text:
Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Saturday, October 07, 2006
Taking Trust
When Tiger Woods addresses the ball, he's focused like a cat that heard a rustle in the leaves. He takes a few practice swings, moves up to position, adjusts his feet, steadies his shoulders, locks his eyes onto the target. He waits until there's absolute silence, brings his breathing under control, funnels all his energy into the impending swing; takes the club back, and explodes in an immensely balletic movement. It stops the breath of an onlooker, ripples the air in a wave that goes forever. Making a surgical incision is nothing like that.
But it almost is; and it should be.
Having held the patient's hand as she goes to sleep, having whispered "We'll take good care of you" as his eyes flutter to stillness, the personal remnant is still very much there as I begin, even as the person is covered in sterile green paper, exposing only the belly. It's the midline incision, especially the one in the upper belly, from breastbone to navel, that's the most intimate. To me, anyway. It's so direct, so frontal, so against the rules of personal space. Maybe even sexual. Because it's right into the middle of who she is -- the thrust aimed where anyone -- even a friend -- would hunch away to protect himself; yet, here I am, purposefully slicing deep into his core, willing and able, allowed, invited, trusted, observed. Going through the skin, the initial cut -- that's the cataclysm, the breaking of the barrier, the crossing of the line. It's the leap of her faith, the breaching of the wall, the stepping into space. Within moments, it's routine, nearly generic: his insides look like mine, yours. Been there. But the primal cut, the slice through that first and last line of protection, his skin, her freckles, the fine little hairs, the vulnerable innocence: I feel the intrusion, the awfulness, the promise made and broken simultaneously. After all these years, I never lost the wonder, the momentary look inward, the catch of breath, the faint crescendo of pulse. Primum non nocere!
These young guys: they like to cut only part-way through the dermis and put down their knife, finish off the skin with electrocautery; cook their way through the fat, smoke rising, stops and starts, pissily branding each little bleeder. I think they don't know -- really know -- what an incision is. No wonder their love for it is less personal, more abstract, more easily stolen. Take the knife in your hand, sister, and don't put it down. Watch me: take a clean and deep stroke through skin, fat, right down to fascia.. Have the courage of your convictions; make good on your promise and carry that same cut through the white line, the linea alba; let's see that little layer of fat that covers the peritoneum, let it show on the first swing. The patient deserves your best shot, your most bold. Honor your covenant to address him with all of your conviction and purpose. Swaddle the wound with pads, the bleeding isn't much and can wait.
I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I've circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I'm here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I'll stay until it's right. It's what I must do. You think you'll never touch me so intimately as I've touched you. But you have. You have.
48 comments:
- james gaulte said...
- scalpel said...
Very touching.
You are amazing!
B. Perky - 10/07/2006 2:17 PM
Thank you. I have always felt that surgery is, or should be, a sacrament. That is one of the reasons that harmony in the OR is important to me. If the CRNA and the circulator want to fight, they can do it somewhere else. The patient deserves our best.
- Sid Schwab said...
Sacrament is just the way to put it. We dip our hands into the holiest of waters. Which is not to say there can't be lightness and fun in the OR: sheer joy, or jocularity to break the tension. That, it seems to me, doesn't disrespect the nature of the relationship. But the solemnity of the duty is always there, or should be.
- Rick Lee said...
Wow, I am having a lap on Monday and I am totally freaked about. Your post helps. I know my dr will do fine and I trust him. But it is still surgery.
- Sid Schwab said...
anonymous: Of course you're freaked out; everyone is, or they aren't thinking. But it's amazingly safe nowadays; anesthesia equipment is so sophisticated there's almost no way anything can go wrong. I used to say you're never safer than when you're having surgery: things are known about your important functions at all times, in ways they aren't otherwise. I think you'll be fine!
oh my God! this was s o poetic! you have shown me a side of a physician that i have never seen before. and ive been around the medical profession all my life. my mother was an xray tech for over 35 years. now i am a medical assistant, even though i work in the fron office at my job.
but this was awesome, truely! i am so moved that you shared this. i hope there are others who feel this way too.
again, than you! - 10/07/2006 6:59 PM
- Medblog Addict said...
I discovered medblogs after undergoing an open chole. It was the first time I had ever had surgery and I became fascinated by the whole process. I purchased your book after I saw it on "Cut to Cure". I wanted to know what kind of person becomes a surgeon; what he/she feels when making that initial cut, how they handle the responsibility and pressure of their job. I enjoyed the book but this entry was right on point. I am kinda glad you waited a while to address this on your blog. It gave us a chance to get to know you first. It was way too intimate to reveal to strangers.
I'm speechless.
With goosebumps.... - 10/08/2006 1:32 AM
- Surgical Resident said...
Awesome! I will think about what you said tomorrow in the OR!
That was unbelievable! I will never see surgery - or surgeons - the same again. Dr. Schwab ... please, put this post into your next book.
Dr. Schwab, I read this post on Saturday, got freaked out, and came back to it today to see if I could try to open my mind to it. I had this theory that perhaps trying to understand how a surgeon thinks will help me.
I had surgery for ovarian cancer six months ago. I expected a BSO/TAH; I did not expect to wake up with 48 cm of perfectly functional colon removed and a colostomy, but that's what I got. A few months into chemo the midline incision "dehisced" and drained pus from a fistula formed by the stapled end of the rectal stump, which never healed properly. It drained for six weeks. By now the midline has drawn down into the belly and has a hideous 2-inch oval scar in the center, with a pronounced bulge around the stoma. Fungal infection and acid from stool leakage has turned the skin into a red angry mess. Before someone says it, yes, I am grateful to be alive. In fact, every time I look at my gut (that's six times a day with a transverse colostomy), I say to it, "this is better than being dead."
I am not shallow. I am just an average-looking single 44-year-old with a mutilated abdomen who has to handle her own feces all day because a surgeon whom I had never met before was called into the OR after my abdomen was opened and decided that the risk of future bowel obstruction outweighed whatever objections I might have raised had I been conscious and consulted. Subsequent to surgery and five cycles of chemo, two separate BE examinations of the rectal stump and two separate CT scans show no pelvic masses, no definite signs of metastasis and no stricture or obstruction. That's the good news, and it's very good news indeed. Except for the fact that insurance won't cover a "takedown" of the colostomy because it's "elective." And the (new) surgeon doesn't think I'd be happy with a takedown anyway, because so much bowel is missing that I will have chronic diarrhea for the rest of my life, and it might be easier on my body in the long run to handle that with a colostomy. He says.
Now I have to decide whether to continue with chemo or to undergo a second-look laparotomy. The internist is willing to continue chemo; the surgeon is willing to operate; there is no "right" answer, they say; the decision is mine. I lost one-fifth of my body weight and all my hair on chemo, it gave me permanent nerve damage in my feet, it gave me anemia and electrolyte problems serious enough to require hospitalization. I know chemo. It wasn't until I read your post that I really realized why I refuse to consent to further surgery unless they tell me I'll die immediately without it. Why I have agreed with open eyes to take more of the punishment that I know chemo has in store for me.
Your writing is beautiful. I tried to imagine my surgeon writing like that, thinking like that, if only to convince myself that the covenant of reciprocal trust can be restablished, and I can't. I have no way of knowing whether this is "fair" to the surgeon who cut out half my colon or not. I have no way of knowing whether it's "fair" to my new surgeon. I have no way of knowing whether it's "fair" to myself. It's just true. If surgery is a sacrament, then I am excommunicate. - 10/09/2006 2:42 PM
- Sid Schwab said...
anonymous: what a difficult situation, graphically and well told. I wish I could offer something meaningful, beyond sympathy. It's hard to second guess an inta operative decision like the one that was made in your case; most especially without having been there or knowing lots of detail. But I'd say a couple of things: unless you have really horrible insurance, a colostomy takedown certainly should be covered. If the prescribed appeal process doesn't work, I'd even consider having a lawyer familiar with such things look at the fine print in your contract. Second: most people have pretty close to normal bowel function with half a colon or less. I've had several patients in whom it was necessary to take the entire colon except for the rectum, who had good function and control with their small intestine hooked to their rectum. If the management of your colostomy is really not tolerable, it's something to consider. Mainly, I'm sorry to hear your sad story. None of us surgeons can say that every decision we made -- especially those made without advance planning -- have worked out perfectly.
- Cathy said...
Wow...That was just beautiful..I didn't know these surgeries I had effected my surgeon in this way..I will never forget this.
- The Tundra PA said...
What an absolutely stunning piece, Dr. S! Lyrical. Deeply moving. It is gratifying on an intimate level to know that a surgeon can feel this way about the patients in their care; I wish all surgeons did. Thank you for sharing such a profoundly personal perspective. You have brought me to tears, and given me hope.
Dr. Schwab, thank you for your kind response to me. My own surgeon is so instantly defensive about the subject that it does me more psychological harm than good to discuss it with him, and he wasn't even involved in the original surgery. I should say that it has never even crossed my mind to think that I am a victim of malpractice; even at my worst moments of self-pity I cannot bring myself to think that a bad decision is anything other than just a bad decision, and we've all made them. That said, I believe that the surgeon responsible for this was too aggressive, too unwilling to consider medical-chemo alternatives to surgery, a little arrogant about his ability to successfully resect unprepared bowel, and, from what I learned in his one and only 5-minute visit to my bedside post-op, shockingly blase about the psychological burdens of this surgical procedure. I am sure that most of the time his surgical aggressiveness is warranted and successful. It's just "life's a bitch" for for me that damn near everything that could have gone wrong did, and for what in 20/20 hindsight appears very little reason. He is not, of course, around to help me clean up the mess or learn to live with it. I understand that that "isn't his job." I can imagine how painful it must be to perform an operation you know will traumatize the patient, and that you fear may end up with terrible complications. But the fact is, I got more sympathy and respect in the comment section of a blog of a doctor who doesn't know me, didn't do it, and was just there when I surfed by than I ever got from my own surgeon. I suspect it isn't any fun to follow up with your mutilated patients. Perhaps someday I will develop some sympathy for that. It probably won't be any time soon.
May I say, just for the record, that WOC nurses are second only to Onc nurses in hierarchy of angels? And even though he's a surgeon, Dr. Schwab is fit to be in their company?
Thank you for being willing to hear it all. Your patients are so very lucky. - 10/10/2006 4:30 PM
- Red Rabbit said...
Yes, absolutely. As a med student and (hopefully) future surgeon, and having done only a few proper incisions myself, I think you have captured the intimacy completely. I thought I only felt that way because I am so NEW at this; it's fantastic to see that experienced surgeons still feel this.
I spent last month with a young staff who let me do a great deal, and it was fantastic. But I also assisted at a few surgeries with a senior surgeon, and watching him work was indescribable. He was unhurried and yet, everything happened much faster than I would have thought possible.
I want to be like that someday. - 10/12/2006 3:26 PM
- Sid Schwab said...
newdoc: I love harking back to the times when it was all so new. And remembering how watching good surgery made me feel: awed; and unsure I'd ever be able to do it that well. That's what I tried to capture, along with the progress to actually getting to the point of doing it, in my (plug, plug) book.
Everyone else seems to find this touching, amazing . . .
I almost died during surgery, and instead I find this entry disturbing. You are correct; it is about trust. - 10/14/2006 11:40 AM
- Sid Schwab said...
To the extent that it is disturbing, clearly I failed in my attempt in communicating. Perhaps I should have chosen my words differently. My respect for the body of the patient, my awe that I am allowed this amazing thing, the contract that it implies between me and my patient -- those are the things I had in mind. Perhaps I overestimated my ability as a writer. Maybe I got carried away. But doing surgery is a mystical thing to me in some ways; I wanted to convey that. For some, I failed. I might add that the only patients of mine that nearly died (or did die) in surgery were ones that came to the OR with unsalvageable situations. I won't claim perfection, nor gifts beyone those of any other surgeons. But I did approach every operation with the belief -- formed in part by my respect for what I was about to do -- that I owed the patient my very best at all times: the best preparation, the best thoughts about what I was going to do. If I were to be trusted, I had to be worthy of it. Maybe I should have stuck to operating and not trying to describe it.
I read the discussion over at the Dino site and I have to say, Dr. Schwab, that you did not fail as a writer.
Invasive, violating, intimate, healing, helping - health care tends to cross all these boundaries in ways that we usually don't think about or acknowledge.
After experiencing a medical injury, I felt violated. It didn't help when I had to have surgery to fix the damage. Especially since no one was talking to me. I felt like a pariah, which unfortunately is pretty typical for people in these types of situations.
There was no way to convey the sense of outrage. No one would ever have understood it.
Dr. Schwab, you captured all the ambivalence. For a writer, that's a real feat. - 10/16/2006 8:30 AM
A beautifully written post Dr S, but I too can see why anyone with a traumatic surgical experience would find it disturbing, unsettling. Exactly because surgery is an intimate experience - and requires trust. The violation of the initmacy of surgery on the core of one's body is horrific, and my condolances to those who do go through this... and who wake up every morning reminded of it. As Docs, we need, nay, we must be ever concious of the sensitivity of the risks attached to any surgery, and of fully informing the patient about everything, all along the way.
I too was wowed by this, especially the ending. Sid Schwab, you have touched my emotions, even more so than as Anysurgeon you may have touched my organs. I have entrusted you, whom I may have met only once or twice before, with my life, and in that moment of the first cut there are just the two of us, even though I have no awareness of it. You are right - what could be more intimate? and yes, maybe sacrament is not too strong a word to use.
I like to think that you have spoken for the many compassionate surgeons who, even if they share your gift of words, may not have the time to use it.
Thank you. - 10/17/2006 5:12 PM
Your post is stunningly beautiful and most importantly, respectful of the care required to embark on the enormous task of cutting into a living human being, doing your work, closing up in a way that minimizes the evidence you were ever there, and see the patient through recovery.
I sympathize with those who have been victims of medical malpractice or who feel violated in some way from those in whom they placed their trust. Especially disturbing is the story posted here which bordered on a violation of informed consent; whether or not that was the case is not as much the point as living with the aftermath. But those who think this post accurately describes a violation probably are keying into out-of-context descriptions of holding a uterus or ovary; I seriously doubt you'd get the same reaction from a post describing the slick, spongy feel of a healthy liver, for example. In that sense, this is more of a problem of psychology than bad wordsmithing.
Just as not everyone is able to handle working in medicine, be it a doctor, nurse--anyone on the front lines of health care who come face to face with death, disease, abscesses shooting pus across your shoulder during an I&D, shit and piss on the sheets, bilious, green vomit (yes, I'm being intentionally graphic)--not everyone will be able to read a post such as this and see the beauty, awe and respect. They will never understand. I could have a lenghy conversation of how incredible various molecular mechanisms of cancers can be, the way they evade the body's defenses, using normal, benign processes as hideous tools of destruction. I'd never think to have that conversation with a patient, because without the context, it sounds as though I'd enjoy seeing another cancer, whereas the real motivation would be fearful awe and respect.
The difference is that you write for yourself with your audience in mind, not modulate/second guess your writings with what people might think. If they don't like it or understand it in spite of your best efforts, the loss is theirs. Bring things with honesty from your perspective of such a long history of service to medicine, surgery and humanity, and you'll find there will be just as many people willing to read as there will ever be. - 10/19/2006 4:00 PM
- Kiran said...
it was simply awesome hope my teachers teach surgery like this
it was simply awesome hope surgery is taught like this
- rdl said...
Great post! Wish I could find an Orthopedic surgeon that I liked- actually like the current one, he's nice but I don't know if I trust him with my elbow.
- Bongi said...
some of the comments expressed hope that surgery is taught like this. i have fairly recently qualified as a general surgeon and in my experience surgery is most definitely not taught like this. in fact the brutal way that surgery is taught inspired me to attempt to be an exception to the rule and rather try to impart my love for surgery to the juniors that work with me. i always chant my mantra,'love surgery, not the surgeon.' this is because the surgeon is more often than not such a megalomaniac prick that it would not be possible to like, nevermind love him. this is the first time i've seen someone express humble appreciation to his patients. it is after all they that afford us the priveledge of practicing our proffession. thank you for sharing this post.
- outre said...
Wow, you've put into words what I was unable to describe. I've always thought surgery had a romantic side to it. A surgeon gets to go where even the individuals themselves won't ever get to. Cut into a sealed envelope that is the person. I had to observe surgeries in college as part of my degree requirements and was always hugely jealous.
I'm glad to know I'm not the only one that think surgery is a beautiful thing, blood, guts and all. - 11/17/2006 6:43 PM
- ditzydoctor said...
hullo! i'm a medical student but all i've seen of surgeries nowadays is the diathermy. quite sad really, to think about it. no one seems to use a scalpel anymore!
i've had a huge op done as a kid (which might explain why i'm in medicine now) but being a kid, i only knew fear. thank you =D - 11/26/2006 6:04 AM
- SeaSpray said...
I just reread this and will read it again and will be recommending it on my blog. I AM STILL in awe of this post. So eloquently written. Intimate,sacred and amazing! When I get a little more blog savey I am definitely linking to you!
I wanted to tell you how much I liked your post about the intimacy of a surgeon-patient relationship. 16 years ago (I was a young adult) I sustained a severe brain injury in a car accident and was in a coma. I had a ventriculostomy, and my husband says a feeding tube was put into my stomach some time later. When I woke up everyone thought I would be paralyzed. My trauma surgeon took me for a walk (I remember how sleepy I felt so I didn't want to get out of bed for anyone but him), and now its as if I was never injured. I still get a bit dizzy once and a while if I turn fast, but I've returned to college and am earning a 3.8 GPA and I'm always running after my six children. I dedicate every class I take in college to my trauma surgeon and I write him about once every week or two to give him an update on my grades. I'm so grateful for his kindness as well as his skill. I know how busy he is with the work he does that I hold in such awe, and the last thing I would want to do is bother him with so many letters. However, after reading about how much honor you give your patients I feel less bothersome. Thank you so much.
"Wow" indeed. I hope this is how my surgeon felt. Thanks for this memorable and revealing post.
- SeaSpray said...
STILL my favorite! :)
What more can I say than WOW! I thoroughly enjoy your blog posts! I am a med/surg RN and I take care of a lot of abdominal surgeries. Your posts always hit home, enlighten me, as well as remind me that the surgeons I work with are truely artists. You write with such poetic yet precise steps- it reminds me of how I talk my patients thorugh procedures such as NG placement- Keep up the great work- both the caring and the writing you are very gifted!
- The Caffeine Lady said...
I found this post exhilarating. My breath hitched. I've never second guessed my decision to pursue surgery. It's given me the drive I need to finish this game with everything I have.
As a new surgeon, I find that my job is filled with hassles and intrusions that I never anticipated. Insurance companies calling, discharge planning to set up, paperwork always looming, the phone endlessly ringing. The OR always was a haven, even during residency, but now even more so. The few times a week that I get to settle into a case, focus in on the few square centimeters in front of me, and just operate....they are the moments that keep me going. Medicine is special, but surgery is phenomenal. Surgeons are different, thank goodness for that.
- Rebecca.Boardman said...
Dr. Scwab, what mixed emotions I have had reading this post and its comments. Your own personal experience was beautiful. Intimate, personal, like you said - almost sexual. After all, the intercourse we experience with procreation is not nearly as invasive as what a surgeon does when they come into our bodies.
However, having experienced the "rape" type surgery as well as the "lover" type surgery... it leaves me with a sadness that the brilliant surgeon who probably saved my knee function and gave me the last 20 years of a relatively normal life, was also the kind of surgeon that did not consider the mental welfare of the patient, but rather saw the successful result of his surgery as the end all of whatever means he used to an end.
It also makes me wonder how my current surgeon rates on this scale. I do not know if he holds the reverence of the body that you have held for your patience, but I think he might - at least to an extent... when consulting for this last surgery, he told me he had been thinking of this surgery (mine) literally for months, which would indicate to me that he has proper reverence and concern for me (or at least my knee). He also had another experienced surgeon who he works with come in and work with him during the procedure. This also would give me reason to trust him.
I wonder if I will ever get over my sense of paranoia concerning my surgeons. It makes a stressful situation much worse when you feel a lack of trust. How I wish I could be certain he felt as you do! - 1/18/2009 3:11 PM
- Rebecca.Boardman said...
oooops - PATIENTS instead of patience.... LOLOL
- Jordan said...
As a 27-year-old chick who's had nine surgeries for a plethora of medical issues (only two of which were deemed "delicate operations"), it's incredibly comforting to see the philosophical, virtually spiritual experience for the person on the other end of the scalpel that slices into my prone body. My first surgery was at age 3, so I never correlated fear with medical procedures. Thankfully, I've only had one surgical experience that was negative- and I have a feeling it's because most of the doctors I've chosen (after being thoroughly vetted) shared your same passion and respect for the human aspect of your particular niche in the health industry.
Thank you for your blog. Not only is it a great resource for patients who wish to supplement their education for an impending specific operation, but also introduces a certain element that's so often missing in a clinical setting: heart and soul. - 11/16/2009 9:46 PM
- Sid Schwab said...
Thanks, JJ. Glad you found the blog.
- Chaoticalm said...
I love this post. Your writing brings light to all the things I love, that I feel privileged to do, in the OR. I hope I never lose this sense of wonder and awe. Thanks for writing!
OK-- now I might have to buy your book! Your ongoing sense of awe, each time you "entered" the patient's inner realm--is wonderful. Thank you for sharing your thoughts. As a RN I loved the OR though I did not make a career of it (in nursing) I did have a brief stint. It is my opinion that general surgeons are extraordinary in many ways--I have been privileged to work with several(good ones)and their 'grace under pressure' and tireless work ethic inspired. But not many of them can write!
- Sid Schwab said...
Thanks, DD!
Fascinating. Probably said before but written in such a way as to take you through such intimate procedure as to place the reader there, with you; that first cut, such bravery, poignant, a love of the human beneath. I thank you for sharing these moments.
Chris Devismes. - 11/03/2015 12:29 AM
- Sid Schwab said...
Thanks. As the blog lays fallow, I greatly appreciate that people still find it, and find it worthy of their time.
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In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favora...
Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it'...
I finished the previous post with the sad story of my patient, illustrating diagnostic difficulties at the fringes of biliary disease. An...


text:
Princeton University administrators shared updated plans for the design and phased construction of the Arts and Transit Project at a campus meeting Feb. 11.
Ron McCoy, the University architect, discussed the design of the project while Anne St. Mauro, assistant vice president for facilities, design and construction, discussed the construction schedule at a meeting of the Council of the Princeton University Community (CPUC), a deliberative body made up of faculty, students, staff and alumni.
The project, which covers an area along University Place and Alexander Street just south of the McCarter Theatre Center and just east of Forbes College, includes a new Wawa convenience store and new Dinky train station for the NJ TRANSIT train that runs between Princeton and Princeton Junction, three new campus arts buildings, and renovation of the existing rail station buildings for a restaurant and café. It also includes infrastructure improvements to the site and adjacent roadways, a multimodal transit center and extensive landscaping.
With the Regional Planning Board of Princeton's approval of the project in December, the site is being prepared for construction. Some University-owned buildings along Alexander Street have already been marked for demolition, with placards for first responders as to the condition of the building. Some of the buildings were vacant and University offices in other buildings have been relocated.
"Within the next month, we envision the (construction) fences coming up, and the buildings coming down," St. Mauro said.
The planned project schedule is:
- Spring 2013: Demolition begins, and the sidewalk in front of Forbes is diverted as utility work begins along Alexander Street. Some power lines will be buried below ground, and some utility lines will be moved across the street.
- June 2013: Soon after the University's June 4 Commencement activities, the section of Alexander Street between University Place and College Road is closed for about six weeks as utility work is completed. Alexander Street traffic is rerouted via University Place and College Road.
- July 2013: Alexander Street re-opens. Initial demolition on the Arts and Transit site is completed and the construction of a new commuter parking lot and temporary train platform begins. For a one-week period, the Dinky is out of operation and is replaced by bus service.
- Fall 2013: The temporary train platform and new commuter parking lot open. Though the Dinky is operational from the temporary platform, riders have the option of taking an express bus between the existing station and Princeton Junction, until the new station opens in summer 2014. Renovation of the existing train station buildings begins, and construction starts on the transit plaza, new train station, new Wawa, and access road to the West Garage (Lot 7).
- Fall 2013 to early 2014: The new roundabout at the intersection of Alexander Street and University Place is under construction. A temporary road provides access through the site and to temporary parking at the Wawa.
- Early 2014: Traffic roundabout opens and road detours end.
- Summer 2014: The new Dinky train station, Wawa, transit plaza and access road to the West Garage (Lot 7) open. The Wawa remains open at its current location until this point in time, when it moves into its new location.
- Summer 2014 to summer 2017: The three arts buildings and public arts plaza are constructed. The opening date for the restaurant and café depends on the partner selected to operate the establishments.
- Fall 2017: The Arts and Transit Project is completed, with the arts buildings in use for the fall semester.
St. Mauro said the construction phases were designed to minimize disruptions, and the University will be notifying affected groups about work that will impact them. As pedestrian and vehicular paths shift to accommodate construction, signs will be posted to advise the public about new routes. In addition, maps that identify construction zones and new routes will be available on the Arts and Transit Project website.
Much of the construction information discussed at the CPUC meeting also has been posted on the Arts and Transit Project website, along with a new set of frequently asked questions about construction and a page for individuals to sign up for email alerts about new construction or transit information.
The project is a major element of Princeton President Shirley M. Tilghman's initiative to make the arts a central part of the academic experience at the University. The three arts buildings to be constructed will provide additional space for the University's Lewis Center for the Arts and the Department of Music, and will bolster an arts neighborhood that includes McCarter Theatre Center and creating writing and dance spaces in the New South building.
McCoy presented detailed illustrations of the academic buildings and pathways, public and commercial buildings, open spaces, traffic improvements, and landscaping. He began by noting the scope of the project.
"This is a transformation of the western side of campus in a large way," McCoy said. "It's 22 acres. It's the largest single development in the history of the campus, larger than the original campus of Princeton University."
Highlights of the project include:
- The Steven Holl-designed arts buildings — for dance, theater, music and administrative offices — will be connected on street level by a plaza and reflecting pool, and below ground by an open gathering space called the Forum.
- The Rick Joy Architects-designed Dinky Station and Wawa complex alongside the Dinky train tracks will be joined by a canopy, include heated and cooled spaces and restrooms, and provide easy access to the train and transit plaza.
- The existing station buildings will be renovated. The northern building will retain much of its interior and exterior character and become a café. The southern building will be expanded to house a restaurant with indoor and outdoor seating for 100 patrons.
- A new crosswalk at Forbes College will mark the beginning of an east-west walkway across campus that will extend across Streicker Bridge to the Frick Chemistry Laboratory, while Blair Walk will extend from Blair Arch to the transit plaza, with new magnolia trees lining the portion of the path near the restaurant and café.
- Parking Lot 6 will be converted to a green space, Baker Green, which may be used for outdoor arts events such as film screenings.
- Covered bike parking, including secured bicycle storage, will be available at the West Garage (Lot 7) and accessible from Alexander Street via the transit plaza.
- Sustainability features of the project include "green" roofs on all three arts buildings, geothermal wells for heating and cooling the structures, and a net reduction of 240 fewer miles traveled a day due to the access road from Alexander Street to the West Garage (Lot 7).

subset: commoncrawl


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text:
House Speaker John Boehner and President Barack Obama spoke on the phone twice Tuesday, a day after the president offered to reduce his initial demand for $1.6 trillion in higher tax revenue over a decade to $1.4 trillion. But Obama continued to insist that much of the revenue come from raising top tax rates on the wealthy.
Boehner countered later Tuesday with another offer that aides to the Ohio Republican said stuck close to a document delivered to the White House a week ago. A top White House aide, Rob Nabors, came to the Capitol to respond.
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"I think it's getting worse, not better," House GOP Whip Kevin McCarthy, R-Calif., said.
The Boehner camp again said it's up to the White House to proffer additional spending cuts to programs like Medicare. The White House countered that Republicans still need to cave on raising tax rates for the rich.
House Minority Leader Nancy Pelosi, meanwhile, warned Republicans against insisting on raising the Medicare eligibility age as part of any deal.
"One of the things that we object to is raising the Medicare age," Pelosi said on "CBS This Morning." ''Don't go there."
Pelosi said raising the retirement age wouldn't contribute much savings toward an agreement, adding "Is it just a trophy that the Republicans want to take home?"
Raising the Medicare age from 65 to 67 could cut Medicare costs by $162 billion over a decade, according to a Congressional Budget Office estimate last year. But by 2035, it would cut Medicare's projected budget by 7 percent.
The White House, for its part, detailed numerous proposals Obama has made to cut spending, including recommendations to cull $340 billion from Medicare over a decade and an additional $250 billion from other government benefit programs.
Obama remains determined that tax rates rise on family income exceeding $250,000, a move Republicans say would strike many small businesses that are engines of new jobs and file as individuals when paying their taxes.
Two weeks before the year-end holidays, time to find agreement was short, but not prohibitively so.
"I think it's going to be extremely difficult to get it done before Christmas, but it could be done," Senate Majority Leader Harry Reid, D-Nev., said.
Boehner's office took the step - unusual in secretive talks - of announcing that Republicans "sent the White House a counteroffer that would achieve tax and entitlement reform to solve our looming debt crisis and create more American jobs."
Democrats have watched with satisfaction in recent days as Republicans struggle with Obama's demands to raise taxes, but Reid privately has told his rank and file they could soon be feeling the same distress if discussions grow serious on cuts to benefit programs.
In an ABC interview, Obama did not reject a Republican call to raise the age of Medicare eligibility from 65 to 67, a proposal many Democrats strongly oppose.
The proposal is "something that's been floated," Obama said, not mentioning that he had tacitly agreed to it in deficit-reduction talks with Boehner more than a year ago that ended in failure.
"When you look at the evidence, it's not clear that it actually saves a lot of money," Obama said. "But what I've said is, let's look at every avenue, because what is true is we need to strengthen Social Security, we need to strengthen Medicare for future generations, the current path is not sustainable because we've got an aging population and health care costs are shooting up so quickly."
Obama's plan would raise $1.6 trillion in revenue in part by raising tax rates on incomes over $200,000 for individuals and $250,000 for couples. He has recommended $400 billion in spending cuts over a decade.
He also is seeking extension of the Social Security payroll tax cut due to expire Jan. 1, a continuation in long-term unemployment benefits and steps to help hard-pressed homeowners and doctors who treat Medicare patients.
The White House summary noted that Obama last year signed legislation to cut more than $1 trillion from government programs over a decade, and was proposing $600 billion in additional savings from benefit programs.
Boehner's plan, in addition to calling for $800 billion in new revenue, envisions $600 billion in savings over a decade from Medicare, Medicaid and other government health programs, as well as $300 billion from other benefit programs and another $300 billion from other domestic programs.
It would trim annual increases in Social Security payments to beneficiaries and gradually raise the eligibility age for Medicare.


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Thursday, January 22, 2009
Splenic Cysts
This was a young patient who was sent to me for chronic left upper abdominal pain. She also complained of early satiety and occasional nausea. After about her third or fourth ER visit, a CT scan was obtained which showed a 6x7 cm benign-appearing splenic cyst (pictured above) with some compression of the adjacent stomach.
The cyst did not have the characteristics of a malignancy (septations, calicified wall, etc) and she was symptomatic, so I proposed a laparoscopic partial cystectomy. Splenic preservation is paramount in benign splenic disease, especially in a younger patient. So that's what we did. The surgery went beautifully. Once the cyst was decompressed by needle aspiration (yellow/green fluid) I incised the cyst wall and then divided it circumferentially with the Harmonic scalpel in a relatively bloodless manner. The wall was sent to pathology for a frozen section to rule out malignancy and while we waited I cauterized the aspect of the cyst left in the splenic parenchyma (Argon laser is another option).
Once the path confirmed a benign epidermoid cyst, we took out the ports and closed up shop. Twenty minute case. Fun stuff....
39 comments:
- OHN said...
Another happy customer :)
- January 22, 2009 at 11:23 AM
- rlbates said...
Sounds like a very sweet case!
- January 22, 2009 at 1:05 PM
But did the symptoms resolve?
- January 22, 2009 at 6:04 PM
- Jeffrey Parks MD FACS said...
So far..... - January 22, 2009 at 6:42 PM
- DHS said...
20 minutes? you have a very fast lab. the last frozen section I was involved in, it took longer than that just to get stuff to and from the lab.
- February 5, 2009 at 5:32 PM
I have a laprascopic picture of a 7.5 cm splenic cyst if you want it to post.. Its MUCH BETTER than ultrasound pics. I tried looking them up when I found out my 15 yr old son had one.,.. First cyst came back after just cyst removed.. second time had to take spleen out. He had same symptoms but was found by palpatation by pediatrician then ct scan and ultrsound...
- February 20, 2009 at 9:21 PM
I have a 6 x 8 cm cyst in my spleen that was noticed when I had an ultrasound checking for an appendix problem. I went to my doctor and to a surgeon which the surgeon said to leave it alone and because there's many problems when working with the spleen (bleeding)... I told me that what's on the net doesn't tell the whole story....
I'm in no pain but trying to research as much possible... It seems that there's not many successful operation preserving the spleen only complete removal? any answers? - June 12, 2009 at 5:29 PM
Well, I had another CT scan last Thursday and will find out if the cyst has enlarged? I was told the next step is to get a biopsy but there's a risk of bleeding then removal! Any other methods?
- September 13, 2009 at 2:28 PM
My son has been c/o severe epigastric pain that wakes him up; 3 md's said it was anxiety; we just found a small cyst in the spleen; he has other symptoms which may be related...I'm nervous..we are going to a specialist..any suggestions?
- October 6, 2009 at 4:11 PM
- Jeffrey Parks MD FACS said...
Anon 10/6-
Small splenic cysts highly unlikely to be source of your son's symptoms. - October 10, 2009 at 9:12 PM
- evilgurl said...
my son is 20 & had some severe pain. at the ED they decided to do a CT because everything else was normal & found a spleen cyst that is 9x7x7. they said he needs surgery & they would try to reserve the spleen. reading your description eased my mind. everything else i've read scares the hell outta me.
- October 20, 2009 at 12:13 PM
- Unknown said...
Jeff I was researching the topic of spleen cyst and found your blog, if I may please ask you a question, for the last 2.5 months I have been having daily terrible spikes of pain in my left mid and upper back, sometimes the pain would radiate through out my shoulder and I even feel it in my left arm, in addition at times I have upper abdominal discomfort but nothing close to the back/shoulder pain. As a result I have undertaken a CT Scan, and the report showed this:
"The spleen is not enlarged. There is however an 8mm diameter low-density area peripherally in the spleen on the posterolateral aspect of the anterior portion of the spleen. The nature of this is uncertain"
My doctor and the radiologist does not think much of it, and they don't believe it is the cause of my symptoms, the only treatment I was offered is pain killers (amitriptyline); I am not sure what to do since the doctor is not really helping as he believes this cyst is insignificant, do you believe that my pains and this cyst is a coincidence? Or do you think they are related? What do you advice I do next?.
Thank you very much for your time,
Nawar - December 11, 2009 at 7:28 PM
- TomR said...
Hi I'm wondering if you can help. For 3 months prior to finding a Cyst on my spleen (ultra sound scan) I had problems digesting food and passing stools. The pain presented itself in the bottom of my left rib and left side of my colon as well as the middle and left side of my spine. Other symptoms include numbness in my right thigh and left abdominal muscle spasms.
My doctor is convinced the cyst and the problems I am having are unrelated. However I have recently read that an enlargement of the spleen or cyst can cause displacement on the stomach and colon. Although rare might this be possible for my symptoms and if so what are the treatments?
I'm a bit annoyed as this has been going on for 6 months. I've lost 3 stone in weight, and I have to take daily pain killers. Other tests such as blood tests and a clonoscopy have came back fine but I believe these are not looking in the right areas. - December 14, 2009 at 4:57 PM
I have a 10yr old daughter with an 8cm cyst on spleen after visits with many docs we finally have been referred to a pediatric surgeon on Monday. She has no pain but this cyst goes thru the middle of her spleen. Is the likelyhood they will remove the spleen just because of the size?
- May 1, 2010 at 9:09 PM
- the quiet one said...
Hi Everyone. Guess what? Yup, I've got a splenic cyst. It's 11.5cm by 11.4 cm by 13cm. I just found out on Monday.
My question, Dr. Parks, is: What kind of surgeon should I consult with? I saw a general surgeon and he seemed baffled. This made me feel even more scared.
Or, if you have any recommendations of surgeon in the Los Angeles area, please let me know.
~Sandra - August 1, 2010 at 4:05 AM
I too had a splenic cyst back in October 2007. My surgeon laprascopically unroofed the cyst. 3 years later, I am feeling the same symptoms I did the first time. Pain in the upper left rib cage which is caused from the cyst laying on the diaphragm. I thought I was done with this chapter in my life, guess not - here we go again! I really wanted to try and save the spleen.
- September 14, 2010 at 9:26 PM
After two months of treatment for left shoulder pain, I was rushed to the ER with abdominal pain. BP 198/111, WBC 27000. CT showed 9cm cyst in my spleen. Three days later, docs drained 500cc brown fluid(very painful) and loaded me down with anitbiotics. A week later, nothing had grwoth per pathology. Still have no idea what caused this or will it return. WBC back to normal...still slight abdonimal and shoulder pain.
- October 16, 2010 at 6:53 AM
My 17 year old daughter has been complaining for 1 month of a pain in her left shoulder that radiates to her left ribcage and she has difficulty breathing. Her episodes lasted 2 to 3 days and lessened after each day. After two trips to emergency room, and after being told she had pleurisy and muscle spasms, I took it upon myself to bring her to a cardiologist. Her heart is fine, but they found a 9.5x8.0x9.6 cm cystic lesion on her spleen. She is scheduled for surgery next week to have the cyst removed. They surgeon said the cyst would continue to grow if we leave it in. We can't ever remember her having any type of injury to her spleen that would result in this cyst. Can't really find any information on removal of cystic lesions other than the one Buckeye Surgoen spoke about. Any information would be appreciated.
- November 19, 2010 at 10:08 PM
Our 16 yr old son presented with left shoulder pain and shortness of breath. CT scan identified an 8x8.4x7.4 size cyst on his spleen. It is positioned posterirly and superiorly. This location is not very conducive for the dr.
We have seen three surgeons, each with varying objectives. One surgeon is absolute about removing the entire spleen. He feels due to the position under the diaphragm and the size of the cyst this is the safest solution. He feels by leaving a wall of the cyst it will return and then our son will face another surgery to finally remove the spleen.
The next surgeon is a pediatric surgeon and his objective would be to preserve the spleen and remove as much of the cyst as possible by doing very much same procedure as Buckeye Surgeon did on this original post. This pediatric surgeon feels there would be about a 10-15% chance of reoccurance of the cyst. It is not definitive but cyst appears to be congenital, so who knows how long it took to grow to this size?
As his parents we are perplexed with which route to go. We are leaning toward preservation of the spleen. Even if it only buys him a few more years.
Anyone have any more experiences with this type of situation?
Dr. Buckeye, I would be glad to send you a copy of the CT scan for an opinion too! :) - December 8, 2010 at 2:26 PM
- Jessica said...
im 19 i have a 13x 11 cyst in my spleen....
- December 10, 2010 at 9:49 PM
I was told back in December of '10 that I have a 13.5X16.4X17.8cm cyst on my spleen.
I have to have surgery to have it removed this Monday (1-31-11).
I get really bad shoulder pain. And here recently, I've been having really bad neck pain. Can the size of the cyst cause the neck pain, too?
They are going to try to do a laparscopic surgery, but they say it still can turn into an open surgery. - January 29, 2011 at 9:24 AM
- Jessica said...
I had my cyst removed in january it was 11x13 by the end of February beginning of March i started gettin shoulder pain again and then i started to notice that my spleen was swelling up and i was feeling the way i had before i was informed that it was a cyst. By mid march my cyst had returned and at that time it was bout 3cm.. i was told there was no sign of cancer which was great but i was probably born with it.
They had put a put a lining of fat where my cyst had started hoping that it would help it from not coming back. Surgeon thought i was crazy when i told him i had signs of it coming back.
I go back next month to see how much my cyst has grown since March. I do not wish this on anyone at all it is horrible. The surgery was not fun at all and the days after sucked. - May 25, 2011 at 1:04 AM
i got a 8cm cyst on my spleen i had it drain once already when it was 10cm they took 230mls out of it but after 2 weeks it come back and it hurts twice as bad then the first time my surgeon team that i am going through said i will be waitting 2- 3 months to have it remove and i am worryed that it will bersh what can i do to get in sooner
p.s i have 2 young childern under 3years old that i have to look after and it is very had to look after then
thank you for your time i hope to hear from you soon - August 8, 2011 at 9:12 AM
- Jessica said...
so my cyst is now 11cm...surgeon wont do surgery yet...could the cyst harm my immune system?? just wondering cuz i know the spleen helps fight infections so i was wondering if the cyst could stop it from fighting infections...my cyst isnt on the outside of the spleen like it seems like most are..mines actually in my spleen
- August 22, 2011 at 5:06 AM
- jiya said...
hi, iam 29 weeks pregnant and having a larga cyst with 17cm x15cm ,i have already had a laproscopy , but it came again. iam jus so worried abt my pregnancy, just hope it will not cause any complications during my pregnancy. pls help me and my unborn!!!!!
jiya - September 16, 2011 at 7:30 PM
Well, I posted on this thread Feb. 20th 2009 with a spleen cyst which I still have and is increasing in size at very low rate...Now, I'm starting to get pressure points in my back (not pain) and to date no new developments on dealing with spleens cyst other than removing just like in the 1800's. All these new tools and the surgeons answer is removal? Any bright educated answers?
- September 26, 2011 at 11:07 AM
I dont think I have spleen cysts but a lesion on my spleen that they saw on the CT last night. They are sending me for an MRI next week. I have fever on and off for a month and pain in my upper left tummy area. Any suggestions on what this could be? Should I be worried?
- September 28, 2011 at 11:25 PM
- blogger2011 said...
I stumbled upon your site while researching splenic cysts. I found out last August that there is a 6.6cm cyst on my spleen. It was found accidentally and I left it alone because the ER doctor didn't seem worried and didn't recommend me to see my PCP or a Specialist. Then I went to my gyno yesterday and asked about the cyst and if she could shed some light on the subject. She looked up my history and found that when I was in the ER a cyst was found on my spleen but no orders were given as to what to do with it. She said not to worry because if there was something to worry about they would've told me. Well, curious, i started to research and everything I find tells me otherwise. Can you please give me some advice? I don't have the symptoms others seem to have but I'm worried this could turn into something and I'd rather have it taken care of before anything truly bad happens.
Thanks so much - October 12, 2011 at 8:14 PM
hey there i am a 18 year old male with a 8x6 cm cyst on my spleen, yesterday i went to the emergency part of the hospital an had an x ray showing 6 staples in the top left part of my rib cage.. he said it was from when i was 8 an had the cyst burst (not the first time ive had them i guess) but my spleen is in the lower part of my abdomen.. any explanations, im having severe pain by my heart or on my heart and lower left abdomen, and he said i dont have to worry it should be fine.. but im skeptical cause it reallllly hurts? shed any light?
- December 5, 2011 at 8:18 AM
My ct scan showed decreased attenuation within the liver 5 mm cyst in the inferior aspect of right hepatic lobe 8 mm splenic cyst adjacent to the peritoneum there is a 3. Cmx1.8 cmx3.6 cm partially cystic lesion with enhancing internal septation and enlarged lymph nodes and benign appearing fatty hilum and small subcentimeter bilateral inguinal lymph nodes. No one seems to think it is a big deal and I can not keep spending money and do not know where to begin with what to do with my pain. So I have stopped going to the dr. Untill symptoms get worse because dr. Said sometimes symptoms need to get worse before diagnoses. I feel dizzy and weak but have a appetite.
- December 6, 2011 at 10:10 AM
Well, it's been about 3 years since the discovery of my spleen cyst which has been increasing at a very slow rate.... I'm not reading any new developments on preserving the spleen but the same old 1800's method of choice "splenectomy"...? Can the surgeon that produces this forum shed some light on the subject of new procedures, surgeons on the cutting edge...anything????
- February 20, 2012 at 7:15 PM
A couple of years ago I had a cyst on my spleen. I was active in sports but didn't know of any time when trauma may have caused the injury. The pain was especially felt in my left shoulder but began hurting in the upper left side (front and back) of my abdomen. I initially thought the pain in my shoulder was a badly pinched nerve or my back being out of alignment, but it was actually the spleen sending pain signals through the nerve that runs from the diaphragm up to the shoulder (known as referred pain). It was painful to lean back in a chair, to lay down, to breathe deeply, and sometimes movements in general (like the vibrations caused from walking).
After a year or so, and as the cyst grew, the pain and discomfort got to the point that I eventually went to the emergency room. They did a CAT scan and found a large cyst on my spleen. Soon after they did a peculation to drain the cyst and see if that resolved it. They drained a liter of fluid out of the cyst! It was mostly comprised of old blood (no cancer or anything). Unfortunately, the cyst came back and they had to result to surgery. Initially my doctor thought he was going to have to remove the spleen, but he decided to call around for second opinions (thank you doc!). He found an alternative solution and ended up doing a laparoscopic procedure that removed the cyst and then he burned the surface of the spleen to try and prevent it from coming back. It worked. I still have my spleen today. - May 22, 2012 at 1:42 PM
In 2005, I was down with mild fever for 5 days and I admitted myself to hospital. They did a check up and ultrasound and said I had a splenic cyst about 7cmx8cmx8cm. Initially doctor asked me to remove my entire spleen. I was not so agreeable to such drastic measure so he did a drainage instead. The cyst reduced in size and I was finally discharged after 5 days. After a month I came back for a follow up and they found that the cyst had filled up back to the same size. I had no pain and I have no other symptoms till this day and it has not cause me any discomfort or pain what so ever.
- July 31, 2012 at 10:27 AM
Nine years ago I had laproscopic surgery to deroof a large splenic cyst. It was causing a lot of pain after eating. Now I find it's back and bigger (15cm x 12cm x 10cm). Suprisingly I'm fairly asymtompatic expect craming on the left side while running. I was going to have the cyst drained and then put alcohol in to help kill the membrane cells since the surgey did not work and I want to keep my spleen. Has anyone tried this? There is too much of a shared membrane with my spleen to really remove a lot of the membrane w/o spleen removal. Also, has anyone had surgery twice with the cyst not returning the second time?
- January 3, 2013 at 2:08 PM
- whiskas said...
20 years ago, when I was 14, they discovered a huge splenic cyst. They initially drained, and it grew back quickly. The second time, they drained it and put some alcohol in it to irritate the lining of the cyst. Again, it grew back. The third time, they put more alcohol in, and it apparently did the trick.
However, they did not do a follow-up CT scan at the time to actually check what it looked like afterwards.
So...fast forward 20 years to last year, where I felt some mild discomfort in the area, had a CT scan, and yes the cyst was still there, however much smaller. But it was very calcified (possibly from all the alcohol).
I went to a few different doctors/surgeons, some said to remove the spleen altogether. Another said if possible, it would be good to try and preserve the spleen.
So I opted to drain it and do the alcohol, which wasn't successful as the cyst grew back.
Anyway, now I'm just not sure what to do. One idea that's been suggested to me is: Laparoscopic fenestration with omentopexy.
It seems some people have had success with laparoscopic procedures.
Here'a a link to an article about a ten-year study of lapascopic treatment of splenic cysts:
- February 10, 2013 at 11:16 AM
I'm curious too if anyone has ever done a second surgery and had it successful. I had mine splenic cyst deroofed back in 2007 and I'm feeling symptoms again. Really would like to keep my spleen!
- September 18, 2013 at 11:37 AM
- Kirs71 said...
Advice please. I have been told I have a calcified splenic cyst 13cm in my spleen. The registrar I saw (+ my Dr) have not seen this before!
Confused and worried, I have upper left abdominal and back pain with swelling & fatigue.
Thanks in advance. - October 10, 2013 at 6:02 AM
- Diana said...
Not sure is anyone is still checking this, I have a splenic cyst 15cm x 14.4cm x 13cm found accidentally during an ultrasound. I have had left shoulder pain for years and occasional left abdo pain but because I wwasn't having the ultrasound for those reasons the Dr didn't want to touch it. I have a follow up booked for 3 months but I wonder if removing it would help with my shoulder pain and bad acid reflux. The radiographer noted that it appeared to be pushing my stomach up. Should I get a second opinion to see if it should be removed
- May 26, 2014 at 11:58 PM
- Unknown said...
A 54 year old non smoking non drinking white female, was recently treated for sinus infection with anti biotic. She is now being treated for pleurisy with anti biotic. She has a splenic cyst with calcification around it, 5 cm.
Without seeing her in your office, what can you tell us? I thank you most kindly, John - November 3, 2014 at 11:09 AM


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On Oct. 8, 1912, the tiny Kingdom of Montenegro declared war on a weakened Ottoman Empire, kicking off what is now known as the First Balkan War. Three other Balkan states in league with the Montenegrins—Bulgaria, Greece and Serbia—rapidly followed suit, waging war on the Turks, the old imperial enemy, while drawing upon a wellspring of national sentiment in each of their homelands. By March 1913, their blood-soaked campaigns had effectively pushed the enfeebled Ottomans out of Europe. Yet by July, Greece and Serbia would clash with Bulgaria in what's known as the Second Balkan War—a bitter month-long struggle that saw more territory change hands, more villages razed and more bodies dumped into the earth. Some 200,000 soldiers died in less than a year, while countless civilians were slaughtered in pogroms or died of disease and starvation. The conflict, as argued here, in many senses set the tone for the future of war and ethnic strife in the 20th century.
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By a margin of 8-2, the Indiana State Senate's Education Committee passed a bill designed to insert the teaching of "creation science" alongside evolutionary theory in public school science classrooms. Senate Bill 89, which the Republican-dominated committee passed last week, would give schools the freedom to decide if they wanted to allow "the teaching of various theories concerning the origin of life," one of which is creationism.
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The bill will now be considered by the full Indiana Senate, which, according to the Chicago Tribune, has until this Wednesday to win approval.


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COREY FLINTOFF, BYLINE: Kazansky Station faces east, its tracks running toward the Ural Mountains. On a winter's day, it's a damp, cavernous place that smells of coal smoke, where passengers rattle their suitcases over the platform tiles.
Sergei Lozhkin is waiting for a train heading home to Ufa, an industrial city on the edge of the Urals, about a thousand miles east of Moscow. He looks relaxed and prosperous, younger than his 51 years; with a sandy, bristling mustache. He's fairly cheerful about his life.
SERGEI LOZHKIN: (Foreign language spoken)
FLINTOFF: My wife and I both work, he says. We're not eating our last piece of bread - meaning, we're doing all right.
He's proud that his son has an advanced degree in chemistry, and that his daughter-in-law is a doctor. They got everything they have with their brains, he says. Lozhkin himself is a welder who's been in his current job for 20 years. He and his wife lived through the turmoil after the fall of the Soviet Union.
LOZHKIN: (Foreign language spoken)
FLINTOFF: He says he prizes stability, and credits Vladimir Putin with achieving it. He says Putin has done a good job and will get his vote.
Valentina Dregunova is waiting for a train to Tolyatti, a car-manufacturing town on the Volga River. She's an imposing figure, a tall woman of 69 with white hair clamped under a helmet-like hat. Dregunova is a retired teacher who says things have gotten better over the past 10 years or so.
VALENTINA DREGUNOVA: (Foreign language spoken)
FLINTOFF: She says she and her husband have had their pensions raised several times recently, and state workers have seen a salary hike.
Dregunova says she, her son and her daughter live well, with nice apartments and a dacha, or summer house.
DREGUNOVA: (Foreign language spoken)
FLINTOFF: As to the presidential candidates, she's impressed by Mikhail Prokhorov, the billionaire newcomer to Russian politics. But this time, she says she'll vote for stability and Vladimir Putin.
FLINTOFF: Further down the platform stands a young man who's also waiting for the train to Tolyatti. His name is Dmitry Chevozyorov. He did his schooling and started his working life during the Putin years, but he knows his family suffered in the years before Putin came to power. After the fall of the Soviet Union, Chevozyorov's father started a finance company, but lost it to a bribery scheme.
DMITRY CHEVOZYOROV: It's criminal. And people in power, they take his business. They said, it's not good; you don't pay for us. You must pay for us. He said no and so now, he's jobless.
FLINTOFF: He's had no job since 1999, and Chevozyorov blames the political movers and shakers in Tolyatti. It may not be surprising that Chevozyorov became a lawyer, or that he thinks corruption is one of the country's biggest problems. He looks as if he belongs in a play by Chekov - tall and thin, with rimless glasses, and sandy hair that reaches to the collar of his turtleneck sweater. Now 26, he says he and his wife plan to have children but that they're waiting.
CHEVOZYOROV: I worry about money. And I worry about my own house, or flat.
FLINTOFF: He says if the Russian government really wants to raise the birth rate to counter the country's population decline, it must provide affordable housing.
CHEVOZYOROV: I think it's wrong. Our government must change politic, because I'm not interested to born a lot of children when I haven't got own house or flat.
FLINTOFF: Chevozyorov says he's certain that Vladimir Putin will win, but he likes Mikhail Prokhorov.
CHEVOZYOROV: But I think he can't win. But I think I'll vote for Prokhorov. Why not?
FLINTOFF: Chevozyorov welcomes the big opposition protests in Moscow, and says there were demonstrations in Tolyatti as well.
CHEVOZYOROV: I think it's popular to be interested in politic, and lots of young people interested now.
FLINTOFF: And, he says, boarding the train, that includes his friends at home.
Corey Flintoff, NPR News, Moscow. Transcript provided by NPR, Copyright NPR.


text: Good morning. I'm Steve Inskeep. A French woman received a telephone bill and immediately noticed something wrong. The numbers showing how many euros she owed had the decimal point in the wrong spot and an extra 12 zeroes. She owed 11 quadrillion euros. She called the phone company and an operator said, sorry, a computer generated that, can't change it. The company finally relented, which is too bad, because if she'd paid it could've solved the European debt crisis. You're listening to MORNING EDITION. Transcript provided by NPR, Copyright NPR.


text:
As the days get warmer I find myself turning to salads more often. Add a bit of meat to a salad and you have a nice light meal. One of my favorite meats is salmon and one of my favorite ways to cook it is teriyaki style. I thought that a spinach salad with asparagus and salmon teriyaki would make a nice meal. This would be a great way to use up any leftover salmon teriyaki that you might have. I rarely find myself with leftover salmon teriyaki though and this dish was well worth the effort of cooking the salmon. I dressed the salad with a simple teriyaki based dressing and I filled the salad out with vegetables that I had on hand.
Teriyaki Salmon and Asparagus, Spinach Salad
- 1/4 cup teriyaki sauce
- 1 serving salmon (deboned)
- 1 handful asparagus
- 1 tablespoon teriyaki sauce
- 1 teaspoon honey
- 1 teaspoon ginger (grated)
- 1 clove garlic (grated)
- 1 lime (juice and zest)
- 1 teaspoon sesame oil
- 2 handfuls baby spinach
- 1 handful grape tomatoes
- 1 handful cucumber (sliced)
- 1 handful peas
- 1 green onion (sliced)
- sesame seeds (toasted)
- Place the teriyaki sauce and the salmon in a ziplock bag and let marinate in the fridge for a 30 minutes to a few hours.
- Cook the salmon in a preheated oven set to broil for 5-10 minutes. Pour some of the marinade over the salmon several times while cooking.
- Let the salmon cool.
- Steam the asparagus until just tender.
- Run the asparagus under cold water to stop the cooking process.
- Mix the teriyaki sauce, honey, ginger, garlic, lime juice, lime zest and sesame oil in a small bowl.
- Assemble salad and top with flaked teriyaki salmon and pour teriyaki dressing on.
Salmon Teriyaki
Teriyaki Mushroom Salad
Chicken and Asparagus Salad with Creamy Tarragon Dressing


text:
9740 Scranton Road
San Diego, CA 91913
This Privacy Policy and Data Processing Statement (the "Policy") explains the use of information that PriceSmart, Inc. ( "PriceSmart") is provided with by the owners of the information (be it a member, vendor, contractor, employee or any other person, by virtue of a relationship with PriceSmart), whether provided in connection with shopping in any of our warehouse clubs ("Warehouse Clubs"), when registering in our website, or by any other means. This Policy enables you to make knowledgeable choices about whether to provide your personal information to us, and also advises you of the opportunity to direct us to limit the manner in which your personal data is used by us.
PriceSmart believes it is important to protect the privacy of our members and other personal data owners. We gather and use your information, including your name, contact information, mailing address, email address, other identifying information, purchasing history, etc. only to serve you better and to fulfill our corporate mission.
By using this website to send personal data, by submitting your application for a PriceSmart membership or its renewal, by shopping in our Warehouse Clubs, and/or by having a commercial or employment relationship with PriceSmart, you are performing an unequivocal act that allows us to conclude that you have accepted the terms and conditions described in this Policy.
You provide and we obtain your personal information when you:
We undertake commercially reasonable efforts to protect such information from unauthorized access, loss, misuse or alteration, through technical, contractual, physical and administrative measures.
When you visit our website, we may automatically collect information that may help us recognize you as a member and help us better serve you, such as, without limitation: your computer's network address and operating system, the site from which you linked to us, your site activity and the time and date of your visit and purchases. In a confidential and responsible manner, we collect, process and maintain certain payment information, in compliance with the data security rules adopted by credit card companies such as Visa, MasterCard and American Express. This means that we do not retain full credit card numbers, debit card PINs or credit card security codes, and that any time we maintain the last four digits of a credit card number, we use access controls and suitable encryption to protect it. If you use our website to provide us with personal data, your transmission will be protected by Secure Socket Layer (SSL) or Transport Layer Security (TLS) cipher encryption technologies.
As discussed below, we may share your personal identifiable information with affiliated companies and with others under the limited circumstances described below.
In the case of members, PriceSmart uses the personal information we collect to process your orders or transactions, to follow up on any requests or comments you may have, to provide quality member service, and to understand your shopping needs so we can better serve you. We may also use your personal information to provide you with promotional information, products and services as well as special notifications, as a part of the value of your membership. In the case of employees and suppliers, PriceSmart uses your personal information to process payments, support external/internal audit processes, and additional purposes in an effort to enhance the relationship between you and PriceSmart.
If you provide us with personal information, we will not sell, license, transmit or disclose it outside the PriceSmart group database unless: (i) you expressly authorized us to do so, or (ii) it would facilitate providing products or services to you, or (iii) it is to be disclosed to entities that provide services of marketing on our behalf or to other entities with which we have joint marketing agreements, or (iv) required or permitted by law or court order.
Within the above terms, PriceSmart may disclose your personal information to affiliated companies which are owned or controlled by PriceSmart and also to third parties. Additionally, we may disclose your personal information to our bank affiliate(s) in the PriceSmart Co-branded Card program for the purpose of facilitating credit card offers and applications as well as other promotions related to the Co-branded Credit Card program.
If you apply for, or request certain products, offers or services, the personal information you provide may be shared directly with the third parties providing the requested products, offers or services. Affiliated third parties with whom we may share information are required not to use personal information we share for any purposes other than to provide the services we request. Because we are not responsible for any additional information you provide directly to these parties, you should become familiar with their privacy and security practices and policies before disclosing information to them. We are not responsible for any information you provide to third parties. If you provide additional information to third parties, they may (subject to applicable laws and their privacy policies) share with us the information you provided and information about your use of the services. In addition, if we terminate our relationship with the third party, information you provided to them may be provided to us, and we may provide that information to a new third party offering the same or similar services.
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Similarly, we may transfer or transmit (as applicable) your personal data to other companies abroad for reasons of security, administrative efficiency and better service, unless you instruct us otherwise. PriceSmart has adopted these measures so that those companies implement, in their jurisdiction and in accordance with the applicable laws, standards of safety and protection of personal data similar to those provided for in this document andPriceSmart policies in general. Additionally, please be advised that if our need for processing your data ceases, it may be removed from our databases.
Under agreements between PriceSmart and third parties, PriceSmart may match user information with third party data. Also, PriceSmart may disclose aggregated member statistics (e.g. percentage of female shoppers, percentage of online users) in order to describe our business or services to prospective partners, advertisers, and other third parties and for other lawful purposes.
Cookies are alphanumeric identifiers that we transfer to your computer's hard drive through your web browser to help us identify you when you come to our website. You have choices with respect to cookies. By modifying your browser preferences, you have the choice to accept all cookies, to be notified when a cookie is set, or to reject all cookies. If you choose to reject all cookies you will be unable to use those PriceSmart services (e.g. PriceSmart.com online purchasing) which require registration in order to participate.
In accordance with the above, you may direct us not to send to you any promotional offers or other communications for marketing purposes, or request that we otherwise limit the use and distribution of your personal information. As a PriceSmart member you may give PriceSmart the foregoing direction by written notice to our membership services desk at any of our Warehouse Clubs, or by contacting us via email (see below) or by updating your personal profile on this website if one exists and checking the desired direction(s). Although the information is collected, you may limit the way it is used.
PriceSmart uses Google Analytics to analyze traffic to this web site. Google Analytics does not create individual profiles for visitors and only collects aggregate data. For more information about Google Analytics, please click here: http://www.google.com/analytics/
You have the right to access your personal identifiable information held by PriceSmart. You may correct factual errors in such information by sending a request to us that credibly shows the error. Contact any of our Membership Services representatives at our Warehouse Clubs about how to exercise your rights, or you may otherwise contact us as described below. To protect your privacy and security, we will take reasonable steps to verify your identity before granting access or making corrections.
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Date of Issuance: March 15, 2014
Modified: October 3, 2014


text:
A Surrey State of Affairs
Ceri Radford
The trends are changing for writing fiction – Blogs, Facebook and Twitter have altered communication, moreover how we get our information. Bloggers use their online space to explore ideas, fears and the banal, like what they had for lunch. It's user-generated content in its rawest form.
Ceri Radford is no stranger to blogging. She's the author of a popular Telegraph character blog, which helped to inform her debut, A Surrey State of Affairs featuring the quintessential Home Counties wife, mother and village bell-ringer, Constance Harding.
Constance starts her blog on 1 January 2008, charting her journey through the trivia of suburbia. Her 25-year-old son refuses to get married, while her 18-year-old daughter has a penchant for reality TV and older men. As Constance struggles to accept that reality isn't necessarily a bed of roses, through her blog she begins deciphering the true meaning of life. She's a lovable character, wrapped tightly in her own little world, and as the passages continue there's a wry humour that grips the novel making it a truly fast, but enjoyable read.
Shirley Stevenson
Bryony Byrne


text:
Get the spin feel and control you need to attack the pin with the Forged Dark Chrome Wedges from Callaway Chief Designer Roger Cleveland.
Temporarily unavailable.
Get the spin, feel, and control you need to attack the pin with the new forged clubs from Callaway Chief Designer Roger Cleveland. These clubs come with new finishes that say confidence with their striking looks. Get ideal trajectory and distance control with the Tour CC Grooves, along with precise shot-making and versatility with the softer 'C' shape.
The 21 grooves are tightly spaced and conforming with sharper edges from our superior triple net forging process, which gives you the best distance and trajectory control. Moisture is swept away with the maximum conforming groove capacity so more edges hit the ball to increase friction and maximize spin.
The wedges are made from 1020 carbon steel for a softer feel. Callaway Chief Designer Roger cleveland designed these wedges with a traditional look, including a straighter edge and higher toe. It all combines for a square look at address.
A muted smokey look is included in with the Trivalent Dark Chrome. Callaway used copper for the first time in the Copper Finish. It will oxidize and look better and more distinctive every day.


text:
Visa and MasterCard are
renewing a push to speed the adoption of microchips into U.S. credit and debit
cards in the wake of recent high-profile data breaches, including this week's
revelation that hackers stole consumer data from eBay's computer systems.
Card processing companies
argue that a move away from the black magnetic strips on the backs of credit
cards would eliminate a substantial amount of U.S. credit card fraud. They say
it's time to offer U.S. consumers the greater protections microchips provide by
joining Canada, Mexico and most of Western Europe in using cards with the more advanced technology.
Chips aren't perfect, says
Carolyn Balfany, MasterCard's group head for U.S. product delivery, but the
extra barrier they present is one of the reasons criminals often choose to
target U.S.-issued cards, whose magnetic strips are easy to replicate.
"Typically, fraudsters
are going to go to the path of least resistance," Balfany says.
The chip technology hasn't been adopted in
the U.S. because of costs and disputes over how the network would operate.
Retailers have long balked at paying for new cash registers and back office
systems to handle the new cards. There have been clashes between retailers,
card issuers and processors over which processing networks will get access to
the new system and whether to stick with a signature-based system or move to
one that requires a personal identification number instead. These technical
decisions impact how much retailers and customers have to pay - and how much
credit card issuers make - each time a card is used.
The disputes have now largely
been resolved. And the epic breach of Target's computer systems in December,
which involved the theft of 40 million debit and credit card numbers, along
with smaller breaches at companies such as Neiman Marcus and Michaels, helped
garner support for chip-based cards among retailers who were previously put off
by the costs.
Chip cards are safer, argue
supporters, because unlike magnetic strip cards that transfer a credit card
number when they are swiped at a point-of-sale terminal, chip cards use a
one-time code that moves between the chip and the retailer's register. The
result is a transfer of data that is useless to anyone except the parties
involved. Chip cards, say experts, are also nearly impossible to copy.
For its part, Target is
accelerating its $100 million plan to roll out chip-based credit card
technology in its nearly 1,800 stores. New payment terminals will appear in
stores by September, six months ahead of schedule. Last month, the retailer
announced that it will team up with MasterCard to issue branded Target payment
cards equipped with chip technology early in 2015. The move will make Target
the first major U.S. retailer with its own branded chip-based cards.
Even so, the protections chips
provide only go so far, according to opponents who note that chips don't
prevent fraud in online transactions, where consumers often enter credit card
numbers into online forms. Some opponents also point to other technologies,
such as point-to-point encryption, as better long-term solutions.
Ken Stasiak, founder and CEO
of SecureState, a Cleveland-based information security firm that investigates
data breaches, says that while chips would be a big security improvement, they
wouldn't have stopped the hackers from breaching Target's computer systems
where they also stole the personal information, including names and addresses,
of as many as 70 million people, putting them at risk of identity theft.
"Chip and pin is just
another security component," Stasiak says. "What matters is how
companies like Target use consumer information, how they protect it."
Banks generally pick up the
tab for credit card-related losses, but companies such as Visa and MasterCard
stand to lose too, if data breaches continue to occur with increasing frequency.
After all, if consumers don't feel safe using cards, they may choose other ways
to pay for purchases.
"It's not just about
fraud and losses, it's about the trust involved in electronic payments that's
destroyed," says Ellen Ritchey, Visa's chief enterprise risk officer.
In March, Visa and MasterCard
announced plans to bring together banks, credit unions, retailers, makers of
card processing equipment and industry trade groups in a group that aims to
strengthen the U.S. payment system for credit and debit cards. The initial
focus of the new group will be on banks' adoption of chip cards.
That comes ahead of a
liability shift set to occur in October 2015, when the costs resulting from the
theft of debit and credit card numbers will largely fall to the party involved
with the least advanced -and most vulnerable- technology. For example, if a
bank has updated to chip technology, but the retailer involved hasn't, the
retailer will be liable for the costs.
Stasiak says many of the
retailers he works with already have the technology in place. Once the banks
start issuing chip cards, the retailers will activate their new systems, he
Banks say that despite the
jump in high-profile data breaches, fraud still accounts for a small fraction
of total transactions processed, while the cost related to issuing chip cards
to all of their customers and switching out all of their ATMs is substantial.
Banks have urged lawmakers to make retailers more accountable for their own
security in hopes of recouping more of the losses from cybercrime.
Richard Hunt, CEO of Consumer
Bankers Association, says that in cases of major fraud, banks have generally
been able to collect only pennies on the dollar from the retailers involved.
Hunt says even if banks put
chips in cards, it won't do any good if retailers don't upgrade their systems.
"We have to improve fraud
prevention across the board," he says. "There are people who get up
every day across the world with one mission and that's to break credit card
technology. But there's no magic pill out there. The solution involves
The article above is a repost from Abney
and Associates.


text:
Fedora 网站项目最初的目的是提升 Fedora 的图像体验并对用户和贡献人员制作最好的用户界面。
关于 Fedora 网站项目
- Consolidating all key Fedora websites onto one uniform scheme
- Maintaining content that doesn't fall under any particular sub-project
- Generally, making the sites as fun and exciting as the project they represent
In order to better achieve these goals, as well as to benefit the community, the work of this project will involve third-party site maintainers where possible. The direct work of this project is limited to the formal Fedora site.
Work on specific sections of the sites will be coordinated by the appropriate projects. A great deal of coordination will be necessary with the Fedora Infrastructure Team , Fedora Documentation Project and the Fedora Marketing Project .
For a list of community websites, see the CommunityWebsites page.
请前往 加入 页面了解具体要求。
- 邮件列表: 所有人必须订阅 websites 邮件列表。
- IRC频道: #fedora-websites[?] 是您讨论有关网站问题的最佳去处。
- 会议: 网站团队会议。
找到了一个 Bug?
Create a new ticket and we'll be notified.
Alternatively, email webmaster AT fedoraproject DOT org which is sent to the websites list.
Fixing a bug or sending patches?
Here is how to fix bugs on the Fedora Project website.
Patches can be sent to our websites list.
跟踪一个 Bug?
Bug tracking for the Fedora websites is handled through our Fedora Websites Trac instance.
Bugs that are related to the Fedora Documentation Project or http://docs.fedoraproject.org can be reported using this template .
这些任务各不相同,从html/css 修改到 python 编程都有。
These are projects with specific goals being worked on. They're in rough order of the priority, but remember, you decide priority by voting with your feet and doing things to move these projects forward.
Wiki Theme Update
Update this Wiki's theme to match fedoraproject.org's 960.gs design.
Team: Sijis Aviles, Ian Weller
Status: Not started
Deadline: Spring 2012
All Fedora Websites Theme Update
Update all Fedora websites simialar to fedoraproject.org's 960.gs design. The list to tackle are the ones in the website git repository.
Team: Sijis Aviles (lead)
Status: Not started
Deadline: Summer 2012
Make sure all websites, primarily fedoraproject.org is translated for Fedora releases.
Team: Nobody yet! Please help!
Deadline: Ongoing
(If you are interested in picking this up and keeping us from panicking then, that would be awesome. Please email the list if you are keen on this, and someone will respond to you.)
Decision making process
Articulate and document the consensus-based decision making process of the websites team.
Team: Sijis Aviles (lead)
User gallery
Create a gallery for mini-interview-style user profiles and stories. This may end up being in conjunction with existing projects/frameworks/pages such as Community.
Team: Hiemanshu Sharma (lead)
Status: Stalled
Deadline: N/A
CSS and Images
All CSS files and images used in Fedora sites can be found in our fedora-web.git repository. The community may use the css directly from our urls in a cascading implementation.
We encourage using the stylesheets in a cascading method when working on official Fedora Project domains (sites on this list): Websites/DomainsList
Fedora CSS in your application
Load the Fedora CSS file fedora.css
And then load your custom css file and override elements as needed. As an example, something like main.css (as used for fedoraproject.org/wiki).
Boilerplate responses to common mailing list inquires
- Fedora 定制发行版页面
- 重新设计 fedoraproject.org
- join.fedoraproject.org (fedoraproject.org 重设计的一部分)