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Early diagnostic markers of sepsis after oesophagectomy (including thromboelastography)
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Early diagnosis of sepsis and its differentiation from the noninfective SIRS is very important in order that treatment can be initiated in a timely and appropriate way. In this study we investigated standard haematological and biochemical parameters and thromboelastography (TEG) in patients who had undergone surgical resection of the oesophagus to find out if changes in any of these parameters could help in early differentiation between SIRS and sepsis development.
We enrolled 43 patients (aged 41–74 years) of whom 38 were evaluable. Blood samples were obtained on the morning of surgery and then at 24-hour intervals for the next 6 days. Samples were analysed for procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL- 6), aspartate transaminase (AST), alanine transaminase (ALT) , lactate, white blood count (WBC), D-dimers, antithrombin (AT), international normalised ratio (INR), activated partial thromboplastin time (APTT) and parameters of TEG.
Significant differences between patients who developed sepsis during this period (9 patients) and SIRS were found in ALT on Day 1, in AST on Days 1–4, in PCT on Days 2–6; in CRP on Days 3–6; in IL-6 on Days 2–5; in leucocytes on Days 2, 3 and 6; and in D-dimers on Days 2 and 4. Significance values ranged from p < 0.0001 to p < 0.05.
Sequential measurements of ALT, AST, PCT and IL-6 during the early postoperative period can be used for early differentiation of sepsis and postoperative SIRS after oesophagectomy. Among the coagulation parameters measured, only D-dimer concentrations appeared to be helpful in this process. TEG does not seem to be a useful early predictor of sepsis development; however it can be used to differentiate sepsis and SIRS from Day 5 after surgery.
KeywordsSepsis Biochemical Hematological Thromboelastography
Sepsis is a common, life-threatening condition in critically ill patients and, despite the availability of new therapeutic options for treating it, mortality rates remain high [1]. One reason for this may be delays in reaching a diagnosis and beginning treatment.
Patients undergoing major surgery often develop postoperative systemic inflammatory response syndrome (SIRS) in response to trauma, ischaemia, inflammation and/or infection. When due to an infection, SIRS may be self-limiting or may progress to severe sepsis [2]. In SIRS, proinflammatory cytokines induce intravascular coagulation and fibrinolysis is inhibited by production of plasminogen activator inhibitor 1 [3]. In septic patients this leads to hypercoagulability and the consumption of coagulation inhibitors and microthrombi formation with development of multiple organ dysfunction syndrome (MODS [4, 5]. A marker that could distinguish an inflammatory septic response from inflammatory non-infective events would be helpful, therefore, to ensure that patients receive early treatment.
Biochemical markers that are believed to help in early diagnosis of sepsis include procalcitonin (PCT), interleukin 1 (IL 1), IL 6, IL 10 and C-reactive protein (CRP), although reports of sensitivity and specificity differ [6, 7]. Thromboelastography (TEG) is a reliable method for evaluating hypercoagulability [8]. Unlike standard coagulation tests, such as prothrombin time (PT) or activated thromboplastin time (aPTT), TEG provides information about all phases of the coagulation process, from initiation of blood clot formation through fibrinolysis. Moreover, because whole blood is analysed, TEG takes account of interactions between all blood components (platelets, coagulation factors, leucocytes etc.) in the coagulation process.
Some authors have also identified markers of liver dysfunction in patients with SIRS or sepsis [9, 10]. The mechanisms by which this occurs in sepsis involve the leaking of bacterial products into the systemic circulation, thus promoting the production of proinflammatory cytokines. Liver dysfunction can therefore be considered a part of SIRS which characterizes sepsis [11, 12, 13].
The aim of our study was to find early diagnostic marker of sepsis that might help to differentiate septic patients from patients with non-infective postoperative SIRS. We investigated changes in biochemical and hematological parameters during the early postoperative period, in patients who had undergone surgical oesophagectomy – a double cavity surgery, which has an accompanying high risk of postoperative complications, including sepsis, and is associated with high mortality rates [14].
Forty three patients undergoing surgical oesophagectomy with a thoracoabdominal approach were included in this study. All patients received preoperative chemotherapy (epirubicin, cisplatin, 5-fluorouracil) ending 3 weeks before undergoing the operation. Exclusion criteria included hepatic insufficiency and coagulation disorders. This study was approved by the Ethics Committee for Multi-Centric Clinical Trials of the University Hospital Motol, Prague, Czech Republic. All patients provided informed consent before inclusion in the study.
Following surgery, all patients were extubated in the operating theatre and then transferred to the surgical intensive care unit (ICU). Post-surgical medications for all patients included antibiotics (for the first 48 hours), thoracic epidural analgesia, Diclofenac 1 x 75 mg/24 h and 1 x 0.4 ml (40 mg) Clexane (Enoxaparin) at 10 p. m.
Blood samples were obtained from the cubital vein using the syringe-needle method on the morning and of surgery and then at 24-hour intervals for the following 6 days. Samples were analysed for: PCT (Elecsys BRAHMS PCT; Roche Diagnostics, Mannheim, Germany); IL- 6 (EIA IL-6; IMMUNOTECH, Marseille, France); lactate (Cobas Integra 400+; Roche, Switzerland); CRP, aspartate transaminase (AST) and alanine transaminase (ALT) (all Advia 1800; Siemens, USA). White blood count (WBC) (Coulter LH 750 Hematology Analyzer; Beckman-Coulter, Miami, FL); and antithrombin (AT) activity, D-dimer concentration, international normalized ratio (INR) and activated partial thromboplastin time (aPTT) (all CA-7000 automated coagulation analyzer; Sysmex; Kobe, Japan). TEG analysis was conducted with a computer-controlled thrombelastograph haemostasis system (TEG Haemoscope, Niles, IL) using native cuvettes (without heparinase) and the native method (non-activated, without kaolin). Recently TEG is being validated as a tool for assessment of coagulation abnormalities in sepsis [15, 16]
Patients who fulfilled the criteria of sepsis defined by ACCP-SCCM conference [17] during this period formed the 'septic' group. Other patients formed the 'non-septic' group. The ICU doctors, who were in charge of the definition and division of the patients into the groups, were blinded to the results of the study tests.
(6) The laboratory results of all investigated parameters mentioned above were compared between the two groups every day. For those parameters, in which singnificant diferences were found during the first 3 days, cutoff points for differentiations between sepsis and non-sepsis were set up.
Statistical analysis
Statistical analysis was performed using Prism 5.0 statistical software (Graph Pad Software, Inc.). Values were tested for normality of distribution. Results are reported as mean ± SEM. We used parametrical tests for normally distributed data, unpaired t-tests for comparisons of the two groups, repeated-measures analysis of variance (ANOVA) with Bonferroni´s multiple comparison test for analyses within a group and the Pearson coefficient for correlation analyses. In non-normally distributed data, the differences between two groups were tested using the Mann–Whitney test and the Friedman test with Dunn´s multiple comparison for comparison of repeated measurements within a group. Correlations were expressed using the Spearman correlation coefficient. A P value of less than 0.05 was considered statistically significant. A receiver operating characteristics (ROC) curve was used for every parameter to find optimal value with best specificity and sensitivity with respect to discrimination of sepsis from non-sepsis.
In all, 43 patients were enrolled in the study: four patients were excluded because the surgery did not proceed as planned, and one patient withdrew from study. Among the evaluable patients, there were seven females and 31 males ranging in age from 41 to 74 years. Prior to surgery, the overall mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 4 (range 0–9)., APACHE II scores tended to be higher in patients who went on to develop sepsis, but the scores were not significantly different to those in the non-sepsis group (mean 4.4 vs. 3.8, respectively; p = 0.36).
Development of sepsis
All patients developed SIRS within 48 hours following surgery. Subsequently nine out of 38 patients (23.7 %) started to develop sepsis within the next 4 days after surgery. Five of these had pneumonia diagnosed from clinical symptoms (cough, expectorating coloured sputum and sepsis criteria) and confirmed by X-ray. In the four remaining cases dehiscence of the gastroesophageal anastomosis (diagnosed by radiology examination of the esophagus and confirmed by surgical revision of thorax) was the cause of sepsis. The median time to sepsis diagnosis was 3 days. According to our findings detectable changes in laboratory markers could be found as soon as 24–48 hours before diagnosis.
Estimates of liver function
Cutoff points (generated from ROC curves) for early diagnosis of postoperative infectious complication and its prediction within 6 days for Day 1 postsurgery
Day 1
Sensitivity ( %)
Specificity ( %)
AST ukat/l
ALT ukat/l
Cutoff points (generated from ROC curves) for early diagnosis of postoperative infectious complication and its prediction within 6 days for Day 2 postsurgery
Day 2
Sensitivity (%)
Specificity (%)
AST ukat/l
PCT ug/l
IL-6 ng/l
Cutoff points (generated from ROC curves) for early diagnosis of postoperative infectious complication and its prediction within 6 days for Day 3 postsurgery
Day 3
Sensitivity (%)
Specificity (%)
AST ukat/l
PCT ug/l
IL-6 ng/l
CRP mg/l
Biochemical parameters
Cutoff points for early diagnosis of development of postoperative infectious complications within 6 days of surgery are shown in Tables 2 and 3 (for days 2 and 3 after surgery).
Haematological and coagulation parameters
Patients who have undergone major surgery are at high risk of developing complications associated with sepsis [14, 18]; however, differentiation between postoperative SIRS and septic complications is difficult. Long-term prophylaxis with high-dose antibiotics or wide-spectrum antibiotics, which might prevent the development of sepsis, may obscure the host response and induce the development of resistance. Identification of septic patients at the beginning of the process can help in better and more specific diagnostic and therapeutic procedures and overall management. On the contrary, exclusion of sepsis might help in better and rationale antibiotics treatment.
In our study, we investigated both hematological (including TEG) and biochemical markers of sepsis, as there is a link between inflammation and coagulation (5). We also examined markers of liver dysfunction because of the important role reported to be played by the liver in sepsis. This is a very interesting finding and is, in all probability, underestimated in practice. Interestingly, levels of AST and ALT were significantly higher in the septic group of patients compared with the nonseptic group, and those changes could be detected as early as the first day after surgery and persisted to the fourth day (see Figure 1). For cutoff points for early diagnosis of development of postoperative infectious complications within 6 days of surgery see Tables 1, 2 and 3.
Our findings of higher liver enzymes levels in septic patients are in accordance with findings of others who say that liver dysfunction is common in patients with sepsis, ranging from mild elevations of serum aminotransferases to severe cholestasis [11, 12, 13, 19, 20]. However, we think that in our case liver dysfunction might rather be a cofactor participating in sepsis development. Liver has a central role in the regulation of host defenses. It serves as a source of inflammatory mediators and is a major site of the removal of bacteria and endotoxins from systemic circulation. Kupffer cells (KCs) of the liver make up 80 %-90 % of the fixed-tissue macrophages of the reticuloendothelial system. KCs take up bacteria, endotoxins and are stimulated to release a wide range of products implicated in liver injury, such as tumor necrosis factor, interleukin-1 and interleukin- 6 [12]. It is proposed that Kupffer cell phagocytic depression associated with liver dysfunction permits spread of endotoxin and inflamatory mediators and thus predisposes to sepsis and multiple organ failure.
The cause of postoperative liver dysfunction in our patients is not known. All patients had received the same kind of anaesthesia (isofluran, remifentanil, rocuronium) and postoperative care and there are some reports of isofluran side effect on liver function [21]. Transient hypotension and hypoxia cannot be ruled out and individual response of the patient to surgery can also play a part. That could have played a role in development of ,,postanaesthetic hepatitis" and subsequently in development of sepsis. Importantly, unlike the expensive tests used for detection of inflammatory markers, measurements of liver dysfunction are cheap and routinely available and can be helpful in screening of patients susceptible to sepsis for early signs of sepsis development.
Overall, the earliest markers of the development of sepsis seem to be AST and ALT. Differences in PCT and IL-6 in septic and non-septic patients with SIRS are detectable from Day 2 (see Figure 2). For cutoff points for early diagnosis of development of postoperative infectious complications within 6 days of surgery see Tables 2 and 3. Both parameters showed similar trends on subsequent days, which means that, as IL-6 is measured mostly experimentally, measurements of PCT should be sufficient to provide the necessary information. Ito and colleagues actually found that PCT is better for monitoring the development of sepsis in patients who had undergone oesophageal surgery for carcinoma; however they were able to predict sepsis one day earlier than in our study [22]. Unlike our patients though, their patients did not receive preoperative chemotherapy. In another study, Mokart and colleagues investigated PCT and IL-6 to predict sepsis development in patients who had undergone gastrointestinal or gynaecological tumour resections. They were also able to predict the development of sepsis from as early as Day 1 after surgery, although levels of IL-6 and PCT were not as high as those of our patients [7]. It should be noted, however, that unlike our patients, those patients had only undergone surgery in the abdominal cavity.
When it comes to CRP, we found significant differences between the groups from Day 3, when CRP levels in the septic group rose by comparison with those of patients in the non-septic group (see Figure 2). For cutoff points for early diagnosis of development of postoperative infectious complications within 6 days of surgery see Table 3. This finding is similar to that described by Ito, although the differences were not statistically significant in that study. Although it is questionable just how valuable this marker is for early diagnosis of sepsis, the tests are cheap and can help in sepsis diagnosis.
Surprisingly, among the coagulation parameters, only concentrations of D-dimers were statistically significantly higher during the early postoperative period (from Day 2 to Day 4). However, since the concentrations of D-dimers subsequently decreased (Figure 3A), the value of this marker for early diagnosis of sepsis is questionable.
Because this kind of operation is not very often, the sample size might be the limitation of this study. However, we were able to find some interesting laboratory changes in patients who would develop infectious complication untill the 6-th postoperative day, as soon as the 1-st postoperative day, no matter if sepsis was diagnosed on day 3 or 6. This findings could attract our attention to those patients in the risk of sepsis development more then 24 hours before sepsis diagnosis.
Our finding of decreased fibrinolytic activity (represented by levels of LY30) in the septic group versus the non-septic group is in accordance with those of a recent study by Adamzik and colleagues. This group investigated coagulation changes in septic patients using TEG and also found decreased fibrinolytic activity [23]. In that study, TEG did not detect changes until 24 hours after severe sepsis had been diagnosed and the patients were in a much more serious condition than ours. In both our study and the Adamzik study then, patients had already developed sepsis before TEG detected changes in fibrinolysis. Thus, while TEG is useful to diagnose sepsis in later state, it is not useful for early diagnosis of sepsis or predicting which patients will go on to develop sepsis.
Sequential measurements of ALT, AST, PCT and IL-6 during the early postoperative period can be used for early differentiation of sepsis and postoperative SIRS after oesophagectomy. Among the coagulation parameters measured, only D-dimer concentrations appeared to be helpful in this process. TEG does not seem to be a useful early predictor of sepsis development; however it can be used to differentiate sepsis and SIRS from Day 5 after surgery.
We can conclude that sequential measurements of biochemical parameters, such as AST, ALT, PCT and IL-6, during the early postoperative period can be useful for the early diagnosis of sepsis development and its prediction following oesophagectomy, and to differentiate sepsis from postoperative SIRS. Among coagulation parameters, only D-dimer concentrations appeared to be helpful in this process. By contrast, TEG does not seem to be helpful as an early diagnostic marker of sepsis development; however, it can be used to differentiate between sepsis and SIRS from Day 5 after surgery.
This study was supported by the grant agency of Charles University (No. 21509). Editorial assistance was provided by Jane Tricker of Elmcroft Editorial Services Ltd, and was funded by the Second Medical Faculty of the Charles University.
Supplementary material
Copyright information
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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Michael Peck
Michael Peck's artistic practice is concerned with the sensation of disorientation and dislocation that is often felt within the post modern world. Exploring issues regarding the loss of cultural identity, his work particularly focuses on the effects within minority groups and individuals existing on the fringe who are challenged to assimilate within the larger community.
The scenes in Michael's paintings are quiet, the participants are paused as they stand withdrawn, juxtaposed against a dynamic population; they are overwhelmed by mass-culture; one which has been composed from the interaction, assimilation and constant change of subcultures. His work looks at the place of the individual within a pluralistic society where a constant shift of values and beliefs leaves a great uncertainty of belonging.
Michael Peck holds a BFA in painting from Monash University. He has exhibited his work in Metro Gallery and Gallery 101 in Melbourne, Australia. Winner of the National Gallery of Victoria Trustees award on 1998. He lives and works in Australia.
Images and text provided by the artist
Related posts:
- Michael Smith & Mike Kelley at the SculptureCenter
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subset: commoncrawl


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Credit: Banner art provided by the talented, Nova Scotia artist, Lindsay Hicks (paintlife.ca)


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Nasus Build Guide by
Not Updated For Current Season
This guide has not yet been updated for the current season. Please keep this in mind while reading. You can see the most recently updated guides on the browse guides page.
Nasus Build
Ability Sequence
Welcome welcome, to another year at hogwa-...
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Pros / Cons
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|"William A. Rowe, Jr." <wr...@apache.org>
|Re: apr_mmap_t
|Sat, 23 Nov 2002 06:39:59 GMT
At 05:54 PM 11/20/2002, firstname.lastname@example.com wrote: >BTW, I want to be 100% clear. We don't use incomplete types for binary >compatibility. The only reason that we use incomplete types is for >portability reasons. In APR 2.0, I fully expect most of the incomplete >types to shrink, and for a good portion of APR to use complete types. Huh? Incomplete types have absolutely zero impact on portability, other than preventing authors from doing stupid things. We've never been against users making stupid errors, so that can't be it :-) They are 100% about maintainability. Cliff's particular change is the perfect case-in-point. By 2.0, I hope to have helped flesh out a reasonably portable way of introducing inline accessors, so the entire performance issue flies out the window. Of course, when one enables the inlines, one binds oneself to an exact version of APR (al la HTTP's own internal build of APR). If one does not use inlines, then you have complete freedom to use different APR versions as a dynamic library. Incomplete types were the correct initial design decision, and they will continue to be a good decision. Bill
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"Can this be used for tea as well?"
One of my best purchases on Overstock! I wanted a stainless steel french press, as I've had a few glass presses break in the past, and really wanted to get rid of my normal coffee makes. This is well made, has nice features, etc. If they had a 12-cup available I would have ordered that instead, but this 8-cup press is all-around perfect....
BonJour Insulated Stainless Steel French Pressby BonJour
ITEM#: 14215949The perfect solution for a quick, delicious, and aromatic cup of your favorite roast, this excellent French press. The patented flavor lock filtering system preserves the perfect flavor in every brew, while the microscreen lid filters out grounds and other sediment. The double walled design keeps your coffee hot, while the sleek stainless steel body makes a perfect addition to any kitchen.
- BonJour French press
- Made of stainless steel
- Brushed finish with mirrored accents
- Holds up to 8 cups of liquid
- Beverage output may vary
- Insulated double wall design
- Flavor lock filter system
- Micro screen filter lid
- Measures 8 inches high x 5 inches long x 4 inches wide
|Metal, Stainless Steel
|8 inches x 5 inches x 4 inches
|Model Number
|Country of Origin
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Customer Reviews
Most Recent
This is the best coffee press I ever bought. The coffee taste smooth and fresh. but the coffee grinds leaks throughRead More
Beautiful, well made,and functional
One of my best purchases on Overstock! I wanted a stainless steel french press, as I've had a few glass presses break in the past, and really wanted to get rid of my normal coffee makes. This is well made, has nice features, etc. If they had a 12-cup available I would have ordered that instead, but this 8-cup press is all-around perfect.Read More
Works ok
This pot works okay, but it is really small, and it does allow grounds past the screen worse than the other ones I have owned. I wouldn't really recommend it.Read More
BonJour French coffee press
Perfect in every way! Still in daily use here. Makes morning coffee without too much of a bite, unlike brewed or drip coffee. Looks well with the electric tea kettle I bought. Very good value.Read More
Ok but does not make much coffee-maybe two cups. Not worth the money.Read More
Most Helpful
I love coffee made in a French press. I wanted one without glass parts so I wouldn't worry about breaking it. This press is beautiful in design. There are two features that I have not seen in other presses. One, there is a filter at the spout to catch any grounds that escape the plunger. The filter in the plunger is closed off by turning the shaft after plunging, which stops the brewing completely. I served coffee from this press to friends who are serious about their coffee. They complimented the coffee and wanted to know how it was made! I an very pleased.Read More
great product
love it love it love it. great cup of coffee.. as i like to sit outside and have mine, this can be taken and it stays hot for some time, even in cold weather. double filter, no grains in coffee cup.Read More
Insulated, solid, adjustable, use it camping too
I like this french press because I can adjust the amount of press and close when not using. It has a nice clean design. It is solidly built. I used it camping too--no worry about broken glass.Read More
late for work
It doesn't matter what time I wake up or what time I need to leave the house...I make sure to make and drink all my coffee from this French Press. No more Dublin Donuts. I throw a shot of espresso in and I'm good to go. The extra effort it takes to make this coffee is more than worth it. When I wear this 1 out in 15 years (eventually the mesh has to give right?) I will buy another Bon Jour press. Do not hesitate or 2nd guess this purchase.Read More
Great product
Keeps the extra coffee warm til the next cup. I like this beautiful pot:Read More
Questions & Answers
I don't see how you can use it for tea. Have you ever used a coffee press for tea? With as much coffee grounds that end up in you coffee with this press you would have dirty tea.
I really wish I could help, but I ordered this for a Christmas gift, and won't have an answer until after that.....
"Why did you choose this product?"
Looking for a French press that was insulated that others liked.
Wonderful reviews and love this French press coffee maker.
Only one with extra filter to remove grinds.
We no longer use this one. The spout sucks it dribbles and after we cleaned it we could no longer get all the parts to move correctly. The coffee was always dirty and no one wanted the last cup.
"Is there any plastic inside the pot?"
Hello ellen29, no, there is not any plastic inside this pot. Thank you for shopping with us!
"can this coffee pot be heated on the stove"
Hello munmun12, This can not be heated on the stove. Thank you for shopping with us!
Absolutely not.
"Can this coffee pot be put in dishwasher?"
Hello, gstuart. Hope your day is going well. This item has virtually no plastic and does not have any rubber pads. This means placing it in the dishwasher is not a problem. Thank you for shopping with us and please feel free to contact us again with any further questions.
"How many ounces is the capacity?"
Thank you for your interest in the BonJour Insulated Stainless Steel French Press. The carafe capacity: 33.8 oz.
It is actually 33.8oz. I just received mine and need to return it. Perhaps Overstock sent the wrong one?
"What country is it made in?"
Hello, greyhoundlady. Hope your day is going well. This item was made in China. Thank you for shopping with us and please feel free to contact us again with any further questions.
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text: I have a 2010 fastrak super duty 25/54 that I bought last fall and now have 35hrs. Since new it will leave straglers when mowing and when mowing taller grass (5-6" grass and I cut at 3 1/4") it will leave two strips of unmowed/taller grass to the inside of each rear tire track. I have healthy grass with few weeds. I have checked and the dealer has checked that the blades are sharp, the correct part number, and are on correct, that the deck is level side to side and a 1/4" pitch to the front, belt tension is good, tire pressures set,deck is kept clean. The dealer came out and check the cut and agreed that it was not cutting as it should in taller grass and tried cutting a couple different ways by over lapping passes and different width passes putting the front tire left or right of the strip, only solution was to mow at 1/2 speed. My dealer is great and has been a great help, but I bought this mower for its speed and quality of cut. Hoping that you'll a solution for this. Thank-you


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Henry, from Ultima VII
Henry is a simple and humble shepherd living on New Magincia. He is deeply in love with a woman named Constance.
Some years prior to meeting the Avatar, he and Katrina had developed quite a close friendship. However, in the end she decided that it would be unfair with her vastly longer lifespan for the relationship to become romantic, so they stayed friends.
In Ultima VII, Henry was deeply depressed when the Avatar found him. After some coaxing, he revealed what was wrong. Katrina had given him a locket for his love, Constance, so that he could show her his affection. However, after he had already promised her the locked, it got lost and now she was mad at him. Henry suspected the three strangers Robin, Leavell, and Battles had stolen the locket and asked for help.
The Avatar indeed found out what had happened. The strangers had stolen the locket, but then lost it at the tavern when Boris stole it from them, then Magenta found it and thought it was a gift for her. The Avatar first showed the locket to Robin and he revealed his true colors. Afterwards, the Avatar returned the locket to Henry, who was much relieved, and he forgave Constance when she said how sorry she was for treating him so badly.
Trivia Edit
- Returning the locket to Henry and then talking to Constance should be done while they are close to each other for added dialogue.


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Let's descend to the bottom of the Elbe river! The old Elbe tunnel, opened in 1911, is one of the oldest still operating tunnels in Europe. Open to traffic and pedestrians, it connects the inner city of Hamburg at Landungsbrücken (north entrance) with the shipyards at Steinwerder (south entrance). The south side of the Elbe river offers a spectacular view of Hamburg's cityscape that is most impressive when it's lit at night.
If you feel daring, walk down the staircase, which takes you 24 m below the surface. If you'd rather save your energy, hop onto one of the elevators instead. The best time to explore during the week is after 20:00, or on weekends when the tunnel is closed to traffic. Take in the full scope of the decorative elements, and admire the glazed ceramic reliefs depicting maritime motifs on the walls of the 426 m long tiled tubes.
Currently, the tunnel is under construction with only one accessible tube. You'll find the entrance of the tunnel (with elevators and stairs) to the right of the Landungsbrücken (piers) gates. When you get to the south side, turn right (make a u-turn) and walk around the back of the building to the Elbe viewing platform.


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Cala Gonone is situated on the eastern coast of Sardinia in the Gulf of Orosei. This beautiful area of Sardinia is characterised by its white sand beaches, dramatic mountains and clear blue seas. The Hotel Conchiglia is positioned less than 50 metres from its own white sand beach. This modern 4 star hotel looks out across the beautiful gulf, offering exquisite sea views.
There is a boat departure point nearby, where you can take boat trips out to see the beautiful coves, bays and beaches of the Gulf of Orosei. There are also shuttle services which can take visitors inland to the surrounding towns and villages so you can experience the local cuisine.
Next to the hotel is a complex which offers sporting facilities including tennis, table tennis, football and swimming. There is also a facility for younger children supervised by qualified staff, with a range of activities.
Distance from Airport:
Approx. 100km from Olbia airport.
All rooms have bathroom/shower - WC - air conditioning - refrigerator - phone - cable/satellite TV - hairdryer - balcony.
Transfer time:
Approx. 1 hour 45 minutes.
Location and Resort:
The hotel is situated on the east coast of Sardinia, in the centre of Cala Gonone. Cala Gonone itself is found in the picturesque Gulf of Orosei offering some of the finest beaches and bays in Sardinia. The Hotel Conchiglia is positioned on the promenade of Cala Gonone in the heart of the town.
Eating and Drinking:
The hotel has its own restaurant and bar.
Swimming pools:
The hotel has an outdoor swimming pool.
Right choice:
The Hotel Conchiglia is a great choice for families who want a relaxing holiday in beautiful surroundings, with access to the beach and other activities. It is also ideal for couples or groups wanting to relax and explore this beautiful region of eastern Sardinia.
Suitable for:
Couples, Groups and Families.


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Fertilizer use has exploded, overloading plants worldwide, likely altering ecosystems for decades to centuries, scientists report Thursday.
In the journal Science, a review led by Donald Canfield of the University of Southern Denmark found that fertilizer use worldwide increased 800% from 1960 to 2000. "Given the rising costs of synthetic fertilizer production, this overuse is not only economically expensive, but also initiates a cascade of large-scale environmental impacts," says the review.
Fundamentally, nitrogen from fertilizers has led to an explosion in "dead zones" in seas and oceans, upsetting a cycle of nutrients balanced with growth that has lasted for billions of years, the authors find:
"Humans may have produced the largest impact on the nitrogen cycle since the major pathways of the modern cycle originated some 2.5 billion years ago."
As well, the excess nitrogen is forming large amounts of nitrous oxide, a powerful greenhouse gas in wetlands, adding to climate change. Agriculture today produces about a quarter of the nitrous oxide in the atmosphere.
"The effects of humans have been profound. In the last few decades we have doubled the worldwide biological availability of nitrogen, an element that often limits growth of plants and algae," says Thomas Jordan of the Smithsonian Environmental Research Center in Edgewater, Md., who was not part of the review.
The review,"is a very careful analysis of the nitrogen cycle by three of the world authorities in this area," says biochemist Robert Blankenship of Washington University in St. Louis, who also was not part of the review. "The concerns they raise for how the nitrogen cycle is now significantly out of balance are important and need to be addressed by changing agricultural practices. The world's food supply depends directly on nitrogen application in the form of fertilizer, but current practices are such that much of the applied nitrogen ends up in rivers and eventually in the ocean where it causes serious problems."
"Natural feedbacks driven by microorganisms will likely produce a new steady state over time scales of many decades , " say the review authors. "However, because of the projected increase in human population through at least 2050, there will be demand for a concomitant increase in fixed nitrogen for crops to feed this population." And that will mean a lot more dead zones, they warn, like the one that blooms yearly, in 2010 about the size of New Jersey, in the Gulf of Mexico.
"Several new approaches and a much wider use of more sustainable time-honored practices, however, can decrease nitrogen use substantially," they conclude, noting steps such as:
The rising cost and environmental toll of fertilizers will increase demand for less use on farms, they add. "However, even with management, the future cycle will likely be different from the one that preceded the Industrial Revolution."
By Dan Vergano
Visit Science Fair for your daily dose of scientific news, from dinosaurs to distant galaxies. Science Fair is written by science reporters Dan Vergano and Elizabeth Weise and weather reporter Doyle Rice. Their subjects are often controversial -- and always fascinating -- be they stem-cell research, slime mold, or underground slush on Mars. More about the team


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Recent articles have mentioned progress being made in Atlantic City regarding the improved visual condition of the Boardwalk and a decrease in crime. Each time, myriad organizations - including the FBI, the Casino Reinvestment Development Authority, the CRDA's Special Improvement Division, the Atlantic City Alliance, casino properties, etc. - were credited as being responsible for the progress.
However, the city of Atlantic City is not mentioned.
The improved Boardwalk image starts with the city Department of Public Works and its beach, Boardwalk and sanitation divisions. These dedicated employees clean the beach, repair and maintain the Boardwalk and collect trash and other debris on a daily basis. The city's code-enforcement, mercantile, construction and demolition divisions, as well as the Atlantic City Police Department and the new Class II officers, are the catalysts for making our Boardwalk one of the best in the nation.
It is simply amazing to me how when anything bad happens in the city, it is the city's fault. But whenever there is praise or credit to be handed out for anything good that happens, the city is conveniently left out.
Is this accidental, coincidental or intentional?
I believe it is the latter, which leads me to believe that this would not be the case if the politics and face of the current administration were different.
Atlantic City
Wilbur Banks is the director of the Atlantic City Department of Health and Human Services.