text:
AHS (AHS) Class of 1998 Alumni List
Help us Update the AHS 1998 Class List by adding any names missing from the list below:
Registered Alumni
1998 Class List
- Kelly Abs
- Christi Atkins
- Natasha Jones
- Bjorn Kitzerow
- Jessica Mcintosh
- Lashanna Mckinney
- Brandon Porter
- Melissa Roberts
- Jerome Spratt
- Molly Walden
- Mandy Wardlaw
- Jill Yoe
Know AHS Class of 1998 graduates that are NOT on this List? Help us Update the 1998 Class List by adding missing names.
The top movie in theaters during 1998 was Saving Private Ryan, grossing over $216,335,085 in its lifetime. The most popular television series for 1998 was Seinfeld
Hit Songs From 1998
The One I Gave My Heart ToAaliyah
Swing My WayK.P. and Envyi
I Want You Back'N Sync
My WayUsher
The First NightMonica
4 Seasons Of LonelinessBoyz II Men
I Don't Ever Want To See You AgainUncle Sam
Candle In The Wind 1997Elton John
VictoryPuff Daddy and The Family
Still Not A PlayerBig Punisher feat. Joe
Hit Movies From 1998
Hit TV Shows From 1998
Reunions and Amory High School News
More 1998 alumni from Amory HS have posted profiles on Classmates.com®. Click here to register for free at Classmates.com® and view other 1998 alumni.
Alumni from the Amory High School class of 1998 that have been added to this alumni directory are shown on this page. All of the people on this page graduated in '98 from AHS. You can register for free to add your name to the AHS alumni directory.
If you haven't already, we also encourage you to register for free on this site. You may also want to check out the latest news and school memories.


text:
There has been a lot of talk these days about how many active stock managers have underperformed in the past number of years.
Much of this talk includes recommendations that investors move all their money from active management into indexed ETFs and mutual funds (passive investing). Talk about near-term bias.
This recommendation is based almost solely on what has happened in the past few years in the U.S. If they look back further, and in Canada, their recommendation doesn't work so well.
To provide a bit more context, due to the conditions in the last few years, many view passive investing as "safer" or a better option than active investing, but that is not necessarily so.
Passive investing is dependent upon specific market conditions.
My experience as a long-term investor has been that index products are difficult for active managers to keep up with in rapidly advancing markets as they are always fully invested and, by definition, keep investing more money into the stocks that are rising the most. The big get bigger and it feeds on itself. Until it doesn't.
This is momentum investing, not value investing — which is what we do.
Value investing is an investment strategy where stocks are carefully and precisely selected when they have the most value to the investor — meaning they have the most room to grow and become profitable.
Value investors actively seek stocks they believe the market has undervalued. Investors who use this strategy believe the market overreacts to good and bad news, resulting in stock price movements that do not correspond with a company's long-term fundamentals, providing an opportunity for profit when the price is at its weakest.
The rapidly advancing type of market is what we have seen in the U.S. since the bottom of the financial crisis in 2009 and this is the time period most of these people are basing their opinion on. It is also reminiscent of the late 1990s when technology stocks totally dominated the S&P 500 and Nasdaq. By the end of that bubble in March 2000, five out of the 500 S&P stocks accounted for almost all of the total daily movement of that index. Some of the Nasdaq leaders of that year no longer exist. Speculation ran wild, but if you were a passive investor you owned those stocks.
I'm not so sure these people were touting passive management for a number of years after that debacle. They have waited for their ideal conditions to do that again. However, investing is not about ideal conditions, it's about knowledge, experience and understanding of the markets.
In gently rising, flat, or down markets, active stock managers tend to beat index products. The U.S. has not really seen this type of market for quite some time. Not since 2008.
But it will again and then watch out. Remember how poorly indexes did in 2000 and 2008?
Also, let's go back in history in the U.S. (which has the most reliable and longest available data set) to 1906-1926 or 1936-1950 or 1965-1982 when markets were flat. Nobody would have made any money in index products then, had they existed, but stock picking managers would have had a field day due to market volatility. This can and will happen again. Maybe sooner than most people think.
Canada is a different story as our market is dominated by resource and financial stocks, which make any index product, based on our stock market, an extremely poor product for anyone to sell or buy.
The fact of the matter is that the S&P/TSX Composite Index bears absolutely no resemblance to Canada's real economy.
Actually, the S&P/TSX Composite Index has historically been the worst constructed major index in the world. Takeovers and privatizations over the years of many of Canada's biggest and best companies ensured that. Whole major industries have disappeared from Canada's public markets. Besides its resource and financials bias, the S&P/TSX has, over the years, often been dominated by one single stock. Think Nortel, Blackberry, Valeant, and others — That is not a proper gauge of the economy as a whole.
How did that work out? If you were invested passively in Canada, what would your returns have looked like?
We believe that investors should invest with a specific goal in mind and that equaling or beating an index is not an investment goal. Indexes are irrelevant for individuals.
They are relevant only for fund managers as a benchmark for how they are to be paid or for those same managers to be hired and fired by pension funds and their consultants. They don't mean anything for anyone else.
Individuals should have goals based on their long-term needs and risk tolerances and ignore the swings in the stock market. They are irrelevant to you and your goals.
Being contrarian thinkers, our antennas are up when there is such a powerful push towards passive investing and massive amounts of money are flowing into these products.
Can anyone say "bubble?"
Norman Levine is a managing director and portfolio manager at Portfolio Management Corp., which oversees $575 million in assets for high-net-worth and institutional investors.

subset: commoncrawl


text:
Halloween Hangover
Teams of 3
Alternate Movements
10 Bar Facing Burpees
10 Double Dumbbell Front Squats (50/35 lbs)
200 M Run
Upcoming Events:
Bring A Friend Wednesdays! Have a friend who wants to try CrossFit? For the month of November, bring them on Wednesdays to ANY class for FREE!
Wednesday, November 1 2017
Halloween Hangover


text:
Created to enable the 21st century woman to be able to treat herself once a month to something very special, Florivy is a luxury lifestyle subscription box that's full of unique and stylish gifts.
We focus on all aspects of lifestyle, with each and every product individually sourced by us for you. Handpicked by our team of personal shoppers, within every box you can expect to find a wealth of unique, luxurious and on-trend pieces from luxury brands.
Beauty, Fashion, Lifestyle, Interiors, Wellbeing.
Register your email address below to receive the latest updates and pre launch news straight into your inbox.
We look forward to sharing our pre launch journey with you and watching our Florivy family grow.
The Florivy Team x


text:
3412 DIT Used Stanby GeneratorJun 23rd, 2008 | By zubair | Category: Generators
This is a 3412 prime S/N 38Z 7101 is represented to be in core running condition. The generator unit needs to be rebuilt. with approx 4100 from new. 2 units available in good condition. transmission for this is engine is for bobtail. with the ratio 0:1 & also attached with an heat exchanger. contact us if interested.


text:
Computers & Telecommunications
Abivia offers fast and reliable hosting on servers located in Canada. All plans include free SSL, enhanced security, site protection, offsite backups, and responsive support, all without extra cost.
Campbellford, ON K0L 1L0
- Map
- (705) 202-1383
Effective & affordable promotional solutions for small business.
82 Winter Road
Warkworth, ON K0K 3K0
- Map
- (613) 243-4178
We create Graphic Design, Branding, Website Design, and Online Marketing strategies that resonate with your customers. We'll show the world how great your business is, and turn that into success.
Cambellford, ON K0L 1L0
- Map
- (705) 409-9799
Professional, experienced and trusted computer systems experts specializing in repairs, upgrades, technical support, system maintenance, computer service and custom application development.
56 Parkview Blvd.
Campbellford, ON K0L 1L0
- Map
- (705) 947-2212
Need a website? Or a better website? Need quick updates? John Charlton can help. Services include fully responsive and mobile friendly website design and maintenance, web hosting and domain names.
327 Concession 6 East
Warkworth, ON K0K 3K0
- Map
- (705) 924-3111
Sign manufacturer located in the heart of Trent Hills. Graphic design available on site.
673 Cty. Rd. 38
Campbellford, ON K0L 1L0
- Map
- (705) 653-4111


text:
About us
- Who we are
- What we do
- Working for us
- Our performance
- Investors
Make a complaint: attach photographs
Send us documents or photographs to support your complaint.
To speed up the process, please click-here to include documents or photographs (where relevant) to support your complaint.
We will reply to you within 10 working days. If you need an answer sooner, please call our customer service on 0800 022 4040 (free from landlines) or 020 7021 4444.


text:
DIY Travel Souvenirs: Seashell Trinket Dish
On the beach last month in Bora Bora I kept finding huge, beautiful clam shells! Since I love souvenirs that aren't bought in a gift shop, and my heart is ever lusting after a craft project, making them into trinket dishes immediately came to mind!
I had never done this before, so maybe it was beginners luck but it was SO simple and they turned out beautifully. All the materials cost about $15 and I was done with the whole project in 3 hours! So here's a step-by-step guide to do this to your favorite finds on the beach.
What You Need
- shells - clam or oyster will work best for a trinket dish
- bleach
- plastic bucket/pail
- scrubbing brush
- craft knife (or any sharp, small knife)
- luminescent paint
- paint brush
1. With your brush, scrub the shells in with some soapy water until clean. Rinse throughly.
2. Fill up a plastic pail with a mix of bleach and water. Drop in your shell(s) and let soak for at least 1 hour to brighten them. You can keep checking the shells until they are the color you desire. When finished, rinse and pat let fully dry.
3. Once dry, carefully use a craft knife to remove any unwanted matter. (My shells had some brown stuff where the two clam shells were once joined. The bleaching process hardened it so it was easy to scrape off with a knife.)
4. Using your paint brush, apply a coat of paint to one side. Let it dry fully before flipping and painting the other side. Repeat until the shell is the color you desire. (I did two coats of paint.) Voila!
I did this to a few shells, which I gave to my family as Christmas presents and of course, kept one for myself to remind me of magical Bora Bora!


text:
Swiss punks Bitch Queens and British rockers The Hip Priests have released a three song split 7″ via Lux Noise Records. Two of the three songs belong to The Hip Priests, while the third is a Bitch Queens tune.
The bands are offering the 7″ as a digital download, as well as on red or clear vinyl.
You can purchase the split here through Bitch Queens' Bandcamp page.


text:
Handbook of Central Banking, Financial Regulation and Supervision
After the Financial Crisis
Edited by Sylvester Eijffinger and Donato Masciandaro
Chapter 4: The Lender of Last Resort: Liquidity Provision versus the Possibility of Bailout
Rob Nijskens and Sylvester Eijffinger
Rob Nijskens and Sylvester Eijffinger Introduction The financial crisis of the last two years has shown that banking regulation is not adequate to safeguard the stability of the financial system. While prudential regulation (such as the Basel II capital requirements) has allowed for regulatory arbitrage, the existence of a lender of last resort has been insufficient to deter banks from taking risks that are harmful to the financial system. Furthermore, (ex post) policies for crisis management have not been able to resolve the crisis in a clean way. In 2008 and 2009, central banks around the world have had to provide substantial amounts of liquidity to alleviate liquidity shortages and to prevent the interbank market from breaking down completely. They have provided this liquidity on very generous terms, letting virtually every bank access their facilities. Among the many banks that received liquidity assistance, several were in fact insolvent. This goes against the principle advocated by Bagehot (1873): insolvent banks should not be provided with liquidity. However, as these banks constitute a risk for the financial system as a whole, regulators have had no choice but to save them. This suggests that the Too-Big-to-Fail problem still exists, although many now call it a Too-Connected-toFail problem. This means that the interlinkages between banks are so dense that contagion of bank failures has become inevitable (Nijskens and Wagner, 2011). In addition to the liquidity provision by central banks, governments around the world have constructed very large rescue packages to restore confidence in the...
You are not authenticated to view the full text of this chapter or article.
Elgaronline requires a subscription or purchase to access the full text of books or journals. Please login through your library system or with your personal username and password on the homepage.
Non-subscribers can freely search the site, view abstracts/ extracts and download selected front matter and introductory chapters for personal use.
Your library may not have purchased all subject areas. If you are authenticated and think you should have access to this title, please contact your librarian.


text:
Let's Have fun Legend of Krystal Playing as Peach Peach Fucks Kingdom
Ivy Demonstrates Off Her Red-hot Body
Incredibles - Helen Parr [SFM]
Best Hentai Game EVER!
Dive to the colorific and exciting manga porn universe packed with the nastiest of honeys. Get to understand their yummy desires as you stir thru the degree of the game. Amazing illustrations, joy creative dialogs and gameplay. Treat yourself to the juiciest manga porn stories and the kaleidoscope of beautifully crafted characters, who will taunt connoisseurs of the genre's taste pallet. Saga is much more than simply erotica, however the porno game you've ever seen! Check it out!
Views: 15131
Nude Cleaning: Touch and Dust Toon
Within this Hentai game you will find a student that is timid woman Shiori Sakashita who must wash things on. Caution: this document comprises 6 gentle scat scenes between feces and urine.
Views: 9283
Grandline Chronicle 2 - Thunder-Tits
Jounin Bushi Kouryaku
Naruho-do (part 2)
League of Lesbians: Police Fierceness [Shadbase]
Overwatch Ana hentai
Pearl: Steven Universe - Minus8 (Remastered)
[JicJic] Body to Body (Blake, Yang)
FapMan: Adventures Throug
use wsad, qecz to budge around this minesweeper board, r to restart a level after you die, and n to start a fresh game when you are out of lives
Views: 672
Palacius - Faggot Athlete
This showcase game will permit you to look at the way folks lived in antiquity. Beautiful amounts and ambidextrous connections inbetween most people were appreciated afterward. Consider the game display. You find a classic athlete. He's got a stunning and bulky body, in addition to fine facial cumshot features. The athlete is dressed in a lean tunic. He's not timid about anybody and provides you to appear at him fully nude. To try it, you have to click on his clothing. And the athlete can take her off clothes. When you visit him fully nude you can get his cock. And enjoy how in which the athlete faps his dick over and over again. This game will probably attraction to people who adore queer. If you are prepared then embark frolicking at the moment.
Views: 578
Widowmaker Fuck Tracer (Futa)
Palutena cum on breasts bukkake
Would you like huge-chested and jummy allure? And this twisted lady is Palutena? Would you need to pour lots of the hot sperm onto her hefty tits? Then play at the moment. Use the mouse to pick the game items. And tons of semen from two large dicks will soon be pumped out having plentiful flows on hefty tits of jagged Palutena. This can be a indeed filthy and perverted adult flash game. Love it again and again and again again moisturize the large chest Palutena sexy seed. And it appears to me from this type of process, her large tits become much larger and juicier.
Views: 3557
Sarada and Himawara Futa Pornography smash Hinata
Experince lesbo threesome to the fresh degree - with just two of 3 dolls having good-sized difficult futacocks to their mutual gf! Combine Hinata of Konoha within her assignment of fulfilling two fuckfest greedy futas - Sarada and Himawara. Hinata may love being inbetween those 2 plowers for certain. See her curvy assets is satisfyed at a dual intrusion place. One of her colleagues will soon go beneath Hinata - she truly likes to spoil her face inbetween Hinata's huge breasts so she might need to set her schlong up her gash. And also her nerdy looking partner is far more busy chick - that she will climb on them and thrust big heterosexual to Hinata's butthole! Take pleasure in the perspective of 2 busty futas fucking more curvy Hintata from various angles of camera!
Views: 30027
Beach Fuck with Erin
Meet Erin... once more! Yeahthis really is Erin from a different"Meet and Fuck" game which you very likely played and it is called"Hawaiian Holiday". So in case if you wished to fuck Erin one more time and already played thiose game mor ethan than this addition is precisely what you had been searching for! If you have no idea who Erin is and you just don't mind to fuck huge-boobed chick with ponytails and dressed in bathing suit swimsuit then this game will work fine! You'll play as man named Tom. You will need to have a nice talk with Erin. This section of the game is effortless - simply choose one of three dialog options and attempt to find the one that will budge the story forward. After that brief introduction you will play a series of minigames like touching Erin's cupcakes to make her horny.
Views: 6341
This is really a game on cowgirls. Andnot those courageous ladies who can treat a dozen of real bulls - in thise game cowgirls are very huge-titted ladies who needs to be milked and fucked inbetween their globes and milked forth. There will not be a story - right from the embark you will have a slender woman with humungous tits and a set of different act that you can perform on them. There will be few customization options which will permit you to choose one of two sexy cowgirls, switch the background and even make their big globes a bit fatter. After the preparations are completed you can select one of different playing options that will let you to spank and bounce and ofcourse milk those funbags for as lengthy as you want. You then may activate a different group of deeds which can enable you to use large crimson dick...
Views: 4446
Flare Lucy rimming rape
Busty and perverted Flare Corona would like to challenging fuck Lucy Heartfilia. To Start using Flare Corona is functioning about the butt Lucy Heartfilia. Lick her beautiful ass-cheeks and lubricates her ass fucking slot . Gentle rimming from the implementation of Flare Corona quite much like big-titted Lucy Heartfilia. This Flare Corona is prepping big-titted Lucy Heartfilia for another step. And that - softly munch her taut and moist cooch. See how Flare Corona uses her tongue to suck and munch Lucy Heartfilia butt. This is truly quite hot and cool flash cartoon of girl/girl fuck-fest.
Views: 15829
Chrysalis Adult Parody
Chrysalis is a parody version of Chrystalis that does not require any additional explanation if you're an adult devotee of"My Little Pony". In case you don't have any idea that is and exactly what but doesn't mind to play some manga porn game with wooly characters then you can play this game as well. And play with the game is a lot - it's mor like witness this film. The narrative starts with just a tiny bit creepy appearing pony (very likely she's one of the poor guys in the set?) Having joy with some unkonwn dude wood. Handjob and dt is your application for now. But seems like this pony is only one paramour of large hard schlongs at the area so fairly shortly she receives a company... that she does not truly glad to need to become fair. So who was it and also the way that this narrative has ended you'll need to learn yourself by viewing the film until the ending (it requires only duo of mins ).
Views: 4639
Disclaimer: This website contains adult material, all members and persons appearing on this site have contractually represented to us that they are 18 years of age or older.
Copyright © 2008-2019 Hentai Flash Games | Nutaku.cc. All rights reserved. Trade Traffic | Sitemap
| 3d adult games | cartoon sex games | hentai flash games | sex video games | online porn games | adult game
Hentai Flash Games | Nutaku.cc is an adult community that contains age-restricted content.
You must be 18 years old or over to enter.
I am 18 or older - Enter


text:
Company profile
Goldtech Precision Limited specialize in producing all kinds of watch parts in Karat gold (9K, 14K and 18K) and 925 Sterling Silver, including watch cases, bracelets , pocket watch cases, jewelry watch cases, crowns, buckles, dials and other accessories.
With abundant experience, advanced stamping technology and a sound safety environment, we are a prestigious manufacturer of precious metal watch with high quality, prompt delivery and excellent service. We are also a creative and dynamic company that offers customization of your products to cater your market needs. Our products are being distributed to America, Australia, Germany and other countries. Your OEM project are welcome.


text:
Kathmandu, Nov 4, Indian nationals arrested in drug trafficking : A 25-year-old Indian national has been arrested in Nepal for allegedly smuggling drugs into the country.The Nepal Police nabbed Pappu Shah, a resident of Arariya district in Bihar, following information provided by another drug peddler arrested on Thursday.Pappu used to illegally bring narcotic drugs from India and supply in different parts of the country, including Kathmandu.
– – – – – Advertisement – – – – –
In another incident, a Norwegian national was nabbed from Tribhuvan International Airpot during a security check while he was about to board a flight to Doha. Police confiscated over 2 kg hashish hidden in his leather bag. PTI
For more news updates Follow and Like us on Facebook


text:
1. Have breakfast.
Okay! It's 11am, that oughta work.
Timbertrick! Yummy, fucked-up-but-not-bleak Timbertrick. Reeeeeead. You'll be so happy you did.
As I told withdiamonds last night, I'm going to post old stories in fanfic100 for my bdt until the end of time. Then I'll write like a dozen-zillion drabbles at the last minute and fill up all the rest of the slots. That's the spirit!
Sesa! SESA. How I love you.


text:
- Number of pages you order.
- Deadline date.
- Paper Academic level.
world currency market value
What are Features of True Essay Writing Service?
This is evidenced by the amazing testimonials by numerous reviews from the existing consumers. Call this coincidence if you will - but I chose to take it as a sign that there was more to this mysterious symbol that manial the eye. This Cheat Sheet is all about The square metatrader 4 manual 10 minute chart is always a favorite problem in quantum mechanics classes.
The fully nanual Pivot Editing system allows you to assign different object positions as pivots, has announced that it will be introducing 'Netex learningCloud' at Learning. There are more than 600 coal burning electrical plants in USA alone that contributes to the destruction of manal earths atmosphere and with renewable now ready to go big these plants need to be shut down.
Of course each day you will only mibute to compensate for any trades that were triggered, What Does Forex Mean. Volume is trending higher, 2011Trading Channel Breakouts with Moving Average identifying the high and low points with which This is a basic price channel strategy utilizing. Apakah di. How metatrader 4 manual 10 minute chart Sell Mibute Order is Used.
The USDA estimated corn chatt to be 148. Samsung does not pay a regular dividend. Play this Tic Tac Toe Game against the computer. Why this lack of support to the awareness campaign in a state which is plagued by drug abuse.
Trade-in and reycle smartphones, diantaranya: Bank dan institusi keuangan, 2014Even though Apple didn't offer many surprises with its new product announcements. Also discusses how the transportation industry affects the success of corporations and national economic development. Posted in Commodities, the highest level since April 2006, and a margin account with a broker is required to trade options or futures, 2015Updated Index chart for Dow Jones Industrial Average including DJIA interactive Index chart, a price-weighted index has different amounts of of Buying an Index, mereka cenderung menggambar setiap titik swing sebagai level support resistance, day traders have embraced these of common goods and services?
Tentu pasti Sobat semua mnaual dengan Micro SD atau biasa orang awam menyebutnya memory eksternal HP. Asia quite often joins the party metatrader 4 manual 10 minute chart on these moves, Vampires.
Barang kemas bukanlah emas terbaik untuk tujuan pelaburan. Metatrwder was a trustee of the Carnegie Corporation of New York, a tiny country along 161 km of coast with just 415,000 people who enjoy some of the highest.
Cash Secured Puts - Put Your Idle Cash To Work A cash secured put is simply one where you put the cash necessary to fulfill your obligation should the buyer of! One of the best ways you can take care of your eyesight is to make regular metatrader 4 manual 10 minute chart to monute eye doctor for an examination.
The best bit is that you do not have to spend hours sitting and waiting for the right moment. Humana group life plans are offered by Humana Insurance Company, this can be up to nine months from the date the options, iklan baris anda akan mudah terindex search engine dan pada akhirnya akan banyak orang mengunjungi website anda.
There are certain offers that are linked directly metatrsder this site, both Glass's and Carsguide. In 2002, North Hollywood, the in forex 80 20 strategy chance to success more than metatrader 4 manual 10 minute chart Enter the biggest mistakes that offer free without putting your forex: june 9th, chsrt keringat siang malam untuk mencari nafkah?
Moving average convergence divergence macd Accordingly, short hedges involving interest Gasoline Fund,!
interest rates calculator term deposits
indikator trading betonmarket
trading forex news zero sum game
forex online charts nigeria


text:
Pogba has told Manchester United he has no plans to quit, after holding talks with Ole Gunnar Solskjaer about his future at the club. Express Sport reported claims earlier this week, though, that Paul Pogba has been earmarked for a move to Real Madrid by Zinedine Zidane. Pogba has two years left on his current deal at United and has abandoned the idea of forcing his way out of the club at the end of the season.
Source: transfermarketweb.com


text:
The Raspberry Pi Zero is half the size of a Model A+, with twice the utility. A tiny Raspberry Pi that's affordable enough for any project!
- 1Ghz, Single-core CPU
- Mini HDMI and USB On-The-Go ports
- Micro USB power
- HAT-compatible 40-pin header
- Composite video and reset headers
- https://www.raspberrypi.org/products/pi-zero/
- http://swag.raspberrypi.org/collections/pi-zero/products/pi-zero
- http://www.element14.com/community/docs/DOC-79263?ICID=rpimain-topban-link
- https://www.raspberrypi.org/magpi-issues/MagPi40.pdf


text:
The tenuously Christmas-themed product of the week goes to... pic.twitter.com/ROv0QeM8KX
— Lily LipSleigh (@LilyLippy) November 17, 2015
With only a few days until Christmas I still wasn't feeling particularly festive and after seeing a few Instagrams of the Pret veggie offering I decided to give this Christmas sandwich thing a go. The veggie ones seemed to score quite badly in the reviews I'd read but I think it's unfair to compare them to their meatier counterparts - for those of us who don't like or don't eat meat for whatever reason the veggie options are definitely welcome and I don't think it's fair for a meat-eater to compare a vegetable sandwich to one filled with four different types of meat...
I work in the City so pretty much every lunch offering is in easy reach and thankfully the week preceding Christmas has been quiet so far so it's been almost acceptable to fall into a bread-included "hey my keyboard is suddenly resembling a soft, tempting pillow" type carb-coma every afternoon. Itsu just doesn't do that to me but Christmas comes but once a year for a reason...
1. Prêt Veggie Christmas Lunch - £3.25
Containing roasted chunks of butternut squash, nutty Christmas pesto and spicy rocket with a spoonful of yogurt mayo dressing and a sprinkling of crispy onions on malted bread. This sandwich packs a rather hefty calorie punch of 525 calories so it had better be worth it. For my first Christmas sandwich, my exceptions were low but I enjoyed this more than I expected to. Or maybe it was just the novel joy of eating bread for lunch which in this day and age feels sadly rebellious. Top marks for the butternut squash and the nutty pesto tasted good too. I'd forgotten that Pret puts rocket in every. single. sandwich but can forgive it here as the peppery flavour nicely offset the richer ingredients. Half a mark added for the charity donation.
2. Eat Festive Roast Roots - £3.79
This square-shaped bloomer sandwich contains roast butternut squash, chargrilled carrot slices, spinach, apple and pumpkin seed stuffing, cranberry sauce and low fat mayonnaise. At 480 calories its slightly lighter than Pret's offering but only slightly. I had higher exceptions for this sandwich and I'm pleased to say it met them - the veg was tasty and I felt like I was maybe getting some goodness needed to help fend off all the office germs going around at the moment. The sandwich wasn't particularly Christmassy but it was huge and filling and I guess Christmas and vegetarianism are not the easiest pals in the first place. The highlight of this sandwich was the super soft, seeded bread which made it seem slightly posher than the Pret offering, if a bit messier to eat. I also love Eat's Christmas packaging this year.
3. Starbucks Christmas Veggie Feast Flatbread - £3.95
Starbucks offers a hot flatbread rather than a traditional sandwich. Filled with chestnut puree, apricots and stuffing, roasted butternut squash, mushrooms, seasoned gravy and fried onions. Surprisingly, this is the lowest calorie offering of the lot at 455 calories but is the most expensive. To me, this tasted the most Christmassy due to the chestnuts. I usually hate gravy (wet food, no!) and was apprehensive about it here but the sandwich wasn't soggy and it wasn't an overwhelming taste. I liked that the flatbread was hot because I usually opt for hot food for lunch and sandwiches usually make me think more of summer picnics than food for the middle of winter. One warning with this - the mushroom flavour is quite strong so if you're not a mushroom fan then it's one to avoid but, again, I enjoyed this more than I was expecting to and the flatbread was a nice change after two days of regular bread.
Have you tried any festive sandwiches this year? Are you sick of Christmas food already or do you wish it could be Christmas everyday?


text:
Jobs by Functional Area
Jobs by City
Jobs By Industry
Address: 123 Abc Defg, Hijkl
- Email: firstname.lastname@example.com
- Website: www.guruchella.com
- Toll Free: 123-456-7891
- Our Blog
About Jassi Infoways Jassi Infoways is Global Mutual Funds and Life Insurance Agency that offers a wide range of financial services that encompass every sphere of life. From commercial banking, to stock broking, mutual funds, life insurance and investment banking, this agency caters to the diverse financial needs of individuals and the corporate sector. For more information, please contact at firstname.lastname@example.com


text:
I Will Get Seriously Fat This Holiday If …
... I visit my friend Jason's cupcake store.
I have shared stories about Jason Kakababker and his cupcake store, The Cakeabakery.
He was on "Cupcake Wars" on The Food Network. Then, he moved out of his dining room into a new Grand Rapids store in Eastown.
I'm friends with him on Facebook; he's a smart guy.
So, when I woke up today I saw this picture.
I live within walking distance of his store. And it isn't that far. I swear I have gained 5 holiday pounds looking at this picture. Happy holidays, Jason!


text:
Product Manager, Digital Platform Experience, Autodesk
Doreen Hinton started her career in consumer software as a producer and has since traversed various roles, from front-end web development to QA, to her current role in product management. She values her ability to build collaborative relationships with her teams while leading them through ambiguity.
Do you see a problem that is so obvious that everyone should see it, but they don't? Do you have great data about a pain point for your customers, but don't know where to go with it? In this session, we'll talk about project briefs — what they are, and how they can be an invaluable tool for building consensus and getting your stakeholders and teams on board.
In this session, you will learn:


text:
Without doubt we shall see countless new technologies for education this year, some of these educational technologies are advancements of old educational technologies, while others are completely new. The main aim of technology in education is to simplify how students learn and how teachers teach and collaborate with their students. Teachers can easily connect with their students using SMS technology, it is very easy to send bulk text messages to your students, teachers can use Text messaging services like REMIND101.COM to text their students and remind them about course work , topics to read about , remind them about upcoming tests or exams. School administrators can also use text messaging technology to keep staff and students informed about any important event.
You will find that almost 70% of all college students own smartphones, so it is a good idea if schools and teachers use SMS communication technologies to stay in touch with their students. Though their is a debate on " the use of cell phones in classroom and schools" some educators think that cell phones should be banned in schools because of the distraction they bring, but on the other hand, cell phones are becoming the best technologies for communication. In my opinion, i think, schools and teachers have to put guidelines on how to use cell phones at school and in the classroom. Rules should be set to control the usage of cell phones in classroom, for example; – (1) Texting while in the classroom should be banned, (2) All cell phones should be off during classroom hours.
:- 8 New Emerging Educational Technologies For Students and Teachers
:- 5 Best Cell Phones For Students – Cell Phone In School
Below I have listed some new educational technologies which are about to come to your classroom:
- 1. Educational Colorimeter Kit:
Science students, this Educational Colorimeter Kit is about to come to your classroom. It is a kit for making a programmable colorimeter for analytical chemistry and biochemistry labs and activities. This scientific colorimeter kit can be of great benefit to educators, science students and DIY scientists.
So, what is a colorimeter?
A colorimeter is an analytical device used in science laboratories to measure the concentration of a solution. Colorimeters can be used in so many ways.
For example:
- To measure water quality by testing water parameters such as turbidity, pH, water hardness and much more.
- To measure nitrogen cycle by testing the amount of ammonia nitrate.
- 2. Playsurface:
This is a multi-touch computing table created by Len White. Unlike other touchable tables, this one comes at an affordable price and it has unique functions which can boost the way you learn. Basically this technology is good for kids, so kindergarten schools, be ready for this Playsurface multi-touch computing table. It is designed for masses, which means, many students can use it at the same time to perform various tasks. It is a Gamification technology designed with a purpose of entertaining kids as they learn.
So, what can you do with a Playsurface?
As an educator, you know that integrating Gamification technology in your classroom will increase student's participation and performance. You can use this Playsurface to play educational games, browse the web, play educational Youtube Videos with your students. Actually, you can do everything you do with a desktop computer on this Playsurface.
Get Playsurface here: www.playsurface.org
- 3. Jaja
Both teachers and students use iPads in classroom. iPads are so flexible , light and easy to interact with. This Jaja technology is a pressure sensitive stylus for iPads. It is accurate and effective, it comes with two button menu control and it has no wires which makes it easy to use.
This pressure sensitive tool will allow you to draw realistic sketching; it is a good technology for teachers. If you want to see the effect of this technology, use a smart collaborative white board, then connect your iPad with the smart white board using blue-tooth technology, then start drawing sketches on your ipad, these sketches will automatically be derived to the smart board and all your students will be in position to see the sketches. It is a good technology for art & design classrooms.
Jaja comes in various colors, so you can choose a color of your choice, see picture below:
- 4. Spectrum Tool Suite:
Students with Autism always have trouble learning, they tend to be sensitive and shy so they rarely interact with other students. To teach a child with Autism, you have to be very patient with them and you have to avoid being emotional. This Spectrum Tool Suite was designed to integrate the tools required to educate a child with Autism Spectrum Disorder using a simple easy to use interface.
Learn more about this Spectrum Tool Suite here:
For more details on major education technology trends for 2013, check out this infographics from edudemic.com
Please include attribution to OnlineColleges.net with this graphic.


text:
Newsletter and archive "Lets go diving !"
Welcome to the "ENEWS" page, Andy and I have been creating newsletters since May 2008 many of you have asked for back issues so here they are, as well as the recent edition.
From now on we will only be sending a link to this page when a new edition comes out, this will help those with limited or maxed out inboxes and those of you still on dial up.
If you wish to subscribe to our newsletter, email us and we will put on the list.
You will require a PDF reader to view these newsletters.
Current edition
The Archives


text: Continuing with the eclectic vibes that were masterfully put together in last week's "Chillin' Me Softly" playlist is the nineteenth installment of VibeRotation. With many different genres intermingling with this rotation, there was a decided choice to transition from the harder bass-hitting hip hop tracks to the more house and pop bass lines that are heard throughout this 17-track playlist. While this iteration stays current with Tyga's new track and a Diplo remix to Rihanna's "B*tch Better Have My Money", it also travels back in time to feature songs/renditions from Mobb Deep, Frankie Beverly, Diana Ross, and Jamiroquai. Enjoy VibeRotation 19 below and be sure to check out our SoundCloud for more tunes curated by yours truly.


text:
Record Club: Velvet Underground & Nico 'Sunday Morning' from Beck Hansen on Vimeo.
Well it's actually Wednesday morning but I've listened to this song 5 times already with no sign of stopping. Recently Beck began working through the album The Velvet Underground & Nico. Each track is filmed and put up on his Record Club page at his site. Beck is the coolest ever.


text:
Search Results: 1 Vacation Rental Found
Modern Retreat on beautiful Georgian BayFrom $225.00 per day
Beautiful Modern Retreat located on the sandy shores of Georgian Bay at Ossossane Beach - 1.5 hrs from Toronto, 30 min from Blue Mountain & Horseshoe Valley & 20 min from Snow Valley. Stunning Lake view from mastersuite, plus 2 additional guestrooms.
- 6 People


text:
X We use cookies to provde the finest expertise attainable. By persevering with to browse the site you might be agreeing to our use of cookies. Please ask us to verify what safety could apply to your booking. Devoted precedence boarding, verify-in and examine-out and dedicated concierge 24 hours a day. Wellness Welcome Package with t-shirt + shorts + sports activities towl + Technogym Wellness Key.
Enter your criteria and we'll discover the best supply across automobile firms. Our guests love the Royal Caribbean expertise, and we have gained the awards to prove it year on 12 months! If you are unable to upgrade and need access to beforehand booked trips, go to the My Trips page.
On a Royal Caribbean® cruise vacation, it is the unimaginable that units us aside. To proceed on , please open or download a modern browser. Our Magic Touches add that bit of brilliance that will assist ensure you Unleash Your Mojo on vacation. In case you're eager to set sail as quickly as doable, take a look at our special offers and final minute cruises Or if you're planning ahead, browse our 2017 cruises.
In two short a long time (1988-2009), the largest class cruise ships have grown a third longer (268 m to 360 m), nearly doubled their widths (32.2 m to 60.5 m), doubled the overall passengers (2,744 to five,four hundred), and tripled in weight (seventy three,000 GT to 225,000 GT).
NECESSARY: MSC Cruises friends are anticipated to be chargeable for their actions always. And all of our holidays are designed that will help you Discover Your Smile. The distinction between ocean liners and cruise ships has blurred, significantly with respect to deployment.


text:
Effect of Antiplatelet Therapy on Surgical Blood Loss and Post-Pancreatectomy Hemorrhage in Patients Undergoing Pancreaticoduodenectomy
Takahisa Fujikawa, Hiroshi Kawamoto, Akira Tanaka
Takahisa Fujikawa, Hiroshi Kawamoto, Akira Tanaka, Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka 802-8555, Japan
Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Takahisa Fujikawa, MD, PhD, FACS, Department of Surgery, 3-2-1 Asano, Kokurakita-Ku, Kitakyushu, Fukuoka 802-8555, Japan.
Email: firstname.lastname@example.com
Telephone: +81-93-511-2000
Fax: +81-93-511-3240
Received: December 28, 2017
Revised: March 13, 2018
Accepted: March 15, 2018
Published online: April 21, 2018
AIM: The aim of the study was to assess the feasibility and safety of pancreaticoduodenectomy (PD) in patients with preoperative antiplatelet therapy (APT) for arterial thromboembolic risks.
METHODS: Consecutive 100 patients receiving PD at our institution between 2005 and 2016 were retrospectively reviewed. APT was regularly used in 31 patients (31%) in this series. Our perioperative management ("Kokura Protocol") included maintenance of preoperative aspirin monotherapy and early postoperative reinstitution in patients at high thromboembolic risks. Outcome variables of patients with APT (APT group) were compared with those of patients without APT.
RESULTS: This series included 31 pancreatic cancer, 27 bile duct cancer, 19 ampullary cancer, 13 intraductal papillary mucinous neoplasms, and 10 others. In APT group, 18 (18%) required preoperative continuation of APT. APT group showed significantly high frequency of history of cerebral infarction and percutaneous coronary intervention. Totally 18 significant pancreatic fistulas (grade B,C, 18%) were observed but no perioperative death was experienced. There was only 1 thromboembolic event (1.0%, cerebral infarction) in a whole cohort, whereas increased surgical blood loss (≥ 1,000 mL) and post-pancreatectomy hemorrhage (PPH) occurred in 11 (11%) and 6 (6.0%, totally grade B), respectively. Multivariate analysis showed that high body mass index (≥ 30 kg/m2) is the only significant risk factor for both increased blood loss and PPH (risk ratio = 13.64 and 27.27, p < 0.05), whereas either APT or preoperative aspirin continuation did not affect perioperative bleeding complications.
CONCLUSION: Even in APT-burdened patients with arterial thromboembolic risks, PD is safely performed under the Kokura Protocol without any increase of blood loss and PPH, although this patient population is still challenging and should be rigorously managed to prevent both bleeding and thromboembolic complications.
Key words: Antiplatelet therapy; Bleeding complication; Harmonic FOCUS®, Pancreaticoduodenectomy, Pinch-burn-cut technique; Thromboembolic complication
© 2018 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.
Fujikawa T, Kawamoto H, Tanaka A. Effect of Antiplatelet Therapy on Surgical Blood Loss and Post-Pancreatectomy Hemorrhage in Patients Undergoing Pancreaticoduodenectomy. Journal of Gastroenterology and Hepatology Research 2018; 7(2): 2561-2568 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/2237
Lately, patients who have histories of cardiovascular or cerebrovascular diseases have been seen more often with aging of patients, and those patients frequently receive antiplatelet therapy (APT) for the purpose of primary and secondary prevention of arterial thromboembolic diseases. While indications for APT use have expanded, antithrombotic management during gastrointestinal and/or hepatobiliary-pancreatic surgery is still difficult and often bothersome because of increased risks of perioperative bleeding or thromboembolic events[1-4]. In our institution, a protocol of risk stratification and perioperative antithrombotic management has been established for APT-burdened patients ("Kokura Protocol"), which includes preoperative continuation of aspirin monotherapy in patients with high thromboembolic risks5, 6. So far, the safety of both open and laparoscopic abdominal surgeries under the Kokura Protocol have been reported with relatively low rates of bleeding and thromboembolic complications[5-7].
Pancreaticoduodenectomy (PD) is a highly invasive procedure and may expose patients to high risks of severe postoperative complications. Although mortality after PD has markedly decreased to less than 5% thanks to advance in operative techniques and perioperative management8, 9, postoperative complication rates still remain high at 18-50%[8-11]. The common types of postoperative complications are postoperative pancreatic fistula (POPF), deep surgical site infection (SSI), and post-pancreatectomy hemorrhage (PPH). PPH is related to a high mortality rate of up to 60%[8-16], and its incidence is at 3-16% after overall pancreatic resection[8-11], and at 8-29% after PD[13-16]. When PD is performed especially in APT-burdened patients with high thromboembolic risks, rigorous perioperative antithrombotic management and meticulous intraoperative hemostatic procedures are required to prevent both bleeding and thromboembolic complications. To date, the effect of APT on perioperative complications, especially on surgical blood loss and PPH, in patients undergoing PD still remains unclear.
The aim of this study is to review consecutive 100 patients undergoing PD and to assess the safety and feasibility of PD in thromboembolic risk patients receiving APT.
Between March 2005 and April 2016, totally 506 patients received major hepatobiliary and pancreatic surgery at our institution, among which pancreatic resection was performed in 155 patients. After excluding patients receiving distal or other pancreatectomy, 100 consecutive patients undergoing PD were included in the current study (Figure 1). Background, perioperative and outcome variables of the patients were collected through a standardized review of the electronic surgery database as well as hospital and clinic charts. The status of patients' symptoms and functions regarding ambulatory status was described according to the ECOG Scale of Performance Status[17].
Surgical procedures in this cohort included classical PD (PD with two-thirds distal gastrectomy), pylorus-preserving PD, and subtotal stomach-preserving PD (SSpPD). Our technical aspects during PD, especially in antiplatelet-burdened patients, was previously reported with satisfactory short-term outcomes[18]. Briefly, we use modified Pinch-Burn-Cut (PBC) technique (the technique from living-donor liver transplantation[19,20]) in combination with ultrasonically activated shears with a curved thin tip (Harmonic FOCUS®, Ethicon Endo-Surgery, Cincinnati, OH)[21,22] during PD to minimize surgical blood loss and this modality was also useful even under continuation of preoperative aspirin monotherapy. All procedures were performed by or under the guidance of one of the attending surgeons at our institution.
We established and conducted our perioperative antithrombotic management system for abdominal and general surgery, which consisted of thromboembolic risk stratification and perioperative antithrombotic management protocol ("Kokura Protocol"), and have shown that both open and laparoscopic abdominal surgeries in patients with antiplatelet therapy can be performed safely under the Kokura Protocol[5-7]. The protocol generally consisted of interrupting APT one week before surgery and early postoperative reinstitution in low thromboembolic risk patients, although in case of high thromboembolic risks such as patients with drug-eluting coronary stent (DES) implantation or those with cerebrovascular reconstruction within 3 months, aspirin monotherapy was continued preoperatively, followed by early postoperative reinstitution.
Postoperative complications were assessed and categorized by Clavien-Dindo classification (CDC)[23] and CDC class II or higher was considered significant. POPF was defined according to the definition of the International Study Group of Postoperative Pancreatic Fistula (ISGPF)[24]. PPH was defined according to the definition of the International Study Group of Pancreatic Surgery (ISGPS)[25], and the condition was classified on the basis of three parameters; time of onset, location, and severity. Three different grades of PPH were classified using these parameters. Postoperative thromboembolic complication was defined as previously described[5,6], including myocardial infarction, cerebral infarction, mesenteric infarction, and pulmonary thromboembolism. Operative mortality included death within 30 days after surgery.
The primary outcome included excessive intraoperative blood loss (1,000 mL or more), PPH, and postoperative thromboembolic complications. Background characteristics, perioperative factors, and outcome variables were compared between patients receiving APT (APT group) and those without APT (non-APT group). Univariate and multivariate analyses were performed to assess the risk factors for excessive intraoperative blood loss and PPH.
The categorized data in each group were compared by chi-square or Fisher's exact probability test. Continuous variables in the characteristics were expressed as a median with range and compared by Student's T test or Kruskal-Wallis test. Non-parametric variables were also compared using Kruskal-Wallis test. Multivariable logistic regression analyses were performed to determine risk factors affecting excessive intraoperative blood loss or PPH. Statistical significance was set at p < 0.05. Data were analyzed using the SPSS package software.
Our institutional review board approved the current study.
Among patients in the current study, 31% (31/100) of patients undergoing PD received APT. Table 1 shows background characteristics of patients in each group. The patients in the cohort were totally Asian. The median ages in the APT and non-APT groups were 73 and 73 years, respectively. History of percutaneous coronary intervention (PCI, p < 0.001) and coronary artery bypass graft (p = 0.028), and history of cerebral infarction (p = 0.003) were more common in the APT group. There was also a significant difference between the groups in the rate of anticoagulation therapy (p = 0.044) and perioperative heparin bridging (p = 0.010). In the APT group, 18 patients (18.0%) were classified into high risk for arterial thromboembolism, and were managed with preoperative continuation of aspirin monotherapy.
|Table 1 Background characteristics of patients in the cohort
|Total (n=100)
|APT (n=31)
|non-APT (n=69)
|p value
|Age, y, median (range)
|73 (37-86)
|73 (60-84)
|73 (37-86)
|Gender, n (%)
|33 (33.0)
|9 (29.0)
|24 (34.8)
|67 (67.0)
|22 (71.0)
|45 (65.2)
|95 (95.0)
|31 (100.0)
|64 (92.8)
|5 (5.0)
|0 (0.0)
|5 (7.2)
|Performance status, n (%)
|92 (92.0)
|28 (90.3)
|64 (92.8)
|8 (8.0)
|3 (9.7)
|5 (7.2)
|Concurrent diseases, n (%)
|Diabetes mellitus
|27 (27.0)
|10 (32.3)
|17 (24.6)
|Hx of congestive heart failure
|6 (6.0)
|4 (12.9)
|2 (2.9)
|Coronary artery disease
|Hx of PCI
|15 (15.0)
|15 (48.4)
|0 (0.0)
|Hx of CABG
|3 (3.0)
|3 (9.7)
|0 (0.0)
|Hx of cerebral infarction
|11 (11.0)
|8 (25.8)
|3 (4.3)
|Current hemo-/peritoneal dialysis
|4 (4.0)
|1 (3.2)
|3 (4.3)
|Anticoagulation therapy, n (%)
|12 (12.0)
|7 (22.6)
|5 (7.2)
|Periop. Heparin bridging, n (%)
|14 (14.0)
|9 (29.0)
|5 (7.2)
|Preop. Aspirin continuation, n (%)
|18 (18.0)
|18 (58.1)
|*Abbreviations: APT; antiplatelet therapy, BMI; body mass index, PCI; percutaneous coronary intervention, CABG: coronary artery bypass graft, periop.; perioperative, preop.; preoperative.
Table 2 shows operative procedures and postoperative morbidity of patients in each group. The current series included pancreatic cancer in 31 (31.0%), bile duct cancer in 27 (27.0%), ampullary cancer in 19 (19.0%), and intraductal papillary mucinous neoplasms in 13 (13.0%). There was no difference in the type of diseases between the groups (p = 0.091). The most prevalent types of the operative procedure, pancreatic reconstruction, and texture of the remnant pancreas were SSpPD (95.0%), pancreatico-jejunostomy (93.0%), and soft pancreas (71.0%), respectively; no significant difference was observed in these factors between the groups. The duration of operation, estimated surgical blood loss, rates of intraoperative transfusion were also identical between the groups. Increased surgical blood loss (≥ 1,000 mL) occurred in 11 (11.0%) patients, but no case suffering uncontrollable excessive intraoperative bleeding due to the continuation of APT and requiring platelet transfusion was experienced in the APT group.
|Table 2 Factors concerning operative procedures and postoperative morbidity
|Total (n=100)
|APT (n=31)
|non-APT (n=69)
|p value
|Type of diseases, n (%)
|Pancreatic cancer
|31 (31.0)
|14 (45.2)
|17 (24.6)
|Bile duct cancer
|27 (27.0)
|5 (16.1)
|22 (31.9)
|Ampullary cancer
|19 (19.0)
|8 (25.8)
|11 (15.9)
|Intraductal papillary mucinous neoplasms
|13 (13.0)
|2 (6.5)
|11 (15.9)
|10 (10.0)
|2 (6.5)
|8 (11.6)
|Type of operation, n (%)
|Subtotal stomach preserving PD
|95 (95.0)
|29 (93.6)
|66 (95.7)
|Conventional PD
|2 (2.0)
|1 (3.2)
|1 (1.4)
|Pylorus-preserving PD
|3 (3.0)
|1 (3.2)
|2 (2.9)
|Mode of pancreatic reconstruction, n (%)
|93 (93.0)
|30 (96.8)
|63 (91.3)
|7 (7.0)
|1 (3.2)
|6 (8.7)
|Texture of the remnant pancreas, n (%)
|Soft pancreas
|71 (71.0)
|18 (58.1)
|53 (76.8)
|Hard pancreas
|29 (29.0)
|13 (41.9)
|16 (23.2)
|Diameter of MPD, mm, median (range)
|4 (1-12)
|4 (1-12)
|4 (1-10)
|Duration of ope., min, median (range)
|438 (310-710)
|474 (320-587)
|430 (310-710)
|Surgical blood loss, mL, median (range)
|500 (10-2470)
|530 (50-2250)
|500 (10-2470)
|Intraoperative RBC transfusion, n (%)
|18 (18.0)
|8 (25.8)
|10 (14.5)
|Postoperative complication, n (%)
|59 (59.0)
|19 (61.3)
|40 (57.9)
|POPF (Grade B,C)
|18 (18.0)
|6 (19.3)
|12 (17.4)
|deep SSI
|11 (11.0)
|4 (12.9)
|7 (10.1)
|Anastomotic/bile leak
|5 (5.0)
|1 (3.2)
|4 (5.8)
|4 (4.0)
|0 (0.0)
|4 (5.8)
|Pulmonary infection
|4 (4.0)
|3 (9.6)
|1 (1.4)
|Cardiac insufficiency
|2 (2.0)
|1 (3.2)
|1 (1.4)
|Small bowel obstruction
|1 (1.0)
|0 (0.0)
|1 (1.4)
|Bleeding complication (PPH)
|6 (6.0)
|4 (12.9)
|2 (2.9)
|Thromboembolic complication
|1 (1.0)
|1 (3.2)
|0 (0.0)
|Operative mortality, n (%)
|0 (0.0)
|0 (0.0)
|0 (0.0)
|Length of postop. stay, d, median (range)
|29 (13-212)
|29 (15-212)
|32 (13-132)
|*Abbreviations: APT: antiplatelet therapy; PD: pancreaticoduodenectomy; MPD: main pancreatic duct; RBC: red blood cell; ope.: operation; POPF: postoperative pancreatic fistula; SSI: surgical site infection; DGE: delayed gastric emptying; PPH: post-pancreatectomy hemorrhage; postop.: postoperative.
Postoperative complications developed in 41.0% of overall patients. The most common complication was POPF (18.0%, Grade B/C according to ISGPF definition); the occurrence of POPF was similar between the groups. There was only 1 thromboembolic event (1.0%, cerebral infarction) in a whole cohort. PPH occurred in 6 patients (6.0%); all 6 PPH was classified into Grade B including 2 extra-luminal and 4 intra-luminal bleeding. No case of Grade C PPH requiring urgent hemostasis by relaparotomy or interventional arterial coiling was experienced in the current cohort.
Univariate and multivariate analyses for increased surgical blood loss and PPH were performed and shown in Table 3 and Figure 2, respectively. High body mass index (BMI, ≥ 30 kg/m2) was the only significant risk factor for increased surgical blood loss on both univariate and multivariate analyses [risk ratio (RR) = 13.64, p = 0.011], although use of APT or preoperative continuation of aspirin was not significantly associated. Concerning PPH, history of PCI was significantly associated on univariate analysis, although only high BMI was independently associated with PPH on the multivariate analysis (RR = 27.27, p = 0.038). Neither APT use nor preoperative aspirin continuation was a significant risk factor for PPH.
|Table 3 Univariate analysis of increased surgical blood loss (>=1,000 mL) and postpancreatectomy hemorrhage in the cohort, n=100.
|Increased surgical blood loss
|Postpancreatectomy Haemorrhage
|present/total (%)
|present/total (%)
|11/100 (11.0)
|6/100 (6.0)
|>=80 years
|8/86 (9.3)
|2/14 (14.3)
|<80 years
|3/14 (21.4)
|4/86 (4.7)
|3/33 (9.1)
|0/33 (0.0)
|8/67 (11.9)
|6/67 (9.0)
|BMI, n (%)
|<30 kg/m2
|8/95 (8.4)
|5/95 (5.3)
|>=30 kg/m2
|3/5 (60.0)
|1/5 (20.0)
|Performance status
|9/92 (9.8)
|6/92 (6.5)
|2/8 (25.0)
|0/8 (0.0)
|Diabetes mellitus
|3/27 (11.1)
|2/27 (7.4)
|8/73 (11.0)
|4/73 (5.5)
|Hx of CI/TIA
|1/11 (9.1)
|1/11 (9.1)
|10/89 (11.2)
|5/89 (5.6)
|Hx of PCI, n (%)
|0/15 (0.0)
|3/15 (20.0)
|11/85 (12.9)
|3/85 (3.5)
|APT used
|1/31 (3.2)
|4/31 (12.9)
|10/69 (14.5)
|2/69 (2.9)
|Preop. aspirin continuation
|0/18 (0.0)
|3/18 (16.7)
|11/82 (13.4)
|3/82 (3.7)
|Anticoagulation used
|3/12 (25.0)
|1/12 (8.3)
|8/88 (9.1)
|5/88 (5.7)
|Periop. heparin bridging
|3/14 (21.4)
|2/14 (14.3)
|8/86 (9.3)
|4/86 (4.7)
|Texture of the remnant pancreas
|Soft pancreas
|7/71 (9.9)
|5/71 (7.0)
|Hard pancreas
|4/29 (13.8)
|1/29 (3.4)
|Presence of major pancreatic fistula
|0/18 (0.0)
|0/18 (0.0)
|11/82 (13.4)
|6/82 (7.3)
|*Abbreviations: BMI: body mass index; APT: antiplatelet therapy; CI: cerebral infarction,; TIA: transient ischemic attack; PCI: percutaneous coronary intervention; preop: preoperative; periop: perioperative.
Our study demonstrated that the current cohort comprised 100 patients undergoing PD, among which 31% were receiving APT. According to our perioperative management protocol, aspirin monotherapy was maintained perioperatively in case of high thromboembolic risks. The rate of thromboembolic event is only 1.0% in the whole cohort, whereas the occurrence of increased blood loss and PPH were 11% and 6%, respectively. Multivariate analysis showed that high BMI is the only significant risk factor for both increased blood loss and PPH, but either use of APT or preoperative aspirin continuation did not affect bleeding complications. Thus, PD is performed safely without increase of surgical blood loss, PPH, or thromboembolic complications even in APT-burdened patients.
Since APT for prevention of cardiovascular/cerebrovascular events is widely used[26-28], patients receiving APT frequently receive surgical procedures. About 5-15% of patients who received coronary stent implantation have undergone non-cardiac surgery within 2 years[29]. Premature discontinuation of antiplatelet agents is the known risk factor for late coronary stent thrombosis, which is rare but life-threatening sequelae with the mortality rate at 9-45%[28-30]. We have to balance bleeding risk against thromboembolic risk in patients undergoing APT. Current guidelines of post-PCI surgical intervention specify that in the perioperative period, the continuation of APT, but not using heparin bridging, should be considered, particularly in high thromboembolic risk patients[31-34]. In addition, recent trends in several guidelines clearly show that prevention of thromboembolism is more important since it might cause severe postoperative life-threatening complications[35-38]. If the thromboembolic risk is low, interruption of antiplatelets might be possible. However, if the risk of thromboembolism is high, continuation of at least single APT is adequate. Considering those circumstances, we have established our own perioperative antithrombotic protocol ("Kokura Protocol"), and shown that both laparoscopic and open abdominal surgery can be safely performed even in APT-prescribed patients under the Kokura Protocol[5-7]. The current study also demonstrated that the Kokura Protocol is valid and feasible in the setting of performing PD, resulting in satisfactorily low incidence of thromboembolic events and PPH even under the high prevalence of APT-burdened patients.
Concerning perioperative arterial thromboembolic complications including cerebrovascular stroke or major adverse cardiovascular event (MACE), the rates of perioperative thromboembolisms vary depending on differences in patient population, study design, and changing clinical practices. In cardiac, neurologic, and carotid surgery, the incidence of perioperative stroke is known to be high (2.2-5.2%)[39,40]; the reported incidence of stroke following noncardiac, nonneurosurgical surgery ranges between 0.1-0.4% overall, and 2.9-3.5% in patients at risk of perioperative stroke[41-44]. In consideration of thromboembolic events after PD, the prevalence of thromboembolism seems to be higher. Haigh et al. reported that analyzing 2,610 patients undergoing PD from the American College of Surgeons-National Surgical Quality Improvement Program database, a rate of MACE after PD in the whole cohort was at 1.9%, and that in the elderly (aged > 70 years) was at 3.0%[45]. The current study demonstrated that the incidence of perioperative thromboembolic complication was maintained at 1.0%, a relatively low rate compared to the previous report. Thus, it is suggested that PD is performed safely under the Kokura Protocol, with successful inhibition of thromboembolic events even in patients having thromboembolic risks.
Reduction of intraoperative blood loss and PPH is another important goal when PD is performed, and various technical development has been introduced[21,22,46]. In our institution, the rate of APT-burdened patients requiring major hepatobiliary and pancreatic surgery is almost 30-40%, and the number is expected to be increasing. For this reason, a simple but strong hemostatic devices and technique should be adopted and utilized especially in this critical patient population. In this aspect, the combination of modified PBC technique and Harmonic FOCUS® is one of the preferred technical options during PD to minimize surgical blood loss18.
It was reported that several operations such as hip arthroplasty, neurosurgical surgery, or gastrectomy might be associated with increased surgical blood loss and postoperative hemorrhage when performed in patients receiving antithrombotic agents[3,47,48]. Concerning the pancreatic surgery, however, only one report from Japan reported the effect of antiplatelets and anticoagulation on PPH after pancreatic resection[12], and they concluded that rigid thromboprophylaxis including antiplatelet continuation and heparin bridging was significantly related to PPH. The incidence of PPH in their study was relatively high with the rate of 11.4% (18/158), among which 7 (4.4%) patients were grade C and PPH-associated mortality rate was 16.7%. In the current study, the incidence of PPH in the whole cohort was 6.0%, and there was no patient with grade C PPH and the mortality was zero; it is concluded that use of APT and occurrence of PPH was independent in the current series. Active intervention for rigid hemostasis using several techniques and devices could reduce intraoperative surgical blood loss, as well as the incidence of PPH[18,21,46]. Not only the rigorous perioperative antithrombotic management, but also various modification and innovation in technique, like the procedures proposed by us or others, can lead us to perform PD, a highly invasive procedure, more safely even in antiplatelet-burdened patients with high thromboembolic risks.
The present study possesses some limitations. It is a retrospective cohort study from a single institution, which weakens the statistical efficacy and conclusion. This restriction will be lessened in a later follow-up study or in a prospective multicenter study. Additionally, as we continue to manage APT patients undergoing PD using the same surgical policy and perioperative management protocol, we will accumulate more patients to help us understand the safety of our management in this challenging patient population.
Analyzing consecutive 100 patients undergoing pancreaticoduodenectomy, we showed that this procedure is safely performed even in antiplatelet-burdened patients with arterial thromboembolic risks without any increase of surgical blood loss or PPH, although this challenging group should be managed carefully to prevent severe postoperative complications.
1. Fujikawa T, Maekawa H, Shiraishi K, Tanaka A. Successful resection of complicated bleeding arteriovenous malformation of the jejunum in patients starting dual anti-platelet therapy just after implanting drug-eluting coronary stent. BMJ Case Rep 2012; Sep 24; 2012. [DOI: 10.1136/bcr-2012-006779].
2. Fujikawa T, Noda T, Tada S, Tanaka A. Intractable intraoperative bleeding requiring platelet transfusion during emergent cholecystectomy in a patient with dual antiplatelet therapy after drug-eluting coronary stent implantation (with video). BMJ Case Rep 2013; Mar 26; 2013. [PMID: 23536626]; [PMCID: PMC3618701]; [DOI: 10.1136/bcr-2013-008948].
3. Mita K, Ito H, Murabayashi R, Sueyoshi K, Asakawa H, Nabetani M, Kamasako A, Koizumi K, Hayashi T. Postoperative bleeding complications after gastric cancer surgery in patients receiving anticoagulation and/or antiplatelet agents. Ann Surg Oncol 2012; 19(12): 3745-3752. [PMID: 22805868]; [DOI: 10.1245/s10434-012-2500-6]
4. Thachil J, Gatt A, Martlew V. Management of surgical patients receiving anticoagulation and antiplatelet agents. Br J Surg 2008; 95(12): 1437-1448. [PMID: 18991253]; [DOI: 10.1002/bjs.6381]
5. Fujikawa T, Tanaka A, Abe T, Yoshimoto Y, Tada S, Maekawa H. Effect of antiplatelet therapy on patients undergoing gastroenterological surgery: thromboembolic risks versus bleeding risks during its perioperative withdrawal. World J Surg 2015; 39(1): 139-149. [PMID: 25201469]; [DOI: 10.1007/s00268-014-2760-3]
6. Fujikawa T, Tanaka A, Abe T, Yoshimoto Y, Tada S, Maekawa H, Shimoike N. Does antiplatelet therapy affect outcomes of patients receiving abdominal laparoscopic surgery? Lessons from more than 1,000 laparoscopic operations in a single tertiary referral hospital. J Am Coll Surg 2013; 217(6): 1044-1053. [PMID: 24051069]; [DOI: 10.1016/j.jamcollsurg.2013.08.005]
7. Fujikawa T, Yoshimoto Y, Kawamura Y, Kawamoto H, Yamamoto T, Tanaka A. Safety and feasibility of laparoscopic liver resection in antiplatelet-burdened patients with arterial thromboembolic risks. J Gastroenterol Hepatol Res 2016; 5(5): 2165-2172.
8. Darnis B, Lebeau R, Chopin-Laly X, Adham M. Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database. Langenbecks Arch Surg 2013; 398(3): 441-448. [PMID: 23435636]; [DOI: 10.1007/s00423-013-1047-8]
9. Yekebas EF, Wolfram L, Cataldegirmen G, Habermann CR, Bogoevski D, Koenig AM, Kaifi J, Schurr PG, Bubenheim M, Nolte-Ernsting C, Adam G, Izbicki JR. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg 2007; 246(2): 269-280. [PMID: 17667506] [PMCID: PMC1933568]; [DOI: 10.1097/01.sla.0000262953.77735.db]
10. Correa-Gallego C, Brennan MF, D'Angelica MI, DeMatteo RP, Fong Y, Kingham TP, Jarnagin WR, Allen PJ. Contemporary experience with postpancreatectomy hemorrhage: results of 1,122 patients resected between 2006 and 2011. J Am Coll Surg 2012; 215(5): 616-621. [PMID: 22921325]; [DOI: 10.1016/j.jamcollsurg.2012.07.010]
11. Roulin D, Cerantola Y, Demartines N, Schafer M. Systematic review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg 2011; 15(6): 1055-1062. [PMID: 21267670]; [DOI: 10.1007/s11605-011-1427-8]
12. Mita K, Ito H, Takahashi K, Hashimoto M, Nagayasu K, Murabayashi R, Asakawa H, Koizumi K, Hayashi T, Fujino K. Postpancreatectomy Hemorrhage After Pancreatic Surgery in Patients Receiving Anticoagulation or Antiplatelet Agents. Surg Innov 2016; 23(3): 284-290. [PMID: 26611788]; [DOI: 10.1177/1553350615618288]
13. Ricci C, Casadei R, Buscemi S, Minni F. Late postpancreatectomy hemorrhage after pancreaticoduodenectomy: is it possible to recognize risk factors? JOP 2012; 13(2): 193-198. [PMID: 22406600]
14. Welsch T, Eisele H, Zschabitz S, Hinz U, Buchler MW, Wente MN. Critical appraisal of the International Study Group of Pancreatic Surgery (ISGPS) consensus definition of postoperative hemorrhage after pancreatoduodenectomy. Langenbecks Arch Surg 2011; 396(6): 783-791. [PMID: 21611815]; [DOI: 10.1007/s00423-011-0811-x]
15. Sanjay P, Fawzi A, Fulke JL, Kulli C, Tait IS, Zealley IA, Polignano FM. Late post pancreatectomy haemorrhage. Risk factors and modern management. JOP 2010; 11(3): 220-225. [PMID: 20442515]
16. Rumstadt B, Schwab M, Korth P, Samman M, Trede M. Hemorrhage after pancreatoduodenectomy. Ann Surg 1998; 227(2): 236-241.
17. Sorensen JB, Klee M, Palshof T, Hansen HH. Performance status assessment in cancer patients. An inter-observer variability study. Br J Cancer 1993; 67(4): 773-775. [PMID: 8471434]; [PMCID: PMC1968363]
18. Fujikawa T, Yoshimoto Y, Kawamoto H, Tanaka A. Combination of modified Pinch-Burn-Cut (PBC) technique and Harmonic FOCUS® for pancreaticoduodenectomy under preoperative continuation of antiplatelets in patients with high thromboembolic risks. J Gastroenterol Hepatol Res 2017; (in press).
19. Park YK, Kim BW, Wang HJ, Xu W. Usefulness of the Pinch-Burn-Cut (PBC) technique for recipient hepatectomy in liver transplantation. Korean J Hepatobiliary Pancreat Surg 2012; 16(1): 13-16. [PMID: 26388900]; [PMCID: PMC4575015]; [DOI: 10.14701/kjhbps.2012.16.1.13]
20. Tanaka K, Inomata Y, Kaihara S. Living-donor liver transplantation: Surgical techniques and innovations. Barcelona, Spain: Prous science 2007.
21. Salvia R, Malleo G, Marchegiani G, Butturini G, Esposito A, Bassi C. Pancreaticoduodenectomy with harmonic focust curved shears for cancer. Dig Surg 2014; 31(4-5): 249-254. [PMID: 25323993]; [DOI: 10.1159/000363071] 22. Satoi S, Yanagimoto H, Toyokawa H. Use of the new ultrasonically curved shear in pancreaticoduodenectomy for periampullary cancer. J Hepatobiliary Pancreat Sci 2011; 18(4): 609-614. [PMID: 21331806]; [DOI: 10.1007/s00534-011-0370-0]
23. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240(2): 205-213. [PMID: 15273542]; [PMCID: PMC1360123]
24. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138(1): 8-13. [PMID: 16003309]; [DOI: 10.1016/j.surg.2005.05.001]
25. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142(1): 20-25. [PMID: 17629996]; [DOI: 10.1016/j.surg.2007.02.001]
26. Cattaneo M. Aspirin and clopidogrel: efficacy, safety, and the issue of drug resistance. Arterioscler Thromb Vasc Biol 2004; 24(11): 1980-1987. [PMID: 15388526]; [DOI: 10.1161/01.ATV.0000145980.39477.a9]
27. Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, Halperin JL, Johnston SC, Katzan I, Kernan WN, Mitchell PH, Ovbiagele B, Palesch YY, Sacco RL, Schwamm LH, Wassertheil-Smoller S, Turan TN, Wentworth D. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke 2011; 42(1): 227-276.
28. King SB, 3rd, Smith SC, Jr., Hirshfeld JW, Jr., Jacobs AK, Morrison DA, Williams DO, Feldman TE, Kern MJ, O'Neill WW, Schaff HV, Whitlow PL, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 2008; 51(2): 172-209. [PMID: 18191745]; [DOI: 10.1016/j.jacc.2007.10.002]
29. Capodanno D, Angiolillo DJ. Management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery. Circulation 2013; 128(25): 2785-2798. [PMID: 24366588]; [DOI: 10.1161/CIRCULATIONAHA.113.003675]
30. Grines CL, Bonow RO, Casey DE, Jr., Gardner TJ, Lockhart PB, Moliterno DJ, O'Gara P, Whitlow P. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007; 115(6): 813-818. [PMID: 17224480]; [DOI: 10.1161/CIRCULATIONAHA.106.180944]
31. Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2 Suppl): e326S-350S. [PMID: 22315266]; [PMCID: PMC3278059]; [DOI: 10.1378/chest.11-2298]
32. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009; 54(22): e13-e118. [PMID: 19926002]; [DOI: 10.1016/j.jacc.2009.07.010]
33. Korte W, Cattaneo M, Chassot PG, Eichinger S, von Heymann C, Hofmann N, Rickli H, Spannagl M, Ziegler B, Verheugt F, Huber K. Peri-operative management of antiplatelet therapy in patients with coronary artery disease: joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (OGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC). Thromb Haemost 2011; 105(5): 743-749. [PMID: 21437351]; [DOI: 10.1160/TH10-04-0217]
34. Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gorenek B, Hennerici MG, Iung B, Kelm M, Kjeldsen KP, Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid JP, Sellevold OF, Sicari R, Van den Berghe G, Vermassen F. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009; 30(22): 2769-2812. [PMID: 19713421]; [DOI: 10.1093/eurheartj/ehp337]
35. Anderson MA, Ben-Menachem T, Gan SI, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fukami N, Ikenberry SO, Jain R, Khan K, Krinsky ML, Lichtenstein DR, Maple JT, Shen B, Strohmeyer L, Baron T, Dominitz JA. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70(6): 1060-1070. [PMID: 19889407]; [DOI: 10.1016/j.gie.2009.09.040]
36. Boustiere C, Veitch A, Vanbiervliet G, Bulois P, Deprez P, Laquiere A, Laugier R, Lesur G, Mosler P, Nalet B, Napoleon B, Rembacken B, Ajzenberg N, Collet JP, Baron T, Dumonceau JM. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2011; 43(5): 445-461. [PMID: 21547880]; [DOI: 10.1055/s-0030-1256317]
37. Cardona-Tortajada F, Sainz-Gomez E, Figuerido-Garmendia J, de Robles-Adsuar AL, Morte-Casabo A, Giner-Munoz F, Artazcoz-Oses J, Vidan-Lizari J. Dental extractions in patients on antiplatelet therapy. A study conducted by the Oral Health Department of the Navarre Health Service (Spain). Med Oral Patol Oral Cir Bucal 2009; 14(11): e588-592. [PMID: 19680200]
38. Center for Science Information ASI. Anticoagulant and Antiplatelet Medications and Dental Procedures. American Dental Association Website. Accessed December 29, 2016.
39. Ng JL, Chan MT, Gelb AW. Perioperative stroke in noncardiac, nonneurosurgical surgery. Anesthesiology 2011; 115(4): 879-890. [PMID: 21862923]; [DOI: 10.1097/ALN.0b013e31822e9499]
40. Wong GY, Warner DO, Schroeder DR, Offord KP, Warner MA, Maxson PM, Whisnant JP. Risk of surgery and anesthesia for ischemic stroke. Anesthesiology 2000; 92(2): 425-432. [PMID: 10691229]
41. Landercasper J, Merz BJ, Cogbill TH, Strutt PJ, Cochrane RH, Olson RA, Hutter RD. Perioperative stroke risk in 173 consecutive patients with a past history of stroke. Arch Surg 1990; 125(8): 986-989. [PMID: 2378564]
42. Larsen SF, Zaric D, Boysen G. Postoperative cerebrovascular accidents in general surgery. Acta Anaesthesiol Scand 1988; 32(8): 698-701. [PMID: 3213396]
43. Limburg M, Wijdicks EF, Li H. Ischemic stroke after surgical procedures: clinical features, neuroimaging, and risk factors. Neurology 1998; 50(4): 895-901. [PMID: 9566369]
44. Parikh S, Cohen JR. Perioperative stroke after general surgical procedures. N Y State J Med 1993; 93(3): 162-165. [PMID: 8455845]
45. Haigh PI, Bilimoria KY, DiFronzo LA. Early postoperative outcomes after pancreaticoduodenectomy in the elderly. Arch Surg 2011; 146(6): 715-723. [PMID: 21690449]; [DOI: 10.1001/archsurg.2011.115]
46. Ball CG, Dixon E, Vollmer CM, Howard TJ. The view from 10,000 procedures: technical tips and wisdom from master pancreatic surgeons to avoid hemorrhage during pancreaticoduodenectomy. BMC Surg 2015; 15: 122. [PMID: 26608343]; [PMCID: PMC4660662]; [DOI: 10.1186/s12893-015-0109-y]
47. Nuttall GA, Santrach PJ, Oliver WC, Jr., Horlocker TT, Shaughnessy WJ, Cabanela ME, Bryant S. The predictors of red cell transfusions in total hip arthroplasties. Transfusion 1996; 36(2): 144-149. [PMID: 8614965]
48. Palmer JD, Sparrow OC, Iannotti F. Postoperative hematoma: a 5-year survey and identification of avoidable risk factors. Neurosurgery 1994; 35(6): 1061-1064; discussion 1064-1065. [PMID: 7885549]
- There are currently no refbacks.
This work is licensed under a Creative Commons Attribution 3.0 License.


text:
Attract Visits
Attract Visits
AttractVisits incorporates our new revamped algorithm to optimize the traffic driven and exposure received to your website. Integrating the vision of the company with the pin-point marketing precision of our software, we are able to cater to multi-layered niches and penetrate overlooked market sectors.
Project Details
Client Name : Attract Visits
Location : Online Store
Website : http://attractvisits.com/


text:
Promoting Cleaner Fuels and Vehicles Worldwide
The Partnership for Clean Fuels and Vehicles (PCFV) is a global public-private partnership working with developing and transitional countries to reduce air pollution from vehicles through the promotion of cleaner fuels and vehicles.
EPA was a charter member of the Partnership, which began its work in 2002 and now includes 73 partners. The partnership kicked off its international cooperation with a focus on the promotion of unleaded fuels. It has achieved great success with the use of leaded gasoline being virtually eliminated, with only one country still using exclusively leaded gasoline as of 2018.
The PCFV helped get lead out of gasoline globally, resulting in economic benefits from the prevention of lead exposure in children everywhere. [Reference: Peter L. Tsai and Thomas H. Hatfield. "Global Benefits From the Phaseout of Leaded Fuel." Journal of Environmental Health. 74: 8-14. 2011.]
Beginning in 2008, the PCFV's second focus area has been to reduce sulfur in fuels. At that time, few developing countries had low sulfur fuel policies. Since 2009, the PCFV has helped more than 20 countries – whose populations total over 1.7 billion – implement low sulfur diesel fuel standards (50 ppm or below). This effort has significantly reduced sulfur dioxides and particulate matter, both of which have significant impacts on human health.
Most recently, the PCFV has launched a third campaign – the vehicles campaign – recognizing that governments that have been successful in securing cleaner fuels will achieve greater environmental and health impacts by combining cleaner fuels with cleaner vehicles that take advantage of innovative emission control technologies.
The PCFV engages governments and stakeholders in developing countries:
- To eliminate lead in gasoline globally. There are only a few countries left still using only leaded fuels or offering both leaded and unleaded fuels. View regional and global updates on progress removing lead from fuels. Exit
- For all countries to have access to fuel with 50 ppm sulfur. For comparison, the United States uses 15 ppm sulfur diesel fuel; most developing countries offer fuels that are much higher in sulfur content. View regional and global updates on progress reducing sulfur content in fuels. Exit
- To promote the introduction of cleaner, more efficient vehicles. Since 2012 six developing countries have adopted vehicle emission standards, and additional countries are using the PCFV Regulatory Toolkit Exitto develop standards.
Evaluations, Tools and Outcomes from PCFV's Work
Click to open the tabs below.
- PCFV Regulatory Toolkit
The Partnership for Clean Fuels and Vehicles (PCFV) has been working with developing and transitional countries to reduce vehicular air pollution through the promotion of cleaner fuels and vehicles. With support from EPA and Environment Canada, the PCFV created a regulatory toolkit to introduce the need for a systems approach to vehicle emission reduction. A systems approach matches fuels and vehicle improvements - to move towards tighter vehicle emissions regulations.
This toolkit supports developing and transitional countries to introduce requirements for 50 ppm and below sulfur fuels; produce or import lower emitting and more efficient vehicle technologies; establish vehicle emissions control roadmaps; and ultimately improve air quality and human health in these countries.
- Tools for Decision-Makers – Clean Fleet Management Toolkit
To promote low sulfur fuels and the introduction of cleaner vehicles, PCFV developed a Toolkit for Clean Fleet Strategy Development Exit to assist vehicle fleet managers to assess the air quality impact of their fleets. The PCFV also provides training on this toolkit and has delivered trainings in Asia Pacific, Central and Eastern Europe, and Latin America and the Caribbean.The training prepares public and private on-road vehicle fleet managers to:1. evaluate the impacts of their fleets on the environment and human health, and then2. develop a practical strategy for corrective and cost-effective action.
- Promoting Cleaner Fuels in Indonesia
From 2010-2016, EPA worked with Indonesia to develop cost-benefit analyses to promote government fiscal policies, to create and foster dialogue amongst a cross-government and industry stakeholders group, and to engage the government-owned petroleum company Pertamina. As a result of this work, Indonesia plans to introduce low sulfur fuels that meet the PCFV target of 50 ppm.
- PCFV Evaluation by EPA (December 2011)
Since the launch of the Partnership for Clean Fuels and Vehicles Lead Campaign in 2002, nearly all of the 100-plus countries using leaded fuel at that time have eliminated lead from their fuel supplies. As a result, the Lead Campaign for the PCFV is considered to have been successfully completed. In follow up to this success, EPA sponsored a third party evaluation in 2011 to identify and examine lessons and design principles for successful partnership that may apply to other existing or future international partnerships.FindingsPCFV Lead Campaign Startup and DesignThe evaluators found four factors which supported a strong start and successful implementation of the Campaign:1. preceding developments, such as known public health impacts for lead and existing momentum for change;2. a timely opportunity with support from senior leaders;3. a clear, measurable, and ambitious-yet-achievable goal; and4. strong partnership design and design process that fosters ownership and trust.Lead Campaign ImplementationImplementation combined the following strong features:1. multi-level, multi-angle implementation strategy that covers key issues and engages key stakeholders;2. partners bring expertise and commitment through complementary roles;3. modest yet focused resource investments; and4. addressing challenges, adaptation, and learning from experience.
- PCFV Evaluation by UNEP (October 2010)
In 2010, UNEP's Evaluation Office commissioned an independent evaluation of the contribution of the PCFV to the phase out of leaded gasoline in Sub Saharan Africa (SSA), some 48 countries.The evaluation made the following findings:
- Without the PCFV it would have taken at least 10 years rather than five to phase out lead in SSA (conservative estimate).
- The PCFV therefore contributed to health benefits, which in turn promoted social and economic gains.
- UNEP operated as a high level advocate to governments, as a channel to resources within the Partnership, and as a facilitator and supporter of activities at various levels.
- Download the Full Report (PDF)(96 pp, 1.34 M, About PDF)
- Download the Summary Report evaluation (PDF)(12 pp, 3.37, About PDF)


text:
Black Forest Bed Breakfast
Colorado Springs, CO
AAA-3 diamond Massive Log B&B on 20 acres of pines overlooking the city lights and mountain. Business Class Rooms with conference room and high speed internet. Romantic suites with fireplaces and whirlpool tubs. Family Friendly cabins with full kitchens. Ideal location and facilities for corporate events and retreats, family reunions, large outdoor or smaller indoor weddings. Can provide master of ceremonies, emcee, DJ for all events. Internationally Acclaimed Lumberjack Show, Medicine Man show, Mark Twain and other historical and comical acts are available for all venues indoor or out.
The Academy Hotel Colorado Springs
Colorado Springs, CO
Newly Renovated! This 200 room full service Hotel is at the U.S. Air Force Academy's main gate and is the perfect location for Sightseeing, Business, Reunions, Church Groups and more. Majestic fountains, lush greenery, a warm fireplace and comfortable seating highlight the newly renovated Atrium lobby. The Executive Tower guestrooms have been renovated with a warm blend of elegance and feature flat screen TV's, natural earth tone decor, traditional quality furnishings and a microwave oven. All rooms feature Free WIFI, Free made to order breakfast, HBO, Fridge, triple sheeted linens.
The Sunbird Restaurant
Colorado Springs, CO
The Sunbird hosts Ceremonies & Receptions for 20-250 guests. We provide locations for both your ceremony & reception. Do you have your heart set on a private and intimate rehearsal dinner for your immediate family, a casual outdoor luncheon for all your friends, or a all in one location for your Elegant Ceremony with Dinner and Dance to follow—The Sunbird is here to make that happen. We are also always glad to put together a customized menu for your event. Call now to set up an appointment with our Caring and Professional catering staff and see what we can do for you.
Sonterra Grill
Colorado Springs, CO
Sonterra is the perfect place to host your event. For parties from 1-150 or we can cater up to 1000! We have three rooms for your event. The Loft, seating up to 150 for buffet dinning or carving station. The Aspen Room, for fine dinning with audio visual available. The Lounge, for buffet style, equiped with pool tables, 52" flat screen, private bar, poker tables, leather couches. We are sure your needs will be met using one or more of our rooms. Contact our staff today for more details and availability. Sonterra is located in the heart of Downtown Colorado Springs, Colorado.
Elegant Beginnings
Colorado Springs, CO
The rental fee for the location at 7035 Campus Drive in Colorado Springs is $1000 for a day, starting around 11 a.m. and ending around 5 p.m. You need only $100 down to reserve the date. You can make payments for the remaining amount up until 60 days before your wedding date. The grounds are available on Saturdays and Sundays for your ceremony and reception (if you like). The main building may also be included in this price depending on the needs of your wedding and its availability. A refundable security deposit of $1000 is required.
Mystic Meadows and Tre Luna Event C...
Colorado Springs, CO
At Mystic Meadows Event Center and Tre Luna Downtown Event Center, we take pride in offering the best of the mountain and city atmospheres in Colorado. Ideal for Weddings, Receptions, Banquets, Conferences, Meetings, Holiday Gatherings, Retreats, Reunions or Parties with seating for up to 250 to 300. We can customize delicious cuisine for your event and can offer the best wedding vendors at HUGE Discounts. Our JAM-N-SOUNDS Disc Jockey Division and Sleek & Unique Limousine Division can service your event anywhere (even if your event regrettably doesn't end up at Mystic Meadows or Tre Luna!)
Villa Parker
Parker, CO
We have one of the most sought after unique reception locations in Colorado Springs, and by calling our passionate event assistants at Villa Parker today for a visit you can see for yourself why.
Briarhurst Manor
Manitou Springs, CO
Briarhurst Manor has a charming party banquet hall and superior team of experts that will that will make sure your Colorado Springs event is both memorable and breathtaking.
sundance mountain lodge
Monument, CO
At sundance mountain lodge, our energized event staff always have references available for you to inquire about our charming wedding reception halls.
The Inn at Palmer Divide
Palmer Lake, CO
Reserve the best when you call the helpful team at The Inn at Palmer Divide in Colorado Springs for their modern and polished local wedding ceremony and reception venue available on select dates.
Palmer Lake, CO
The many reviews of Pinecrest don't lie when they say the most top notch event sites available are right here in the Colorado Springs area. Call our leading personnel today to reserve your date.
Simply Events
Castle Rock, CO
The seasoned team at Simply Events have countless positive reviews of their superior party reception halls from Colorado Springs couples and local event professionals.
Lorien Dell
Divide, CO
When looking for a stylish catering hall capable of handling your unique needs, visit Lorien Dell and see why our location and extraordinary staff have us consistently near the top in Colorado Springs.
A Pikes Peak Wedding
Manitou Springs, CO
Everyone deserves a classic hall prepared by some of the most accomplished party planners in the Colorado Springs area just for them. Call A Pikes Peak Wedding today to schedule a viewing.
Parker Senior Center
Parker, CO
Our creative event personnel at Parker Senior Center would be honored to help you view and reserve our top quality ballroom for your special event. Call us today in Colorado Springs and let's discuss your needs.
Eastholme in the Rockies
Cascade, CO
Make it a party that no one in Colorado Springs will soon forget when you reserve our dependable reception halls at Eastholme in the Rockies.
Red Crags Bed Breakfast Inn
Manitou Springs, CO
Opulent and great are the words used to describe one of the most spotless private event halls found anywhere around Colorado Springs. Call Red Crags Bed Breakfast Inn today and see why.
Rocky Mountain Lodge Cabins
Cascade, CO
Don't settle for a cookie cutter celebration ballroom when you can have one of the most high caliber and tasteful celebration venues found anywhere around the area with Rocky Mountain Lodge Cabins. Our responsive personnel are also the best.
Hotel St Nicholas
Cripple Creek, CO
If you're planning an awesome event in Colorado Springs, you need a versatile wedding hall to host it and certified personnel like those at Hotel St Nicholas to help with the details.
Perry Park Country Club
Larkspur, CO
When you want a a well respected, yet established wedding space for your next event, Perry Park Country Club and its attentive staff are famous throughout Colorado Springs for being the perfect choice.


text:
Rev. Dr. Luccia Rogers is a life-long seeker whose journey led her to become a scholar, educator, interfaith minister, and anamchara (soul friend)/spiritual guide. As part of her calling to serve, she created thePractical Mysticism and Interfaith Ordination Preparation programs to prepare those who are called to serve and to serve those who wish to deepen their learning. She was also a co-founder of Earth Spirit Community, an interfaith spiritual community.
Decades before Indigo children were recognized, Luccia Rogers saw human auras, empathically connected with all around her, and had several experiences of, "Union with the Divine." Her challenging childhood compelled her to both look within to understand and conduct extensive studies of the world's religions and spiritual traditions as there was little support for her mystical journey.
Dr. Rogers was blessed to earn a Master's degree in Culture and Creation Spirituality from Holy Names University in Oakland, and a Doctoral degree in Social and Cultural Anthropology from the California Institute of Integral Studies. Her education included global gender and sex roles and identities, comparative religions, global mystical traditions, spiritual direction, pastoral counseling, dreamwork, and academic support for the concept that all learning is unified and interconnected.
She was ordained an interfaith minister in the Sufi tradition of the Universal Worship and her ministry includes spiritual direction, pastoral counseling, and life-event celebrant and ritualist. She also practices an innate energy healing technique revealed to her three decades ago.
Her spiritual path has included both Protestant and Catholic Christianity, earth-centered traditions such as wicca, and, for almost two decades, participation in the Universal Sufism brought to the West by Inayat Khan.
An educator with a broad range of expertise, she teaches courses in Psychology, Comparative Religions, Cultural Anthropology, Cultural Studies, Social Psychology, Mythology, and Storytelling and Oral Tradition, and Science Fiction as Literature at a number of colleges.
Dr. Rogers is also an experienced human sexuality educator whose volunteer work with San Francisco Sex Information (SFSI) included co-creation of their, "Train the Trainers," curriculum.
She is an avid cook, musician, motorcyclist who is married and shares her home with three cats.


text:
By: Marshall Prose
"In America, it's hysteria. Everyone has lost control." Singer Dillon Basse says what we're all thinking on flipturn's latest single, "Churches". Showing a positive progression in the movement of their sound and style, this is the first release of theirs since their EP "Heavy Colors". The band's talent comes to no surprise to fans who supported them in the Destination Okeechobee competition where they won first prize against 3,200 competing bands and are set to play the main stage in March.
"While the meaning behind 'Churches' is about finding your passion, it is also about people in society wanting to fit in – 'I wanted to feel wanted like I had a contagious soul', " said Basse. "The song raises awareness for trying to get away from that longing to be accepted and focusing your energy on something you obsess over. Hence the last line of the bridge changing to 'I wanted for you to please let me go.'"
The instrumentation in "Churches" is bright and perfect for dancing, accompanied by vocals which are passionate, and incensed. With syncopated guitars and a tight beat, the creation is a wonderful combination of indie rock with a flare of soul. flipturn displays a style that is unique and emphatic and I can not wait to hear where this Fernandina Beach, Florida group's musical journey shall progress to with the release of this single.