google Glass app that provides performance stats in real-time.
The new Chevrolet Google Glass app connects to the Corvette Stingray and provides real-time data such as gear, speed, engine RPM, and G-force on the Glass display.
The new Corvette Stingray has an integrated WiFi and LTE connection and the concept app can connect directly to the car and display two screens of performance data, shown in clear and simple graphics. The stats pass through the servers of Chevrolet first via the car's LTE connection and are then delivered to the Glass via Google's Mirror API.
According to Slash Gear, Chevrolet sees the app as something more suited for the car's passengers rather than the driver because of the potential safety risks.
The app is being demoed at the CES 2014.
Source, Images: Slash Gear


text:
Trocar location for total laparoscopic pancreaticoduodenectomy. Reprinted with permission from the Mayo Clinic.
Kendrick ML, Cusati D. Total Laparoscopic PancreaticoduodenectomyFeasibility and Outcome in an Early Experience. Arch Surg. 2010;145(1):19-23. doi:10.1001/archsurg.2009.243
© 2017
Total laparoscopic pancreaticoduodenectomy is a safe and effective therapeutic approach.
Single-institutional retrospective review.
Tertiary referral center.
All consecutive patients undergoing total laparoscopic pancreaticoduodenectomy from July 2007 through July 2009 at a single center (n = 62).
Main Outcome Measures
Blood loss, operative time, postoperative morbidity, length of hospital stay, and 30-day or in-hospital mortality.
Of 65 patients undergoing laparoscopic resection, 62 patients with a mean age of 66 years (SD, 12 years) underwent total laparoscopic pancreaticoduodenectomy. The pancreaticojejunostomy consisted of a duct-to-mucosa anastomosis with interrupted suture. Median operative time was 368 minutes (range, 258-608 minutes) and median blood loss was 240 mL (range, 30-1200 mL). Diagnosis was pancreatic adenocarcinoma (n = 31), intraductal papillary mucinous neoplasm (n = 12), periampullary adenocarcinoma (n = 8), neuroendocrine tumor (n = 4), chronic pancreatitis (n = 3), cholangiocarcinoma (n = 1), metastatic renal cell carcinoma (n = 1), cystadenoma (n = 1), and duodenal adenoma (n = 1). Median tumor size was 3 cm (range, 0.9-10.0 cm) and the median number of lymph nodes harvested was 15 (range, 6-31). Perioperative morbidity occurred in 26 patients and included pancreatic fistula (n = 11), delayed gastric emptying (n = 9), bleeding (n = 5), and deep vein thrombosis (n = 2). There was 1 postoperative mortality. Median length of hospital stay was 7 days (range, 4-69 days).
Laparoscopic pancreaticoduodenectomy is feasible, safe, and effective. Outcomes appear comparable with those via the open approach; however, controlled trials are needed. Despite this series representing experience within the learning curve, laparoscopic pancreaticoduodenectomy holds promise for providing advantages seen with minimally invasive approaches in other procedures.
Laparoscopic pancreaticoduodenectomy represents one of the most advanced abdominal operations owing to the necessity of a complex dissection and reconstruction. Despite its first description by Gagner and Pomp1 in 1994, there has not been wide acceptance of the procedure to date. Pessimism has stemmed from long operative times, lack of apparent advantages, and the requirement of advanced laparoscopic skills. The current literature contains several case reports and small series of laparoscopic pancreaticoduodenectomy. However, in many of these articles, very few patients actually underwent a totally laparoscopic procedure.2- 4 Rather, many choose to perform laparoscopic resection with subsequent open reconstruction. These hybrid approaches and the lack of sufficient patient numbers preclude any meaningful assessment of the maximal advantages of minimally invasive techniques or the feasibility and outcomes of a total laparoscopic approach to resection and reconstruction. Our aim was to describe the feasibility and outcome of total laparoscopic pancreaticoduodenectomy (TLPD) at a single institution.
A review of prospectively collected data was performed for all patients undergoing TLPD from July 2007 through July 2009. Demographic data, preoperative evaluation, operative procedure, pathology, perioperative data, and clinical follow-up were reviewed. All patients underwent a full clinical evaluation to assess overall health and medical comorbidities. Helical computed tomography was performed routinely and endoscopic ultrasound selectively to evaluate the primary lesion and exclude vascular invasion or distant metastases. Exclusion criteria for laparoscopic pancreaticoduodenectomy were having tumors adjacent to the portal vein or superior mesenteric vein on radiographic imaging for which venous resection may be necessary. During the study period, 34 additional patients underwent open pancreaticoduodenectomy performed by one of the authors (M.L.K.). These patients either met the exclusion criteria or chose not to undergo the laparoscopic approach. All results are presented as mean (standard deviation [SD]) or median (range).
The procedure is performed with the patient in the supine position. Typically, a total of 6 (12-mm) trocars are used for the procedure, placed in a semicircle in the lower and lateral aspects of the abdomen (Figure). When deemed necessary for adequate exposure, a seventh trocar (5 mm) is placed in the subxiphoid position for liver retraction. After establishing a pneumoperitoneum, a thorough diagnostic laparoscopy is performed inspecting all visible peritoneal and visceral surfaces. A 7.5-MHz laparoscopic ultrasound probe is used to perform ultrasonography of the liver and pancreas. Using ultrasonic shears, the gastrocolic ligament is divided and the lesser sac widely exposed. The hepatic flexure of the colon is mobilized inferiorly and a Kocher maneuver is performed. The portal vein is identified at the superior border of the pancreatic neck and the superior mesenteric vein at the inferior border. A tunnel is dissected posterior to the pancreatic neck, anterior to the superior mesenteric vein and portal vein. The gastroduodenal and right gastric arteries are ligated, clipped, and divided. The first portion of the duodenum is dissected and transected with a linear stapler 2 to 3 cm distal to the pylorus. The right gastroepiploic vessels are ligated and divided. The bile duct at the superior border of the pancreatic head is dissected, ligated distally, and divided. A cholecystectomy is performed. The fourth portion of the duodenum and proximal jejunum are mobilized and the jejunum is transected 15 cm distal to the ligament of Treitz with the linear stapler. The jejunal stump is passed into the supramesocolic compartment. The pancreatic neck parenchyma is divided with electrocautery or (more recently) ultrasonic shears, and the pancreatic duct is divided sharply with scissors. Dissection of the pancreatic head and uncinate process off the portal vein, superior mesenteric vein, and superior mesenteric artery is typically performed using Ligasure (Tyco Healthcare Group, Dublin, Ireland). Larger tributary vessels (pancreaticoduodenal vessels) are ligated or clipped. All peripancreatic lymphatic tissue is taken en bloc with the specimen. The specimen is then removed in an endosac via the infraumbilical trocar site extended 4 to 7 cm. The portal vein groove and retroperitoneal/uncinate margin are inked, and separate bile duct and pancreatic neck margins are obtained prior to sending the specimen for frozen section analysis. After fascial closure of the extraction site, the pneumoperitoneum is reestablished and intracorporal reconstruction begun once margin status is confirmed on histology. The jejunum is brought through the duodenal resection bed, posterior to the superior mesenteric vessels into the supramesocolic compartment. An end-to-side, pancreaticojejunostomy, duct-to-mucosa anastomosis is performed over an 8-cm Silastic tube with an inner layer of 5-0 Vicryl sutures and an outer layer of interrupted 3-0 silk sutures. Approximately 10 cm distally, an end-to-side hepaticojejunostomy is performed with running (bile duct >5 mm) or interrupted (bile duct ≤5 mm) Vicryl sutures. The jejunum is secured, closing the defect at the ligament of Treitz. Approximately 40 cm distal to the biliary anastomosis, an antecolic, end-to-side duodenojejunostomy is performed with 2 layers of running 3-0 Vicryl. Operative drains are not routinely used. Trocars are removed and trocar sites are closed with an absorbable, monofilament, subcuticular suture.
After anesthesia recovery, patients are admitted to a general surgical unit unless significant medical comorbidities or intraoperative hemodynamics warrant continuous monitoring overnight. On postoperative day 1, the nasogastric tube is removed and the patient is not given any food or water orally. A clear liquid diet is begun on postoperative day 2, and an oral diet is advanced as tolerated. Analgesia consists of scheduled intravenous ketorolac and supplemental intravenous morphine via a patient-controlled analgesia pump. Once the patient is tolerating oral intake, patient-controlled analgesia is discontinued and oral narcotic analgesics are given as needed. Perioperative prophylactic antibiotics (preincision and 2 postoperative doses) and subcutaneous unfractionated heparin (preincision and 3 times a day during hospitalization) are given. Patients are discharged after postoperative day 5 if tolerating oral intake and there are no signs or symptoms of complications.
Of 65 patients who underwent laparoscopic pancreaticoduodenectomy, 3 patients underwent conversion to laparotomy. One patient underwent a planned conversion for the reconstruction phase after laparoscopic resection early in the experience; the other 2 patients were converted owing to unsuspected findings of tumor invasion into the superior mesenteric vein. These 3 patients were excluded from the analysis. The remaining 62 patients underwent TLPD and comprise the study population. Patients included 30 women and 32 men with a mean age of 66 years (SD, 12 years), median body mass index (calculated as weight in kilograms divided by height in meters squared) of 26 (range, 17-40), and median American Society of Anesthesiologists score of three.2,3 Indication for pancreaticoduodenectomy included benign (n = 17 [27%]) and malignant (n = 45 [73%]) diseases. Operative findings and perioperative data are summarized in Table 1. In all patients who underwent TLPD, the procedure was performed with curative intent; no patient had evidence of local unresectability, superior mesenteric vein vascular involvement, or metastatic disease. The pancreatic parenchymal texture was reported as soft (n = 15), intermediate (n = 24), or firm (n = 20). Median pancreatic duct and bile duct diameters were 4 mm (range, 1.5-9 mm) and 9 mm (range, 4-17 mm), respectively. In 59 patients, a pylorus-preserving pancreaticoduodenectomy was performed; 3 patients had a standard Whipple resection. While all procedures were performed totally laparoscopically (intracorporal resection and reconstruction), in 8 patients robotic assistance was used for laparoscopic reconstruction. Median operative time and blood loss were 368 minutes (range, 258-608 minutes) and 240 mL (range, 30-1200 mL), respectively. A Jackson-Pratt drain was left at the completion of the procedure near the pancreaticojejunostomy in 12 patients at the discretion of the surgeon.
Histologic diagnosis was confirmed in all patients and included pancreatic adenocarcinoma (n = 31), intraductal papillary mucinous neoplasm (n = 12), periampullary adenocarcinoma (n = 8), neuroendocrine carcinoma (n = 4), chronic pancreatitis (n = 3), cholangiocarcinoma (n = 1), metastatic renal cell carcinoma (n = 1), cystadenoma (n = 1), and duodenal adenoma (n = 1). The median tumor size was 3 cm (range, 0.9-10 cm) and the median number of lymph nodes retrieved was 15 (range, 6-31). In 89% of patients, an R0 (margin-negative) resection was possible. Regional lymph node metastases were identified in 27 of 45 patients (60%) with malignancy. Pathology findings are summarized in Table 2.
Perioperative complications occurred in 26 (42%) patients and included pancreatic anastomotic leak (n = 11 [18%]), delayed gastric emptying (n = 9 [15%]), postoperative anemia (n = 5 [8%]), superficial surgical site infection (n = 4 [6%]), deep venous thrombosis (n = 2), atrial fibrillation (n = 1), urinary retention (n = 1), and pneumonia (n = 1). Reoperation was necessary in 3 patients for control of sepsis after pancreatic anastomotic leak, control of hemorrhage after percutaneous drain placement, and revision of a biliary anastomotic leak. Six days postoperatively, another patient with a pancreatic leak developed intraperitoneal bleeding that required angiography with embolization of the superior pancreaticoduodenal artery arising from a replaced right hepatic artery; this patient also developed transient renal failure. Thirty-day or in-hospital mortality occurred in 1 patient. This 85-year-old patient developed persistent cardiopulmonary failure after control of sepsis from a pancreatic anastomotic leak; care was withdrawn and the patient died 61 days postoperatively. Overall median length of hospital stay was 7 days (range, 4-69 days). Follow-up was complete in all patients for a mean of 7.2 months. Of the 45 patients with malignancy, hepatic or pulmonary recurrence was identified in 7 (16%) within a mean of 7.4 months; 6 of these patients died of progressive malignancy a mean of 9 months3- 14 after resection. No port-site recurrences were identified in any patient during the observation period.
Minimally invasive approaches to pancreatic resection are of increasing interest. The typical advantages of decreased pain, reduced wound-related complications, shorter hospitalization, and quicker recovery that have been observed with several minimally invasive surgical abdominal procedures would also be beneficial in patients undergoing pancreatic resection. The most logical and feasible initial application of minimally invasive surgical approaches has been for distal pancreatectomy, for which there is limited dissection and reconstruction is not required. In the past several years, there has been an increasing acceptance of laparoscopic distal pancreatectomy, with evidence suggesting advantages of reduced blood loss, complication rate, and shorter hospitalization with laparoscopic over open approaches.4 For pancreaticoduodenectomy, however, enthusiasm has been much more dampened. Despite the initial description of laparoscopic pancreaticoduodenectomy approximately 15 years ago, acceptance has been limited owing to the technical demands of this procedure.2,5 Several authors have described hybrid, laparoscopic-open approaches to avoid the complexity of a purely laparoscopic procedure.6- 8 While these approaches may obviate some of the limitations, they may also reduce the potential benefits of purely laparoscopic approaches and limit the ability to assess the feasibility and outcome of totally laparoscopic pancreaticoduodenectomy. After excluding patients with conversion to laparotomy or hybrid laparoscopic-laparotomy approaches, there are only 2 series in the current peer-reviewed literature in which TLPD was performed in more than 10 patients.9,10 These studies have demonstrated favorable results of TLPD. Table 3 summarizes the outcomes of these 2 studies and our current series of 62 patients. Gumbs and Gayet,11 in an abstract accompanying an online video submission, briefly mention performance of laparoscopic pancreaticoduodenectomy in 35 patients. However, there is insufficient information available to assess the extent of the laparoscopic approach, operative data, or outcomes.
Pessimism of laparoscopic pancreaticoduodenectomy has risen from initial long operative time, advanced laparoscopic skills necessary, and lack of perceived benefits over open approaches. Fortunately, initially long operative times have decreased in our experience from a mean of 7.7 hours in the first 10 patients to 5.3 hours in the last 10. We agree that advanced laparoscopic skills are necessary to perform this procedure to reduce operative time, morbidity, and surgeon frustration. It is also imperative that surgeons attempting TLPD have sufficient experience with open pancreatic operations to avoid significant complications and ensure that oncologic standards of pancreatic resection are understood and maintained.
Robotic-assisted procedures are also of interest in pancreatic resection. We have used this technology in only 8 patients to date, largely because of the limited availability of the robot in our practice during this study period. Potential advantages of robotic assistance, such as added maneuverability and fine movement, may be balanced by the disadvantage of lack of haptic feedback, especially in patients with a soft, friable pancreas or a tenuous anastomosis. Controlled trials performed by those experienced with both approaches will be necessary to establish any potential advantages of robotic assistance over purely laparoscopic approaches.
The current literature is insufficient to demonstrate any clear advantages of laparoscopic compared with open pancreaticoduodenectomy. Based on an increasing body of literature with regard to other laparoscopic procedures, it is reasonable to assume that the typical laparoscopic benefits of decreased pain, wound complications, and length of hospital stay will be realized. Wound complications can be a significant early (surgical site infection or dehiscence) or late (ventral hernia) morbidity of the open approach. In addition to the morbidity, these complications delay recovery and may delay adjuvant treatments. Despite the potential advantages of minimally invasive approaches, the major morbidity of pancreatic resection is pancreatic fistula and delayed gastric emptying. Whether the laparoscopic approach can reduce either of these complications is speculative. Our data suggest, however, that even within the initial learning curve of TLPD, these complication rates are comparable with those seen reported in open series, and outcomes beyond the learning curve are eagerly awaited. The learning curve for this complex procedure is not yet defined, but our early experience suggests that operative time and even leak rate may be decreasing. Our exclusion of patients for TLPD with tumors in proximity to the portal vein or superior mesenteric vein may also have resulted in a selection bias toward patients with smaller, nonobstructing lesions leading to patients with greater risk for pancreatic anastomotic leak. Both a soft pancreas and small pancreatic duct have been suggested to increase the risk of pancreatic fistula.12 In our series, 9 of the 11 pancreatic fistulae occurred in patients with a soft pancreas or pancreatic duct 3 mm or smaller. The use of prophylactic drains in patients undergoing pancreaticoduodenectomy remains controversial. We do not routinely use operative drains after open or laparoscopic pancreaticoduodenectomy, as existing studies suggest that they offer no clear benefit, may increase abscess or fistula rates, and are frequently insufficient to manage the leak without additional percutaneous intervention.13,14 We used prophylactic drains selectively in patients with a soft pancreas and pancreatic duct 3 mm or smaller, who we felt were at high risk of pancreatic leak.
The oncologic outcomes of laparoscopic approaches in pancreatic resection have not yet been adequately evaluated. This series lacks a sufficient number of patients and length of follow-up to accurately assess oncologic outcomes such as tumor recurrence and disease-free and overall survival. Possible surrogates to assess the oncologic procedure itself, however, may include extent of resection, margin status, and number of lymph nodes harvested. In this series, these outcomes are comparable with those reported for open pancreaticoduodenectomy,15,16 suggesting at least the possibility of noninferiority. Additionally, we did not identify any patient with port-site recurrence of malignancy.
Beyond oncologic outcomes, perhaps the most important outcome measures that should direct further study in TLPD are patient recovery and quality of life. Patients with benign disease are anxious to return to normal function, and those with malignancy may need adjuvant treatments and have shortened survivals. Any approaches that improve the patient's recovery to allow necessary adjuvant treatment or improve the quality of life would clearly be praiseworthy. For this reason, minimally invasive procedures should continue to be investigated in patients undergoing pancreatic resection.
In conclusion, this early experience suggests that TLPD is feasible and safe. Experience in pancreatic resection and possession of advanced laparoscopic skills are recommended prerequisites. While it is plausible that the typical benefits of laparoscopic approaches may be realized in patients undergoing TLPD, this remains to be substantiated. Patients undergoing pancreaticoduodenectomy could benefit greatly from reduced wound complications, quicker recovery, and improved quality of life. With increasing experience with TLPD, large series and controlled trials may become feasible to explore these possible advantages.
Correspondence: Michael L. Kendrick, MD, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (email@example.com).
Accepted for Publication: February 10, 2009.
Author Contributions:Study concept and design: Kendrick. Acquisition of data: Kendrick and Cusati. Analysis and interpretation of data: Kendrick and Cusati. Drafting of the manuscript: Kendrick and Cusati. Critical revision of the manuscript for important intellectual content: Kendrick and Cusati. Study supervision: Kendrick.
Financial Disclosure: None reported.
Previous Presentation: This work was presented in part at the 116th Annual Meeting of the Western Surgical Association; November 11, 2008; Santa Fe, New Mexico.


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Recent comments from Feodora
Very nice! This is encouraging me to do it. Just afraid of pain. My doctor said it's a 3 out of 10 pain level, and probably with an anesthetic of some sort I guess(not topical because that doesn't go deep enough), but some people make... READ COMMENT