text:
Journal of Cancer Therapy
10.4236/jct.2014.514147
Complications Following Surgery for Gastric Cancer: Analysis of Prospectively Collected Data
Lorenzo Bruno1*, Lucia Barni1, Sabrina Pacciani1, Gaia Masini1, Lorenzo Tofani2, Federica Tofani1, Filippo Melli1, Antonio Taddei1, Manuela Andonova Miloeva1, Luca Boni2, Giancarlo Freschi1, Paolo Bechi1
1Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
2Clinical Trials Coordinating Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
Email: *lbruno@katamail.com
Academic Editor: Sibu P. Saha, University of Kentucky, USA
Received 17 October 2014; revised 18 November 2014; accepted 27 November 2014
Background and Aims: The complication rate after surgery for gastric cancer varies according to the particular definition of morbidity, so it's necessary to report them using a standardized method, the Clavien-Dindo system. The purpose of this study was to prospectively analyze all post- gastrectomy complications in patients with gastric adenocarcinoma according to the severity grade using Clavien-Dindo system, in order to identify risk factors for postoperative complications and their prognostic significance on survival. Methods: This study is based on data from 90 consecutive patients who underwent gastrectomy for gastric neoplasia between January 2010 and February 2014 at the same unit. 15 patients were excluded (benign tumors, GISTs, missing data). Complications were categorized according to the Clavien-Dindo classification (uncomplicated patients vs pa- tients classified ≥Grade I). The following risk factors were studied: age, BMI, sex, operation method, extent of resection, duration of surgery, transfusions, TNM staging, and lymph node ratio. Multivariate logistic regression was used to evaluate the association between risk factors and presence of complications. To assess the effect on overall survival, after selection of covariates using backward elimination, the Cox proportional hazard model was applied. Results: Among these patients, 49 (65.3%) developed complications, stratified as follows: Grade I, 6 (8%); Grade II, 24 (32%); Grade III, 6 (8%); Grade IV, 13 (17.3%). The laparoscopic technique (OR = 0.050; 95% CI = 0.005 - 0.550, p = 0.0143) and no transfusions (OR = 0.219; 95% CI = 0.058 - 0.827, p = 0.0251) were found to reduce the incidence of postoperative complications in the multivariate analysis. With regard to the survival analysis, lymph node ratio, malnutrition, extended resection and presence of complications were significant predictors of reduced survival in the multivariate analysis. Conclusions: Some variables can predict the risk of postoperative complications, the occurrence of which is a predictor of reduced probability of survival. In this respect it's essential to reduce complications.
Gastric Cancer, Complications, Clavien-Dindo Classification, Survival Probability
Gastric cancer is the fourth most common malignancy and the second most common cause of cancer-related death worldwide [1] . Italy is classified as an intermediate incidence area for gastric cancer.
Surgery still remains the main method for successful treatment of gastric cancer and the incidence of post- operative complications can be regarded as an index showing the outcomes of surgical performance [2] .
Accurate grading of complications is essential to analyze surgical outcomes, but methods for classification of complications are not uniform. The Clavien-Dindo system, proposed in 2004 [3] , has been applied to many surgeries [4] - [8] and has been considered simple, reproducible, flexible, and irrespective of the cultural background. Moreover an increasing number of studies using this classification for assessing gastric cancer surgery have been published [1] [2] [4] [5] .
Many studies have shown that, in gastric cancer, the presence/absence of complications is an important factor that could influence the prognosis of patients following curative gastrectomy [1] [5] .
In gastric surgery the most commonly reported complications were intra-abdominal abscesses, wound infection, necrosis or dehiscence, diffuse peritonitis, sepsis, malnutrition, fluid and electrolyte disturbances, acute cholecystitis, pancreatitis, abdominal bleeding and pneumonia [9] . Less common ones are represented by: anastomotic leakage, fistula of duodenal stump, pancreatic fistula and chylous fistula [10] .
The reason why post-operative complications affect prognosis remains open to speculation; many studies [1] [5] suggest that prolonged inflammatory response could promote metastatic diffusion of residual tumor cells.
The aims of this study were: firstly, to analyze post-gastrectomy complications for gastric adenocarcinoma by prospectively collecting complication data according to the Clavien-Dindo system in order to investigate risk factors for post-operative complications; secondly, to assess the impact of postoperative complications on long- term survival.
The present study was limited to the last years of our series because it seemed mandatory to evaluate data prospectively collected on account of the peculiar accuracy of Clavien-Dindo classification.
2.1. Patients
A total of 90 consecutive patients with gastric neoplasia underwent surgery between January 2010 and February 2014 in our surgical unit, that is a secondary-care unit located in a high-risk gastric cancer area. Eligibility criteria for inclusion in this study were as follows: 1) gastric adenocarcinoma identified by histopathological examination; 2) availability of information regarding postoperative complications and mortality. As a result, 75 patients were eligible, whereas 15 patients were excluded: 2 GISTs, 1 lymphoma, 6 benign tumors, 6 missing data. Patients were asked about their informed consent and approval by the ethic committee was requested. For each patient we analyzed the following parameters: age, sex, BMI, operation method, extent of resection, duration of surgery, pre- and intra-operative transfusions, TNM staging, lymph node ratio. 5 patients were lost to follow-up, so they were excluded from the survival analysis. 70 patients were followed up for a minimum of 6 months after gastric resection.
2.2. Assessment of Complications
The Clavien-Dindo classification was used to grade post-operative complications: complications were defined as "any deviation from an uneventful post-operative course" within the hospital stay and we considered as complicated patients those with complication grade ≥ I (Table 1).
Table 1. Classification of complication according Clavien-Dindo system.
‡Brain hemorrhage, ischemic stroke, subarrachnoidal bleeding, but excluding transient ischemic attacks (TIA); IC: Intermediate care; ICU: Intensive care unit.
2.3. Statistical Analysis
All statistical analyses were performed by SAS Version 9.3. Spearman's rank correlation coefficient was used to identify relation between quantitative parameters and chi-square index for qualitative variables. To evaluate the association between qualitative and quantitative parameters the simple linear regression was applied.
Multivariate logistic regression was used to evaluate the association between risk factors and presence of complications. Stepwise approach for variable selection was used. To evaluate discriminant capability of the risk factors included in the model, area under ROC curve was used.
To evaluate the association between qualitative and quantitative variables and complications chi-square test was used. Survival analysis was performed by Kaplan-Meier curves with log-rank test. To assess the effect on overall survival, after selection of covariates using backward elimination, the Cox proportional hazard model was applied. p < 0.05 indicated significant differences.
3.1. Patient Characteristics
Clinicopathological characteristics of the 75 patients are summarized in Table 2. As far as the operative technique is concerned, open, laparoscopic and laparoscopic converted to open gastrectomies were performed respectively in 48 (64%), 11 (14.7%) and 16 (21.3%) cases. Lymph node ratio (NR) was stratified into 3 groups: 0, >0 and <0.2, ≥0.2. Duration of surgery was significantly shorter in the open surgery group (Table 3). The mean duration of hospitalization was 12 ± 4.8 days and the median was 10 (ranging between 7 and 32) (Table 4).
3.2. Postoperative Complications
Of the 75 patients who underwent gastrectomy, 49 (65.3%) developed complications. The numbers of Clavien- Dindo Grade I, II, III, IV and V complications were 6 (8%), 24 (32%), 6 (8%), 13 (17.3%) and 0 (0%), respectively (Figure 1).
3.3. Structured Data Analysis
After assessing the absence of correlation between the above-mentioned parameters, using a multivariate logistic
Table 2. Clinical records 2010-2014: 75 patients.
Table 3. Duration of operation (minutes).
Table 4. Duration of hospitalization (days).
Figure 1. Incidence of complications.
regression model, significant factors were: the laparoscopic technique (OR = 0.050; 95% CI = 0.005 - 0.550, p = 0.0143) and no transfusions (OR = 0.219; 95% CI = 0.058 - 0.827, p = 0.0251), which were found to reduce post-operative complications (Table 5). The area under the ROC curve (Figure 2) for these factors is 76%: it shows that the significant factors which were found can quite well identify post-operative complicated patients. In Figure 3 we can see the expected probability to develop a post-operative complication based on identified factors: when a patient undergoing open technique and received pre-operative or intra-operative transfusions, the probability to have a post-operative complication is 90%, conversely, in patients undergoing laparoscopy and without transfusions, the probability falls to 1%.
Afterwards, the influence of post-operative complications and other risk factors on survival was evaluated. As far as perioperative transfusions are concerned, the differences between survival curves do not attain statistical significance (p = 0.3775) (Figure 4). On univariate analysis (Figure 5), complications are significant factors for survival: the probability of 1 year survival after the operation in a complicated patient is about 75%, whereas in a non complicated patient is 95%. Dividing complications in 3 levels (not complicated, complicated I-II, complicated ≥III which are life-threatening complications), this significance is evident (Figure 6). BMI (p = 0.0252) and NR (p = 0.0033) are also important. Then, using the Cox proportional hazards regression model, independent prognostic factors were (Table 6).
- Post-operative complications: patients complicated ≥Grade I have a poorer prognosis than not complicated (HR = 7.39; 95% CI = 1.64 - 33.21, p = 0.0091);
- BMI: underweight patients have a worse prognosis than overweight/obese (HR = 8.402; 95% CI = 1.08 - 64.90, p = 0.0413);
Table 5. Multivariate analysis: risk factors for complications (LOGIT model).
Figure 2. ROC curve.
Figure 3. Complications probability considering transfusions and surgical approach.
Figure 4. Complications and survival probability.
Figure 5. Complications and survival probability (II).
- Extent of resection: patients undergoing subtotal gastrectomy show a better prognosis than those undergoing total gastrectomy (HR = 0.308; 95% CI = 0.098 - 0.966, p = 0.0434);
- Lymph node ratio: patients with NR ≥ 0.2 show a survival probability lower than those with NR = 0 (HR = 14.380; 95% CI = 1.716 - 120.534, p = 0.0140), whereas there is no difference between NR = 0 and NR between 0 and 0.2 (HR = 2.179; 95% CI = 0.201 - 23.607, p = 0.5218).
Figure 6. Perioperative transfusions and survival probability.
Table 6. Multivariate logistic regression model: risk factors and survival probability.
Our patients are representative of a western gastric cancer series whereas most studies on this item evaluate eastern people. Western patients suffer from greater heart, lung and metabolic comorbidities and have a higher BMI than eastern people [11] ; moreover, gastric cancer is diagnosed at elder ages and in more advanced stages because of the lack of screening programs. Another difference concerns the histological features: gastric cancer in western countries is usually proximal and diffused according to Lauren classification and it has a more aggressive behaviour than the intestinal and distal one [12] .
If we compare our findings with the results of the Clavien-Dindo study which included 6336 patients, the lower percentage of complications in this latter study is evident. However, some of the differences may be due to the inclusion in their group of patients who underwent minor surgical procedures [3] .
Quing-Guo Li et al. [13] include only patients operated upon for gastric cancer and report 12.5% of patients with ≥Grade I complications, which is exceedingly lower when compared with our finding of 65.3% of complications. However, the two groups seem hardly comparable, since in Quing-Guo Li's study the surgical technique isn't described and their series was made up of and patients with a lower ASA score and lower median age who were operated at an earlier stage.
Results similar to ours were obtained in Ju-Hee Lee et al. study [4] , with an overall complication rate of 65.4%, (25.3% in patients undergoing laparoscopy and 40.1 in patients undergoing laparotomy). This higher complication rate is closely related to the precise application of the definition of complication as "any deviation from normal postoperative course": for example, asymptomatic fever or transient anomalies in laboratory tests are classified as Grade I and II complications, in spite of their conservative treatment. This type of complications represented the most part of the complications which were observed in both the Ju-Hee Lee's and our studies.
In our study, age is not a significant risk factor for complications, conversely other studies [2] [14] consider it a risk factor and the authors discourage this kind of surgery in older people.
The relationship between obesity and complications is still controversial: most studies report an increasing risk in obese patients, because of technical complexity due to poorer surgical exposure, blood oozing from soft tissue, dissection planes hindered by adipose tissue, difficulty with anastomoses, and so forth [15] . On the contrary, our study, consistently with other ones [16] , has shown that BMI doesn't represent a risk factor for complications. These different results may be due to the fact that BMI doesn't distinguish between muscle and fat accumulation or between central and general obesity. Recently, a new anthropometric measure, "A Body Shape Index" (ABSI), has been proposed and when compared with BMI, it seems to better correlate with complications [17] [18] .
Moreover, in our clinical records, obese patients were only 5, all of whom belonged to class I obesity (BMI ≥ 30 and <35). This is the reason why no technical difficulties were due to the excess of adipose tissue in our series. On the contrary, all our patients with BMI < 18.5 (underweight) developed postoperative complications. In our records they are represented by only 4 patients (5.4%). However, similar results were reported by other studies in larger series [2] .
As previously reported, overweight/obese patients may even have a better prognosis [19] [20] . These might be explained on the basis of the loss of weight, which occurs after gastric surgery [21] and which could restore the ideal weight in this category of patients.
Previous studies focused the attention between intraoperative bleeding loss (IBL) and complications [22] [23] . Unfortunately, IBL was not measured in our series. Therefore, only the transfusion datum could be utilized in the present series and a direct correlation between transfusion and post-operative complications was observed. On the contrary, the inverse correlation between transfusions and long-term survival which has been previously shown was not confirmed. However, most studies [24] - [26] have shown that perioperative surgical stress cause immunosuppression, which could be exacerbated by concomitant transfusions. This condition could promote tumor relapse and metastatic process and could be explained by the infusion of an incompatible MHC antigen.
The surgical technique seems to have a statistically significant effect: patients undergoing open surgery have a greater risk to develop complications than those undergoing laparoscopy. This finding agrees with other studies [4] [27] [28] . Ju-Hee Lee et al. [4] have reported that complications ≥Grade I are present in 25.3% of patients undergoing laparoscopy and 40.1% undergoing laparotomy. Our results are similar: 27.3% and 77.1% of complications in patients undergoing laparoscopy and laparotomy, respectively (p = 0.005). We also, as previously done [4] , have separately considered "life-threatening" complications (≥Grade IIIa). The results were as follows: patients operated with an open access had 20% of life threatening complications, (Ju-Hee Lee et al. [4] 5.4%) whereas the laparoscopic group only 1.33% (Ju-Hee Lee et al. [4] 2.1%) (Table 7). Both series stand for the evidence that complications are not uncommon after open surgery. Li H.T. et al. [27] underline, despite a significantly longer operation time, the advantages which derive from laparoscopy: less intraoperative blood loss, shorter hospitalization time, shorter time to mobilization, shorter time to bowel opening and shorter time to normal dietary intake. These advantages could be explained by the reduction of the so-called "surgical stress" in laparoscopic surgery. How could it be measured? Toru Aoyama et al. [29] have compared surgical stress of laparotomic and laparoscopic procedures through the evaluation of the white blood cell count and the IL-6 level. They didn't find any differences between the two surgical approaches. Other authors [30] - [32] obtained the same results, although different methods for the evaluation were employed.
Table 7. Technique vs complications in 3 levels.
As far as long-term results are concerned, no deaths were observed in the laparoscopic group, although differences in overall survival between the laparoscopic and laparotomic group were not attained.
Recently, robot-assisted gastrectomy has been introduced for gastric cancer treatment and its advantages/ disadvantages in comparison with the other techniques are under investigation. K.M. Kim et al. [33] underline that open surgery and minimally invasive approach achieve similar complication and mortality rates, but complications like anastomotic leaks are more common after the latter technique. According to M.H. Hyun meta- analysis, short term oncological outcomes are similar with all the three different operative approaches, minimally invasive surgery provides substantial advantages and more specifically laparoscopy is less time-consuming and expensive than robotic [34] . Koichi Suda et al. [35] , adopting Clavien-Dindo classification, have compared laparoscopic and robotic approaches and pointed out that postoperative complications could be reduced by robotics. However, robotic approach to gastric cancer needs further experience before possible advantages may be fully understood.
In our study the duration of hospitalization proceeds at the same pace of the incidence of postoperative complications, but it cannot be considered as a risk factor for complications since it can be evaluated only a posteriori. However, it must be questioned whether complications influence the hospital stay or patients who have longer hospital stay have more probability to develop complications.
In this respect, possible benefits due to fast track surgery, must be underlined. In our study, stage of the disease and nodal status (i.e. NR) did not appear to be correlated with the incidence of complications. However, they are obviously related to the survival rate: NR was shown as an independent prognostic factor.
Our finding of a relationship between postoperative complications and reduction of survival probability is in agreement with previous papers [1] [5] [13] . Some hypotheses in order to explain these data may be put forward: postoperative complications may induce an extended period of immunosuppression due to generalized inflammation. This may lead to residual tumor cell increased survival and proliferation [1] . For several other malignancies perioperative blood transfusions correlated with negative immunomodulatory effects and earlier cancer recurrence [36] . Moreover it has been shown that infection and sepsis potentiate proinflammatory cytokine cascades. The immune modulators which are implied (TNF-α, IL-1, IL-6, IL-8) could affect the function and regulation of natural killer cells [37] . Therefore, hypothetically, micrometastases may rapidly progress during brief and/or prolonged periods of relative immunosuppression due to postoperative complications. Moreover, both sepsis and blood transfusion may stimulate vascular endothelial growth factor (VEGF) release which is one of the most potent stimulators of metastatic growth. In this way transfusions and sepsis may stimulate cancer recurrence [38] [39] .
The incidence of postoperative complications varies according to the different classifications. Recently, the Clavien-Dindo system, which is characterized by objectivity and reproducibility, has been proposed for and applied to most surgical specialties. For this reason it makes possible comparisons between different series. The present results, as previously reported in an interim analysis [40] , could be considered similar to those in the literature in spite they mostly concern eastern series.
Significant risk factor for postoperative complications are represented by surgical approach and pre/intra- operative transfusions. Laparoscopic approach appears to be capable of reducing post-operative complications and of increasing overall survival. Moreover, patients who didn't receive transfusions in the perioperative period showed lower incidence of complications.
The effect of complications on long term survival seems also worth of notice. According to several studies the inflammatory response determined by complications, as well as by transfusions, cause immunosuppression, which, in turn, could promote neoplastic cell proliferation and metastatic potentiality.
In view of these findings, two strategies may be consequently adopted. First of all it seems useful to promote laparoscopic approach (that, in turn, reduces intraoperative blood loss and postoperative complications) and anyway to discourage perioperative transfusions in oncologic patients. In this respect, when needed, alternative methods must be used in order to improve hemoglobin levels in the preoperative period. Secondly, because of the relevant impact of postoperative complications on prognosis, an adequate perioperative care is mandatory in order to prevent complications due to possible comorbidities.
Kubota, T., Hiki, N., Sano, T., Nomura, S., et al. (2014) Prognostic Significance of Complications after Curative Surgery for Gastric Cancer. Annals of Surgical Oncology, 21, 891-898. http://dx.doi.org/10.1245/s10434-013-3384-9
Lee, K.G., Lee, H.J., Yang, J.Y., et al. (2014) Risk Factors Associated with Complication Following Gastrectomy for Gastric Cancer: Retrospective Analysis of Prospectively Collected Data Based on the Clavien-Dindo System. Journal of Gastrointestinal Surgery, 18, 1269-1277. http://dx.doi.org/10.1007/s11605-014-2525-1
Dindo, D., Demartines, N. and Clavien, P.A. (2004) Classification of Surgical Complications: A New Proposal with Evaluation in a Cohort of 6336 Patients and Results of a Survey. Annals of Surgery, 240, 205-213. http://dx.doi.org/10.1097/01.sla.0000133083.54934.ae
Lee, J.H., Park, D.J., Kim, H.H., Lee, H.J. and Yang, H.K. (2012) Comparison of Complications after Laparoscopy- Assisted Distal Gastrectomy and Open Distal Gastrectomy for Gastric Cancer Using the Clavien-Dindo Classification. Surgical Endoscopy, 26, 1287-1295. http://dx.doi.org/10.1007/s00464-011-2027-0
Jiang, N., Deng, J.Y., Ding, X.W., Zhang, L., Liu, H.G., Liang, Y.X. and Liang, H. (2014) Effect of Complication Grade on Survival Following Curative Gastrectomy for Carcinoma. World Journal of Gastroenterology, 20, 8244- 8252. http://dx.doi.org/10.3748/wjg.v20.i25.8244
Novara, G., Ficarra, V., D'Elia, C., Secco, S., Cavalleri, S. and Artibani, W. (2010) Prospective Evaluation with Standardised Criteria for Postoperative Complications after Robotic-Assisted Laparoscopic Radical Prostatectomy. European Urology, 57, 363-370. http://dx.doi.org/10.1016/j.eururo.2009.11.032
Wechter, M.E., Mohd, J., Magrina, J.F., Cornella, J.L., Magtibay, P.M., Wilson, J.R. and Kho, R.M. (2014) Complications in Robotic-Assisted Gynecologic Surgery According to Case Type. A Six-Year Retrospective Cohort Study Using Clavien-Dindo Classification. Journal of Minimally Invasive Gynecology, 21, 844-850. http://dx.doi.org/10.1016/j.jmig.2014.03.016
Sink, E.L., Leunig, M., Zaltz, I., Gilbert, J.C. and Clohisy, J. (2012) Reliability of a Complication Classification System for Orthopedic Surgery. Clinical Orthopaedics and Related Research, 470, 2220-2226. http://dx.doi.org/10.1007/s11999-012-2343-2
Orsenigo, E., Bissolati, M., Socci, C., Chiari, D., Muffatti, F., Nifosi, J. and Staudacher, C. (2014) Duodenal Stump Fistula after Gastric Surgery for Malignancies: A Retrospective Analysis of Risk Factors in a Single Centre Experience. Gastric Cancer, 17, 733-744. http://dx.doi.org/10.1007/s10120-013-0327-x
de Manzoni, G., Roviello, F. and Squini, W. (2012) Surgery in the Multimodal Management of Gastric Cancer, Foreword by Keiichi Maruyama GIRCG. Springer-Verlag, Italia.
http://www.iss.it/lgac/docu/cont.php?id=278&lang=1&tipo=%2032
Bickendach, K. and Strong, V.E. (2012) Comparisons of Gastric Cancer Treatments: East vs. West. Journal of Gastric Cancer, 12, 55-62. http://dx.doi.org/10.5230/jgc.2012.12.2.55
Li, Q.G., Li, P., Tang, D., Chen, J. and Wang, D.R. (2013) Impact of Postoperative Complications on Long-Term Survival after Radical Resection for Gastric Cancer. World Journal of Gastroenterology, 19, 4060-4065. http://dx.doi.org/10.3748/wjg.v19.i25.4060
Hayashi, T., Yoshikawa, T., Aoyama, T., Ogata, T., Cho, H. and Tsuburaya, A. (2012) Severity of Complications after Gastrectomy in Elderly Patients with Gastric Cancer. World Journal of Surgery, 36, 2139-2145. http://dx.doi.org/10.1007/s00268-012-1653-6
Pata, G., Solaini, L., Roncali, S., Pasini, M. and Ragni, F. (2013) Impact of Obesity on Early Surgical and Oncologic Outcomes after Total Gastrectomy with "Over-D1" Lymphadenectomy for Gastric Cancer. World Journal of Surgery, 37, 1072-1081. http://dx.doi.org/10.1007/s00268-013-1942-8
Fraczek, M., Jeziorski, A., Krawczyk, M., Starzynska, T. and Wallner, G. (2010) Implications of Overweight in Gastric Cancer: A Multicenter Study in a Western Patient Population. European Journal of Surgical Oncology, 36, 969-976. http://dx.doi.org/10.1016/j.ejso.2010.07.007
Eom, B.W., Joo, J., Yoon, H.M., Ryu, K.W., Kim, Y.W. and Lee, J.H. (2014) A Body Shape Index Has a Good Correlation with Postoperative Complications in Gastric Cancer Surgery. Annals of Surgical Oncology, 21, 1115-1122. http://dx.doi.org/10.1245/s10434-013-3409-4
Krakauer, N.Y. and Krakauer, J.C. (2012) A New Body Shape Index Predicts Mortality Hazard Independently of Body Mass Index. PLoS ONE, 7, e39504. http://dx.doi.org/10.1371/journal.pone.0039504
Wu, M.H., Lin, M.T. and Chen, W.J. (2008) Effect of Perioperative Parenteral Nutritional Support for Gastric Cancer Patients Undergoing Gastrectomy. Hepatogastroenterology, 55, 799-802.
Kong, F., Li, H., Fan, Y., Zhang, X.W., Cao, S., Yu, J.P., et al. (2013) Overweight Patients Achieve Ideal Body Weight Following Curative Gastrectomy Resulting in Better Long-Term Prognosis. Obesity Surgery, 23, 650-656. http://dx.doi.org/10.1007/s11695-012-0847-1
Kiyama, T., Mizutani, T., Okuda, T., Fujita, I., Tokunaga, A., Tajiri, T., Barbul, A., et al. (2005) Postoperative Changes in Body Composition after Gastrectomy. Journal of Gastrointestinal Surgery, 9, 313-319. http://dx.doi.org/10.1016/j.gassur.2004.11.008
Sah, B.K., Zhu, Z.G., Chen, M.M., Xiang, M., Chen, J., Yan, M. and Lin, Y.Z. (2009) Effect of Surgical Work Volume on Postoperative Complication: Superiority of Specialized Center in Gastric Cancer Treatment. Langenbeck's Archives of Surgery, 394, 41-47. http://dx.doi.org/10.1007/s00423-008-0358-7
Liang, Y.X., Guo, H.H., Deng, J.Y., Wang, B.G., Ding, X.W., Wang, X.N., et al. (2013) Impact of Intraoperative Blood Loss on Survival after Curative Resection for Gastric Cancer. World Journal of Gastroenterology, 19, 5542- 5550. http://dx.doi.org/10.3748/wjg.v19.i33.5542
Sutton, J.M., Kooby, D.A., Wilson, G.C., Squires III, M.H., Hanseman, D.J., Maithel, S.K., et al. (2014) Perioperative Blood Transfusion Is Associated with Decreased Survival in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma: A Multi-Institutional Study. Journal of Gastrointestinal Surgery, 18, 1575-1587.
Waters, J.H., Yazer, M., Chen, Y.F. and Kloke, J. (2012) Blood Salvage and Cancer Surgery: A Meta-Analysis of Available Studies. Transfusion, 52, 2167-2173. http://dx.doi.org/10.1111/j.1537-2995.2011.03555.x
Adamina, M., Gié, O., Demartines, N. and Ris, F. (2013) Contemporary Perioperative Care Strategies. British Journal of Surgery, 100, 38-54. http://dx.doi.org/10.1002/bjs.8990
Li, H.T., Han, X.P., Su, L., Zhu, W.-K., Xu, W., Li, K., et al. (2014) Short-Term Efficacy of Laparoscopy-Assisted vs. Open Radical Gastrectomy in Gastric Cancer World. Journal of Gastrointestinal Surgery, 6, 59-64.
Cheng, Q., Pang, T.C.Y., Hollands, M.J., Richardson, A.J., Pleass, H., Johnston, E.S. and Lam, V.W.T. (2014) Systematic Review and Meta-Analysis of Laparoscopic versus Open Distal Gastrectomy. Journal of Gastrointestinal Surgery, 18, 1087-1099. http://dx.doi.org/10.1007/s11605-014-2519-z
Aoyama, T., Yoshikawa, T., Hayashi, T., Hasegawa, S., Tsuchida, K., Yamada, T., et al. (2014) Randomized Comparison of Surgical Stress and the Nutritional Status between Laparoscopy-Assisted and Open Distal Gastrectomy for Gastric Cancer. Annals of Surgical Oncology, 21, 1983-1990. http://dx.doi.org/10.1245/s10434-014-3509-9
Huscher, C.G., Mingoli, A., Sgarzini, G., Sansonetti, A., Di Paola, M., Recher, A. and Ponzano, C. (2005) Laparoscopic versus Open Subtotal Gastrectomy for Distal Gastric Cancer: Five-Year Results of a Randomized Prospective Trial. Annals of Surgery, 241, 232-237. http://dx.doi.org/10.1097/01.sla.0000151892.35922.f2
Adachi, Y., Shiraishi, N., Shiromizu, A., Bandoh, T., Aramaki, M. and Kitano, S. (2000) Laparoscopy-Assisted Billroth I Gastrectomy Compared with Conventional Open Gastrectomy. Annals of Surgery, 135, 806-810. http://dx.doi.org/10.1001/archsurg.135.7.806
Kim, H.H., Hyung, W.J., Cho, G.S., Kim, M.C., Han, S.-U., Kim, W., et al. (2010) Morbidity and Mortality of Laparoscopic Gastrectomy versus Open Gastrectomy for Gastric Cancer: An Interim Report―A Phase III Multicenter, Prospective, Randomized Trial (KLASS Trial). Annals of Surgery, 251, 417-420. http://dx.doi.org/10.1097/SLA.0b013e3181cc8f6b
Kim, K.M., An, J.Y., Kim, H.I., Cheong, J.H., Hyung, W.J. and Noh, S.H. (2012) Major Early Complications Following Open, Laparoscopic and Gastrectomy. British Journal of Surgery, 99, 1681-1687. http://dx.doi.org/10.1002/bjs.8924
Hyun, M.H., Lee, C.H., Kim, H.J., Ton, Y. and Park, S.S. (2013) Systematic Review and Meta-Analysis of Robotic Surgery Compared with Conventional Laparoscopic and Open Resections for Gastric Carcinoma. British Journal of Surgery, 100, 1566-1578.
Suda, K., Man-I, M., Ishida, Y., Kawamura, Y., Satoh, S. and Uyama, I. (2014) Potential Advantages of Robotic Radical Gastrectomy for Gastric Adenocarcinoma in Comparison with Conventional Laparoscopic Approach: A Single Institutional Retrospective Comparative Cohort Study. Surgical Endoscopy.
Katz, S.C., Shia, J., Liau, K.H., Gonen, M., Ruo, L., Jarnagin, W.R., Fong, Y., et al. (2009) Operative Blood Loss Independently Predicts Recurrence and Survival after Resection of Hepatocellular Carcinoma. Annals of Surgery, 249, 617-623. http://dx.doi.org/10.1097/SLA.0b013e31819ed22f
Balkwill, F. and Mantovani, A. (2001) Inflammation and Cancer: Back to Virchow? The Lancet, 357, 539-545. http://dx.doi.org/10.1016/S0140-6736(00)04046-0
Mynster, T., Christensen, I.J., Moesgaard, F. and Nielsen, H.J. (2000) Effect of the Combination of Blood Transfusion and Postoperative Infectious Complications on Prognosis after Surgery for Colorectal Cancer. British Journal of Surgery, 87, 1553-1562. http://dx.doi.org/10.1046/j.1365-2168.2000.01570.x
Nash, G.F., Chopada, A., Patel, H. and Kakkar, A.K. (2002) Stored Blood Products Stimulate Cancer Growth. British Journal of Surgery, 89, 19. http://dx.doi.org/10.1046/j.1365-2168.89.s.1.9_10.x
GIRCG (2013) Tailored and Multidisciplinary Gastric Cancer Treatment. Proceedings of the 10th International Gastric Cancer Congress, Verona, 19-22 June 2013.
● JCT Subscription
●Most popular papers in JCT
●About JCT News


October is the offical month of mental heath awareness. It's a trending on social media, and I even had the chance to attend a live Q&A segment on depression – which is experienced by 1 in 6 people at some stage in their life. As the state of our mental health becomes increasingly recognised as a problem, more attention is being paid to seemingly 'smaller' solutions. One such solution is kindness. And the idea that, even in small doses, it can make a big difference in how someone feels.
ABC has been crowd sourcing for stories about kindness, so I've decided to share a bit of my work. In the large sprawling city where I live, people rush on by while appearing to be trapped in their heads. Sometimes their expression says everything they aren't saying.
To avoid coming across as confronting, I've been leaving little messages behind for those who need them. Through the gift of technology – and without directly crossing paths – these are some of the people who've made my day, by telling me that I've made theirs.


ShopSleuth's CATO Store Locator found 12 store locations in malls and outlets in 8 states. Below is the count of all of these CATO locations broken down by state.
CATO is ranked #90 out of 1,316 Women's Clothing stores in the U.S., based on the number of locations.


Fourth-year attainment at Banff Academy stayed at the same levels in 2018.
The technical department at Banff Academy has been revamped with decades-old equipment making way for brand new machines and furniture.
New desks and chairs have been moved in along with a sawdust extraction system designed to protect pupils.
It is hoped the modernisation programme will improve the learning environment for children at the Bellevue Road secondary and help prepare them for the workplace.
Banff Academy head teacher Alan Horberry said the changes will boost the prospects for his pupils.
He said they will also be able to offer some student engineers somewhere to train closer to home.
Mr Horberry said: "It allows us to deliver a range of courses better than before.
"In addition we've secured an agreement with Nescol for one of their courses to be delivered without young people having to travel for an hour.
"Our vision for the school is building skills for today, tomorrow and the future. We are literally building skills and it is a really nice for.
Macduff councillor, and former Banff Academy pupil, Mark Findlater welcomed the changes made to make the classroom fit for the 21st century.
Mr Findlater said: "The work that has been carried out at Banff Academy is brilliant.
"This was by the new head of the technical department and the head teacher at Banff Academy.
"Up until very recently they were using the same equipment I had when I went to school there and they really needed changing.
Last night a council spokesman confirmed that the project was finished and that the new classrooms were ready to be used.
He said: "We are pleased to announce the work to improve the technology department and repairs to the roof of Banff Academy is now complete.
"The improvements worth £770,500, which was funded by the council, will make the school's technology workshops more accessible and modern.


The company of private investigation is expected or is already growing when it comes to demand. This could be brought about by the fact that there was an economic crisis throughout the past two years. The economic crisis has been the root cause of firms having to remove some workers this increases the unemployment rate of not simply in creating countries but also in first-world countries. Monetary capabilities of people have grow to be restricted and these have created some people commit crimes. Vandalism, theft, robbery and fraud had been among probably the most frequent crimes committed throughout the economic crisis. Companies and Firms have been one of the hardest hit by these crimes ranging from former employees committing theft to employees committing fraud.
Using the economic downturn, organizations and business establishments are now slowly recovering from the effects of the economic crisis. Sales are starting to move back up and investors are already becoming confident again in investing their dollars. It really is because of this rise in the economy that men and women most specially the enterprise owners and firm CEO's have began to pay attention to the troubles of fraudulent acts that were committed by their former workers or even their current staff. It's as a result of this that business CEO's and business owners have hired the services of private investigators and private detectives so that you can investigate some business staff as well as former company employees. Apart from this the insurance sector or the pre-need sectors have also begun hiring the services of private investigators to investigate fraudulent insurance claimants who had been abound throughout the economic crisis. Right after the economic crisis the require for private investigators elevated particularly in the places of investigating fraudulent workers, fraudulent insurance claimants and even debtor tracing and asset tracing.


Michelle C. Cora, D.V.M., D.A.C.V.P.
Michelle Cora, D.V.M., D.A.C.V.P., is a veterinary medical officer and board certified clinical pathologist working with Greg Travlos, D.V.M., D.A.C.V.P., in the NTP Clinical Pathology Group, which provides collaborative and consultative support to investigators at the NIEHS. Additionally, she provides clinical pathology oversight and preparation of technical reports for various NTP studies. Dr. Cora's current research interests include disorders of the hematological system.
Dr. Cora received her B.S. degree in biology and chemistry from Illinois College in 1995 and her doctorate in veterinary medicine from the University of Illinois in 2000. After graduating from veterinary school, she moved to the Seattle area and practiced small animal medicine for 7 years. In July of 2007, she began her residency in veterinary clinical pathology at North Carolina State University - College of Veterinary Medicine. In 2010 Dr. Cora completed her residency training and accepted a position as a research fellow at NIEHS in CMPB/NTP Toxicological Pathology Training Program. She received her board certification from the American College of Veterinary Pathologists in 2011. She joined the Cellular and Molecular Pathology Branch's staff in March of 2013 as a Veterinary Medical Officer/NTP clinical pathologist.
Cora, MC. (2012). Laboratory Tests: ACTH. In Clinical Veterinary Advisor: The Horse (DA Wilson, ed.), pp. 902-03. Elsevier, St. Louis, MO.


Our shop is updated weekly with new designs so put it in your favourites list and check regularly for great decals and stickers.
Check out the variety of available designs in the products categories and find the one for you.
You can even spice up your office and reduce the stress around it with any of our song lyrics decals.
Custom decals are always welcome with us. Inquire within if you have an idea, we will do the design and will get back to you with it.
A great and cost-effective method to customize your world with our decals.


We are committed to providing a range of 'Outstanding' services to schools and the wider community. We aim to raise the standard of Physical Education and sport being delivered in schools and the community.
Our school's thoughts and opinions of us are extremely important, see how highly they recommend us by following the above link.


If you're not doing online marketing in 2018, you're missing out. Here are some of the top online marketing tips you can try out for your small business this year and enjoy the best results.
Website rules have completely changed so you need to reflect the same to serve your customers' needs. For instance, nowadays customers want quick results because they are impatient. On the other hand, they have the shortest attention spans so if you have a confusing website or it is loading slowly, you're completely losing out. The same goes if you have a website that's not attractive.
You need a website that loads very fast and provides the most relevant results. Also, it needs to be easy to navigate so your customers can find what they need very fast. Finally, you should add very clear call-to-action, telling the customer what to do. Note that, mobile optimization is also very important because most of your customers are on their mobile devices.
If you want to get more tracking on the search engine results, you need to consider link building. However, as popular as link building might make your site, you need to use white hat practices. That's because any hat of bad practices will force the search engines to penalize you.
The right way to do link building is to use few links of very high quality rather than many low-quality ones. Immediately, Google finds your website relevant and very high quality so it will be shown in the local search results. You can look for bloggers or business owners willing to link to your site for the best link building efforts.
Do you have a special promotion coming up? You can ask the local news websites to run a story about you. That's a very high-quality link building activity that will play into your ranking metrics.
Your digital marketing strategy should include keyword research. There are so many ways you can take advantage of the relevant keywords for your business. Start by looking for the best and most relevant keywords that potential customers are using to search your products or services. You can also take advantage of online tools such as Google AdWords, Google Trends or Keyword Planner and many more to find more recommendations.
In conclusion, digital marketing is a very important aspect of the success of any online business. With the right practices, you can get a unique listing online and stand out from your competitors.
Hello my name is Cynthia Barbour and I am a caregiver of my special needs adult triplets. I am also a very successful entrepreneur.
I have been involved in several successful home-based businesses, and am a mentor and trainer. It has been a joy to touch many, and I never charged anyone, I just enjoy sharing my knowledge. I have met so many people from all over the world and those relationships are still ongoing.
I believe that it is better to be an entrepreneur than to work a traditional job. I have had the freedom to be able to work online and be a caregiver to my triplets.
And my why is to be able to make a better life for them in the future.


text:
Home ENTERTAINMENT 'Chicago Fire' season 5 spoilers: Brett to develop romance with 'Chicago P.D.'s'...
'Chicago Fire' season 5 spoilers: Brett to develop romance with 'Chicago P.D.'s' Antonio
K.Dumaraog
The upcoming season of "Chicago Fire" brings a new dynamic which will make it more entwined with sister show "Chicago P.D." as two of its mainstays are set to be embroiled in a love affair.
Entertainment Weekly has recently tipped that "Fire's" Sylvie Brett (Kara Killmer) and "P.D.'s" Antonio Dawson (Jon Seda) will become involved with each other when both their shows make their much anticipated comebacks this year.
"There's plenty to play in terms of the May-December version of Brett to Antonio his character has a couple kids, he's divorced, no way should he be with this woman, but she's had her heart broken," executive producer Matt Olmstead explained. "She's looking for a real man, he qualifies. He's looking for a real soul, a real heart, and she qualifies."
While the specifics of how the relationship will blossom have yet to be disclosed, a scheduled crossover between the shows is the most probable way to jump-start it. Fortunately, this development broke out not long after creator Dick Wolf confirmed that a four way tie-in will happen involving his "Chicago" franchise. Aside from "Fire" and "P.D.," the sophomore run of "Chicago Med" and the soon to debut "Chicago Justice" will join the fun.
Given this, it can be assumed that this is where Brett and Antonio will cross paths followed by guest appearances in both shows even after the crossover event has ended.
Wolf even teased what fans can expect in this year's "Chicago" get-together.
"An arson case [on 'Fire'] could show up in 'Justice.' Obviously, a 'P.D.' case that's resolved could show up in 'Justice,'" the producer told reporters during the recently held Television Critics Association fall previews. "And doctors, aside from a massive medical murderer or something … you would have, for example, Oliver [Platt] become one of the go-to expert witnesses on psychiatry, much like Elizabeth Olivet was on 'Law & Order.' … I think the integration will be as seamless as they have been for the past three or four years now."
It appears that Wolf and his team are still planning the intricacies of this crossover event. Nevertheless, they have been the masters of such television craft since they have been doing it for a couple of years now. So it might be safe to say that the inter-show romance between Brett and Antonio will feel organic. As for the future of the budding romance, the "Chicago" franchise has a 50 percent rate of survival with "Fire's" Mouch (Christian Stolte) and "P.D.'s" Platt (Amy Morton) eventually tying the knot, while "Fire's" Severide (Taylor Kinney) and "P.D.'s" Lindsay (Sophia Bush) headed to splitsville.
"Chicago Fire" returns on Oct. 11, 10 p.m. ET, while "Chicago P.D." comes back almost a month earlier on Sept. 21, 10 p.m. ET.
Chicago Fire season 5 crossover
Chicago Fire season 5 news
Chicago Fire season 5 spoilers
Chicago Franchise
Chicago Franchise 2016 crossover
Chicago P.D. season 4
Chicago P.D. season 4 crossover
Previous article'Rick and Morty' season 3 spoilers: Co-creators reveal dream cast, Vin Diesel to guest star?
Next articleiPad Pro 2 release date at Apple's September event or early next year
'Tom Clancy's Rainbow Six Siege' news: two new operatives, game map,...
'Prison Break' season 5 air date, spoilers: time for Lincoln to...

redpajama_set_name: RedPajamaCommonCrawl


text:
Senator Lankford Opposes Confirmation of Secretary of Education
Lankford: "Regrettably, Dr. King has refused to commit to stopping these regulatory abuses if he were confirmed."
CLICK HERE to view the YouTube video
WASHINGTON, DC – Senator James Lankford (R-OK) today delivered a speech on the Senate floor regarding his concerns with the confirmation of John B. King, Jr. as Department of Education Secretary.
On January 7, 2016, Lankford sent a letter to King to question the authority under which the Office of Civil Rights issued two particular Dear Colleague guidance documents, prescribing policies relating to harassment, bullying and sexual violence. The Department of Education responded on February 17, but failed to address Lankford's legal concerns. Lankford has continued to press the Department by responding with another letter on March 4 and during a Q&A in a Senate Appropriations Subcommittee hearing.
Excerpts:
On the issues with Secretary King's Confirmation:
I share with Dr. King and the view of many legal experts and school officials across the country, the Department of Education has been bullying schools to comply with policies that simply do not have the force of law. This use of power, however well intentioned, is wrong and it's unlawful. Leadership requires making sure the department conducts themselves in full compliance with the law. I have an obligation to the people of Oklahoma to ensure that the President's nominees adhere to the law. Regrettably, Dr. King has refused to commit to stopping these regulatory abuses if he were confirmed. For that reason, I will oppose his nomination today.
For far too long, we have witnessed executive overreach in this administration. From the Clean Power Plan to the Waters of the United States, federal departments and agencies have usurped the power to invent law with increasing boldness. The Department of Education overreach is similar in this kind. Instead of promulgating rules that conflict with Congressional intent, the Department of Education has skirted the rule-making process altogether by issuing guidance documents they call 'Dear Colleague' letters.
On the issues of federal agencies using guidance documents:
Guidance documents cannot and do not have the force of law. Guidance documents only interpret existing obligations found in statute or regulation. Some agencies complain that the rule-making process is too long and requires too much public input so it's easier just to say the new rules simply interprets an existing rule and then skip the compliance with the Administrative Procedures Act that's required for a new rule. It's a complete irony that agencies see regulatory compliance as too burdensome so they impose new regulatory guidance on states, local governments, tribes and private institutions at a faster pace, and those institutions have no way to fight the rules, only comply.
On the examples of executive overreach:
Let me give you an example, from the Department of Education's Office of Civil Rights. They have a great responsibility to promote our shared American values of equal opportunity, ensuring gender equality and work with federally funded schools to prohibit sexual harassment and sexual violence. As a father of two daughters, I fully support the objectives with Title IX and condemn all forms of sexual discrimination. The Office of Civil Rights' enforcement authorities that come from Title IX of the Education Department's 1972 bill, those Office of Civil Rights' Dear Colleague letters that are now being put out there supposedly notify schools of their obligations under Title IX, but two of the Office of Civil Rights Dear Colleagues letters significantly expands schools liability by prescribing policies required neither by Title IX nor by OCR's regulations.
On the abuse of power stopping universities from challenging the letters:
While individual companies or entire industries can and often do fight back against regulatory overreach by the Department of Labor or EPA, the Department of Education positions itself to hold federal funding ransom if universities don't comply with its policies even when those policies are unlawful abuses of regulatory power. This is unacceptable. Just because we share an objective of equality and school safety doesn't mean we can turn a blind eye to a federal department running roughshod over the very regulatory process we require. Here the ends certainly do not justify the means. Schools and the very students we want to protect suffer as a result.
On the path forward to ensure departments do not overstep their authority:
As part of my continued discussions with the Office of Civil Rights, the Department has assured me they will take steps to clarify the interpretive role of guidance, increase its transparency and enhance opportunity for public input. I'm encouraged that the Office of Civil Rights has committed these improvements and I look forward to a continued discussion on how better guidance practices, both within the Office of Civil Rights and across the entire government, can actually occur. Unfortunately, these proposals don't answer the questions that I've asked Dr. King…
Dr. King does not acknowledge that this overreach is even occurring within the agency he's nominated to lead, I have no choice but to oppose his nomination today. Time will tell whether this Department of Education is about to take a new direction with new leadership or continue the same path of coercive overreach they've already been on. This needs to stop. The American people require a voice into the rule-making process and I hope this can press on today.


You are here: Home / Beauty / Sephora Favorites Sunkissed Glow | Summer 2017.
Sephora Favorites Sunkissed Glow | Summer 2017.
One of summer's new launches from Sephora that I knew I had to get my hands on was the new Sephora Favorites Sunkissed Glow ($54, sephora.ca), a curated collection of 9 bronzing and highlighting essentials retailing for $54. Within the collection, three of the items are full-sized and more than justifies the price of the entire set itself, particularly if you are already a fan of the product, colours or formula!
The new Sephora Favorites Sunkissed Glow comes in a rose gold, semi-transparent makeup bag which would be perfect as a clutch of some sort as well if it had come with a strap. That being said, I still like the size of the bag and functionality of it – makes it perfect to reuse for travelling!
I think at this point most of you already know of my love affair with a lot of Sephora's value sets and this was one where I felt that the colours are quite varied, appropriate for many skintones and includes a combination of new formula's I haven't tried and a few staples as well.
Of the entire set, I was most excited to give the Hourglass bronzer a try – I wasn't a fan of their highlighter or original setting powder but I liked their blushes well enough so I thought it was worth to give the set a go. I'm also curious to try out the Marc Jacobs Highliner Gel Eye Crayon again – it didn't impress me too much the first time I tried it but everyone seems to rave about it. I'm glad Sephora decided to include something from Milk Makeup in this set because it's a brand I've been wanting to try out but never got around to yet!
I'm already a huge fan of the Too Faced Chocolate Soleil Bronzer included in this set – I haven't run out of my deluxe mini size but it's good to have a backup of a favourite!
I don't personally wear glosses too often so given one of the full-sized product in this collection is said gloss, I'm not really keen about it – wished it might have been the other highlighter or bronzer that got the full-size upgrade!
I think I would have appreciated to see a bit of variation from Becca – as much as I love Opal, I think this shade has been included in so many different sets from the brand and Sephora so I think most of us already have quite a collection of this at home already!
I still think it's worth the price!
Despite my reservation about some of the pieces mentioned above, this set will make for a lovely gift and addition to your makeup collection. I've stopped buying too many full-sized items as I am finding it difficult to finish and I'm one to get bored easily so I need a bit of change every once in a while.
That being said, not only are these pieces perfect for travelling, there's a good variety of formula and products that will keep you pretty excited about discovering a new formula / colour with the set!
Now over to you – what do you think of the new Sephora Favorites Sunkissed Glow set?


text:
How the brain paralyzes you while you sleep
IMAGE: How the brain paralyzes you while you sleep
Tsukuba, Japan -- We laugh when we see Homer Simpson falling asleep while driving, while in church, and while even operating the nuclear reactor. In reality though, narcolepsy, cataplexy, and rapid eye movement (REM) sleep behavior disorder are all serious sleep-related illnesses. Researchers at the University of Tsukuba led by Professor Takeshi Sakurai have found neurons in the brain that link all three disorders and could provide a target for treatments.
REM sleep correlates when we dream. Our eyes move back and forth, but our bodies remain still. This near-paralysis of muscles while dreaming is called REM-atonia, and is lacking in people with REM sleep behavior disorder. Instead of being still during REM sleep, muscles move around, often going as far as to stand up and jump, yell, or punch. Sakurai and his team set out to find the neurons in the brain that normally prevent this type of behavior during REM sleep.
Working with mice, the team identified a specific group of neurons as likely candidates. These cells were located in an area of the brain called the ventral medial medulla and received input from another area called the sublaterodorsal tegmental nucleus, or SLD. "The anatomy of the neurons we found matched what we know," explains Sakurai. "They were connected to neurons that control voluntary movements, but not those that control muscles in the eyes or internal organs. Importantly, they were inhibitory, meaning that they can prevent muscle movement when active." When the researchers blocked the input to these neurons, the mice began moving during their sleep, just like someone with REM sleep behavior disorder.
Narcolepsy, as demonstrated by Homer Simpson, is characterized by suddenly falling asleep at any time during the day, even in mid-sentence (he was diagnosed with narcolepsy). Cataplexy is a related illness in which people suddenly lose muscle tone and collapse. Although they are awake, their muscles act as if they are in REM sleep. Sakurai and his team suspected that the special neurons they found were related to these two disorders. They tested their hypothesis using a mouse model of narcolepsy in which cataplexic attacks could be triggered by chocolate. "We found that silencing the SLD-to-ventral medial medulla reduced the number of cataplexic bouts," says Sakurai.
Overall, the experiments showed these special circuits control muscle atonia in both REM sleep and cataplexy. "The glycinergic neurons we have identified in the ventral medial medulla could be a good target for drug therapies for people with narcolepsy, cataplexy, or REM sleep behavior disorder", says Sakurai. "Future studies will have to examine how emotions, which are known to trigger cataplexy, can affect these neurons."
http://dx.doi.org/10.1523/JNEUROSCI.0688-20.2020


text:
<?php

namespace Hoa\Observer {

/**
 * Class \Hoa\Observer\Exception.
 *
 * Extending the \Hoa\Core\Exception class.
 *
 * @author     Ivan Enderlin <ivan.enderlin@hoa-project.net>
 * @copyright  Copyright © 2007-2012 Ivan Enderlin.
 * @license    New BSD License
 */

class Exception extends \Hoa\Core\Exception { }

}

redpajama_set_name: RedPajamaGithub


The completion threading model is intended for providers that make use of manual progress. Applications must serialize access to all objects that are associated through the use of having a shared completion structure. This includes endpoint, transmit context, receive context, completion queue, counter, wait set, and poll set objects.
Progress frequently requires action being taken at both the transmitting and receiving sides of an operation. This is often a requirement for reliable transfers, as a result of retry and acknowledgement processing.
Manual progress requirements not only apply to endpoints that initiate transmit operations, but also to endpoints that may be the target of such operations. This holds true even if the target endpoint will not generate completion events for the operations. For example, an endpoint that acts purely as the target of RMA or atomic operations that uses manual progress may still need application assistance to process received operations.
Memory registration occurs at the endpoint level, rather than domain.
The optimal number of memory regions supported by the domain, or endpoint if the mr_mode FI_MR_ENDPOINT bit has been set. The mr_cnt value may be a fixed value of the maximum number of MRs supported by the underlying hardware, or may be a dynamic value, based on the default attributes of the domain, such as the supported memory registration modes. Applications can set the mr_cnt on input to fi_getinfo, in order to indicate their memory registration requirements. Doing so may allow the provider to optimize any memory registration cache or lookup tables.


text:
Q: C# ArrayList.Add() overwriting previous objects on add I have written a simple method that receives a Generic that I wish to place into an ArrayList using the ArrayList.Add() method. However I have discovered that when I go add a new item with the same type as previous items in the ArrayList this new item overwrites the previous items individual properties.
Here's the code its pretty basic and rather embarrassingly I can't seem to rectify this overwriting problem.
public class ChromosomeTree<T>
{
    private GeneNode<T> root;
    private ArrayList children = new ArrayList();
    private int depMax;

    string stemp;

    public ChromosomeTree()
    {
        root = null;
    }

    public virtual void Clear()
    {
        root = null;
    }

    public GeneNode<T> Root
    {
        get
        {
            return root;
        }
        set
        {
            root = value;
        }
    }

    public int MaxDepth
    {
        get
        {
            return depMax;
        }
        set
        {
            depMax = value;
        }
    }

    public ArrayList Children
    {
        get
        {
            return children;
        }
    }

    public GeneNode<T> lastChild()
    {
        return (GeneNode<T>)this.Children[this.Children.Count - 1];
    }

    public void addFull(GeneNode<T> node)
    {
        //check if the chromosome tree has a root if not add the first node as the chromosomes root

        if (this.Root == null)
        {
            this.Root = node;
            children.Add(node);
            stemp += " " + node.Value;
        }
        else
        {
            for (int i = 0; i <= this.Children.Count - 1; i++)
            {
                GeneNode<T> parent = (GeneNode<T>)this.Children[i];

                //check to ensure maxDepth of chromosome tree is not exceeded
                if (parent.Depth != this.MaxDepth)
                {
                    //check to see if the current node stil has room for another node to be added to it
                    if ((parent.Children == null) || (parent.Children[1] == null))
                    {
                        children.Add(node);
                        parent.Add(node);

                        stemp += " " + node.Value;

                        break;
                    }
                }
                else
                {
                    break;
                }
            }
        }
    }

    public override string ToString()
    {
        string chromosome = String.Empty;

        foreach(GeneNode<Gene> gene in this.Children)
        {
            chromosome += " " + gene.Value.GeneValue.ToString();
        }

        return chromosome;
    }
}

Im pretty sure its a simple mistake but ive looked at this for so long I cant see the wood from the trees. Any thoughts would be greatly appreciated.
Many thanks in advance.
Luke
here is the code that utilises the this class.
EDIT : THE OVERWRITE HAPPENS WHEN THE METHOD IS CALLED NOT AFTER THE METHOD HAS EXECUTED ITS LOGIC
 class SimpleChromosome
{
    Random rand = new Random();

    Gene funcGene = new Gene();
    Gene termGene = new Gene();

    private string sChromosome;

    private int currentdepth;

    private string grownChromosome()
    {
        return sChromosome;
    }

    public ChromosomeTree<Gene> fullChromosome()
    {
        ChromosomeTree<Gene> chromosone = new ChromosomeTree<Gene>();
        //chromosone.MaxDepth = rand.Next(1, 5);
        chromosone.MaxDepth = 1;

        int maxGenes = (int)Math.Pow(2, chromosone.MaxDepth + 1) - 1;

        for (int i = 0; i <= chromosone.MaxDepth; i++)
        {
            int numNodesForLevel = (int)Math.Pow(2, i);
            int numNodesOnLevel = 0;

            for (int j = 0; j < numNodesForLevel; j++)
            {
                if (currentdepth != chromosone.MaxDepth)
                {
                    funcGene.GenerateValue(GeneType.Function);
                    GeneNode<Gene> geneNode = new GeneNode<Gene>(funcGene);
                    sChromosome += " " + geneNode.Value;
                    chromosone.addFull(geneNode);

                    numNodesOnLevel++;
                }
                else
                {
                    termGene.GenerateValue(GeneType.Terminal);
                    GeneNode<Gene> geneNode = new GeneNode<Gene>(termGene);
                    sChromosome += " " + geneNode.Value;
                    chromosone.addFull(geneNode);

                    numNodesOnLevel++;
                }

                if ((numNodesForLevel == numNodesOnLevel) && (currentdepth != chromosone.MaxDepth))
                {
                    currentdepth++;
                }
            }
        }
        currentdepth = 0;

        //Console.WriteLine("Before ADD :" + sChromosome);

        sChromosome = "";

        return chromosone;
    }
}

A: Post the code where you are adding a new object of this type to your ArrayList.
My guess is that you are using two references to the same object.
Remember that objects are reference types, therefore if you assign them to each other you are only assigning their references. e.g. in the following code:
Foo foo1 = new Foo();
foo1.x = 1;
Foo foo2 = new Foo();
foo2.x = 2;

foo2 = foo1; // foo2 now points to the same object as foo1;
// foo1.x does not get copied into foo2.x.
// You have also lost your reference to the original foo2 object here and it will be garbage collected.
foo2.x = 100;
// since foo2 and foo1 are now pointing to the same object. both foo2.x and foo1.x will be 100

A: For this sort of relationship you really should be coding to interfaces. eg.
public interface IGeneNode{
  //genenode definition including perhaps equality interfaces etc
}

If the above is correct then you can overload your Assignment operator to pass the values you wish to pass.
This might be useful to you as well.
C# - Multiple generic types in one list

A: in this loop parent == Children[i] and Children is a getter for children
Do you really mean to be adding the same node to children and parent, which would make the same node a sibling of parent in addition to a child? I'm not clear on what you're really trying to do but this seems wrong:
    if ((parent.Children == null) || (parent.Children[1] == null))
     {
          children.Add(node);
          parent.Add(node);
..
     }

edit
From the supporting code you posted the problem could be related to how you create objects:
/* outside the loop */
    Gene funcGene = new Gene();
    Gene termGene = new Gene();

...
/* inside the loop*/
    funcGene.GenerateValue(GeneType.Function);
    GeneNode<Gene> geneNode = new GeneNode<Gene>(funcGene);
    sChromosome += " " + geneNode.Value;
    chromosone.addFull(geneNode);

Seems like you are create a new GeneNode multiple times using a one of two instances of Gene in its constructor. Assuming that your GeneNode is saving that as a property value, each GeneNode is going to reference the same instance of Gene (well, one of two, either funcGene or termGene). I'm guessing this is what you mean when you say new item with the same type as previous items in the ArrayList this new item overwrites the previous items individual properties. Any changes to a Gene property assigned from the constructor in any node of the same type will refer to the same Gene. Even though you are creating new GeneNodes they are constructed from the same Gene.
So assuming that GeneNode.Value references the Gene that it was constructed with, there can only be two different values returned (corresponding to the the current value of one of the two Gene instances) by any node at any given point in time.
Probably, you want to move the code to create a new Gene inside your loop.

redpajama_set_name: RedPajamaStackExchange


text:
What was Japan's main reason of aggression?
Why was Japan acting aggressively Pearl Harbor?
Why did Japan become aggressive after the Great Depression?
Why was Japan angry at the US and what did Japan do about it?
Why did Japan invade Korea?
Why did Japan want to destroy the Pacific fleet?
How did America respond to Japanese aggression?
What is one factor that motivated Japan's imperialism?
Why did Japan invade Indochina?
What are the three main reason why Japan invaded the Philippines?
Did Japan think they could beat the US?
Did US bomb Japan because of Pearl Harbor?
Who won in the Korean War?
When did Japan invade Philippines?
Motivations. Facing the problem of insufficient natural resources and following the ambition to become a major global power, the Japanese Empire began aggressive expansion in the 1930s.
Why Attack Pearl Harbor? As war was inevitable, Japan's only chance was the element of surprise and to destroy America's navy as quickly as possible. Japan wanted to move into the Dutch East Indies and Malaya to conquer territories that could provide important natural resources such as oil and rubber.
Japan was hit especially hard. With practically no natural resources, the nation had to import oil, iron, steel, and other commodities to keep its industry and military forces alive. … As Japan's economy grew worse, the country became more aggressive.
While the United States hoped embargoes on oil and other key goods would lead Japan to halt its expansionism, the sanctions and other penalties actually convinced Japan to stand its ground, and stirred up the anger of its people against continued Western interference in Asian affairs.
IT IS INTERESTING: Is Tokyo banana a Twinkie?
Between 1910 and 1945, Japan worked to wipe out Korean culture, language and history. … In order to establish control over its new protectorate, the Empire of Japan waged an all-out war on Korean culture. Schools and universities forbade speaking Korean and emphasized manual labor and loyalty to the Emperor.
To the Japanese, Pearl Harbor was an irresistible target. The plan was simple: Destroy the Pacific Fleet so that the Americans would not be able to fight back as Japan's military spread across the South Pacific. By the time the attack was over, every battleship in Pearl Harbor had sustained significant damage.
How did America respond to Japan's aggression in Asia? The United States replied in July 1939 by lending Chiang Kaishek's Nationalist Chinese government $25 million and by announcing the cancellation, within six months, of its 1911 trade treaty with Japan.
What is one factor that motivated Japan's imperialism before World War II? Japan lacked many important natural resources . How was Japan's government under Hideki Tojo similar to the governments of Germany under Adolf Hitler and Italy under Benito Mussolini?
The main objective of the Japanese was to prevent China from importing arms and fuel through French Indochina along the Kunming–Hai Phong Railway, from the Indochinese port of Haiphong, through the capital of Hanoi to the Chinese city of Kunming in Yunnan.
IT IS INTERESTING: Is Sapporo an island?
To prevent the use of the Philippines as an advance base of operations by American forces. To acquire staging areas and supply bases to enhance operations against the Dutch East Indies and Guam. To secure the lines of communication between occupied areas in the south and the Japanese Home Islands.
And although the Japanese government never believed it could defeat the United States, it did intend to negotiate an end to the war on favorable terms. … It hoped that by attacking the fleet at Pearl Harbor it could delay American intervention, gaining time to solidify its Asian empire.
Japan's attack on Pearl Harbor took place on December 7, 1941. The U.S. military suffered 18 ships damaged or sunk, and ~2,400 people were killed. Its most significant consequence was the entrance of the United States into World War II.
Charts.
Pacific 10 6
Who Won the Korean War? Neither side actually won the Korean War. In fact, the war goes on to this day, since the combatants never signed a peace treaty. South Korea did not even sign the Armistice agreement of July 27, 1953, and North Korea repudiated the armistice in 2013.
IT IS INTERESTING: Do kids in Japan wear yellow hats?
The Japanese occupation of the Philippines occurred between 1942 and 1945, when Imperial Japan occupied the Commonwealth of the Philippines during World War II. The invasion of the Philippines started on 8 December 1941, ten hours after the attack on Pearl Harbor.


"I. Gold cometh gladly and in increasing quantity to any man who will put by not less than one-tenth of his earnings to create an estate for his future and that of his family.
II. Gold laboreth diligently and contentedly for the wise owner who finds for it profitable employment, multiplying even as the flocks of the field.
III. Gold clingeth to the protection of the cautious owner who invests it under the advice of men wise in its handling.
IV. Gold slippeth away from the man who invests it in businesses or purposes with which he is not familiar or which are not approved by those skilled in its keep.
Current time: 04-24-2019, 05:01 PM Powered By MyBB, © 2002-2019 MyBB Group.


Confounding gender stereotypes with brush and lens.
Lorenzo Triburgo is an artist whose work plays with common assumptions of identity and artistry. With his series "Portraits of Transgender Men" Triburgo's aim is to remind us that the limit of gender identity is determined by individual, rather than social norms. Here, Triburgo places transgendered men in heroic poses in front of richly painted kitsch depictions of nature.
View the entire Transportraits series.
Read Lorenzo Triburgo's statementr on the Transportraits series.


text:
Q: Meaning of phase relationship for a superposition of states I have studied an introductory course in quantum mechanics, and yet I still do not understand the significance of a phase difference between quantum states that a system is in a superposition of. In my lecture notes, it is stated that

Form a linear combination of two quantum states:
$|\psi \rangle = c_1|\phi_1\rangle + c_2|\phi_2\rangle $
$|\psi \rangle = e^{i\theta_1}|\phi_1\rangle + e^{i\theta_2}|\phi_2\rangle $
$|\psi \rangle = e^{i\theta_1}(|\phi_1\rangle + e^{i(\theta_2-\theta_!)}|\phi_2\rangle) $
The resultant vector, and therefore the outcome of any experiemt, depends on the relative quantum phase difference between the two states

This has me confused on many levels. Aside from the fact that the state is simple not normalised here (we would require a factor of $\frac{1}{\sqrt2}$ at the front), the magnitudes of each of the coefficients are equal, unless we allow $\theta$ to be complex which I do not think is intended here.
Also, I initially thought that the outcome of some measurement is only dependent on the magnitudes of the coefficients, and not their phase. This is immediately obvious if the eigenstates of the observable that you are measuring are the $|\phi_i\rangle$, although I considered whether it might be dependent on the relative phase of the coefficients if $|\phi_i\rangle$ are not the eigenstates. I think I then get a phase-dependent factor in the expectation value, although I would like verification on this. An additional problem that then brings up is that the result is sensitive to multiplying a basis vector by an arbitrary phase factor $e^{i\theta}, which it shouldn't be, although I think this might be resolved in considering the coefficients of some state in terms of the eigenstates of the observable.
Emilio Pisanty's answer to this question gos some way towards answering my questions, however it only mentions the significance of the phases when two states are superposed. However experiemntally, I don't understand what thi means. Does it mean having two non-entangled photons, say, and performing an experiment on them? I thought that this becomes a new system and the basis vectors form this are found from the cartesian product of basis vectors of the two states, and not their sum. I feel like this is such a basic concept, however I do not understand it! I get how a system can be in a superposition of states of some chosen basis and you can choose a different basis so that the state is in one of the basis states. However what does it mean to have two existing states, and then superpose them? Surely this means you have two systems and are interacting them in some way, but I don't see how...
Summary of question:
In what way and in what contexts does the phase between coefficients in a quantum superposition matter, and does the term 'relative quantum phase different' refer only to phase of coefficients, or also to their magnitudes which would seem to make more sense.

A: The relative phase matters in all kinds of circumstances.  Imagine a spin-1/2 system with $\vert +\rangle$ and $\vert -\rangle$ the spin-up and spin-down states in the $\hat z$ direction.
Consider the state
$$
\vert \psi\rangle =\frac{1}{\sqrt{2}}\vert +\rangle + \frac{i}{\sqrt{2}}\vert -\rangle. \tag{1}
$$
The average value $\sigma_z$ is
$$
\langle \sigma_z\rangle =\frac{1}{2}(+1)+\frac{1}{2}(-1)=0
$$
and in this case only depends on the magnitude of the coefficients.  However, if you ask what is the probability of obtaining $s_y=+\hbar/2$, the answer to this is $1$, whereas the probability of obtaining $s_y=-\hbar/2$ is $0$.  This is because (1), with the correct phase, is an eigenstate of $\sigma_y$ with eigenvalue $+\hbar/2$.  Surely you can see here that the relative phase matters.
As another example, consider the superposition
\begin{align}
\Psi(x,t)&= \alpha \Psi_0(x,t)+\beta\Psi_1(x,t)\\
&=\alpha e^{i\omega t/2}\psi_0(x)+\beta e^{3i\omega t/2}\psi_1(x)
\end{align}
of harmonic oscillator states.  The probability density for such a state is
$$
\Psi(x,t)^*\Psi(x,t)= \vert\alpha\vert^2 \psi_0(x)^2+ \vert\beta\vert^2 \psi_1(x)^2 + (e^{i\omega t}\alpha^*\beta + e^{-i\omega t}\alpha\,\beta^*)\psi_0(x)\psi_1(x)
$$
where I've taken $\psi_0(x)$ and $\psi_1(x)$ to be real, as is usual convention.  Clearly this probability density depends the relative phase of $\alpha$ and $\beta$ (as well as their magnitude).
In the simplest example of above, imagine $a=\frac{\sqrt{3}}{2}$ and $b=\frac{i}{2}$.  At $t=0$ the probability density would be
$$
\vert\Psi(x,0)\vert^2= \frac{3}{4}\psi_0^2(x)+\frac{1}{4}\psi_1(x)^2
$$
but on the other hand, if I take $a=\frac{\sqrt{3}}{2}$ but $b=\frac{1}{2}$, then the probability density becomes
$$
\vert\Psi(x,0)\vert^2 =
\left(\frac{\sqrt{3}}{2}\psi_0+\frac{1}{2}\psi_1(x)\right)^2\ne
\frac{3}{4}\psi_0(x)^2+\frac{1}{4}\psi_1(x)^2
$$
because of the cross terms that appear in expanding the square in the middle part.  Both of these have the same average energy, the same probabilities of getting either $E=\frac{1}{2}\hbar\omega$ or $\frac{3}{2}\hbar\omega$, but will produce different $\langle x\rangle$.
In general, the relative phase will control the way states superpose, either completely constructively, completely destructively, or partially.  It is the exception rather than the rule when this relative phase is unimportant.

A: There are a few distinct questions here, so I'll answer quote by quote. $\newcommand{\ket}[1]{|#1 \rangle}$

[...] the state is simple not normalised here (we would require a factor of $\frac{1}{\sqrt2}$ at the front)

People often omit explicit normalization to save space; you should just imagine the $1/\sqrt{2}$ is really there in the background. After you write $1/\sqrt{2}$ a few hundred times you'll start doing the same!

I initially thought that the outcome of some measurement is only dependent on the magnitudes of the coefficients, and not their phase. This is immediately obvious if the eigenstates of the observable that you are measuring are the $|\phi_i\rangle$, although I considered whether it might be dependent on the relative phase of the coefficients if $|\phi_i\rangle$ are not the eigenstates. I think I then get a phase-dependent factor in the expectation value, although I would like verification on this.

Absolutely. For example, suppose that the states $\ket{\phi_1}$ and $\ket{\phi_2}$ represent 'spin up' and 'spin down' respectively. That is, we have chosen the states to be eigenstates of $L_z$. Then the 'spin left' and 'spin right' states are
$$\ket{\phi_1} - \ket{\phi_2}, \quad \ket{\phi_1} + \ket{\phi_2}$$
and only differ by a phase factor. The expectation value of $L_x$ depends on the phase.

An additional problem that then brings up is that the result is sensitive to multiplying a basis vector by an arbitrary phase factor $e^{i\theta}$, which it shouldn't be...

Physical results never depend on these choices, but our intermediate expressions could be. For example, suppose we defined a new basis
$$\ket{\psi_1} = \ket{\phi_1}, \quad \ket{\psi_2} = - \ket{\phi_2}.$$
Then the spin left and spin right states are now
$$\ket{\psi_1} + \ket{\psi_2}, \quad \ket{\psi_1} - \ket{\psi_2}.$$
That is, the expressions for these states have changed because we changed the phase convention, but the states themselves haven't. The phase difference between two coefficients is of course dependent on the convention, as is its physical meaning, but once the convention is fixed it is meaningful. For example, the phases for the spin states I've been talking about are usually fixed by demanding the $L_i$ are proportional to the Pauli matrices $\sigma_i$.

However what does it mean to have two existing states, and then superpose them? Surely this means you have two systems and are interacting them in some way, but I don't see how...

Usually 'superposition' shouldn't be used in verb form in quantum mechanics. This usage is referring to the classical intuition where waves superpose: if two sound waves are sent at each other then they superpose when they meet. But you're right that this is usually not how we prepare quantum superpositions: you don't get a $1s$ and $2s$ superposition in the hydrogen atom by slamming two hydrogen atoms in these states into each other. I recommend mentally substituting "prepare a superposition" whenever you hear "superpose".

A: Suppose $\phi_1$ and $\phi_2$ are 1s states of two hydrogen atoms in an $H_2$ molecule. Then the bonding orbital has $c_1=c_2$ and the antibonding orbital has $c_1=-c_2$. So the phase matters. Note that I skipped over the fact that the $\phi_i$ overlap, but this does not invalidate the argument.
For a crystal orbital the phase vector looks like $e^{i\vec{k}\cdot\vec{r}}$ where $\hbar\vec{k}$ is the crystal momentum.


text:
Q: How to squeeze all but one torch dims? torch.squeeze can convert the shape of a tensor to not have dimensions of size 1.
I want to squeeze my tensor in all dimensions but one (in this example, not squeeze dim=0).
All I can see in the doc is

dim (int, optional) – if given, the input will be squeezed only in
this dimension

I want the opposite:
t = torch.zeros(5, 1, 6, 1, 7, 1)

squeezed = torch.magic_squeeze(keep_dim=3)

assert squeezed == (5, 6, 1, 7)

Can this be done?

A: Reshape will let you accomplish what you want to do:
import torch

t = torch.zeros(5, 1, 6, 1, 7, 1)
t = t.reshape((5, 6, 1, 7))
>>> torch.Size([5, 6, 1, 7])

A: You can just squeeze and add a dimension with unsqueeze():
import torch

t = torch.zeros(5, 1, 6, 1, 7, 1)
squeezed = t.squeeze().unsqueeze(2)
print(squeezed.shape)
>>> torch.Size([5, 6, 1, 7])


Motivated by cell adhesion in hydrodynamic flow, here the authors study bond formation between a spherical Brownian particle in linear shear flow carrying receptors for ligands covering the boundary wall. They derive the appropriate Langevin equation which includes multiplicative noise due to position-dependent mobility functions resulting from the Stokes equation. They present a numerical scheme which allows to simulate it with high accuracy for all model parameters, including shear rate and three parameters describing receptor geometry (distance, size, and height of the receptor patches). In the case of homogeneous coating, the mean first passage time problem can be solved exactly. In the case of position-resolved receptor-ligand binding, they identify different scaling regimes and discuss their biological relevance.


Students read and write in all subjects! LDC!
Animoto (to make a music video), Prezi (a zooming slideshow), iMovie (a movie slideshow), GoAnimate (a cartoon animation), Easely or Piktochart (an animated collage poster), Powtoon (an animated slideshow), StoryJumper (a children's storybook), iPhoneFakeText (a conversation), Google Tour Builder (a virtual tour).