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Gastroenterología (ENARM / Atención médica al paciente)
by Kelley Chuang, MD
Quiz questions 154
Concept Pages 54
Concept Pages
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Imaging of the Intestines
Imaging of the intestines is typically performed utilizing a multimodal approach, with clinical suspicion being the primary indicator for which study should be completed and in what order. There are also many differences between outpatient imaging versus emergency or inpatient imaging of the intestines. Imaging varies widely based on the patient's history, symptoms, and physical exam findings. The patient's age will also play a factor in the modality chosen. For example, appendicitis is typically 1st evaluated via ultrasound in the pediatric population versus CT in adults.
Liver and Biliary Tract Imaging
The hepatobiliary system is composed of the liver, gallbladder, and bile ducts (within the liver and external to the liver). The liver produces bile, which is a fluid made of cholesterol, phospholipids, conjugated bilirubin, bile salts, electrolytes, and water. Bile, which assists in digestion and helps eliminate waste products, is stored in the gallbladder. The hepatobiliary system can be affected by infections, cysts, solid masses, ischemia, and mechanical flow obstruction, which mandate the presence of reliable imaging tests to determine the etiology. The methods that evaluate structural changes in the liver and biliary tract include ultrasonography, CT scan, and MRI (including magnetic resonance cholangiopancreatography). Additionally, cholescintigraphy, a functional imaging study, helps identify gallbladder pathology by tracking the biliary pathway.
Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver function tests assess the levels of various hepatic proteins and enzymes to determine the state of liver metabolic activity, homeostasis, bile metabolism, and protein synthesis capacity. The standard hepatic panel includes the levels of total protein, bilirubin, albumin, ALT, AST, AST/ALT ratio, and alkaline phosphatase (ALP).
Diarrheagenic E. coli
Diarrheagenic Escherichia coli is a strain of pathogenic bacteria that can cause intestinal infection. Transmission is often through the fecal–oral route via the consumption of contaminated food or water. Pathogenesis varies based on the strain, but it can include toxin production, invasion of the mucosal surface, and adhesion with alteration of enterocyte structure. Noninvasive disease tends to present with watery diarrhea, while invasive infections cause bloody diarrhea. The diagnosis can be established with PCR. Management generally consists of supportive therapy (fluids and electrolytes). Antibiotics are reserved for severe or persistent infections and are contraindicated with enterohemorrhagic E. coli because of the risk of hemolytic uremic syndrome.
Portal hypertension is increased pressure in the portal venous system. This increased pressure can lead to splanchnic vasodilation, collateral blood flow through portosystemic anastomoses, and increased hydrostatic pressure. There are a number of etiologies, including cirrhosis, right-sided congestive heart failure, schistosomiasis, portal vein thrombosis, hepatitis, and Budd-Chiari syndrome. Most individuals are asymptomatic until complications arise, including esophageal varices, portal hypertensive gastropathy, ascites, and hypersplenism. The diagnosis is clinical, but it can be supported by ultrasound findings (and hepatic venous pressure gradient measurement in unclear cases). Management requires treating the underlying etiology and managing the complications. This can include nonselective beta blockers to prevent bleeding from varices, diuretics and sodium restriction for ascites, and transjugular intrahepatic portosystemic shunt for refractory complications.
Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). Hepatitis C virus is an RNA virus and a member of the genus Hepacivirus and the family Flaviviridae. The infection can be transmitted through infectious blood or body fluids and may be transmitted during childbirth or through IV drug use or sexual intercourse. Hepatitis C virus can cause both acute and chronic hepatitis, ranging from a mild to a serious, lifelong illness including liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis C infection is diagnosed by testing for the presence of HCV antibodies and HCV RNA. Management is supportive but includes direct antiviral agents (DAAs) if infection does not resolve spontaneously.
Hepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Hepatitis B virus is transmitted by exposure to infectious blood or body fluids. Examples of types of exposure include sexual intercourse, IV drug use, and childbirth. The virus can cause potentially life-threatening liver disease. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Management of acute hepatitis is typically supportive. Administration of antivirals or liver transplantation may be necessary in fulminant and chronic cases.
Pseudomembranous colitis is a bacterial disease of the colon caused by Clostridium difficile. Pseudomembranous colitis is characterized by mucosal inflammation and is acquired due to antimicrobial use and the consequent disruption of the normal colonic microbiota. C. difficile infections account for the most commonly diagnosed hospital-acquired diarrheal illnesses. C. difficile infections can range from asymptomatic colonization to diarrhea and progress to fulminant colitis with systemic sepsis in severe cases. The diagnosis is established based on stool studies. Management of pseudomembranous colitis is mainly using antibiotics. Fecal transplant is considered in a few cases, whereas surgical intervention is required in severe cases.
Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Etiologies often involve the liver and can be prehepatic, intrahepatic, or posthepatic. Other symptoms of hyperbilirubinemia include pruritus, pale stools, and darkened urine. The diagnosis is made based on liver function tests and imaging. Management is focused on treatment of the underlying condition.
Crohn's disease is a chronic, recurrent condition that causes patchy transmural inflammation that can involve any part of the gastrointestinal tract. It is a type of inflammatory bowel disease (IBD) along with ulcerative colitis (UC). The terminal ileum and proximal colon are usually affected. Crohn's disease typically presents with intermittent, non-bloody diarrhea and crampy abdominal pain. Extraintestinal manifestations may include calcium oxalate renal stones, gallstones, erythema nodosum, and arthritis. Diagnosis is established via endoscopy with biopsy that shows transmural inflammation, characteristic "cobblestone" mucosa, and noncaseating granulomas. Management is with corticosteroids, azathioprine, antibiotics, and anti-TNF agents (infliximab and adalimumab). Complications include malabsorption, malnutrition, intestinal obstruction or fistula, and an increased risk of colon cancer.
Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Diagnosis is clinical. Management requires treating the underlying disease, managing complications, and, if required, liver transplantation.
Congenital Diaphragmatic Hernias
Congenital diaphragmatic hernias are embryologically derived defects in the diaphragm through which abdominal structures can pass into the chest cavity. The presence of intestines and intra-abdominal organs in the chest interferes with embryonic development of the lungs, which is the major cause of pathology postnatally. Prenatal diagnosis is commonly made by ultrasound during pregnancy followed by confirmation on chest X-ray after birth. Immediate respiratory resuscitation at birth with endotracheal intubation and mechanical ventilation are required. Surgical repair is the only curative option. Prognosis varies, but children with diaphragmatic hernias usually suffer from lifelong pulmonary complications.
Chronic Pancreatitis
Chronic pancreatitis is due to persistent inflammation, fibrosis, and irreversible cell damage to the pancreas, resulting in a loss of endocrine and exocrine gland function. The most common etiologies are alcohol abuse and pancreatic duct obstruction. Patients often present with recurrent epigastric abdominal pain, nausea, and features of malabsorption syndrome (diarrhea, steatorrhea, and weight loss). Characteristic computed tomography (CT) findings include pancreatic atrophy, dilated pancreatic ducts, and pancreatic calcifications. Therapy focuses on alcohol cessation, diet changes, pain management, and treatment of pancreatic insufficiency.
Primary biliary cholangitis (PBC) is a chronic disease resulting in autoimmune destruction of the intrahepatic bile ducts. The typical presentation is that of a middle-aged woman with pruritus, fatigue, and right upper quadrant abdominal pain. Elevated liver enzymes and antimitochondrial antibodies (AMAs) establish the diagnosis. Medical management is limited to using ursodeoxycholic acid, a disease-modifying agent. Definitive treatment is liver transplantation, which is performed in late stages (cirrhosis).
Acute Cholangitis
Acute cholangitis is a life-threatening condition characterized by fever, jaundice, and abdominal pain which develops as a result of stasis and infection of the biliary tract. Septic shock, liver abscess, and multi-organ dysfunction are potential serious complications. The diagnosis is confirmed with ultrasound showing dilation of the common bile duct (CBD) or gallstones, elevated liver function tests, and leukocytosis. Treatment includes hemodynamic stabilization, broad-spectrum antibiotics, urgent biliary drainage, and cholecystectomy to prevent recurrence.
Acute pancreatitis is an inflammatory disease of the pancreas due to autodigestion. Common etiologies include gallstones and excessive alcohol use. Patients typically present with epigastric pain radiating to the back. Diagnosis requires 2 of 3 criteria, including: characteristic abdominal pain, serum amylase and lipase 3 times the upper limit of normal, or characteristic radiology findings. Ranson's criteria is commonly used to assess the severity. Management includes aggressive intravenous (IV) hydration, analgesia, nutritional support, and treatment of the underlying cause.
The most common benign liver tumors include hepatic hemangiomas, focal nodular hyperplasia, and hepatic adenomas. These tumors are mostly asymptomatic and/or found incidentally on abdominal imaging. While these tumors are benign, large lesions can cause symptoms such as upper abdominal pain, or produce complications such as bleeding. Malignant potential is a concern for hepatic adenoma, depending on risk factors. The diagnosis is based on imaging studies, with characteristic findings defining the tumor. Biopsy generally is reserved for equivocal cases. Management is observation for most small, asymptomatic, and non-growing tumors. However, high-risk factors, symptoms, increasing tumor size, and complications dictate the need for surgical intervention.
Small Bowel Obstruction
Small bowel obstruction (SBO) is an interruption of the flow of the intraluminal contents through the small intestine, and is classified as mechanical (due to physical blockage) or functional (due to disruption of normal motility). The most common cause of SBO in the Western countries is post-surgical adhesions. Small bowel obstruction typically presents with nausea, vomiting, abdominal pain, distention, constipation, and/or obstipation. The diagnosis is established via imaging. Up to 80% of all cases will resolve with supportive management (bowel rest, intravenous (IV) hydration, and nasogastric decompression). However, surgery is required for persistent or complicated cases.
Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Common causes of functional dysphagia include achalasia, scleroderma, and diffuse esophageal spasm (DES). Mechanical causes of dysphagia include esophageal rings, webs, strictures, and cancer. Oropharyngeal dysphagia may be due to structural abnormalities or abnormal neuromuscular function and coordination. The diagnostic workup depends on the patient's presenting symptoms, but may include manometry, barium esophagram, or direct visualization with nasopharyngeal laryngoscopy or endoscopy. Treatment varies depending on the underlying cause.
Colorectal cancer (CRC) is the 2nd-leading cause of cancer-related death in the United States. Almost all cases of CRC are adenocarcinoma and the majority of lesions come from the malignant transformation of an adenomatous polyp. As most CRCs are asymptomatic, screening is essential in detecting early disease. Screening is recommended to start at the age of 45 years, utilizing various screening tools available with colonoscopy, flexible sigmoidoscopy, and fecal tests among them. For high-risk individuals, earlier and more frequent screening is recommended. Other stool-based strategies and visualization tests are also available for CRC screening.
Short bowel syndrome is a malabsorptive condition most commonly associated with extensive intestinal resection for etiologies such as Crohn's disease, bowel obstruction, trauma, radiation therapy, and vascular insufficiency. The short length of bowel results in insufficient surface area for fluid and electrolyte absorption. Patients typically present with diarrhea, electrolyte abnormalities, and dehydration. Management options include antimotility agents, antisecretory agents, and total parenteral nutrition for patients who cannot maintain themselves with oral intake. Last-resort options include surgical intestinal lengthening procedures and small bowel transplant.
Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Primary/functional constipation can be divided into normal transit, slow transit, and outlet constipation. Constipation is a symptom, not a disease, and appropriate management requires an evaluation of possible etiologies, such as systemic disorders and drugs. Once secondary causes have been eliminated, idiopathic constipation can be managed with lifestyle modifications and medications.
Intestinal Ischemia
Intestinal ischemia occurs when perfusion fails to meet the demands of the intestines, resulting in ischemic tissue injury that can be life-threatening if bowel necrosis and/or perforation occurs. Symptoms can range from mild indigestion or diarrhea to severe abdominal pain. Imaging techniques including CT and angiography are used to detect stenosis or occlusion. The chronic form of intestinal ischemia benefits from medical therapies and revascularization procedures (stents, bypass surgery) while acute forms require urgent interventions to restore blood flow and remove any dead bowel tissue. Delay in the diagnosis and management of acute intestinal ischemia results in high mortality and severe complications, including intestinal perforation and sepsis.
Rare Malignant Liver Tumors
Although hepatocellular carcinoma (HCC) is by far the most common malignant liver tumor, there are several rare malignant tumors that are important to keep in mind when making a differential diagnosis. These tumors include cholangiocarcinoma; hepatoblastoma and mesenchymal tumors, such as epithelioid hemangioendothelioma (EHE); and angiosarcoma. While these conditions differ in their etiology and pathology, they often present similarly, with nonspecific symptoms such as fatigue, weight loss, and abdominal discomfort. Diagnosis is by imaging, which can be supported by a biopsy. Surgical excision is the only curative approach for these tumors.
Hepatocellular Carcinoma (HCC) and Liver Metastases
Hepatocellular carcinoma (HCC) typically arises in a chronically diseased or cirrhotic liver and is the most common primary liver cancer. Diagnosis may include ultrasound, CT, MRI, biopsy (if inconclusive imaging), and/or biomarkers. Treatment options include resection and chemo-/radiotherapy, and liver transplantation in select cases. Liver metastases are much more common than primary liver cancers and usually originate from colorectal, lung, breast, and pancreatic primary sites. Metastases are most commonly diagnosed by CT or PET scans. Management depends on the type and stage of primary cancer.
Exocrine Pancreatic Cancer
Pancreatic cancer, consisting mostly of invasive pancreatic ductal adenocarcinoma (PDAC), arises from the ductal cells of the exocrine pancreas and is the 4th leading cause of cancer-related deaths in the United States. Pancreatic cancer has the highest mortality rate among the major cancers, with a 5-year survival rate of only 8%–10%. Clinical presentation includes symptoms of abdominal pain, jaundice, and weight loss. Diagnosis is made by CT, MRI, and endoscopic ultrasonography (EUS). Management by surgical resection, usually with neoadjuvant or adjuvant chemotherapy, provides the only chance for cure in the 15%–20% of patients who have resectable disease at the time of diagnosis. Other rare malignant tumors arising from the exocrine pancreas are acinar cell carcinoma and pancreatoblastoma.
Colon polyps are growths of mucosal tissue in the colon, the most common site of polyps in the GI tract. Polyps can be classified as neoplastic or nonneoplastic and may be associated with genetic syndromes. Hyperplastic polyps are nonneoplastic and are the most common type overall, whereas adenomas are the most common type of neoplastic polyp and have the potential to progress to cancer. For most people without hereditary syndromes, colon cancer screening should begin at age 50 (at age 45 for Black individuals) and in adolescence for those with the rare familial adenomatous polyposis (FAP) syndrome. Diagnosis is by biopsy, and management includes frequent surveillance in people with adenomatous polyps or screening every 10 years in the general population until age 75.
Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammation, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Patients will typically have severe tenderness with associated rigidity and rebound tenderness. Laboratory evaluation will demonstrate leukocytosis, acidosis, and in some cases, abnormal hepatic function tests. Imaging helps narrow the differential diagnosis; first-line imaging is always an upright chest X-ray to evaluate for pneumoperitoneum. The treatment and prognosis of acute abdomen strongly depend on the underlying cause, but the vast majority of these cases constitute a surgical emergency with associated morbidity and mortality.
Ulcerative colitis (UC) is an idiopathic inflammatory condition that involves the mucosal surface of the colon. It is a type of inflammatory bowel disease (IBD), along with Crohn's disease (CD). The rectum is always involved, and inflammation may extend proximally through the colon. Ulcerative colitis causes diffuse friability, erosions with bleeding, and loss of haustra, which are visible on endoscopy. Patients typically present with bloody diarrhea, colicky abdominal pain, tenesmus, and fecal urgency. Diagnosis is established via endoscopy with biopsy and by ruling out other causes of bloody diarrhea. Management is primarily through topical mesalamine, 6-mercaptopurine, or colectomy for severe cases. Complications include fulminant colitis, toxic megacolon, intestinal perforation, and increased risk of colorectal cancer.
Alcoholic liver disease is a spectrum of disorders ranging from fatty liver to cirrhosis secondary to chronic alcohol abuse. Excessive and prolonged consumption of alcohol results in impairment of the lipolysis pathway, causing inflammatory changes within the hepatocytes. Patients typically present during the hepatitis stage with jaundice, fever, and abdominal pain. Diagnosis is based on a history of alcohol abuse and confirmed by laboratory derangement with an AST/ALT ratio > 2. Alcoholic liver disease carries a high mortality rate if patients present with severe hepatitis. Management aims at alcohol abstinence for reversal (at certain stages) and addressing contributing factors (such as viral infections or drugs) to minimize damage to the hepatocytes. Approximately 10% of patients regress with alcohol abstinence during the hepatitis stage. Cirrhosis is frequently irreversible.
Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Associated symptoms, including fever, nausea and vomiting, weight loss, and bloody stools are also important to elicit from the history. Most causes of acute diarrhea are infectious and do not require additional workup. Since diarrhea is usually a self-limited condition, management is generally supportive. However, chronic diarrhea can require laboratory studies, stool studies, imaging, or procedures to determine the cause. Management ultimately hinges on treating the underlying pathology, though symptomatic and empiric therapies may be utilized under the right circumstances.
Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Almost all cases of CRC are adenocarcinoma, and the majority of lesions come from the malignant transformation of an adenomatous polyp. Since most CRC cases are asymptomatic, screening colonoscopy or stool tests are generally recommended in patients ≥ 50 years of age. Along with screening, diagnosis is reached by colonoscopy, which allows visualization as well as tissue sampling. Treatment is primarily surgical, with chemotherapy reserved for advanced disease.
Barrett's esophagus is a chronic gastroesophageal reflux disease (GERD) that leads to the replacement of stratified squamous epithelium with gastric columnar epithelium in the esophagus. The condition is associated with an increased risk of esophageal adenocarcinoma. Workup includes an esophagogastroduodenoscopy (EGD) showing proximal displacement of the squamocolumnar junction (Z-line) from the gastroesophageal junction (GEJ). Biopsies will confirm the diagnosis by revealing columnar epithelium and goblet cells in the distal esophagus. Treatment is primarily with proton pump inhibitors (PPIs) and lifestyle modifications. Surveillance with repeated EGD and biopsy is necessary to monitor for early signs of dysplasia.
Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). This condition may eventually lead to inflammation (esophagitis), metaplasia (Barrett's esophagus), and progression to esophageal cancer. Uncomplicated GERD can be managed with lifestyle changes and over-the-counter medications. Sometimes, however, stronger medications or surgery may be required to ease symptoms and prevent complications.
Esophagitis is the inflammation or irritation of the esophagus. The major types of esophagitis are medication-induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia, and retrosternal chest pain. Diagnosis is by endoscopy and biopsy. Laboratory tests and imaging are obtained, depending on the degree of damage and involvement of other organ systems. Treatment for esophagitis depends on the underlying etiology and includes dietary changes, avoidance of offending agents, antibiotic therapy, or proton pump inhibitor use. In severe cases such as in corrosive injury, surgery may need to be performed. If left untreated, esophagitis can lead to complications such as strictures, metaplasia of the esophagus, and development of malignancy.
Primary Sclerosing Cholangitis
Primary sclerosing cholangitis (PSC) is an inflammatory disease that causes fibrosis and strictures of the bile ducts. The exact etiology is unknown, but there is a strong association with inflammatory bowel disease (IBD). Patients typically present with an insidious onset of fatigue, pruritus, and jaundice, which can progress to cirrhosis and complications related to biliary obstruction. The diagnosis is established with magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). Liver transplantation is the only definitive treatment and is indicated in patients with advanced liver disease.
Diverticula are protrusions of the bowel wall occurring most commonly in the colon. The condition of having diverticula (called diverticulosis) is mostly asymptomatic. These diverticula can become symptomatic, however, when associated with diseases. Diverticulitis is the inflammation of diverticula, often presenting with lower abdominal pain and changes in bowel habits. The condition may be further complicated by abscess, perforation, fistula, and bowel obstruction. Management consists of antibiotics, fluid resuscitation, and bowel rest. Surgery is required for complications, failure of medical management, and recurrent disease. In most cases of diverticular bleeding, spontaneous cessation occurs. Invasive intervention will be needed for persistent or recurrent bleeding.
Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. The diagnosis can frequently be established clinically, but imaging is used in uncertain cases. Computed tomography (CT) scan provides the highest diagnostic accuracy. Perforation occurs in 13%–20% of cases and can present as localized (abscess/phlegmon) or free perforation with generalized peritonitis. The standard treatment is appendectomy, but localized perforations are frequently managed non-operatively with antibiotics.
Drug-induced Liver Injury
Drug-induced liver injury (DILI) is the most common cause of acute liver failure (ALF). Hepatotoxic drugs can cause injury to the hepatocytes directly in a predictable dose-dependent way or through idiosyncratic reactions (which may be mediated by immune or non-immune processes). The injury mechanisms can have the following effects: hepatitis, cholestasis, vascular lesions, or overlapping changes. The presentation can be acute or chronic, with severe toxicity manifesting as fulminant liver failure. The diagnosis of DILI requires a thorough history and laboratory tests including liver function tests (LFTs) and drug levels, if available. Management consists of discontinuing the drug, supportive therapy, and monitoring for complications. Acetaminophen, 1 of the most common causes of DILI, has a specific treatment, N-acetylcysteine (NAC).
Hereditary Hemochromatosis
Hereditary hemochromatosis (HH) is an autosomal recessive disorder most often associated with HFE gene mutations. Patients have increased iron intestinal absorption and iron deposition in several organs, such as the liver, heart, skin, and pancreas. The clinical presentation includes the triad of cirrhosis, diabetes, and skin bronzing. Other findings depend on the organ(s) involved. Diagnosis consists of iron studies, showing transferrin (Tf) and ferritin elevation. Genetic screening is recommended among family members. Imaging and invasive studies are performed depending on the associated complications. Management requires phlebotomy (or iron chelation therapy in some cases) to prevent disease progression. The prognosis is good for patients who are early in the disease and undergoing treatment. The presence of hepatic fibrosis is a poor prognostic factor.
Peptic Ulcer Disease
Peptic ulcer disease (PUD) refers to the full-thickness ulcerations of duodenal or gastric mucosa. The ulcerations form when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies include Helicobacter pylori (H. pylori) infection and prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). Patients may be asymptomatic or may present with abdominal pain, nausea, and early satiety. Peptic ulcer disease typically responds well to medical treatment consisting of H. pylori eradication, eliminating risk factors, and proton pump inhibitors (PPIs). If left untreated, it can lead to bleeding, perforation, gastric outlet obstruction, and gastric cancer.
Gastritis refers to inflammation of the gastric mucosa. Gastritis may occur suddenly (acute gastritis) or slowly over time (chronic gastritis). Gastritis may be asymptomatic or with symptoms, including burning abdominal pain (which either worsens or improves with eating), dyspepsia, nausea, and vomiting. The most common etiologies for gastritis are Helicobacter pylori infection and autoimmune disease. Chronic gastritis is a risk factor for gastric cancer. Management involves the use of proton pump inhibitors with antibiotics (in case of H. pylori infection), avoidance of offending agents, and replacement of associated deficiencies.
Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis (calculous cholecystitis) but inflammation without gallstones (acalculous cholecystitis) can occur in a minority of patients. The acute type usually presents with right upper quadrant (RUQ) pain, fever, and leukocytosis. The diagnosis is made clinically and confirmed via ultrasound (US). The definitive management is cholecystectomy, preferred to be performed within 72 hours. This condition can present as a mild condition or as a severe disease (with complications such as gallbladder gangrene, perforation, empyema) which require emergent intervention.
Cholelithiasis (gallstones) is the presence of stones in the gallbladder. Most gallstones are cholesterol stones, while the rest are composed of bilirubin (pigment stones) and other mixed components. Patients are commonly asymptomatic but may present with biliary colic (intermittent pain in the right upper quadrant). The diagnosis is established by ultrasound. Management options include supportive care to prevent and control associated symptoms. When indicated, cholecystectomy is the definitive treatment. Gallstones may lead to complications such as choledocholithiasis (a stone trapped in the common bile duct), cholecystitis (inflammation of the gallbladder), or cholangitis (biliary sepsis). These conditions require urgent medical attention.
Hepatic encephalopathy is a reversible condition in which elevated ammonia levels cause impaired brain function in patients with advanced liver disease. Hepatic encephalopathy can be precipitated by conditions that affect the normal absorption, metabolism, or clearance of ammonia, including dehydration, renal failure, infections, and gastrointestinal bleeding. Patients present with a progression of symptoms, from minimal confusion and asterixis to stupor and coma. Diagnosis is clinical and requires the exclusion of alternative diagnoses. Management involves addressing the causative factor and decreasing the systemic absorption of ammonia with lactulose or rifaximin.
Hepatorenal syndrome (HRS) is a potentially reversible cause of acute kidney injury that develops secondary to liver disease. The main cause of HRS is hypovolemia, often as a result of forced diuresis or drainage of ascites. This leads to renal vasoconstriction resulting in hypoperfusion of the kidneys. Patients typically present with edema, oliguria or anuria, and ascites in the setting of acute or chronic liver injury. Hepatorenal syndrome is considered a diagnosis of exclusion. Treatment is with agents that cause systemic vasoconstriction and, therefore, improve renal perfusion. This includes octreotide and midodrine. Most cases of hepatorenal syndrome have a poor prognosis.
Irritable bowel syndrome (IBS) is a functional bowel disease characterized by chronic abdominal pain and altered bowel habits without an identifiable organic cause. The etiology and pathophysiology of this disease are not well understood, and there are many factors that may contribute. Irritable bowel syndrome is a diagnosis of exclusion, and organic causes should be ruled out. Once diagnosed, the emphasis is on education and reassurance. Dietary modifications and symptom-control measures may also be instituted.
Gastrointestinal bleeding (GIB) is a symptom of multiple diseases within the gastrointestinal (GI) tract. Gastrointestinal bleeding is designated as upper or lower based on the etiology's location to the ligament of Treitz. It is more common to have bleeding in the upper GI tract, with peptic ulcer disease being the most frequent cause. Depending on the location of the bleeding, the patient may present with hematemesis (vomiting blood), melena (black, tarry stool), or hematochezia (fresh blood in stools). Some patients presenting with GIB can be hemodynamically unstable and require emergent stabilization and evaluation. The source of the bleed can often be located and treated with endoscopy.
Celiac disease (also known as celiac sprue or gluten enteropathy) is an autoimmune reaction to gliadin, which is a component of gluten. Celiac disease is closely associated with HLA-DQ2 and HLA-DQ8. The immune response is localized to the proximal small intestine and causes the characteristic histologic findings of villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis. Patients typically present with diarrhea and symptoms related to malabsorption (steatorrhea, weight loss, and nutritional deficiencies). Patients are screened with serological antibody testing, and diagnosis is confirmed by small intestine biopsy. Treatment requires a lifelong gluten-free diet.
Gastric cancer is the 3rd-most common cause of cancer-related deaths worldwide. The majority of cases are from adenocarcinoma. The modifiable risk factors include Helicobacter pylori infection, smoking, and nitrate-rich diets. Hereditary syndromes, pernicious anemia, and prior partial gastrectomy are among the endogenous risk factors. When symptoms such as epigastric fullness, vomiting, and weight loss occur, it is likely that the cancer is in the advanced stage. Diagnosis is confirmed with esophagogastroduodenoscopy and biopsy. Imaging studies and laparoscopy aid in determining the cancer stage. Consequently, staging dictates the management approach. Management consists of gastrectomy and chemoradiotherapy. Most cases are diagnosed in late stages, indicating a generally poor prognosis.
Esophageal cancer is 1 of the most common causes of cancer-related deaths worldwide. Nearly all esophageal cancers are either adenocarcinoma (commonly affecting the distal esophagus) or squamous cell carcinoma (affecting the proximal two-thirds of the esophagus). Major risk factors for adenocarcinoma include smoking, obesity, and Barrett's esophagus. For squamous cell carcinoma, risk factors include smoking, alcohol consumption, and certain dietary factors. Early-stage cancer is often asymptomatic, with dysphagia and weight loss presenting as the disease progresses. Diagnosis is by endoscopic biopsy or image-guided biopsy of the metastatic site. Management depends on the disease stage. Options include surgical resection, chemotherapy, and radiation. For unresectable esophageal cancers, palliative measures are provided for symptom relief and to prolong survival.
Achalasia is a primary esophageal motility disorder that develops from the degeneration of the myenteric plexus. This condition results in impaired lower esophageal sphincter relaxation and absence of normal esophageal peristalsis. Patients typically present with dysphagia to solids and liquids along with regurgitation. Diagnosis is established by high-resolution manometry. To rule out malignancy as a cause of achalasia, upper endoscopy is performed. Barium swallow study helps evaluate the esophageal morphology. Management options include pneumatic balloon dilation, surgical myotomy, and botulinum toxin injection. Choice of treatment is dependent on the type of achalasia and surgical risk. Medications are available for those who fail initial intervention; however, they provide the least benefit.
Wilson's Disease
Wilson disease (hepatolenticular degeneration) is an autosomal recessive disorder caused by various mutations in the ATP7B gene, which regulates copper transport within hepatocytes. Dysfunction of this transport mechanism leads to abnormal copper accumulations in the liver, brain, eyes, and other organs, with consequent major and variably expressed hepatic, neurologic, and psychiatric disturbances. Liver involvement may manifest as hepatitis, liver failure, or cirrhosis, while basal ganglia involvement causes the extrapyramidal signs. Most patients are diagnosed between the ages of 5 and 35 years (mean: 13 years). Diagnosis is established if the patient has low plasma ceruloplasmin, corneal deposits of copper (Kayser-Fleischer rings), and elevated copper levels in the urine. However, other tests are often needed since not all patients will have all these findings. The prognosis is good for patients without advanced liver disease and who are treated with the chelating agents penicillamine or trientine. Untreated Wilson disease is ultimately fatal, with patients dying from cirrhosis, acute liver failure, or complications due to progressive neurologic disease.
Autoimmune hepatitis (AIH) is a rare form of chronic liver disease in which the immune system attacks the liver causing inflammation. It predominantly affects women. Clinical presentation ranges from asymptomatic cases to patients that present with symptoms of acute liver failure (jaundice, right upper quadrant pain). Because AIH has a 40% mortality in 6 months without treatment, early diagnosis and treatment are imperative. Diagnosis is established by detecting anti-smooth muscle antibodies and performing a confirmatory liver biopsy. Treatment includes corticosteroids and azathioprine. If treatment is initiated early in the disease course, the prognosis is favorable.
Gastroenterology 05:15 h / 67 videos 12 free
Gastroenterology 54 concept pages 54 free
Gastroenterology 154 quiz questions 31 free
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Your Educators of course Gastroenterología (ENARM / Atención médica al paciente)
Kelley Chuang, MD
Dr. Kelley Chuang is an Assistant Clinical Professor at the David Geffen School of Medicine at the University of California in Los Angeles (UCLA), USA, and works as a hospitalist at the VA Greater Los Angeles Healthcare System.
She obtained her medical degree from the Icahn School of Medicine at Mount Sinai and completed a chief residency in Internal Medicine at UCLA.
Dr. Chuang also holds a Master's Degree in Teaching and combines her interests in medicine and teaching as a medical educator.
Within Lecturio, she teaches courses on Gastroenterology.
4,7 of 5 stars
Excellent teaching acumen in presenting concepts
By Henry L. on 26. January 2023 for Acute Cholecystitis with Case
Exceptional acumen in anticipating difficulties and nuances in learning the different concepts involving biliary pathology.
Excellent summary of most GI pathologies, perfect if you want to refresh your memory.
By Ameli A. on 01. August 2022 for Disorders of the Hepatobiliary Tract
4.5/5 Excellent summary of most GI pathologies, perfect if you want to refresh your memory. Great slides and presentations. Concise and to the point. I would have given it a 5 if the slides were complete but that's more of a technical problem. Thanks!
By Dr-Nadeem N. on 23. April 2022 for Disorders of the Hepatobiliary Tract
Excellent but there is missing like your should express pathphysiology of important sign symptoms like why that particular sign is happening in disease then it will be a grear job.
By Raza khan A. on 25. February 2022 for Approach to Patients with GI Symptoms
As a Gestroentrologist, I would like to say it helps to repeat the important points in GI system. Good luck and more success in the future.
See all 41 user reviews with text
top lecture
By George H. on 25. November 2021 for Alcohol-induced Liver Disease with Case
top lecture very usefyl. why is it so diffiucult to leave reviews. trying to study here
Hepatobiliary diseases and their treatment.
By Raza khan A. on 22. November 2021 for Disorders of the Hepatobiliary Tract
Well, she describes diseases by very comprehensive way where we can use these fruitfull informations in our basic rutine. Finally, I am going to recommend this side for those doctors who need more improvement in both clinically and theoretically.best of luck
Advance level in both physical and theory method.
By Raza khan A. on 20. November 2021 for Disorders of the Esophagus and the Stomach
Well, it is very comprehensive and skillful metod not only for medical student but also for postgraduate doctors. I have learent more then ever I have tried im my life. Best of luck
Great job Dr. Chuang!
By Suzanne S. on 01. November 2021 for Chronic Pancreatitis with Case
All of her lectures are clear and concise, and the cases allow us to come up with our own answer before she explains them.
Very thorough
By Alaena A. on 01. October 2021 for Acute Pancreatitis with Case
Dr. Chuang explains management and treatment well and provides more detailed information in the Q&A which is helpful for understanding and solidifying the lesson.
well done coverage of management
By Alaena A. on 22. September 2021 for GI Bleed: Initial Management and Diagnostic Studies
I love the details for the management of the patient and the lecture follows Step Up To Medicine well.
Good presentation
By Mahziar K. on 12. September 2021 for Spontaneous Bacterial Peritonitis (SBP) with Case
A concise yet complete presentation of SBP. Using a case to present a disease helps to consolidate the concepts in mind. Thank you.
high yeild
By S C. on 07. September 2021 for Hepatocellular Carcinoma (HCC) with Case
excellent lecture. good amount of detail. high yeild. thank you
Outdated and too small content
By Neuer N. on 07. September 2021 for Disorders of the Hepatobiliary Tract
Little outdated information and less content. Can expand the explanation and add more questions for spaced repetition
Good high yield material! Don't miss this
By JOSE ANTONIO P. on 30. August 2021 for Disorders of the Esophagus and the Stomach
I enjoy it a lot, it was concise, quick, and to the point. An HY lecture and a must. Amazing job from Dr. Chuang. Thank you.
Rate of the course
By Kiana M. on 22. August 2021 for Disorders of the Esophagus and the Stomach
Videos were Brief and to the point and I found quizzes helpful and practical
Clear explanation.
By S C. on 05. August 2021 for Irritable Bowel Syndrome (IBS) with Case
I dont know why this is rated poorly. This is excellent and explained well in terms of symptomology and diagnosis.
By Nour el Houda E. on 29. May 2021 for Hereditary Hemochromatosis with Case
this is a clear and concise explanation and learning through cases is very useful
Well organized lecture
By Joyce K. on 21. May 2021 for Approach to Patients with GI Bleed
THE LECTURE INCLUDE All the most information about G I BLEEDING
By Angie J. on 21. April 2021 for Approach to Patients with GI Symptoms
Very easy to understand and great diagnostic and treatment approaches.
By Cerys C. on 10. January 2021 for GI Case: 35-year-old Woman Complaining of 5 Days of Diarrhea
The case was explained well and the reasoning for the management explained so it is much more memorable.
By Cerys C. on 09. January 2021 for Acute Cholecystitis with Case
really well explained. simple and informative, not too complicated. management helpful
Pretty disappointed by the quality.
By Renan A. on 26. December 2020 for GI Case: 35-year-old Woman Complaining of 5 Days of Diarrhea
Very general video, I feel a little offended because of the low quality of the description given by the lecturer.
If it's only one comment, I will say it's awesome because it's to the point
By Wesam E. on 05. December 2020 for Disorders of the Hepatobiliary Tract
Very very very awesome To the point, 5 stars Excellent doctor
Very Poor explanation or no explanation at all
By Yuno t. on 04. December 2020 for Hepatocellular Carcinoma (HCC) with Case
90 percent of the stuff she says is written on the lecture , she does not add anything to it , does not explain anything . The lectures are very simple and not in detail , not good for med students
short lectures and nothing explained
By Shero j. on 30. November 2020 for Irritable Bowel Syndrome (IBS) with Case
The lectures of GIT are very short and few, Respiratory and CVS are very good , And Other doctors explain everything more clearly and in detail but GIT Every lecture is about a minute or two And the doctor does not explain almost anything she only reads what is written in the lecture .
By Natalia B. on 25. October 2020 for Disorders of the Esophagus and the Stomach
I liked the cases and the detailed explanation for each of them
I like her teaching style and the cases she used as examples. The lectures were explicit
By Ernest A. on 04. October 2020 for Approach to Patients with GI Symptoms
Nice lecture! Very simple and informative. She has very good grasp of the topics and she delivered the lectures perfectly
Good lecture
By Sha Ron u. on 01. September 2020 for Acute Liver Failure with Case
Great format. Inclusion of lab findings and correlation to clinical presentation is so useful.
Just perfect !
By Marion E. on 15. July 2020 for Approach to Patients with Jaundice with Case
Thank you so much, It is very clear and I loved the way you explain the course with a case.
Excellent teacher
By Ricardo G. on 14. July 2020 for Colonic Polyps with Case
All of her lectures are awesome , she should make more lectures , wonderful teacher
Really good course
By Alejandra C. on 24. June 2020 for Disorders of the Esophagus and the Stomach
I really enjoyed this course, clinic cases are so helpful when learning, for me it's the best way to learn.
On point explanations.
By Melissa H. on 29. May 2020 for Approach to Patients with GI Symptoms
Great explanations!! She tells you excactly what you need to know. Thank you so much Dr. Chuang
Very clear and thorough
By McKenna T. on 27. May 2020 for Chronic Mesenteric Ischemia with Case
She is very thorough and clear. I appreciate pointing out the different etiologies of chronic vs acute mesenteric ischemia
By KARLA S. on 11. May 2020 for Disorders of the Hepatobiliary Tract
Great lecture, easily explained with a dinamic presentation and an amazing teacher
Highly recommended series
By Lou Jorel T. on 24. April 2020 for Approach to Patients with GI Symptoms
Dr Chuang's series is probably the best as she discusses cases alongside theoretical information. We are able to integrate the patient history and PE to formulate a proper diagnosis and management. I hope more formats are similar to hers.
Nice overview
By Masooma S. on 23. April 2020 for Approach to Patients with GI Symptoms
It was a very good combination of general clinical approach and a little bit of information about the key features of each disease. This is a nice place to start if you want to sort through all the different symptoms your patients could present with.
By Olga M. on 22. April 2020 for Disorders of the Esophagus and the Stomach
Great explanation, great visuals pictures . Throughly explained Thank you so much
By rosemarie m. on 09. April 2020 for Disorders of the Esophagus and the Stomach
All your lecturers are excellent. I am very happy. Good revision.
I Appreciate the distinguishing features
By Catherine F. on 19. February 2020 for Disorders of the Small and Large Intestines
It is an excellent review. I really appreciate how she walks us through the steps for diagnosis and distinguishing small vs large intestine criteria. I have much more clarity now! Thank you!
Crisp and highly effective lectures
By Sourav B. on 11. January 2020 for Approach to Patients with GI Symptoms
Need more cases type question to boost up the clinical knowledge....Plzz make the kind of videos in clinical neurology module
I love her confidence and knowledge she gave me thanks
By Nassor mohammed J. on 31. December 2019 for Definitions: Types of Diarrhea
this is the way exams and real patients occur and easy to understand how to apply the knowledge in real life and exams I recommend more of symptoms in other departments too like pediatrics gynecology and surgery
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"Characteristics of Streaming Media Stored on the Web" by Mingzhe Li, Mark Claypool et al.
The increasing power and connectivity of today's computers have spurred the growth in streaming audio and video available on the Internet through the Web. While there is substantial research characterizing the performance of streaming media and characterizing documents stored on theWeb, there have been few studies characterizing streaming audio and video stored on the Web. We crawled over 17 millionWeb pages from key geographic locations and extracted nearly 30,000 streaming audio and video clips for analysis. Using custom built tools, we analyzed the characteristics of these multimedia objects, determining such information as media type, encoding format, playout duration, bitrate, resolution, and codec. We find proprietary audio and video formats dominate all multimedia content, primarily content by RealNetworks followed next by Microsoft and with Apple following just behind MP3. The playout durations of streaming audio and video clips are long-tailed, suggesting streaming media may contribute self-similar traffic on the Internet. More than half of all streaming media clips on the Web are video, with 90% of videos targeted for broadband connections. Video resolutions are considerably smaller than typical monitor resolutions, implying that video bitrates, which are directly related to resolutions, have enormous potential to increase. The detailed results from this study should be useful for future studies characterizing the performance of streaming media on the Web and also valuable for those interested in generating more accurate Internet traffic simulations.
Li, Mingzhe , Claypool, Mark , Kinicki, Robert , Nichols, James (2003). Characteristics of Streaming Media Stored on the Web. .


SIZED DOUBLE AIR BED The dimension of air mattress is 80 X 60 X 9 inch so that ensure a more adequate sleeping space. This inflated mattress is large enough to sleep two adult or 3-4 children, you can also sleep alone and relax yourself !
SOFT FLOCKING LAYER TOP The material is skin-friendly which can offer you a comfortable sleeping experience, while the waterproof pvc underside prevent slipping and sliding. The top of the air bed is also easy to clean, simply wipe it with a cloth.
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The air mattress will come with a nylon bag which is perfect for storage and travel transport.


The U.S. Green Building Council has debuted the initial phase of the GIS-based Green Building Information Gateway.
The U.S. Green Building Council, acting through the USGBC Research Program, takes access of visual and statistical information on LEED Certified properties to a new technological level. The Research Program has debuted the initial phase of the GIS-based Green Building Information Gateway (GBIG), an information technology system that will have the real estate industry and proponents of sustainable development literally seeing green.
GBIG's first phase covers the state of Illinois and consists of three pilot projects: the GBIG Pilot for Illinois, GBIG Analyst and GBIG Explorer.
The GBIG Pilot is a web-based portal that provides details on green building projects across the state, statistics on the prevalence and expansion of LEED Certified projects over time, as well as information that allows for the comparison of projects to state averages or other subsets by certification standard and Carbon Index values.
The other two segments of GBIG's first phase consist of mobile applications that can be used with either iPhones or iPads and downloaded free of charge. GBIG Analyst offers a database of LEED Certified developments that can be categorized by credit and Carbon Index values and compared to state averages. GBIG Explorer is a more specific application, providing photos, text and an interactive GPS map for 250 LEED Certified projects in metropolitan Chicago.


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Jerusalem Post Israel News
Prof. Ash visits COVID-infected Arab town, stresses vaccination importance
"Even now, with the arrival of vaccines, we need to continue keeping the guidelines," Ash said, noting that "It will take time for the vaccines to have an impact."
By TOBIAS SIEGAL
Coronavirus commissioner Prof. Nachman Ash during his visit to the Arab town of Reineh on Saturday, December 19, 2020. (Health Ministry)
Coronavirus commissioner Prof. Nachman Ash visited the Arab town of Reineh in northern Israel on Saturday, stressing the importance of going to get vaccinated while still maintaining social distance guidelines, a Health Ministry statement read.
"In the past few days there has been a spike in coronavirus morbidity rates in Reineh," Ash said after his visit, adding that "I've seen the municipality step up in order to handle the situation and decrease the spread of the virus."
"The village is currently quarantined. The only thing that people can do now is to go and get tested in order to identify more patients – that's the only way of slowly returning to normal life."
Ash also addressed the arrival of coronavirus vaccines and the beginning of Israel's nationwide vaccination campaign, expected to kick off later on Saturday in a broadcasted event that will see Prime Minister Benjamin Netanyahu and Health Minister Yuli Edelstein receiving the vaccine.
Ash noted that "vaccines are our hope of finally changing our reality and going back to the way things were," but he emphasized that "it depends on people actually going and getting vaccinated."
Regarding speculations about the safety of the vaccines, Ash said that "the vaccines have been tested, they're safe; they don't cause those problems you hear about on social media."
However, he also said that "even now, with the arrival of vaccines, we need to continue keeping the guidelines."
Ash noted that "It will take time for the vaccines to have an impact," and addressed a message to the local population: "Go get vaccinated!" he said, "But keep wearing masks, maintain social distancing and avoid gatherings – even during the holidays."
Tags Yuli Edelstein quarantine Nachman Ash

redpajama_set_name: RedPajamaCommonCrawl


The Northern Bureau (located in the City of Nazareth) – which provides authorized companies for the Northern Area. Failing that, those other persons shall attach to the applying their authorization in writing for the legal aid centre to confirm that information with the taxation authorities concerned, a financial establishment, an company, an educational establishment, a government division or an employer.
Legal support centers will be punished for offering authorized assist to ineligible applicants, not offering it to eligible ones, receiving compensation for their work, participating in for-revenue legal companies, and misusing authorized aid heart funds.
The method of structural authorized assist is just not solely via the authorized help -in the sense of litigation and non-litigation works, but also by way of advocacy or strategic suit to change the order of law, whether or not it is structurally, culturally or authorized substance, become more justice.
The body of regulation coping with wrongs which might be punishable by the state with the thing of deterrence is known as prison law. We could hope that, because of co-operation between jurisprudents specialising in felony and personal legislation, the emergence of the Tartu college of legal liability need not be dominated out. A citizen and the courts will need to have a transparent understanding of a criminal regulation's necessities and prohibitions. However, if a person fails to be aware of a considerable and unjustifiable danger, an act or omission involving that risk may constitute negligent conduct that leads to legal charges. Crimes are behaviors declared by laws as unlawful (felony offenses) AND have specified punishments/sanctions connected for participating in these behaviors.
The speeches made by Van Spronken (A place of higher safety, 2003) and Klip (EU felony legislation, 2004) are testaments to the good changes going down within the area of criminal (procedural) regulation. The analysis group is also host to a number of analysis occasions inside prison regulation. The situation that in an effort to make an arrest in a misdemeanor, the arresting officer should have personally witnessed the crime being dedicated. Children under the age of seven are conclusively presumed to lack the capability to commit a crime.
Along with this influence, which examines the origins of legal regulation and the factors that impact criminal regulation, a new improvement has emerged during which society expects more from its criminal justice system. As a basic rule, an attempt to commit against the law is a misdemeanor, whether the crime itself is a felony or a misdemeanor. An omission, or failure to behave, may constitute a criminal act if there is a obligation to behave. Secondly, prohibition of an act in civil or public law and the truth that the act is contained within the necessary elements of a prison offence at all times means also illegality in criminal regulation, that's, the unlawful nature of the act. This intention relates particularly to a fourth analysis programme on the Faculty of Legislation dealing with theoretical views on legal regulation. An individual's conduct is formed by interactions with key social institutions-family, faculty, peer group, and the like.


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You are here: Home / Exposures / Barberis, Klipp, Vanoni, Alberghina, 2007 / Cell Size at S Phase Initiation: An Emergent Property of the G1/S Network
Cell Size at S Phase Initiation: An Emergent Property of the G1/S Network
This CellML version of the model runs in PCEnv and COR to produce graphs that are similar in shape but not in magnitude to the graphs in figure 3 of the published paper. This could possibly be due to a missing variable k55 in the equation for cdk1_c. The units have been checked and are consistent.
ABSTRACT: The eukaryotic cell cycle is the repeated sequence of events that enable the division of a cell into two daughter cells. It is divided into four phases: G1, S, G2, and M. Passage through the cell cycle is strictly regulated by a molecular interaction network, which involves the periodic synthesis and destruction of cyclins that bind and activate cyclindependent kinases that are present in nonlimiting amounts. Cyclin-dependent kinase inhibitors contribute to cell cycle control.
Budding yeast is an established model organism for cell cycle studies, and several mathematical models have been proposed for its cell cycle. An area of major relevance in cell cycle control is the G1 to S transition. In any given growth condition, it is characterized by the requirement of a specific, critical cell size, PS, to enter S phase. The molecular basis of this control is still under discussion.
The authors report a mathematical model of the G1 to S network that newly takes into account nucleo/cytoplasmic localization, the role of the cyclin-dependent kinase Sic1 in facilitating nuclear import of its cognate Cdk1-Clb5, Whi5 control, and carbon source regulation of Sic1 and Sic1- containing complexes. The model was implemented by a set of ordinary differential equations that describe the temporal change of the concentration of the involved proteins and protein complexes. The model was tested by simulation in several genetic and nutritional setups and was found to be neatly consistent with experimental data. To estimate PS, the authors developed a hybrid model including a probabilistic component for firing of DNA replication origins. Sensitivity analysis of PS provides a novel relevant conclusion: PS is an emergent property of the G1 to S network that strongly depends on growth rate.
The complete original paper reference is cited below:
Cell Size at S Phase Initiation: An Emergent Property of the G1/S Network, Matteo Barberis, Edda Klipp, Marco Vanoni, Lilia Alberghina, 2007, PLOS Computational Biology . (A PDF version of the article is available to subscribers on the journal website.) PubMed ID: 17432928
Main Events That Occur during the Yeast Cell Cycle
Derived from workspace Barberis, Klipp, Vanoni, Alberghina, 2007 at changeset a0e3ce568d9e.


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"Extremely professional and wise, with great commercial sense and a wonderful personality. What else can a client ask for?"
IFLR1000 (2020)
Hannah Ha is a partner of the Corporate & Securities practice of Mayer Brown in Hong Kong and leads the firm's Mergers & Acquisitions practice in Asia. Hannah's primary practice focuses on mergers and acquisitions and she has extensive experience in foreign direct investment in China, cross-border mergers and acquisitions, private equity transactions and general corporate and commercial matters. Hannah's practice also covers competition law, and she co-heads the firm's award winning Antitrust & Competition Team in Asia.
Hannah advises sovereign wealth funds, blue-chip companies, multi-national corporations and mainland Chinese companies. Her industry experience is wide-ranging, including aviation, chemicals, construction, consumer products, pharmaceuticals, transport, financial services and real estate.
Consistently recognised by independent commentators, clients told IFLR1000 2020 that "Ms Hannah Ha, who we've worked very closely with for years is exceptionally professional, she is always able to provide extremely commercially sensible legal advice to the group topped with great wisdom. We are thankful to have wise and helpful lawyers like her to work hand-in-hand with us". Legal 500 Asia Pacific 2020 also described Hannah as "well-positioned to guide local clients through investigations initiated by the Competition Commission, while on the non-contentious side, as well as her regular involvement in merger clearance work, Ha also assists multinational corporations to implement compliance programmes for antitrust and anti-corruption in Asia".
Hannah is an active advocate of pro bono and diversity & inclusion initiatives. She has been named leading lawyer for Mergers and Acquisitions by Expert Guides: Women in Business Law in 2014-2016 and she has also been recognized as a Women Leader in Asia by a mainstream legal publication in 2020.
Hannah is a China-Appointed Attesting Officer (appointed by the Ministry of Justice of PRC) and a Notary Public in Hong Kong. She speaks English, Cantonese and Mandarin.
Financial Institutions M&A
Private Equity, Funds & Investment Management
Hong Kong Competition Law
Advised a US Fortune 100 corporation listed on the New York Stock Exchange on an acquisition of a global oil & gas division of a FTSE 250 Index constituent company. The deal is valued at US$405 million and involved target assets across multiple jurisdictions. A six-practice, eight-office Mayer Brown team assisted the transaction.
Advised a world leading biotech company, which was a member of a Chinese SoE, on the establishment of a JV with a Shenzhen listed company under the same parent group, and another Shanghai listed company under its parent group's peer group. This matter also involves comprehensive structuring and compliance issues.
Advised a world leading biotech company, which was a member of a Chinese SoE, on the establishment of a JV with a Shenzhen listed company. This matter also involves comprehensive structuring and compliance issues.
Advised a prominent airline based in Asia on the restructuring of a joint venture with a prominent PRC airline. The JV was put in place with a very novel structure for compliance and business reasons under some specific circumstances, which brought challenges to the restructuring work. We also advised on the establishment of the JV.
Advised the investment arms of a world-class Japanese conglomerate on its investments in a Vietnamese financial institution that operates a highly regulated business, the transaction includes both a primary and a secondary tranche and our work includes merger control, M&A and other aspects. This is our client's first direct investment in Vietnam and one of the largest investments ever in Vietnam's burgeoning fintech space.
Advised a conglomerate listed group in Hong Kong with substantial PRC background to acquire several port businesses in various provinces of Australia from a prominent Australian listed company.
Advised a conglomerate listed group in Hong Kong with substantial PRC background together with a fund in China focusing on investments in Africa for investing into Nigeria.
Advised a PRC national in acquiring a landmark hotel in San Francisco.
Advised a Chinese leasing company on its subscription of shares, loan arrangements and joint venture in a special purpose vehicle holding three vessels with a total value of approximately US$276 million.
Advised a leading global consumer goods manufacturer on the disposal of the China manufacturing and distribution business of one of its internationally renowned food brands. This disposal is part of a global transaction with total cash consideration of $700 million. We advised on corporate and competition law matters of the deal.
Advised Ascott Holdings Limited, the subsidiary of CapitaLand Limited, on the acquisition of the entire issued share capital of Excel Chinese International Limited which owns a piece of land in Sheung Wan and operates a boutique hotel in Sheung Wan, The Mercer.
Advised China Resources Group on acquiring the distribution network of an Italian fashion brand "LIUJO" in the PRC and obtaining a license for the LIUJO brand in the PRC.
Advised a consortium led by a worldwide prominent hotel/serviced residences operator for investing into an online apartment sharing platform in China.
Advised the worldwide prominent hotel/serviced residences operator for forming a joint venture with an entity operating an online apartment sharing platform in China for managing a portfolio of serviced residences in China.
Advised a world renowned financial institution in its acquisition of a minority interest in a prominent bank in Shanghai.
Advised a leading PRC real estate developer in the establishment of a joint venture with a private equity fund (targeted with a total capital contribution of up to US$2 billion) to invest in and develop mixed-used commercial real estate projects in the PRC with a total construction area of approximately 2 to 4 million square metres.
Advised China Resources Cement Holdings Limited in respect of its acquisition of 50% interest in several entities (indirectly held by Yue Xiu Enterprises (Holdings) Limited) that engage in the clinker, cement and concrete operations in Guangzhou and Hong Kong, for an aggregate consideration of HK$1.24 billion.
Advised a major Hong Kong utilities company in connection with its joint venture to develop their utility meter business. The joint venture partner, an international utilities meter provider, has injected its existing utility meter business in China, Hong Kong and the US by two stages to the newly established joint venture in China, Hong Kong and the US respectively. Our client is the majority shareholder in the joint venture.
Advised Cathay Pacific Airways Limited on a proposed multi-party ground handling joint venture in Shanghai. The 4-party joint venture involves 3 public listed entities and 3 PRC state-owned companies.
Advised Cathay Pacific Group in the establishment of a cargo airline joint venture with Air China Limited ("Air China"). The Cathay Pacific Group will subscribe for 25% equity interest directly in Air China Cargo Co., Ltd. ("ACC") for a consideration of approximately RMB851 million and obtain 24% economic interest in ACC through the returns on the loan in the sum of approximately RMB 817 million provided by Cathay Pacific Group. Air China will retain 51% equity interest in ACC. Four Boeing 747-400 converted freighters and two spare engines will also be sold by the Cathay Pacific Group to ACC as part of the transaction.
Advised EUROFER (the association of European steel producers) in the filing of submissions to various international competition regulators, including China's Ministry of Commerce, opposing the contemplated Australian iron ore joint venture between BHP Billiton and Rio Tinto. The team's representation of EUROFER on this matter was recognised via Global Competition Review's the 2011 "M&A Transaction of the Year, Asia-Pacific, Middle East & Africa" award.
Advised Hong Kong Aviation Engineering Co, Ltd. (HAECO) on its acquisition and the related merger control issues of an aircraft engine maintenance, repair, overhaul and testing facility in Xiamen, PRC from leading aircraft engine manufacturer, GE. The transaction involves the acquisition by HAECO and its affiliates of a PRC subsidiary of GE and a "branded service arrangement" between GE and the required facility. The total transaction value amounts to over US$100 million. We advised the client on both corporate and competition law aspects of this transaction.
Advised Modern Terminals Limited to form a joint venture with China Merchants Holdings (International) Company Limited for the purposes of rationalizing and consolidating their respective interests in 3 container terminal companies in Shekou, Shenzhen, China. Total value of the transaction is approximately US$1.7 billion.
Advised Americold Realty in the establishment of a joint venture to develop cold chain logistics services in China and Asia with China Merchants Holdings (International) Co. Ltd. (China Merchants), a large dock operator in China. China Merchants will take a 51% controlling stake in the joint venture with Americold Realty, a large provider of temperature-controlled food distribution services in the U.S, taking the remaining stake. The parties will jointly invest RMB 70 million in the joint venture.
Advised Agilysys, Inc., a NASDAQ-listed company in its acquisition of a Shanghai company, and the assets and business of a Hong Kong company, which are both engaged in providing computer hardware and software- related technology and solutions. Handled the acquisition in Hong Kong and the PRC, and also negotiated and arranged the signing of novation contracts with suppliers and customers.
Advised various private equity funds in US on pre-merger control filings in China in respect of their respective acquisitions in various industry sectors.
Advised a leading marketer of apparel and consumer soft goods, a NYSE listed company to conduct a corporate restructuring of its subsidiaries in Hong Kong and a few Asian countries before selling those subsidiaries to a listed group in China.
Advised a prominent bank in Hong Kong on the formation of a joint venture in relation to a credit card business in China, with one of the largest banks in China.
Advised HSBC in establishing HSBC ZhongHua Insurance Brokers Co., Ltd. in China.
Advised HSBC on its sale of a 27 percent stake in Ping An Bank Limited to Shenzhen Commercial Bank Company Limited (SZCB, a subsidiary of Ping An Group). The transaction was part of Ping An Group's consolidation of its banking businesses within SZCB.
Advised Hang Seng Bank on its US$210 million acquisition of a 15.98% stake in Industrial Bank.
Individual Liability for Contravention of the Hong Kong's Competition Ordinance and Ten Recommendations for Avoiding it
The First Commitments Accepted by the Hong Kong Competition Commission
Merger Control in Asia – More Scrutiny?
Belt and Road Summit 2018
Seminar to The Hong Kong Chinese Enterprises Association on Hong Kong Competition Ordinance
Four Mayer Brown partners recognized as 2020 "Women Leaders" by IFLR1000
The University of Warwick, MBA
The University of Hong Kong, PCLL
The University of Hong Kong, LLB
Australia, Queensland
Australia, New South Wales
Australia, Victoria
Australia, Tasmania
Standards and Development Committee, Hong Kong Society of Notaries
Council Member, Hong Kong Society of Notaries
Member, Competition Law Working Group, Association of China-Appointed Attesting Officers & Society of Notaries
Member, Disciplinary Committee of Association of China-Appointed Attesting Officers
Member, New York Bar Association
Member, Chartered Institute of Arbitrators
Member, China Committee, The British Chamber of Commerce in Hong Kong
Member, Executive Committee of the Hong Kong Competition Association
Leading Individual - Competition/Antitrust, China (International Firms) – Chambers Global (2012-2020)
Leading Individual - Competition/Antitrust, China (International Firms) – Chambers Asia Pacific (2009-2021)
Recommended Lawyer - Corporate (Including M&A), Hong Kong – The Legal 500 Asia Pacific (2020)
Leading Individual - Antitrust & Competition, Hong Kong – The Legal 500 Asia Pacific (2018, 2020)
Highly Regarded Lawyer - Mergers and Acquisitions, Hong Kong – IFLR1000 (2020, 2021)
Highly Regarded Lawyer - Competition, Hong Kong – IFLR1000 (2018-2021)
Acritas Star – Acritas Stars Report (2017)
Leading Individual - Corporate/M&A: Hong Kong-based, China (International Firms) – Chambers Global (2012-2017)
Leading Individual - Corporate/M&A: Hong Kong-based, China (International Firms) – Chambers Asia Pacific (2011-2017)
Leading Lawyer - Competition, Hong Kong – IFLR1000 (2011-2017)
Leading Lawyer – Mergers and Acquisitions – Expert Guides: Women in Business Law (2014-2016)
Expert, Competition and Antitrust – Expert Guides: Women in Business Law (2012, 2014 and 2016)
Expert – Expert Guides: Women in Business Law (2015)
Asia Women in Business Law Awards - Best in Competition and Antitrust award – Euromoney LMG (2013)
Expert, Mergers and Acquisitions – Expert Guides: Women in Business Law (2013)
"The way they understand client needs is a notch above others. They know how to solve problems and not escalate them." – Chambers Asia Pacific (2013)
"She was devoted to the project, took care of all the details and worked within deadlines" – Chambers Asia Pacific (2013)
Leading Practitioners China (Competition and Antitrust: Greater China International Firms) – Expert Guides (2012)
"an all-rounder who interacts well with clients and gives good advice on competition transactions." – Chambers Asia Pacific (2012)
"Interviewees respect her 'level of commitment and accommodating nature that suits client schedules and timetables.'" – Chambers Asia Pacific (2012)


What's more refreshing on a long hot summer evening, than a refreshing G&T?
And if you mix gin with art, you can come up with some extremely creative results. Premium gin brand, BOMBAY SAPPHIRE is leading a global mission to 'Stir Creativity' which is set to inspire everyone to engage with their creativity and unlock their creative potential with events taking place around the globe this summer.
For a limited time, a unique living gallery has been created in a unique destination in Shoreditch, London. Not only can you sip delicious gin based cocktails, you will be taking part in real-life art installations, and trying out your own creative personal twists on BOMBAY SAPPHIRE gin cocktails from the bar. You are also actively encouraged to funk up your own creations with edible paint and glitter!
The London 'CANVAS' is showcasing the work of 12 emerging and established, international artists, including signwriter and glass gilder Alex May Hughes, illustrator and designer Josh McKenna, and graphic artist Supermundane, who is joined by fellow creatives and artists from Spain, Germany and The Netherlands.
With movers and shakers from the art, film and fashion world attending the launch night party, they mingled with the artists, who were transforming the spacious venue, into a living work of art using the floors, walls and furniture as their canvas.
With a large gin on entry, the 'Tonic Wall' set the scene; Four flavoured tonics laid out in a maze of piping for you to choose your preference. Ranging from spicy to fruity to sour and refreshing, you were invited to finish them off with garnish from the pick-your-own garnish garden, before mingling with the guests and artists at the event. With nightly DJs and comfortable seating, this is a new kind of pop-up bar, which if you like gin or art, you will want to join in and stir your creativity, and be part of the movement.
Tickets are priced at £10 and can be purchased by visiting www.bombaysapphirecanvas.com.
As part of the global mission to Stir Creativity, BOMBAY SAPPHIRE will donate all ticket sales proceeds from the CANVAS London event to charity Developing Artists.


text:
Q: Cannot get simple SignalR Azure worker role to work I am trying to get a simple WebSocket server going using SignalR, OWIN and Azure Worker Roles.
WorkerRole.cs:
public class WorkerRole : RoleEntryPoint
{
    public override void Run()
    {
        string url = "http://" + RoleEnvironment.CurrentRoleInstance.InstanceEndpoints["MyEndpoint"].IPEndpoint;
        using (WebApp.Start<Startup>(url))
        {
            Trace.WriteLine(String.Format("Server running on {0}", url));
        }

        while (true)
        {
        }
    }
    /* ... */
}

Startup.cs:
public class Startup
{
    public void Configuration(IAppBuilder app)
    {
        app.MapSignalR();
    }
}

MyHub.cs:
public void Send(string name, string message)
{
    Clients.All.addMessage(name, message);
}

The Endpoint "MyEndpoint" is defined in the Service as http, public and private port 5001.
After starting the service, it shows up under Azure Compute Emulator as running on 5001. However, if I try to connect to ws://127.0.0.1:5001/signalr (or just ws://127.0.0.1:5001) there is no response. I am using two different web socket clients for this purpose (both are Chrome plugins and they both worked fine using other WebSocket servers).
Questions:
1) Is there anything obviously wrong with my setup?
2) Do I need to use the SignalR JS client libraries to connect to the SignalR server, or should any vanilla client implementing the WebSocket protocol be able to connect?

A: I know this is a bit of an old post but just in case someone needs it...
1) There are two problems you need to address.
First of all, Start method in:
    using (WebApp.Start<Startup>(url))
    {
        Trace.WriteLine(String.Format("Server running on {0}", url));
    }

returns an IDisposable (hence the using(...){} block) means it is immediately disposed after creation since execution continues right passed Trace.Writeline(...) without pause.
It's also a bit tricky running these things under the Azure Compute Emulator for a few reasons, mainly because it remaps ports to avoid collisions. If you open up a command prompt and run
    netstat -a

you'll find that you have open ports (listening) looking something like this (in my case I'm using port 81):
    TCP    127.0.0.1:82           MyComputer:0              LISTENING
    TCP    127.0.0.3:81           MyComputer:0              LISTENING

In the general console ouput of Visual Studio, you'll also most likely see something like
    "Windows Azure Tools: Warning: Remapping private port 81 to 82 in role 'MyRoleThingy' to avoid conflict during emulation."

This all means that in order to connect to the server you're hosting using your worker role, you'll have to connect to port 82 instead of 81 (probably 5002 in your case).
2) If you implement the protocol, anything should work I think. Managing an initial connection on the port should always work.

redpajama_set_name: RedPajamaStackExchange


text:
NY Meta
Gang Member Loses Vision From Self-Tattooing His Eye Balls
Florencio Conchuza Gonzalez is an L.A. gang member from the infamous Ms-13 gang. He has become blind from getting his eye balls tattooed. The tattoos were to celebrate his 17th birthday.
The man has been captured on video camera this week when he fled a convenient store after an armed burglary. Hoping police would assist in helping him get his vision back, he admitted his crimes to the officers.
It was shocking to officer Juan Simons when the young man came to the police station on his own, and admitted his crimes to him.
"He just started crying and told us he would tell us anything we wanted as long as we would bring him back his vision" recalls the police officer. "I reassured him we would do the best we could and called an ambulance immediately as his eyes were bleeding and were so swollen they looked like they were going to come out of his eye sockets" he admits, still visibly shaken.
In exchange for the hopeful eye healing assistance, Florencio has reportedly turned and snitched on his former friends.
"He has given us, in only a short time, a comprehensive list of drug and weapon resell points, gang leader names and even names of possible corrupt officers within our own forces, which need to be authenticated" admits a spokesman for the Los Angeles Police Department.
There's a saying, "snitches get stitches," that runs rampant throughout gang culture, so his eyesight may be just the beginning of his problems.
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by Mick Feuerbacher, July 2007.
The current project is my latest iteration of a single-chip LM3886 design. The circuit is boiled down to the absolute necessary parts. It is even more simple than that of the three-resistor amp - I left out one more resistor, so now it is essentially a two-resistor descendant. The amp is build up double mono. The channels are completely separated and each has its own power supply.
This the first project where I started with the case. I wanted a very stable, small and optimized case. Furthermore I planned to place the chips on a large copper mount as this material has, according to several professional as well as diy builders, superior acoustic properties.
The central element: a big block of copper. The chip will be directly mounted on this block, which by itself will be connected to a copper support.
I decided to build the amp into a commercial case from Conrad. It turned out that the build quality of the case was very low. The front and back plates were made of awfully thin aluminum and the screw connections were worn right from the beginning.
Therefore I only used the upper and lower steel covers and made the complete rest by myself, using massive aluminium. The front and back plates are 8 mm thick, the bottom plate is 4 mm.
On the picture you also see some of the parts to be used. The Cs capacitors are well approved Panasonic FC types, the pot is a stepped attenuator as sold by http://diyfidelity.com.au/.
The LM3886 with the inner parts connected: you see the muting resistor, the pin1-pin5 connection, the redirection of V- to pin11 and, in the background, the feedback resistor.
The core part of the apm on the copper block. The wires to the connectors are already soldered to the chip.
After completion the amp was subjected to the usual tests. The DC offset was only 6mV on each channel.
The front plate was grinded and sandblasted to give it a nice matte finish. After sandblasting, it was spray laquered to avoid corrosion.
The volume knob is recessed. For now I use a knob which I once found in a dumpster. It will later be replaced by a dedicated turned piece.
With my other chip amps, I tried several versions of power supply. I tested high-capacity snubberized supply, switch-mode supply, discrete regulated and chip regulated supply. With this amp, I decided to go for the simplest solution, which was my first option and which I eventually preferred over all the others.
The PSU consists of a rectifier bridge - one per rail - only. There is no capacitance, only the 2200uF directly at the chip as seen above.
The finished PSU. It is built up completely double mono. The toroids are 2 x 18V, 120 VA types.
The copper amp is now continuously running since a couple of days in my system. I am very pleased with the sound and, compared with my previous iterations, it has increased detail in the mids and highs, and a temendous dynamics.
The source is a heavily modified Sony Playstation 1 with an external linear power supply, the speakers are Audio Physic Tempo IIIi.


text:
Ueli Bänziger (* 21. Oktober 1945 in St. Gallen, heimatberechtigt in Lutzenberg; † 8. Juli 2004 in Ardez) war ein Schweizer Künstler. Sein Werk umfasst Malerei, Kunst am Bau, Druckgrafiken, Plastiken und Skulpturen.

Literatur

 Agathe Straumann (Konzeption), Erziehungsdepartement Basel-Stadt, Abteilung Kultur (Hrsg.): Kunst für Basel. 75 Jahre Kunstkredit Basel. Kunst im öffentlichen Raum. Schwabe Verlag, Basel 1994, ISBN 3-7965-0968-1, S. 73, 112, 160

Weblinks

 Ueli Bänziger in mural.ch
 Ueli Bänziger In: WorldCat

Bildender Künstler (Schweiz)
Schweizer
Geboren 1945
Gestorben 2004
Mann

redpajama_set_name: RedPajamaWikipedia


Upon trying to deploy the VHD to Hyper-V, SCVMM reported that the disk was corrupt. Knowing that I was just booting from this device, I stubbornly tried again but I was not successful. Upon failing again, I remembered I had a similar issue when resizing my XenApp VHD previously and I recalled I had worked around the issue by using VHD Resizer. I mirrored this file for easy access.
I don't know what the cause is yet of these corrupt VHD's, however both VHD's were created with the PVS imaging utility.
We utilize PVS and when we were attempting to update the target device software utilizing Hyper-V we got several error messages saying the VHD is corrupted. The actual root of the issue is that PVS makes 16MB block size VHD files (thanks SAMAN!) and Windows 2008 only reads VHD files that are 512KB or 2MB block sized files.
Thanks for the tip Justjeff! I wonder what the implications are for PVS for using a Hyper-V created VHD with the smaller blocksize or if Server 2012/2012R2 can read them.


This month's witchcraft is about making poppets.
A poppet is a figure representing a person or animal and is used in spells. Poppets date back to Babylonia and Mesopotamia, and can be made from clay, cloth, wax, fruit, sticks, dolls or other materials. The magic works on the principles of similarity and associated contact – a witch will effect change through use of the icon.
Like other ritual tools, once made, the poppet needs to be consecrated, named and dedicated to the work in hand. It can be infused with your personal energy and intentions by breathing life into the figure. Once created and magically charged, whatever action is performed upon the poppet will cause a similar effect on the person it represents. That's why the more like the poppet is made to resemble the individual it represents, the better.
Poppets can also be made in the likeness of a god or goddess. Corn dollies are poppets, as are voodoo dolls and the Brigid dolls placed in beds on Imbolc.
In my practice, I've made poppets to represent myself and the characteristics I wished to embody, and I've made poppets to be used in binding rituals as a way to defend myself – wrapping them in red ribbon and burying them to keep the person from harming me, themselves or others.
Poppets and binding can also combine to hold a spirit – for example, binding the powers of the Goddess Diana into a poppet and giving it to a pregnant woman for protection during childbirth.
The money poppet in the accompanying photo was made by a witch as part of a money spell. In addition to the images of money imprinted on the fabric, it is stuffed with herbs and objects meant to attract money. It sits on her altar and she's gotten through some incredibly difficult financial times.
Research can help you identify the materials that will best mesh with your desired outcome.
If the poppet is not burned or buried as part of your ritual, keep it safe. It can be stored with some salt or other appropriate gems or herbs – all wrapped in white cloth. When it is no longer desired, it can be undone in the same order it was made or it can be left in the woods with an offering from which you walk away without looking back.


The art of mobile testing is increasingly important for any company that wants to remain competitive. Mobile application testing is a process by which application software developed for handheld mobile devices is tested for its functionality, usability and consistency. Mobile application testing can be an automated or manual type of testing. My presentation would be an introduction to automated mobile testing, and I would like to show to participants how to set up one project and use C# with Appium for testing mobile application. I would like to pay attention to them on problems and solutions in setup and to show a small example of one Appium project.


text:
"Casablanca" Piano Sells In New York For More Than $600K
The piano used for the song "As Times Goes By" was sold to an unidentified buyer.
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Humphrey Bogart's in "Casablanca." The piano prop from the film was sold at auction in New York Friday.
The piano used for the song "As Times Goes By" in the classic 1942 film "Casablanca" has fetched more than $600,000 at auction.
The 58-key upright was sold to an unidentified buyer for $602,500 at Sotheby's New York on Friday.
Its pre-sale estimate was up to $1.2 million.
It was offered by a Japanese collector on the film's 70th anniversary.
Celebrity Baby Boom
The collector purchased the movie prop at a Sotheby's auction in 1988 for $154,000.
Humphrey Bogart played Rick Blaine in the Oscar-winning World War II love story, opposite Ingrid Bergman's character, Ilsa Lund.
In a famous flashback scene, Rick and Ilsa lean on the piano at a Paris bistro. Sam, played by Dooley Wilson, plays and sings.
In Memoriam: 2012
They toast as Rick says: "Here's looking at you, kid."