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Obama is the new Dubya
Barack Obama has more in common with his predecessor, George W. Bush, than he might want to acknowledge. Like Bush, Obama is convinced of the righteousness of his own judgment, and lets all of us know it.
While Republicans accuse Obama of everything from being crypto-Muslim to foreign-born to committing high crimes and misdemeanors, the reality is that Obama is running American foreign policy from a watered-down version of the Bush playbook. Drones, check; NSA surveillance, check; overreach, check.
If the rap on Bush 43 was that he wanted to be policeman to the world, Obama seems to have the same ambition—only to do it on the cheap. Bush failed at his "mission accomplished" while spending a lot of money; Obama is failing while spending less.
Yes, Obama presided over the withdrawal American forces from Iraq, and announced a timetable for their pullout from Afghanistan. Still, he seeks to project U.S. force around the globe, regardless of priority or magnitude of crisis, as if our military was a hybrid of cops and Hessians. No matter seems too small for Obama's attention, even if the upside for America is negligible or nonexistent.
Take the Middle East as an example. In Libya, he sought to lead from behind, only to see our embassy in Benghazi sacked by jihadists. In Syria he made chemical weapons a "red line," and then folded in the face of public outcry and congressional opposition. At no time did Obama lay out what America's vital interest might be in either hot spot. But it didn't end there.
More recently, Secretary of State John Kerry wasted his time and prestige in a futile shuttle between Jerusalem and Ramallah in another failed attempt to broker a peace between Israel and the Palestinians. Kerry's quest was as much rooted in reality as W's dream of grafting a secular democracy upon a religiously riven Iraq, or transforming the Arab world into something it isn't and may never be.
Iraq is in chaos as radical Sunnis march toward Baghdad, and American ships move into position to strike. Meanwhile, Syria has transformed itself from a dictatorship into a murderous cesspool, while Palestinians are kidnapping Israeli teenagers, and Israel's parliament, the Knesset, elected an opponent of the "two-state solution" as the country's president. In other words, it's the same Middle East, only worse.
To top it off, an American drone might kill a Sunni militant who was seeking to topple the Iranian-backed Shia-led Iraqi regime. But, if that same Sunni rebel turned westward to Syria he'd be—armed with American weapons—to take on Syria's Iranian-backed government.
Yet despite the region living up to its reputation, some things have changed here at home for the better. In 2013 the United States produced enough energy to satisfy 84 percent of its needs, a huge jump from its historic 2005 low, according to areport issued by the U.S. Energy Information Administration. Energy output rose 18 percent from 2005 to 2013, while our energy use dropped 2.7 percent. In other words, we are not as vulnerable to the whims of sheiks, mullahs, and deranged holy men as we once were.
More and more of our energy is saying "made in the USA." Shale gas and fracking have made the difference. In practical terms, that means fewer Americans need to die to secure our foreign energy pipelines, and like it or not, dependence on foreign oil has been a driver of our recent wars, especially since the downfall of the Soviet Union.
Yet the Obama administration has been doing its best to block this energy renaissance, in the name of "climate change." It's almost enough to make one think that it prefers the good old days, when American policymakers were preoccupied with the Middle East as an energy hub, thus justifying any number of military adventures—and misadventures.
Fortunately, the American public may be imposing needed restraints upon Washington, and the itch to pull on a trigger wherever and whenever trouble arises. According to CBS, more than three in five Americans opposed intervention in Syria. In recent Republican congressional primaries, the rank-and-file has voted "no" to reflexive interventionism. There's a reason John McCain never became president.
Read The Full Article On The Daily Beast
More articles from The Daily Beast:
- America's Anniversary Memory Porn…or How I Realized I Would Never Be Free of Kato Kaelin
- At the Supreme Court, the NRA Finally Loses One
- Teens Are Huge Buyers of Flavored E-Cigs, Studies Show
© 2013 Newsweek/Daily Beast Company LLC


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Standoff ends in fire and death
Investigators return to the scene in North Plains Thursday after a suspected gunman was killed and the house he was in was destroyed by fire.
It began Wednesdayaround 11:15 a.m., Washington County Sheriff's Deputies responded to an incident at 35053 NW Mountaindale Road in the community of North Plains, where someone was allegedly shot with a gun. Minutes later a deputy arrived and located James Crandall, 24, in a vehicle with a gunshot wound to his upper abdomen. The vehicle was parked across the street from where he was originally shot. The vehicle was driven by his mother, 49 year-old Pamela Crandall. The deputy was able to move the vehicle to a safe location to help Crandall into an ambulance and get him transported to a local hospital.
The initial information given to the deputies was that Brian Olson, 30, and Crandall had been in a dispute at the home that all three people shared. Brian Olson is a male companion of Pamela Crandall. At some point during the dispute, Olson shot Crandall with a high powered rifle and then retreated into his house. The house was contained by deputies who also closed down NW Mountaindale Road at the Dairy Creek Road intersection to keep traffic safe from any potential future assaults by Olson.
The Washington County Tactical Negotiations Team (TNT) and the Crisis Negotiations Unit (CNU) responded to attempt communication with Olson for a peaceful resolution. After all remote communication attempts failed, TNT moved into a position close to the house and loud hailed for Olson to exit the house and surrender. Olson continued to ignore all attempts of communication and stayed barricaded in the house.
After several dozen unsuccessful communication attempts, TNT deployed gas canisters into the house to prompt Olson to surrender. Shortly after the gas was deployed, deputies saw a fire develop inside the house. Fire personnel were unable to extinguish the fire due to the belief that Olson was inside armed with a rifle. It is not yet known if Olson or the gas deployment started the fire.
As the house filled with smoke, deputies heard what they believed to be a single gunshot from inside the house. There was a period of time until it was safe for fire personnel to extinguish the fire. Shortly after the fire was out, investigators discovered Olson deceased inside the house.
Washington County Violent Crimes Unit Detectives, Tualatin Valley Fire & Rescue investigators, and the Bureau of Alcohol, Tobacco, Firearms and Explosives are assisting with the investigation. It is expected to take at least two days to determine the cause of the fire and the cause of Olson's death.

subset: commoncrawl


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I ffffinally got myself an invite to ffffound! Hooray. For whatever reason it is next to impossible to get an invite to join the site.
Anyways, I was poking around the site and came across these great images used to promote ffffound's in-house t-shirts. What do you do when you can't get a decent looking model for your photoshoot? You force Paris Hilton and Kate Moss to model your gear by ripping up the photos and sticking them together! Brilliant.


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About Us
The National Council of Jewish Women is a progressive Jewish organization that has been at the forefront of social change for over a century — championing the needs of women, children, and families — while courageously taking a progressive stance on such issues as child welfare, women's rights, and reproductive freedom.
That pioneering spirit continues to this day. Informed by Jewish values — and our understanding that these values have universal appeal — the National Council of Jewish Women is nothing less than the voice of, the place where women from across society come together to make the world at large and their communities, in particular, a better place.
NCJW embraces women of diverse backgrounds and temperaments, thinkers and doers, who want to play a part at the local, national, and even global level.
Yet, all who come to NCJW share this: a belief that progressive ideals put into action can improve the world. NCJW is the most potent, most effective, most satisfying place where you can take that action and become a positive force for change.


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PHILADELPHIA – The biggest race of the season is upon the University of Pennsylvania cross country teams: the Heptagonal Championships. The field will consist of the top-ranked men's teams in the Mid-Atlantic and Northeast Regions as well as the second-place women's teams in those respective regions.
For the third year in a row, the Ancient Eight will gather on Saturday for the showdown at Princeton's West Windsor Field, with the men running at 11 a.m. followed by the women at noon.
A live blog of the races can be found by clicking here.
Live results can be found by clicking here.
Ranked ninth in the Mid-Atlantic Region by the USTFCCCA, the men from Penn will look to a number of young runners to help them improve from last year's seventh-place finish. Two of the Quakers' top two runners, sophomores Thomas Awad and Brendan Smith, competed at Heps last year, while freshmen Brendan Shearn and Nick Tuck will be making their first trip to race in the 8K. The Red and Blue will be contending with the 2012 champion and current No. 1 team in the Mid-Atlantic Region, Princeton, and the No. 1 team in the Northeast Region, Columbia.
Last year, the Penn women finished last among the Ancient Eight and will again compete in a strong field of runners. Ranked eighth in the region, the Quakers will also have fresh legs, freshman Cleo Whiting and sophomore Elyssa Gensib, leading the pack in the 6K. The Red and Blue looks to challenge Princeton and Dartmouth, who enter the meet ranked second in the Mid-Atlantic and Northeast Regions, respectively.


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sheeeeitt.... an o for $15?? yes plz!
sheeeeitt.... an o for $15?? yes plz!
wisconsin = cows
ontario= lots of cows but im too dumb to go and get shrooms
kentucky = Appalachian Mtns backwoods weed farms
i am. i said wisconsin = cows.
but then i stated kentucky = Appalachian Mtns backwoods weed farms
because its true
PS: Watch this when you're high. shit is ridiculous!
Last edited by Vagrant; 10-19-2008 at 11:47 PM.
loL, found my mate walking up the freeway this morning driving to uni, he's been disappeared since friday night, wtf is datura?
i hope cops choose me out of all the users on this site to investigate because i want them to know that i smoke weed alllllllll the time, among millions of other illegal things. so check my ip right now fellas because i am all about fucking with you dumbasses and if i got the chance i would punch every last one of you in the face.
joooooookes lol
thats the most pro-revolution thing i've ever heard.
abor; "...you know the dude...the dude on bombingscience with the xzibit signature?"


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Bookmark this site
MONTREAL -- AnywhereCommerce, a payments technology company, will supply mobile point-of-sale (mPOS) products for Spindle Inc.'s MeNetwork. Spindle is a mobile commerce solutions provider.
AnywhereCommerce has a patented magnetic-stripe card payment acceptance technology that turns smartphones and tablets into mobile payment terminals. MeNetwork customers will now have access to it.
The addition of AnywhereCommerce's audio-jack-connectable mPOS appliances allows merchants served by Scottsdale, AZ-based Spindle to transact business from anywhere on their smartphones or tablets.


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I want to:
More help
Change Your Router PasswordIt's very important that you change your router's password so you're not using the factory default. Since the default router password is well-known, your network is more vulnerable to hackers if you haven't changed it. You should create a strong password that is unique to your device and easy for your to remember.
Use the graphics below to select your network's router.


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I don't believe in predetermined paths or what have you, but I don't believe in free will, in a sense (I find free will a difficult word). Wouldn't free will require absolute knowledge? How can you chose an option that you have no knowledge of, and if you don't know ALL the options available at any given time can you then truly have free will?
As I said though, I have trouble with free will as a concept. I'm not sure I understand it.
I'm doomed to choose a pre-destined route; i'm not even a bus, I'm a tram.
'Go read a fucking book, you piece of shit.'
It doesn't even need to be an important issue... say you decide to have chicken and chips for food tonight - did you choose that out of free will or was it always the case that you would have made that choice because of the laws of the universe (or some omnipotent being). Could you have chosen something different?
http://www.ChrisReesAcademy.com - http://thetattooedchimp.blogspot.co.uk/
there are to many social constraints for there to be free will
Oh the humanistic approach is one of the five approachs is psychology. They believe that each person is an individual with unique beliefs, behaviours and thoughts. They also believe that humans have free will and they are the only approach that believe it. They dont think we should create general laws of behaviour because everyone is different. Maslows hierachy of needs was created with the humanistic approach and that has been used for lots of different things its been one of the more successful theories put forward by the humanistic approach. Personally i think the social learning theory speaks the most truth it is a eclectic approach even if it doesnt take into account the biological approach.
You're talking about influencing decision making processes rather than ruling out the ability to make decisions based on free will.
http://www.ChrisReesAcademy.com - http://thetattooedchimp.blogspot.co.uk/
i was thinking about this the other day (looking at the sea).
From birth we have been exposed to various experiences that shake how we will act and think in the future. We have biological template with the addition of experience and natural variance creates our character, personality and identity.
The world and our living spheres are full of people of the same schema. All acting on present decisions based on our past that will shape our future. With all the external stimuli and things that go on it creates a highly unpredictable world with huge variety. But is it deterministic or not?
If you look at the brain as a machine that takes the external, calculates with biological and ascertained knowledge from prior learned information. Then how can we have free will? Surely we are executing a pre-determined path of near-infinite actors in system.
Imagine an ocean with a rampant tide, surely the is mathematical potential to predict where the ocean will move if modeled to the appropriate level of granualisation (atomic, sub-atomic?) and take in all the factors wind, gravity eternal heat from all other systems etc.
We can do it in smaller controlled experiments. It's just the complexity of the systems and volume of data need to do this on a global level is beyond our capacity. However the concept is the same.
Our concept of consciousness give the impression that we are the driver, but could we be actually be the spectator? Obviously seeing, thinking and doing are different things, but what if these are just the different media of the experience?
This is highly dependent on the view of the human brain being an organic machine or processor. The only way you interpretate freewill into this view point is of another factor or force (e.g. spirituality?)


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Meet the Google Nexus 7 tablet, two days before Google unveils it at the I/O event on Wednesday. The 7in Tegra 3 toting slate leaked when Gizmodo Australia got a look at a Google training document. So what can we expect?
The Nexus 7, built by Asus, will come with the first example of Android Jelly Bean OS and it'll be supercharged by the quad-core Nvidia Tegra 3 processor running at 1.3GHz, a GeForce 12-core GPU, and 1 GB RAM. The multi-touch IPS display should look great running a 1280x800 resolution and lasting for a good 9 hours of use. It'll also be sporting NFC for Beam sharing and Google Wallet functions. The only camera mentioned is a 1.2MP front facing, presumably for video chats only.
The 8GB version will cost US$200 (£130) with a 16GB version available for US$250 (£160) – making it a big competitor for Amazon's Kindle Fire. Check back on Wednesday for full confirmation of the Nexus 7 tablet.
[Via Gizmodo]
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GSAs Loewentritt Appointed Deputy General Counsel
DATE: February 22, 2008
Contact: Steve Hoffman, (202) 219-1805
WASHINGTON — The U.S. General Services Administration today announced the appointment of Lennard Loewentritt as GSA Deputy General Counsel. Mr. Loewentritt's appointment is effective as of March 2, 2008. Mr. Loewentritt will also continue as Acting General Counsel.
"We're proud to announce this appointment," said GSA Administrator Lurita Doan. "Lenny's leadership skills and institutional knowledge have been invaluable to me and to all leaders at GSA. Under his guidance, I'm certain the Office of General Counsel will continue to provide timely and insightful advice that will help us achieve our mission of service for the American people."
Mr. Loewentritt has served in various capacities in the Office of General Counsel for more than 35 years. As Acting General Counsel, he has been responsible for providing all legal services to components of the agency including the Federal Acquisition Service, Public Buildings Service, and the Office of Governmentwide Policy.
"I am greatly honored to be appointed to the position of Deputy General Counsel and I look forward to providing support to the Administrator and to other GSA officials to accomplish GSA's mission," said Loewentritt.
Mr. Loewentritt began his career at GSA as a law clerk in 1972 and has served his entire career at the agency, providing legal service to all components of GSA. He holds a Bachelor of Arts degree in economics from the University of Wisconsin at Madison and a jurist doctorate from American University.
The Office of General Counsel provides all legal services to the agency and is responsible for legally sound implementation of GSA's mission responsibilities nationwide.
Founded in 1949, GSA serves as a centralized procurement and property management agency for the federal government. GSA manages more than one-fourth of the government's total procurement dollars and influences the management of $500 billion in federal assets, including 8,300 government-owned or leased buildings and 205,000 vehicles. GSA helps preserve our past and define our future, as a steward of more than 420 historic properties, and as manager of USA.gov, the official portal to federal government information and services. GSA's mission to provide superior workplaces, expert technology solutions, acquisition services, purchasing and E-Gov travel solutions and management policies, at best value, allows federal agencies to focus on their core missions.
Did you know? Roughly 12,000 GSA associates support over one million federal workers located in 8,300 government-owned and leased buildings nationwide.


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And that was when Taylor Hanson beat me in a chugging contest.
The tribute episode drew in 7.9 million viewers.TVLine Taylor Swift: I've yet to find my 'great love'.
Taylor is the author of a number of books about colonial America, the American Revolution, and the early American republic.
[Taylor] met his future wife in Burgos at supper one night, and that was it!
Hey, remember that time Kanye West interrupted Taylor Swift at the VMAs?
Oh, he is a poor boy who works around Miss Taylor's place—a distant cousin of hers, I believe.
Miss Morton entered the room just as Mrs. Taylor ceased speaking.
My honorable friend, the gentleman from South Carolina, (Mr. Taylor,) spoke of the crimes of these men.
In the evening went to hear a Mr. Taylor who had been a sailor.
Taylor apparently had given up all thoughts of resisting, and walked on by the detective's side without another word.


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An in-depth report on the causes, diagnosis, treatment, and prevention of cirrhosis.
Causes of Cirrhosis
Cirrhosis is a liver disease characterized by permanent scarring of the liver that interferes with its normal functions. Causes include:
- Alcoholism
- Chronic hepatitis B and C
- Autoimmune hepatitis
- Bile duct disorders such as primary biliary cirrhosis and primary sclerosing cholangitis
- Nonalcoholic fatty liver disease (NAFLD), which includesnonalcoholic steatohepatitis (NASH)
- Metabolic disorders such as hemachromatosis, Wilson's disease, and alpha-1 antitrypsin deficiency
- Excessive exposure to certain chemicals and medications
Cirrhosis can cause many serious complications including:
- Ascites (fluid buildup in the abdomen)
- Variceal hemorrhage, severe bleeding from varices (enlarged veins in the esophagus and upper stomach)
- Spontaneous bacterial peritonitis, a severe infection of the membrane lining of the abdomen
- Hepatic encephalopathy, impaired mental function caused by buildup in the body of toxins such as ammonia
- Hepatocellular carcinoma, a type of liver cancer
- Hepatorenal syndrome, when kidney failure occurs along with severe cirrhosis
Dietary and Lifestyle Changes
All patients with cirrhosis can benefit from certain lifestyle interventions. These include:
- Stop drinking alcohol.
- Restrict dietary salt.
- Follow a good diet plan, which may include protein restriction.
- Get vaccinations for influenza, hepatitis A and B, and pneumococcal pneumonia (if recommended by your doctor).
- Inform your doctor of all prescription and nonprescription medications, and any herbs and supplements, you take or are considering taking.
Cirrhosis is generally considered an irreversible condition. Treatment focuses on slowing the progression of liver damage and reducing the risk of further complications. Your doctor will treat any underlying medical conditions that are the cause of your cirrhosis. If liver damage progresses to liver failure, patients may be candidates for liver transplantation. Liver donations can come from either a cadaver or from a living donor. Patients with cirrhosis who have a liver transplant have very good chances for survival.
Cirrhosis is a chronic condition marked by scarring of the liver and poor liver function. It results from various disorders that damage liver cells over time. Eventually, damage becomes so extensive that the normal structure of the liver is distorted and its function is impaired.
Scarring. The main damage in cirrhosis is triggered by scarring (fibrosis) that occurs from injuries due to alcohol, viruses, or other assaults. The scar tissue and other changes in liver cells gradually replace healthy liver tissue and act like small dams to alter the flow of blood and bile in and out of the liver.
Altered Blood and Bile Flow. The changes in blood and bile flow have significant consequences, with both the liver and other organs responding to the altered flow:
- The small blood vessels and bile ducts in the liver narrow (constrict). Blood vessels in other organs, including the kidney, also narrow.
- Blood flow coming from the intestine into the liver is slowed by the narrow blood vessels. It backs up through the portal vein and seeks other routes.
- Enlarged, abnormally twisted and swollen veins called varices form in the stomach and lower part of the esophagus to transport the blood diverted from the liver.
- Bilirubin, a substance found in bile, also builds up in the bloodstream, resulting in jaundice, a yellowish discoloration of the skin and eyes, as well as dark-colored urine.
- Fluid buildup in the abdomen (called ascites), and swelling in the legs (edema)are common.
Functions of the Liver
The liver is the largest internal organ in the body. In the healthy adult, it weighs about 3 pounds. The liver is wedge-shaped, with the top part wider than the bottom. It is located right below the diaphragm and occupies the entire upper right quadrant of the abdomen.
The liver performs over 500 vital functions. Damage to the liver can impair these and many other processes. Among them are the following:
Processing Healthful Nutrients. The liver processes all of the nutrients the body requires, including proteins, glucose, vitamins, and fats.
Producing Proteins The liver is the body's "factory" where many important proteins are made. The blood protein albumin is one example that is often underproduced in patients with cirrhosis.
Producing Bile. The liver produces bile, a green-colored fluid that helps the body absorb fats and fat-soluble vitamins. Bile contains bilirubin, a yellow-brown pigment produced from the breakdown of hemoglobin, the oxygen-carrying component in red blood cells. Bile also contains bile salts, fatty acids, cholesterol, and other substances.
Bile travels from the liver to the gallbladder, where it is stored until after a meal. It is then secreted into the intestines where it helps digest fat. Because bile can also travel directly from the liver to the intestines, patients who have had their gallbladders removed can still absorb fat normally.
Eliminating Toxins. One of the liver's major functions is to render harmless potentially toxic substances, including alcohol, ammonia, drugs, and harmful by-products of digestion.
Structure of the Liver
The vital processes the liver performs rely on well-organized liver architecture.
The basic building blocks of the liver are the following structures:
- Bile ducts
- Blood vessels
- Working liver tissue (called the parenchyma)
- Supportive (connective) tissue
The liver is a built on a framework of lobes:
- Lobes. The liver is divided into two major lobes, a right and a smaller left, which are separated by tough, fibrous connective tissue.
- Lobules. The liver's two major lobes contain about 100,000 smaller lobes, called lobules. Each lobule contains microscopic columns of liver cells and blood vessels. Bracing the corners of each lobule column are an artery and a vein that carry blood and a bile duct that drains bile.
- Bile ducts. The bile ducts in the column corners collect bile draining from tiny canals around the liver cells. These ducts eventually join to form the large common bile duct that leads from the liver to the gallbladder.
- Arteries and veins. The arteries bring oxygen-rich blood to nourish the liver cells. The veins supply the liver cells with blood containing the nutrients and toxins that the liver cells process. A central vein runs through each column and collects the processed blood from both sources. These veins join to form the hepatic vein.
The Liver's Blood Supply. The liver is rich in blood. Its vessels contain about a pint, or 13% of the body's supply. It gets its blood from two large vessels, the hepatic artery and the portal vein, and is drained of blood by the hepatic vein. (The word "hepatic" derives from the Latin word for liver.)
The hepatic artery. This artery carries blood from the heart directly to the liver. This blood nourishes the liver.
The portal vein. The portal vein carries blood that has circulated through the stomach, spleen, and intestine to the liver. The liver processes this blood, extracting nutrients and toxins.
The hepatic vein. This vein carries blood away from the liver and connects to the inferior vena cava, a large vein that carries blood back to the heart.
Several processes can lead to cirrhosis.
Chronic alcoholism particularly endangers the liver by causing alcoholic liver disease (also called alcohol-induced liver disease). Alcoholic liver disease includes fatty liver (build-up of fat cells in the liver), alcoholic hepatitis (inflammation of the liver caused by heavy drinking), and alcoholic cirrhosis. Alcoholic cirrhosis is the primary type of cirrhosis in the U.S. It develops in 10 - 20% of heavy drinkers, usually after 10 - 15 years of heavy alcohol consumption. People who drink heavily and who also have hepatitis C are at particular risk of developing cirrhosis. In the liver, alcohol converts to toxic chemicals that trigger inflammation and tissue injury, which lead to cirrhosis.
Chronic Viral Hepatitis
Chronic viral hepatitis, both hepatitis B and hepatitis C, is anothermajor cause of cirrhosis. Chronic hepatitis C is a more common cause of cirrhosis in developed countries, while hepatitis B is a more common cause of cirrhosis worldwide, especially in sub-Saharan Africa and parts of Asia. People with chronic hepatitis B who are co-infected with hepatitis D are especially at risk for cirrhosis. The longer a patient has had chronic hepatitis, the greater the risk for eventually developing cirrhosis.
Hepatitis viruses can produce inflammation in liver cells, causing injury or destruction. If the condition is severe enough, the cell damage becomes progressive, leading to scar tissue in the liver. In advanced cases, the liver shrivels in size, a condition called postnecrotic or posthepatic cirrhosis.
Autoimmune Hepatitis
Autoimmune hepatitis, like other autoimmune disorders, develops when a misdirected immune system attacks the body's own cells and organs. People who have autoimmune hepatitis also often have other autoimmune conditions, including systemic lupus erythematosus, rheumatoid arthritis, Sjögren syndrome, scleroderma, inflammatory bowel disease, glomerulonephritis, and hemolytic anemia. Autoimmune hepatitis typically occurs in women ages 15 - 40.
Bile Ducts Disorders
Disorders that block or damage the bile ducts can cause bile to back up in the liver, leading to inflammation and cirrhosis. These diseases include primary biliary cirrhosis and primary sclerosing chlorangitis.
Primary Biliary Cirrhosis. Up to 95% of primary biliary cirrhosis (PBC) cases occur in women, usually around age 50. In people with PBC, the immune system attacks and destroys cells in the liver's bile ducts. Like many autoimmune disorders, the causes of PBC are unknown.
Primary Sclerosing Cholangitis. Primary sclerosing cholangitis (PSC) is a chronic disease that mostly affects men, usually around age 40. The cause is unknown, but immune system defects, genetics, and infections may play a role.
Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH)
Nonalcoholic fatty liver disease (NAFLD) resembles alcoholic liver disease, but it occurs in people who do not drink a lot of alcohol. NAFLD is the most common liver disease in the United States.
NAFLD is actually a progressive spectrum of liver diseases that include:
- Nonalcoholic fatty liver (NAFL), or fatty liver, is the earliest stage of NAFLD. It is marked by the presence of fat in the liver (steatosis), but liver damage has not occurred. While a fatty liver is not normal, NAFL is not considered a serious condition.
- Nonalcoholic steatohepatitis (NASH) is the next stage of NAFLD. NASH is characterized by liver inflammation and injury, as well as a fatty liver. NASH is dangerous because it can lead to the scarring of the liver associated with cirrhosis. NASH is one of the leading causes of cirrhosis.
- Cirrhosis is the final irreversible stage of NAFLD.
Obesity and type 2 diabetes are the two main causes of NAFLD. Metabolic syndrome is another major factor. Metabolic syndrome is a collection of risk factors that include abdominal obesity, unhealthy blood lipid levels, high blood pressure, and insulin resistance.
Nonalcoholic fatty liver disease is usually benign and very slowly progressive. But, in certain patients, it can lead to cirrhosis and eventual liver failure. NAFLD also increases the risk for heart disease, which is the leading cause of death for these patients.
Hereditary Disorders
Hemochromatosis. Hemochromatosis is a disorder of iron metabolism. This disease interferes with the way the body normally handles iron. People with hemochromatosis absorb too much iron from the food they eat. The iron overload accumulates in organs in the body. When excess iron deposits accumulate in the liver, they can cause cirrhosis.
Other Hereditary Disorders. Other inherited diseases that can cause cirrhosis include Wilson's disease (which causes an accumulation of copper in the body), alpha-1 antitrypsin deficiency (a genetic disorder caused by defective production of a particular enzyme), and glycogen storage diseases (a group of disorders that cause abnormal amounts of glycogen to be stored in the liver).
Other Causes
Other causes of cirrhosis include:
- Schistosomiasis, a disease caused by a parasite found in the Asia, Africa, and South America.
- Long-term or high-level exposure to certain chemicals and drugs, including arsenic, methotrexate, toxic doses of vitamin A, and certain prescription medications.
Cirrhosis is divided into two stages: Compensated and decompensated.
- Compensated cirrhosis means that the body still functions fairly well despite scarring of the liver. Many people with compensated cirrhosis experience few or no symptoms.
- Decompensated cirrhosis means that the severe scarring of the liver has damaged and disrupted essential body functions. Patients with decompensated cirrhosis develop many serious and life-threatening symptoms and complications.
Early stages of compensated cirrhosis may cause few or no symptoms. When symptoms do begin, they may include:
- Fatigue and loss of energy
- Loss of appetite and weight loss
- Nausea or abdominal pain
- Spider angiomas may develop on the skin. These are pinhead-sized red spots from which tiny blood vessels radiate.
As cirrhosis progresses to a decompensated stage, patients may develop the following symptoms:
- Fluid buildup in the legs and feet (edema) and in the abdomen (ascites). (Ascites is associated with portal hypertension, which is described in the Complications section of this report.)
- Jaundice. This yellowishdiscoloration ofthe skin and eyes occurs because the liver cannot process bilirubin for elimination from the body.
- Itching. Itching (pruritus) develops from buildup of bile products.
- The palms of the hands may be reddish and blotchy, a condition known as palmar erythema
- In men, swelling of breasts or shrinkage of the testicles may occur.
- Easy bruising and excessive bleeding may occur.
A damaged liver affects almost every bodily process, including the functions of the digestive, hormonal, and circulatory systems. Decompensated cirrhosis increases the risk of serious and potentially life-threatening complications. Once decompensation occurs, mortality rates without liver transplantation can be as high as 85% within 5 years.
The most serious complications of cirrhosis are those associated with portal hypertension (increased pressure in the portal vein that carries blood from the intestine to the liver). They include:
- Ascites (fluid buildup in the abdomen)
- Variceal hemorrhage (bleeding in the upper stomach and esophagus from ruptured blood vessels)
- Spontaneous bacterial peritonitis, a form of peritonitis (inflammation of the membrane that lines the abdomen), which is associated with ascites. Other bacterial infections are also a common complication of cirrhosis.
- Hepatic encephalopathy (brain dysfunction). Impaired brain function occurs when the liver cannot detoxify harmful substances, and can lead to coma.
Liver cancer is a serious long-term risk with cirrhosis. Other complications also occur.
Ascites is fluid buildup in the abdominal cavity. It is uncomfortable and can impair breathing and other functions. Ascites is caused by a combination of portal hypertension (high pressure in the blood vessels of the liver) and low albumin levels. Albumin is a protein produced by the liver. Although ascites itself is not fatal, it is a marker for severe progression.
Hepatorenal syndrome occurs if the kidneys drastically reduce their own blood flow in response to the altered blood flow in the liver. It is a life-threatening complication of late-stage liver disease that occurs in patients with ascites. Symptoms include dark colored urine and a reduction in volume, yellowish skin, abdominal swelling, mental changes (such as delirium and confusion), jerking or coarse muscle movement, nausea, and vomiting.
Variceal Bleeding
One of the most serious consequences of portal hypertension is the development of varices, veins that enlarge to provide an alternative pathway for blood diverted from the liver. In most patients, they form in the esophagus. They can also form in the upper stomach. Varices pose a high risk for rupture and bleeding because they are thin-walled, twisted, and subject to high pressure. Variceal intestinal bleeding is a life-threatening event. Symptoms include vomiting blood or black and tarry stools.
Spontaneous Bacterial Peritonitis
Spontaneous bacterial peritonitis is a life-threatening bacterial infection of the membrane that lines the abdomen. The main symptoms include confusion and altered mental status, fever, chills, and abdominal pain. Certain medications, such as proton pump inhibitors (used for treating acid reflux and gastroesophageal reflux disease), can increase the risk for spontaneous bacterial peritonitis in patients with cirrhosis.
Hepatic Encephalopathy
Mental impairment is a common complicationof advanced cirrhosis. In severe cases, the disease causes encephalopathy (impaired brain function), with mental symptoms that range from confusion to coma and death. Hepatic encephalopathy is caused by a buildup in the blood of harmful intestinal toxins, particularly ammonia, which then accumulate in the brain. Encephalopathy can be triggered by many different conditions including internal bleeding, infection, constipation, and dehydration. Certain medications such as opoids, sedatives, and some anti-anxiety drugs may increase the risk for hepatic encephalopathy.
Early symptoms of hepatic encephalopathy include confusion, forgetfulness, and trouble concentrating. Sudden changes in the patient's mental state, including agitation or confusion, may indicate an emergency condition. Other symptoms include fruity-smelling bad breath and tremor. Late-stage symptoms of encephalopathy are stupor and eventually coma.
Liver Cancer
People with cirrhosis have an increased risk for hepatocellular carcinoma, a type of liver cancer. Hepatitis B and C, alcoholism, hemochromatosis, and primary biliary cirrhosis -- all causes of cirrhosis -- are some of the major risk factors for liver cancer. Cirrhosis due to hepatitis C is the leading cause of hepatocellular carcinoma in the United States.
Other Complications
Kidney Failure. Portal hypertension and spontaneous bacterial peritonitis can cause several secondary complications, including kidney failure. Nonsteroidal anti-inflammatory drugs (NSAIDs) -- such as ibuprofen (Advil, Motrin, generic), naproxen (Aleve, generic), and aspirin -- can also cause kidney failure in patients with cirrhosis.
Osteoporosis. Many patients with cirrhosis develop osteoporosis, a bone-thinning disease.
Insulin Resistance and Type 2 Diabetes. Cirrhosis often causes insulin resistance, a primary feature in type 2 diabetes. As insulin resistance progresses, it causes excess sugar (glucose) to build up in the blood, which leads to type 2 diabetes. In turn, type 2 diabetes is also a risk factor for nonalcoholic fatty liver disease, one of the causes of cirrhosis.
Heart Problems. Cirrhosis may increase the risk for heart failure and other cardiovascular complications.
A doctor diagnoses cirrhosis based on results from a patient's physical exam, medical history, blood tests, and imaging tests. A liver biopsy is the definitive test for confirming a diagnosis of cirrhosis.
A physical examination may reveal the following in a patient with cirrhosis:
- The cirrhotic liver is firm and often enlarged in early stages of the disease. The liver may feel rock-hard. (In advanced stages of cirrhosis, the liver may become small and shriveled.)
- If the abdomen is swollen, the doctor will check for ascites by tapping the flanks and listening for a dull thud and feeling the abdomen for a shifting wave of fluid.
- The doctor will also check for signs of jaundice, muscle wasting, and (in male patients) breast enlargement.
A patient's medical history is another indicator of the risk for cirrhosis. Patients with a history of alcoholism, hepatitis B or C, or certain other medical conditions are at high risk.
Other tests (blood tests, imaging tests, liver biopsy) may also be performed. The results of these tests along with the presence of specific complications (ascites and encephalopathy) are used for calculating the Child-Pugh Classification. This is a staging system (A to C) that helps doctors determine the severity of cirrhosis and predict the development of future complications.
Blood Tests
A patient's medical history can reveal risk factors (such as alcoholism) that warrant screening for conditions such as hepatitis. Blood tests are also performed to measure liver enzymes associated with liver function. Enzymes known as aminotransferases, including aspartate (AST) and alanine (ALT), are released when the liver is damaged. Blood tests may also measure:
- Serum albumin concentration. Serum albumin measures the protein in the blood (low levels indicate poor liver function).
- Prothrombin time (PT). The PT test measures in seconds the time it takes for blood clots to form (the longer it takes the greater the risk for bleeding).
- Alkaline phosphatase (ALP). High ALP levels can indicate bile duct blockage.
- Bilirubin. One of the most important factors indicative of liver damage is bilirubin, a red-yellow pigment that is normally metabolized in the liver and then excreted in the bile. In patients with hepatitis, the liver cannot process bilirubin, and blood levels of this substance rise, sometimes causing jaundice.
Imaging Tests
Magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound are all imaging techniques that are useful in detecting and defining the complications of cirrhosis, such as ascites and hepatocellular carcinoma. These imaging tests can also provide information on the extent of liver damage.
Liver Biopsy
A liver biopsy is the only definite method for confirming a diagnosis of cirrhosis. It also helps determine its cause, treatment possibilities, the extent of damage, and the long-term outlook. For example, patients with chronic hepatitis C who show no significant liver scarring when biopsied may have a low risk for cirrhosis.
A biopsy involves a doctor inserting a thin biopsy needle, guided by ultrasound, to remove a small sample of liver tissue. Local anesthetic is used to numb the area. Patients may feel pressure and some dull pain. The procedure takes about 20 minutes to perform.
The biopsy may be performed using various approaches, including:
- Percutaneous Liver Biopsy. This approach uses a needle inserted through the skin over the liver area to obtain a tissue sample from the liver. Various forms of needles are used, including those that use suction or those that cut out the tissue.
- Transjugular Liver Biopsy. This approach uses a catheter (a thin tube) that is inserted in the jugular vein in the neck and threaded through the hepatic vein (which leads to the liver). A needle is passed through the tube, and a suction device collects liver samples.
- Laparoscopy. This procedure requires a small abdominal incision through which the doctor inserts a thin tube that contains small surgical instruments and a tiny camera to view the surface of the liver.
Other Tests Used to Detect Complications of Cirrhosis
Endoscopy. Endoscopy may be used for patients newly diagnosed with mild-to-moderate cirrhosis in order to screen for esophageal varices. (These are enlarged veins in the esophagus that increase the risk for bleeding). In this test, a fiber-optic tube is inserted down the throat. The tube contains tiny cameras to view the inside of the esophagus, where varices are most likely to develop.
Paracentesis. If ascites is present, paracentesis is performed to determine its cause. This procedure involves using a thin needle to withdraw fluid from the abdomen. The fluid is tested for different factors to determine the cause of ascites:
- Bacteria cultures and white blood cell counts. (These are used to diagnose infection.)
- Protein levels. Low levels of protein in the fluid plus a low white blood cell count suggest that cirrhosis is the cause of the ascites.
Tests for Liver Cancer. Some doctors recommend screening patients with cirrhosis every 6 months to check for the development of liver cancer (hepatocellular carcinoma). To do this, a doctor will use both a blood test to check for levels of alpha-fetoprotein and an imaging test (ultrasound, MRI, or CT scan).
Cirrhosis is generally considered an irreversible condition. Treatment goals are to slow the progression of liver damage and reduce the risk of further complications. There are currently no drugs available to treat liver scarring, although researchers are investigating various anti-fibrotic drugs.
Dietary and Lifestyle Changes
All patients with cirrhosis can benefit from certain types of lifestyle interventions. These include:
- Stop drinking alcohol. It is very important for people with cirrhosis to completely abstain from alcohol.
- Restrict dietary salt. Sodium (salt) can increase fluid buildup in the body. Eating a variety of foods every day can help you limit the amount of salt you are getting. It is best to eat fresh vegetables and fruits whenever possible and to avoid eating processed foods.
- Eat a healthy diet. People with cirrhosis areusually malnourished and require increased calories and nutrients. (Excess protein, however, can trigger hepatic encephalopathy.) They also need to avoid certain foods, such as raw seafood or shellfish, which carry risks of blood poisoning (septicemia). A dietician can provide dietary guidelines.
- Get vaccinated. Patients with cirrhosis should ask their doctors which vaccinations (such as hepatitis A, hepatitis B, influenza, pneumococcal pneumonia) they need.
- Discuss all medications with your doctor. ·Before you take any medications, (including nonprescription pain relievers such as acetaminophen), ask your doctor if they are safe for you. Liver damage affects the metabolism of drugs. Opoids, sedatives, anti-anxiety drugs, and proton pump inhibitors can trigger serious complications in patients with cirrhosis. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen should not be used by patients with cirrhosis as they can trigger bleeding, worsen the condition, and potentially cause kidney failure. In recommended doses, acetaminophen (Tylenol, generic) is a safer choice for pain management.
- Inform your doctor of any herbs or supplements you are considering taking. Certain types of herbal remedies (kava, chaparral, kombucha mushroom, mistletoe, pennyroyal, and some traditional Chinese herbs) can increase the risk for liver damage. Although some herbs, such as milk thistle (silymarin) have been studied for possible beneficial effects on liver disease, there is no scientific evidence that they can help.
Recognizing Signs of Dangerous Complications
Patients with cirrhosis are susceptible to infections and bleeding, both of which can be life threatening. Contact your doctor's office or go to the emergency room if you experience any of the following symptoms:
- Fever (temperature greater than 101 °F)
- Confusion that is new or suddenly becomes worse
- Vomiting more than once a day
- Rectal bleeding, black, tarry stools, vomiting blood or dark "coffee ground" material, or blood in the urine
- Diarrhea
- Abdominal or chest pain
- Shortness of breath
- Abdominal swelling or ascites that is new or suddenly becomes worse
- Jaundice (yellowing skin or eyes) that is new or suddenly becomes worse
Treatment of Underlying Conditions
Treatment for cirrhosis depends on the cause of cirrhosis. In some cases, treatment of an underlying condition may help reverse early-stage cirrhosis.
Chronic Hepatitis. Many types of antiviral drugs are used to treat chronic hepatitis B, including pegylated interferon, entecavir, and tenofovir. Treatment for chronic hepatitis C depends on the genotype. Patients with genotype 1 hepatitis C may receive triple combination therapy with pegylated interferon, ribavirin, and a protease inhibitor drug such as telaprevir or boceprevir. In 2013, the FDA approved simeprevir and sofosbuvir, two new oral treatments for hepatitis C. Successful treatment of hepatitis can sometimes lead to regression of cirrhosis.
Autoimmune Hepatitis. Autoimmune hepatitis is treated with the corticosteroid prednisone and also sometimes immunosuppressants, such as azathioprine (Imuran).
Bile Duct Disorders. Ursodeoxycholic acid (Actigall, generic), also known as ursodiol or UDCA, is used for treating primary biliary cirrhosis but does not slow the progression. Itching is usually controlled with cholesterol drugs such as cholestyramine (Questran, generic) and colestipol (Colestid). Antibiotics for infections in the bile ducts and drugs that quiet the immune system (prednisone, azathioprine, cyclosporine, methotrexate) may also be used. Several surgical procedures may also be tried to open up the bile ducts.
Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH). Weight reduction through diet and exercise, and diabetes and cholesterol management are the primary approaches to treating these diseases.
Hemochromatosis. Hemachromatosis is treated with phlebotomy, a procedure that involves removing about a pint of blood once or twice a week until iron levels are normal.
Treatment of Complications
Treatment of Ascites
First-line treatment of patients with ascites (fluid accumulation in the abdomen) involves:
- Dietary salt restriction (generally less than 1,500 mg/day of sodium).
- Drug treatment with diuretics, usually spironolactone (Aldactone, generic) and furosemide (Lasix, generic).
- Complete abstention from alcohol.
- Discontinuing all nonsteroidal anti-inflammatory drugs (NSAIDs). Other drugs that may be harmful for patients with ascites are certain blood pressure medications, includingACE inhibitors and angiotensin receptor blockers (ARBs).
- Fluid restriction is usually not necessary unless sodium levels in the blood are low.
- Liver transplantation may be considered.
Treatment for Recurring or Refractory Ascites. Patients with ascites that does not respond to standard diuretics after a month (refractory ascites) may be treated with the drug midodrine (Orvaten, generic) to reduce ascetic fluid. If they do not respond to this drug treatment, they may require other procedures to reduce fluid:
- Large-volume paracentesis, (which involves using a thin needle to withdraw fluid from the abdomen), may be used for ascites refractory to medical treatment or when complications are present.
- Transjugular intrahepatic portosystemic shunt (TIPS) uses a stent placed in veins in the middle of the liver to keep open a passage connecting the hepatic and portal veins. This helps reroute blood around the scarred liver. In the procedure, a long needle is inserted into the jugular vein in the neck and passed down to the hepatic and portal veins. Alternatively, a peritoneovenous shunt may be used.
•Liver transplantation.
Treatment of Spontaneous Bacterial Peritonitis
Patients with ascites who have high white blood cell counts should receive intravenous antibiotic therapy (usually cefotaxime) or oral antibiotic therapy with ofloxacin. Patients who have had an episode of spontaneous bacterial peritonitis are treated with long-term antibiotic therapy of norfloxacin (Noroxin) or trimethoprim/sulfamethoxazole (Bactrim, Septra, generic) to prevent further infection but doctors must also consider the risk for drug resistance.
Treatment of Hepatorenal Syndrome
Hepatorenal syndrome can occur in patients with ascites. This is a life-threatening condition in which kidney failure develops because of altered blood flow in the liver. Patients with hepatorenal syndrome are usually treated with intravenous infusion of albumin or with the drug pentoxifylline. Studies suggest that the vasoconstrictor drug terlipressin, given in combination with albumin, may be helpful for treating hepatorenal syndrome.
Treatment of Hepatic Encephalopathy
The first step in managing encephalopathy (damage to the brain) is to treat any precipitating cause, such as:
- High ammonia levels
- Bleeding
- Low oxygen
- Dehydration
- Infection
- Use of sedatives
Protein-restricted diets used to be recommended to lower ammonia production. However, extremeprotein restriction can cause malnutrition and be harmful. Guidelines now recommend that patients receive adequate protein intake and have small meals throughout the day including a late-night snack of complex carbohydrate.
Diets rich in vegetables and fiber are also important. Patients who are critically ill may need intravenous or tube feedings. The laxative lactulose, given as a syrup or enema, is used to empty the bowels and to help improve mental status. The antibiotic neomycin may be added for patients who do not improve with lactulose alone. Rifaximin (Xifaxan) is another antibiotic used for treatment of hepatic encephalopathy. Sedatives and medications containing ammonium (such as certain antacids) should be avoided.
Treatment of Variceal Bleeding
Primary Prevention. Primary prevention means treating the varices (swollen or distended veins) before they have bled. Varices that are present in the esophagus, stomach, or intestines are always at risk of bleeding. Nonselective beta-blockers drugs, which are commonly used to treat high blood pressure, may be given to prevent bleeding. Propanolol (Inderal, generic) or nadolol (Corgard, generic) are the standard beta-blockers used for variceal prevention.
Patients with medium-to-large varices that have not bled may also be treated with a surgical procedure called endoscopic variceal ligation (EVL). EVL is also called band ligation. It involves inserting an endoscope or tube down through the esophagus. The equipment contains microcameras and tiny instruments. Latex bands are wrapped around the bleeding varices to shut off the blood supply.
Treatment. When varices located in the digestive tract begin to bleed (variceal hemorrhage), it is considered an emergency situation. The first step is to immediately achieve normal blood clotting (hemostasis) in order to stop the current bleeding episode. Patients almost always need blood transfusions.
The primary treatment for variceal hemorrhage is drug therapy with a drug that tightens blood vessels (vasoconstrictor) such as ocreotide (Sandostatin, generic). Medical procedures to stop bleeding include endoscopic variceal ligation (described above). An alternative procedure is endoscopic sclerotherapy. In endoscopic sclerotherapy, the endoscopic tube is inserted through the mouth and a sclerosant (a solution that toughens the tissue around the variceal blood vessels) is injected to stop the bleeding.
If these treatments do not control the bleeding, or bleeding recurs, a transjugular intrahepatic portosystemic shunt (TIPS) procedure is performed. (For more information on TIPS, see "Treatment of Ascites" above.) TIPS is not useful as the first choice for stopping an initial bleeding episode or for preventing rebleeding since it poses a high risk for encephalopathy.
Another procedure, called balloon tamponade, may be used to temporarily control bleeding prior to the TIPS procedure. Balloon tamponade is performed only for bleeding that cannot be controlled by drugs or endoscopy. It involves inserting a tube through the nose and down through the esophagus until it reaches the upper part of the stomach. A balloon at the tube's end is inflated and positioned tightly against the esophageal wall. It is usually deflated in about 24 hours. Balloon tamponade poses a risk for serious complications, the most dangerous being rupture of the esophagus.
Secondary Prevention. Patients who survive an episode of variceal bleeding need to be treated with drugs to prevent bleeding recurrence. Patients are prescribed either a combination of a nitrate drug (such as isosorbide, which is used to treat angina) and a nonselective beta-blocker (propanolol or nadolol) or a beta-blocker alone. Patients may also be given several sessions of endoscopic variceal ligation over the course of several months. The TIPS procedure may be recommended for patients who experience recurrent bleeding despite drug and endoscopic therapy. Liver transplantation may also be an option.
Treatment of Septic Shock
Patients hospitalized for cirrhosis are at high risk for septic shock. Septic shock is a life-threatening condition that occurs when severe bacterial infection causes extreme low blood pressure. It is very important that patients with cirrhosis and septic shock receive immediate and appropriate antibiotic treatment. A combination of broad-spectrum antibiotics is recommended.
Liver Transplantation
When cirrhosis progresses to end-stage liver disease, patients may be candidates for liver transplantation. Patients with liver cancer that has not spread beyond the liver are also candidates for transplant.
Current 5-year survival rates after liver transplantation are about 75%. Patients report improved quality of life and mental functioning after liver transplantation. Patients should seek medical centers that perform more than 50 transplants per year and produce better-than-average results.
A scoring system called Model for End-Stage Liver Disease (MELD) is used to determine which patients are most in need of a donor liver. A MELD score predicts 3-month survival based on laboratory tests of creatinine, bilirubin, and blood-clotting time. Priority is given to patients who are most likely to die without a liver transplant.
Unfortunately, there are many more patients waiting for liver transplants than there are available organs. Patients may also want to consider living-donor liver transplantation. In living-donor transplantation, surgeons replace the patient's diseased liver with a part of the liver taken from a donor. The donor's liver regenerates to full size within a few weeks of surgery, and the recipient's liver also regrows. This procedure produces excellent results for patients, but there are some risks for the donor.
Transplantation surgery generally takes 4 - 12 hours to perform, and patients stay in the hospital for up to 3 weeks after the surgery. Most patients return to normal or near-normal activities 6 - 12 months following the transplant. For the rest of their lives, patients need to take immunosuppressive medication to prevent rejection.
Liver Transplantation in Patients with Viral Hepatitis. One of the primary problems with performing liver transplantation in patients with hepatitis is recurrence of the virus after transplantation. Recurrence typically occurs with hepatitis C. Viral recurrence can also occur with hepatitis B. HepaGam B is an immune globulin preparation approved to prevent recurrence of hepatitis B after transplantation. Patients need to receive periodic HepaGam B injections on a lifelong basis.
Liver Transplantation for Patients with Primary Biliary Cirrhosis. Patients who require transplantation for primary biliary cirrhosis are those who develop major complications of portal hypertension and liver failure or who have poor quality of life and short survival without the procedure. Survival rates after transplantation are excellent.
Liver Transplantation for Patients with Autoimmune Hepatitis. The outlook is also good for patients who have autoimmune hepatitis who require a transplant. Survival rates are about 90% after 1 year, and 70 - 80% after 5 years. Rejection usually occurs in those patients whose immune systems are very compromised.
Liver Transplantation for Patients with Alcoholism. Liver transplantation is generally not recommended for patients with active alcohol or drug abuse addictions.
- www2.niddk.nih.gov -- National Institute of Diabetes and Digestive and Kidney Diseases
- www.aasld.org -- American Association for the Study of Liver Diseases
- www.liverfoundation.org -- American Liver Foundation
- www.gastro.org -- American Gastrointestinal Association
- www.unos.org -- United Network for Organ Sharing
- www.organdonor.gov -- US government organ donor site
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Brown RS Jr. Live donors in liver transplantation. Gastroenterology. 2008 May;134(6):1802-13.
Cárdenas A, Ginès P. Management of patients with cirrhosis awaiting liver transplantation. Gut. 2011 Mar;60(3):412-21. Epub 2010 Dec 30.
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Chapman R, Fevery J, Kalloo A, Nagorney DM, Boberg KM, Shneider B, et al. Diagnosis and management of primary sclerosing cholangitis. Hepatology. 2010 Feb;51(2):660-78.
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Review Date: 12/23/2013�
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.


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Scarlett Johansson Talks 'Lucky You' Horseshoe Tattoo with Letterman
Hot on the promotional trail, Scarlett Johansson was one of the guests on last night's (November 21) episode of "Late Show with David Letterman."
The "In Good Company" actress looked gorgeous as she chatted with the show's host about her upcoming movie "Hitchcock" and her new 'Lucky You' horseshoe tattoo during the pre-taped interview.
Scarlett began, "I have another one. It's on my ribcage. It's not a tattoo that I expected everybody to see, obviously. Listen, Dave, that was a personal photograph and the very lovely tattoo artist who did the work- bless his sweet old heart- he decided to share it with a few people and now you have it on your desk."
When Letterman questioned her as to why she was feeling embarrassed, Johansson exclaimed, "That wasn't meant for everybody, just the lucky ones!"


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The New York Daily News reported Tuesday that general manager John Idzik, coach Rex Ryan and owner Woody Johnson"avoided" communication with Revis's camp over the last week despite the sides being "separated by three tenths of a mile" in Indianapolis while the NFL Scouting Combine commenced.
The Combine is a popular meeting spot for teams and agents, as it has everyone in one place just a few weeks before free agency. Revis is set to hit free agency at the end of the 2013 season, and if the Jets don't extend him before then, he'll hit the open market and go to the highest bidder.
Ryan refuted reports that the Jets were shopping Revis as of last week, though Gang Green might be just as well served getting something for him now, if the return is reasonable, since they won't be able to afford him in a year.


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Sony Announces PS4, Loves on Developers, Unveils Mobile Vita PS4 Gaming
Jason Mick
February 20, 2013 7:01 PM
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Console packs an x86 GPU, 8 GB of DDR3, a powerful GPU, and a custom processor for background processing
Sony Group President Andrew House kicked off Sony Corp.'s (
) 6 p.m. press conference with the expected news, commenting, "The demand for a new console were clear....Today we will give you a glimpse into the future of play. The most personalized gaming experience available today... the most powerful platform ever.We believe that PlayStation 4 represents a shift from thinking of a box or console... PlayStation is the best place to play."
Sony's fourth generation console
, which will enter the eigth generation of console wars has been in the works since at least 2007. The console packs a new x86 processor replacing the International Business Machines, Inc. (
) derived CELL processor from the PS3. The system has 8 GB of DDR3 RAM (unified) shared by the GPU and CPU. Sony did not specify the hard drive size, but it promises it is "huge".
The new controller has a light bar, which is recognized by a 3D camera on the console, allowing motion control (similar to the Wii, Kinnect, etc.). The new controller also features a headphone jack and share button, as rumored. The controller also features a power button that can pause games; all games will be equipped with power save features.
Sony DualShock 4 Controller
Games can be downloaded while the console is in the low power/background mode. The background processing is handled by a secondary "custom" chip. Lead architect Mark Cerny explains, "[Our] long-term vision is to reduce download times to zero... if we know enough about you we know what game you'll purchase next and download it in the background."
There's also continual support for hardware video compression when the console is on.
The console also supports using smartphones, tablets, and the PlayStation Vita as controllers via custom apps on the latter two (specific platforms were not announced). Most PS4 titles will be playable on the PlayStation Vita as a secondary screen.
For sharing Sony is pairing up with Facebook, Inc.'s (FB) ubiquitous social network and Ustream. Describes Mr. Cerny, "By combining the PS4, the PlayStation Network, and these social platforms, our goal is to become the social platform for gaming."
One thing Sony views as key to the upcoming console's success is to woo developers big and small. Much like Apple, Inc. (
) Sony made it clear that it's all about the developers and will promote small third party studios and big studios alike via abundant resources and a set of accessible APIs.
For big end studios, there's plenty of room for creativity; high end game titles are expected to feature characters with up to 30,000 polygons. Some of the high end games shown off included Killzone: Shadowfall, inFAMOUS: Second Son, Driveclub, Deep (Capcom Comp., Ltd. (
)), Final Fantasy (unnamed) (Square Enix Holdings Comp., Ltd. (
)), Watch Dogs (Ubisoft Entertainment SA (
)), a Diablo III port (Activision Blizzard, Inc. (
)), and (now-independent) Bungie's new title "Destiny".
"Game reviewers fought each other to write the most glowing coverage possible for the powerhouse Sony, MS systems. Reviewers flipped coins to see who would review the Nintendo Wii. The losers got stuck with the job." -- Andy Marken
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text: Taryn Manning seems to have a tough time with female friends. She got into a knockdown drag out fight with her makeup artist who was also her best friend and that fight got them both in trouble. Now, another long time friend of Manning got arrested and served with a restraining order after Manning said the friend would not stop e-mailing her or texting her. According to the charges, Jeanine Heller is accused of sending Manning hundreds of e-mails and texts between April and June. Why do I think there is way more to this story? Heller was ordered to stay away from Manning and Manning's family and even Manning's dog. Considering how quickly Manning made up with her makeup artist, I have a feeling that Manning and Heller will see each other soon and then when Taryn gets mad again will probably have Heller arrested.


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Italia 2010 black jacket.Features full zip jacket with 2 side zippered pockets.Embroidered team crest on the left and Puma cat logo on the left chest.Designed with gold ribbonstitched on both sleeves down the stretch from shoulder.Elastic waist and cuffs with mesh panel inside the jacket.Embroidered ` ITALIA` inside the open collar.100% polyester.
Soccerplus first opened in 1994. We were one of the first soccer websites to hit the webView more
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text:
Future Pros Basketball League
Rohi Christian Church
Tuesday, January 8, 2013 at 6:00 PM - Wednesday, January 30, 2013 at 3:00 PM (PST)
Who's Going
San Francisco, California
London, United Kingdom
Florence, Italy
Event Details
$120 before 12/20/12
$150 after
$20 discount for teams of 7 or more.
Fee Includes:
- Skills Clinic
- 8 weeks of competitive, fun games (2 games each Saturday)
- Team Jersey
- Participation Award
Future Pros Basketball League is a fun, affordable, high-quality competitive league for boys and girls ages 8-14. We strive to train youth to be pros on and off the court. We provide a positive and safe place for youth to play and learn about basketball and team work.
The league begins Tuesday, January 8, 2013 at 6:00 pm with a skills clinci. Sfter the clinic all participants will be placed ona team within their divisions.
All teams are coached by former NCAA coaches, high school coaches or college athletes.
For more information visit www.futureprosbasketball.com or call (408) 270-4854.
When & Where
Boys and Girls Club
2195 Cunningham Ave
San Jose,
Tuesday, January 8, 2013 at 6:00 PM - Wednesday, January 30, 2013 at 3:00 PM (PST)
Add to my calendar
Rohi Christian Church
Rohi Christian Church is a non-denominational, multi-cultural church. Visit www.rohichurch.org for more information


text:
Research background
The context is (almost) the same as last year: the research covered the 5 major markets in Europe i.e. UK, Germany, France, Italy & Spain. It includes 32 brands (last year I forgot Skoda -shame on me!) present on the European soil including premium and luxury ones. That represents in total 135 websites. Note that some brands only have one global website (or local sites under same main .com domain name).
As said, I used WASP to detect "core" Web Analytics solution used on the websites - I didn't look at ad tracking, voice-of-customer nor behavioral targeting solutions. It may be possible that some manufacturers are using other tracking solutions, either own-made or tweaked ones that are not recognized by WASP.
- Google Analytics took pole position, being present on almost half of the sites (45.9%). Its share progressed by more than +100%! But is it really a surprise? In many case, Google Analytics coexists with a major paid solutions. It is probably used to track specifically search engine traffic and paid search performances as it fully integrates with Google Adword. Yet, Google Analytics is also used main primary solution in 23% of all sites.
- More surprising is the result for Sophus 3 eMetrics, the industry specific solution, that managed to strengthen its position & presence (30.7% of all sites, +10% vs. 2008). Not only it is resisting against traditional Web Analytics vendors and but it managed to get new customers (Peugeot & Citroen, all major markets) in spite of the crisis. (Updated on 25th of November)
- Omniture (16.3% of all sites) took the last place on the podium away from WebTrends (14.1%), leading traditional paid vendors (Note: for more details about Omniture result vs. last year - see post comments). In most case it is used as a global Web Analytics solution (i.e. on all local sites) by big players like Audi, Volskwagen or Mercedes-Benz.
- More and more manufacturers are using more than one solution on their site. The average is 1.25 solution per site vs. 1.1 last year.
- Some paid vendors lost customers: WebTrends (Ferrari, BMW Germany(!?), Volvo (!?)) and Nedstat (Nissan replaced it by Omniture Site Catalyst).
- The number of sites with no (known) Web Analytics solution found decreased - only 5 sites with no solution found (vs. 14 last year).
- The paradox: luxury brands (Lotus, Ferrari, Maserati, Porsche) seems to not want to spend money on Web Analytics as all adopted Google Analytics.
- The missing ones: Yahoo Web Analytics, Coremetrics & Unica were not found - same situation as last year.
- "Automotive manufacturers & Web analytics tools - 2009" - full results (PDF report)
- Automotive & Web Analytics in Europe – what are they using?" post (October 2008)
- "Web Analytics Solution Profiler" official Website


text:
Nicholaas Myburgh (7th generation of the Myburgh family, and father of present owner Hannes Myburgh) took over the farm in 1950, but the condition of the property had declined severely from its 18th century splendor. Nicolaas set about an extensive restoration of both the buildings and the vineyards. One of his first projects was the construction of a damn that allows for irrigation in exceptionally dry years, but is usually used only after the vintage. He also replanted the vineyards with mainly red varietals.
The farm is approximately 15 kilometers outside Stellenbosch, and is the Stellenbosch estate nearest the Indian Ocean (the name Meerlust is of German origin, and translates to "pleasure of the sea"). The cooling breezes off False Bay allow a slower, steadier ripening period for the grapes. This translates to less loss of fruit aromas, and there is also a lesser risk of a crop being ruined in the event of a sudden, dramatic rise in temperature. View all Meerlust Wines
About South AfricaView a map of South Africa wineries South Africa
Shop our most popular wine from South Africa
Shop our top rated wine from South Africa
A long history of growing grapes and making wine, but less of a history on exporting it, and even lesser on the quality aspect. At the turn of the century (1900, that is), a surplus of wine in South Africa created a hierarchy of cooperatives, the biggest and best known being KWV. This organization seemed to favor quantity over quality and had most control over wines and vineyards until the late 1980's. Now, with a bit more competition, quality is coming around. Yet, South African wine was not even seen in American wine stores until the mid-1990's – the trade embargo on the country for their racial apartheid laws kept South African wine out of the US. When apartheid fell, so did the embargo, and SA bottles began showing up on US shelves.
Notable Facts
White wine has always been the cash crop of South Africa, with much of it distilled to make brandy. More white than red is planted, much of it the Steen variety – known elsewhere in the world as Chenin Blanc. Good producers are making top quality dry wines from this grape. Another grape gaining some raves is Sauvignon Blanc, producing whites that are dry and crisp, yet rounder than many of its Southern Hemisphere counterparts. For reds, the top grapes are Syrah/Shiraz, Cabernet Sauvignon (& blends) and Pinotage. Cabernet Sauvignon and Bordeaux blends was once the favorite and most-produced, but Shiraz is taking over as wineries crank out high quality wines from the variety. Pinotage, which used to be a grape only your mother could love, has improved dramatically and is often as delicious as it is distinctive. The most popular regions of the country include Stellenbosch and Paarl.


text:
There are no Upcoming Shows listed for this artist.
Comedy Central Certified
Brad Williams
Brad Williams has become one of the funniest, most in demand comedians working today. A California native, Brad started doing stand-up at age 19 and has been touring ever since.
He has appeared on numerous TV shows including Legit, Dave Attell's Comedy Underground, Sam and Cat, Live at Gotham, the Tonight Show, Jimmy Kimmel Live, Mind Of Mencia, and Pitboss.
In addition to stand-up, Brad has become a dynamic on-air personality as well. His podcast "About Last Night" is a mainstay on the iTunes Charts. He is a regular on KROQ's Kevin and Bean Show in Los Angeles as well as the Adam Carolla podcast.
Brad's show is high energy. Robin Williams called him "Prozac with a head." Brad's ability to make humorous observations on disability, relationships, sex, and race are winning over audiences and proving anyone can overcome their shortcomings.
Check out his hilarious weekly podcast at: http://sideshownetwork.tv/category/podcasts/comedy/about-last-night


text:
The fiscal year (FY) 2012 Financial Report of the United States Government (Report) provides the President, Congress, and the American people with a comprehensive view of the Federal Government's finances, i.e., its financial position and condition, its revenues and costs, assets and liabilities, and other obligations and commitments. The Report also discusses important financial issues and significant conditions that may affect future operations, including the need to achieve fiscal sustainability over the medium and long term.
Pursuant to 31 U.S.C. § 331(e)(1), the Department of the Treasury (Treasury) must submit the Report, which is subject to audit by the Government Accountability Office (GAO), to the President and Congress no later than six months after the September 30 fiscal year end. To encourage timely and relevant reporting, the Office of Management and Budget (OMB) accelerated both individual agency and government-wide reporting deadlines.
The Report is prepared from the audited financial statements of specifically designated Federal agencies, including the Cabinet departments and many smaller, independent agencies (see organizational chart on the next page). As it has for the past fifteen years, GAO issued a "disclaimer" of opinion on the accrual-based, consolidated financial statements for the fiscal years ended September 30, 2012 and 2011. GAO also issued disclaimers of opinion on the 2012, 2011, and 2010 Statements of Social Insurance (SOSI), following unqualified opinions on the 2008 and 2009 SOSI, and a disclaimer of opinion on the 2012 and 2011 Statement of Changes in Social Insurance Amounts (SCSIA). A disclaimer of opinion indicates that sufficient information was not available for the auditors to determine whether the reported financial statements were fairly presented in accordance with Generally Accepted Accounting Principles (GAAP). In FY 2012, 311 of the 35 most significant agencies earned unqualified opinions on their financial statement audits.2
The FY 2012 Financial Report consists of:
In addition, the Government has produced a Citizen's Guide to provide the American taxpayer with a quick reference to the key issues in the Report and an overview of the Government's financial position and condition.
The Government's fundamental mission is derived from the Constitution: "…to form a more perfect union, establish justice, insure domestic tranquility, provide for the common defense, promote the general welfare and secure the blessings of liberty to ourselves and our posterity." The Congress authorizes and agencies implement programs as missions and initiatives evolve over time in pursuit of key public services and objectives, such as providing for national defense, promoting affordable health care, fostering income security, boosting agricultural productivity, providing veteran benefits and services, facilitating commerce, supporting housing and the transportation systems, protecting the environment, contributing to the security of energy resources, and helping States provide education.
Exhibit 1 provides an overview of how the U.S. Government is organized.
1 The 31 agencies include the Department of Health and Human Services, which received a disclaimer of opinion on its 2012, 2011, and 2010 SOSI and on its 2012 and 2011 SCSIA.(Back to Content)
2 The Federal Deposit Insurance Corporation (FDIC), the National Credit Union Administration (NCUA), and the Farm Credit System Insurance Corporation (FCSIC) are among the 35 significant entities. However, because these entities operate on a calendar year basis (December 31 year-end), their 2012 audits are not yet complete. Statistic reflects 2011 audit results for these organizations.(Back to Content)
From Treasury.gov
File Viewing Tools


text:
On the Shelf
Meet Me in Treasondale, and Other NewsBy Dan Piepenbring
- Before there was MFA vs. NYC, there was Flannery O'Connor, discussing the merits of an MFA program: "It can put [a writer] in the way of experienced writers and literary critics, people who are usually able to tell him after not too long a time whether he should go on writing or enroll immediately in the school of Dentistry."
- The love letters of a young Ian Fleming reveal him to be a jealous, sadistic romantic: "I would have to whip you and you would cry and I don't want that. I only want for you to be happy. But I would also like to hurt you because you have earned it and in order to tame you like a little wild animal. So be careful, you."
- Beware intemperance! Exhumed from the Library of Congress: a 1908 map depicting "the negative consequences of drinking and ungodliness, using an imaginary set of railroad lines, states, towns, and landmarks." Highlights: Selfishburg, Hypocrisy Heights, Lewd Castle, Whiskeyton, Gossip Center, Presumptionville, Treasondale, and Embezzle City.
- John Coltrane's tenor saxophone will join the collection of the American History Museum. (This year also marks the fiftieth anniversary of his seminal album A Love Supreme.)
- On CNN's coverage of Flight 370: "This willingness to fixate on one big story and sensationalize it reflects CNN's growing embrace of the phenomenology of news. It's an approach that emphasizes the viewer's experience of singular news events as much, if not more than, the news itself."


text:
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In a universe where the world's countries come alive, action and chaotic world meetings are the least of your problems. Welcome to Hetalia International!
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This is a forum made for the community of Rivers SMP to discuss topics, trends, and problems going on inside of the server.
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text:
reading comprehension fail. sincere apologies, I'll send you some duct tape to help.
Need a flyweight to enter the tournament due to an injury to Martin Wong.
Great opportunity to become Flyweight champ especially for any bantams moving down
Gutted this is a week before SnA, I`d have a few guy`s all over this if not.
If you love fighting you can never really lose!!!!!
Is Platts available?.. He's only as experienced as Niko really.
Karl Harrison looked great against Seery, he would be a nice inclusion
Still need to match the following pros
LW Uche Ihiekwe 6-3-0
WW Billy Glossop 3-3-0
FW Greg Grimshaw 0-0-0


text:
Rob Zombie Apologizes For Short Rock Fest Show
Listen to Rob Zombie Radio on iHeartRadio
Rob Zombie is offering another apology after cutting his show at Rock Fest short this past weekend.
The rocker reiterated in a post on Facebook that his voice was completely shot after just two songs at the Wisconsin event, and added a photo of his throat to show just what he's dealing with. He says he would have kept going if there was any way he could, revealing that it was actually the first time in nearly three decades that he wasn't able to finish a concert.
Zombie closed his statement by saying that he doesn't take his fans for granted and isn't taking this situation lightly. His goal is to "never let the fans down," and he's very sorry that he did just that on Sunday night. He adds that they're currently trying to figure out a time and place to make it up to everyone.
Photo: Getty Images


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We offer a range of rooms, the majority of which are en suite. Complimentary for our guests we provide flat screen TV's with satellite channels including Sky Sports and entertainment pack, DVD players, and excellent wireless broadband (subject to availability).
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