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Filed under Gastroenterology and Hepatology
CHAPTER 19 Gastrointestinal Bleeding
Thomas J. Savides, Dennis M. Jensen
Initial Assessment and Management of Acute Gastrointestinal Bleeding 285
Physical Examination 286
Laboratory Studies 288
Clinical Determination of the Bleeding Site 288
Hospitalization 288
Resuscitation 288
Initial Medical Therapy 288
Endoscopy 289
Endoscopic Hemostasis 291
Radiologic Imaging 292
Upper Gastrointestinal Bleeding 293
Epidemiology 293
Risk Factors and Risk Stratification 293
Upper Endoscopic Technique 293
Peptic Ulcer 294
Other Causes 303
Varices 306
Lower Gastrointestinal Bleeding 308
Mortality 309
Diagnostic and Therapeutic Approach 309
Causes and Management 311
Obscure Overt Gastrointestinal Bleeding 315
Causes and Diagnostic and Therapeutic Approaches 315
Diagnostic Tests 318
Obscure Occult Gastrointestinal Bleeding and Iron Deficiency Bleeding 320
Fecal Occult Blood 320
Iron Deficiency Anemia 321
The annual rate of hospitalization for any type of gastrointestinal (GI) hemorrhage in the United States is estimated to be 350 hospital admissions/100,000 population, with more than 1,000,000 hospitalizations annually.1 Approximately 50% of admissions for GI bleeding are for upper GI (UGI) bleeding (from the esophagus, stomach, duodenum), 40% are for lower GI (LGI) bleeding (from the colon and anorectum), and 10% are for obscure bleeding (from the small intestine).
This chapter focuses on overt GI bleeding that may be severe and prompts the patient to seek medical attention. The source of most GI bleeds can be suspected by the clinical symptoms and physical examination and confirmed by upper or lower endoscopy. Initial management focuses on medical resuscitation, followed by endoscopic diagnosis and interventions to stop acute bleeding and prevent recurrent bleeding. Pharmacologic therapy is playing an increasingly important role in the management of UGI bleeding from peptic ulcers and varices. Optimal patient outcomes depend on successful medical resuscitation, precise endoscopic diagnosis, and appropriate use of therapeutic endoscopy.
Severe gastrointestinal bleeding is defined as documented gastrointestinal bleeding (i.e., hematemesis, melena, hematochezia, or positive nasogastric lavage) accompanied by shock or orthostatic hypotension, a decrease in the hematocrit value by at least 6% (or a decrease in the hemoglobin level of at least 2 g/dL), or transfusion of at least two units of packed red blood cells. Most patients with severe gastrointestinal bleeding are admitted to the hospital for resuscitation and treatment. Overt bleeding implies visible signs of blood loss from the GI tract. Hematemesis is defined as vomiting of blood, which is indicative of bleeding from the esophagus, stomach, or duodenum. Hematemesis includes vomiting of bright red blood, which suggests recent or ongoing bleeding, and dark material (coffee-ground emesis), which suggests bleeding that stopped some time ago. Melena is defined as black tarry stool and results from degradation of blood to hematin or other hemochromes by intestinal bacteria. Melena can signify bleeding that originates from UGI, small bowel, or proximal colonic source. Melena generally occurs when 50 to 100 mL or more of blood is delivered into the GI tract (usually the upper tract), with passage of characteristic stool occurring several hours after the bleeding event.2,3 Hematochezia refers to bright red blood per rectum, and suggests active UGI or small bowel bleeding, or distal colonic or anorectal bleeding. Occult gastrointestinal bleeding refers to subacute bleeding that is not clinically visible. Obscure gastrointestinal bleeding is bleeding from a site that is not apparent after routine endoscopic evaluation with esophagogastroduodenoscopy (upper endoscopy) and colonoscopy, and possibly small bowel radiography. An algorithm for the initial management of acute, severe UGI bleeding is shown in Figure 19-1.
Figure 19-1. Algorithm for the initial management of severe upper gastrointestinal (UGI) bleeding. The steps in the algorithm may take place simultaneously or in varying orders and in the emergency department depending on the clinical situation.
INITIAL ASSESSMENT AND MANAGEMENT OF ACUTE GASTROINTESTINAL BLEEDING
Initial assessment of the patient with acute GI bleeding includes medical history taking, obtaining vital signs, performing a physical examination, including a rectal examination, and nasogastric lavage. During history taking, patients should be questioned about risk factors and historical features that help identify diagnostic possibilities for the bleeding source (Table 19-1). Bleeding from a peptic ulcer should be suspected in patients with a history of an ulcer or those taking daily aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). Patients who have known or suspected liver disease or who are alcoholics should be suspected of bleeding related to portal hypertension. Patients with heavy alcohol intake, a feeding or chronic nasogastric tube, or a history of gastroesophageal reflux disease are at risk of erosive esophagitis. Patients who have had prior surgical repair of an abdominal aortic aneurysm should be considered to have a fistula from the graft to the duodenum until proven otherwise. Patients on an anticoagulant such as warfarin should be evaluated for the possibility of excessive anticoagulation. Prior radiation to the abdomen should raise the possibility of radiation enteritis or colitis. Weight loss suggests possible malignancy. Abdominal pain may suggest malignancy, inflammatory bowel disease, or ischemic colitis. A change in stool caliber suggests colon cancer or a colonic stricture. Chest pain or syncope suggests possible cardiovascular complications related to blood loss.
Table 19-1 Suspected Source of Gastrointestinal Bleeding as Suggested by a Patient's History
SUSPECTED SOURCE OF BLEEDING
Nasopharynx
History of nasopharyngeal radiation
Recurrent epistaxis
Prior nasopharyngeal malignancy
Lungs Hemoptysis
Esophageal ulceration
Heavy alcohol use
Odynophagia
Pill ingestion
Traumatic nasogastric tube placement
Mallory-Weiss tear
Alcohol binge
Cameron's erosions Large hiatal hernia
Esophageal or gastric varices or portal hypertensive gastropathy
Gastric angiodysplasia Chronic kidney disease
Epigastric discomfort
Frequent aspirin or nonsteroidal anti-inflammatory drug use
History of peptic ulcer disease
Primary aortoenteric fistula Prior severe acute unexplained bleeding
Secondary aortoenteric fistula Prior abdominal aortic aneurysm surgical repair with synthetic graft
Ampulla of Vater Recent endoscopic sphincterotomy
Bile ducts Recent liver biopsy or cholangiography
Pancreatic ducts Pancreatitis, pseudocyst
Recent pancreatography
Small intestine malignancy
Hereditary nonpolyposis colorectal cancer
History of intra-abdominal metastatic cancer
Intermittent small intestinal obstruction
Recurrent unexplained gastrointestinal bleeding
Meckel's diverticulum Unexplained gastrointestinal bleeding since childhood
Small intestine or colon ulcerations Use of aspirin or other nonsteroidal anti-inflammatory drug
Small intestine telangiectasias
Frequent nosebleeds
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)
Small intestine angiodysplasia Age > 60 years
Colonic diverticulosis
Hematochezia without abdominal pain
History of diverticulosis
Colonic neoplasia
Change in bowel habits
Personal or family history colon neoplasia
Subacute bleeding
Ischemic colitis
Hematochezia with abdominal pain or discomfort
Family history of IBD
History of ulcerative colitis
History of Crohn's disease
Chronic abdominal discomfort
Anal fissure Hematochezia with anal pain
Dripping blood with bowel movements
Hematochezia with normal bowel movements
Postpolypectomy ulcer
Recent colonoscopy with polypectomy
Use of anticoagulants or antiplatelet drugs
Colonic or small intestinal angioectasias
Age > 70 yr
Recurrent bleeding of variable severity
Anastomotic ulceration Prior intestinal surgical anastomosis
Radiation enteritis or proctitis History of abdominal radiation therapy
IBD, inflammatory bowel disease.
On initial evaluation, physical examination should focus on the patient's vital signs, with attention to signs of hypovolemia such as hypotension, tachycardia, and orthostasis. The abdomen should be examined for surgical scars, tenderness, and masses. Signs of chronic liver disease include spider angiomata, palmar erythema, gynecomastia, ascites, splenomegaly, caput medusae, and Dupuytren's contracture. The skin, lips, and buccal mucosa should be examined for telangiectasias, which are suggestive of hereditary hemorrhagic telangiectasia (HHT), or Osler-Weber-Rendu disease. Pigmented lip lesions may suggest Peutz-Jeghers syndrome. Purpuric skin lesions may suggest Henoch-Schönlein purpura. Acanthosis nigricans may suggest underlying malignancy, especially gastric cancer. The patient's feces should be observed to identify melena or maroon and red stool; however, the subjective description of stool color varies greatly among patients and physicians.4
Nasogastric or orogastric tube placement to aspirate and visually characterize gastric contents can be useful to determine the presence or absence of large amounts of red blood, coffee-ground material, or nonbloody fluid. Occult blood testing of a nasogastric tube aspirate is not useful, however, because trauma from the nasogastric tube may cause sufficient, although scant, bleeding to cause a false-positive result. Patients who have coffee-ground emesis or fresh bloody emesis that is witnessed do not require placement of a nasogastric tube for diagnostic purposes but may need a nasogastric tube to help clear the gastric blood for better endoscopic visualization and to minimize the risk of aspiration.
Blood from the patient with acute GI bleeding should be sent for standard hematology, chemistry, liver biochemical, and coagulation studies and for typing and crossmatching for packed red blood cells. The hematocrit value immediately after the onset of bleeding may not reflect blood loss accurately because over 24 to 72 hours there is equilibration of red blood cells in the vascular space with extravascular fluid and hemodilution resulting from intravenous administration of saline.5 The mean corpuscular volume (MCV) is an important indicator of the chronicity of blood loss; an MCV lower than 80 fL suggests chronic GI blood loss and iron deficiency, which can be confirmed by the finding of low blood iron, total iron-binding capacity (TIBC), and ferritin levels. A low MCV and negative fecal occult blood test result raise the possibility of celiac disease. A high MCV (>100 fL) suggests chronic liver disease or folate or vitamin B12 deficiency. An elevated white blood cell count may occur in more than half of patients with UGI bleeding and has been associated with greater severity of bleeding.6 A low platelet count can contribute to the severity of bleeding and suggests chronic liver disease or a hematologic disorder.
The blood urea nitrogen (BUN) and serum creatinine levels can help assess the patient for hemoconcentration (elevated levels) or chronic kidney disease, which may lead to chronic anemia because of decreased erythropoietin production. In patients with UGI bleeding, the BUN level typically increases to a greater extent than the serum creatinine level because of increased intestinal absorption of urea after the breakdown of blood proteins by intestinal bacteria.7
The prothrombin time (PT) and international normalized ratio (INR) assess whether a patient has impairment of the extrinsic coagulation pathway. Values can be elevated in chronic liver disease or with the use of warfarin. Liver biochemical test levels may indicate the presence of acute or chronic liver disease; a low serum albumin level suggests possible chronic liver disease, malnutrition, or protein loss via the intestine or kidney.
CLINICAL DETERMINATION OF THE BLEEDING SITE
Presentation with hematemesis, coffee-ground emesis, or nasogastric lavage with return of a large amount of blood or coffee-ground emesis indicates an UGI source of bleeding. A small amount of coffee-ground material or pink-tinged fluid that clears easily may represent mucosal trauma from the nasogastric tube rather than active bleeding from an UGI source. A clear (nonbloody) nasogastric aspirate does not necessarily indicate a more distal GI source bleeding, because 16% of patients with actively bleeding UGI lesions have a clear nasogastric aspirate.8 The presence of bile in the nasogastric aspirate makes UGI bleeding unlikely but can be seen with an intermittently bleeding UGI source.
Melena generally indicates an UGI source but can be seen with small intestinal or proximal colonic bleeding. Hematochezia generally implies a colonic or anorectal source of bleeding unless the patient is hypotensive, which could indicate a severe, brisk UGI bleed with rapid transit of blood through the GI tract.4 Maroon-colored stool can be seen with an actively bleeding UGI source or a small intestinal or proximal colonic source.
On the basis of the patient's initial history, physical examination, and laboratory test results, the location of bleeding (upper or lower), suspected bleeding lesion, and severity of bleeding can be predicted. Patients with severe GI bleeding require hospitalization, whereas those who present with only mild acute bleeding (self-limited hematochezia or infrequent melena) and who are hemodynamically stable (not suspected to be volume depleted), have normal blood test results, and can be relied on to return to the hospital if symptoms recur may be candidates for semiurgent outpatient endoscopy rather than direct admission to the hospital.9,10 On the other hand, patients should be hospitalized in an intensive care unit if they have large amounts of red blood in the nasogastric tube or per rectum, have unstable vital signs, or have had severe acute blood loss that may exacerbate other underlying medical conditions. Patients who have had an acute GI bleed but are hemodynamically stable can be admitted to a monitored bed (step-down unit) or standard hospital bed, depending on their clinical condition.
Several small studies have suggested that urgent endoscopy performed in the emergency department in patients with suspected UGI bleeds can help determine optimal hospital placement; however, widespread implementation of this practice is unlikely.11,12
Resuscitation efforts should be initiated at the same time as initial assessment in the emergency department and continue during the patient's hospitalization. At least one large-bore (14- or 16-gauge) catheter should be placed intravenously, and two should be placed when the patient has ongoing bleeding. Normal saline is infused as fast as needed to keep the patient's systolic blood pressure higher than 100 mm Hg and pulse lower than 100/min. Patients are transfused with packed red blood cells, platelets, and fresh-frozen plasma as necessary to keep the hematocrit value higher than 24%, platelet count higher than 50,000/mm3, and prothrombin time less than 15 seconds, respectively. A GI endoscopist should be consulted as soon as possible to expedite the patient's assessment and determine the optimal timing of endoscopy. In hospitals with a liver transplantation program, the transplantation hepatology service should also be notified if the patient is known to have advanced liver disease and is a potential transplant candidate.
The patient's vital signs should be monitored frequently, as appropriate to the level of hospitalization. Laboratory-determined hematocrit values (not fingerstick hematocrit values, which are less reliable) should be obtained every four to eight hours until the hematocrit value is stable. In patients with active bleeding, an indwelling urinary catheter should be placed to monitor the patient's urine output.
Endotracheal intubation should be considered in patients with active ongoing hematemesis or with altered mental status to prevent aspiration pneumonia. Patients who are older than 60 years, have chest pain, or have a history of cardiac disease should be evaluated for myocardial infarction with electrocardiography and serial troponin measurements. A chest x-ray should also be considered.
INITIAL MEDICAL THERAPY
Administration of a proton pump inhibitor (PPI) is useful for reducing rebleeding rates in patients with peptic ulcer disease (see later). Starting a PPI in the emergency department or intensive care unit (ICU) before endoscopy is performed in patients with severe UGI bleeding has become a common practice but is still controversial.13 Several clinical studies and meta-analyses have shown that infusion of a high-dose PPI before endoscopy accelerates the resolution of endoscopic stigmata of bleeding in ulcers (see later) and reduces the need for endoscopic therapy but does not result in improved clinical outcomes in the transfusion requirement, rebleeding rate, need for surgery, or death rate.14–17 Patients with a strong suspicion of portal hypertension and variceal bleeding should be started empirically on intravenous octreotide (bolus followed by infusion [see later and Chapter 90]), which can reduce the risk of rebleeding to a rate similar to that associated with endoscopic therapy (Fig. 19-2; also see Fig. 19-1).18,19
Figure 19-2. Algorithm for the endoscopic and medical management of severe ulcer hemorrhage following hemodynamic stabilization. IV, intravenous; NBVV, nonbleeding visible vessel; PPI, proton pump inhibitor; UGIB, upper gastrointestinal bleed.
GI endoscopy will identify the bleeding site and permit therapeutic hemostasis in most patients with GI bleeding. Endoscopy should be done only when it is safe to do so and when the information obtained from the procedure will influence patient care. Ideally, the patient should be hemodynamically stable, with a heart rate of less than 100 beats/min and a systolic blood pressure higher than 100 mm Hg. Respiratory insufficiency, altered mental status, or ongoing hematemesis indicates the need for endotracheal intubation before emergency upper endoscopy to stabilize the patient and protect the airway. Coagulopathy and thrombocytopenia should be corrected with transfusions prior to endoscopy. Proper medical resuscitation will not only allow safer endoscopy, but also ensure a better diagnostic examination for lesions, such as varices, that are volume dependent and will allow more effective hemostasis because of the correction of coagulopathy (Figs. 19-3 and 19-4; also see Figs. 19-1 and 19-2).
Figure 19-3. Algorithm for the management of severe hematochezia. RBC, red blood cell.
Figure 19-4. Algorithm for the management of severe hematochezia modified according to the patient's history. RBC, red blood cell.
Patients with active hemorrhage (i.e., a high-volume bloody gastric lavage or ongoing hematochezia) should undergo emergency endoscopy soon after medical resuscitation. Where emergency endoscopy should be performed in the hospital depends somewhat on local circumstances, but, in general, emergency endoscopy is best performed once the patient has reached an ICU bed, rather than in the emergency department, because resources (personnel, medications, space) are more readily available in the ICU. Patients suspected of having cirrhosis or an aortoenteric fistula or who rebleed in the hospital should undergo emergent endoscopy, usually within six hours of admission or rebleeding. Patients who are hemodynamically stable without evidence of ongoing bleeding can undergo urgent endoscopy (within 12 hours), often in the GI endoscopy unit rather than the ICU. Middle-of-the-night endoscopy should be avoided, except for the most severely bleeding or high-risk patients, because well-trained endoscopy nurses, endoscopic equipment, and surgical backup may not be available at night. In the rare patient with massive bleeding and refractory hypotension, endoscopy can be performed in the operating room, with the immediate availability of surgical management, if necessary.
In patients with severe UGI bleeding, gastric lavage with a large (34-Fr) orogastric tube should be performed to evacuate blood and clots from the stomach to prevent aspiration and allow good endoscopic visualization. Special lavage systems can help remove blood rapidly. The intravenous administration of erythromycin (a gastric prokinetic agent) 30 to 90 minutes before upper endoscopy to induce gastric contraction and push blood from the stomach into the small intestine helps endoscopic visualization.20,21 Therapeutic single- or double-channel endoscopes with large-diameter suction channels should be used to allow quick removal of fresh blood from the GI tract during endoscopy. Additionally, a water pump can be used to irrigate target lesions through an accessory channel and dilute blood for suctioning, both of which facilitate visualization. Using iced saline lavage to prevent or decrease UGI bleeding is of no particular value and may impair coagulation and cause hypothermia. Gastric lavage with lukewarm tap water is as safe as lavage with sterile saline and much less expensive.
In patients with severe hematochezia and suspected active colonic bleeding, urgent colonoscopy can be undertaken after a rapid purge (see Figs. 19-3 and 19-4).22,23 Patients should receive 4 to 8 L of polyethylene glycol purge orally or via a nasogastric tube over four to six hours until the rectal effluent is clear of stool, blood, and clots. Additional polyethylene glycol bowel purge may be required in some patients, particularly those with active bleeding, severe constipation, or the onset of hematochezia in the hospital. Metoclopramide, 10 mg, may be given intravenously before the purge and repeated every four to six hours to facilitate gastric emptying and reduce nausea. In patients with severe or ongoing active hematochezia, urgent colonoscopy should be performed within 12 hours, but only after thorough cleansing of the colon. Patients with mild or moderate self-limited hematochezia should undergo colonoscopy within 24 hours of admission, and a colonic purge is also recommended in this situation to cleanse the colon thoroughly.
Patients with maroon stool in whom there is pretest uncertainty about the bleeding source should be considered for an urgent polyethylene bowel preparation as well. Colonoscopy immediately after push enteroscopy (see later), while the patient is still sedated, will expedite a patient's care if push enteroscopy does not provide a diagnosis (and is also indicated for colon cancer screening in patients older than 50 years; Fig. 19-5).
Figure 19-5. Algorithm for the management of severe overt obscure gastrointestinal bleeding.*Deep enteroscopy includes double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy.
Wireless small bowel capsule endoscopy (or capsule endoscopy; see later) can be useful in patients with overt GI bleeding who have normal push enteroscopy and colonoscopy results and in whom a small bowel source of bleeding is suspected.24 Capsule endoscopy has the advantages of directly visualizing the small intestine to identify potential sources or active bleeding. Disadvantages are that the procedure takes eight hours to complete and additional time to download and review the images, does not permit therapeutic hemostasis, and is difficult to perform in inpatients because of limited availability of staff trained to place the capsule. A follow-up endoscopic procedure, such as single- or double-balloon enteroscopy or retrograde ileoscopy, may be indicated for definitive diagnosis and treatment if a focal bleeding site is found on capsule endoscopy.
Complications related to emergency endoscopy and endoscopic hemostasis may occur in up to 1% of patients, depending on the type of endoscopy and treatment performed.25,26 The most common complications include GI tract perforation, aspiration pneumonia, induced hemorrhage, an adverse medication reaction, hypotension, and hypoxia (see Chapter 40).
ENDOSCOPIC HEMOSTASIS
Thermal contact probes have been the mainstay of endoscopic hemostasis since the 1970s. These probes come in diameters of 7 and 10 Fr and in lengths that can fit through panendoscopes, enteroscopes, or colonoscopes. Contact probes can physically tamponade a blood vessel to stop bleeding and interrupt underlying blood flow, and thermal energy is then applied to seal the underlying vessel (coaptive coagulation). The most commonly used probe is a multipolar electrocoagulation (MPEC) probe, also referred to as a bipolar electrocoagulation probe, with which heat is created by current flowing between intertwined electrodes on the tip of the probe. Animal studies in which MPEC probes were used to stop bleeding in mesenteric vessels have shown that optimal coagulation occurs with low-power settings (12 to 16 W) applied for a moderate amount of time (8 to 10 seconds), with moderate pressure on the bleeding site.27 Heater probes can provide a predetermined amount of joules of energy, which does not vary with tissue resistance. Animal studies have shown that heater probes can effectively coagulate arteries up to 2 mm in diameter, a diameter considerably larger than most secondary or tertiary branches of arteries (usually 1 mm) found in resected bleeding human peptic ulcers.28,29 The main risk of using a thermal probe is perforation with excessive application of coagulation or pressure, especially in acute or nonfibrotic lesions. Thermal probes can also cause a coagulation injury that can make lesions larger and deeper and may induce delayed bleeding in patients with a coagulopathy.
Injection therapy is performed most commonly with the use of a sclerotherapy needle to inject epinephrine, diluted to a concentration of 1 : 10,000 or 1 : 20,000, submucosally into or around the bleeding site or stigma of hemorrhage (see later). The advantages of this technique are its wide availability, relatively low cost, and safety in patients with a coagulopathy. Additionally, it is associated with a lower risk of perforation and thermal burn damage than the thermal techniques. The disadvantage of epinephrine injection is that it is not as effective for definitive hemostasis as thermal coagulation, hemoclipping (see later), or combination therapy.30,31 Injection therapy can also be performed with a sclerosant, such as ethanolamine or alcohol, but these agents are associated with increased tissue damage and other risks.
Endoscopic hemoclips (or clips) have been available since 1974, and have become popular as technical improvements have been introduced.32 Hemoclips serve to apply mechanical pressure to a bleeding site, as is done with surgical clips or sutures. Endoscopic hemoclips differ from surgical clips, however, in that they do not have as much compressive strength, and the currently available clips do not close completely but leave a small space between the prongs. Animal studies have shown that the first-generation hemoclips could not stop bleeding in vessels larger than a diameter of 1 mm.33 Subsequent hemoclips have been larger and stronger and have had a grasp and release mechanism that improves endoscopic deployment and hemostasis. By not causing significant thermal damage, hemoclips are especially useful for patients with malnutrition or coagulopathy.34 Nevertheless, hemoclips can also be difficult to deploy depending on the location of the bleeding site, the degree of fibrosis of the underlying lesion, and limitations to endoscopic access.
Band ligation is a technique in which mucosal (with or without submucosal) tissue is suctioned into a cap placed on the end of the endoscope, and a rubber band is rolled off the cap and over the lesion to compress its base. This technique is widely used for the treatment of esophageal varices (see Chapter 90) and occasionally can be used for other bleeding lesions. An advantage of band ligation is that it is relatively easy to perform; however, a disadvantage is that sufficient mucosa must be suctioned into the cap for ligation to be successful. Depending on the manufacturer, some band ligation devices can only fit on diagnostic endoscopes, and switching from a larger therapeutic endoscope to a smaller diagnostic endoscope during a case is time-consuming and inefficient.
RADIOLOGIC IMAGING
Angiography may be used to diagnose and treat severe bleeding, especially when the cause cannot be determined by upper and lower endoscopy. Angiography generally is diagnostic of extravasation into the intestinal lumen only when the arterial bleeding rate is at least 0.5 mL/min.35 The sensitivity of mesenteric angiography is 30% to 50% (with higher sensitivity rates for active GI bleeding than for recurrent acute or chronic occult bleeding), and the specificity is 100%.36 An advantage of angiography is that it permits therapeutic intra-arterial infusion of vasopressin or transcatheter embolization for hemostasis if active bleeding is detected, without the need for bowel cleansing. Nevertheless, the rate of major complications, including hematoma formation, femoral artery thrombosis, contrast dye reactions, acute kidney injury, intestinal ischemia, and transient ischemic attacks, is 3%.37 Another disadvantage of angiography is that it usually does not identify the specific cause of bleeding, only its location.
Radionuclide imaging is occasionally helpful for patients with unexplained GI bleeding, although it is used less frequently now than in the past because of the widespread use of endoscopy and lack of availability of nuclear medicine services for emergencies, particularly at night and on weekends. Radionuclide imaging can be performed relatively quickly and may help localize the general area of bleeding and thereby guide subsequent endoscopy, angiography, or surgery. The technique involves injecting a radiolabeled substance intravenously into the patient's bloodstream and then performing serial scintigraphy to detect focal collections of radiolabeled material. Radionuclide imaging has been reported to detect bleeding at a rate of 0.04 mL/min.38 The two tracers used for radionuclide imaging for bleeding (bleeding scans) are technetium sulfur colloid and technetium pertechnetate–labeled autologous red blood cells. Technetium sulfur colloid is cleared rapidly from the bloodstream and is therefore useful for identifying acute, active bleeding. Technetium pertechnetate–labeled red blood cells remain in the circulation for up to 24 hours and therefore can be used for repeated scanning in patients with intermittent bleeding. A comparative study of patients with suspected GI bleeding has found technetium pertechnetate–labeled red blood cell scans to be more sensitive, specific, and accurate than technetium sulfur colloid scans.39
The overall rate of a diagnostic radionuclide scan is approximately 45%, with a 78% accuracy rate in the localization of the true bleeding site.40,41 Up to 25% of bleeding scans suggest a site of bleeding that proves to be incorrect.41–43 The rate of true-positive scans is higher for active bleeding with hemodynamic instability than for less severe bleeding.44 The most common reason for a false-positive result is rapid transit of luminal blood, so that labeled blood is detected in the colon even though it originated from a more proximal site in the GI tract. Caution is recommended in using the results of delayed scans to localize and target lesions for resective surgery.45
Technetium pertechnetate scintigraphy can identify ectopic gastric mucosa in a Meckel's diverticulum. This diagnosis should be considered in a pediatric or young adult patient with unexplained GI bleeding. The positive predictive value, negative predictive value, and overall accuracy of a so-called Meckel's scan has been reported to be higher than 90% in young patients.46,47 In patients older than 25 years, however, Meckel's scans are much less sensitive (<50%). Caution is recommended in interpreting a negative Meckel's scan result in an adult patient with GI bleeding.48
Conventional radiographic imaging is usually not needed in a patient with GI bleeding but occasionally may provide some important information. In patients with a prior abdominal aortic aneurysm repair and graft, computed tomography (CT) with intravenous contrast can identify inflammation between the graft and duodenum and thus suggest graft fistulization into the duodenum.49 In selected patients, an abdominal CT scan can also identify a mass lesion, such as an intra-abdominal tumor, or small bowel abnormalities that may suggest a cause of bleeding. Advances in CT scan technology have permitted CT enterography and CT angiography to be performed, with promising results.50,51
Barium radiography is not indicated (and contraindicated if endoscopy or angiography is planned) in the emergency setting. Barium studies were used in the past to identify small bowel diverticula and ulcerations, but this approach has been supplanted by CT enterography and capsule endoscopy.
Most patients admitted for acute GI bleeding have bleeding of mild to moderate severity and do not need surgical consultation. In selected patients with severe, ongoing GI bleeding in whom a diagnosis is not made by urgent endoscopy or colonoscopy, surgical consultation during the hospitalization is recommended. Also, patients who have massive hemorrhage and cannot be stabilized hemodynamically should undergo emergency angiography or urgent surgical exploration (either without prior endoscopy or with emergency endoscopy in the operating room; see later). Patients with bleeding that cannot be controlled with endoscopy or angiography may require surgery.
UPPER GASTROINTESTINAL BLEEDING
UGI bleeding is a common medical emergency that accounts for more than 500,000 hospital admissions each year, or approximately 170 patients/100,000 population/year.1 Of the potential causes of severe UGI bleeding, peptic ulcer is the most common, accounting for approximately 40% of cases (Table 19-2).52,53 Despite advances in medical therapy, ICU care, endoscopy, and surgery, the mortality rate of 5% to 10% for severe UGI bleeding has not changed since the 1970s.1,52–56 The lack of decline in the mortality rate may be explained by an increase in the proportion of older patients with GI bleeding, who may die as a result of worsening of other medical conditions rather than from exsanguination, and an increase in the number of patients with cirrhosis and variceal bleeding.
Table 19-2 Causes of Severe Upper Gastrointestinal Bleeding in the UCLA CURE Database
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Portal Hypertension and Gastrointestinal Bleeding
Tumors of the Esophagus
Adenocarcinoma and Other Tumors of the Stomach
Primary Biliary Cirrhosis
Chronic Pancreatitis
Gastritis and Gastropathies
Sleisenger and Fordtrans Gastrointestinal and Liver Disease- 2 V


In recent years there has been a spate of books addressing the problem of the "Canaanite genocide" by Wright, Copan, and Seibert. Even Lamb entered the fray. In 2013, a collection of essays edited by Thomas, Evans, and Copan addressed the issue of Holy War in the Bible. In my contribution, I argue that biblical warfare shouldn't be associated with holiness since, according to the text, divine anger and compassion are its primary motivations.
The most recent addition to the discussion of biblical warfare comes from Paul Copan and Matthew Flannagan (C&F): Did God Really Command Genocide? Coming to Terms with the Justice of God. In Part 1 of my review (click here) I examine the first section of the book, and Part 2, I will look at the next section of the book which begins to work through the relevant textual issues, which is the section of the book I'm personally most interested in.
Chapter 4 asks, "Does the Bible Command Us to Kill Innocent Human Beings?" The answer to this question might seem to be an obvious "No." But the argument is sometimes made that the Canaanite slaughter could be seen as establishing a biblical precedent for later slaughters (let's mention the Crusades, since that's the obvious one always referred to). C&F argue persuasively that the command to "utterly destroy" was unusual and shouldn't be understood as establishing a precedent.
Chapter 5 asks, "Does the Bible portray the Canaanites as innocent?" The answer here again is "No" and C&F make three points. First, Israel owned the land because God gave it to them. I generally agree with this point, but a skeptic or an atheist won't be convinced by it, because the Canaanites were in possession of the land. Second, the crimes of the Canaanites, which included human sacrifice, were serious crimes, worthy of punishment. Third, the Israelites needed to remain free from the influence of the Canaanites. They conclude the chapter with three examples of Canaanites who were spared: Caleb (not sure about this one), the Shechemites, and Rahab, who is the best example since she's clearly Canaanite (not like Caleb), and yet she and her family are spared.
Chapter 6 makes the point that instead of annihilating the Canaanites the most common textual image for the conquest is that of "driving them out," a point I also make in God Behaving Badly (p. 100). This point is helpful for several reasons. It takes the text seriously and it acknowledges that the process of removing the Canaanites from the land may have taken awhile and wasn't exclusively done by extermination.
Chapter 7 argues that readers of the "utterly destroy" texts of Joshua should not read these texts literally, but as examples of hyperbole. A hyperbolic interpretation makes a lot of sense, particularly as one compares these more problematic texts with other texts in Joshua and Judges. I make this point in my Relevant article ("Reconciling the God of Love with the God of Genocide"), but C&F use Wolterstorff and Kitchen, which are probably a better choices. For the most in-depth academic discussion of the topic of hyperbole in ancient conquest narratives, check out the monograph of Lawson Younger here.
If my review continued I'd get in trouble for too many spoilers. So, for the motivated reader who's interested in making sense of the problem of the so-called "Canaanite Genocide" I'd highly recommend this book.


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Tata Memorial Hospital in Mumbai
Tata memorial hospital is one of the best comprehensive cancer research centers with International exposure and the entire hospital is dedicated in offering best health care and treatment solutions for carcinogenic diseases. The Tata Memorial Hospital project was initiated by Dr. Homi N Sethna at complete support from Department of Atomic Energy and Dr. Shetna headed the institution till 1962. This cancer specialized treatment center project was commissioned by Sir Dorabji Tata Trust on 28 February 1941, and the hospital was established for offering quality treatment solution for cancer affected people in India.
Tata Memorial Hospital Mumbai is strategically closely related to Advanced Center for Treatment, Research and Education in Cancer (ACTREC). This hospital cum cancer research institute is recognized as one of the most authentic treatment centers for acute lymphoblastic leukemia (A.L.L), and has a claim to cure almost 99% A.L.L. patients treated so far here. Tata Memorial Hospital is one of those few hospitals in India have a P.E.T scanner. Presently the Director of this health institution is Dr Rajendra A Badwe. The hospital is also taking care of Covid 19 patients and has ranks among the best Covid hospitals in Mumbai.
TATA MEMORIAL HOSPITAL
Dr. E Borges Road, Parel, Mumbai - 400 012 India
Tel. +91-22- 24177000, 24177300, 24161413
E-mail : msoffice@tmc.gov.in (for patient care and queries)
feedback@tmc.gov.in (for feedback from patients)
cash@tmc.gov.in (for accounts related)
fundraising@tmc.gov.in (for donors and donation related)
registrar@tmc.gov.in (for education and training)
hrd@tmc.gov.in (for administrative - HRD matters)
https://tmc.gov.in/index.php/en/
TATA MEMORIAL HOSPITAL: +91-22-24177000, 24177300, 24161413
Parel, Mumbai Maharashtra, India
ACTREC: +91-22-2740 5000, Kharghar, Navi Mumbai, Maharashtra, India
Webmaster: +91-22-24177000, 24177300, 24161413, Parel, Mumbai, Maharashtra, India
Information regarding Covid-19 Testing at TMH
History of Tata Memorial Hospital
In the year 1952 the Indian Cancer Research Centre was founded as a leading research institute for elementary research on carcinoma and its related disease—later on it was known as the Cancer Research Institute (CRI). In the year1957 the Ministry of Health undertook the administrative responsibility of the cancer Research institute.
The migration of the administrative body of Tata Memorial Hospital & Cancer Research Institute to the Department of Atomic Energy in the year 1962 was a major change in its history. At the sole effort of Sir Dorabji Tata Trust, the hospital and Cancer Research Institute got merged with each other as the two integral wings of the Tata Memorial Centre (TMC) on the year 1966: this professional merging has initiated a balanced philanthropic venture for eradication and treatment of cancer at the best level support from Indian Government.
Tata Memorial Hospital Offered Services For Patients
Online Patient Service
Online patient service has three modules to offer: these are online patient registration, availing laboratory and imaging services, and accessing e records.
Out Patient Procedure
In this process patients get enrolled in the treatment process of the hospital. A patient has two options for registration: he can register as general patient or he can get registered as privet patient. In case of general patient the doctor in charge in OPD will check his documents and privet patients can select their doctor as per recommendation. After registration, the patients can avail the consultation process of the hospital and then decide the road map of treatment process.
Hospital Dispensary
The Tata Memorial Hospital maintains its dispensary. Besides providing best support for supplying medicines and required consumables, the dispensary takes back unused medicines within 3 month time after it is sold from the same place.
Diagnostic Service
Tata Memorial Hospital maintains their diagnostic department for proper medical diagnosis of the admitted patients as per the recommendation of the attending doctors. After due diagnosis the doctors evaluate the reports and accordingly a road map for further treatment process is planned with due discussion with patient and his relatives.
Other Value Added Services
Tata Memorial Hospital offers other value added services for patients' welfare. Facility of availing day care department, pre fixed appointment benefits, and financial assistance for NC category patients are some of the services available on board.
Medical Departments in Tata Memorial Hospital
Tata Memorial Hospital maintains different medical departments for offering round the way medical treatment facilities for admitted patients. The concerned departments of Tata Memorial Hospital are:
Anesthesia department is comprised of 15 consultant anesthetists and more than 40 resident medical professionals including students of post graduate courses. It takes care of anesthesia service, pain management, and in charge of intensive care unit, etc.
Biochemistry department has three divisions: Main Biochemistry Lab, Tumor Marker Service, and Emergency Service. The department is dedicated to offer the best probable support in diagnosis and monitoring of cancer patients' disease by using tests and techniques that meet the international standards of quality reassurance while continuing high standard of ethical practice with clinical colleagues, patients and staff.
Cytopathology Department was established in the year 1957 and currently it has two services to offer like exfoliative cytopathology for gynecological and non-gynecological sites, and fine needle aspiration cytology.
Dental Department deals with prophylactic denture care of all cancer patients including requisite cancer treatment wrt, radiotherapy, chemotherapy, surgery, bone marrow transplant etc.
Digestive Diseases Department deals with digestive Diseases and clinical nutrition solution via a wide range of services for patients.
Hematopathology Department at Tata Memorial Hospital is accredited by NABL. For contact: Department of Hemato-pathology, 7th floor, Annexe Building, Tata Memorial Hospital, Phone: 24177000 Ext: 4367,4530, 4529
Medical Oncology Department deals with medicinal treatment of cancer with the help of modern anticancer drugs with satisfactory success rate.
Medical Physics Department works in close association to the Department of Radiation Oncology in radiation treatment arena. The department deals in treatment planning, calibration, Quality assurance and periodical maintenance of treatment machines, monitoring of Radiation Safety as well as of room designing, and concerned education.
Microbiology Department offers services in areas of Bacteriology, Mycology (Fungal infections), Checkup/investigation of urine and stool, Mycobacteriology (Tuberculosis), Serology for treatment of viral infections, and Molecular diagnostic curative approaches for healing viral infections.
Nursing Department provides best quality nursing care for patients and assets doctors in offering best quality services.
Pathology department in Tata Memorial Hospital Mumbai deals in four major departments like surgical Pathology, Immunohistochemistry and Molecular Pathology, Hematopathology and Clinical Pathology, cytology, and biochemistry.
Preventive Oncology suggests solution for prevention of cancerous diseases.
Radiodiagnosis deals with x-ray, digital mammography, ultra sound color Doppler, computerized CT scan, magnetic resonances Imaging(MRI), Intervention Radiology, Picture Archival And Communication System, etc.
Nuclear Medicine assists in detecting and treatment of carcinogenic tumor, etc.
Radiation Oncology is treatment of cancer by radiation: two methods are used here, and these teletherapy and brachytherapy.
Surgical Oncology deals with surgical intervention for cure and care of cancerous diseases.
Plastic Surgery deals with deformation and modification of organs for better wellness of life.
General Medicine Department deals with treatment of cancer with medicines, as per symptoms of the concerned patients.
Ancillary Services of Tata Memorial Hospital
Medical Social Work provides accommodation assistance for needy outstation patients at subsidized rate at first come first serve basis.
Palliative care of Tata Hospital offers holistic medicinal therapy and support for relief and well being.
Rehabilitation service offers support for patients to get back to their normal life as maximum as possible.
Psychiatric unit and clinical psychology supports patients to deal with trauma of the disease.
Stoma clinic helps in care and cure of cancer patients.
Tissue Bank is a non-profit service committed to supply of safe, dependable human tissues for transplantation in budget price.
Tumor Tissue Repository deals with tissue collection and preservation with best possible care and with the use of ultra-modern technology.
The Public Relation Department monitors customer care and works as liaison between patients and hospital administration department.
Working Hours of Tata Memorial Hospital Mumbai
The working hours of Tata Memorial Hospital are from 9.15 a.m. to 5.30 p.m. from Monday to Friday. Working hours get closed at 2.15 p.m. on Saturdays
The Hospital remains closed on all gazetted Central Government holidays. Emergency services are available at 24x7 manners.
Also See: Aravind Hospital | Occupational Therapy in Mumbai | Agrawal Hospital
Explore more about Healthcare Facilities in Mumbai

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Latest HappeningsPopular Posts
Americans Share Their First Impression Of Pakistani Actresses
Saud
This interesting new trend of asking Americans what they think of things that are genuinely Pakistani is getting some reactions which are in many ways entertaining too. This time a group of Americans which consisted of 4 girls and 2 boys were asked separately their first impressions of Pakistani actresses after they had a look at their instagram accounts. The reactions these Americans gave were very interesting.
These people were shown Aiza Khan's instagram account first and were told that she wasn't running this account herself. This generated some funny comments because they were surprised that a fan could get their hands on these personal photographs. One of the girls thought this was a smart move. All of them thought that Ayeza looked royal in Hoorain's birthday celebration pictures and they all thought she was very pretty. "She looks like a beautiful princess" was one of the responses. But what won everyone's heart was the fact that she had a baby too. The family pictures gave them the impression that she was family oriented, something which surely won the girls over. Everyone said they would definitely follow her to see what was going on in her life.
Mehwish Hayat's instagram was shown to this group next and the comments were very interesting. Some said she should have been a teacher and others thought she was real and had a nice energy Her name was interpreted as "May I wish" instead of Mehwish! Cute, gorgeous, cool, real, good actress (guessing from the video clip on the page) were some of the compliments she got. But when it came to the question whether they will follow her or not, one of the boys said "casual like" and the other one said unfollow. Only 2 girls said they will follow here, rest said there wasn't anything too interesting on her page.
Mahira got the wow she is so pretty reaction from everyone. All of these people were blown away by her looks. Sexy, hot, beautiful, edgy, stylish were the comments she got. The boys said she was a winner because her page was not all about selfies. Most of them said they won't just follow her but would directly message her because they liked her so much.
Sanam Baloch was another actress whose instagram page was shown to the group. The first reaction from the boys was "she also looks like a princess." They also said, she looked very intelligent. Everyone loved her outfits, the boys said she had tons of outfits and the girls said they wanted to go shopping her. the boys said they won't follow her because she wasn't glamorous enough. The girls said they would DM her for advice or follow her.
Mawra was the last actress on the list. First reaction was that she looked very young. one girl said she loved her outfits and she would follow her for outfits!The boys and girls wanted to follow her except for only one.
Shukria Pakistan Concert – Pictures
Drama Serial "Sanam" – BTS Pictures
Pakeeza Dar


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Hedge Funds Didn't Lose Confidence In New Residential Investment Corp (NRZ)
Published on June 16, 2020 at 9:39 am by Debasis Saha in Hedge Funds, News
We at Insider Monkey have gone over 821 13F filings that hedge funds and prominent investors are required to file by the SEC The 13F filings show the funds' and investors' portfolio positions as of March 31st, near the height of the coronavirus market crash. In this article, we look at what those funds think of New Residential Investment Corp (NYSE:NRZ) based on that data.
New Residential Investment Corp (NYSE:NRZ) shares haven't seen a lot of action during the first quarter. Overall, hedge fund sentiment was unchanged. The stock was in 23 hedge funds' portfolios at the end of March. The level and the change in hedge fund popularity aren't the only variables you need to analyze to decipher hedge funds' perspectives. A stock may witness a boost in popularity but it may still be less popular than similarly priced stocks. That's why at the end of this article we will examine companies such as Vishay Intertechnology (NYSE:VSH), Simmons First National Corporation (NASDAQ:SFNC), and Diodes Incorporated (NASDAQ:DIOD) to gather more data points. Our calculations also showed that NRZ isn't among the 30 most popular stocks among hedge funds (click for Q1 rankings and see the video for a quick look at the top 5 stocks).
At the moment there are several indicators stock market investors put to use to evaluate their holdings. Two of the most under-the-radar indicators are hedge fund and insider trading interest. Our experts have shown that, historically, those who follow the top picks of the best hedge fund managers can trounce the broader indices by a healthy amount (see the details here).
Steven Cohen of Point72 Asset Management
At Insider Monkey we leave no stone unturned when looking for the next great investment idea. For example, 2020's unprecedented market conditions provide us with the highest number of trading opportunities in a decade. So we are checking out trades like this one. We interview hedge fund managers and ask them about their best ideas. If you want to find out the best healthcare stock to buy right now, you can watch our latest hedge fund manager interview here. We read hedge fund investor letters and listen to stock pitches at hedge fund conferences. Our best call in 2020 was shorting the market when the S&P 500 was trading at 3150 after realizing the coronavirus pandemic's significance before most investors. Keeping this in mind we're going to take a look at the fresh hedge fund action surrounding New Residential Investment Corp (NYSE:NRZ).
How are hedge funds trading New Residential Investment Corp (NYSE:NRZ)?
Heading into the second quarter of 2020, a total of 23 of the hedge funds tracked by Insider Monkey were long this stock, a change of 0% from one quarter earlier. By comparison, 18 hedge funds held shares or bullish call options in NRZ a year ago. With the smart money's positions undergoing their usual ebb and flow, there exists an "upper tier" of noteworthy hedge fund managers who were increasing their holdings significantly (or already accumulated large positions).
Of the funds tracked by Insider Monkey, Steve Cohen's Point72 Asset Management has the number one position in New Residential Investment Corp (NYSE:NRZ), worth close to $4.8 million, amounting to less than 0.1%% of its total 13F portfolio. On Point72 Asset Management's heels is Millennium Management, led by Israel Englander, holding a $4.1 million position; the fund has less than 0.1%% of its 13F portfolio invested in the stock. Other hedge funds and institutional investors that hold long positions encompass Josh Donfeld and David Rogers's Castle Hook Partners, Peter Rathjens, Bruce Clarke and John Campbell's Arrowstreet Capital and David Harding's Winton Capital Management. In terms of the portfolio weights assigned to each position Swift Run Capital Management allocated the biggest weight to New Residential Investment Corp (NYSE:NRZ), around 0.58% of its 13F portfolio. Castle Hook Partners is also relatively very bullish on the stock, earmarking 0.36 percent of its 13F equity portfolio to NRZ.
Judging by the fact that New Residential Investment Corp (NYSE:NRZ) has faced a decline in interest from the entirety of the hedge funds we track, we can see that there is a sect of money managers that slashed their entire stakes by the end of the first quarter. Interestingly, Renaissance Technologies said goodbye to the biggest position of all the hedgies tracked by Insider Monkey, totaling an estimated $33.2 million in stock, and Ken Heebner's Capital Growth Management was right behind this move, as the fund said goodbye to about $29.8 million worth. These transactions are interesting, as total hedge fund interest stayed the same (this is a bearish signal in our experience).
Let's now take a look at hedge fund activity in other stocks – not necessarily in the same industry as New Residential Investment Corp (NYSE:NRZ) but similarly valued. These stocks are Vishay Intertechnology (NYSE:VSH), Simmons First National Corporation (NASDAQ:SFNC), Diodes Incorporated (NASDAQ:DIOD), and DouYu International Holdings Limited (NASDAQ:DOYU). All of these stocks' market caps resemble NRZ's market cap.
VSH 23 266555 3
SFNC 4 2712 -2
DIOD 13 49641 -5
DOYU 15 30200 9
Average 13.75 87277 1.25
As you can see these stocks had an average of 13.75 hedge funds with bullish positions and the average amount invested in these stocks was $87 million. That figure was $28 million in NRZ's case. Vishay Intertechnology (NYSE:VSH) is the most popular stock in this table. On the other hand Simmons First National Corporation (NASDAQ:SFNC) is the least popular one with only 4 bullish hedge fund positions. New Residential Investment Corp (NYSE:NRZ) is not the most popular stock in this group but hedge fund interest is still above average. Our calculations showed that top 10 most popular stocks among hedge funds returned 41.4% in 2019 and outperformed the S&P 500 ETF (SPY) by 10.1 percentage points. These stocks gained 13.9% in 2020 through June 10th but still beat the market by 14.2 percentage points. Hedge funds were also right about betting on NRZ as the stock returned 59.8% in Q2 (through June 10th) and outperformed the market. Hedge funds were rewarded for their relative bullishness.
Follow Rithm Capital Corp. (NYSE:RITM)
(NYSE:NRZ)Is NRZ A Good Investment Right Now?Is NRZ A Good Stock To Buy?Yahoo Finance
Hedge Fund and Insider Trading News: Steve Eisman, Carl Icahn, Voce Capital... Were Hedge Funds Right About Piling Into New Residential Investment Corp (NRZ...
Here's What Hedge Funds Think About New Residential Investment Corp (NRZ) Is New Residential Investment Corp (NRZ) A Good Stock To Buy ?
Is New Residential Investment Corp (NRZ) A Good Stock To Buy ? Hedge Funds Are Betting On New Residential Investment Corp (NRZ)


Signs showing the Catwalk in recent years..
Doesn't this look like somewhere back East?
As we were leaving we saw this beautiful peacock.
Oh I just love the baby, :) Thank you for sharing!
I just love the Catwalk and wish that I could go again soon.
I am glad that you are liking your new camera!
How beautiful! God was very creative when he made this earth! Love your blog!
Very nice pictures! How far is New Mexico from where you live?


TOLEDO, OHIO - The Durham Bulls earned a 6-5 victory over the Toledo Mud Hens Thursday night at Fifth Third Field, squaring the best-of-five Governors' Cup First Round series at one game apiece as the series shifts to Durham.
Micah Johnson sparked the Bulls, finishing the night 3-for-4 with three RBI and a run scored. The designated hitter gave Durham an early 1-0 lead with an RBI single in the second inning, and delivered the go-ahead blow with a two-run triple in the eighth inning, breaking a 3-3 tie. After his triple, Roberto Pena lifted a sacrifice fly to right, plating Johnson and giving the visitors a 6-3 lead.
In the bottom of the ninth the Mud Hens made it a 6-4 game and loaded the bases with nobody out. Hoby Milner then entered the game and induced a sacrifice fly as the score flipped to 6-5, before earning a double play to close the contest.
After Johnson's RBI knock in the second, Toledo scored a pair in the bottom of the frame for a 2-1 advantage. The Bulls struck back in the third on a sacrifice fly off the bat of Brandon Snyder, knotting the game at 2-2.
In the fourth the home side took the lead once more, as Will Castro launched a solo homer to right. Snyder countered in the fifth though, again lifting a sacrifice fly to score Joe McCarthy, and tie the game at three.
McCarthy, Kean Wong, Nate Lowe and Jason Coats all finished with two hits for the defending Triple-A champions, and Kyle Bird picked up the victory by tossing 1.2 scoreless frames out of the bullpen. Hunter Cervenka took the loss after surrendering one run in one inning of relief.
The series shifts to Durham for Games 3, 4 and 5 (if necessary), with Game 3 scheduled for 7:05 p.m. Friday at the DBAP. RHP Chih-Wei Hu (5-7, 4.66) is scheduled to start for the Bulls opposite RHP Spencer Turnbull (1-1, 2.03) for Toledo.


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« Integrating the effects of ocean acidification across functional scales on tropical coral reefs
Population-dependent effects of ocean acidification »
Current methods cannot predict damage to coral reefs
Published 12 April 2016 Press releases Closed
Ocean acidification poses a dynamic, hard-to-model threat.
The potentially devastating effects of ocean acidification on coral reefs are well reported. However, the methods used to evaluate the potential harm are often focused on individual species, viewed in isolation. According to an international research team led by Peter J. Edmunds of California State University, Northridge, this simplistic approach neglects broad-scale inter-species and inter-population dynamics that may have unforeseen consequences for ecosystems.
"Most studies address the effects of ocean acidification on single species of corals and calcified algae in tanks," write the team members in an article for the journal BioScience. This approach, they argue, will be inadequate for evaluating the emergent properties of acidification-afflicted reef ecosystems. Answering the wider question of whether reefs will grow or dissolve "requires a consideration of scaling effects."
Differences across scales—from organisms to populations, to communities and ecosystems—have "particularly strong implications for coral reefs," say the authors. At the narrow scale, species-specific responses to acidification are highly variable, a result of corals' varied protective tissue layers, differing skeletal solubilities, and numerous other factors. Such differences have far-reaching implications at broader scales. For instance, differently responding symbiotic genotypes (zooxanthellae) could have major effects on a reef's community structure—and, ultimately, on the health of the reef as a whole.
To address these neglected dynamics, the authors propose an approach that combines empirical evidence with traditional biological scaling models and computer simulations to achieve a broader understanding of acidification effects. Only by synthesizing theory and existing empirical practices, they say, will it be possible to ascertain "how the population-level impacts of ocean acidification sum to community- and ecosystem-level impacts."
Despite the promise of their work, the authors caution that "we should not expect a 'grand unifying theory' of the effects of ocean acidification on coral reefs to emerge." Rather, they report that the best hope for unraveling the complex web of ocean acidification effects lies in the deployment of a diverse "suite of complementary modeling approaches." Peter J. Edmunds will appear on the podcast BioScience Talks (bioscienceaibs.libsyn.com) on May 11, 2016.
BioScience, via EurekAlert, 11 April 2016. Press release.


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George Walker: Lilacs For Voice And Orchestra
Today we're excited to share with you a beautiful, Pulitzer Prize winning composition from classical composer George Walker, the first African-American recipient of the prize.
Song Of The Day: Cheer-Accident, "Salad Days"
Taken from the Skin Graft release, Salad Days: Remastered.
Song Of The Day: Grandaddy, "Miner At The Dial-A-View"
RIP Kevin Garcia.
Ryan Adams: Heartbreaker (Deluxe Edition) (Pax-Am)
In 2000, Whiskeytown frontman Ryan Adams's creative and personal life was in turmoil. So what did he do? He wrote songs-fantastic songs-and launched his career with this superb debut album, reissued with generous helpings of Adams in his prime.
3AM Eternal: Eric Matthews on "The Lonely Sea" (2000)
We have a little chat with Eric Matthews about his fantastic cover of this early Brian Wilson track.
Super Furry Animals Mwng (Domino)
Mwng was a creative rebellion against the failure of Welsh band Super Furry Animals' attempt at commercial success. Then something funny happened….
AIR: The Virgin Suicides (Rhino)
Fifteen years after its release, French duo AIR's superb score to Sofia Coppola's debut film The Virgin Suicides sees a welcome reissue. It hasn't aged a bit.
3AM Eternal: Coldplay "Trouble" (2000)
Love 'em or hate 'em, Coldplay once excelled at dark, introspective, moody ballads. Here's a fine one that we adore.
3AM Eternal: The Appleseed Cast Mare Vitalis (2000)
The Appleseed Cast's second album was the first of what would become a handful of masterpieces.
3AM Eternal: Imbroco Are You My Lionkiller? (2000)
If there were an "emo supergroup," it would have been Imbroco, featuring members from several notable bands, releasing only this sole EP.


GENEVA (9 August 2013) – The United Nations Special Rapporteur on the rights of indigenous peoples, James Anaya, today urged Governments worldwide to respect all agreements -new and old- with indigenous peoples to provide a basis for much needed reconciliation and overcome all obstacles to the full realization of indigenous peoples' rights.
"Indigenous peoples around the world face significant challenges that are related to widespread historical wrongs, including broken treaties and acts of oppression and misguided government policies, that today manifest themselves in disadvantages and impediments to the exercise of their individual and collective rights," the expert said on International Day of the World's Indigenous Peoples.
"Full respect for treaties, agreements and other constructive arrangements is a crucial element in advancing toward reconciliation with indigenous peoples," he underscored, "and in addressing persistent deep-rooted problems related to historical wrongs, failed policies of the past, and continuing barriers to the full realization of indigenous peoples' rights".
"Honouring treaties and other long-standing agreements can go far in helping to build trust among indigenous peoples and to rebuild relationships between States and indigenous peoples in a true spirit of good faith, partnership, and mutual respect," he noted.
With respect to new treaties and agreements being developed, including in relation to extractive industries operating in or near indigenous lands, the UN expert underscored that these should be consistent with international standards concerning the rights of indigenous peoples, both in relation to indigenous participation in these processes as well as in terms of substantive outcomes.
"In no instance should new treaties or agreements fall below or undermine the standards set forth in the Declaration on the Rights of Indigenous Peoples or established in other international sources," he said.
"Broken treaties must become a thing of the past," he stressed.