text:
If the sound bite is the new order, then how do we make every word count?
If the sound bite is the new order, then how do we make every word count? In todays surplus world of communication overload and cultural clutter, writer and cultural critic Masha Tupitsyn turns to the media matrix of Twitter to explore the changing ways that we construct and consume narrative. Loosely applying the discerning aphorism—a compressed genre in itself—to a 21st century context, LACONIA: 1,200 TWEETS ON FILM offers meditations on film and popular culture that resonant with laconic meaning and personal insight while getting to the heart of the matter. Inspired by Chris Markers free-associative film impressions in La Jet èe and Sans Soleil, LACONIA is part film diary, part cultural inventory, and part mashup. Pulling from an array of film, popular culture, books, and mainstream news, it offers penetrating critical commentary on an increasingly muddled virtual world. LACONIA consists of brick by brick prose, as Tupitsyn thinks in sentences and lines that culminate in an architecture of thinking.
"Tweet by tweet (brick by brick), LACONIA creates a web of insightful cultural criticism, it creates a bridge between the present – through its tweet form, through the films and current pop culture taken under the microscope – and the past – again through its form (the aphorism, the fragment), through the author's nostalgia for the American cinema of the 1970s (the very cover of the book, with its 1970s blue and yellow, announces this nostalgia), nostalgia for real faces, untouched by the plastic surgeon's knife, through a perceptiveness for actors and acting (real vs. fake, then vs. now) that echoes Robert Bresson's concern for his models. LACONIA is a very powerful book – and you realize that later, when you're watching a random film and something (a face, a phrase) will seem to echo fragments from LACONIA." ~ Anamaria Dobinciuc, Projectorhead Magazine
"...Upon opening the book that is Masha Tupitsyn's LACONIA: 1,200 Tweets I found myself struck by its layout as an interrogation of space, one which contains and spells out an inventory of nuance in the form of 1,200 time-stamped tweets. So rarely does one encounter 'the official' time of writing, or, the ticker, as it were, of criticism. And yet, Tupitsyn's LACONIA is both intriguing and alluring in that it is timed and timed right: it is a kind of culture bomb which implodes the space between forms, between the haiku and the tweet, between the book that you hold and the text that you scroll. Furthermore, the fall-out of Tupitsyn's bomb is carefully curated and concise...But where one might claim the instant as favored by Tupitsyn is not a palpable or rich site of theoretical and cultural inquiry, LACONIA invites the skeptic to imagine otherwise and to take seriously the nano-caesuras between times, thoughts, and insights as an urgent, dynamic, and desperately needed critical space. In this way, LACONIA's logic functions as a proposition: one which accepts the challenge as described by filmmaker Su Friedrich where 'the challenge comes in trying to push film beyond its usual narrative capacities--so that the form takes as many risks as the content.' Tupitsyn accepts the challenge and makes a mosaic out of risky critique.'" ~ Lara Mimosa Montes, Puerto del Sol Magazine
"There is a useful but not very respected mode of criticism — lets call it micro-criticism — that is made possible by the Internet," writes Girish Shambu in an entry inspired, at least in part, by the ongoing Project: New Cinephilia. "[W]hen it is practiced well, it can be valuable, insightful, and forward-looking, while working in small, daily, and humble ways. His focus, of course, is on Facebook and Twitter and the subtle yet vital differences between the kinds of critical discourse each enables, and he eventually works his way into a quote from Raymond Durgnat: "The business of criticism seems to me matters arising, and naturally varies from film to film. Id rather be wrong but open up a perspective than be right, i.e., dismiss opportunities for the full, intellectual, sensual, emotional experience of reflective hesitation." The emphasis is Girishs, and he adds, "I think theres a lesson here for Internet micro-criticism. The short, succinct form of tweets or Facebook status updates furnishes a useful freedom — to record observations, try out ideas, hazard lines of analysis, risk hypotheses, identify contradictions, think laterally rather than linearly, all in a spirit of reflective hesitation.
As examples of just a few of micro-criticisms "gifted practitioners," he points to the Twitter feeds of Michael Sicinski, Ignatiy Vishnevetsky, Steven Shaviro and Mike DAngelo, a selection I, too, will whole-heartedly endorse. And as always at Girishs place, the comments that follow are thought-provoking. Srikanth Srinivasan, for example, ventures a comparison between tweets and the aphorisms with which Godard punctuates his films, adding, "To paraphrase Dan North: Bresson would have tweeted Notes on Cinematography if he was alive. When grappling with any new form of writing (or, for that matter, any new form of art-making), theres always an impulse to feel out correlations between the new thing and whats been written (or made) before, and youll find more than a few examples in reviews of Masha Tupitsyns LACONIA: 1200 Tweets on Film, a new title out from Zer0 Books, the British publishing house thats given us Mark Fishers Capitalist Realism, Owen Hatherleys Militant Modernism and Steven Shaviros Post Cinematic Affect.~ David Hudson, Mubi.com
"Reading Masha Tupitsyn's LACONIA: 1,200 Tweets on Film, you make notes in the margin in the same aphoristic manner as the content. I came to LACONIA cynically and sceptically. I was suspicious of the delegation of content's role to form; that by tweeting about film Tupitsyn was hoping that this device would hold far more than it should: the burden and necessity of argument. Because the form itself already made oblique comment on the subject at hand, the content was relieved of its obligation to be rigorously argued. Yet somehow the opposite is true, content sweeps up form, and LACONIA creates a rigor all its own, a remarkable series of tumbling thoughts through and about visual culture. At points it is quite stunning. They carry over to one another, reflect, argue with one another. The potential problems of this sort of formal construction – that each tweet would be isolated, irrelevant to anything beyond itself, a casual observation that has no particular interest or quality – dissolve as you read. Because you read. You make narratives, connections. Including Tupitsyn herself."~ Mark West, Glasgow Review of Books
"The 1200 tweets that constitute Masha Tupitsyns LACONIA are, each one, an aphorism in a bottle set adrift into the midst of all the other crisscrossing messages that movies and the media universe have spawned and continually and more or less blindly emit. Everything is happening in real time – not recollected in tranquility but intercepted in passing – even when the messages emanate from the deep past or (perhaps) a future around the next bend. Its a collage of the present moment, a continuous and unyielding dialogue, open-ended and alert to the barrage of signals that has become our home."
~ Geoffrey O'Brien, Author of The Fall of the House of Walworth, Phantom Empire, Dream Time, and Hardboiled America.
"In Masha Tupitsyn's extraordinary new book of cultural criticism through film criticism, LACONIA: 1200 Tweets on Film, the use of the tweet-form dramatizes the kinds of remembering and thinking at stake in contemporary social media and the culture it informs and is informed by. How can we begin today to think about the relationship between virtual memory and cultural memory; between digital memory and embodied memory? So much of what is moving in Tupitsyn's criticism is her way of locating, animating, and mourning the loss of the material, the loss of texture, the loss of the real—where material, texture and realness are qualities as spiritual and moral as they are embodied; where fidelity to those qualities can be a way of calling out a culture of violent alienation and commodification. The idea of a radiant wholeness only elusively possible through fragments is an apt way of thinking about LACONIA. This is the the political context of both his mournful idealism and his recourse to the fragment; LACONIA's context is comparable. The book's radical and engaged nostalgia is also a radical and engaged anger, indignance and grief. What has been lost? And what can be recovered?
What interests me with LACONIA's use of the tweet-form is not only its engagement with the kind of memory storage made possible (and impossible) by such social media, but also the way in which the form itself—its immediacy, its succinctness, its outreach—can be used in thoughtful and subversive ways. Rather than respond to the corruption of brevity with a long-form book or essay, LACONIA does something more provocative; it takes brevity back. So that the wit, clarity and concision of the short form are organized around, rallied around, the kind of criticism that currently feels as sorely needed as it is sometimes sorely lacking: a deeply feminist criticism, invested in the personal and the interpersonal (and their burgeoning degradation at the hands of individualist and capitalist culture), a profound attention to how dehumanizing and exploitative gender relations and equally dehumanizing and exploitative systems of production manifest themselves in popular representation—and perhaps most of all, an attention to attention...LACONIA is testament to the daily, hourly, minute-by-minute act (each fragment time-stamped and dated) of what Susan Sontag called paying attention to the world."
~ Elaine Castillo, Big Other
"Masha Tupitsyns LACONIA: 1,200 Tweets on Film considers the question of intimacy and visual culture at large through the private/public sphere of the internet. LACONIA is a fascinating experiment in both form and thought, creating what cultural theorist Lauren Berlant would call an intimate public: What makes a public sphere intimate is an expectation that the consumers of its particular stuff already share a worldview and emotional knowledge that they have derived from a broadly common historical experience. A certain circularity structures an intimate public. LACONIA, written entirely on Twitter between April 2009 and June 2010, uses popular culture to a create a personal world. It stays focused and intimate; personal albeit public. Tupitsyn seeks to do what seems almost impossible--inhabiting the present moment to its fullest. The book calls to mind Blaise Pascal's Pensées or Simone Weil's Gravity and Grace, fragmented texts or aphorisms that are innately spiritual and political in nature. LACONIA, however, is not so much steeped in religious mysticism as much as it is a demystification of image, celebrity, and consumerism. It is at once diary, film criticism, and cultural collage. In a time when self-expression is a form of entertainment ready to be monetized by social networks, Tupitsyn asks: "In a performance culture like America, what happens if you're not seen performing? Are you as good as dead?" Yet Tupitsyn is not performing for others; instead, she is draining the socialness out of Twitter, using these "small gestures" as a means to navigate her own poetic investigations."~ Christine Hou, The Brooklyn Rail
"There was a time when the Duc de La Rochefoucaulds book of Reflections or Sentences and Moral Maxims accompanied me wherever I went. If the Duc were alive today, there is a very high likelihood he would be tweeting, his maxims anticipate Twitter...Ive read a couple of books consisting of email exchanges, both were dire, and I expected little from a collection of tweets published in book form. Masha Tupitsyns LACONIA: 1,200 Tweets on Film is remarkable. Ostensibly a series of condensed thoughts on film and gender, Tupitsyns literary experiment expands into extended cultural commentary and diary. Masha Tupitsyn, like Geoff Dyer, writes with that tender attentiveness, and perceptive humour, that reveals truths."~ Anthony Brown, Time's Flow Stemmed
"The first time I read Masha Tupitsyn's name was on a book, Beauty Talk and Monsters, at Spoonbill and Sugartown in New York -- its cover was all white, red text, save a rainbow stare-you-down photo of lips and a nose, bound in crystals and washed in paint and light. How did it stare me down if it didn't have eyes? I don't know! But it did. I got a crush like I was in seventh grade and it was the cool girl in eighth. I got a crush on the prose, too. That look, that light at once sensitive and unflinching -- it turned out to be what I've loved first about all Tupitsyn's books so far. Sure, it's the spotlight and soft light of movie stars (she writes a lot about film, and feminism, fame and nostalgia), but it's also one of rhetoric, and love, and what comes of being driven towards obsessions till you see their bones. Her "I" is at once intimate and everyone, vibrating and rooted and glitchy. Tupitsyn dedicated her latest book, LACONIA: 1200 Tweets on Film, to the film critic Robin Wood, a writer known for elegantly lasered analysis, as well as his refusal to split that analysis from the personal and political. LACONIA is of a feather, and not gimmickly so at all -- it's a prismatic mix of head and heart, love and death, onscreen and off, plus the gem notes of Joubert, the tightness of LeWitt's geometry. It's so chiseled that at first I wished Tupitsyn'd let herself laugh a little more (so what if Hot Tub Time Machine's a little goofball?) but then I realized she just wasn't wasting any of her 140 characters, just wasn't using any to waffle or acquiesce, as folks so often do on the Internet. I finished it in a rush, with a rush, then got to ask her a few questions by e-mail, from Chicago to New York."
~ Mairead Case, Bookslut
"...Heres a great example of good mini-criticism from Masha Tupitsyns book, LACONIA: 1,200 Tweets on Film: Eastern Promises & A History Violence are twin parables: one film looks at violence from the outside in and the other from the inside out. Thats something worth thinking about as you examine how the two films work."~ Jim Emerson, Scanners/Suntimes.com
"When I first read Masha Tupitsyn's hybrid-genre book Beauty Talk & Monsters (Semiotexte, 2007), I was completely floored by it. So I was excited to read her new book LACONIA: 1,200 Tweets on Film (ZerO Books)—a book of aphoristic film and media commentary written in the spirit of cultural observers like Chris Marker. There is something beautiful about Masha Tupitsyns way of "reading" culture, how she honors the connections and resonances of the media she encounters, the way it is processed, assimilated and re-invented when it is filtered through her perception; intermingling with specific memories and preoccupations. Tupitsyn integrates the subjective and the critical in a way that demonstrates the specificity of our encounters with media. Both Beauty Talk and LACONIA could be described as a literary approach to film criticism, but it's also fitting to describe the works as a cinematic approach to literary writing. In Beauty Talk, narrative and a criticism are tightly interwoven. As stories, the essays are stunning; as critical analysis, sharp. Tupitsyns recent book LACONIA reminds me of the ways in which the viewer is also a meaning-maker, a participant critic...Good cultural criticism is difficult to do. On one hand, you don't want to sound like a dogmatic Frankfurt School elitist decrying the baseness of all things popular. But you also don't want to lapse into a mindless valorization of capitalism-guised-as-subversion. Both types of readings use a highly "motivated" (dare I say, ideologically-driven) lens to look at culture in ways that reduce, schematize, and mold texts, allowing for the loss of nuance or the jamming of media into certain theoretical frameworks. It's true—there are no unmotivated readings, but there are readings that are more thoughtful than others, and I strongly feel that Masha Tupitsyns commentary on film accomplishes what a lot of contemporary cultural criticism fails to do— it's accessible while still being complex, philosophical while being specific; it strikes a balance between the subjective and the social in its approach. Her perspective is totally singular and specific to her way of looking without making you feel bludgeoned by some kind of Critic Ego. By the end of the book, you actually do get a feel for the architecture of Masha Tupitsyns thinking...The only criticism I find really compelling is the kind that incorporates subjectivity, the kind that is built around the idea that the reader-writer of culture is a conduit through which media is filtered. The body that the media travels through, the marvelous specificity of Tupitsyns entire being and the sum of her lived experiences, cannot be ignored. What is to be gained from disregarding the relationship between the artist and their art?"~ Jackie Wang, HTML Giant
"I admire Masha Tupitsyns LACONIA: 1,200 Tweets on Film, which as far as I know is the first book of film criticism composed entirely on Twitter. Not the novelty stunt some might suspect it of being, the book shows Tupitsyn engaging in earnest with the platform, seeing how far and deep she can take the quality of movie writing in 140 characters or less (at times breaking that limit with reflections spanning several tweets)...Pointedly, Tupitsyn's project is utterly solitary, even while conducted in a public sphere. It seeks to renegotiate the boundaries of public and private that social media has left in utter disarray. There are plenty of nuggets to be found among this virtual micro-film journal spanning from April 2009 to June 2010. LACONIA is not only a chronicle of film viewings but of film culture itself, which Tupitsyn tears into for its promulgation of utter superficiality – pretty damn ironic given the medium she's using for her message...LACONIA is as much a documentary snapshot of the symptoms of our lives and times as it is a genuine effort to elevate them to a plane of true reflection."
In LACONIA: 1,200 Tweets on Films, Masha Tupitsyn explores the curious intersection of the print tradition of books and the micronarrative model of Twitter. The project is essentially an experiment that appropriates the forms of social media — soundbites, fragmented commentary, quotes, condensed reactions — in a work of film criticism that preserves the cultural purpose of the genre but divorces it from its traditional medium of essayistic narrative. What makes Tupitsyn's project exceptional, however, is that it reverse-engineers the now-familiar frameworks of Twitter anthologies — unlike Tweets from Tahrir, for instance, which sought to capture of a slice of the social narrative about the Egyptian revolution by culling tweets after the fact, Tupitsyn's approach put the intention of the book before the composition of each tweet, so that every tweet was deliberately crafted with the larger narrative in mind. Rather than a cohesive analysis of one idea at length, however, that narrative instead connects dots across diverse sources and constructs a mosaic of cultural patterns that explore the relationships between films. At its heart, the book is as much about film itself as it is about how Tupitsyn thinks about film in the age of infinite connectivity and on a platform that has more in common with poetry than with prose. LACONIA is an ingenious experiment in fragmented film criticism."~ Maria Popova, Brain Pickings
"More and more, I read in pieces. So do you. Digital media, in all its forms, is fragmentary. Even the longest stretches of text online are broken up with hyperlinks or other interactive elements (or even ads). This is neither a good nor bad thing, necessarily — it is simply a part of modern reading. And because of that, works that deal with fragmentation, that eschew not only a traditional narrative structure but the very idea of a work comprising a single, linear whole — take on a special kind of relevance. Fragmentary writing is (or at least feels) like the one avant-garde literary approach that best fits our particular moment. It's not that it's the only form of writing that matters of course, just that it captures the tension between "digital" and "analog" reading better than anything else out there. And that tension, in many ways, is the defining feature of the contemporary reading experience...The most interesting use of the digital platform that I've seen is Masha Tupitsyns (print) book Laconia: 1,200 Tweets on Film, which she composed entirely on Twitter. The end result, however, is presented not as a mere assembly of Tweets, but as an experiment in form. As she explains in the introduction, "I avoided tweeting arbitrarily or simply churning out a collection of tweets that would result in a book. Instead, I wrote and crafted each entry as though it was for and part of a book, rather than the other way around." One of Nicholas Carr's great worries about the digital realm is the way it appropriates and changes print forms. As he explains [in The Shallows], "When the Net absorbs a medium, it re-creates that medium in its own image." With Laconia, Tupitsyn attempts the reverse, re-creating a digital medium (Twitter) in an "analog" space. In a sense, Tupitsyn is appropriating a digital space into print.
What's especially interesting about that appropriation is the way she toys with Twitter's 140-character limit. Often, she will break multi-tweet passages abruptly, calling attention to the platform's tendency toward fragmentation. But by breaking them so abruptly, by taking Twitter's "hard" character count so literally and writing right up until it is reached, Tupitsyn underlines the digital origin of the project....Tupitsyn plays a similar trick with the book's content. Though the book is ostensibly a work of film criticism, it does not contain anything that resembles a conventional movie review. Instead, it appropriates what social media specializes in — quotations, personal reactions, biographical revelations, and commentary about pop culture — and turns them into something more ambitious. The different fragments are not so much about film as they are about how Tupitsyn watches film. As she puts it, the book dramatizes the act of thinking through film…"
~ Guy Patrick Cunningham , The Millions
"LACONIA--1200 tweets linking everything from Fellini to Jaws--is no gimmick. Its complex and engaging: a minimalist flaneurie, a fantastic syllabus, and a way-smart rebellion to boot. Twitter is a device, not a short-cut--if Tupitsyn wants to say something wordier than 140 characters, she continues the thought in her next tweet, sometimes deliciously: "...and the media is the/shark." While Tupitsyn loops back to certain people and places--John Cusack, the 1980s, Oprah, New York--she doesnt use hash-tags or acronyms, and the tweets are reordered to read chronologically. So its a smooth read. And a beautiful book--about movies, sure, but also about privacy, feminism, and industry, all linked by an encyclopedic knowledge (covering not just films but cities, soundtracks, bodies) and a deep, un-syrupy nostalgia. Tupitsyn writes about movies she repeat-watches or just cant stomach, scenes that illuminate politics or fashion. She tells us about the time she spotted Monica Lewinsky waiting in line to see Secretary. She drops bulls-eye aphorisms. Everything is sharp, light-catching. By setting one dramatic observation on top of another, Tupitsyns using her medium--Twitter--as cleanly as possible. Shes building not a book, but a model, a solid matrix standing out against all the unedited online hullabaloo. In the end, the shape the dots make is dazzling. I read it twice, then went to the movies."~ , Make/Shift Magazine: Feminisms in Motion
"The two towers under construction on the cover of Masha Tupitsyn's latest book of and on film criticism are an explicit homage to Ludwig Mies van der Rohe, whose famous declaration that 'architecture starts when you carefully put two bricks together' serves as the fittingly aphoristic model for Tupitsyn's approach to constructing the book. Each of the 1,200 tweets that make up the edifice of LACONIA is a carefully placed brick, and the book itself, the authors explains, is 'in essence, an architecture of thinking'...I've come to view those theoretical statements as the necessary foundations of LACONIA, the key to its becoming an object to think with...To evaluate Tupitsyn's work solely as a printed book, with its comforting physicality and its rough edges, would be limiting, for LACONIA as a rhetorical experiment does indeed exist between media, in an interstice from where it interrogates writing, and writing about film more specifically, as a heuristic process...The practice of daily writing and the platform that enabled this sustained process (criticism as a form of living, as Tupitsyn calls it in the dedication to film critic Robin Wood) is the book's true subject, and LACONIAs economy of expression – itself a counterpoint to the ritual complaints that the web in general and Twitter in particular are primary producers of meaningless chatter – becomes the lens through which to observe other acts of making culture. 'What is it that we need to say and what is it that we don't,' asks Tupitsyn, and 'how much "art" do we really need' (2)? Regular readers will now just how fond I am of both of these questions."~ Giovanni Tiso , A Weblog on Memory and Technology, May, 2011
"The sheer number of films and books to be encountered in Laconia is remarkable: 421, as indexed in order of appearance at the back of what is an extraordinary (and somehow unlikely) book: '1,200 Tweets on Film' by film critic, cultural theorist and fiction writer Masha Tupitsyn. Tupitsyn's 2007 book Beauty Talk and Monsters blended film criticism with fiction and memoir, not getting into any of those categorical wardrobes, but leaving them all wide open with the contents disturbed. Movies in Beauty Talk and Monsters are a part of the experience of reality, and reality as full of special effects and elaborate Hollywood trickery as any movie; both above all potent arenas for feminist critique and politics.
In many ways, Laconia continues this project, replacing the fictional framework of Beauty Talk and Monsters' with the structural scaffolding provided by Twitter. And the importance of their origin on Twitter makes itself strongly felt throughout the text; it's a very different book to what 1,200 Aphorisms on Film would have been, for example. It's impossible inLaconia to get away from the fact that this book forms just a part of the long stream-like text that Twitter users compose everyday, and beyond that the long text we're all always writing with every utterance, every email etc, etc. There's an awareness that the text is in the broadest sense a part of the culture it's critiquing...With Laconia, Tupitsyn does for Twitter what Kevin Killian did for the Amazon review in his two-volume Selected Amazon Reviews. They've taken the structures and conventions of networking features on internet mega-sites and attuned and altered them into art forms and vehicles for their particular, nuanced, extraordinary artistic intelligences."~ Colin Herd, 3 AM Magazine
"The 1200 tweets that constitute Masha Tupitsyn's LACONIA are, each one, an aphorism in a bottle set adrift into the midst of all the other crisscrossing messages that movies and the media universe have spawned and continually and more or less blindly emit. Everything is happening in real time – not recollected in tranquility but intercepted in passing – even when the messages emanate from the deep past or (perhaps) a future around the next bend. It's a collage of the present moment, a continuous and unyielding dialogue, open-ended and alert to the barrage of signals that has become our home."~ Geoffrey O'Brien, Author of The Fall of the House of Walworth, Phantom Empire, Dream Time, and Hardboiled America.
"There's something about the way Masha Tupitsyn's mind works when she addresses gender and film. It's different from how pretty much all other contemporary feminist theorists do it. Amid so much detached deconstruction, Tupitsyn's criticism is refreshingly full of life. LACONIA, a document of Tupitsyn's public thoughts on film, is a stream of intimate, immediate, and specific reflections on movies, as well as a broad and sustained interrogation of things like whether we can any longer truly see corporatized cities like LA and NY other than in old movies, how to understand David Lynch's women, and whether there is any real possibility for connection in social media, or for that matter, in watching films."~ Jessica Hoffman, Writer and co-editor, Make/Shift Magazine
Ghosts of My Life
Mark Fisher
Collected essays on popular culture by a major critic.
One Dimensional Woman
Nina Power
Exposes the dark heart of contemporary cultural life by examining pornography, consumer capitalism and the ideology of women's work.
Towards Speculative Realism: Essays and Lectures
Graham Harman
These writings chart Harman's rise from Chicago sportswriter to co founder of one of Europe's most promising philosophical movements: Speculative Realism.
Post Cinematic Affect
Steven Shaviro
This book ponders the fate of the movies in a world of digital media, globalization, and massive financial flows.
Weird Realism
Graham Harman
As Hölderlin was to Martin Heidegger and Mallarmé to Jacques Derrida, so is H.P. Lovecraft to the Speculative Realist philosophers.
Adam Kotsko
Argues that the awkwardness of our age is a key to understanding human experience.
Why We Love Sociopaths
Adam Kotsko
Argues that our fascination with cold and ruthless television characters reflects a broken social contract.
Meaning of David Cameron, The
Richard Seymour
What you won't have got in the televised debates, party manifestos, campaign trail propaganda and media coverage, portaining to Cameron the cipher and the social forces he represents.
Thing, The
Dylan Trigg
Phenomenology redefined through body horror.
Combined and Uneven Apocalypse
Evan Calder Williams
From salvagepunk to zombie hordes, wastelands to plagued cities, Combined and Uneven Apocalypse grapples with the apocalyptic fantasies of our collapsing era.
- Visit the John Hunt Publishing website


text:
This is the final submission of National University's Jonathan Gardner's Scholarly Project. He is a Nurse Anesthesia Resident at National University.
In Adult Patients Undergoing Total Knee Arthroplasty How Does The Adductor Canal Block As Compared To The Femoral Nerve Block Affect Postoperative Morbidity?
By the year 2030 the demand for primary total knee arthroplasty (TKA) is projected to grow by 673% to 3.48 million procedures. The anesthetic management for TKA has profound and distinct effects on recovery and rehabilitation, with multiple anesthetic options available for perioperative management. We set out to answer the question In adult patients undergoing total knee arthroplasty how does the adductor canal block as compared to the femoral nerve block effect postoperative morbidity?
A comprehensive review of the literature was conducted for comparing adductor canal block (ACB) to femoral nerve block. One meta-analysis, 8 randomized controlled trials and 3 retrospective cohort studies were included with a date range from 2013-2015. Current literature demonstrates that adductor canal blocks are equal to, if not superior to femoral nerve block for TKA patients as evidenced by: less morbidity and equivalent or even superior analgesia noted in ACB patients. An adductor canal block allows for improved range of motion and ambulation times postoperatively, resulting in increased success and engagement in physical therapy. Adductor canal blocks can reduce hospital stays, potentially saving the patient and hospital thousands of dollars. The ACB is a viable and superior anesthetic technique to the femoral nerve block for management of TKA.
The aging and increasingly overweight population in the United States (US) has a high incidence of osteoarthritis.1 Major weight bearing joints, in particular, the knees and hips are primarily affected by the constant physiologic stress and tissue trauma that leads to primary osteoarthritis. Weinstein et al. provides evidence that over half the adults in the US diagnosed with osteoarthritis of the knee will progress to a total knee replacement.2 Currently in the US approximately 4 to 6.7 million adults have undergone a total knee replacement surgery.2,3
A total knee arthroplasty (TKA) involves removing arthritic cartilage and underlying bone of the distal femur and proximal tibia. These are replaced with metal implants on the femur and tibia with a plastic spacer placed in between the implants. The posterior portion of the patella is resurfaced to glide smoothly over the new joint. With the growing need for TKA surgeries in the US, an optimal anesthetic is essential to improve postoperative morbidity, patient safety, financial efficacy, and patient satisfaction.2
Suboptimal postoperative recovery has far reaching effects beyond the obvious safety and satisfaction of the patient. Patients experiencing an adverse reactions to opioid administration including fall risk, respiratory depression, and episodic hypotension have an overall increased cost, longer hospitalization, and increased likelihood of readmission.7,9 By the year 2030 the demand for primary TKAs is projected to grow by 673% to 3.48 million procedures.10 The estimated hospital expenditures for TKA procedures will equal $28.5 billion annually.11 With an average increase in cost of $4,707 per patient experiencing an opioid related adverse event, it is clearly evident the importance of utilizing the safest and most effective anesthetic and analgesic regimen to decrease overall morbidity, cost, and increase patient satisfaction.9
Background and Significance
There are a variety of different anesthetic options for TKA surgery: general anesthesia, general anesthesia combined with subarachnoid or epidural block, general anesthesia with peripheral nerve block, and regional anesthesia with monitored anesthesia care. Regional anesthetic options can be further delineated into different types of peripheral nerve blockades available: femoral nerve block, femoral nerve block with a sciatic block, fascia iliaca block, fascia iliaca block with a sciatic block and the adductor canal block. Each of these anesthetic options have their respective positive and negative attributes. The optimal anesthetic plan for the patient should be driven by outcome data and evidenced based research.
The anesthetic management for TKA has profound and distinct effects on recovery and rehabilitation. The current practice of general anesthesia alone without the addition of neuraxial or peripheral nerve blockade is dependent on opioid analgesia for the management of postoperative pain. Large or sequential opioid consumption increases episodes of hypotension, respiratory depression and unsafe ambulation.6 These morbidity issues related to opioid analgesia can impede recovery and increase negative patient outcomes.4 The prolonged immobility due to extensive pain from inadequate analgesia or over consumption of opioids leads to decreased participation in rehabilitation due to sedation and overall general weakness.7 This predisposes the patient to sedentary patterns and the increased risk of deep vein thrombosis formation.8 Current and continuing research invariably proves the integration of a regional anesthetic in the analgesic perioperative course decreases overall opioid consumption by as much as 50%.4,5
Anesthesia providers, surgeons and patients collaborate to decide on the most appropriate type of anesthetic for the individual patient and planned surgery. Two common regional anesthesia techniques for TKA are the femoral nerve block (FNB) and the adductor canal block (ACB). Single shot and continuous femoral nerve blocks are commonly used for analgesia after total knee arthroplasty with great success. With the increased availability and efficacy of ultrasound guided peripheral nerve blocks, the adductor canal block is a viable and arguably a better alternative for post-op analgesia in TKA patients regarding functional outcomes and decreased morbidity and mortality.
Femoral Nerve Block
The regional anesthetic technique of interrupting the pain sensation transmitted along the femoral nerve via femoral nerve block was first described in medical literature in 1952.12 Since then, the femoral nerve block has become a primary adjunctive anesthetic option for TKA patients.13 The femoral nerve supplies motor innervation to the quadriceps and is the primary afferent/sensory nerve of the knee and thigh. The traditional approach for placing a femoral nerve block involves injecting local anesthetic in the fascial sheath of femoral nerve at the femoral crease.14 At this location the femoral nerve has not divided into distinctive afferent or efferent branches. Local anesthetic infiltration at this level of the femoral nerve produces both motor and sensory nerve blockade of the skin and anterior thigh muscles and most of the femur and knee joint.14
The term single shot FNB refers to a one time injection of local anesthetic which can be performed pre- or postoperatively. Another option is a continuous catheter inserted at the location of the single shot FNB and threaded into fascial compartment surrounding the femoral nerve and covers the same distribution of the femoral nerve at that location. The catheter allows for continuous infusion and the option of bolus dosing of anesthetics and analgesics.
Adductor Canal Block
The adductor canal is a triangular shaped fascial tunnel containing the femoral artery, femoral vein and the distal afferent branch of the femoral nerve named the saphenous nerve and another distal branch of the femoral nerve that provides motor innervation to vastus medialis muscle. The obturator nerve is contained within the canal as well and provides sensory innervation of the medial aspect of the thigh and motor innervation of the adductor muscles of the thigh. Notably, the nerves contained within the adductor canal do not innervate the major quadriceps muscles of the thigh. Therefore the adductor canal block (ACB) is primarily a sensory block and may offer a favorable alternative to the continuous femoral nerve block as quadriceps function is largely preserved. Thus the patient with an ACB can participate in rehabilitation sooner and more effectively than a patient with a FNB.
The traditional non-ultrasound guided peripheral nerve block technique of using landmarks with verification of location by stimulation of efferent nerves with predictable motor response is not possible, as the ACB is an isolated sensory fiber block. It was first described in the medical literature in 1993 using a landmark approach on cadavers. An ultrasound guided approach was documented in medical literature in 2009.15 It wasnt until 2011 that the anesthetic community acknowledged and reported its efficacy in providing adequate postoperative analgesia in TKA patients.16,17 Similar to the continuous FNB catheter, an indwelling catheter is also a viable option for the ACB allowing for postoperative infusions of analgesics and or anesthetics.
Review of Evidence
A comprehensive review of the current literature was performed utilizing search terms of: adductor canal block, femoral nerve block, saphenous nerve block, postoperative pain after TKA, and ambulation after TKA. Preference was given to evidence within the last 10 years. 1 meta-analysis, 8 RCTs, and 3 cohort studies were included in this evidence review focusing on the efficacy and therapeutic benefits of an adductor canal block when compared to a femoral nerve block.
Complications of TKA Surgery
In healthcare today, major orthopedic surgery is commonplace in most hospitals throughout the US. Orthopedic surgeries, including the TKA, come with a distinct and equally as commonplace set of complications. Venous thrombosis, falls, and arthrofibrosis, are common complications that delay recovery and contribute to increased hospital length of stay. It is in the patients and healthcare providers best interest to minimize the incidence of these injuries and insults by implementing the safest and most effective perioperative anesthetic and recovery plan.
Venous Thromboembolism
Venous thromboembolism (VTE) caused by venous stasis, vascular insult and hyper coagulability is a known complication of TKA surgery.18 Its prevalence has been reported as high as 48% with general anesthesia.19 Another study found 47% incidence of deep venous thromboembolism (DVT) in TKA surgeries with 87% percent of the positive for thrombus" occurring in the first 24 hour period postoperatively.20 The odds of developing a thromboemoblic complication is significantly reduced by the greater distance that the patient mobilizes within the first 24 hours postoperatively.21 This level of iatrogenic insult is surprisingly high, but early ambulation, a benefit of an ACB versus FNB, decreases this incidence even more.
The American Academy of Orthopedic Surgeons has issued a consensus based recommendation to promote early ambulation after TKA to reduce the incidence or severity of VTE.22 In a meta-analysis by Li et al. including 434 patients, the ACB was proven to increase postoperative mobility and functional recovery compared to the FNB.23 A study by Mudumbai evaluated the effectiveness of a continuous ACB compared to a continuous FNB in promoting early ambulation as measured on post-op day 1 and post-op day 2 defined by the sum of the distances ambulated in 2 physical therapy sessions. Preoperatively both groups had ultrasound guided catheter placement and postoperatively both groups had a portable continuous infusion device that delivered an infusion of local anesthetic. Results of the study showed a significantly greater ambulation distance in ACB group of 37 meters on post op day 1 versus FNB group of 6 meters. On post op day 2 it was 60 meters for ACB versus 21 meters ambulated for the FNB group.24 All of the research reviewed comparing ACB to FNB shows increased ambulation and quadriceps strength in the patients who received the ACB.6,23-29
A key element of recovery, healing, and return to functional mobility is the reduction of arthrofibrosis. In post TKA patients, early ambulation and range of motion ability is key to preventing and minimizing arthrofibrosis.30 Patients satisfaction scores after knee replacement surgery mainly depend on the amount of physical activity the patient can resume once they have recovered from surgery .This directly correlates to the post operative TKA range of motion.31
Fall prevention campaigns are omnipresent in healthcare facilities nationwide and for good measure. A patient fall can cost the hospital anywhere from $3,500 to $27,000 based on the severity of the fall. Additionally, the Center for Medicare and Medicaid Services has deemed falls a preventable event and will accordingly not reimburse the hospital.32 Pelt et al. found in their study of 707 TKAs with a femoral nerve catheter 19 out 707 patients sustained a fall (2.7%) and they noted this was their most common postoperative complication of TKAs.33 The profound motor nerve blockade of a femoral nerve block causes quadriceps weakness, predisposing a post TKA patient to increased fall risk whereas an adductor canal block, as stated previously, is motor blockade sparing.30,34
In Mudumbais study of 167 patients comparing continuous ACB to continuous FNB after TKA, 4 FNB patients sustained falls while 0 ACB sustained falls.24 Multiple studies have proven that ACBs are associated with increased quadriceps motor strength, mobility and faster ambulation times, which bolsters the argument that the ACB leads to a decrease in fall risk.6,23, 24, 26-28, 34-36
In Jaegers study of 12 healthy male volunteer subjects, assessing quadriceps motor impairment was assessed between an ACB and a FNB, with secondary outcomes measuring adductor strength and ability to ambulate in the 6-hour period subsequent to the block.27 Eleven patients were analyzed. One subject dropped out of the study because he sustained a fall after the FNB when measuring his ability to ambulate. Each subject on day 1 of their study had either an active single shot ultrasound guided ACB or FNB. They received both blocks; one leg had an ACB that was active (30ml 0.1% Ropivacaine) or placebo (30 ml normal saline) and the other leg had a FNB that was active or placebo with only one leg being actively blocked. The same subject at least 72 hours later received the opposite blockade of what they had previously. This reliably measured the effect of the blockade of ACB vs FNB when compared against the subjects baseline quadriceps strength. Both the investigator and study subjects were blinded to the treatment. Various tests and exercises were administered to the subjects to determine mobility and quadriceps strength. The results of the study showed that in the 6-hour post intervention period mean quadricep strength reduction was 8% in the ACB group and 49% in the FNB group. Performance in mobility tests were significantly better in the ACB group compared to the FNB group.
Opioid Consumption
The ideal anesthetic for TKA is one that promotes the most rapid recovery with the least amount of pain. Insufficient postoperative analgesia has been correlated with poor functional recovery in the TKA patient.37 The most influential factor in patient participation in post operative physical therapy and mobilization is the presence of pain.38 Severe pain is present in 60% of patient undergoing TKA while 30% of patients describe it as moderate.38 The traditional approach to severe to moderate pain relief is to mitigate and alleviate the pain with a narcotic regimen. Narcotics are not benign, with the most common side effects being post-operative nausea and vomiting, ventilatory depression, sedation and impairment of bladder and bowel function. These side effects create unnecessary complications and discomfort, unless the amount of narcotic pain management can be reduced.39
It is well described in the literature the effectiveness of the FNB in reducing both postoperative pain and the concomitant need for large doses of narcotics.40 The ACB offers at least equivalent postoperative pain reduction to the FNB6,24-26,28,35 and some studies have even shown the ACB is superior in pain relief postoperatively.23 In a meta-analysis including 8 RCTS, Li et al. concluded that post operative TKA pain relief from an ACB showed statistically significant decreases in pain scores when compared to a FNB within 8 hours and at the 24 hour mark postoperatively, and there was no degradation in efficacy in comparison to the FNB beyond the 24 hour period.23 The adequate relief from pain encourages a more active recovery and decreases unproductive physical therapy .
In Grevstads study comparing ACB to FNB to determine if pain relief from the ACB improved functional quadriceps strength and pain scores, a sample of 50 patients undergoing TKA was divided equally into 2 groups, an ACB group (n=25) and a FNB group (n=25). Both groups received a standardized multimodal analgesic regimen. Surgery was performed under general anesthesia with propofol and remifentanil or with spinal anesthesia of 10-15mg 0.5% Bupivacaine. The study period was 2 hours immediately post-operative. Baseline pain scores and quadriceps strength were measured before receiving peripheral nerve blockade. The individual patient received both an ACB and a FNB injection. The patient and the anesthesia provider were blinded to which actual block the patient received by having the provider inject 30ml of either saline or 0.2% Ropivacaine to both the adductor canal and the femoral nerve area with pharmacy ensuring the different injectates were indistinguishable. The ACB group received the ropivacaine in the adductor and 30 ml of saline in the femoral nerve area with the opposite being true for the FNB group. Results of the study show a 20% increase in quadriceps strength in the ACB group and similar pain scores and opioid consumption between the groups. In a timed test to measure safe mobility (TUG test) 7/25 patients who received the FNB were not able to perform the test where all 25 of the ACB were able to engage in the test after the nerve blockade.25
Hospital Length of Stay
Healthcare fiscal responsibility affects consumers and providers of surgical and anesthetic services simultaneously. It is the goal to reduce anesthetic perioperative complications and provide a service that decreases known risk factors with unnecessary side effects that can increase morbidity and hospital length of stay. In Ludwigsons cohort study of 297 patients comparing single shot ACB to a FNB catheter, the ACB patients length of stay was 2.5 days compared to FNB catheter of length of stay of 3 days. Although the length of stay was longer for the FNB group, the study was limited by the fact that the two groups received different modalities. The FNB catheter allowed for continuous infusion or bolus dosing to cover breakthrough pain if required. The ACB group was a one-time administration.28
A more balanced randomized control trial of 97 TKA patients by Shah et al compared continuous catheter ACB to a continuous catheter FNB and found the ACB length of hospital stay at 3.08 days versus FNB 3.92 days which amounts to almost a full day difference.26 In terms of hospital dollars this can amount to approximately $1760-$2150 per day on US national average.40,41 When confounding factors such as falls, thrombosis, or the negative sequelae of increased opioid consumption are included, these costs increase exponentially, with some of them potentially not being reimbursed by insurance providers.
Clinical Recommendations
Any changes made to clinical management of a patient needs to be agreed upon by the patient, surgeon and anesthesia provider. Many of the institutions in the research had protocols for patients that had received a FNB or ACB including the nurses and physical therapists involved in the patients care and rehabilitation. These protocols served to educate the patient and the staff involved in their care of limitations, expectations and any safety concerns (ambulation, loss of sensation, etc). Possible negative post-operative ramifications to the institution and care providers of substituting an adductor canal block for a femoral nerve block are very minimal. As illustrated earlier, the changes are favorable for all parties involved; shorter hospital stay, equal analgesic properties and decreased incidence of falls.
A possible barrier to administering an adductor canal block is the availability of an ultrasound machine, and competently trained providers. The adductor canal block is a sensory nerve block and, without motor nerve fibers present a nerve simulation technique is not possible, and ultrasound guidance is necessary. Conversely, some practitioners may still utilize a nerve stimulation/anatomical landmark approach to a femoral nerve block where an ultrasound machine is not necessarily required. As technology and standards improve it may be legally challenging to defend against the omission of ultrasound guidance when performing peripheral nerve blocks.
The common and recommended technique for performing an ACB found in literature is positioning the patient supine with the thigh externally rotated and abducted for ultrasound probe placement on the medial thigh to locate the femoral nerve and saphenous artery in the adductor canal space. The saphenous nerve is located subsartorius, bounded medially and superiorly by the vastus medialus and inferiorly by the adductor longus in the adductor canal. Needle placement technique either in plane or out of plane may be utilized to deposit the local anesthetic in the adductor canal space anterior to the femoral artery so that the anesthetic envelops the artery and subsequently the saphenous nerve runs which runs parallel to it. Most studies have used larger doses of up to 30ml of 0.75% Ropivicaine for up to 24 hours of analgesia.14,25,29 It is this authors recommendation after the culmination of research, the effective and safe amount of local anesthetic is 25-30 ml of 0.5% Ropivicaine. According to NYSORA there have not been any prospective studies on peripheral nerve blocks in anticoagulated patients and the American Society of Regional Anesthesia at this time does not delineate a peripheral nerve block from neuraxial anesthesia in regards to recommendations on needle or catheter placement in anticoagulated patients. Therefore, it is recommended to follow the established guidelines when placing a peripheral nerve block in a patient as if they were receiving neuraxial anesthesia. NYSORA does state that many clinicians opt for applying those guidelines when the peripheral nerve block is in a highly vascularized area and or non-compressible.
It is imperative to minimize the incidence of falls, excessive opioid use, delayed recovery and insults by implementing the safest and most effective perioperative anesthetic and recovery plan. Current literature provides substantial evidence to support the utilization of an adductor canal block rather than a femoral nerve block whether utilizing single shot or catheter administration. Early improved range of motion and ambulation times are recommended to decrease the incidence of venous thromboembolism and arthrofibrosis. An ACB allows for improved range of motion and ambulation times postoperatively. The motor sparing effect of an ACB has decreased the incidence of falls in the post TKA population compared to a FNB; while in the studies to date it is shown that patients receiving a FNB have an increased incidence of falls. Finally, hospital length of stay has been shown to be decreased by up almost a full day in the ACB patients.26 ACBs are superior to FNB for TKA patients as evidenced by: less negative sequelae and equivalent or even superior analgesia noted in ACB patients, and with improved ambulation and early recovery, it benefits the patient, surgeon, hospital and anesthetic providers to utilize an ACB block versus a femoral nerve block in TKA patients.
1. Robert Wood Johnson Foundation Report: F as in Fat How Obesity Threatens Americas Future 2012.http://healthyamericans.org/assets/f...FasInFat18.pdf Accessed September 17, 2015
2. Weinstein AM, Rome BN, Reichmann WM, et al. Estimating the burden of total knee replacement in the United States. J Bone Joint Surg Am. 2013;95(5):385-92.
3. PREVALENCE OF TOTAL HIP AND TOTAL KNEE ARTHROPLASTY IN THE UNITED STATES http://icjr.net/news_310_prevalence_...m#.VdowqtNViko. Accessed August 23, 2015.
4. Allen H, Liu S, Ware P, Nairn C, Owens B. Peripheral Nerve Blocks Improve Analgesia After Total Knee Replacement Surgery. Anesth Analg 1998;87:93-7
5. Macfarlane AJR, Arun Prasad G, Chan VWS, Brull R. Does Regional Anesthesia Improve Outcome After Total Knee Arthroplasty? Clinical Orthopaedics and Related Research. 2009;467(9):2379-2402. doi:10.1007/s11999-008-0666-9.
6. Patterson ME, Bland KS, Thomas LC, et al. The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study. J Clin Anesth. February 2015;27(1):39-44.
7. Hebl JR, Dilger JA, Byer DE, et al. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008;33(6):510-7.
8. Ragucci MV, Leali A, Moroz A, Fetto J. Comprehensive deep venous thrombosis prevention strategy after total-knee arthroplasty. Am J Phys Med Rehabil. 2003;82(3):164-8.
9. Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother. 2013;27(1):62-70.
10. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-5.
11. Murphy L, Helmick CG. The impact of osteoarthritis in the United States: a population-health perspective. Am J Nurs. 2012;112(3 Suppl 1):S13-9.
12. Wanderer JP, Rathmell JP. A brief history of femoral nerve blocks. Anesthesiology 2014;121(2):A21.
13. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d'Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999 Jul;91(1):8-15
14. Femoral Nerve Block. New York School of Regional Anesthesia http://www.nysora.com/techniques/ner...rve-block.html Accessed September 16th, 2015
15. Horn JL, Pitsch T, Salinas F, Benninger B. Anatomic basis to the ultrasound-guided approach for saphenous nerve blockade. Reg Anesth Pain Med. 2009;34(5):486-9.
16. Lund J, Jenstrup T, Jaeger P, et al. Continuous adductorcanal-blockade for adjuvant post-oper tive analgesia after major knee surgery: preliminary results. Acta Anaesthesiol
Scand. 2011;55:1419.
17. Saranteas T, Anagnostis G, Paraskeuopoulos T, et al. Anatomy and clinical implications of the ultrasound-guided subsartorial saphenous nerve block. Reg Anesth Pain Med. 2011;36(4):399-402.
18. Izumi M, Ikeuchi M, Aso K, et al. Less deep vein thrombosis due to transcutaneous fibular nerve stimulation in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3317-23.
19. Williams-russo P, Sharrock NE, Haas SB, et al. Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement. Clin Orthop Relat Res. 1996;(331):199-208.
20. Maynard MJ, Sculco TP, Ghelman B. Progression and regression of deep vein thrombosis after total knee arthroplasty. Clin Orthop Relat Res. 1991;(273):125-30.
21. Chandrasekaran S, Ariaretnam SK, Tsung J, Dickison D. Early mobilization after total knee replacement reduces the incidence of deep venous thrombosis. ANZ J Surg. 2009;79(7-8):526-9.
22. AAOS. Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty http:// www.aaos.org/research/ guidelines/VTE/VTE_guideline.asp. Accessed November 11, 2015.
23. Li D, Yang Z, Xie X, Zhao J, Kang P. Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block: a systematic review and meta-analysis. Int Orthop. 2015;
24. Mudumbai S, Kim T, Mariano E, et al. Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical Orthopaedics & Related Research. May 2014;472(5):1377-1383.
25. Grevstad U, Mathiesen O, Lind T, Dahl JB. Effect of adductor canal block on pain in patients with severe pain after total knee arthroplasty: a randomized study with individual patient analysis. Br J Anaesth. 2014;112(5):912-9.
26. Shah N, Jain N. Is Continuous Adductor Canal Block Better Than Continuous Femoral Nerve Block After Total Knee Arthroplasty? Effect on Ambulation Ability, Early Functional Recovery and Pain Control: A Randomized Controlled Trial. The Journal Of Arthroplasty. November 1, 2014;29(11):2224-2229.
27. Jæger P, Nielsen Z, Henningsen M, Hilsted K, Mathiesen O, Dahl J. Adductor Canal Block versus Femoral Nerve Block and Quadriceps Strength: A Randomized, Double-blind, Placebo-controlled, Crossover Study in Healthy Volunteers. Anesthesiology. February 2013;118(2):409-415.
28. Ludwigson JL, Tillmans SD, Galgon RE, Chambers TA, Heiner JP, Schroeder KM. A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty. J Arthroplasty. 2015;30(9 Suppl):68-71.
29. Jenstrup MT, Jæger P, Lund J, et al. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand. 2012;56(3):357-64.
30. Sharma S, Iorio R, Specht LM, Davies-lepie S, Healy WL. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res. 2010;468(1):135-40.
31. Farahini H, Moghtadaei M, Bagheri A, Akbarian E. Factors Influencing Range of Motion after Total Knee Arthroplasty. Iranian Red Crescent Medical Journal. 2012;14(7):417-421.
32. Quigley PA, White SV. Hospital-based fall program measurement and improvement in high reliability organizations. Online J Issues Nurs. 2013;18(2):5.
33. Pelt CE, Anderson AW, Anderson MB, Van dine C, Peters CL. Postoperative falls after total knee arthroplasty in patients with a femoral nerve catheter: can we reduce the incidence?. J Arthroplasty. 2014;29(6):1154-7.
34. Kwofie MK, Shastri UD, Gadsden JC, et al. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med. July -August 2013;38(4):321-5.
35. Kim D, Lin Y, Yadeau J, et al. Adductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial. Anesthesiology. March 2014;120(3):540-550.
36. Jæger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013;38(6):526-32.
37. Wang H, Boctor B, Verner J. The effect of single-injection femoral nerve block on rehabilitation and length of hospital stay after total knee replacement. Reg Anesth Pain Med. 2002;27(2):139-44.
38. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg. 1998;87(1):88-92.
39. Good RP, Snedden MH, Schieber FC, Polachek A. Effects of a preoperative femoral nerve block on pain management and rehabilitation after total knee arthroplasty. Am J Orthop. 2007;36:554557.
40. Average Cost Per Inpatient Day Across 50 States in 2010. Becker Hospital Review. http://www.beckershospitalreview.com...s-in-2010.html Accessed November 11, 2015.
41. Hospital Adjusted Expenses per Inpatient Day. Kaiser Family Foundation http://kff.org/other/state-indicator...inpatient-day/ Accessed November 11, 2015.
42. Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev. 2014;5:CD009941.
43. Mitchell D, Friedman RJ, Baker JD, Cooke JE, Darcy MD, Miller MC. Prevention of thromboembolic disease following total knee arthroplasty. Epidural versus general anesthesia. Clin Orthop Relat Res. 1991;(269):109-12.
44. Peng L, Ren L, Qin P, et al. Continuous Femoral Nerve Block versus Intravenous Patient Controlled Analgesia for Knee Mobility and Long-Term Pain in Patients Receiving Total Knee Replacement: A Randomized Controlled Trial. Evid Based Complement Alternat Med. 2014;2014:569107.
45. The Evolution of the Adductor Canal Block: The Emerging Technique for
Motor-Sparing Analgesia to the Knee Adductor Canal John Kline CRNA
|Purpose of Study
|Sample size
|Study Type
|A meta-analysis to try to find out if ACB is better than FNB in pain treatment and joint functional recovery after TKA.
|434 patients
|Meta Analysis
|ACB provide better ambulation ability, faster functional recovery and better pain control at rest after TKA compared to FNB.
|Li D, Yang Z, Xie X, Zhao J, Kang P. Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block: a systematic review and meta-analysis. Int Orthop. 2015;
|Prove efficacy of ACB post op TKA on total morphine consumption, pain measures and early ambulation
|CACB Cath vs Placebo-
Decreased pain, faster ambulation, decreased morphine requirement with ACB Cath
|Jenstrup MT, Jæger P, Lund J, et al. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand. 2012;56(3):357-64.
|Prove efficacy of ACB in established pain after TKA
|RCT, double blind
|ACB required 10mg less morphine in immediate 6 hour post op period.
|Jaeger P, Grevstad U, Henningsen MH, Gottschau B, Mathiesen O, Dahl JB. Effect of adductor-canal-blockade on established, severe post-operative pain after total knee arthroplasty: a randomised study. Acta Anaesthesiol Scand. 2012;56(8):1013-9.
|Prove ACB is as effective as FNB for TKA
|Cohort, Retrospective
|ACB single shot compared to Continuous FNB in 24 hour postoperative period showed ACB able to ambulate further and had equal opioid consumption
|Patterson ME, Bland KS, Thomas LC, et al. The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study. J Clin Anesth. February 2015;27(1):39-44.
|Compare ACB to FNB for TKA
|No significant difference in opioid consumption between the groups and a significant difference with increased motor strength of the ACB group compared to the FNB group
|Kim D, Lin Y, Yadeau J, et al. Adductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial. Anesthesiology. March 2014;120(3):540-550.
|Compare ACB to FNB for TKA
|RCT, Double Blind
|ACB group had significantly higher percentage of quadriceps strength and there was no statistically significant difference between ACB and FNB in pain scores, opioid consumption, adductor strength, mobility or morphine related adverse effects
|Jæger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013;38(6):526-32.
|Compare continuous ACB to continuous FNB after TKA to show that ACB would be associated with greater postoperative ambulation without a reduction in analgesia
|Cohort, Retrospective
|Greater ambulation distance in ACB group on POD 1 of 37meters versus and 6 meters for FNB. On POD 2 it was 60 meters for ACB versus 21meters. No significant difference between the groups in all items measured except that the FNB group had four falls and the ACB group had zero falls
|Mudumbai S, Kim T, Mariano E, et al. Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical Orthopaedics & Related Research. May 2014;472(5):1377-1383.
|Compare ACB to FNB to determine if pain relief from the ACB improved functional quadriceps strength and pain scores
|RCT, Blinded
|20% increase in quadriceps strength in the ACB group, similar pain scores, opioid consumption between the groups. In a timed test to measure safe mobility (TUG test) 7/25 FNB were not able to perform the test where all 25 of the ACB were able to engage in the test after the nerve blockade
|Grevstad U, Mathiesen O, Valentiner L, Jaeger P, Hilsted K, Dahl J. Effect of adductor canal block versus femoral nerve block on quadriceps strength, mobilization, and pain after total knee arthroplasty: a randomized, blinded study. Regional Anesthesia & Pain Medicine. Jan-Feb 2015;40(1):3-10.
|ACB compared to FNB if ACB produced less quadricep strength impairment. Secondary outcomes measured were adductor strength and ability to ambulate.
|RCT, Blinded, Crossover Study
|In the 6 hour post intervention period mean quadricep strength reduction was 8% in ACB group and 49% in FNB group. Performance in mobility tests was better in the ACB group compared to the FNB group
|Jæger P, Nielsen Z, Henningsen M, Hilsted K, Mathiesen O, Dahl J. Adductor Canal Block versus Femoral Nerve Block and Quadriceps Strength: A Randomized, Double-blind, Placebo-controlled, Crossover Study in Healthy Volunteers. Anesthesiology. February 2013;118(2):409-415
|Compare ACB as opposed to continuous FNB on ambulation ability, pain scores and opioid consumption
|Ambulation and mobility was significantly improved in the ACB versus the FNB group. There was no significant intergroup difference in pain scores or opioid requirements. Length of hospital stay was ACB 3.08 vs FNB 3.92 which amounts to almost a full day difference.
|Shah N, Jain N. Is Continuous Adductor Canal Block Better Than Continuous Femoral Nerve Block After Total Knee Arthroplasty? Effect on Ambulation Ability, Early Functional Recovery and Pain Control: A Randomized Controlled Trial. The Journal Of Arthroplasty. November 1, 2014;29(11):2224-2229.
|Compare effect on quadricep strength of single shot ACB to single shot FNB.
|RCT, Blinded
|Statistical significant motor strength and balance were maintained in the ACB group compared to the FNB group
|Kwofie MK, Shastri UD, Gadsden JC, et al. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med. July -August 2013;38(4):321-5.
|Compare sngle shot adductor canal block to femoral nerve catheter for TKA
|Cohort, Retrospective
|ACB had shorter length of stay by half day, further ambulatory distances(POD1 and 2) similar pain control and earlier discharge when compared to FNC. undergoing TKA.
|Ludwigson JL, Tillmans SD, Galgon RE, Chambers TA, Heiner JP, Schroeder KM. A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty. J Arthroplasty. 2015;30(9 Suppl):68-71.

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2307 Rose LnCovington, KY 41011
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2307 Rose Ln Covington, KY 41011
Adorable Ranch with Great Curb Appeal and Neutral Dcor. Private Fenced Yard. Beautiful Hardwood Floors. 1-Year HMS Home Warranty. A Pleasure to Show!
NOTE: This property was sold on 6/24/2016 and is no longer available. The details listed below are believed accurate to the date of the sale and are subject to change.
|Room Dimensions
|Bedroom 1:
|15 x 12 (Level: 1)
|Bedroom 2:
|10 x 11 (Level: 1)
|Dining Room:
|12 x 15 (Level: 1)
|9 x 18 (Level: 1)
|Living Room:
|12 x 15 (Level: 1)
|Kenton County
|0.17 Acres
|Dryer, Oven/Range, Refrigerator, Washer
|Part Finished, Walkout
|Basement Type:
|Brick, Wood
|Central Air
|Brick, Wood
|Built in, Front, Oversized
|Garage spaces:
|Forced Air, Gas
|Inside Features:
|Multi Panel Doors
|Ceramic Tile, Eat-In, Vinyl Floor, Walkout, Window Treatment
|1 Story
|Lot description:
|50 x 150
|Master Bedroom:
|Walk-in Closet, Wall-to-Wall Carpet, Window Treatments, Wood Floors
|Cable TV, Ceiling Fan, Garage Door Opener, Home Warranty, Smoke Alarm
|Cul-de-sac St, Metal Fence, Patio, Porch, Wood Fence
|School district:
|Covington Independent
About Covington
Covington is Northern Kentucky's largest city and is the fifth largest city in Kentucky. The city is currently undergoing a dynamic surge of growth and renovation. The city is located between the Licking and Ohio Rivers and has a population of 43,000 residents. The city was founded in 1814.
New hotels, office towers and riverboat restaurants along the riverfront are among the most prestigious in the Greater Cincinnati area. Covington is also aware of the importance of maintaining its heritage of fine old homes. Many of these lovely homes and 19th century row houses are on the National Register of Historic places. In recent years, homes and condominiums that take advantage of the spectacular river and Cincinnati skyline views have been built. With this combination of progress and heritage, Covington offers its residents an exciting urban lifestyle with a touch of history.
The Transit Authority of Northern Kentucky (T.A.N.K.) services Covington extensively. I-75 travels through Covington, and within a 10-minute drive is Interstate I-275. There are three bridges connecting Covington with Cincinnati to the north and 2 bridges with Newport and the rest of Campbell County to the east. Covington is a 15-minute drive to the Cincinnati/Northern Kentucky International Airport.
St. Elizabeth Medical Center North is located within the City of Covington. The University of Cincinnati Medical Center is just minutes away. Children's Hospital is located in Cincinnati.
The historic Mainstrasse area of the city is a very attractive renovated shopping area with a distinctive German flavor, and many small specialty shops. Major department stores are just across the bridge in downtown Cincinnati.
Covington is famous for "Devou Park" which contains 700+ acres of beautiful grounds complete with an 18-hole golf course, tennis courts, museum and amphitheater as well as a beautiful view of downtown Cincinnati and Covington.
"Randolph Park" has an Olympic-sized swimming pool as well a picnic shelter, playground basketball court and ball field. "Peaselburg Little Peoples Playland" has a fenced-in playground. The "Lance Corporal Justin Sims Memorial Park" has a playground and picnic table."Goebel Park"offers trails, picnic shelter, playground and water park/pool. The "Annie Hargraves Park" has a playground, basketball court and picnic areas."The "30th Street & Decoursey Park" features trails, a picnic shelter, playground and basketball court. The "Barb Cook Park" has a playground and basketball court. The "George Rogers Clark Park" is along the Ohio River offering beautiful views of downtown Cincinnati to those who walk and bike along the sidewalks. "Kenney Shields Park" offers trails and a basketball court and connects to the Goebel pool via a walking trail. "Goebel Park" is best known for its German-style Carroll chimes clock tower. This park has trails, a picnic shelter, playground and waterpark/pool. "Hard Pike Park" is the southernmost park in Covington has a playground, picnic tables and benches. The " Licking River Greenway Trails" connects the Licking River, Covington, Taylor Mill and Newport with a 12-14 miles trail system when it is completed. The "George Steinford Park" is the Sixth Street Promenade in Covington and is the heart of the MaineStrasse Village. Many residents stroll and walk their dogs while enjoying the village-style views. Many events are held along this promenade. The "Bill Cappel Youth Sports Complex" is a large park that includes five lit ball fields, two soccer fields, picnic shelter, walking paths and a zero-depth water park. "BF Howard Park" features a beautiful fountain and benches.
The annual WEBN Fireworks along the Ohio River riverfront are held during the Labor Day weekend. Covington residents have stunning views of this fireworks display from along the river banks to the top of Devou Park.
Twin Oaks golf course is located in the Rosedale section of Covington and is a beautiful, well maintained 18-hole golf course. The Devou Park golf course offers 18 holes for golfers of all abilities.
Covington is an active community hosting numerous events including an annual Oktoberfest.


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Nishat Linen gives you something special on this Valentine's Day. We have good news for our fashion lover because your favorite fashion band Nishat Linen has presents its Spring Summer Dress collection 2015. This NL spring summer dress collection has been launched from 14th Feb 2015 and available at all leading stores. NL has many other collections such as printed, embroidered and prêt collection. For spring summer season, this brand is introducing many of stylish and classy designed collections like as classic textile, arabesque charm, garland girl, embrace the power of design, monochrome magic and get down to earth. Nishat Linen has decorated this summer spring dress collection with the exterior of an eye-catching and well-designed.
Special gathering challenging different dresses so in order to inclusive this necessitate of people Nishat Linen summer dress collection 2015 offering dresses for casual, formal wearing and parties function This summer lawn collection 2015 has contains long length shirts with tight pants. Every summer dress has been embellished with stylish prints like digital prints, abstract prints and screen prints. NL has uses high quality fabric and vivid colors. They have used vigorous, bright and soft colors in these dresses Beautiful color shades boost the beauty of your personality. To create it even more unique, the brand is present a 'pre-launch sale' wherever you get 10% off when you order one of the brand new Nishat Lawn suits 2015. The prices of these summer dress collection are affordable. The price ranges are PK Rs. 3,175 to 3,375. Hope you will like Nishat Linen spring summer Dress collection 2015.
Nishat Linen Spring Lawn Collection 2015
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Recruitment Consultant
- Recruiter
- The Job Office Ltd
- Location
- Leeds & West Yorkshire
- Salary
- 35000.00 GBP Annual + 00
- Posted
- 14 Jan 2019
- Closes
- 18 Jan 2019
- Sector
- Healthcare, Recruitment to Recruitment
- Job Function
- Recruitment Consultant
- Contract Type
- Permanent
- Hours
- Full Time
Recruitment Consultant - Construction Niche - White Collar
Recruitment Consultant - Key Facts:
- Exec level white collar Interim and perm desk recruitment
- Award-winning business
- Superb office facilities
- Established client base and enviable reputation for quality of service
- Very experienced team/management team
- Very low staff turnover
- Base salary to ??35 k + bonus - negotiable
Recruitment Consultant - Benefits:
- Pension
- On site parking
- Non kpi environment
- Further Learning and Development (In-House and External Training)
Recruitment Consultant - The Company:
My client has a track record of success and an enviable reputation for staff retention, career development and outstanding benefits and reward schemes in today's recruitment market.
Recruitment Consultant - The Role / Client expectations:
- Recruitment experience a must
- Fast-paced environment
- Proactive sales
- Management of client meetings
- New business wins
- Candidate interviewing and assessment
- Team player
- Good attention to detail
- Self-motivator
- Proven overachiever
- Target driven and reward motivated
Can you answer the following question?
Do you have proven experience and success working within the recruitment industry?
Required skills
- Recruitment experience in an agency setting a must
- Recruitment Process / sales
- Temporary or permanent Staffing
- Business to business sales experience in a recruitment setting
- Resilience
- A proven Relationship builder
- Articulate
- Tenacious
- Professional Work Ethic
- Recruitment consultant
- Executive Recruitment
- Interim Recruitment
- Perm recruitment
- Temp recruitment
- Tele sales experience
We are always interested in hearing from experienced recruiters such as : Recruitment Consultant / Resourcer / Executive Search and Selection/ Business Development Manager / Recruiter /Account Manager / Managing Consultant / Senior Consultant / New Business Manager / Service Delivery Consultant / Recruiter / Recruitment Manager / Business Development Executive /Senior
Unfortunately, we are unable to contact all applicants due to the vast amount of applications that we receive, therefore if you have not heard from us within 1 week of your application then please assume you have not been shortlisted for interview
The Job Office Ltd is acting as an employment business / employment agency regarding this position. The Job Office Ltd is an employment agency practicing within Recruitment to Recruitment. We offer a confidential service to both client and candidate. We positively welcome applications from suitably qualified candidates, no matter what their age, race, gender or lifestyle and those who have the right to live and work in the UK.


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Axis Communications offers 211 Network Camera
Axis Communications' 211 Network Camera is designed for indoor and outdoor use. The 211 provides image quality using progressive scan and offers built-in support for power over the Ethernet, motion detection and advanced event management. It delivers Motion JPEG and MPEG-4 video streams simultaneously, to optimize image quality and bandwidth. The MPEG-4 compression mode can be used when available bandwidth is restricted and higher frame rates are required.
For more information, call Axis at 800-444-2947 or visit www.axis.com.
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Global team
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Founded in 2006 in New Zealand, Xero is one of the fastest growing software as a service companies globally. We lead the New Zealand, Australian, and United Kingdom cloud accounting markets, employing a world-class team of more than
2,300 people. Forbes identified Xero as the World's Most Innovative Growth Company in 2014 and 2015.
Small business makes the world go round – it's the heart of the global economy. We want millions of small businesses to thrive through better tools, information and connections. Like all great challenges, we can't do it by ourselves: we work closely with our customers, partners, and other friends to push innovation forward, turning Xero into the online business platform for the world.
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text: On Jun 5, 2012, at 7:48 PM, Nathan Moore wrote: > All, > > This is barely beowuf related... > > New desktop machine is a Shuttle SX79R5, http://us.shuttle.com/ > barebone/Models/SX79R5.html > > In the past, shuttles have been very quiet, but this one has a > fairly loud variable speed fan on the CPU heat exchanger. You sure this one is easy to replace? It seems that it doesn't have a cooler at all for the cpu but as you say it's some sort of cheapskate thing tubing that pumps liquid through the socket and then seemingly with 1 fan that is doing cooling both for the PSU as well as the cpu fan at once. Then from inside it pushes that air seemingly to outside and there it goes through a tiny grill, which also will impact the airflow bigtime i'd guess. So whatever you do, you need a fan that delivers at least the same CFM and has the same airpressure. Most likely the replacement fan for 9CM there still will be something of at least a 5000 RPM or so, so very noisy, and just don't believe all the manufacturer specs there, they usually 'overclock' fans nowadays effectively generating a far higher RPM and *that* CFM they put on the box. If you'd get a tad bigger fan it's easy to get it more quiet, but it seems difficult to fit in. Maybe if you remove the grill and produce a kind of cardbox thing channels the air into the tiny PSU/heat exchanger. Just tape won't do i'd guess, as after a while that'll losen too much, so some glue also needed, then it would be a lot easier to get it quiet. It's a tiny fan for a CPU/PSU combo. Just 9 CM is not much. At 12 CM there is a wonderful fan i'm very happy about that's the aerocool shark fan. It's only there in red incarnation. Nowadays the fans that do not have leds are either more expensive or produce less CFM so you'll have no escape except to get one with leds, as they produce those massively. You'll have to measure though whether a bigger fan fits inside and if so what its maximum dimensions are and how it impacts your cardbox creature. > I normally buy replacement parts from vendors like newegg, but > their selection of 90mm case fans mainly seems to be described by > CFM and whether the fan has LED lights mounted in it (FYI, that is > not a selling point). > > So, is there an engineer's version of newegg that ya'll know about? > There must be a super quiet 90mm fan out there that I can pick up > for $10... > > Nathan Moore > Physics, Winona State University > _______________________________________________ > Beowulf mailing list, Beowulf at beowulf.org sponsored by Penguin > Computing > To change your subscription (digest mode or unsubscribe) visit > http://www.beowulf.org/mailman/listinfo/beowulf


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Israel News - Stay Informed, Pray Informed
Once again demonstrating his penchant for theatrics, Palestinian leader Mahmoud Abbas last month made an impassioned call to the Arab world to stop the insidious Jewish plot to rebuilt the Jewish Temple in its historic location - Jerusalem's Temple Mount.
In an interview with Saudi Arabia's Al-Watan daily newspaper, Abbas was asked to comment on the notion that "Jewish organizations are making frantic efforts, both visible and hidden, to complete the Judaizing of the Al-Aqsa [Mosque] and to take control of it, especially following the recurring invasions of Al-Aqsa and the attacks on worshipers."
It can only be assumed that the interviewer was referring to incidents of Jewish visitors to the Temple Mount committing the hideous crime of saying prayers to anyone other than Allah.
But Abbas understood him to also be talking about what he called the "dangerous excavations Israel is conducting" in the vicinity of the Temple Mount, excavations that constantly bring to light further evidence of the city's and the holy site's rich Jewish history.
"All these actions indicate an evil and dangerous plot to destroy Al-Aqsa and build the alleged Temple," insisted Abbas. "Unfortunately, these dangers, which are clear for everyone to see, have yet to receive proper Arab, Islamic and international responses."
Palestinian Media Watch, which translated the interview, noted that Abbas' use of the term "alleged Temple" is part of an ongoing and systematic effort by the Palestinian Authority to erase Jewish history, and therefore claims to sovereignty, in Jerusalem.
Abbas is held aloft as a "moderate" leader by most in the West. His predecessor, Yasser Arafat, was not. In fact, one of the things that most convinced former US President Bill Clinton of Arafat's extremism was his open refusal to accept that the Temple Mount had once been home to the biblical Temple, and was therefore important to Jews.
One must wonder why Abbas is treated any differently when he holds the same extreme position?
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Cindy Moua scored on a penalty kick, Chue Thao also had a first-half goal and the Oroville High girls soccer team defeated crosstown rival Las Plumas 3-1 Tuesday at Harrison Stadium.
Valerie Cagnacci added a goal in the second half for the Tigers (2-10-2, 1-8-1 Eastern Athletic League).
Oroville goalie Crystal Malto had one save, while the Tigers out-shot the Thundebirds 20-3.
Gridley 5, Winters 1
Juan Velasquez and Ivan Tinoco both had a goal and an assist, Alfonzo Hernandez, Humberto Arroyo and Rodrigo Olmos also scored goals, and the Bulldogs won on the road.
Ernesto Orozco added an assist for Gridley.
Hamilton 12, Biggs 1
Adrian Chavarria had two goals and six assists, Arturo Gonzales and Emilio Gallegos also scored two goals each and the Braves won a road match.
Anthony Romero, Erik Torres, Gabriel Mancera, Angel Montes, Jesus Ortiz and Luis Polino scored one goal apiece for Hamilton.
Pierce 7, Durham 2
Cesar Barrera scored two goals, Eric Mojica had an assist and goalie Thomas Ratana recorded five saves for Durham (2-6-3, 0-5-2 Sacramento Valley League).
Willows 1, Live Oak 1
Giovanni Guttierez scored the lone goal for Willows (9-5-2, 2-3-2 Sacramento Valley League), and coach Jose Cano credited David Cisneros, Omar Flores, Daniel Macias and Luis Armenta for their strong defense. Goalie Josue Valenzuela recorded 12 saves.
Gridley 74, Wheatland 63
Tyler Abrego scored 20 points to lead the Bulldogs to victory. Samuel Cota and Shobi Khan collected 10 points apiece for Gridley (14-8, 3-1 Butte View League).
Orland 80, Winters 55
Jud Sailsbery put up a team-leading 30 points for Orland (18-4, 4-0 Butte View League), Aneas Rosales scored 11 points and Kavi Ram added 10 for the Trojans.
Durham 53, Quincy 46
Nathan Beck scored 17 points, Will Belton added 14 and Kyle LaMalfa chipped in 12 points for Durham (5-15).
Live Oak 39, Hamilton 33
Leland Prior scored 12 points in a home loss for the Braves. Austin Burbank grabbed 15 rebounds to go with nine points for Hamilton (13-9, 5-3 Sacramento Valley League).
Redding Adventist 63, Champion Christian 27
Daniel Lee and Robbie Spicer each scored eight points to lead the Mustangs (0-13, 0-4 Pioneer Valley League).
Dunsmuir 69, Mercy 59
Malachi Jones scored 31 points for Mercy (4-16).
Hamilton 50, Live Oak 18
Audra Jones scored 17 points and pulled in nine rebounds, and Christy Verboom added 13 points and seven steals for Hamilton (11-10, 6-2 Sacramento Valley League).
Orland 34, Winters 33
Dominique Walker hit the go-ahead jumper with 9 seconds left and the Trojans (6-16) beat the Warriors at home. Jessica James led Orland with 10 points.
Mercy 61, Dunsmuir 43
Marissa Starman scored 17 points, Jessica Curl added 16 and Kayce Kemp had 14 points for Mercy (8-12, 2-4 Five Star League).
Redding Adventist 38, Champion Christian 12
No Mustang scored more than four points as Champion Christian (0-11, 0-5 Pioneer Valley League) fell behind 16-0 by the end of the first quarter.


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The stage is one of the most important factors in selecting treatment options. It is also the most significant (but not the only) factor in predicting a man's outlook for survival (prognosis). A prostate cancer's stage indicates how far it has spread within the prostate, to nearby tissues, and to other organs.
An overview of the stages of prostate cancer:
Stage I: The cancer cannot be found during a digital rectal exam. It is found as a result of prostate biopsies for an elevated or increasing PSA or by chance when surgery is done for another reason, usually for lower urinary tract symptoms. (Stage I=T1)
Stage II: The cancer is palpable — a nodule is detected on prostate exam, but it has not spread outside the prostate. (Stage II=T2)
Stage III: The cancer has spread outside the prostate. It may be in the tissues adjacent to the prostate or invaded the seminal vesicles. It has not spread to the lymph nodes. (Stage III=T3)
Stage IV: The cancer may be in nearby pelvic muscles or organs (beyond the seminal vesicles). It may have spread to the lymph nodes. It may have spread to other parts of the body. (Stage IV includes T4 and spread to the pelvic lymph nodes or distant sites)
A staging system is a standardized way in which the cancer care team describes the extent to which a cancer has spread. The TNM System of the American Joint Committee on Cancer (AJCC) is the most commonly used system in the United States. The TNM System describes the extent of the primary tumor (T), the absence or presence of spread to the nearby lymph nodes (N), and the absence or presence of spread to distant organs (M). The spread of cancer is called metastasis.
A detailed look at the TNM System of Cancer stages:
T CATEGORIES There are two types of T classifications for prostate cancer:
- The clinical stage is your doctor's best estimate of the extent of the disease based on digital rectal exam (DRE), needle biopsy, and any imaging studies that were done.
- The pathologic stage is based on surgical removal and examination of the entire prostate gland, both seminal vesicles (two small sacs next to the prostate that store semen) and, in some cases, nearby lymph nodes.
The clinical stage is used in making treatment decisions. However, the clinical stage may underestimate the amount of cancer and the presence of metastasis (spread of the cancer). If surgery is done, the pathologic stage assigned after surgery is more accurate. Men who do not have a radical prostatectomy (surgery to remove the prostate gland, seminal vesicles, and nearby tissues) do not have a pathologic T stage determined. There are 4 categories for describing the prostate cancer's T stage.
TX is the primary tumor cannot be assessed.
T0 is there is no evidence of primary tumor.
T1 refers to a tumor that is not felt during a digital rectal exam, but cancer cells are found in a prostate biopsy or prostactectomy specimen. T1 prostate cancers can be further subclassified as T1a, T1b and T1c.
- T1a describes prostate cancers found by accident during transurethral resection of the prostate (TURP) (a procedure in which an instrument is inserted through the urethra to remove prostate tissue that is pressing against the upper part of the urethra and restricting the flow of urine) or open prostate removal (simple prostatectomy). When prostate tissue is removed during these surgical procedures and checked under the microscope, cancer may be found, even though the doctor did not expect cancer to be present. T1a indicates that less than 5% of the tissue removed is cancer and more than 95% is benign.
- T1b also describes cancers found incidentally during TURP or simple prostatectomy, but more than 5% of the removed tissue is cancer.
- T1c cancers are found by biopsy. In these cases a core needle biopsy is usually done because the PSA blood test result was elevated, suggesting that a cancer might be present.
T2 means that a doctor can feel the prostate cancer by DRE and that the cancer is thought to remain within the prostate gland. This category is subclassified into T2a and T2b and T2c.
- T2a means that the cancer is in only one side of the prostate, and is in only half (or less) of that side.
- T2b cancers are in only one side of the prostate, but are in more than half of that side.
- T2c cancers are found in both sides of the prostate.
T3 means the cancer has spread beyond the outer rim (capsule) of the prostate into the connective tissue next to the prostate and/or the seminal vesicles and/or the bladder neck. Cancer has not spread to any other organs. This group is subdivided into T3a and T3b.
- In T3a, the cancer is growing outside the prostate but has not spread to the seminal vesicles.
- A T3b cancer has spread to the seminal vesicles.
T4 means that the cancer has spread to tissues next to the prostate (other than the seminal vesicles or bladder neck), such as the external sphincter (muscle that helps control urination), the rectum, the muscles in the pelvis, or the wall of the pelvis.
N Categories
The N category is determined by whether or not the cancer has been found in nearby lymph nodes.
- NX means that tests to detect lymph node spread have not been done.
- N0 means that the cancer has not spread to any lymph nodes.
- N1 means spread to nearby lymph nodes in the pelvis.
M Categories
The M category stands for metastasis (whether or not the cancer has spread to distant organs).
- M0 means that the spread of cancer cannot be found by physical exam or x-rays but is presumed present due to abnormal PSA blood tests.
- M1 means the cancer has spread to distant sites.
- M1a – the cancer has spread to distant lymph nodes.
- M1b – the cancer has spread to bone(s).
- M1c – the cancer has spread to other organs such as lungs, liver or brain.
Recurrent cancer is cancer that has come back (recurred) after a time when it was in remission (could not be detected). It may recur in or near the prostate, or in any other part of the body, such as the bones. Read more information on recurrent cancer.