text:
Peer reviewer: Jessica A Davila, PhD, Assistant Professor, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, 2002 Holcombe Blvd. (152), Houston, TX 77030, United States
S- Editor Wang YR L- Editor Logan S E- Editor Lin YP
The Epstein-Barr virus (EBV) has an important and multifaceted role in liver pathology. As a member of the herpes virus family, EBV establishes a persistent infection in more than 90% of adults. Besides acute hepatitis during primary infection, many clinical syndromes of interest for the hepatologist are associated with EBV infection. The role of EBV in the evolution of chronic hepatitis from hepatotropic viruses is considered. Chronic EBV-associated hepatitis is suspected in immunocompetent adults with compatible serology, suggestive histology and detection of the viral genome in the liver and/or increase of specific circulating cytotoxic T-lymphocytes. EBV is the main cause of post-transplant lymphoproliferative disorders which occur in up to 30% of cases. EBV-driven lymphoproliferative diseases are also recognized in non-immunocompromised patients and liver is involved in up to a third of the cases. Directly implicated in the pathogenesis of different tumors, EBV has a disputable role in hepatocellular carcinoma carcinogenesis. Further research is required in order to establish or reject the role of EBV in human liver cancer. This paper attempts to discuss the range of EBV-associated chronic liver diseases in immunocompetent patients, from mild, self-limiting mononuclear hepatitis to liver cancer.
The Epstein-Barr virus (EBV) is a member of the Gammaherpesvirinae subfamily of herpes viruses. It infects more than 90% of the adult population all over the world. EBV shares the tendency of establishing latency in the host with other herpes viruses[1]. Primary infection leads to transitional viremia, followed by a strong T-cell adaptive immune response, which actually holds the infection latent in immunocompetent individuals[2]. Short episodes of spontaneous reactivation and consequent viral replication normally occur in healthy individuals[3]. In the immunocompetent individual the occurrence of EBV reactivation leading to immortalization of B-lymphocytes is strongly regulated by cytotoxic T lymphocytes (CTLs) specific for lytic and latent antigens[4]. It is believed that almost no specific symptoms indicate these events. Viral replication may cause significant clinical entities and even severe complications in patients with diminished cell-mediated immunity[5,6]. The latter refers to immunosuppression, physical or psychological stress, other infections, etc[7].
The EBV DNA encodes more than one hundred proteins expressed during the lytic infection. Only ten of these proteins are expressed in latently infected B-cells in vitro[8]. Limited gene expression during latency ensures successful escape from CTL recognition. However, this has led to sophistication of the diagnostic tools for detection of EBV gene products in different tissues. Different types of latency regarding expression of EBV latent genes are established in different diseases and states. EBV-encoded nuclear antigen 1 (EBNA-1) and small RNAs (EBER) are found in Burkitt's lymphoma, whereas latency type of Hodgkin's disease is represented by additional expression of the latent membrane proteins (LMP-1 and LMP-2)[9]. These differences further hamper the diagnosis of EBV-associated disease and challenge both the clinicians and molecular biologists to reveal the causal links.
The classical form of primary EBV infection in the immunocompetent individual is infectious mononucleosis (IM, or first-kiss-disease). Albeit not a challenge for general physicians, in some cases it could be of interest for hepatologists. Almost half of patients with IM have hepatitis, while jaundice is present in 5%-10% of cases[10,11]. Besides transient liver enzyme elevations, cholestatic pattern of severe hepatitis[12-14] and even fatal liver failure might complicate the IM[15-17].
Chronic active EBV infection (CAEBV) is thought to be a rare disorder, defined by chronic severe illness, which begins as a primary EBV infection associated with abnormal EBV serology, histological evidence for organ disease (including hepatitis) and demonstration of EBV gene products in tissue. The CAEBV infection might progress to a chronic or recurrent infectious mononucleosis-like disease[18]. This is a result of a disturbance in the host-virus balance and Th1/Th2 disbalance. It is reported that CAEBV is associated with an aggressive clinical course[19] but the pathogenesis and pathophysiology of CAEBV are still not well characterized. Patients with iatrogenic, congenital, or acquired immunodeficiency are at increased risk for EBV-associated lymphomas and CAEBV. It seems that CAEBV in Western countries is milder than in Asian countries[20]. The mild forms from the Western world are characterized by intact immune control of B-cells, relatively low viremia and EBV-specific CTL expansion comparable to seropositive donors. Under the heading of the popular clinical term CAEBV, novel EBV lymphoproliferative diseases (LPDs) have been identified recently in non-immunocompromised hosts, both in Asian and Western countries. Immune senescence in the elderly is also associated with both reactive and neoplastic EBV-driven LPDs[21]. Almost a third of the patients with some EBV-driven LPDs have liver involvement, and liver failure is an important cause of death in this group[22].
Some reports have suggested EBV to be a trigger agent for an autoimmune hepatitis[23]. It should be kept in mind that liver involvement in CAEBV might mislead even experienced physicians to misdiagnose an autoimmune hepatitis (AIH)[24]. Nobili et al[25] identified EBV and hepatitis A virus infections as possible initiating agents in a cohort of AIH type I patients. In similar cases a suppressor T-cell dysfunction and consequent loss of control and raising of ASGRP antibodies have been seen to be involved in the evolution of the viral disease[26-28]. EBV has been suspected as a probable cause of particular granulomas in the liver[29] and even in a rare vanishing bile duct syndrome[30].
In some patients with chronic liver disease caused by a major hepatotropic virus, an infection with other viral agents may be discovered. We previously evaluated patients with chronic hepatitis B and C regarding their EBV serology. Our patients with reactivated EBV infection had lower levels of HBV DNA and higher mean values of serum hepatitis C virus (HCV) RNA respectively, compared to EBV-seropositive patients without reactivation[31]. Several hypotheses were put forward to explain those results. Reactivation of the EBV-specific T cells leads to significant production of several cytokines, especially interferon-γ (IFN-γ), interleukin (IL)-1, IL-2 and IL-10[32]. Additionally, the EBV BCRF1 shares high sequence homology with human IL-10 and exerts the same activity. Exogenous IL-10 enhances HCV replication[33]. IFN-γ inhibits HBV replication in the absence of cell necrosis[34]. It is unclear why the effect on viral replication was opposite in HBV and HCV cases. Most probably, T cell cross-activation could explain the hepatitis virus reactivation. The latter conclusion has been drawn from a small group of patients whose EBV reactivations preceded HBV flares[35]. Sugawara et al[36] have shown in vitro that EBNA1 promotes HCV replication. Speculative viral or immune interference in cases of chronic hepatitis B or C and EBV infection needs further research.
Bertolini et al[37] investigated an experimental model (nu/nu mice) of chronic EBV hepatitis with typical intrasinusoidal lesions after inoculation of EBV-infected B-cells. The study provided evidence for EBV replication in a very rare proportion of hepatocytes. Despite lack of evidence, we might speculate that infection of non-lymphoid cells is possible via a specific integrin-dependant mechanism[38]. Hesitant reports have linked EBV to chronic hepatitis in non-immunocompromised humans. The existence of EBV-associated liver disease is still accepted with caution as EBV has not been detected in human hepatocytes[13]. Specific latent antigens as well as EBER transcripts are detected in infiltrating lymphocytes. It has been proposed that liver cells suffer from a form of collateral damage[13]. Chronic hepatitis might also be induced by a soluble Fas-ligand, tumor necrosis factor and IFN-γ[39-41]. In most cases the infiltrating lymphocytes are CD8+ CTLs. It has also been found that activated CD8+ cells might be selectively trapped in the liver as they are bound to specific adhesive molecules expressed by Kupffer cells[42]. In the last year, several studies have tried to lift the curtain regarding chronic hepatitis associated with EBV infection. Drebber et al[43] proposed a list of criteria to establish the diagnosis: presence of suggestive histopathological features, serological profile and detection of viral genome in the liver tissue. In spite of some methodological limitations, this study addressed the necessity of new scoring systems regarding the possible EBV-associated chronic liver disease. Their work revived the interest in this issue both for pathologists and molecular hepatologists[43]. The critics of a hypothesis for chronic EBV liver disease in non-immunocompromised patients discuss so called "incidental virus" or amplification of the genome in circulating B cells which turn up in the liver. The existence of acute mononuclear hepatitis during primary EBV infection has been already accepted. Hence, it is most likely that the reactivation leading to liver damage occurs whether the infected lymphocytes are incidentally or intentionally in the liver. We previously discussed cases of EBV-associated chronic hepatitis in patients with reactivated EBV infection and increased specific CTL-response to a lytic EBV-epitope compared to healthy controls[44]. We presumed frequent reactivations in these patients because we had found an increased percentage of terminally differentiated CD28(-) CD27(-) CD8(+) T cells, suggestive of chronic antigen stimulation and replicative senescence. Diminished expression of co-stimulatory molecules CD28 and CD27 could further compromise CD8+ reactivation and characterize these terminally differentiated cells as more resistant to apoptosis[45,46]. Focused T-cell pull with low expression of CD28 and CD27 has low ability to control reactivations and is a typical finding in an elderly group. Surprisingly, very similar changes were found in younger patients under chronic cytomegalovirus and EBV antigen stimulation[47].
We surmise that a chronic liver disease might be a manifestation of a chronic EBV infection with frequent reactivations and persistent, moderate or low level of viral load. Based on recent studies and cases we can propose the expansion of Drebber's criteria by adding recurrent EBV reactivations, increased circulating EBV-specific CTLs, and increased CD38 B-cell expression. We are also inclined to accept as additional clinical signs the increase of LDH levels, mild spleen enlargement and tendency for thrombocytopenia.
EBV infection is the main cause of post-transplant lymphoproliferative disease (PTLD). The incidence of PTLD ranges from 0.5% to 30% depending on the organ being transplanted, the EBV status of the transplant recipient and donor, and the therapies used to achieve immunosuppression[48,49]. EBV seronegativity at the time of transplant and pediatric age are predisposing factors. The disorder occurs commonly in combined liver-kidney transplants, followed by cardiac, liver, lung, and then kidney transplants. In addition, constitutional factors such as cytokine gene polymorphism may play a predisposing role. Little is known about the chronic carrier state and its relation to late PTLD. Most pediatric liver transplant candidates are EBV-naïve when listed for orthotopic liver transplantation (OLT). Those immunosuppressed, EBV-naïve children, who receive an adult EBV-positive liver, are unable to adequately control EBV primary infection, hamper viral replication and avoid lymphoproliferation[50]. For this reason, PTLD has become one of the major threats in transplantation, complicating the course of up to 10% of pediatric liver graft recipients, with a mortality reported up to 50%[51]. All data support the recommendation of strict EBV monitoring in the first months after the transplantation. However, little is known about late and chronically persistent infection. Helpful insights into how often and how long we should monitor viremia during follow-up are insufficient. D'Antiga et al[52] revealed that none of their pre-OLT seropositive patients had sustained positivity of EBV serology or polymerase chain reaction (PCR) for 6 mo or longer, versus as many as 65% of those who were EBV-negative pre-OLT. A prolonged EBV viral load was strictly related to pre-OLT immunity against the virus and appeared to be associated with the occurrence of PTLD[52]. In fact, it is well established that persistence of EBV is a risk factor for development of lymphomas[53]. Patients who demonstrate a sustained viral detection are at risk for the development of late PTLD which implies necessity for preliminary testing as well as for long-term EBV infection follow-up. The development of molecular genetic diagnosis for EBV (PCR) means that progressive disease, or PTLD, may be prevented by preemptive reduction of immunosuppression in response to rising EBV titers.
EBV was the first human virus directly implicated in carcinogenesis. Since its discovery it has been considered as a major player in the development of a wide range of cancers both in immunocompetent and immunocompromised individuals. Recent studies have concluded EBV itself or infected cell clones might promote replication of the HCV[31,36]. Presumably, EBNA1 is responsible for supporting HCV replication, suggesting that EBV may be involved in the development of hepatocellular carcinoma (HCC)[54]. The detection of EBV gene products in HCC additionally supports this assumption. Sugawara et al[55] reported a higher amount of EBV DNA in HCV-positive HCC compared to HBV-associated HCC. EBV-infected cells support HCV replication better than uninfected cells, suggesting that EBV may act as a helper virus to promote HCV replication in the HCV-positive HCCs, especially in Japanese patients. Li et al[56] found that almost 30% of liver cancers harbored EBV DNA (vs 8% in the control group, P < 0.05) suggesting that the herpes virus might be involved in hepatocellular carcinogenesis in China. However, studies from Western countries do not confirm the hypothesis that EBV may promote the development of HCC. Akhter et al[57] examined cancer tissues of 31 non-cirrhotic, HCC patients. None of the tumor samples were found to be positive for EBV DNA. Being unable to confirm an association between EBV and infection with hepatitis viruses in HCC, the authors suggested environmental or genetic factors which could predispose Chinese and Japanese patients to develop EBV-infected HCC. On the other hand, a possible source of detected EBV DNA might be the infiltrating lymphocytes. Furthermore, a study from The Netherlands concluded that the absence of epithelial-specific BARF1 transcripts and other EBV transcripts and proteins in EBV DNA PCR-positive cases argues strongly against a role for EBV in HCC[58]. However, weak signals for EBV DNA in 5 of 16 HCCs (31.25%) and in two of four HCV-related hepatitis cases were detected and actually no EBV DNA was found in non-neoplastic and normal liver tissue, using DNA PCR-Enzyme Immunoassay for the detection of the BamHI W repeat fragment of EBV. The weak positivity of EBV DNA in some liver tissues was explained by amplification of EBV DNA in the lymphoid infiltrate or blood, reflecting a high EBV DNA load in these patients. Chen et al[59] showed that circulating EBV-positive peripheral B cells express BARF0 transcripts which could also explain the negative BamHI A rightward transcripts RNA in situ hybridization results. Moreover, we cannot exclude the presence of EBV-positive lymphocytes or EBER-positive hepatocytes in the larger amounts of tissue, as most studies usually test routine histology sections (5 μm thick paraffin-embedded or cryosections). This fact raises the question whether usual techniques such as immunohistochemistry and in situ hybridization lack enough power to detect the virus in the liver regardless of its place of persistence - infiltrating lymphocytes, hepatocytes or Kupffer and other liver cells. We would welcome better evidence for or against the causative (and/or supportive) role of EBV in human HCC carcinogenesis.
Undeservedly neglected within hepatological society, EBV-associated chronic liver disease demonstrates the challenges in discovering the intimate mechanism of viral-host interactions leading to different clinical syndromes. Since proven to induce acute hepatitis during IM, to affect the liver in a PTLD setting, possibly to contribute to liver carcinogenesis, it would not be surprising if EBV causes chronic hepatitis. Undoubtedly, follow-up of patients is required to reveal the long-term complications of EBV-associated liver disease before we decide that this viral infection belongs in a group of meaningless companions of cryptogenic disease.
Peer reviewer: Jessica A Davila, PhD, Assistant Professor, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, 2002 Holcombe Blvd. (152), Houston, TX 77030, United States
S- Editor Wang YR L- Editor Logan S E- Editor Lin YP
|Cohen JI. Epstein-Barr virus infection. N Engl J Med. 2000;343:481-492.
|Klenerman P, Hill A. T cells and viral persistence: lessons from diverse infections. Nat Immunol. 2005;6:873-879.
|Maurmann S, Fricke L, Wagner HJ, Schlenke P, Hennig H, Steinhoff J, Jabs WJ. Molecular parameters for precise diagnosis of asymptomatic Epstein-Barr virus reactivation in healthy carriers. J Clin Microbiol. 2003;41:5419-5428.
|Rickinson AB, Kieff E. Epstein-Barr virus. Fields virology. 4th ed, Vol 2. Philadelphia: Lippincott Williams & Wilkins; 2001;2575-2627.
|Babel N, Schwarzmann F, Prang N, Jaeger M, Wolf H, Kern F, Volk HD, Reinke P. Association between Epstein-Barr virus infection and late acute transplant rejection in long-term transplant patients. Transplantation. 2001;72:736-739.
|Rooney CM, Loftin SK, Holladay MS, Brenner MK, Krance RA, Heslop HE. Early identification of Epstein-Barr virus-associated post-transplantation lymphoproliferative disease. Br J Haematol. 1995;89:98-103.
|Gleeson M, Pyne DB, Austin JP, Lynn Francis J, Clancy RL, McDonald WA, Fricker PA. Epstein-Barr virus reactivation and upper-respiratory illness in elite swimmers. Med Sci Sports Exerc. 2002;34:411-417.
|Kieff E. Epstein-Barr virus and its replication. Fields virology. 3rd ed, Vol. 2. Philadelphia: Lippincott-Raven; 1996;2343-2396.
|Kerr BM, Lear AL, Rowe M, Croom-Carter D, Young LS, Rookes SM, Gallimore PH, Rickinson AB. Three transcriptionally distinct forms of Epstein-Barr virus latency in somatic cell hybrids: cell phenotype dependence of virus promoter usage. Virology. 1992;187:189-201.
|Crum NF. Epstein Barr virus hepatitis: case series and review. South Med J. 2006;99:544-547.
|Cocuz ME, Idomir ME, Ticău OC. [Clinical and biological aspects of liver damage in infectious mononucleosis]. Bacteriol Virusol Parazitol Epidemiol. 2003;48:177-181.
|Hinedi TB, Koff RS. Cholestatic hepatitis induced by Epstein-Barr virus infection in an adult. Dig Dis Sci. 2003;48:539-541.
|Kimura H, Nagasaka T, Hoshino Y, Hayashi N, Tanaka N, Xu JL, Kuzushima K, Morishima T. Severe hepatitis caused by Epstein-Barr virus without infection of hepatocytes. Hum Pathol. 2001;32:757-762.
|Edoute Y, Baruch Y, Lachter J, Furman E, Bassan L, Assy N. Severe cholestatic jaundice induced by Epstein-Barr virus infection in the elderly. J Gastroenterol Hepatol. 1998;13:821-824.
|Papatheodoridis GV, Delladetsima JK, Kavallierou L, Kapranos N, Tassopoulos NC. Fulminant hepatitis due to Epstein-Barr virus infection. J Hepatol. 1995;23:348-350.
|Markin RS, Linder J, Zuerlein K, Mroczek E, Grierson HL, Brichacek B, Purtilo DT. Hepatitis in fatal infectious mononucleosis. Gastroenterology. 1987;93:1210-1217.
|Feranchak AP, Tyson RW, Narkewicz MR, Karrer FM, Sokol RJ. Fulminant Epstein-Barr viral hepatitis: orthotopic liver transplantation and review of the literature. Liver Transpl Surg. 1998;4:469-476.
|Straus SE. The chronic mononucleosis syndrome. J Infect Dis. 1988;157:405-412.
|Shibuya A, Tsuchihashi T, Watanabe M, Nakazawa T, Takeuchi A, Sakurai K, Mitomi H, Saigenji K. Severe chronic active Epstein-Barr virus infection associated with multiple necrotic lesions in the liver. Hepatol Res. 2003;25:447-454.
|Savoldo B, Huls MH, Liu Z, Okamura T, Volk HD, Reinke P, Sabat R, Babel N, Jones JF, Webster-Cyriaque J. Autologous Epstein-Barr virus (EBV)-specific cytotoxic T cells for the treatment of persistent active EBV infection. Blood. 2002;100:4059-4066.
|Cohen JI, Kimura H, Nakamura S, Ko YH, Jaffe ES. Epstein-Barr virus-associated lymphoproliferative disease in non-immunocompromised hosts: a status report and summary of an international meeting, 8-9 September 2008. Ann Oncol. 2009;20:1472-1482.
|Jaffe ES, Wilson WH. Lymphomatoid granulomatosis: pathogenesis, pathology and clinical implications. Cancer Surv. 1997;30:233-248.
|Vento S, Cainelli F. Is there a role for viruses in triggering autoimmune hepatitis? Autoimmun Rev. 2004;3:61-69.
|Chiba T, Goto S, Yokosuka O, Imazeki F, Tanaka M, Fukai K, Takahashi Y, Tsujimura H, Saisho H. Fatal chronic active Epstein-Barr virus infection mimicking autoimmune hepatitis. Eur J Gastroenterol Hepatol. 2004;16:225-228.
|Nobili V, Comparcola D, Sartorelli MR, Devito R, Marcellini M. Autoimmune hepatitis type 1 after Epstein-Barr virus infection. Pediatr Infect Dis J. 2003;22:387.
|Vento S, Guella L, Mirandola F, Cainelli F, Di Perri G, Solbiati M, Ferraro T, Concia E. Epstein-Barr virus as a trigger for autoimmune hepatitis in susceptible individuals. Lancet. 1995;346:608-609.
|Kojima K, Nagayama R, Hirama S, Maeda T, Takikawa H, Miyake K, Yamanaka M, Shiga J. Epstein-Barr virus infection resembling autoimmune hepatitis with lactate dehydrogenase and alkaline phosphatase anomaly. J Gastroenterol. 1999;34:706-712.
|Aceti A, Mura MS, Babudieri S, Bacciu SA. A young woman with hepatitis after a sore throat. Lancet. 1995;346:1603.
|Biest S, Schubert TT. Chronic Epstein-Barr virus infection: a cause of granulomatous hepatitis? J Clin Gastroenterol. 1989;11:343-346.
|Kikuchi K, Miyakawa H, Abe K, Fujikawa H, Horiuchi T, Nagai K, Kako M. Vanishing bile duct syndrome associated with chronic EBV infection. Dig Dis Sci. 2000;45:160-165.
|Petrova M, Kamburov V, Nikolovska D, Kosseva O, Nikolova M, Krastev Z. Epstein-Barr virus: is there any contribution to chronic hepatitis B and C? Liver Int. 2010;30:488-489.
|Jabs WJ, Wagner HJ, Schlenke P, Kirchner H. The primary and memory immune response to Epstein-Barr virus infection in vitro is characterized by a divergent production of IL-1beta/IL-6 and IL-10. Scand J Immunol. 2000;52:304-308.
|Nelson DR, Tu Z, Soldevila-Pico C, Abdelmalek M, Zhu H, Xu YL, Cabrera R, Liu C, Davis GL. Long-term interleukin 10 therapy in chronic hepatitis C patients has a proviral and anti-inflammatory effect. Hepatology. 2003;38:859-868.
|Guidotti LG, Rochford R, Chung J, Shapiro M, Purcell R, Chisari FV. Viral clearance without destruction of infected cells during acute HBV infection. Science. 1999;284:825-829.
|Santolamazza M, Marinelli RM, Bacosi M, D'Innocenzo S, Miglioresi L, Patrizi F, Delle Monache M, Ricci GL. What kind of hepatitis? J Int Med Res. 2001;29:441-444.
|Sugawara Y, Makuuchi M, Kato N, Shimotohno K, Takada K. Enhancement of hepatitis C virus replication by Epstein-Barr virus-encoded nuclear antigen 1. EMBO J. 1999;18:5755-5760.
|Bertolini L, Iacovacci S, Bosman C, Carloni G, Monaco V, Bangrazi C, Serafino A, Gualandi G, Prantera G, Fruscalzo A. Low cell dosage of lymphoblastoid human cell lines EBV(+) is associated to chronic hepatitis in a minority of inoculated Nu/Nu mice. J Med Virol. 2002;66:70-81.
|Tugizov SM, Berline JW, Palefsky JM. Epstein-Barr virus infection of polarized tongue and nasopharyngeal epithelial cells. Nat Med. 2003;9:307-314.
|Kondo T, Suda T, Fukuyama H, Adachi M, Nagata S. Essential roles of the Fas ligand in the development of hepatitis. Nat Med. 1997;3:409-413.
|Küsters S, Gantner F, Künstle G, Tiegs G. Interferon gamma plays a critical role in T cell-dependent liver injury in mice initiated by concanavalin A. Gastroenterology. 1996;111:462-471.
|Bradham CA, Plümpe J, Manns MP, Brenner DA, Trautwein C. Mechanisms of hepatic toxicity. I. TNF-induced liver injury. Am J Physiol. 1998;275:G387-G392.
|Mehal WZ, Juedes AE, Crispe IN. Selective retention of activated CD8+ T cells by the normal liver. J Immunol. 1999;163:3202-3210.
|Drebber U, Kasper HU, Krupacz J, Haferkamp K, Kern MA, Steffen HM, Quasdorff M, Zur Hausen A, Odenthal M, Dienes HP. The role of Epstein-Barr virus in acute and chronic hepatitis. J Hepatol. 2006;44:879-885.
|Petrova M, Muhtarova M, Nikolova M, Magaev S, Taskov H, Nikolovska D, Krastev Z. Chronic Epstein-Barr virus-related hepatitis in immunocompetent patients. World J Gastroenterol. 2006;12:5711-5716.
|van Baarle D, Tsegaye A, Miedema F, Akbar A. Significance of senescence for virus-specific memory T cell responses: rapid ageing during chronic stimulation of the immune system. Immunol Lett. 2005;97:19-29.
|Dunne PJ, Faint JM, Gudgeon NH, Fletcher JM, Plunkett FJ, Soares MV, Hislop AD, Annels NE, Rickinson AB, Salmon M. Epstein-Barr virus-specific CD8(+) T cells that re-express CD45RA are apoptosis-resistant memory cells that retain replicative potential. Blood. 2002;100:933-940.
|Wills MR, Okecha G, Weekes MP, Gandhi MK, Sissons PJ, Carmichael AJ. Identification of naive or antigen-experienced human CD8(+) T cells by expression of costimulation and chemokine receptors: analysis of the human cytomegalovirus-specific CD8(+) T cell response. J Immunol. 2002;168:5455-5464.
|Randhawa PS, Markin RS, Starzl TE, Demetris AJ. Epstein-Barr virus-associated syndromes in immunosuppressed liver transplant recipients. Clinical profile and recognition on routine allograft biopsy. Am J Surg Pathol. 1990;14:538-547.
|Holmes RD, Sokol RJ. Epstein-Barr virus and post-transplant lymphoproliferative disease. Pediatr Transplant. 2002;6:456-464.
|McDiarmid SV. Management of the pediatric liver transplant patient. Liver Transpl. 2001;7:S77-S86.
|Smets F, Sokal EM. Epstein-Barr virus-related lymphoproliferation in children after liver transplant: role of immunity, diagnosis, and management. Pediatr Transplant. 2002;6:280-287.
|D'Antiga L, Del Rizzo M, Mengoli C, Cillo U, Guariso G, Zancan L. Sustained Epstein-Barr virus detection in paediatric liver transplantation. Insights into the occurrence of late PTLD. Liver Transpl. 2007;13:343-348.
|Thorley-Lawson DA, Gross A. Persistence of the Epstein-Barr virus and the origins of associated lymphomas. N Engl J Med. 2004;350:1328-1337.
|Sugawara Y, Makuuchi M, Takada K. Detection of Epstein-Barr virus DNA in hepatocellular carcinoma tissues from hepatitis C-positive patients. Scand J Gastroenterol. 2000;35:981-984.
|Sugawara Y, Mizugaki Y, Uchida T, Torii T, Imai S, Makuuchi M, Takada K. Detection of Epstein-Barr virus (EBV) in hepatocellular carcinoma tissue: a novel EBV latency characterized by the absence of EBV-encoded small RNA expression. Virology. 1999;256:196-202.
|Li W, Wu BA, Zeng YM, Chen GC, Li XX, Chen JT, Guo YW, Li MH, Zeng Y. Epstein-Barr virus in hepatocellular carcinogenesis. World J Gastroenterol. 2004;10:3409-3413.
|Akhter S, Liu H, Prabhu R, DeLucca C, Bastian F, Garry RF, Schwartz M, Thung SN, Dash S. Epstein-Barr virus and human hepatocellular carcinoma. Cancer Lett. 2003;192:49-57.
|zur Hausen A, van Beek J, Bloemena E, ten Kate FJ, Meijer CJ, van den Brule AJ. No role for Epstein-Barr virus in Dutch hepatocellular carcinoma: a study at the DNA, RNA and protein levels. J Gen Virol. 2003;84:1863-1869.
|Chen H, Smith P, Ambinder RF, Hayward SD. Expression of Epstein-Barr virus BamHI-A rightward transcripts in latently infected B cells from peripheral blood. Blood. 1999;93:3026-3032.


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sexual beauty or physical attraction v's attraction of inner beauty or emotions? what is more important? a blend of both? what are your views?
Most Helpful Girl
To be honest, I've never fully trusted extremely good looking people. I do know it's more about ME than them, but I've always been afraid to try for something that was desired by others. I hate competition and pretty much just went with what I made me most comfortable.
I'm a personality person. I can't tell you how many times I've met a guy and there was zero attraction until I got to know him. After that, he was the best looking man I ever saw.
I've met women like that as well, how they looked so plain at first glance, but after a fantastic conversation the glow of her inner beauty overtook her external features. And she was the most beautiful woman in the room.
I look at beautiful people, how can you not notice perfection? But I am drawn to people with personality more.
And I just wanted to add, I have met devastatingly beautiful people with wonderful personalities, but it's their good looks that intimidate me.00|00|0

subset: commoncrawl


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From early as I can remember I have heard the story of an ancestor with our maiden name "Groves" that was born a slave. He was freed as a result of the emancipation proclamation as a small child. As a young man he worked as a sharecropper eventually becoming successful enough to farm his own land. Junius Groves a very rich man and was so popular farming potatos he became known as the "Potato King" of Kansas.
While I was in college my mother located her relatives still living on the land that Junius farmed years ago. She met half brothers and sisters that she heard about as a child but never had a chance to meet. My mother died the year I graduated college and we buried her in Junius Groves family cemetary.
Six years later I googled Junius Groves name and found a picture of him in Booker T Washington's book about The Negro in Business. It was amazing to see the man I have heard about from childhood come to life right before my eyes. My mother's stories were very accurate and as a result Booker T. Washington was very interested in his success.
About 6 months later I googled Junius again and found a picture of Junius and his wife. I'm still not sure if Junius Groves is a uncle of my grandfather or dad. I hear conflicting stories from family members.
Hearing this story about an ancestor building the "American Dream" right out of slavery gives me a sense of pride, belonging, and importance that I might not have had if my mother did not keep her father's stories alive. As a result I understand the importance of sharing my personal and family history with my own children and have the desire to seek out more of my family heritage.
Major corporate funding for African American Lives 2 and its outreach initiatives is provided by The Coca-Cola Company and Johnson & Johnson. Additional corporate funding is provided by Buick.


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This article describes how to symbolically debug non-Language Environment® (LE) assembler applications running on z/OS®. When LE is not active, you can debug only assembler, disassembly, or OS/VS COBOL programs because debugging programs written in other languages requires an active LE.
The article is intended for application programmers who are familiar with Eclipse, Rational® Developer for System z®, and assembler. You also need a rudimentary understanding of job control language (JCL) and JCL procedures.
This article explains how to write an assembler program, build the executable, and symbolically debug the assembler application using Rational Developer for System z V7.5 and Debug Tool V9.1 when LE is not active. When symbolically debugging the assembler application, you can view and change the values of the variables within the assembler application using the names of the variables, animate the step-by-step execution of the assembler routine while viewing the assembler listing file, and establish breakpoints within the assembler listing file.
|Article in PDF format
- developerWorks WebSphere on System z zone
- High Level Assembler and Toolkit Feature
- Rational Application Developer for WebSphere Software technical resources
- Rational Developer for System z technical resources
- Rational Developer for System z online demos
- Techdocs: Managing Language Environment Options in WebSphere for z/OS Servers
- Debug Tool for z/OS


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Asian Development Outlook 2010
Has developing Asia's rebound from the global economic crisis taken a firm hold? ??Is the pace of global growth solid enough for Asia to unwind its economic stimulus? What threats are emerging within the region, and among its major trading partners in the U.S., Europe, and Japan, that could thwart the region's recovery? How should policy makers confront these challenges?
Jong-Wha Lee, Chief Economist of the Asian Development Bank, will address these issues and others at the launch of the Asian Development Outlook 2010 (ADO), ADB's flagship economic publication. It includes comprehensive economic analysis of more than 40 economies in developing Asia and the Pacific. The ADO examines the medium-term prospects for developing Asia, by country and by sub region'East Asia, Southeast Asia, South Asia, Central, and West Asia and the Pacific.
This year's ADO special theme chapter, "Macroeconomic Management Beyond The Crisis," explores how authorities in developing Asia can effectively manage their macroeconomic policies for sustained growth in the aftermath of the global financial crisis and economic downturn. The chapter will touch on issues such as monetary policy frameworks, exchange rate regimes, fiscal sustainability, and the use of macroeconomic policy tools to help rebalance the region's growth.
Jong-Wha Lee is the Chief Economist of the Asian Development Bank. He is the chief spokesperson for ADB on economic forecasts and trends, and oversees the Economics and Research Department (ERD). ERD does economics and policy research and capacity building, supports ADB operations, and networks with the international research community. He worked as Economist at the International Monetary Fund and taught at Harvard University as a Visiting Professor. Dr. Lee served as a consultant to the Harvard Institute for International Development, the Inter-American Development Bank, the International Monetary Fund, the United Nations Development Programme, and the World Bank. Dr. Lee also was a member of the National Economic Advisory Council in the Republic of Korea. Dr. Lee, a national of the Republic of Korea, obtained his Ph.D. and Master's degree in Economics from Harvard University, and his Master's and Bachelor degrees in Economics from Korea University in Seoul.
Registration: 6:00 - 6:30 pm
Program: 6:30 - 8:00 pm
Reception: 8:00 - 9:00 pm
Please note: this event will also be a free live video webcast from 6:30 to 8:00 pm ET on AsiaSociety.org. Online viewers are encouraged to submit their questions to [email protected].
Event Details
725 Park Avenue, New York, NY


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Beccles Black Boy
also traded as as: Black Boyshistorical era: late 20th century
closed 1991
last owner Steward & Patteson (Watneys)
grid reference TM 425 899Something we've got wrong about this establishment? Something more you think we should know about it? Please email us
View in Google Earth
CAMRA North-East Suffolk branch.
last updated 17/06/2017
Since closure it has been demolished for new housing.
The pub can be seen here on the 1883 OS map (it's named on the 1884 Town Plan).
The main picture was shared with us by David Wallace who was pictured in the Beccles and Bungay Journal in April 1971 when he was repainting the exterior of the pub. Described in the paper as "a hazardous business because the public house stands flush with a sharp bend on the busy Lowestoft-Beccles main road." Many thanks to David for sharing this image with us.
(Most pub, location & historic details collated by Nigel, Tony or Keith - original sources are credited)
(some old PO directory information courtesy of londonpublichouse.com)
(** historic newspaper information from Bob Mitchell)


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"Tears of the North" garnered a two-digit ratings percentage despite the fact that it was a re-run.
According to AGB Nielsen Media Research on January 2nd, "Encore – Tears of the North" rated 12%.
This days broadcast was controversial as the role of the Japanese Ocean Defense Forces had been edited out.
"Tears of the North" is the final of the "Tears" series and the first part will be shown on the January 6th.
Source : news.nate.com/view/20...Copy & paste guideline for this article
"Re-runs of "Tears of the North" score a 12% rating"
by HanCinema is licensed under a Creative Commons Attribution-Share Alike 3.0 Unported License.
Based on a work from this source
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Lee Min-ho, the only actor in his 20s nominated for the SBS Grand Prize
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Micky Yuchun "It's a hard time to receive this
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Today's birthdays
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Card Name: Genesis Wave
Mana Cost: {X}{G}{G}{G}
Colors: Green
Type: Sorcery
Types: Sorcery
Rarity: Rare
Artist: James Paick
Number: 122
Power / Toughness: /
Card Text
Reveal the top X cards of your library. You may put any number of permanent cards with converted mana cost X or less from among them onto the battlefield. Then put all cards revealed this way that weren't put onto the battlefield into your graveyard.
Near Mint Condition
A card in Near Mint condition shows minimal to no wear from shuffling or general play. Cards classified as Near Mint/Mint are generally indistinguishable from cards in an unsleeved deck of other Near Mint/Mint cards. Foils in this condition have little or no scuffing or clouding on the front and edges of the card.
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STARmeterSEE RANK
Up 311,962 this week
Margara Alonso (1928–2006)
Margara Alonso was born in 1928 in Argentina. She was an actress, known for Cien años de perdón (2000), Cautiva (2003) and Yepeto (1999). She died on June 21, 2006 in Buenos Aires, Argentina. See full bio »
Born:in Argentina
Died:(age 78) in Buenos Aires, Argentina


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Federal Style House PlansSeptember 25th, 2010
Usually built as a two story wood frame box-like house, linear floor plan, one room deep. Fortunately, New York architects used the Federal style for row houses The typical row house of the period worked on a basic plan. What did Federal Style houses really look like? A local funeral home will now start serving Starbucks coffee. Find a large selection of Adam – Federal House Plans and Designs at BuilderHousePlans. This Federal-style home plan is beautiful in its simplicity, with lintels above the windows and a row of dormers lining the side-gabled roof. Federal colonial architecture and Adam house plans defined by colonial style features and design. Adam-Federal house plans have their origins in the classical formality of the post-colonial period.
Federal Style House Plans
- Buy Simplicity in a Federal Style Home Plan House Plans at ArchitecturalDesigns.
- com – We have over 15,000 home plans from many leading architects.
- Federal Style We found 94 listings Save this Search.
- New Search Wonderful 1825 Federal Home on the National Register.
- Construction Plans for Federal Style: Mantels.
- Search for Colonial house plans and Colonial style home floor plans with our user-friendly search engine.
More information about Federal Style House Plans on the site: http://www.thehousedesigners.com


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Archinect - News 2017-08-17T00:03:17-04:00 http://archinect.com/news/article/47064911/frank-gehry-s-tiffany-chess-set-is-a-miniature-architectural-marvel Frank Gehry's Tiffany Chess Set Is a Miniature Architectural Marvel Archinect 2012-05-02T15:42:00-04:00 >2012-05-10T21:19:28-04:00
... instead of drawing his inspiration from buildings in his portfolio, Gehry designed the various pieces of this chess set based on their role in the game. So the soft curves of the queen contrast the sharp angles of the king, while the pawns have all been equipped with cannons atop them. Unfortunately the set, which is made from fine bone-china, is only available from Tiffany & Co. as a special order for a staggering $25,000. A check-mate to the bank account for most of us.

<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN" "http://www.w3.org/TR/REC-html40/loose.dtd"> <meta>


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Male - 1959/04/26
•Lighting/cinematography department •Production department •Assistant director •Original idea •Producer •Director •Scriptwriter
In 1980, KIM went to study in Japan while he was a student at the Seoul Institute of the Arts, Department of Film. He completed his courses at the Japan Academy of Moving Images in 1986, and went on to produce commercials and TV programs in Japan, Australia and Hong Kong. He made his big screen debut as assistant director in < Kazoku Cinema > (1998, directed by PARK Chul-soo). His short film, 32nd DEC.: Where is Mr. President? (2002), was invited to the 53rd Berlin International Film Festival. < Driving with My Wifes Lover > is KIMs feature film directorial debut
Source Open the link
Red Vacance Black Wedding DVD JP (No En Sub) (En Sub)
Tokyo Taxi DVD (En Sub)
Driving With My Wife's Lover DVD Limited Edition (En Sub)
View all 12 pictures for Kim Tae-sik
Tokyo Taxi
(Movie, 2009)
도쿄택시 - 東京タクシー
Heartbreak Hotel
(Movie, 2014)
태양을 쏴라
Red Vacance Black Wedding
(Movie, 2011)
붉은 바캉스 검은 웨딩
Tokyo Taxi
(Movie, 2009)
도쿄택시 - 東京タクシー
Driving With My Wife's Lover
(Movie, 2006)
아내의 애인을 만나다
Tokyo Taxi
(Movie, 2009)
도쿄택시 - 東京タクシー
Driving With My Wife's Lover
(Movie, 2006)
아내의 애인을 만나다
White Day Special Video
Official Trailer
Teaser Trailer
Long Trailer
Ryoo Seung-wan Recommendation
Special Music Video
30s Trailer
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Digital Props - 16x20 Backdrops - Storm Clouds
$ 19.99
The Newest addition to our Ashe Design Products: Digital Props - Backgrounds. Each Set comes with (3) different 16x20 Backdrops. Just follow the (3) Simple Steps below to create a scene for all your outdoor photos in just minutes.
1.) Cut out subject from your photo (view video).
2.) Choose your backdrop.
3.) Add your own shadows using a soft black brush.


text:
|Front Page | In-depth | UK Politics | The Tory leadership contest
Or compare other:
Ancram on Ancram
"I must admit that when William Hague invited me to take on this job I knew that I had to be a little mad to accept it."
"I want to be able to be proud of my country without being told that I am politically incorrect. I want to be proud of a country where freedom matters again, where the rule of law matters again, where responsibility counts for something again, and where we do the right thing because it is right."
"I have called my campaign 'One Party, One Nation'. That is the theme upon which I seek election as leader."
"To talk blandly about four wasted years is a real insult to all those who carried the Conservative standard at the last election on a number of policy areas on which I hope we can build."
Others on Ancram
"Michael Ancram is charming, sensible, honest and a true blue toff"
"Mr Ancram wants to come in as a unity candidate. He's neither one thing nor the other. He wants to be all things to all men."
Peter Mandelson MP
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UA, Tuscaloosa Officials to Commemorate Completion of Bryant Drive Project Nov. 25
TUSCALOOSA, Ala – The University of Alabama and the City of Tuscaloosa will commemorate the completion of the Bryant Drive road project with a rededication ceremony Tuesday, Nov. 25 at 10 a.m. on the south side of Bryant-Denny Stadium.
Featured speakers for the event will include UA President Robert E. Witt, Tuscaloosa Mayor Walt Maddox, UA Athletic Director Mal Moore and Tuscaloosa councilman Lee Garrison.
The Bryant Drive project, begun in September 2006, was divided into two projects, Phase 1 from Hackberry Lane to Queen City Avenue and Phase 2 from Queen City Avenue to 25th Avenue.
Construction on Phase 1 consisted of widening improvements from 2 lanes to 3 lanes on a portion of Bryant Drive, with landscaping and relocation of overhead utility lines to underground locations. Bryant Drive, in the Phase 2 portion, was narrowed from 4 lanes to 3 lanes, with the emphasis placed on heavy landscaping and also relocating overhead utilities to underground locations.
The general public is invited to the event. Those attending are asked to park at Calvary Baptist Church. In case of inclement weather, the ceremony will be held in The Zone at Bryant-Denny Stadium.
For more information, please contact Joe Robinson at 349-0245, firstname.lastname@example.com or Emily Jamison at 348-1723, email@example.com
The University of Alabama, a student-centered research university, is experiencing significant growth in both enrollment and academic quality. This growth, which is positively impacting the campus and the state's economy, is in keeping with UA's vision to be the university of choice for the best and brightest students. UA, the state's flagship university, is an academic community united in its commitment to enhancing the quality of life for all Alabamians.
- CONTACT: Suzanne Dowling, UA Media Relations, 205/348-8324, email@example.com
- SOURCE: Joe Robinson, City of Tuscaloosa, 205/349-0245, firstname.lastname@example.com
Emily Jamison, director of UA events, 205/ 348-1723, firstname.lastname@example.com


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Jessica's Style Diary: Thursday
What I'm Wearing Today:
- Forever 21 gray dress
- fake patent leather belt from Windmere
- leggings from ?
- boots from Baker's
- J.Crew sparkly headband
- Banana Republic bangles
I don't have much to say about my outfit today, other than this dress is awesome and I wish I had it in colors other than gray. But can we talk about short hair for a sec?
After a boy-related heartbreak last March, I chopped off my long hair for a chin-length 'do. I happily rocked the cute things you can do with short hair for 10 months—barrettes! hair bands! butterfly clips!—but by now I'm over it. My ears are cold! Give me my ponytail back, please. But, as those of you who've cut your hair short know, you go through this "shaggy" phase in between short hair and shoulder-length hair. Luckily, I've amassed an epic collection of hair doodads to de-escalate the situation. The bejeweled J.Crew headband (which probably cost, like, $30—I must be insane to shop at that store!) that I am wearing today is just one of about a dozen headbands that I have. I think it kinda gives my hair a little Betty Draper flip, don't you think?
If anyone else has growing-out-your-hair tips, please share!


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Wyoming's Jackson Hole Mountain Resort is offering a fourth airline ticket free this winter. Their Fourth Flies Free program provides a fourth air ticket free for up to $500 travel credit for the 2009-10 ski season.
The Fourth Flies Free credit is valid on any of the three major U.S. carriers that fly daily to Jackson Hole. Flights arrive nonstop from eight cities, including Chicago, Dallas, Denver, Minneapolis, and Salt Lake City.
"The 4th Flies Free program is an incredible plus for our customers," states Jackson Hole Mountain Resort Brand Director, Anna Olson. "With the launch of the new tram, our legendary "cowboy" powder, personalized customer service, and a free airline ticket, we're giving potential visitors every reason to make Jackson Hole their first-choice winter destination this year."
The Fourth Flies Free program is available to those visitors who purchase at least five nights of lodging and a three-day lift ticket to Jackson Hole Mountain Resort for each traveler. The program is limited to eight people per group.
The program is available for new reservations only, but it is valid all season long. Reservations, however, must be booked by Jan. 1, 2010.
Blackout dates include the Christmas holidays. Valid dates of travel this winter for the program include Nov. 28 - Dec. 18 and Jan. 3 - April 4.
More information. Or call 888-838-6660.


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Creative Director
Lead Engineer
Front End Developer
Project Manager
We're hiring developers!Come work with us
Great design inspires faith and trust. We visually tell stories with space, line, color, and type, seamlessly guiding customers to engage again and again.
Building for the future is a core facet of everything we do. Starting with fully custom, responsive front-end code, we then choose the latest cutting-edge backend frameworks on a per-project basis.
More than any medium in history, the web has brought us an unparalleled ability to measure. We measure everything utilizing analytics, goal tracking, heat mapping, and more. We continually optimize to reach and exceed your goals.


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- 1 Welcome...
- 2 Experiences Of Previous Incomings...
- 3 Local IFMSA Team
- 4 Trujillo
- 5 Climate
- 6 Brief History
- 7 About the Health Care System in La Libertad
- 8 The Hospitals
- 9 About our Medical Education and School
- 10 Professional Exchange
- 11 Accomodation and Boarding
- 12 How to get to Trujillo?
- 13 Urban Transport
- 14 Cultural Aspects
- 15 Tourism and entertainment activities
- 16 Don't forget!
- 17 Useful Phone Numbers
- 18 Contacts
- 19 Photo Gallery
The LC IFMSA Trujillo UNT looks forward to meet you in Trujillo, the city known as the City of Eternal Spring!
Are you ready for a clash of modern lifestyle and cultural heritage?
Are you ready to meet the God Ai-apaec?
Are you ready to discover the biggest mud city of the world?
Are you ready for dancing Marinera?
Pack your bag and fasten seatbelt for the Experience Trujillo!
Experiences Of Previous Incomings...
"Muchas gracias por todo: rotación, comida, actividades, alojamiento y comite local"
Marion DE ROSA - Clermont-Ferrand/France
July 25th, 2009
"Comité local muy motivado, alumnos simpáticos, ciudad y región interesantes. Gracias al equipo"
Julien BAUDENON - Clermont-Ferrand/France
July 25th, 2009
Convincing? So do not hesitate to experience this vibrating city!
Local IFMSA Team
We are an enthusiastic and motivated team of students ready and willing to get to know you!
¡¡¡ Bienvenidos a Trujillo, Perú !!!
Bienvenue à Trujillo, Pérou!!!
Bem-vindos a Trujillo, Peru!!!
Willkommen in Trujillo, Peru!!!
Trujillo, in northwestern Peru, is the capital of the La Libertad Region, and the third largest city in Peru. The urban area has 811,979 inhabitants and is an economic hub in northern Peru. The city is located at the banks of the Moche River, near its mouth on the Pacific Ocean, in a valley of great cultural hegemony. The Roman Catholic Archdiocese of Trujillo has its seat here.
Trujillo is a city with a vast cultural wealth, as an example: The Chimu Culture. The Chimu Kingdom, with Chan Chan as its capital, reached its apogee in the 15th century, not long before falling to the Incas. The planning of this huge city, the largest in pre-Columbian America, reflects a strict political and social strategy, marked by the city's division into nine 'citadels' or 'palaces' forming autonomous units.
This center represents the largest prehistoric earthen city of pre-Hispanic America. It was declared a World Heritage Site by UNESCO in 1986.
Trujillo is characterized by its semi-arid climate with an average temperature of 21°C. The summers can reach temperatures over 32°C and the winters are never colder than 14°C. Most of the year, the temperature stays in the low to mid twenties. Trujillo is known as "The City of Eternal Spring" (La Ciudad de la Eterna Primavera), because of its very sunny and pleasant weather year-round. The International Spring Festival in early October attracts visitors from all over Peru and from all over the world.
Brief History
Trujillo was one of the first cities founded by Spanish conquerors in America. On December 6, 1534, Diego de Almagro founded the city under the name of "Villa Trujillo," in honour of Francisco Pizarro's birthplace, Trujillo in Extremadura, Spain. On 23 November 1537, King Charles I of Spain gave it the rank of 'city' and the coat of arms that remains a symbol for the city. It was founded among four Chimu settlements (Huanchaco, Huamán, Moche & Mampuesto), so they could ally against the Incas.
In 1619, an earthquake destroyed the city. Years later, in 1624, a new period surge started with the rebuildings of palaces and the opening of the seminary and the school of the Jesuits.
Among 1685 and 1687, given the opulence of Trujillo, and due to the incursions of the pirates, the city was walled for its protection, and this enclosure constitutes today the historical center where the old large houses of exquisite gates, the convents and churches, squares and streets like witness of its old stock stand out, of a severe and elegant, colonial and republican city where the luxury was something common.
The city played a significant role in the struggle against a complete Spanish rule. It was the first important city of Peru that proclaimed its independence of Spain on 1820, serving as temporary capital of Peru in 1825, and was the main headquarters for Simon Bolívar.
Nowadays the city, just eight hours north of Lima along the Panamerican Highway, looks every bit the oasis it is, standing in a relatively green, irrigated valley bounded by arid desert at the foot of the brown Andes mountains. It hardly seems a city of nearly a million inhabitants – walk twenty minutes in any direction and you're out in open fields, hedged by flowering shrubs.
About the Health Care System in La Libertad
The Ministry of Health maintains the mission to protect the personal dignity, promoting health, preventing disease and ensuring health care for all inhabitants of the country. Additionally, it formulates public health policy guidelines in consultation with all government sectors and social actors. The person is the center of its mission, and it's dedicated to them with respect for life and fundamental rights of all Peruvians, since before his birth, and respecting the natural course of his life.
The health of Peruvians will be an expression of important socio-economic development, strengthening democracy of rights and responsibilities of citizens based on the expansion of sources of stable formal employment and education in the values-oriented person, solidarity and in establishing mechanisms for equitable access to health services through a coordinated and decentralized national system of health, developing a national health policy to collect and integrate the contributions of traditional medicine and the various cultural manifestations of our population.
Motto: "People who attends people"
More information: http://www.minsa.gob.pe/
MINSA establishments are managed by the Regional Health Management of La Libertad, located in Las Esmeraldas Street # 403.
It has the vision to contribute to human development with social justice, creating healthy environments, better health of the population policies of state and decentralized health and increasing the rights and duties of in health care.
It is the technical arm of the Regional Government of La Libertad, responsible for implementing national policies and regional health within their territory, to improve the health of the population, is responsible for generating the through proper care of the people and the environment, ensuring universal driving sector, promoting the rights and duties in public health with emphasis on the health of the home and community.
More information: http://www.diresalalibertad.gob.pe/
HEALTH SOCIAL SECURITY OF PERU – EsSalud
Health Social Security of Peru (EsSalud) is a decentralized public agency whose vision is geared to generate a service focused on the insured that exceeds their expectations and improve their welfare.
EsSalud aims to provide coverage to policyholders through the granting of benefits of prevention, promotion, recovery and rehabilitation of health, economic and social benefits that relate to the contributory scheme of social security in health and other insurance risks human. EsSalud is a health social insurance that provides comprehensive care with quality, warmth and efficiency to maintain their health insurance.
Motto: "More Health for more Peruvians"
More information: http://www.essalud.gob.pe/
The Hospitals
IFMSA Peru, through their local committee Trujillo UNT, realizes professional exchanges through the network of hospitals affiliated to Medical School of the National University of Trujillo. There are currently:
Hospital Regional Docente de Trujillo – HRDT / MINSA
Hospital Regional Docente de Trujillo is an institution aimed at preventing risks, protect from harm, restore health and restore the capacity of patients with full accessibility and attention to the person from conception until natural death. It is a center of medical and paramedical training at the Universidad Nacional de Trujillo (UNT), Universidad Privada Antenor Orrego (UPAO) and Universidad Privada César Vallejo (UCV). Hospital Regional Docente de Trujillo hopes to become in 2013 in a tertiary hospital care, with all the capacity, and proven leader in the country's health system, providing highly specialized quality services that meet the rigorous health needs of its users.
Address: Av. Mansiche # 795, Trujillo, La Libertad.
More information: http://www.hrdt.com.pe
Hospital Belén de Trujillo – HBT / MINSA
Hospital Belén de Trujillo maintains the mission to provide medical care and health specialist and comprehensive manner, with quality, equity, efficiency and respecting the autonomy of users. Its functions are achieve health recovery and rehabilitation of patients' ability in terms of opportunity, equity, quality and fully accessible, in outpatients, hospitalization and emergency defending life and protecting the health of the person from conception to natural death, to achieve the prevention and reduction of risk and harm to health, to support the training and specialization of human resources, allocating and clinical staff for teaching and research by the Universities and Institutes, according to the respective conventions, managing human resources, material and financial resources to the economic achievement of the mission and objectives in compliance with existing standards and continuously improve quality, productivity, efficiency and effectiveness of health care setting standards and parameters required as well as creating an organizational culture with values and attitudes towards the needs and expectations of the patient and their family.
Address: Jr. Bolívar # 350, Trujillo, La Libertad.
About our Medical Education and School
The history of our Faculty can be divided in two periods. The first one begins in 1831 when Medicine was included in the "Chairs Plan" of the National University of Trujillo. The second one began in 1935 with the foundation of Pre-Medics Section in order to prepare students who would continue their studies at San Fernando Faculty of Medicine in Lima, along with students from Lima and Arequipa Pre-Medics Sections. However, in 1958 was founded our Faculty of Medicine with his own academic staff and studies' plan. When founded, our Faculty had some of the best national doctors as professors and some of international reconnaissance. Many students have achieved national and international reconnaissance too. In 1965, the Nursery School and the Second Specialization Program were created. In 1988, the Stomatology School was opened and some years later, the Nursery School converted in an independent Faculty. Now, our Faculty includes the Medical School, the Stomatology School and the Second Specialization Program. At the Medical School we have 7 years of Medical studies.
After that we must work one year for Government in rural or emergent urban locations as payment for our education (this service is known as SERUM).
Then we can apply to the National Exam of Medicine (ENAM, by its acronym in Spanish) in order to enter to a residence program (specialization).
Several studies plans were implemented along the years as a search of academic excellence and social consciousness. In these days the Faculty of Medicine of the National University of Trujillo has two studies programs together, as each new program is implemented for new students. The most recent program was implemented since 2008. So Second Year and First Year of studies follow the "New Program" and the other years (Third to Seventh) has the "Old Program". The "Old Program" aspires to a Scientific and Humanistic Physician with Management knowledge, while the "New Program" is based in a sociocognitive paradigm with an interdisciplinary approach and emphasizes formation in Investigation, Ethics and Medical Scientific knowledge.
"Old Program"
It considers four stages: Propaedeutic (First Year), Basics (Second and Third Years), Clinics (Fourth to Sixth Years) and Internship (Seventh Year). Courses are distributed as follows.
First Year: Molecular Biology, Chemistry, Biophysics, Math, Logic, Science Philosophy and Scientific Investigation Methodology, English, Health and Community I, Psychology, Computing, Spanish, Anatomic Design I and Musical Appreciation I
Second Year: Integrated Morphology (includes Embryology, Medical Genetics, Histology, Anatomy and Neuroanatomy), Biostatistics, Health and Community II, Sociology, Medical Psychology, Anatomic Design II and Musical Appreciation II
Third Year: Physiology, Biochemistry, Anthropology, Health and Community III, Microbiology and Parasitology, Basic Pharmacology, Ecology, Medicine History and Investigation Projects
Fourth Year: Medicine I, Clinical Laboratory, Pathology, Epidemiology, Diagnostic Imaging and Ethics.
Fifth Year: Medicine II, Neurology, Surgery I, Pediatrics I, Clinical Pharmacology and Administration in Health
Sixth Year: Medicine III, Psychiatry, Surgery II, Pediatrics II, Gynecology and Obstetrics, Management in Public Health and Legal Medicine
Seventh Year: Rotary Internship (Medicine, Surgery, Gynecology/Obstetrics and Pediatrics)
"New Program"
It considers four areas: Propaedeutic, Scientific-Professional, Investigation and Pre Professional Practice.
Propaedeutic Area
First Year: Ethics I, Psychology, Spanish, Anthropology and Public Health I
Second Year: Ethics II, Medical Psychology II and Public Health II
Third Year: Ethics III and Public Health III
Fourth Year: Ethics IV, Human Nutrition and Public Health IV
Fifth Year: Ethics V and Public Health IV
Sixth Year: Ethics, Deontology and Legal Medicine and Public Health VI
Scientific-Professional Area
First Year: Math, Chemistry, Biophysics, Molecular Biology, Embryology and Medical Genetics
Second Year: Histology, Anatomy and Immunology
Third Year: Physiology and Physiopathology, Biochemistry, Microbiology and Parasitology and Basic Pharmacology
Fourth Year: Medicine I, Imaging, Pathology and Laboratory
Fifth Year: Medicine II, Neurology, Surgery I, Pediatrics I, Gynecology and Obstetrics I and Clinical Pharmacology
Sixth Year: Medicine III, Psychiatry, Surgery II, Pediatrics II, Gynecology and Obstetrics II and Collaborative Actualization
Investigation Area
First Year: Investigation in Medicine I, Biostatistics I and English I
Second Year: Investigation in Medicine II, Biostatistics II and English II
Third Year: Investigation in Medicine III and English III
Fourth Year: Investigation in Medicine IV
Fifth Year: Investigation in Medicine V
Sixth Year: Investigation in Medicine VI
Pre Professional Practice Area
Seventh Year: Rotary Internship (Medicine, Surgery, Gynecology/Obstetrics and Pediatrics)
Professional Exchange
If you really want to learn more about the health care system and medical education in Trujillo, you can benefit a lot from a clerkship here. The most important thing is the readiness to learn and also to support the team on ward.
What else should you know before starting a clerkship in Trujillo?
Equipment & Language
Remember to bring your own white coat, and a stethoscope.
For the department of Surgery and Gynecology/Obstetrics you will also need your own scrubs.
Spanish is the language spoken by medical staff and patients. For an ideal stay you should have some basic knowledge and understand Spanish.
Vaccination & Health Certificate
To make this less complicated please go to the company doctor of your hometown faculty in advance and bring a certificate for the following required things:For all positions:
- You must bring a copy of your vaccination card, which includes: Vaccination for Yellow Fever, Hepatitis A, Hepatitis B, Influenza and Pneumococcus
- Medical attestation from a general/treating physician about your physical fitness.
The following department can only be offered for students who are profficient in Trujillo:
- Medicine
- Surgery
- Pediatrics
- Gynecology & Obstetrics
Working on ward
Normally you will start working at 8:00 a.m. This means that you will be at the hospital at 7:45 a.m. Sometimes, the wards start the morning with a conference where they discuss the most important clinic case of the day. Those sessions are very informative, you should try to join them. You will get a doctor who will guide you most of the time.
Most of the time nobody will tell you when you are allowed to leave. As there are unfortunately not enough employees on ward doctors often forget that you are a student. If time is running out, you should remind the doctors that you would like to go home. The expected working time varies depending on the hospital and ward, but most of the time 4 h in the morning and 3 h in the afternoon are appropriate.
Please remember: We expect all incomings to take their clerkship seriously and to behave accordingly! This means, if you apply for 4 weeks you will have to work 4 weeks!
Accomodation and Boarding
You will stay with a UNT medical student during the time of your clerkship. We try to organize houses or apparmtents near to the hospital you are going to work in, which is not always that easy.
We recommend incoming students to arrive 2 or 3 days before their clerkship starts to get settled and learn how to move around Trujillo without getting lost.
Regard that sometimes there are special conditions concerning the room in which you will stay. We will tell you about this in your CA.
For further details ask to your contact person.
The meal will be provided daily by contact person.
How to get to Trujillo?
When arriving to Peru from abroad you will have to do it through Lima. Then take your connection by plane or bus to the Trujillo City.
By Air
Trujillo City have the "Capitán FAP Carlos Martínez Pinillos" Airport (TRU), located near Huanchaco at 13 km. (8 miles) northwest of the city. It is an airport of small facilities, comfortable, and prepared only for domestic flights.
From Trujillo: Usually daily flights to Lima (flights of 45 minutes), and there are also flights from/to Chiclayo, Cajamarca, Piura and Iquitos.
Airlines operating
LAN Peru More information: http://www.lan.com/index-es-pe.html
Over 2,726 passengers can travel out of Trujillo, PE every week. The longest flight from Trujillo, PE is 303 miles. The largest aircraft flying out of Trujillo, PE is a 32S with 124 seats. There are over 26 domestic flights per week from Trujillo, PE. Trujillo, PE has 26 flights departing per week for short haul destinations. Trujillo, PE connects with 2 cities nonstop. There are 2 nonstop flights per week departing from Trujillo, PE.
Taxis from the airport to the center of the city is around 8 nuevos soles.
By Bus
Trujillo is connected to the Pan-American Highway, being able to arrive through the north to Tumbes and Ecuador, and to the south passing through Lima to Tacna and Chile.
Cruz del Sur --> More information: http://www.cruzdelsur.com.pe/inicio.php
Oltursa --> More information: http://www.oltursa.com.pe/
Línea --> More information: http://www.transporteslinea.com.pe/
Vía --> More information: http://www.via.com.pe/
Distances to some cities from Trujillo:
Cajamarca: 182.7 miles (294 km), following the Pan-American Highway to the north 121 km until the deviation toward Cajamarca.
Chiclayo: 128 miles (206 km) is following the Pan-American Highway to the north.
Lima: 346 miles (557 km) is following the Pan-American Highway to the south.
Urban Transport
To mobilize around the perimeter of the Trujillo City, you can choose the public transport or taxis:
Public transport is cheaper than taxis; the cost is 1 nuevo sol. There are two lines of buses: "Virgen de la puerta" (B) and "Salaverry" (C). They follow a specific route that link the urbanizations (La Merced, San Andrés, San Nicolás, Primavera, and Las Quintanas) with Hospital Regional Docente de Trujillo (HRDT) and also with Medical Faculty of the National University of Trujillo (UNT).
Taxis, service only offered by units painted yellow, white or blue, are not very cheap and you should take into account the price before upload to the vehicle. The cost from the urbanizations to HRDT or Hospital Belén of Trujillo (HBT) is 4 nuevos soles. Near midnight the cost is 5 nuevos soles.
This is a list of reliable taxi companies:
New Takci S.R.L --> Phone number: (+51)-44-290494
ET Service --> Phone number: (+51)-44-223014
Mall Service --> Phone number: (+51)-44-702222
Notice that there is not public transport if you want to go to Belen Hospital, because this hospital is located on the Historic Center. In this area you just go by taxi.
Check how much value your money in: http://www.gocurrency.com/conversor-de-monedas.htm
Cultural Aspects
The people of Trujillo are characterized for been very friendly and talkative, we use to help tourists when they need some help or when they got lost! Just one example of how helpful the people are. You will feel our hospitality and our kindness, when you stayed here for a time.
We usually greet people giving one kiss or shaking the hands.
Some useful and short sentences are:
Spanish – English – Português – Deutsch
¡Hola! - Hello! - Oi! - Hallo!
¡Buenos días! - Good Morning! - Bom dia! - Guten Morgen!
¡Buenas tardes! - Good Afternoon! - Boa Tarde! - Guten Tag!
¡Buenas noches! - Good evening! – Boa Noite! – Guten Abend!
¿Qué hora es? - What time is it? – Que horas são? – Wie spät ist es?
Encantado de conocerte - Nice to meet you – Prazer em conheçê-lo - Es freut mich, Sie kennen zu lernen
Chau, nos vemos! - Bye, see you later! – Tchau, até mais! – Tschüss, bis bald!
La Libertad is known for the good flavor of its cuisine. It is said that 'good taste' is found in the north of the country, and that it is easy to prove. Moreover, there is not a restaurant or picantería that does not give a good serving of the dishes at reasonable prices.
In this part of the Coast, the different varieties of Cebiches (very hot) are outstanding, as well as Seco de Cabrito and Sangrecita.
The most famous Trujillo's dishes are:
Shambar: It's usually prepared on Monday. It's a soup that blends many ingredients, tastes, and seasonings from Spanish, Criollo and Andean cultures, considered the most traditional meal in Trujillo's gastronomy in Perú. It is made of wheat grains, fava beans, green peas, chickpeas and dry beans. It must have three kinds of meat, including chicken, ham, beef, and pork skin, ears or tail.
Cebiche: It's one of the main dishes in the peruvian coast and the flag of our cultures fusion. It contains andean peppers and sweet potato, coastal fishes, lime juice, onion and toasted corn, among others.
Theologian Soup (Sopa Teóloga): Chicken broth with soaking bread.
Beans to trujillana: Black beans with sesame and mirasol chili.
Pepián puranja: Stew turkey with rice and corn.
Meals: The important meals are: breakfast (7-9h), lunch (12.30-14.30h), and dinner (19.30-21.30h). But sometimes people have another 2 little meals: in the morning as a "second breakfast" (10-11h) and the "lonche" in the afternoon (17.30-18.30h).
Smoking: It's forbidden in public buildings except in the restaurants, bars and clubs with license.
Last Week in January: National Marinera Dance Festival. Hundreds of couples come from different parts of the country to participate in this traditional contest organized by the Libertad Club. The finals take place in the Gran Chimú Coliseum.
April 24: Beginning date of the Fiesta de Santo Toribio de Mogrovejo, patron of Tayabamba in Pataz. It lasts until May 1.
July 13: Anniversary of Santiago de Chuco, celebrated in the province that bears the same name, with regional fairs and great celebrations. It lasts until August 2.
July 29: Fiesta del Señor de la Caña, celebrated in Chiclín.
August 15: Fiesta de la Virgen de la Altagracia, also celebrated in Chiclín.
September 20 through 30: International Spring Festival. National and foreign artists participate. There are cockfights, gait horse contests, among other activities. It ends with a great parade with floats riding throughout the city.
December 15: Fiesta de la Virgen de la Puerta, celebrated in Otuzco. This is the greatest manifestation of religious faith in all the north of the country.
Tourism and entertainment activities
Main Square. In the central part is located the monument of Freedom, which represents the country's independence process. The statue was manufactured in France, the materials used are copper and marble, the sculptor was Edmund Moeller.
Cathedral. Built between the years 1647 and 1666, altars are Baroque and Rococo style. In the Cathedral we have the Cathedral Museum with works mainly of the religious colonial era in silver and gold.
Visits (Cathedral Museum): Mon to Sun 7:00-12:00 & 16:00-21:00
Colange Mansion (Urquiaga Mansion). Built with a neoclassical style, between the eighteenth and nineteenth centuries, Simón Bolívar stayed here. You can see the desktop used by Bolivar, gold ornaments from the Chimu culture, and their furniture.
Address: Jr. Pizarro 446.
Visits: Mon to Fri 9:30-15:00; Sat to Sun: 10:00-13:30
Mansion of the Emamcipation (Madalengoitia Mansion). The house is considered Emancipation civic sanctuary of this city, because here the mayor of Trujillo, the Marquis de Torre Tagle, leaded a first separatist movement, and in 1820, him proclaimed the independence of Peru. Emancipation of the house served as headquarters of the first constituent congress and house of government of President José de la Riva Agüero. The monument preserves a series of watercolors of the eighteenth century and is located at the corner formed by the streets Pizarro and Gamarra. It is an active center for cultural exhibitions ranging from plastic to recitals and concerts.
Address: Jr. Pizarro 610.
Visits: Mon to Sat 9:15-12:30 & 16:00-18:30
Ganoza Mansion. Because its architecture, the mansion is more representative of this city. The house is known for "the cover of the Lions" because their entrance is topped by a Baroque Rococo fronton and two lions.
Address: Jr. Independencia 630
De Orbegoso Mansion. This construction was carried out between the eighteenth and nineteenth centuries in colonial style. The house belonged to President Luis José de Orbegoso and Moncada, hero of the independence of Peru. The house retains many of Marshal personal things, such as paintings, furniture, mirrors and silver. Here there are exhibitions related to art.
Address: Jr. Orbegoso 553
Visits: Mon to Sun 9:30-20:00
The Churches...
El Carmen. This temple is notable for the harmony of its architecture, was built in the eighteenth century. It has about 150 paintings, some of the Quito school of the seventeenth and eighteenth centuries. There is also a painting called "The Last Supper" by Otto van Veen who was master of the Flemish artist Peter Paul Rubens. Notably, the painstaking work of carving covered with gold leaf."
Address: Intersection of Colon st. and Bolivar st.
Visits: Mon to Sun 9:00-13:00
La Merced. This temple dates from the seventeenth century, whose design and construction of the Portuguese citizen Alonso de las Nieves, has a mix of architectural styles in its facade. Interestingly, his body Rococo.
Address: Jr. Pizarro 550
Visits: Mon to Sun 8:00-12:00 & 16:00-20:00
San Agustín. The temple was built between the sixteenth and seventeenth centuries, with an altar in Baroque style. Emphasize especially the murals representing the apostles and the colonial pulpit of carved wood and gilded.
Address: Jr. Bolivar 508
Visits: Mon to Sun 8:00-12:00 y 16:00-20:00
San Francisco. In the temple are interesting the aisles as well as the paintings of some characters of the Scriptures and saints. Its main altar is decorated with multicolored retablos and pulpit dating from the seventeenth century. In her convent is the site of the National Traditional "San Juan" where he studied the poet Cesar Vallejo.
Address: Intersection on Jr. Independencia & Jr. Gamarra.
Visits: Mon to Sun 8:00-12:00 & 16:00-20:00
Museums: We have:
- Museum of Archeology, Anthropology and History at the Universidad Nacional de Trujillo
- El Carmen church Pinacotec
- Museum of Zoology John Ormea
- Museum of the Toy
- Archaeological Museum José Cassinelli
- Chan Chan Museum Site
- Huaca Dragon Museum Site
- Museum of Natural History, University Antenor Orrego
- Museum of Modern Art
Chan Chan. Of Chan or Chang (quingnam = Sun), which shows Chan-Chan (literally: Sun Sun), assuming its true meaning in Spanish: "Big Sun", "Shining Sun", or "Glowing Sun" . Is a pre-Columbian adobe city built on the northern coast of Peru by Chimu culture, is located northwest of the metropolitan area among the districts of Trujillo and Huanchaco. Declared a World Heritage Site by Unesco in 1986 and included in the List of World Heritage in danger. Chan Chan, is composed of 9 small walled cities or towns, It was the capital of the Chimor kingdom, state organization of the Chimu culture. Is the largest adobe built Metropolis in Latin America and the second in the world.
El Sol and La Luna Huacas. The El Sol and La Luna are monuments of Peru, located about five kilometers south of Trujillo, in the district of Moche. This archaeological site was the capital of the physically Mochica culture from the first century B.C. until the ninth century.
El Dragón Huaca (Arco Iris Huaca). It is located in the north, on the outskirts of the nearby city of Trujillo and Chan Chan. This is a great religious, ceremonial and administrative monument built in adobe, whose walls are decorated with relief friezes, showing figures representing stylized anthropomorphic and the rainbow. Esmeralda Huaca. Adobe pyramid located 5 kilometers from Trujillo. Archaeological site which dates from the Chimu culture.
El Brujo. The El Brujo Archaeological Complex is located on the right margin of the Chicama Valley, near the coastal district of Magdalena de Cao in the province of Ascope. After about 60 minutes from the city of Trujillo, are the pyramids of mud with more than 4.500 years of existence.
Huanchaco Beach. The Huanchado resort is located in the district of the same name. It is the largest and most beautiful beach in Trujillo city. The name Huanchaco comes from Guaukocha (beautiful lake with goldfish). Today is a traditional and picturesque beach, stop for tourists who visit Trujillo city. In the upper part of the resort stands a beautiful colonial church. This church is dedicated to the Blessed Virgin del Socorro.
Chicama Port. At 70 kilometers from Trujillo city is located in a wide, windy beach, is the preferred place to practice surfing. Equally common is the use of reed boats.
Cerro Chepén. Located 142 kilometers from Trujillo, in the city of Chepen. Is a set of stone buildings, which include rooms, watchtowers and worship.
Otuzco City. Located in the Province of La Libertad, 85 kilometers from Trujillo. A picturesque town in the mountains, surrounded by beautiful Andean landscapes and well visited site because it houses the Virgen de la Puerta, patron of the place. It has attractive wooded landscapes, especially eucalyptus. Built on a rocky and arid zone, was established by the Augustinian missionaries, who found in the region a gateway to the interior of La Libertad, and from the coast. There, more than 360 years ago, erected a chapel. The feast of Virgen de la Puerta takes place in Otuzco between 13 and December 16.
Baths of Cachicadán. Located 183 kilometers from Trujillo in the province of Santiago de Chuco. Settled on the slopes of Cerro La Botica.
Pacasmayo Province. It has a beautiful beach (Poemape), Raimondi Museum and some archaeological sites such as Cerro Dos Cabezas (Moche Culture).
Don't forget!
Remember! Bring your ISIC (International Student Identification Card) because you'll get important discounts in cinemas, museums, transports… Almost every museum has free access or has a student discount.
Useful Phone Numbers
Municipal Police --> Phone number: (+51)-(44)-298734
Police Emergency --> Phone number: 105
Civil Defense - Trujillo Headquarters --> Phone number: (+51)-(44)-473799
Peruvian Red Cross - Trujillo Headquarters --> Phone number: (+51)-(44)-292243
Emergency - Hospital Belén de Trujillo/MINSA --> Phone number: (+51)-(44)-245748
Emergency - Hospital Regional Docente de Trujillo/MINSA --> Phone number: (+51)-(44)-231581
Emergency - Hospital Víctor Lazarte Echegaray/EsSalud --> Phone number: (+51)-(44)-216119
Fire Company --> Phone number: (+51)-(44)-297191
Crhistian Omar Benitez Castro
Local Exchange Officer 2009/2010
Standing Committee on Professional Exchange - SCOPE
IFMSA Peru / LC IFMSA Trujillo UNT
Universidad Nacional de Trujillo
Photo Gallery
We want to say "THANK YOU!" to all of our former incoming that joined our exchange program. It was a unique experience we all made with your different cultures and customs. Thank you for this fantastic possibility of intercultural exchange. We hope we could offer you a great time here in Trujillo!
You are all welcome again anytime you want. All the best to you and yours!
Your LC TRUJILLO-UNT!
Social Program
July '09


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A mentoring project for young people in North Bushey will be able to help more youngsters after being a cash boost.
CHILD UK was given £400 from Hertsmere's Ward Improvement Initiative Scheme (WIIS). The project aims to transform the lives of young people through sport and other leisure activities, improving physical and emotional welfare to build confidence and self-esteem.
John Manitara, from CHILD UK, said: "Our aim is to tackle obesity, drug and alcohol abuse amongst the younger generation, whilst promoting social inclusion and good citizenship.
"The young people attending our mentoring sessions will also be given the opportunity to be trained as volunteers to give something back to their local community. However, all our projects involve having fun too."
There is still some WIIS money left for the current financial year. To apply, contact your local borough councillor.


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"As a practicing Christian in this modern, fallen world, it can be hard to explain why I still go to church," said Colbert. "That's why I want to say thank you, Mike Huckabee, for cementing in the minds of nonbelievers just what my religion stands for: Jesus, the only Son of God, gave His life to redeem mankind by suffering torture and death, then rose from the dead in forgiveness of our sins, ascending to heaven and is seated for eternity at the right hand of the Father in fulfillment of the scriptures. …You know. For chicken."
Stephen Colbert Thanks Mike Huckabee For Teaching Nonbelievers What Christianity Is All About
Current Status: Published/No Action (12)
Seeded on Tue Aug 7, 2012 4:40 AM
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Let's face it: If you build a 106-foot launch tower and then send competitors -- some of them as young as 14 -- careening down the face of it on skis towards a big-ass kicker for a competition like last night's Nature Valley Big Air Challenge in Civic Center Park then, well... let's just say it's a good thing kids these days don't mind wearing helmets.
The bloodthirsty crowds (the U.S. Ski & Snowboard Association's report estimates the number at about 10,000) who came out for the first of two Denver Big Air competitions got what they came for: Grisly agony-of-defeat style wrecks, and plenty of them, punctuating the picture-perfect tricks with stomped landings.
Denver Big Air fans cheer for guts, glory, and gory
Photo by Kate Levy
Vail's John Spriggs: Man, or yeti?
Photo by Kate Levy
The only sound louder than the roar for Best Trick winner John Spriggs, a 6'5 yeti of a Vail local with thick dreadlocks who wowed the crowd with a double cork 1260 degree spin with a mute grab? The collective gasp every time someone went down hard, like Mitch Gilman's brutal Semi-Finals slam that left his Line Skis team with just two competitors heading into Finals. That's what we came for, right? As with any Evel Knievel-style spectacle, big air fans like to get well acquainted with exactly how dangerous these sports can be.
Houston, we have a problem. Head Skis team rider Brendal Wall, heels over head above the Denver Big Air ramp
Photo by Kate Levy
The Armada Skis team -- Spencer Milbocker, Alex Bellemare, and Breckenridge transplant Ben Moxham -- managed to stay mostly on their feet throughout the competition, claiming the night in the event's Battle of the Brands format after staying in front of the Full Tilt Boots team in Semi-Finals and beating out the Line Skis crew in Finals. A total of 14 teams competed in the event, which served as the kickoff for Mile High Snow Week and the SIA Snowshow, SnowSports Industries America's annual trade show at the Colorado Convention Center.
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Armada Skis teammates Spencer Milbocker, Alex Bellemare, and Ben Moxham celebrate on the podium at the Nature Valley Big Air Challenge
Photo by Kate Levy
And wait, there's more! Tonight the Denver Big Air ramp will host an LG FIS Snowboard World Cup event, part of the Fédération Internationale de Ski's tour series. Snowboards don't fly off on impact quite as spectacularly as skis sometimes do, but there should be plenty of yard sale action all the same: Watch for riders like Canada's Sebastien Toutant, the current leader in the World Cup Big Air series, and local heroes Bret Esser (Breckenridge, CO), Broc Waring (Vail, CO) and Jake LaRue (Lord, CO), and try not to hoot and holler too loud when they get the comeuppance they've got coming to them for daring to go big. Keep it classy, Denver: The world is watching.


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One of my favorite memories of Christmas as a child is going through the stockings that Santa left for us. And now, as a mother with 2 small kids, I've enjoyed buying little 'stocking stuffers' for them that I know they'll love.
Only problem: I don't have stockings for them!
And I refuse to buy them. Surely they're not that difficult to make? I'm a new sewer, but I've realized that making things is much easier than I always thought. (BTW, there are some great youtube videos for stockings - heaps of styles & techniques. This one works best for me because it's easy.)
So I had a look through my fabric stash and had all kinds of holiday designs: red & white stripes, green & red plaid, red & white snowflakes... but I live in the tropics and didn't really want to do a 'cliche' red/white/green design. I mean, there's no chance we're having a white Christmas in north Queensland.
Then I thought, "Why not make a non-typical colorful stocking?"
I made my daughter a quilt earlier this year (my first sewing project & inspiration to buy my own sewing machine!), and I had some scraps left over from it.
I read about 'crazy quilting', and thought I'd give it a go.
Start with a 6-sided piece of fabric.
Get another piece and line it up with one of the edges. Sew them right sides together, and using a straight-edge, cut off the excess material.
It should look like this:
Keep doing this with your scraps, and check your stocking template (I made one from newspaper) for size.
Keep going...
It's getting closer!
When you're all done with the sewing, pin the stocking front to the template and cut around it to get the stocking shape. HINT: It's easier to have your pieces overhang the template & trim them to shape rather than forming them to the stocking.
*Optional: If you're going to embellish your stocking, do it now. I didn't embellish mine, but maybe you want to add buttons, ribbon, embroidery, etc. Do it now before you start putting pieces together.
Using another bit of scrap, cut out the stocking back. I had a white cotton shirt that was perfect.
Sew the front & the back together, right sides together. Trim the corners (little fringes) so that the stocking will lay nice & flat. Leave the top open (don't stitch the top closed).
Now you're going to attach the part used for hanging the stocking (hanging tab?). Using ribbon, or scrap fabric, or whatever, sew it to the front of the stocking on the seam of the front/back, sewing it as close to the top as possible. Make sure it's facing DOWN, as pictured.
Again, the stocking is right side out. Set aside for now.
Stocking lining: This is not optional. Not only does the lining make the stocking look & hang nicer, it also allows you to hide the seams. If you have a better way, please let me know :)
Again, using scrap (I used a XXL mens dress shirt), cut out 2 sides & sew them together, right sides facing. And make sure you cut the edges on the lining, too.
***Very important!*** Do not sew all around the lining. Leave the top open AND leave 4-6 inches opening on one of the sides. This is to flip it all through at the end! Trust me... I forgot this and had to unstitch.
So now you have the outer stocking turned right-sides out. And you have the lining turned inside-out.
Stuff the OUTSIDE stocking inside the lining, making sure the toes face the same direction. Sew around the top about 1/4 inch or so.
From the opening in the lining, flip the lining right side out. Sew the opening closed, and stuff the lining into the outside stocking piece.
Hooray, you're finished!
Hang it up,
And admire your finished stocking. Like I said - it's easy! Now i just have to do a few more....
Boka Hotell


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Medical Definition of Alb-
Alb-: Prefix from the Latin "albus" meaning "white." As in albino and albinism. The term "albino" was first applied by the Portuguese to "white" people they encountered in West Africa. Those "white" people probably had partial or complete albinism, an inherited lack of pigment in the skin, hair, and eyes.
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Here is the before picture. I thought she had instant potential.
I painted her Krylon Cherry Red, changed the back to my beloved hounds tooth, and with my Hubby's help, reattached the back.
She turned out better than I expected. 🙂
If I had room for her, I would keep her. BUT….I'm guessing one of you will have room for her! E-mail me at email@example.com for information about buying her. HUSBANDS: This could be a belated Valentine's gift!
I thought I'd accessorize her just for fun!
P.S. Aren't those roses beautiful that my Hubsters got for me?!!?


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Calibre and Shelves
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Originally Posted by
Mine always worked on the first pass for collections I thought. Just needed the second pass for the kobo series info field. Maybe it's changed?
Nope; thats how it has been and still is. The collections work first time as the info required for it is the title of the book and the collection(s) it is in, and those are known when the book IS added.
The Series info however is stored in the database records created by the initial scan done when the Kobo processes the new books when it is disconnected.
Additionally, the collection info is reupdated whenever the device is detected by calibre as long as metadata management is set to automatic; in fact I use that fact for my automared Finished / Reading shelves; I connect the Kobo to calibre, use the Kobo Utilities to store the reading % info, then, without unplugging the Kobo I use the Kobo Utilities function "Refresh the list of books on the device" to update the collections on the device.
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