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Small Intestinal Atresia and Stenosis
Author: Jaime Shalkow, MD, FACS; Chief Editor: Eugene S Kim, MD, FACS, FAAP more...
Sections Small Intestinal Atresia and Stenosis
Antenatal Ultrasonography
Rectal Biopsy
Jejunoileal atresias and stenoses are major causes of neonatal intestinal obstruction. Atresia—derived from the Greek components a- ("no" or "without") and tresis ("hole" or "orifice")—refers to a congenital obstruction with complete occlusion of the intestinal lumen; it accounts for 95% of obstructions. Stenosis—derived from the Greek components stenos ("narrow") and -osis ("process") and denoting narrowing—refers to a partial occlusion with incomplete obstruction and accounts for the remaining 5% of cases.
In 1955, Louw and Barnard demonstrated the role of late intrauterine mesenteric vascular accidents as the likely cause of jejunoileal atresias, rather than the previously accepted theory of inadequate recanalization of the intestinal tract. [1] Since then, other factors (eg, in-utero intussusception, intestinal perforation, segmental volvulus, and thromboembolism) have also been shown to cause jejunoileal atresia. [2] Atresias can also develop in patients with gastroschisis and in those with meconium ileus.
Intestinal atresia or stenosis can occur anywhere along the gastrointestinal (GI) tract, and the anatomic location of the obstruction determines the clinical presentation. Most newborns with intestinal obstruction present with abdominal distention and bilious emesis in the first 2 days of life, though the presentation can be delayed for weeks in infants with stenosis. Bilious vomiting in the neonate should be considered secondary to a mechanical obstruction until proved otherwise, and emergency surgical evaluation is warranted in every newborn with this symptom.
Hyperbilirubinemia is also common. Intestinal obstruction increases the enterohepatic circulation of bilirubin and often results in jaundice. About 10% of infants with jejunal or ileal atresia have cystic fibrosis and meconium ileus.
In 1911, Fockens reported the first successful surgical repair of a patient with small intestinal atresia. However, the mortality associated with surgical correction of this condition remained high for many years, even in the best pediatric surgical centers. [3] The survival of patients with intestinal obstruction has markedly improved over the past few decades as a result of improved understanding of intestinal physiology and the etiologic factors of the condition, refinements in pediatric anesthesia, and advances in surgical and perioperative care of newborns.
Morbidity and mortality are usually linked with other medical conditions, such as short-bowel syndrome and cardiac anomalies, often associated with duodenal atresia (predominantly in infants with Down syndrome), prematurity, respiratory distress syndrome or cystic fibrosis, other congenital anomalies, the complexity of the lesion, and surgical complications.
The pathophysiology of dudoenal stenosis and atresia differs from that of obstructions located more distally in the jejunoileal area; the importance of this difference cannot be overstated. In duodenal atresias, a failure of recanalization of intestinal tube occurs at 8-10 weeks' gestation after obliteration of the lumen by epithelial proliferation at 6-7 weeks; it usually occurs in the second part of the duodenum. Incomplete recanalization can lead to duodenal stenosis or the presence of a duodenal web. [4, 5]
In jejunoileal atresias, however, the underlying process is an ischemic injury to the gut, usually secondary to malrotation with volvulus or intestinal strangulation with the umbilical ring, intestinal perforations, or vasoconstrictive drugs (eg, cocaine, ephedrine, and nicotine). Jejunoileal atresias occur after intestinal development because of the presence of bile droplets, meconium, or lanugo distal to the atresia. [6]
Dalla Vecchia et al performed a 25-year retrospective review and found 277 neonates with intestinal atresia. [7] The level of obstruction was duodenal in 138 patients, jejunoileal in 128, and colonic in 21. Of the 277 neonates, 10 had obstruction at more than one site. Jejunoileal atresia was associated with intrauterine volvulus (27%), gastroschisis (16%), and meconium ileus (11.7%).
In atresias of the small intestine, the jejunum and ileum are equally affected. [8, 9] The proximal jejunum is the site of atresia in 31% of cases, the distal jejunum in 20%, the proximal ileum in 13%, and the distal ileum in 36%. In more than 90% of patients, the atresia is single; however, multiple atresias are reported in 6-20% of cases. [10]
Stollman et al published a large series of jejunoileal atresias as a retrospective review at a large pediatric referral center in the Netherlands. [11] Between 1974 and 2004, they found 114 infants with jejunoileal atresia. In all, 62% of atresia and stenosis cases were noted in the jejunum, 30% in the ileum, and 8% in both the jejunum and the ileum; 7% of patients had intestinal stenosis, 16% had type I atresia, 21% had type II, 24% had type IIIa, 10% had type IIIb, and 22% had type IV (see Classification below).
Heij et al performed a retrospective analysis of 21 patients with jejunal atresia and 24 with ileal atresia and found more differences than similarities between the groups (see Table 1 below). [12, 13, 14, 2, 15]
Table 1. Differences Between Jejunal and Ileal Atresia [12, 13, 14, 2, 15] (Open Table in a new window)
Jejunal Atresia
Ileal Atresia
Gestational age
Lower than that of ileal atresia
Atresias
May be multiple
Antenatal perforation
Associated malformations
Postoperative course
Higher than that of ileal atresia
In this analysis, mean birth weight and gestational age were significantly lower in patients with jejunal atresia than in those with ileal atresia. [12] Most jejunal atresias were multiple, whereas most ileal atresias were single. Antenatal perforation was frequent (10 cases) in ileal atresia but infrequent (two cases) in jejunal atresia. The postoperative course was often prolonged, and mortality increased in patients with jejunal atresia, three of whom died (all of them patients with apple-peel deformity); by comparison, one patient with ileal atresia died.
Heij et al suggested that some of their findings may be explained by a difference in bowel-wall compliance between the jejunum and the ileum. [12] The compliant jejunal wall allows massive dilatation with subsequent loss of peristalsis, accounting for the prolonged postoperative course and the relatively high rate of perforation in ileal atresia.
Duodenal atresias have several basic morphologies, as follows:
Type I atresias constitute luminal webs or membranes, some of which contain a central defect or fenestration of variable size, and result in a marked size discrepancy with mural continuity
Type II atresias have dilated proximal and diminutive distal segments connected by a fibrous cord
Type III atresias are characterized by a complete discontinuity between the segments
The relation between the point of obstruction and the ampulla of Vater is important. Most series document a predominance of postampullary obstructions. Obstructions caused by type I membranes are frequently associated with anomalies of the common bile duct in which the common bile duct may terminate within the membrane itself. [16]
The maximal dilatation of the proximal segment occurs at the point of obstruction. This segment is commonly aperistaltic, of questionable viability, or both. [3] Grosfeld et al modified Louw's original classification into the following description of intestinal atresia, which is currently the most commonly used classification scheme [9] :
Type I – Membrane
Type II – Blind ends joined by fibrous cord
Type IIIa – Disconnected blind end
Type IIIb – Apple-peel deformity
Type IV – Multiple, string of sausages
The proximal dilated intestine is in continuity with the distal nondilated bowel, and the mesentery is intact. Between these portions, a narrow, semirigid segment with a minute lumen is present. The small-bowel length is normal. This lesion might simulate a type I atresia (see the image below).
Intestinal stenosis. Dilated prestenotic bowel is in continuity with distal intestine. No mesenteric gap is present. Bowel length is normal.
Atresia type I
Type I is a mucosal (septal) atresia with an intact bowel wall. The proximal dilated intestine is continuous with the distal narrow one. The mesentery is intact, and the intestinal length is normal. The pressure generated on the internal membrane may elongate it as a windsock, giving a conical appearance to the transition. The distal intestine is collapsed (see the image below) but may contain meconium.
Intestinal atresia type I. Transition area has conical appearance due to windsock elongation of membrane. No mesenteric gap is present. Bowel length is normal.
Atresia type II
In type II, a fibrous cord separates the proximal bowel from the distal segment. The mesentery is usually intact, but a small V-shaped defect may be present. Intestinal length is normal. The proximal blind pouch is grossly dilated, often aperistaltic and cyanotic. Perforations may be noted in patients who present late. Dilatation usually extends 10-15 cm proximally, after which point the intestine appears relatively normal. The distal blind pouch may be mildly distended because of retained cellular debris (as in fetal intussusception) (see the image below).
Intestinal atresia type II. Proximal dilated bowel is separated from distal narrow bowel by fibrous cord, in this case, without mesenteric gap. Bowel length is normal.
Atresia type IIIa
Type III atresias seem to be the most common. [8, 17] Intrauterine resorption of fetal gut subjected to a vascular insult explains the reduced bowel length commonly seen in this type of atresia. The distal bowel is small and decompressed.
In type IIIa atresia, the two blind ends are completely separated without a fibrous cord between them. The atresia has a V-shaped mesenteric gap, and the intestine is shortened (see the images below). The proximal dilated pouch may have questionable viability and undergo torsion.
Intestinal atresia type IIIa. Two blind ends are separated completely. V-shaped mesenteric gap is present. Intestinal length is reduced.
Surgical image of jejunal atresia type IIIa, with proximal dilated pouch, completely separated from the distal narrow intestine, over V-shaped mesenteric defect.
Surgical image of newborn with type IIIa ileal atresia shows two blind ends with dilated proximal segment and decompressed distal segment, with V-shaped gap in mesentery. Overall intestinal length is normal. Image courtesy of Rodrigo Díaz, MD.
Atresia type IIIb
In type IIIb atresia (Christmas-tree or apple-peel deformity), the two intestinal segments are separated as in type IIIa, and the mesenteric defect is large. The proximal atretic segment is in the upper jejunum, near the ligament of Treitz; the pouch is distended and lacks dorsal mesentery. The superior mesenteric artery distal to the middle colic branch is absent. The collapsed distal intestine helically encircles a small vessel (marginal artery) arising from the ileocolic or right colic arcades, or the inferior mesenteric artery, and its vascularity may be impaired.
Type I and type II atresias may coexist in the distal segment. The intestine is always substantially shortened (see the image below). Many patients with this variant have low birth weight (70%) and were born premature (70%); they may also have malrotation (54%), multiple atresias, and an increased number of other associated anomalies that raise the prevalence of complications (63%) and increase the mortality (54-71%). [18, 19]
Intestinal atresia type IIIb (apple-peel or Christmas-tree deformity). Proximal pouch is dilated. Collapsed distal intestine encircles marginal artery helically. Intestinal length is substantially reduced.
Atresia type IV
Type IV atresia refers to any number and combination of type I, II, or III atresias that present simultaneously, creating a string-of-sausages appearance (see the image below). A possible cause is intrauterine inflammation. However, findings of this type of atresia in family members suggest possible autosomal recessive transmission. [20, 10, 21]
Intestinal atresia type IV. Multiple atresias appear simultaneously as "string of sausages." Intestinal length is invariably and considerably shortened.
The presence of multiple GI atresias with cystic dilatation of the bile duct is rare; the association has been described in 37 patients, with no recorded survivors in the world literature. [22, 23] The dilatation of the bile duct seems to be due to normal drainage of bile into a closed-loop duodenal obstruction. Patients present with multiple atresias and die of short-bowel syndrome and complications related to total parenteral nutrition (TPN).
Intrinsic duodenal obstructions and annular pancreas result from events that occur during early development of the foregut. Duodenal atresia and stenosis are believed to result from a failure of recanalization of the embryonic duodenum, which becomes solid as a result of early epithelial proliferation.
Anular pancreas occurs when the ventral pancreatic bud fails to rotate behind the duodenum, leaving a nondistensible ring of pancreatic tissue fully encircling the second portion of the duodenum. It frequently coexists with intrinsic duodenal anomalies and anomalies of the pancreaticobiliary ductal system, suggesting closely linked mechanisms of pancreatic, duodenal, and biliary development during this stage. [16]
That associated congenital malformations are more prevalent with duodenal atresia than with jejunoileal atresia suggests that proximal obstructions occur earlier in fetal life. [7, 24]
Unlike duodenal atresias, many jejunoileal atresias are separated by a cordlike segment or a V-shaped mesenteric gap. This finding and the usual finding of bile pigments and lanugo distal to the atretic segment indicate that an in-utero vascular accident occurring relatively late in gestation (>11-12 weeks) is the likely origin of these atresias, rather than failure of GI tract recanalization. A localized intrauterine vascular accident with ischemic necrosis of the bowel and subsequent reabsorption of the affected segment has been the favored theory. [25, 1, 3, 26]
De Chadarevian et al reported on an infant with inherited thrombophilia that created a hypercoagulable state, favoring a segmental intestinal thrombosis and resulting in terminal ileal atresia. [27] This patient was also found to have Hirschsprung disease, which is rarely associated with intestinal atresia.
The localized nature of a vascular insult explains the low (10%) prevalence of coexisting conditions. Intestinal atresia associated with in-utero intussusception or perforation, malrotation, volvulus, internal hernias, gastroschisis, and omphalocele further corroborates a vascular event as the etiology of most jejunoileal atresias. [28, 26, 29, 30]
Only one case of a newborn patient has been reported to date with multiple intestinal atresias associated with multifocal angiodysplasia of the intestinal wall. [31]
Sweeney et al examined 38 patients with jejunal atresia and 45 patients with ileal atresia at the Children's Research Center in Dublin, Ireland. [24] Compared with patients with ileal atresia, patients with high jejunal atresia had a higher rate of associated congenital malformations (42% vs 2%), a higher rate of multiple or apple-peel (type IIIb) atresias (53% vs 9%), and a higher mortality. These results suggest that jejunal atresia may also develop from a malformative process.
In a collaborative study in France, Gaillard et al reviewed 102 cases from 42 induced abortions and 22 stillborns, as well as surgical findings in 38 neonates. [32] Abnormalities such as meconium ileus (associated with cystic fibrosis) and chromosomal aberrations (eg, Down syndrome) were present during the second trimester of gestation. Intestinal atresia and stenosis were detected in the third trimester of pregnancy and were associated with ischemic conditions.
Although most infants have only one atretic segment, multiple atresias have been described in infants of mothers who ingested ergotamine and caffeine or pseudoephedrine (alone or with acetaminophen) during pregnancy. [33, 34] Other vasoconstrictive factors (eg, cocaine abuse and smoking during pregnancy) have also been linked with increased risk for intestinal atresia. [34] The risk is also higher in patients with graft-versus-host disease and immunosuppression and those with malformative processes that are likely due to autosomal recessive transmission. [35, 21]
Multiple intestinal atresias have been reported in rare association with pyloric atresia and pylorocholedochal fistula. [36]
In a study of 114 cases of jejunoileal atresia in the Netherlands, Stollman et al found other GI anomalies in 24% of patients, genitourinary malformations in 9%, cystic fibrosis in 9%, neurologic anomalies in 6%, and congenital heart disease in 4%. [11]
Duodenal obstructions of congenital origin are often associated with other congenital anomalies, which account for most of the morbidity and mortality in these patients. Various publications report a 50-80% incidence of associated conditions. Congenital heart disease and trisomy 21 are the most common of these associated conditions, each occurring in about 30% of cases. [37] All three conditions may coexist in the same patient. [38]
In a study of patients with trisomy 21 who underwent antenatal ultrasonography (US), about 4% showed prenatal evidence of duodenal atresia. [39] Other associated anomalies include intestinal malrotation (20%), esophageal atresia, imperforate anus (10-20%), thoracoabdominal heterotaxia, and gallbladder agenesis.
One of the most important factors to keep in mind is that in duodenal atresia, as in other neonatal diseases, the outcome for patients depends more on the severity of the associated anomalies and the ease with which they can be corrected than on the surgical management of the obstruction itself. [16]
Familial cases of various types of atresia have been described. [40] In one family, familial type I jejunal atresia affected three members from two generations. Proximal atresia was associated with renal dysplasia. Knowledge of the familial form of the disease indicates that most cases of jejunoileal atresia actually result from disruption of a normal embryologic pathway, most likely the development of the superior mesenteric artery and its branches. They should be considered to be true embryologic malformations rather than acquired lesions. [40]
This association is presumably an autosomal dominant condition. [22] Matsumoto et al reported a case in Japan and reviewed the literature, finding six other cases of small intestinal atresia occurring in twins. [41] All published cases except one involved identical twins. Three pairs of twins had different types of atresia, and four pairs had no other anomalies. The other members of these families were not affected; this finding suggested that such cases may be due to environmental influences during gestation.
Another report of different intestinal atresias in identical twins suggested them to be either the consequence of linkage of two genes or a pleiotropic expression of a single gene. [42]
Congenital duodenal obstruction may be complete or partial, intrinsic or extrinsic. Intrinsic obstruction occurs in about 1 of 7000 live births and accounts for about half of all small-bowel atresias. Extrinsic obstruction has many causes, including malrotation with Ladd bands, other congenital bands not associated with malrotation, [43] preduodenal portal vein, gastroduodenal duplications, cysts or pseudocysts of the pancreas and biliary tree, and anular pancreas (which is commonly associated with a duodenal web, an intrinsic cause of duodenal obstruction [16] ).
In West Africa, intestinal atresia is the fourth most common cause of neonatal intestinal obstruction, after anorectal malformations, Hirschsprung disease, and strangulated inguinal hernias. [44] In an 11-year retrospective review of 500 children in India, Ranan et al found intestinal atresias to be the most common cause of intestinal obstruction in newborns and the second most common cause (11.8%) after intussusception (20.8%) in all age groups. [45]
Boys and girls are equally affected. [8] In most studies, jejunoileal atresias seem to be more common than duodenal atresias, and colonic atresias account for the fewest cases.
Unlike duodenal atresia, jejunoileal atresia associated with Down syndrome is uncommon. Patients with intestinal atresia are epidemiologically characterized by young gestational age and low birth weight. In addition, the atresia is associated with twinning, the parents are more often consanguineous compared with parents of healthy neonates, and vaginal bleeding frequently complicates the pregnancies.
No correlation between jejunoileal atresia and parental age or disease has been proved. [14, 13, 2] However, one study from France reported an increased prevalence of intestinal atresias in infants born to teenagers. [14] Some maternal infections may be associated with ileal atresia. [13]
Before the mid-20th century, the mortality associated with small-bowel atresias was prohibitive (>90%). By the late 1950s, the survival rate had risen to 78%. Survival rates improve with distal atresias, whereas mortality is high in instances of multiple atresia (57%); apple-peel deformity (54-71%); and atresias associated with meconium ileus (65%), meconium peritonitis (50%), or gastroschisis (66%). [18, 4, 19, 26]
Overall survival rates (including preterm babies) have reached 90%, with a surgical mortality of less than 1%. [18, 7, 19] Mortality is related to sepsis, associated anomalies, prematurity, malrotation, meconium peritonitis, and long-term TPN complications in patients with short-bowel syndrome.
The most common cause of death in infants with jejunoileal atresia is infection related to pneumonia, peritonitis, or sepsis. [8] Sato et al reported on an infant with ileal atresia and meconium peritonitis after a perforation who presented with pylephlebitis (air in the portal system) and a pulmonary gas embolism. [46] The patient had respiratory distress, shock, disseminated intravascular coagulation, and intractable diarrhea but eventually recovered and was discharged from the hospital after 4 months.
The most important surgical complications are anastomotic leaks and functional obstruction at the level of the anastomosis; these occur in as many as 15% of patients. [8, 17] In 84 patients with congenital jejunoileal or colonic atresia who were treated in New South Wales, Australia, mortality was higher in infants who underwent stoma formation than in those who received a primary anastomosis. [47] Reoperation may be required to prevent complications. [48]
Short-bowel syndrome refers to a spectrum of malnutrition problems that result from inadequate bowel length, which may occur in patients born with multiple atresias or in those with the apple-peel deformity. It is a cause of intestinal failure, together with other congenital diseases of enterocyte development, and severe motility disorders (total or subtotal aganglionosis or chronic intestinal pseudo-obstruction syndrome). [49] Other common causes of short-bowel syndrome include necrotizing enterocolitis and midgut volvulus. [50]
Of the 114 patients involved in the study by Stollman et al, 28% developed early postoperative complications, whereas 17% experienced late postoperative complications; mortality was 11%. [11] Short-bowel syndrome seems to be the biggest problem, resulting in longer hospital stay, more feeding problems, and higher morbidity and mortality.
Today, the survival rate for patients with short-bowel syndrome is 80-94%. The presence or absence of the ileocecal valve appears not to affect mortality but does affect the length of time for which TPN is required and thus affects the complications related to its use (eg, predisposition to infection, central line sepsis, and TPN-related cholestasis). [7] Malabsorption and steatorrhea are most severe in patients with terminal ileal resection, particularly when the ileocecal valve is excised. Vitamin B supplements are useful in such patients.
Overall mortality due to intestinal atresia does not seem to depend on the location of obstruction. Prematurity, birth weight less than 2 kg, and associated anomalies are independent risk factors for prolonged hospital stay and higher mortality. [51, 52]
Lack of sufficient residual bowel is responsible for considerable morbidity or a poor quality of life. In most instances, maximal intestinal adaptation occurs within 6-12 months, but it may take longer. [26] The use of the longitudinal intestinal lengthening and tailoring (LILT) procedure, proposed by Bianchi and modified by Aigrain, can allow the child to be weaned from parenteral nutrition. [53]
As a consequence of advances in medical care, such as improved surgical techniques and parenteral nutrition, the survival of neonates with intestinal atresias improved dramatically in the 20th century. [54]
The presence of multiple intestinal atresias necessitates repeated surgical interventions and sometimes small-bowel transplantation; the development of short-bowel syndrome in these patients is associated with increased risk of cholestasis, liver cirrhosis, and hepatic failure. The prognosis is poor, with most infants dying early in life. [55] Patients with this condition often have immunodeficiency. [56] Thymic dysplasia and lymphoid depletion are key findings in patients with mutations in the TTC7A gene who have multiple intestinal atresias.
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Plain abdominal radiograph of newborn reveals dilated gastric bubble and massively dilated duodenum and proximal jejunum with gasless abdomen distal to level of obstruction; these findings are consistent with jejunal atresia.
Upper GI contrast study demonstrates dilated stomach and duodenum, with enlarged upper jejunum and lack of passage of contrast agent to distal small bowel; these findings are consistent with high jejunal atresia.
Barium enema study reveals microcolon in infant with long-standing ileal atresia. Image courtesy of Rebecca Stein-Wexler, MD.
Surgical approach to jejunoileal atresia is via upper-right-quadrant transverse incision that can extend across midline if necessary.
Intestinal atresia type IIIa. Clamp is applied to distal bowel, and sodium chloride solution is instilled through purse-string suture to dilate intestine and diminish size discrepancy between two loops so as to facilitate anastomosis. Dotted line marks area of resection.
Proximal dilated pouch is transected at 90° angle to maximize its vascularity, while distal intestine is transected obliquely to diminish size discrepancy between segments.
Gastrostomy used to decompress stomach and to pass transanastomotic tube for early postoperative enteral feeding.
Tapering jejunoplasty performed over 26F tube to diminish diameter of proximal bowel and preserve bowel length.
Manually sewn tapering jejunoplasty.
Clinical image of newborn male with diffuse abdominal distention. Bowel loops and their peristalsis could be seen on abdominal surface. Collateral venous distention is also evident. Patient had distal type IIIa ileal atresia.
Plain abdominal radiograph of newborn with distal type IIIa ileal atresia demonstrates diffuse small-bowel (and gastric) distention, with gasless pelvis. Image courtesy of Rodrigo Díaz, MD.
Upper GI contrast study demonstrates dilated stomach and proximal duodenum without further passage of contrast in newborn with duodenal atresia.
Lower GI contrast study in newborn with ileal atresia demonstrates microcolon with dilated non-contrast-enhanced stomach and proximal small bowel. Image courtesy of Rodrigo Díaz, MD.
Table 1. Differences Between Jejunal and Ileal Atresia [12, 13, 14, 2, 15]
Jaime Shalkow, MD, FACS Pediatric Surgical Oncologist, National Institute of Pediatrics, ABC Cancer Center, Anahuac University, Mexico
Jaime Shalkow, MD, FACS is a member of the following medical societies: American College of Surgeons, International Society of Paediatric Surgical Oncology, Latin American Pediatric Surgical Oncology Group, Mexican Association of Pediatric Surgery, Mexican Association of Pediatrics, Mexican Society of Oncology
Joyce Vazquez-Braverman, MD Instructor of ACLS, BLS, and Heartsavers, American Heart Assocation
Joyce Vazquez-Braverman, MD is a member of the following medical societies: American College of Physicians
Adrian Florens, MD, FAAP Neonatologist, KIDZ Medical Services; Clinical Instructor of Pediatrics, Florida International University and Florida Atlantic University
Adrian Florens, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics
J Antonio Quiros, MD Associate Professor of Pediatrics, Medical University of South Carolina and MUSC Children's Hospital; Chief of Pediatric Gastroenterology, Medical University of South Carolina
J Antonio Quiros, MD is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
Gail E Besner, MD Chief, Department of Pediatric Surgery, Principal Investigator, Center for Perinatal Research, Director, Pediatric Surgery Training Program, Associate Burn Director, Nationwide Children's Hospital; H William Clatworthy, Jr, Professor of Surgery, Department of Surgery, Ohio State University College of Medicine
Gail E Besner, MD is a member of the following medical societies: American Surgical Association, Alpha Omega Alpha, American Academy of Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Medical Women's Association, American Pediatric Surgical Association, Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of Critical Care Medicine, Society of Surgical Oncology, Society of University Surgeons
Eugene S Kim, MD, FACS, FAAP Associate Professor of Surgery, Division of Pediatric Surgery, Keck School of Medicine of the University of Southern California; Attending Pediatric Surgeon, Children's Hospital Los Angeles
Eugene S Kim, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, Society of University Surgeons, Texas Medical Association, Children's Oncology Group
Aviva L Katz, MD Assistant Professor of Surgery, University of Pittsburgh School of Medicine; Consulting Staff, Division of General and Thoracic Surgery, Children's Hospital of Pittsburgh
Aviva L Katz, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Women Surgeons, American College of Surgeons, American Pediatric Surgical Association, Physicians for Social Responsibility, Wilderness Medical Society
Nicholas A Shorter, MD Chief, Pediatric Surgery, Ruby Memorial Hospital, West Virginia University.
encoded search term (Small Intestinal Atresia and Stenosis) and Small Intestinal Atresia and Stenosis
Intestinal Atresia, Stenosis, and Webs
Atresia, Stenosis, and Other Obstruction of the Colon
Pediatric Small-Bowel Obstruction
Pediatric Duodenal Atresia and Stenosis Surgery
Imaging in Ileal Atresia
Pediatric Duodenal Atresia
Use of Proton Pump Inhibitors and the Risk of Cholangitis
Doxapram Alleviates Low SpO2 Induced by the Combination of Propofol and Fentanyl During Painless Gastrointestinal Endoscopy
Review of Direct Oral Anticoagulants and Guide for Effective Drug Utilization
Diseases & Conditions Small Intestinal Atresia and Stenosis
Diseases & Conditions Imaging in Ileal Atresia
Diseases & Conditions Intestinal Atresia, Stenosis, and Webs
Diseases & Conditions Neonatal Small Left Colon Syndrome


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Joan Lowery Nixon Message Board 1/1/2012
Talk about the novels, new and used books that Nixon has written!
Author Nixon's Book Reviews
A Deadly Game of Magic
When stranded at a strangers house in the middle of a storm, Lisa finds out what it is like to go against a magician and a murderer. The story begins with several teenagers in a car. The driver's name is Bo Baxter, however, the first person narrative is from the view of Lisa. The others are a male named Julian Hamilton and an African American female named Teena Wilson. The car breaks down. They are caught in such a terrible rainstorm that the road is un...
A Deadly Promise
As Sarah Lindly's father is dying in her arms, he managed to whisper a mysterious message. He asks her to clear his name of the murder he has wrongly been accused of. She vows to do so and now she can't leave the small mining town of Leadville until she clears his name. She refuses to involve Clint and Jeremy, 2 love buddies, while she tries to reveal the truth and find the missing evidence in a race against time....
The Other Side of the Dark
Stacy wakes up after a four year long coma from a gunshot wound delivered by a man who killed her mother. Now that she's up and around, Stacy knows that she is the only one who can identify the murderer. Although she is still trying to adjust to a new world, friends who have grown up, a married sister, and life without a mother, Stacy must find her mother's killer, before he decides to silence her permanently....
The Specter
Dina is a seventeen-year-old girl suffering from Hodgkin's disease, a form of cancer. During one of her long stays at the hospital, she meets Julie, a nine-year-old child whose parents were killed in a car accident. Julie suffers from an obsessive phobia that causes her to believe that a man named Sikes is out to get her and develops a strong attachment to Dina. Concerned for her friend's safety, Dina launches an investigation to track down Sikes, and...
Nixon booklist
When a wealthy man is shot and seriously wounded, the police search his house and discover that he has been keeping a file on teenager Kristi Evans' life ever since she was born. he had pictures of her, school records of her, adn even pictures that she had drawn since she was an artist. Kristi and her parents do not know Douglas Merson, so it was a little bit of weird news to find out that he had a file in him hone of Kristi. Mr. Merson was unable ...

redpajama_set_name: RedPajamaCommonCrawl


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How do I hire a Junior Editor? The Junior Editor position is the first tier in the Editing career path at Discovery. This position is a supporting role for Editors and Senior Editors in our portfolio of brands. Junior Editors will be encouraged and given the tools to develop and grow the skill sets needed to be a successful broadcast Editor at Discovery Inc.
All Junior Editors should have some knowledge of the broadcast environment and must be able to log, digitize/capture footage, and organize non-linear edit projects.
A Junior Editor must be able to work all shifts when necessary and subject to change, with the possibility of working with or without supervision.
A Junior Editor will be responsible for performing junior level editing sessions. These sessions may involve creating Avid and Premiere projects, capturing and logging footage, prepping and importing graphic and audio files and managing media and editing cut to clocks for domestic and International use. They may be tasked with keeping projects organized.
• Complete all edit sessions assigned.
• Ensure all deliverables are accurate and adhere to Discovery's Global Deliverables.
• Work with all editors, management, audio and engineering to devise creative workflows.
• Must be able to recognize and alert staff of QC issues like frame rate, sample rate, and poor video or audio quality.
• Communicate project status to manager, clients, and editors.
• Maintain positive, constructive and cooperative working relationships with all clients.
• Document daily work completed via work orders and log time in scheduling software, or Workday.
• Perform other post production duties as requested by the editors or management.
• Attention to detail is crucial.
• Understanding and basic use of Avid Media Composer & non-linear editing platforms.
• Knowledgeable of various video file and tape formats.
• Work well under deadline-oriented atmosphere.
• Demonstrate ability to learn quickly, and a working knowledge of Post Production.
• Ability to work with multiple projects.
• Ability to collaborate and work within a team atmosphere.
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• Must be punctual and reliable both in attendance and in meeting deadlines.
Learn more about our company culture and life at Discovery, Inc. at our website.
Discovery is the global leader in real life entertainment, serving passionate fans around the world with content that inspires, informs and entertains. Discovery delivers over 8,000 hours of original programming each year across deeply loved content genres.
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Easy Align is a plugin for Vim that makes it super easy to align your code along certain whitespace or characters. Unlike the Tabular plugin, Easy Align is actually easy to use, not requiring you to create and recall esoteric-looking arguments.
The logic behind these commands is straightforward and is explained in the table of examples on the plugin's Github page.


text:
Published On: Tue, May 19th, 2015
Technology | By Desk of Editor
Mercedes Announce Apple Watch Integration And Continue To Lead The Car Technology Field
Mercedes have always been a manufacturer of high regard. The Mercedes badge is a mark of reputation and status. Their cars are classy, sophisticated and stylish. They are an object of desire and lust in the auto world. They also carry another reputation, a reputation for technology. Mercedes regularly push the boundaries of what is possible in the tech sphere.
Last week, they announced that the new S-Class will feature Apple Watch integration. They are the first manufacturer to claim any co-operation with the Apple Watch. It's a bold move. It's also an exciting one. It's the first glimpse of the practical applications of the watch, and one we had not expected.
Apple Watch Integration
Only a handful of cars can even claim to integrate the iPhone or smartphones effectively. Despite this, Mercedes are already looking ahead to the next generation. It's an impressive leap when we are yet to see how the watch will perform on the market. The connection will aid navigation, as the watch will hook up with the Mercedes COMAND system. It will integrate with the navigation by providing walking directions. Then the car will take over, completing the journey to the destination.
It's a compelling and intriguing use of Apple's new wearable technology. But, how else are Mercedes leading the field in technology?
Mercedes are widely considered the world leaders in terms of autonomous driving. These are the cars that drive themselves without human interruption. Even their older models feature early elements of this technology. Look at the used C-Class offers at Inchcape for example, and you'll see adaptive cruise control as standard. This cruise control has since evolved into fully autonomous, driverless cars. Mercedes have reported that their cars have driven the length of the USA, without a driver, under test conditions. The only thing holding this back from mainstream viability is the federal law!
Pedestrian detection and night vision
The new generation of C-Class and S-Class models come complete with night vision and collision detection. They have the ability to detect and automatically avoid pedestrians and other road hazards. A Mercedes car can think and act faster than a human. In the dark it uses night vision to show the road ahead and behind, highlighting hazards along the way. Mercedes' collision detection system is the most advanced in the world. It will sense a potential collision and apply autonomous braking to separate wheels. Doing so will minimise the potential damage to drivers and their vehicles.
Virtual Dashboards
The concept of infotainment is a relatively new one in the car world. Touch Screen GPS and controls are years behind existing smartphone technology. Except, of course, in Mercedes' secret labs! Their recent virtual dashboards are the most sophisticated on the planet. All the dials are entirely digital, forgoing analogue displays at every turn. As we learnt before, this is what allows them to connect seamlessly with Apple Watch. No other car manufacturer is currently offering this technology.
When it comes to looking to the future, Mercedes are at the forefront of car technology. Not only that, but they have the class and sophistication that only Mercedes provide. We can't wait to see what they come up with next.
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"Trick or treat"… or what? I guess you already know where this quote belongs to, right? Unfortunately I was never a big Halloween fan, but when it comes to costumes and sweets it's hard for me to resist. Honestly, when Halloween is not about sweets and costumes, where does it originally come from? Do you have any idea? If not, you're lucky, because I am going to explain it to you right now.
Of course we all know this American event, but guess what: Halloween originates in Ireland! The Celtics were the first folk that started this tradition. It was a night where ghosts and lost souls were expelled out of town. People held torches and made enough noise to scare and horrify the ghosts. So it doesn't surprise that we celebrate it in Europe. Within the last centuries, as its first appearance is dated in 1556, it has become something quite different: a costume party with sweets and tricks for children!
So now we know where it comes from, but I still don't know what to wear tonight. But of course someone – my best friend Google, possible – helped me find something special to wear. And of course I'm going to share it with you!
To make you curious I show you the look straight away and don't worry, it's not that difficult to recreate.
The very first step is to cut the can. Remember: You're going to need only 40 percent of the original size.
After cutting, you have to sand the can's edge carefully. Otherwise you could hurt yourself.
Then you take the piece of can and hold it to your head. When you're sure where you want to place it you circle it with a kajal.
Put the can back again. Before that you should put vaseline on your skin – this protects it.
Now you can finally start: Use the cosmetic wax and knead and roll it into a long and flat line. Lay the formed wax on the kajal form. It additionally protects your skin against the can's edges.
When you're finished with the wax, you can stick the can onto it. Be careful while pressing it onto your forehead.
Once you're done with that you can already put some colour on it. Use the fake blood and use a lot! You shouldn't save up anything.
For the last part you should use the sponge to create a more realistic look!
How does your Halloween outfit look like and what do you like most about Halloween?


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The Strokes, LCD Soundsystem, Le Tigre, Phoebe Bridgers, Beach House & more give This Ain't No Picnic new life in 2022
December 3, 2021 by Josh Herwitt 5 Comments
This Ain't No Picnic //
Brookside at the Rose Bowl – Pasadena, CA
August 27th-28th, 2022 //
As we have said in this space before, it has not been an easy time for the live music industry by any stretch of the imagination. Whether you're an artist, employee or fan, enduring 18 months without in-person events was painful to experience. So, maybe it's fitting Goldenvoice is reviving a festival that hasn't been around in almost 20 years at this point.
The renowned California concert promoter is bringing back This Ain't No Picnic for the first time since 2002 and taking over the Brookside Golf Course at the Rose Bowl for two days in late August (warning: it will be hot) with a killer roster that screams "Pitchfork Fest!"
A couple of NYC indie-rock giants in The Strokes and LCD Soundsystem, who are currently in the middle of a 20-date residency at Brooklyn Steel, will serve as headliners while the fest's undercard offers its own set of highlights starting with the reunion of Le Tigre, another NYC product who last reunited in 2016 to release "I'm with Her" as their latest single.
Oh baby 💫
⁰Presale starts Thursday 12/9 at 10am PT – sign up for first access to tickets at https://t.co/UvtFFpLE5b 🌐 All orders starting as low as $49 down. pic.twitter.com/XN56LylbKe
— This Ain't No Picnic (@aintnopicnic) December 3, 2021
Other notable names bolstering the iconic indie music festival's lineup in 2022 include Phoebe Bridgers, Beach House, Jorja Smith, Kaytranada, Jungle, IDLES, Isaiah Rashad, Sparks, Turnstile, Circle Jerks, Descendents, Caroline Polachek, Mac Demarco, Slowthai, Courtney Barnett, Four Tet + Floating Points, Tinashe, Earl Sweatshirt, Yves Tumor, Queen Naija, Honey Dijon, Sleep, Deafheaven and more. Peep the poster above for the rest of the artists scheduled to perform.
Making its debut at Oak Canyon Ranch in Silverado where past incarnations of Lightning in a Bottle and other music festivals in the Southern California area have also taken place, This Ain't No Picnic exposed the raw energy of punk-leaning, indie darlings like Sonic Youth, Sleater-Kinney and Guided by Voices in 1999 before taking another step toward the mainstream by booking Beck, Yo La Tengo, Built to Spill, At the Drive-In and Modest Mouse for its 2000 edition.
With there being more optimism surrounding the COVID-19 pandemic heading into next year, you can bet that tickets for this one will go quick so make sure to sign up for the presale occurring on Thursday, December 9th at 10 a.m. PT here before they go on sale at 2 p.m. PT here. GA passes will be available for $299-$349, with VIP going for $799 and Clubhouse at an eye-opening $1,199. But if you're looking to dance and sweat your ass off in the Pasadena heat, this is the only summer picnic you'll want to be at!
UPDATE (May 3rd): This Ain't No Picnic has delivered daily lineups for its return this August, with LCD Soundsystem headlining Saturday and The Strokes closing out the two-day festival on Sunday. Single-day tickets go on sale this Friday, May 6th at 10 a.m. PT here.
UPDATE (August 8th): Set times are here! This Ain't No Picnic has released its schedule with slightly more than two weeks to go while also announcing a few lineup changes, including the addition of Leon Vynehall on Saturday. Unfortunately due to visa issues, Logic1000 and Tems will not be able to perform as previously scheduled, but in the meantime, make sure to download the mobile app here and you can still grab tickets here!
Filed Under: Featured, Festivals Tagged With: Andrew McMahon, Arooj Aftab, Avalon Emerson, Beach House, Brandon, Brookside at the Rose Bowl, Brookside Golf Club, Caroline Polachek, Circle Jerks, Coronavirus, Coronavirus Pandemic, Courtney Barnett, Covid 19, COVID-19 Pandemic, Danilo Plessow, Dave P., Dawn Richard, Deafheaven, Descendents, Despacio, Earl Sweatshirt, Ethel Cain, Floating Points, Four Tet, Four Tet + Floating Points, Fundido, Genesis Owusu, Gerd Janson, Girl Ultra, Godford, Godspeed You! Black Emperor, Hana Vu, Honey Dijon, IDLES, Indigo De Souza, Isabella Lovestory, Isaiah Rashad, Jorja Smith, Julia Jacklin, Jungle, Junior Varsity, Kaytranada, Kelly Lee Owens, King Woman, Lala Lala, LCD Soundsystem, Le Tigre, Leon Vynehall, Logic1000, Mac Demarco, Magdalena Bay, Mall Grab, Maral, Margaritas Podridas, MCDE, Mdou Moctar, Michelle, Mike Watt, Motor City Drum Ensemble, N.A.A.F.I, NAAFI, Nicki Nicole, Nothing, Pachyman, Paris Texas, Peach, Phoebe Bridgers, Queen Naija, Romy, Shame, Sleep, slowthai, Sofia Kourtesis, Sparks, Spellling, SPIRIT OF THE BEEHIVE, Tems, The Descendents, The Strokes, They Hate Change, This Ain't No Picnic, This Ain't No Picnic 2022, This Ain't No Picnic Festival, This Ain't No Picnic Festival 2022, Tinashe, Tre' Amani, TSHA, Turnstile, Wet Leg, Ying Yang Twins, Yves Tumor, Zulu


This was one of my previous project with Greenearth Technovations. Working with one of the leading latex glove manufacturer in Malaysia, Cranberry USA provides a huge range of medical latex glove products. I worked with their marketing team in re-designing their website with a bolder approach.


Axel'Air kitesurfing training will take you from complete beginner to independent kitesurfer.
The goal of the kitesurf lessons is that you can actually kite independently after the course. Teaching techniques like open water relaunch ensures that you master the ground handling to quickly access real autonomy.
We use radio to speed up your kitesurfing progression. Your instructor is with you 100% of the time and you'll gradually became autonomous without you even noticing.
After a few days of teaching, you'll become a proficient kitesurfer and we'll teach you to take what you've learnt and apply it yourself when assessing a new spot and choosing gear that is best suited to the conditions of the day. Our goal is to get you feeling comfortable and ready to go on your own. In general, you'll need 10 to 30 hours of post-course kitesurfing to correctly acquire the up-wind technique.
Kitesurfing is like a drug and our job is to make sure you become addicted!


Enjoy all the speakers at CopyCon from the comfort of your own home.
Please note: This is NOT a live stream.
The videos will be recorded, edited and released along with the slides approximately one week after the event.
So, you can't attend the conference – boo, shame :-( But here's the next best thing. You can buy a video ticket and watch all the sessions from the comfort of your own home. You don't even have to change out of your pyjamas.
Hey, we'll even throw in some snippets of people mingling and eating biscuits, so you can really feel like you're there.
After you place your order, you'll receive an email confirmation.
Then, approximately a week after the event, you'll receive details of how to log into the site to access the CopyCon videos in our private membership area, where you'll also be able to download your handbook.


1. How many metaphors in this statement?
2. Which ones would you let go?
3. Which ones would you challenge and how?
Keen for a metaphorical discussion in the comments below.
Could you see a metaphor in the brain? We're going to ask Professor Robert Coghill this very question at EP3 in March 2015. Come along and you could ask him anything you want as well!
David, I see five. Check out James Geary's TED talk about metaphors. These days I teach image, story, premise and method. Metaphors are all through here. They can't be avoided. Choosing the best ones is an enormous task.
I am going for 7! although I am sure there will be some discussion on what a metaphor is. At least two of them could require clinical attention.
I would never argue with seven. Metaphors are everywhere and in constant use. They form the stories we tell, the way we communicate and, importantly, the effectiveness of our teaching.
I think there are 7 metaphors ( no arguments entered into around Christmastime) . Barrett is right – metaphors are everywhere. Using the broadest definition – "a word or phrase applied to an object or action to which it is not literally applicable"…….
1. "The" is a metaphor perhaps suggesting disembodiment (ie "the" as opposed to "my".
2. "bloody" is a metaphor and a very Australian one too.
6. "gives me" ( as though the pain makes pins and needles).
Reading your deconstruction I can see how I got 9!
Really glad you completed a satisfactory deconstruction of the statement yourself…..that was the only thing putting me off adding a comment to an interesting observation….that I might have to deconstruct it myself ! Metaphors are a very useful tool for exaggerating an issue which requires attention. They also can be used to de-subjectivise the issue, so that it seems more like a possible 'shared' experience, and therefore more worthy of a sensible response. The user of the metaphor will always attempt to express an issue in terms which might seem more familiar to the listener, and thus gain their approval for something which might otherwise be seen as a 'back-away' contentious issue. As such, using metaphors closely resembles the intentions of a confidence trick….but only if the original intention was to exaggerate, and thus earn more attention. The common use of metaphors in subjective medical descriptions probably results from an attempt to overcome the taboo-ism of not wanting to seem that one is only interested in their own problems, and thus losing the sought after attention. So, in the end, it's probably an assumed roundabout method of eliciting advise without offending. There's also the interesting aspect that if the listener realises the amount of effort put into the metaphorical statement, they might also be prepared to treat the issue with more gravity. I know that in the culture I come from, metaphors are highly respected, perhaps because they create a sense of neutrality and humour in the discourse.
On the downside, in terms of making a value judgement based on a loaded metaphorical statement, the question arises….'If someone is capable of constructing metaphors, they can't be in too much pain'. So, in theory, a loaded metaphorical statement, whilst attempting to exaggerate, also allows licence for a metaphorically balanced response. The 'bloody' metaphor probably takes the whole thing over the edge, unless we allow for a reversal of cultural niceties ….and that's not just an Aussie thing , it's more likely an Anglo- Saxon or Scandinavian expression, also common to the Celtic peripheral cultures, and assumed by Aussies for further exaggeration ! And all I can say to that is 'Good on yer' (which is probably a direct translation from the Irish 'Maith is leat' , but only used today in the Polynesian peripherals ! ).
As long as you heard "What the patient said" and tried to understand "What They meant" ………..
That would be ideal, but perhaps over-reliant on the operator's skills to de-metaphorise loaded statements. Exaggerations, framed as metaphors, are likely to encourage an 'opposite' reaction, and that's where the imbalances and dissonance are likely to enter the attempted shared understanding. Up to that point, the one using the metaphor is entitled to their own interpretation of what they're experiencing…..after all, it is their problem. It would seem that translating that into a scientific description which can be acted on with confidence, and with no bias, is vulnerable to variable interpretation because there's no guarantee that the operator is infallible. There is the possible aspect coming into play, that without 100% trust in the operators skills, the loaded metaphorical statement was created to offset any possible misjudgement that the problem presented might be perceived as less serious than intended…that would point to some cultural habit of defying expected responses before they happen…and difficult to read because all based on supposition. Tangled web indeed !
There's an expression in the building trade…." Rip it up, and start again", which is a means towards overcoming 'builder bias' and re-applying oneself to the problem from a new perspective. A typical example might be where a continuing damp problem exists, and although the builder has completed the cosmetic remedial works to a good standard, he failed to identify the cause, and thus the problem persists….and that's the proper use of the term 'persists' , unlike the current tendency to replace the term 'chronic' with 'persistent' ( another issue perhaps, because of the metaphorical context it creates ?). Over the years, I've seen many instances of builders being unable to accept the 'Rip it up and start again' mantra, mostly because it challenges and undermines their trust in their own abilities to correctly define a problem at outset. Quite often, over a cup of tea, they will admit their mistake, but on the surface, they like to maintain an unquestionable professionalism, and consequently the problem 'persists'. Those builders who do 'rip it up', sleep more soundly !
That entire observation is a metaphor, of sorts. I'm using it in order to avoid a possible adverse reaction, where offence might be taken because of the obvious inherent inferences. As a metaphor, it implies a certain neutrality, and I would hope that it helps to show that metaphors can be useful on both sides of the operator / patient equation…..where, importantly, both parties are capable of translating metaphors as they see fit. I think it's probably a mistake to assume that only one party is observing in a professional manner, whilst the other party is somehow oblivious to the complex context. It might seem like that, on the surface, but the very fact that a metaphorical context has been created by one party, points to the possibility that a particular reaction was already assumed before any communication was entered into. Perhaps the reason for such assumptions, requiring the creation of a metaphorical context, is really the core issue which needs analysing, rather than the actual translation of the metaphor which is vulnerable to individual bias.


About - Design Comfort Co., Inc.
Design Comfort Company (DCC) has been owned and operated by Walt Macklin since its inception back in 1979.
Mr. Macklin has a passion for people, their health, and their comfort in both their working environment and their homes.
As a premier HVAC design, install, service, and maintenance company, DCC has been serving the air quality and comfort needs of SE MI offices, plants, and homes, for over 36 years. DCC has earned its reputation by providing high quality work, fair pricing, and treating each customer with honesty and integrity.


text:
Transparency International EU joins ALL alliance for democracy to promote transparency and good governance in the EU
Today, Transparency International EU joins forces with diverse organisations from business and civil society to form the ALL Alliance for Democracy. ALL is a pro-European alliance launched to campaign in support of European cooperation and democracy and to promote a democratic dialogue about shared values.
The EU has a long history of promoting good governance, the rule of law and anti-corruption reform, most notably as part of the enlargement process, which has raised standards in former communist countries, according to Transparency International EU.
"While the EU has its problems, it has been incredibly important in promoting good governance, fighting corruption and increasing checks and balances on power in Europe and beyond," said Carl Dolan, Director of Transparency International EU. "Corruption crosses borders and money flows across the world with ease, that's why the EU is uniquely placed to take on some of the biggest challenges we face, such as money laundering and tax havens, and we should support these efforts," continued Dolan.
Six EU countries currently score less than 50 on Transparency International's Corruption Perceptions Index. However, rising populism and attacks on the independence of the judiciary, media and civil society in Europe is creating a fertile breeding ground for corruption, according to Transparency International EU.
"From Trump to Hungary the language of the anti-corruption movement has been abused to gain power, while the same people then dismantle the very tools which are needed to keep power in check," said Dolan. "Now more than ever is the time to stand up to the kind of populism which threatens European values and the very fabric of our societies, without which corruption will flourish," concluded Dolan.
Strategy 2020: Empowered Citizens, an Accountable Europe
Our new strategy "Empowered Citizens, an Accountable Europe" will guide our work in the next four years. This document provides a framework for sustained growth, clarity of focus and greater impact.
PDF • 2.85 MB Download
Carl Dolan
cdolan@transparency.org


text:
package agent

import (
	"sync"
	"time"

	"github.com/drone/drone/client"
	"github.com/drone/drone/shared/token"
	"github.com/samalba/dockerclient"

	"github.com/Sirupsen/logrus"
	"github.com/codegangsta/cli"
)

// AgentCmd is the exported command for starting the drone agent.
var AgentCmd = cli.Command{
	Name:   "agent",
	Usage:  "starts the drone agent",
	Action: start,
	Flags: []cli.Flag{
		cli.StringFlag{
			EnvVar: "DOCKER_HOST",
			Name:   "docker-host",
			Usage:  "docker deamon address",
			Value:  "unix:///var/run/docker.sock",
		},
		cli.BoolFlag{
			EnvVar: "DOCKER_TLS_VERIFY",
			Name:   "docker-tls-verify",
			Usage:  "docker daemon supports tlsverify",
		},
		cli.StringFlag{
			EnvVar: "DOCKER_CERT_PATH",
			Name:   "docker-cert-path",
			Usage:  "docker certificate directory",
			Value:  "",
		},
		cli.IntFlag{
			EnvVar: "DOCKER_MAX_PROCS",
			Name:   "docker-max-procs",
			Usage:  "limit number of running docker processes",
			Value:  2,
		},
		cli.StringFlag{
			EnvVar: "DOCKER_OS",
			Name:   "docker-os",
			Usage:  "docker operating system",
			Value:  "linux",
		},
		cli.StringFlag{
			EnvVar: "DOCKER_ARCH",
			Name:   "docker-arch",
			Usage:  "docker architecture system",
			Value:  "amd64",
		},
		cli.StringFlag{
			EnvVar: "DRONE_STORAGE_DRIVER",
			Name:   "drone-storage-driver",
			Usage:  "docker storage driver",
			Value:  "overlay",
		},
		cli.StringFlag{
			EnvVar: "DRONE_SERVER",
			Name:   "drone-server",
			Usage:  "drone server address",
			Value:  "http://localhost:8000",
		},
		cli.StringFlag{
			EnvVar: "DRONE_TOKEN",
			Name:   "drone-token",
			Usage:  "drone authorization token",
		},
		cli.StringFlag{
			EnvVar: "DRONE_SECRET,DRONE_AGENT_SECRET",
			Name:   "drone-secret",
			Usage:  "drone agent secret",
		},
		cli.DurationFlag{
			EnvVar: "DRONE_BACKOFF",
			Name:   "backoff",
			Usage:  "drone server backoff interval",
			Value:  time.Second * 15,
		},
		cli.DurationFlag{
			EnvVar: "DRONE_PING",
			Name:   "ping",
			Usage:  "drone server ping frequency",
			Value:  time.Minute * 5,
		},
		cli.BoolFlag{
			EnvVar: "DRONE_DEBUG",
			Name:   "debug",
			Usage:  "start the agent in debug mode",
		},
		cli.DurationFlag{
			EnvVar: "DRONE_TIMEOUT",
			Name:   "timeout",
			Usage:  "drone timeout due to log inactivity",
			Value:  time.Minute * 5,
		},
		cli.IntFlag{
			EnvVar: "DRONE_MAX_LOGS",
			Name:   "max-log-size",
			Usage:  "drone maximum log size in megabytes",
			Value:  5,
		},
		cli.StringSliceFlag{
			EnvVar: "DRONE_PLUGIN_PRIVILEGED",
			Name:   "privileged",
			Usage:  "plugins that require privileged mode",
			Value: &cli.StringSlice{
				"plugins/docker",
				"plugins/docker:*",
				"plugins/gcr",
				"plugins/gcr:*",
				"plugins/ecr",
				"plugins/ecr:*",
			},
		},
		cli.StringFlag{
			EnvVar: "DRONE_PLUGIN_NAMESPACE",
			Name:   "namespace",
			Value:  "plugins",
			Usage:  "default plugin image namespace",
		},
		cli.BoolTFlag{
			EnvVar: "DRONE_PLUGIN_PULL",
			Name:   "pull",
			Usage:  "always pull latest plugin images",
		},
	},
}

func start(c *cli.Context) {

	// debug level if requested by user
	if c.Bool("debug") {
		logrus.SetLevel(logrus.DebugLevel)
	} else {
		logrus.SetLevel(logrus.WarnLevel)
	}

	var accessToken string
	if c.String("drone-secret") != "" {
		secretToken := c.String("drone-secret")
		accessToken, _ = token.New(token.AgentToken, "").Sign(secretToken)
	} else {
		accessToken = c.String("drone-token")
	}

	logrus.Infof("Connecting to %s with token %s",
		c.String("drone-server"),
		accessToken,
	)

	client := client.NewClientToken(
		c.String("drone-server"),
		accessToken,
	)

	tls, err := dockerclient.TLSConfigFromCertPath(c.String("docker-cert-path"))
	if err == nil {
		tls.InsecureSkipVerify = c.Bool("docker-tls-verify")
	}
	docker, err := dockerclient.NewDockerClient(c.String("docker-host"), tls)
	if err != nil {
		logrus.Fatal(err)
	}

	go func() {
		for {
			if err := client.Ping(); err != nil {
				logrus.Warnf("unable to ping the server. %s", err.Error())
			}
			time.Sleep(c.Duration("ping"))
		}
	}()

	var wg sync.WaitGroup
	for i := 0; i < c.Int("docker-max-procs"); i++ {
		wg.Add(1)
		go func() {
			r := pipeline{
				drone:  client,
				docker: docker,
				config: config{
					platform:   c.String("docker-os") + "/" + c.String("docker-arch"),
					timeout:    c.Duration("timeout"),
					namespace:  c.String("namespace"),
					privileged: c.StringSlice("privileged"),
					pull:       c.BoolT("pull"),
					logs:       int64(c.Int("max-log-size")) * 1000000,
				},
			}
			for {
				if err := r.run(); err != nil {
					dur := c.Duration("backoff")
					logrus.Warnf("reconnect in %v. %s", dur, err.Error())
					time.Sleep(dur)
				}
			}
		}()
	}
	wg.Wait()
}

redpajama_set_name: RedPajamaGithub