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Fairfield Inn & Suites Montgomery-EastChase Parkway
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Travel Blogs from Montgomery
Day 6
Breakfast at hotel-same thing, so sick of it lol Bus to a little village-600 years old Tour Lunch there Ice cream there Shopped there Bus to another village Tour-boring Mock traditional wedding Dinner at village Made rice cakes again... Ate Ice cream cakes Party on the deck lolz Sleep in little room at ...
Day 3
Sleep at hotel American breakfast-eggs,ham,bacon,sausage,toast, cresont Bus to hwarang Walk around Meeting Lunch in cafeteria Saw lots of Buddhas in little temples in the mountains Did ceramics- made a bowl Went to Korean restaurant- duck Ate bingsu in hotel coffee ...
Day two
... Saw edge of tomorrow at theater, ate caramel and butter popcorn, sold fried octopus there Walked around more Went to photo shop and took pictures Rode bus back home Went to Korean restaurant and ate bimbipbob, her parents ate hamburger steak with mushroom gravy lol Went to ...
Day one
... We ate Rice pies Toured some area with traditional Korean houses We stopped so her mom could but some pork to cook for dinner Very small apartment Awesome little community; everything in walking distance, lots of these neighborhoods, some bigger than others, I'm in a little one Went to a coffee shop and had some orange sherbet stuff went grocery ...
On the way there
31 hours to get there. The fight was not fun at all. The bus was super nice. Thought we were famous it was so nice and there was a Korean cameraman with us. Lol. The rest area was better than American areas. It had a food court And snack shop, games for kids, things to buy. My stomach hurts really bad. I am exhausted because I haven't slept for more than an hour at a time in the past 31 hours. Got to get up in 6 hours to meet host family! ...


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Enjoy your stay at our B/B with one of the most magnificent views of the entire bay of Valparaíso. Have breakfast in the morning sun on our veranda or enjoy a glass of red wine overlooking the sparkling lights of the city of Valparaíso.
The Grand house es el unico B&B que cuenta con las mas hermosas vistas al mar y ciudad desde todas sus habitaciones. Dispone de 7 habitaciones finamente amobladas, con baño privado, terrazas, cerca de cualquier lugar de interes turistico y cultural
Residencial Rompe Olas is a traditional Chilean residencial situated above the breaking waves in Cartagena. English and Spanish spoken. A family atmosphere and all rooms have an amazing view of the Pacific.
Hostal "Offenbacher-Hof" is located in the city center, in an area known for its tranquility and security. With over 25 years experience we offer our services to tourists creating a welcoming atmosphere which will make it feel like home.
Family run Bed & Breakfast in the quiet neighborhood of Cerro Castillo, near the beach and downtown Vina del Mar. Our services include continental breakfast, laundry, airport transfers, meeting room, parking, Wi-Fi internet, tours and expeditions.
We are located in Providencia, a quiet and accessible neighborhood a couple of blocks away from subway, downtown, great restaurants and the bohemian quarter "Bellavista". You can't miss our European breakfast with home made marmalades and bread!
The Hostel Horizonte Valparaíso is a " SMALL HOSTEL CONCEPT " with a young, nice and resting atmosphere to make you feel between friends, is a favourite destination for travelers during the summer months in Valparaíso. Our breathtaking location in
Ottavia House is located in the center of Valparaiso, it was built in the first decade of the 20th century.
The Grand House has rooms that possess exceptional views to the sea and the city...
Tradición Austral is perhaps one of the best maintained traditional old homes of Puerto Varas in a quiet residential area little changed over the decades.
Find a Valparaiso, Chile bed and breakfast for your romantic weekend getaway. Intimate b & bs are cozy, romantic accommodations that are perfect for a mini-vacation, honeymoon, or wedding anniversary celebration. You will love the unique charm of our Valparaiso, Chile inns. Many guesthouses include complimentary breakfasts and unbeatable hospitality. Browse our bed & breakfasts and plan your Valparaiso, Chile romantic getaway today!

subset: commoncrawl


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Government Policies are Killing Our Republic
By: Art Thompson
JBS CEO Art Thompson's weekly news video update for January 14 - 20, 2013.
In this week's analysis behind the news video, JBS CEO Art Thompson discusses: How our "Arab Spring" policies toward North African and Mideast countries has not brought about better rulers, but instead has brought about more persecution of Christians; how the democracy we work for abroad was considered by Karl Marx as the first step toward communism; how our foreign policy officially became building a New World Order under President H.W. Bush; how President Obama's amnesty programs for illegal immigrants is helping to bring about the North American Union; and how our own government is at war with the American people through a variety of "humanitarian" programs.
New World Order image via Shutterstock.


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Article Archives: Virginia
Supporting Affordable Housing through Tax Credit Syndication
As a tax credit syndicator, CAHEC structures equity funds using investors' capital. CAHEC's most recent fund is the South Carolina Preservation Fund II LP (SCPF II). SCPF II is a $32 million equity fund designed to preserve and renovate a portfolio of older, multifamily housing properties in South Carolina. The targeted portfolio includes 41 properties with a total of 1,548 units. Although all investments in SCPF II were fully subscribed in 2008, banks can invest in other CAHEC equity funds as they are developed. To learn more, visit their Web site or e-mail Dana Boole or call (919) 788-1803.
Small Loans, Big Returns
Headquartered in Milwaukee, WtW makes its loans from 43 offices in 21 states: California, Delaware, Florida, Hawaii, Illinois, Indiana, Louisiana, Maryland, Michigan, Minnesota, Missouri, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Dakota, Texas, Virginia, Washington, and Wisconsin.
WtW offices are located in social service agencies affiliated with the Alliance of Children and Families (ACF). ACF agencies screen and provide financial education to borrowers and service the loans. WtW local offices provide financial education to more than three persons for every individual who receives a loan. Investors in WtW include several national foundations, the Community Development Financial Institution Fund of the U.S. Treasury Department, local United Way offices, and financial institutions. Banks can be involved by investing in the national WtW loan fund, by referring to local WtW offices prospective borrowers who do not meet conventional credit criteria, by participating in local WtW loan committees, and by providing grants and in-kind donations to WtW.
For more information, contact President Jeff Faulkner at (414) 359-1448 ext. 2, e-mail him, or visit his Web site.
[Community Developments Investments, Fall 2008]
Virginia Community Capital Expands Its Mission
VCC offers partnership opportunities for community development loans and investments to banks serving Virginia. In addition, VCC provides technical assistance and credit enhancements for banks making loans for community development.
For more information, contact Jane Henderson, President and CEO at (540) 260-3126, e-mail her, or visit VCC's Web site.


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[Page 369]
[Page 376]
Translated by Jerrold Landau {Photo page 376: Uncaptioned. Reizl David (Rashkes)
As an eyewitness, I will attempt to describe here the beginning of the destruction of Jonava on June 23-24, 1941.
Jonava was one of the army camps of Lithuania. The camp named Poligon was located five kilometers south of the town. When the Russians conquered Lithuania in 1940, they fortified this camp further with tanks and cannons. The Poligon Camp overlooked two large bridges over the Vylia. In Poligon, the Russians demonstrated their greatest opposition to the Germans. I say Russians for the Lithuanians immediately turned into collaborators with the Germans.
The opposition lasted for one day and one night.
On Sunday, June 22, toward morning, the roaring of airplanes at a high altitude was heard in Kovno. The airplanes innocently looked like tiny birds, flying calmly at the beginning of a lovely summer morning.
However, suddenly, those innocent birds began to drop bombs on Kovno (at that time, I was living in Kovno). People ran outside to see what was going on, but it became known immediately that these were German airplanes. The war had also reached Lithuania.
My brother who lived in Kovno, Ben-Zion Rashkes of blessed memory, immediately arrived with packed suitcases. People ran back and forth without knowing where to flee, what to do, how to save themselves the confusion was great. We also ran, but we knew to where we were escaping: home to Jonava, in order to be together with Father, Mother and our sister; to be together with our closest, most beloved relatives, whatever may happen.
Hundreds of Jews escaped. Gentiles, of course, did not escape. We fled via the mountain road. The roads were overloaded. Nobody knew how far they would succeed in reaching during their escape. Everyone ran with great fear in their eyes and with large packages on their shoulders and in their hands. However, they were unable to drag all those bundles for a long period; and the roads were filled with abandoned suitcases, with their contents scattered. Gentile farmers stood in the fields at the side of the road and waited for these treasures, as if they fell from the sky, and grabbed them immediately. However, nobody cared about this, because we only thought that if we were to survive, we would also have belongings.
My brother saw a wagon driven by the Manoshovitzes and loaded up all our bags onto it. He also sat on the wagon, and we never saw him again.
The Russian Army was also in a state of confusion. Soldiers went by foot or traveled on tanks or vehicles without knowing where they were going. We saw them driving in opposite directions, with frightened eyes. They did not know how to answer the questions we asked them. The generals fled first and left the soldiers to their own devices.
We traveled for a full day. In the evening, we reached to a point next to the wooden bridge over the Vylia near Jonava. The bridge was already broken and bombed out, for the Germans had bombed there too. My dear father and sister Rachel were already standing there waiting for us on the banks of the river. Gentile farmers would transport people across the river in boats (of course in exchange for payment). Gentile women joined them in the boats in order to collect the belongings that the Jews had abandoned due to being unable to carry them further. On the other side of the Vylia, that is in Jonava, my dear, beloved mother was standing there waiting for us. This image is etched in my heart forever. She was happy through the tears of her eyes. Simultaneously, a great fear was expressed through her beautiful cherry-like eyes: What would be the end of her endangered chicks?
[Page 377]
Jews ran to and fro: Tell me, Jews, to where are you escaping? Perhaps we will escape along with you! The response was: We also do not know. We were in the train station but the train did not arrive. Thousands of refugees were sitting there waiting for the train, including Jews from Poland who came to Lithuania in order to save themselves from the German, may his name and memory be blotted out. Then we ran to Wilkomir Road. The Germans bombed the roads. Many people were killed.
We remained in Jonava. After one night, the cannons began to shoot over our heads. From one side, the Germans were behind Keidiani Street, and from the other side, the Russians from Poligon. We remained in the middle, as if in a trap.
Then, the Lithuanians began to act in a wanton fashion. They gathered in the bell tower of the church and shot with machine guns at the Jews who were running to seek refuge from the cannons. The young fascist Lithuanians also shot from the progymnasium at their Jewish fellow townsfolk, with whom they had lived in harmony until this time. The good neighbors turned into great, deadly enemies within a moment.
We fled from our house the Street of the Road to the parents of my sister's husband, The Goldmans (who owned a furniture factory). They lived on the Street of the Synagogue. Why did we specifically go to them? Perhaps because their house was close to the synagogue courtyard who knows? We hid in a pit that was quickly dug by the men in the yard of their house. My father and mother did not want to leave their house under any circumstance, for the house was filled with all types of food provisions that they had stockpiled throughout the year, since the time of the Russian regime (for the Russians would send the foodstuffs to Russia). The household economy had been firmly established for many years already, and leaving the house would leave everything ownerless something that the gentiles were awaiting.
In the morning, as we were lying in the pit, we heard a knock on the opening to the pit. We opened the wooden door, and saw Father standing pale. It was difficult to recognize him. With a trembling voice he asked that we give him a jar of honey. When we peered out from the pit, we saw a German in green fatigues. We had taken from the house jars of honey and jam, and other foodstuffs that we would be able to live on as Mother said when she gave them to us. She promised to bring the rest the next morning, when she and Father would come to us. They said that during the day, they would not be suspected of leaving the house. These unfortunate people were na?ve: they had faith in human beings they might come to pillage at night, but during the day, they thought, the gentiles would be embarrassed
We gave Father a jar of honey and asked him if the house is still whole, and why do Mother and he not join us. Father answered quickly, with a trembling voice, Mother is making coffee for the Germans, and he quickly disappeared with the German.
In the meantime, the bombardments increased. A shell damaged the synagogue. It seemed to us that it fell next to our pit. We peered out with our heads and saw that a large portion of the synagogue was missing. We could not continue to remain in the pit, for Jonava was already in flames by the afternoon. We already felt the heat of the fire in our pit, and the smoke penetrated inside. When we exited the pit it seemed that the Street of the Road, upon which our house stood, Kovno Street, Breizer Street, and Vilna Street were all burning. We ran to the Vylia River. At that time, the Lithuanians were shooting at us from their hiding places with machine guns. We miraculously reached the shrubs behind the bathhouse. Some gentiles also fled there with us, for the cannons did not discriminate, and they too were in danger. The gentiles were very friendly to us during those moments, but as soon as the bombardment stopped, they no longer knew us. It was already impossible to run back; therefore we dug as deeply as possible into the ground so that the bullets and shells that were literally flying over our heads would not hurt us. During the bombardment, Monas Klibensky the carpenter got up suddenly and said that he thinks that he did not lock his back door, and he started to go. His son-in-law Avraka Unterschatz dragged him back to the ground with his foot. His daughter Feiga
{Unnumbered page after 377. Photo: Jonava in flames. (The houses of Granovich and Zopovich in the foreground.)}
[Page 378]
began to weep and pleaded, Father, where are you going? Everything is burning. However Monas apparently foresaw the Holocaust and his nerves weakened. He again got up and said that he thinks that he forgot to close the windows. He felt it necessary to go to find out. Avraka once again dragged him to the ground, covered him with his body, and did not let him get up.
I saw the wife of Avraham the shochet lying there with my friend Feigcha, Berele the youngest of the children, and Hirshka. I did not see the daughters Rachel and Rivka, nor Avraham the shochet.
I lay down and wept, for nobody saw Father and Mother anywhere. Anyone we asked was not able to say anything, and I suspected that they all knew something but did not want to tell us. Father and Mother had remained with the Germans. Only G-d knows what they endured on that dark night. What did the Germans do to them? How can I live without Mother and without Father, heaven forbid? How is it possible?
The sight of Jonava that night was terrifying: a frightening sky, very red, and all of Jonava engulfed in flames like hell.
The shells flew over our head with greater strength. We were already able to tell if a shell was falling closer to or farther from where we were. Every time that a cannon was shot and its scream was heard above us, a gentile would be able to determine where the bullet was. (The bullets fell far away, whereas the shells rained upon us.) He would say, A shell has fallen at a distance of ten feet, now a shell has fallen at a distance of five feet. He was right, apparently, for we did no hear him speak anymore. The cannons quieted somewhat, and at sunrise they were almost completely silent. Then, when we began to arise and get up, we saw dead bodies lying near us. We did not realize that we had been lying beside dead bodies all night.
We looked up to see whether Jonava was still burning, and we saw thick smoke bursting forth to the sky. We ran back to the house of the parents of the husband of my sister Rachel. The house was still whole, almost the only one in the entire alley. The Jewish hospital opposite the Goldman's house was burnt. The ill people were lying burnt in the iron beds.
We did not yet know what had happened to our parents. It was dangerous for women to leave the house. I sat and prayed to G-d, and the door at the side of the house opened. They entered quickly, short of breath, sweaty and panting first Father and then Mother. The joy was great. We hugged, kissed, and all wept from joy. Once again, we were all united with an eternal connection. Mother was wearing only a dress, and Father a cloak and pants. They could not salvage any more of their property. Father told us what had happened to them. When they were left alone in the large house, they were unable to sleep at night. Father went out to the yard and dug a deep pit as a refuge from the shells. Father said that the shells were flying very low between the houses. Not a living soul was seen on our street (the Street of the Road). The appearance was terrifying, like a city of ghosts. Only shadows were seen here and there sneaking into the abandoned houses and pillaging, even in the midst of the bombardment. Therefore, Father and Mother were very afraid to remain in the house, lest the pillaging gentiles kill them. They then decided to escape to us, to the Goldmans. However, before they had time to pack various valuables, they heard knocking on the door. It was still dark. Father approached the door with trembling steps and asked who was knocking. They answered in German, Open the door, Jew! With great fear, father opened the door. A group of 30 German soldiers broke into the house. Apparently, these were the first soldiers -- scouts. The commander ordered Father to go through all the rooms with them, then to the cellar and the storehouses in the courtyard, and even the pit that Father had dug in the yard all this in order to check that no Russians were hiding there. Then the commander ordered to bring water. Father brought them pails of water from the well that was in the cellar. They all washed up. As per their order, Mother brought them towels and underwear so that they can change. Then they ordered Mother to make them coffee and give them something to eat. The Germans drank from the cups from the fine dishware set that belonged to my sister. Then they put the dishes into their backpacks along with many other valuables, such as the silver candlesticks, the silver cups, silver boxes, and other such items. Then one of the Germans asked Father
[Page 379]
if he had any honey, for he loved honey. Since Father was naîve and innocent, he told the German that his daughter had taken the honey with her. That is why they came to us to get the honey. All of this took place under the rain of shells, as Jonava was already burning and almost the entire Street of the Road was in flames. The Germans did not permit my parents to escape from the fire and bullets until our house was bombed and began to burn. In the meantime, they saw other Jews, who before had apparently been hiding in the cellars. They also ran. Among them were Gitel Klotz and Zusman Klotz, our maternal cousins. Suddenly shots were fired from some place behind the fleeing Germans. The Germans captured Father, Zusman Klotz and other men whose names I do not know, and stood them against a burning wall in order to shoot them, out of suspicion that they had been shooting at the Germans. They would have been killed within another second, but suddenly two Lithuanians with guns in their hands burst forth from behind the burning wall. They were searching for a refuge from the fire. The Germans caught them and shot them, and freed the Jewish men. The Jewish men continued to escape toward us, but they could not run through the Street of the Synagogue because everything around was burning. Burning houses became shaky, and the streets were filled with ruins and fire. All of Jonava was one large ruin. They ran to a place where it was still somewhat possible to save oneself from the hell, and they came to the brick kiln. They lay down all night. In the morning, when the shelling ended, they ran to us.
Father stood on his feet and said, We do not have time now to speak a great deal. Let us go out to see what the situation is. He told my sister Rachel and I to not dare to go outside. We accompanied him to the rabbi of the town, Rabbi Ginzburg, who was apparently leaving some hiding place. We surrounded him with questions, Rabbi, what will be? His fine face was pale, and his appearance had changed greatly. He spoke in choppy words, with tears choking his throat: We have to be careful with security. G-d will help. Jews, we must be strong. He himself was wailing like a baby. Everyone was weeping. We returned home in order to hide from the dangers that began to stalk us.
After a few hours, Father returned with a darkened face. He told us, An entire group of Jews was burned in Liber Farber's basement. Father was the first one to open the iron door of the cellar burnt skeletons were resting on the door. The first skeleton was the largest, and they realized that it was of Meir Wunder. The door of the cellar locked itself on them, and they were unable to exit and save themselves from the fire.
Our house, Father said, and the streets in general are unrecognizable, for the destruction was great and went to the foundations. Here and there, smoke was coming out of the ruins. Father recognized the lot in which our house had stood from the pit that he had dug. Father noted, A smart cat hides in a pit, but I locked our cat in the house. Perhaps it too was hiding in the pit
In the meantime, the Jews began to search for food, for a morsel of bread. Hunger pervaded the city. One Jewish bakery that by chance remained intact at the end of Kovno Street was taken over by gentiles who chased out the former owners and baked bread for he gentiles. Jews stood and stuck out their hands for a morsel of bread, and the gentiles chased them away, saying, Go ask the Communists. They will give you bread. My sister risked her life and left the hiding place. A gentile acquaintance gave her a piece of bread and told her, Hide and do not go outside. They are plotting to rape the young women of Jonava. The Jews of Jonava began to feel that danger was waiting for them not only from the Germans, but also from their Lithuanian neighbors.
There used to be a pharmacy in our house in which a gentile woman had worked as a cashier. We were good friends. Father came running to me with fear in his eyes and told me that this woman was looking for me, and of course, she was not planning to do anything good to me. She had become an important leader and immediately began to threaten the Jews of Jonava. With his clear sense, Father suspected that a great danger was awaiting me, his youngest daughter: The gentiles were wandering around looking for Jewish girls to rape. When I later was in the Kovno Ghetto, a group of Jonava woman arrived.
[Page 380]
One of them was Chanka Rabinovich who told me that the shkotzim forcefully put young Jewish girls into a barn and tortured hem to death.
Father immediately decided that I was to return to Kovno. There, the gentiles do not know you, he said with a trembling voice. He was about to part from his beloved daughter for who knows how long, perhaps forever. Mother was overtaken by convulsions, and Father began to plead with Mother to calm down. This is the only way, he claimed. As has been said, we, that is my husband and I (I got married only a few months before to Wolf David from Kretingen near Memel), parted also from my sister Rachel, from my brother-in-law Yitzchak Goldman, and from the entire Goldman family, none of whom survived. The Goldmans had five sons and a daughter Batya. The sons were Yitzchak the eldest, Mordechai, Zerach, and two twins whose names I do not recall.
Father said that we must escape back to Kovno via the old path, for he realized that a large army would be passing through the main road, and that we would be safer on the old road that begins on the descent of Kovno Road, for it is an inferior road. That is indeed the way it was, as my wise father had known. Many refugees returned to Kovno. The refugees were from all over Lithuania and also from Poland, who had come to Lithuania a year earlier when the Germans entered Poland. They wanted to reach some safe place, perhaps to Russia, but they had remained in Jonava. We, a full camp, went back to Jonava. All of the family and many other Jonavers accompanied us to the brick kiln. Father pleaded to everyone to refrain from making this public farewell procession, for this might end badly, heaven forbid. Nevertheless, everyone wanted to give us a farewell blessing. Taibl, Rachka Jalinowitz' mother, hugged me, kissed me, and wished me good fortune. I asked her, Where is Rachka? and she answered: Hiding.
This was the last time that I saw my family and that I set foot on the ground of Jonava, my dear birthplace with its dear, heartwarming Jews, may their memory be a blessing, may G-d avenge their blood.
[Page 382]
Translated by Jerrold Landau {Photo page 382: Uncaptioned. Yerachmiel Garber}
In the morning of Monday, June 23, I went as usual to my workplace in the Oren match factory. The war had begun, but the work had to take place no matter what. In any case where was Jonava and where was the front? We were given spades and told to dig protective ditches. Some of the diggers were immersed in thoughts, some tried to joke that there was no need for ditches. The jokers trusted that the Soviets would not let Hitler reach Jonava.
Suddenly, the noise of autos reached our ears. We put down the spades and ran to the road to snatch a glance. We saw the Red Army trucks covered in green branches, such as Sukkot covered with Sechach[1]. The faces of the soldiers were black with dust. We only saw white teeth and glittering eyes. We suddenly heard the sound of thunder, but the skies were clear without any clouds at all. It seems that this was the echo of an artillery battle. Everyone's face became serious. People were immersed in thought.
I did not return to the spade. I hastened to town to see what was going on. It was the same town, but unrecognizable. We felt hasty movement. Everyone's face was serious and perplexed, as if they were seeking a refuge from a crazy situation. Hundreds of people were running on the ascent of the road. Others turned toward the wooden fence. Refugees from Kovno turned in that direction. I turned toward the bridge with large steps. It seemed as if Jews were gathering here for Tashlich[2], however we heard no prayers, but rather conversations between Jonavers and Kovnoites who were astounded at the situation. I could not understand, what was with them? Did they take leave of their senses to run by foot from Kovno?
Among those who were coming, I met a lad who was an acquaintance, Shliten. I had studied together with him in ORT[3]. We turned aside, and I asked,
Oh, what is taking place here?
Don't ask questions, he responded, lift up your feet and get out of here as fast as you can. The Germans are already in Kovno.
I was still rolling my eyes, but the seriousness of the situation penetrated my consciousness. I returned home. I met friends along the way, and we decided to leave Jonava for a brief time and to go to Wilkomir, with the belief that the Germans would quickly receive a deathly blow from the Soviet Army
I ran to my friend Hershe-Yankel Stein. I heard shrieks and screams next to the house, as if during a funeral. Taibl Katzav was taking leave of her son, who was about to leave on his bicycle. This was strange in my eyes: is this how one weeps for a living person? He told me that he and his friends were setting out on their bicycle, and that they would wait for me. I ran home quickly. I met Uncle David, who had moved in with us with his family until the storm would pass. I told my parents about my plan, and they accepted it with understanding. They gave me several rubles, and I went out of the house without even taking leave. We did not grasp the seriousness of the situation, that we would never see each other again.
As we passed by the post office, we ran into young Lithuanians who were looking at us with a bitter smile and gnashing their teeth. We were on the ascent to the mountain. The entire way was strewn with people and wagons. The wagon drivers loaded their belongings and families, and fled for their lives. We passed under the railway crossing. Suddenly, airplanes appeared low above our heads. They shot at us and dropped bombs. We were lying in the ditches at the side of the road. We were not injured. We continued to move. Bad thoughts went through the head. It seemed that we were separating ourselves from Jonava. The journey was not easy, even though we were young and healthy. The repeated running back and forth to search for a hiding place in the ditches drained our strength. The enemy did not stop sending his airplanes at us, shooting at the refugees. Along the way, we lost some people and met up with others until we reached Wilkomir.
It was night. It was dark. The Germans shot shiny bullets that looked like stars from the airplanes. In Wilkomir, I met Mosheke Goldschmid of Jonava immersed in worries: There was a puncture in his tire. I helped him with the repair, and we prepared for the journey. It was only possible to move at night. The question was, in what direction. Some advised to go to Vilna, the capital of Lithuania. It would not be easily captured by the Germans. There, they would break their teeth. Others felt that we should go toward Zarasai (Ezrani) at the Latvian border. I supported this, and the group agreed.
We travelled all night. At dawn, the airplanes appeared again, and everything repeated from the day before. At times, we ran to the ditches. The breaks between the air attacks continued to shorten. We turned away from the road, went up to the side road, and lay in the grass to rest. An army truck stopped next to us. We wanted to have a conversation with them, but they did not know Russian. One person succeeded in asking what was happening in Jonava. The response was: In Jonava the Germans.
This oppressed us, and we did not ask further.
[Page 402]
Translated by Jerrold Landau
During the years of the German occupation, 1941-1944
(A brief account.)
{Photo page 402: Hirsch Levin, one of the important organizers of the Jewish resistance movement of the Kovno Ghetto.}[1].}
In December, 1941, with my initiative, I organized a clandestine meeting in the ghetto with the representative of the Communist underground (Galperin). At this meeting, the foundations for the united underground of the Kovno Ghetto were laid. Its members were Zionists and Communists.
Between 1942 and 1944, I was a member of the leadership of the underground organization. I carried out the following actions:
As I was told by those who had been among the directors of the ghetto, Keitel searched for me until the last day, and nicknamed me Levin the leader of the gangs.
January 24, 1971
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Guiding Principles
CARL members adhere as a closely as possible to several key principles
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(adopted by the membership, November 9, 1993; augmented, June 12, 1995)
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Freedom of Expression
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Topic Title
- Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness
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- Research Review Jan. 31, 2012
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Original Nomination
Executive Summary – Jan. 31, 2012
Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness
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Partly out of date: This report was assessed in October 2015 and some conclusions may not be current.
Table of Contents
- Background
- Objectives
- Key Questions
- Analytic Framework
- Methods
- Results
- Discussion
- Future Research
- Conclusions
- References
- Full Report
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Chronic pelvic pain in women is a commonly occurring and poorly understood condition. Little consensus on the definition of the condition exists—the duration of pelvic pain considered chronic in published studies varies from 3 months to more than 6 months, and the location and pathology of the pain are largely unspecified.1 The American College of Obstetricians and Gynecologists defines chronic pelvic pain as "noncyclical pain of at least 6 months' duration that appears in locations such as the pelvis, anterior abdominal wall, lower back, or buttocks, and that is serious enough to cause disability or lead to medical care."2 Noncyclic chronic pelvic pain (CPP) is the focus of this review. Noncyclic CPP excludes chronic pelvic pain that is limited to dysmenorrhea (pain with menstruation), dyspareunia (pain with intercourse), dyschezia (pain with bowel movement), or dysuria (pain with urination).3,4 Noncyclic CPP is sometimes described simply as "chronic pelvic pain" in the literature because many subdivide chronic pelvic pain into dysmenorrhea, dyspareunia, and nonmenstrual CPP.2
For this review, we defined noncyclic CPP as pain that has persisted for more than 3 months, is localized to the anatomic pelvis (lower abdomen below the umbilicus), and is of sufficient severity that it causes the patient to become functionally disabled or to seek medical care. The chronic pelvic pain must always have a noncyclic component; however, there could also be cyclic pain in some individuals. CPP as described throughout this review refers to noncyclic or mixed cyclic/noncyclic pelvic pain unless otherwise noted.
The causes of CPP are not well understood and may be associated with gynecologic (e.g., endometriosis) and nongynecologic (e.g., irritable bowel syndrome [IBS]) conditions. Diagnosis of an underlying cause is complicated because the pain is rarely associated with a single underlying disorder or contributing factor;5 Howard outlined more than 60 diseases and conditions associated with CPP.5 Frequently diagnosed etiologies include endometriosis, adhesions, IBS, and interstitial cystitis (IC)/painful bladder syndrome (PBS);6 however, a definitive diagnosis is often not made.
Population. We focused this review on women age 18 and older with noncyclic or mixed cyclic/noncyclic chronic pelvic pain. Throughout this review, CPP refers to noncyclic or mixed cyclic/noncyclic pelvic pain unless otherwise noted.
Interventions. Interventions included surgical approaches, such as hysterectomy and laparoscopy, and nonsurgical approaches, including medical management and integrative interventions.
Comparators. Comparators included no treatment, placebo, and comparative interventions or combinations of interventions.
Outcomes. Our outcomes of interest included:
- Pain status (reduction in pain, pain recurrence, subsequent intervention for unresolved or worsening pain)
- Functional status (activities of daily living, sexual functioning)
- Quality of life
- Patient satisfaction with pain management
- Harms or adverse effects of nonsurgical interventions
Key Questions
The Key Questions (KQs) were:
KQ1. Among women who have been diagnosed with noncyclic/mixed cyclic and noncyclic CPP, what is the prevalence of the following comorbidities: dysmenorrhea, major depressive disorder, anxiety disorder, temporomandibular joint pain disorder, fibromyalgia, IBS, interstitial cystitis (IC)/painful bladder syndrome (PBS), complex regional pain syndrome, vulvodynia, functional abdominal pain syndrome, low back pain, headache, and sexual dysfunction?
KQ2. Among women with noncyclic/mixed cyclic and noncyclic CPP, what is the effect of surgical interventions on pain status, functional status, satisfaction with care, and quality of life?
KQ3. What is the evidence that surgical outcomes differ if the etiology of noncyclic/mixed cyclic and noncyclic CPP is identified after surgery?
KQ4. Among women with noncyclic/mixed cyclic and noncyclic CPP, what is the effect of nonsurgical interventions on pain status, functional status, satisfaction with care, quality of life, and harms?
KQ5. What is the evidence for choosing one intervention over another to treat persistent or recurrent noncyclic/mixed cyclic and noncyclic CPP after an initial intervention fails to achieve target outcome(s)?
Analytic Framework
We developed the analytic framework (Figure A) based on clinical expertise and refined it with input from our Key Informants and Technical Expert Panel (TEP) members. The framework summarizes the process by which women with CPP make and modify treatment choices. Treatment choices include surgical or nonsurgical approaches and may lead to outcomes that include changes in pain status (e.g., resolution of pain, continuing pain, continued need for pain medication), patient satisfaction, quality of life, or harms/adverse effects.
Treatment choices may not provide pain relief or improvements in functional status or quality of life, and women with CPP may undergo additional interventions after a treatment approach has failed. In addition, outcomes may vary by diagnosis in those patients receiving a confirmed diagnosis for the etiology of their CPP.
Figure A. Analytic framework for therapies for women with CPP
Abbreviations: BSO = bilateral salpingo-oopherectomy; CAM = complementary and alternative medicine; KQ = key question
Input From Stakeholders
The topic was nominated in a public process. With Key Informant input, we drafted initial KQs, which the Agency for Healthcare Research and Quality (AHRQ) reviewed and posted to a public Web site for public comment. Using public input, we drafted final KQs, which AHRQ reviewed. We convened a TEP to provide input during the project on issues such as setting inclusion/exclusion criteria and assessing study quality. In addition, the draft report was peer reviewed and available for public comment.
Data Sources and Selection
Data sources. We searched four databases: MEDLINE® via the PubMed interface, PsycINFO (psychology and psychiatry literature), Embase Drugs and Pharmacology, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database. We hand searched reference lists of included articles and recent reviews for additional studies.
Inclusion and exclusion criteria. We excluded studies that:
- Did not include women age 18 and older with noncyclic CPP
- Did not report information pertinent to the KQs
- Were primarily focused on coexisting conditions, cancer pain, or pregnancy-related pain
- Were not published in English
- Were published prior to 1990
- Were not original research
- Were retrospective studies or case series (unless they included ≥100 participants and reported nonsurgical harms or comorbidity data)
We also excluded studies with fewer than 50 total participants if the studies assessed the effects of surgical or nonsurgical interventions, addressed differences in surgical outcomes by etiology, or presented evidence for selecting one intervention over another.
We accepted controlled trials and prospective cohort studies with at least 50 participants with CPP and case series and cross-sectional studies that had at least 100 participants with CPP and addressed nonsurgical harms or the prevalence of comorbidities identified in KQ1.
We did not address harms of surgical interventions in this review, as we felt that the studies meeting our inclusion criteria would necessarily provide only chance evidence of harms of surgical interventions. Most of the surgical interventions used for CPP are deployed in a broader context for other indications; a systematic review of the harms of the procedures would require a different and much larger search than the current review assignment, protocol, and KQs dictated. Reporting only the harms represented in the selected studies meeting our criteria for addressing surgical intervention for CPP would present only a partial picture of potential harms of surgery.
Screening of studies. Two reviewers separately evaluated each abstract. If one reviewer concluded that the article could be eligible, we retained it. Two reviewers independently read the full text of each included article to determine eligibility, with disagreements resolved via third-party adjudication.
Data Extraction and Quality Assessment
Data extraction. All team members entered information into the evidence tables. After initial data extraction, a second team member edited entries for accuracy, completeness, and consistency. In addition to outcomes for treatment effectiveness, we extracted data on harms/adverse effects.
Quality assessment. Two reviewers independently assessed quality, with differences resolved though discussion, review of the publications, and consensus with the team. We rated studies as good, fair, or poor quality and retained poor studies as part of the evidence base discussed in this review. More information about our quality assessment methods is in the full report.
Data Synthesis and Analysis
Evidence synthesis. We used summary tables to synthesize studies that included comparison groups and summarized the results qualitatively.
Strength of evidence. The degree of confidence that the observed effect of an intervention is unlikely to change is presented as strength of evidence. Strength of evidence can be regarded as insufficient, low, moderate, or high. It describes the adequacy of the current research, in quantity and quality, and the degree to which the entire body of current research provides a consistent and precise estimate of effect. We established methods for assessing the strength of evidence based on AHRQ's Methods Guide for Effectiveness and Comparative Effectiveness Reviews,7 which is used by Evidence-based Practice Centers.
Our searches retrieved 2,081 nonduplicate citations (Figure B). We reviewed the full text of 623 articles and included 39 articles, comprising 36 unique studies, in the full review. The full report details reasons for exclusion.
Figure B. Disposition of articles located for the review
aThe total number of articles in the exclusion categories exceeds the number of articles excluded because most of the articles fit into multiple exclusion categories.
Note: KQ = Key Question; n = number.
KQ1: Prevalence of Comorbidities
We identified 23 unique studies addressing the prevalence of comorbidities of interest for this review.8-31 Dyspareunia (11 studies), dysmenorrhea (12 studies), and IBS (10 studies) were the most frequently reported comorbidities in women with CPP, with rates ranging from 15 to 88 percent for dyspareunia, 4 to 100 percent for dysmenorrhea, and 24 to 39 percent for IBS. Rates for other comorbidities also varied widely, and studies were largely of poor quality. Studies frequently failed to use validated diagnostic criteria and may not have provided an operational definition for a given comorbidity. We did not assess the strength of evidence for studies addressing this KQ about the prevalence of comorbidities; the strength of evidence evaluation was designed for assessing effectiveness of interventions and is thus not applicable.
KQ2: Outcomes of Surgical Interventions for CPP
We located seven unique studies addressing surgical interventions for CPP: five randomized controlled trials (RCTs)9,13,32-34 and two prospective cohort studies.16,35 All RCTs were conducted in Europe or New Zealand, and all prospective cohort studies were conducted in the United States. Three studies compared surgical with nonsurgical or medical approaches for CPP treatment.13,16,35 Three studies compared an active surgical technique, either laparoscopic utero-sacral nerve ablation (LUNA) or adhesiolysis, with surgical control (diagnostic laparoscopy).9,32,33 One study directly compared two surgical techniques (LUNA vs. utero-sacral ligament resection).34
One good-quality RCT evaluated laparoscopic lysis of intraabdominal adhesions32 and reported no improvement in pain scores over diagnostic laparoscopy. Similarly, no studies reported benefit of LUNA compared with simple diagnostic laparoscopy. One poor-quality study evaluated hysterectomy for CPP pain relief compared with nonsurgical management and reported greater patient satisfaction in the hysterectomy group, although data for women with noncyclic CPP alone are difficult to isolate and participants self-selected surgical or nonsurgical intervention. We assessed the strength of evidence for all surgical interventions except LUNA and lysis of adhesions as insufficient. With two RCTs, one of fair and one of poor quality, we assessed the strength of evidence as low for the lack of efficacy of LUNA to improve pain status over diagnostic laparoscopy alone and low for the effects of adhesiolysis on pain and quality of life (one good-quality RCT).
KQ3: Evidence for Differences in Surgical Outcomes by Etiology
We did not locate any studies addressing this question.
KQ4: Outcomes of Nonsurgical Interventions for CPP
We located 17 unique studies addressing nonsurgical interventions.8,10-16,35-44 Fourteen of these studies were RCTs, and three were prospective cohort studies. Most RCTs investigated hormone-based treatments for CPP. One evaluated antineuropathic agents, and another evaluated the neuromuscular blocking agent botulinum toxin A. Four RCTs examined nonpharmacologic therapies—pelvic floor physical therapy, photographic-enhanced counseling after surgery, pelvic ultrasonography plus counseling, and a standard versus integrated treatment approach. Cohort studies evaluated outcomes of hormone-based therapy and assessed nonsurgical compared with surgical approaches.16,35
Twelve of the 17 studies were performed in Europe, with the remainder conducted in the United States and Australia. Most were conducted at academic institutions. Only one study was rated as good quality,14,15 three were fair quality,10,36,37 and the balance were poor.8,11-13,16,35,38-42,44
Of the nine studies addressing hormonal treatments for endometriosis-associated CPP, all reported equal effectiveness among active agents investigated, with the exception of a placebo-controlled trial of raloxifene. This RCT reported more rapid return of pain in the raloxifene group, and the trial was stopped early.14 The few (n = 3) placebo-controlled studies were of fair or good quality and reported larger size of effect (60- to 70-percent range) than studies comparing two active agents. An RCT of botulinum toxin36 reported some improvements in pain scores. An RCT of gabapentin plus amitriptyline or either agent alone8 reported some improvements in pain scores.
Few studies addressed nonhormonal or nonpharmacologic management. One fair-quality RCT of a pelvic physiotherapy technique reported improvement in pain scores in the treatment group; one poor-quality study reported no benefit from postoperative counseling augmented with displaying operative photographs while discussing findings with participants; and two poor-quality trials reported some benefits from an integrated treatment approach and ultrasonography plus counseling. Reporting of harms data was very limited among trials; among placebo-controlled trials, harms were more frequent in the placebo arms.
We assessed the strength of evidence for all nonsurgical interventions as insufficient, with the exception of low strength of evidence for the effects of raloxifene and depot leuprolide on pain status, both assessed in good- or fair-quality placebo-controlled trials.
KQ5: Evidence for Selecting One Intervention Over Another
We did not locate any studies addressing this question.
Key Findings
The prevalence rates for the comorbidities we examined showed significant variation. Frequently no operational definition or diagnostic criteria for comorbidities were provided. When definitions or criteria were available, they were rarely consistent across studies. Diagnostic methods varied and included patient report of symptoms, patient report that she was given the diagnosis by a health care provider, evaluation by a health care provider, and objective diagnostic criteria.
Given that many women with CPP are treated with invasive surgical procedures, remarkably little evidence exists that supports a surgical approach to the treatment of CPP. We identified and reviewed two articles comparing nonspecific surgical approaches with nonsurgical approaches,13,16 one study addressing hysterectomy specifically,35 one study evaluating laparoscopic adhesiolysis at the time of diagnostic laparoscopy,32 two articles evaluating LUNA compared with diagnostic laparoscopy,9,33 and one paper directly comparing LUNA and utero-sacral ligament resection.34
In none of the studies with comparison data was surgery in general or any specific surgical technique better than either nonsurgical intervention or the comparator technique in improving pain status in patients. Given the limited number of studies addressing heterogeneous surgical interventions and with so few being of good or fair quality, it is difficult to summarize the evidence for the effect of surgical interventions on any of the outcomes proposed. Although no surgical technique emerged as a superior method for surgical intervention, the evidence is insufficient to conclude that surgical intervention is either effective or ineffective for the treatment of CPP.
Studies of nonsurgical interventions were similarly subject to significant variation in study design and interventions addressed, which detracts from the ability to apply these study results to a broader population or provide concrete estimates for clinical effect. We saw this variation in (1) definition of pelvic pain, (2) patient populations, (3) outcome measures, (4) interventions, (5) timing of outcome measures and participant followup, and (6) comparators.
Only 4 of the 17 studies included in this section had a placebo arm for comparison. All of the other studies employed active treatments as comparators. This lack of placebo comparison detracts from the active head-to-head trials because no initial validation of effect has been made. It could easily be assumed that each active intervention works simply by placebo effect, and this could explain why each hormone-based treatment seems equally effective. Many studies also included a population of patients with endometriosis; few studies include participants with CPP due to another etiology. We found the evidence insufficient to assess the effectiveness of any nonsurgical therapies for CPP.
In sum, we found that:
- Noncyclic CPP was variably defined, and diagnostic approaches were rarely reported.
- Disproportionately few studies addressed noncyclic CPP, given the prevalence of the condition.
- Comorbidities were similarly variably defined and frequently not diagnosed using standardized criteria.
- Dysmenorrhea, dyspareunia, and IBS were the most frequently reported comorbidities in the literature meeting our criteria.
- Intervention studies overall included a limited number of participants and typically included only short-term followup.
- Few studies of surgical approaches examined the same approach; none used a placebo control.
- No surgical approach was superior to a nonsurgical approach or comparative surgical approach.
- The strength of the evidence for surgical approaches overall was insufficient to low.
- Most studies of nonsurgical approaches meeting our criteria addressed hormonal approaches and included women with endometriosis-associated CPP.
- Few studies of nonsurgical interventions were placebo controlled, and few addressed nonpharmacologic approaches; strength of evidence was insufficient to low.
- Hormonal studies reported equal effectiveness among the active agents investigated, with the exception of a placebo-controlled trial of raloxifene reporting more rapid return of pain in the raloxifene group.
- Studies of nonhormonal and nonpharmacologic agents reported some positive effects on pain status.
- Few nonsurgical studies reported harms.
- No studies addressed evidence for differences in outcomes by etiology or evidence for selecting one intervention over another if an intervention failed.
- Studies overall addressed a heterogeneous group of interventions and likely had significant variability across populations.
Applicability of Evidence
We set inclusion criteria intended to identify studies with applicability to women with noncyclic or mixed chronic pelvic pain. Studies differed considerably in terms of study populations, interventions, and outcome measures. Many of the studies were noncomparative.
Lack of direct comparisons of treatment options further hinders our ability to know what findings will best extend to a specific patient or to decide about care protocols within clinics or health systems. Overall the data that are available have fair to good applicability to women with noncyclic/mixed CPP in settings within the United States, although many studies were conducted in specialty treatment centers. In the nonsurgical literature, many studies included women with endometriosis-associated CPP.
Gaps in the Evidence and Methodologic Concerns
Despite a prevalence of noncyclic CPP rivaling that of widely studied conditions such as asthma,45 little research assessing therapies exists. While there are many publications regarding pelvic pain in general, there are relatively few addressing noncyclic CPP, and of those, few were evaluated as providing high-quality evidence. Eighteen of 36 studies meeting our criteria were RCTs; however, only 4 were placebo controlled.10,14,36,44 Some surgical studies compared a surgical approach with diagnostic laparoscopy or compared surgical with nonsurgical management. In the nonsurgical literature, most studies compared active agents with active agents, and a number addressed hormonal therapies for endometriosis-associated CPP.
The quality of studies providing data about the prevalence of comorbidities varied by comorbidity, with the bulk of studies assessed as poor quality. Among studies reporting data on the prevalence of comorbidities, the range of prevalence estimates tended to be more narrow in studies that employed validated diagnostic criteria (e.g., Rome criteria for IBS), and studies using validated criteria were of higher quality.
The literature overall is muddled by a lack of standardized definitions for CPP and unclear diagnostic evaluation, which make it difficult to determine whether studies truly include women with CPP. Systematic reviews of the effectiveness of interventions for a symptom or syndrome are fraught with difficulty; the lack of specific diagnostic criteria results in heterogeneity within and across studies. In order to effectively treat any chronic pain, one would assume that a thorough diagnostic investigation would first take place. For many conditions, this typically follows some predetermined algorithm. However, for CPP, no such algorithm exists. Thus, in each study (and likely for each individual practitioner), the patient is approached in a variable manner, and some possible diagnoses may or may not be ruled out before treatment begins. There is no assurance that the treated condition is the causative condition. Treating a symptom means that a study group will likely have a variety of etiologies; some may be amenable to the intervention under study, others may not. Compared with an intervention trial that follows established diagnostic criteria and targets an identified condition, dilution of potential benefits and harms may occur.
Future Research
Research addressing therapies for CPP is largely composed of trials of active agents or approaches, with little placebo-controlled research and little evidence of thorough identification of patient characteristics and potential etiologies of CPP. Notably, we did not locate any studies providing evidence that surgical outcomes differ if the etiology of CPP is identified after surgery (KQ3). We did not locate any studies providing evidence for choosing one intervention over another to treat persistent or recurrent CPP after an initial intervention failed to achieve the target outcome(s) (KQ5). Future research needs include:
- Developing our understanding of the etiology of CPP, including analysis of the distribution of underlying causes (including iatrogenic causes); identification of subgroups at risk of developing CPP; understanding of myofascial dysfunction and visceral hyperplasia in CPP; and assessing the effects of sex steroid hormone levels on pain perception
- Understanding the impact of CPP on health care costs and resource utilization
- Standardizing terminology and definitions in CPP research and research investigating related comorbidities
- Formalizing and standardizing diagnostic approaches to promote clear delineation of patient populations in CPP research
- Standardizing outcome measures
- Investigating nonsurgical and nonpharmacologic approaches to CPP treatment, including acupuncture, psychotherapy, cognitive behavioral therapy, and patient education
- Assessing nonhormonal pharmacologic therapies
- Comparing surgical and nonsurgical approaches in prospective studies
- Investigating the benefit of surgical approaches, including understanding patient populations likely to benefit, timing of intervention, and potential therapeutic benefits of diagnostic laparoscopy
- Employing placebo controls and improving methodologic rigor in studies.
Improved characterization of the targeted condition, intervention, and population in CPP research is necessary to inform treatment choices for this commonly reported entity. A uniform definition of CPP and standardized evaluation of participants are lacking across the literature; study populations are likely to vary widely, and studies may be reporting effects from treating symptoms rather than a diagnosed condition. Thus our understanding of potential treatment effects is diluted. Similarly, understanding comorbidity prevalence with CPP is difficult, as a condition may be considered part of the differential diagnosis or a concomitant condition.
Among studies addressing treatment effects, little evidence demonstrates the effectiveness of surgical approaches. Despite numerous surgical techniques used extensively in treating CPP, few studies included more than 50 participants, and few were considered high quality. All of the studies with comparison data failed to demonstrate that surgery in general or any specific surgical technique was more efficacious than either nonsurgical intervention or the comparator technique in improving pain status in patients. No surgical technique was superior, and the evidence to conclude that surgical intervention is either effective or ineffective for the treatment of CPP is insufficient.
Studies of nonsurgical approaches typically addressed hormonal management of endometriosis-related CPP and were not placebo controlled, thus limiting our ability to understand whether hormonal therapies would be beneficial for women with CPP without endometriosis and whether pain relief reported is due simply to the placebo effect. Some studies reported benefits of other nonsurgical approaches, but nonhormonal and nonpharmacologic management remains understudied.
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- Carlson KJ, Miller BA, Fowler FJ. The Maine Women's Health Study: II. Outcomes of nonsurgical management of leiomyomas, abnormal bleeding, and chronic pelvic pain. Obstet Gynecol. 1994 Apr;83(4):566-72.
- Abbott JA, Jarvis SK, Lyons SD, et al. Botulinum toxin type A for chronic pain and pelvic floor spasm in women: a randomized controlled trial. Obstet Gynecol. 2006 Oct;108(4):915-23.
- Heyman J, Ohrvik J, Leppert J. Distension of painful structures in the treatment for chronic pelvic pain in women. Acta Obstet Gynecol Scand. 2006;85(5):599-603.
- Vercellini P, Barbara G, Somigliana E, et al. Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis. Fertil Steril. 2010 May 1;93(7):2150-61.
- Zupi E, Marconi D, Sbracia M, et al. Add-back therapy in the treatment of endometriosis-associated pain. Fertil Steril. 2004 Nov;82(5):1303-8.
- Vercellini P, De Giorgi O, Oldani S, et al. Depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis. Am J Obstet Gynecol. 1996 Aug;175(2):396-401.
- Parazzini F, Di Cintio E, Chatenoud L, et al. Estroprogestin vs. gonadotrophin agonists plus estroprogestin in the treatment of endometriosis-related pelvic pain: a randomized trial. Gruppo Italiano per lo Studio dell'Endometriosi. Eur J Obstet Gynecol Reprod Biol. 2000 Jan;88(1):11-4.
- Onwude JL, Thornton JG, Morley S, et al. A randomised trial of photographic reinforcement during postoperative counselling after diagnostic laparoscopy for pelvic pain. Eur J Obstet Gynecol Reprod Biol. 2004 Jan 15;112(1):89-94.
- Ghaly AFF. The psychological and physical benefits of pelvic ultrasonography in patients with chronic pelvic pain and negative laparoscopy. A random allocation trial. J Obstet Gynaecol. 1994;14:269-71.
- Walton SM, Batra HK. The use of medroxyprogesterone acetate 50mg in the treatment of painful pelvic conditions: preliminary results from a multicentre trial. J Obstet Gynaecol. 1992;12(Suppl):S50-3.
- Zondervan KT, Yudkin PL, Vessey MP, et al. Prevalence and incidence of chronic pelvic pain in primary care: evidence from a national general practice database. Br J Obstet Gynaecol. 1999 Nov;106(11):1149-55.
Full Report
This executive summary is part of the following document: Andrews J, Yunker A, Reynolds WS, Likis FE, Sathe NA, Jerome RN. Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness. Comparative Effectiveness Review No. 41. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. HHSA 290-2007-10065-I.) AHRQ Publication No. 11(12)-EHC088-EF. Rockville, MD: Agency for Healthcare Research and Quality. January 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
For More Copies
For more copies of Noncyclic Chronic Pelvic Pain Therapies for Women: Comparative Effectiveness: Comparative Effectiveness Review Executive Summary No. 41 (AHRQ Pub. No. 11(12)-EHC088-1), please call the AHRQ Clearinghouse at 1-800-358-9295 or email email@example.com.


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You know what I was just thinking? Well, how could you, unless I post it, right?
I was thinking that the 12" collection keeps excitement brewing for Classic Star Wars fans.
It's been such a long time ago that we got 3 3/4" figures for:
Imperial Officers
Lando SKiff Guard
ATST Driver
the Max Rebo Band Members
the Gamorrean Guard (another perfect highlight from the POTF2 collection)
so that's all old news to us.
They're even going to re-lease a Target exclusive with the Gamorrean figure rehashed.
BUT WE JUST GOT A FRIGGIN HUGE Gamorrean Guard action figure and an equally accurate proportioned Zuckuss for our 12" Collection!!
How cool is that?!!
12" (and PlaysKool and Unleashed) keep bringing the magic back!


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The full trailer for the latest epic adventure from Marvel Studios, Iron Man 3 has just hit the web and it's a doozy. Robert Downey Jr. is, of course, back as everybody's favorite genius, billionaire, playboy, philanthropist, Tony Stark, and is once again joined by Gwyneth Paltrow as Pepper Potts and Don Cheadle as James Rhodes. Bad guys duties this time around fall to Sir Ben Kingsley playing 'The Mandarin' and also possibly to Mike from Neighbours, aka Guy Peace, as Dr. Aldrich Killian.
After a brief bit of moody voiceover, the trailer features more explosions that you would think it possible to fit into two and a half minutes, interspersed with more dialogue than we've seen in the previous teasers and, for the finalé, a whole army of Iron Men as 'back up' for Stark and War Machine as they seemingly battle non-stop to save Pepper, for "just good, old-fashioned revenge."
Of course, the only real questions we need answering are:
1. Where will Stan Lee's cameo be?
2. Will the shawarma be for Thor 2 or Captain America 2 – maybe even Guardians of the Galaxy or Ant Man?
Only two months to wait now as Iron Man 3 hits cinemas on May 3rd.


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Headlines (Campus Updates)
Communications, Public Affairs & Marketing
Amusement park queuing tech idea wins BDO New Venture Competition
Apr 12/13
The new venture idea of Pronto, a queuing technology for amusement parks, won Lauriers 2013 New Venture Competition, sponsored by BDO and co-sponsored by the CGA of Ontario.
This year the students continued to wow us with a level of excellence that is difficult to describe, said Laurier Assistant Professor Laura Allan. I am so proud of the finalists, and look forward to watching them continue to excel in the program and beyond.
More than 1,100 first-year BBA students presented their business plans for the 11th annual event, which took place April 5 and 6. The judging panel included Mike Morrice (BBA/BSc `08), founder and executive director, Sustainable Waterloo Region; Tyler Calder (BA`07), vice president, client strategy, Search Engine People; Jeff Nugent (BBA `95), president and chief executive officer, Contingent Workforce Solutions (CWS); Dean Elliott (BBA`87, CA) partner, BDO; and Tim Sothern (BBA `89, CA, FCA), designated assurance specialist, BDO.
The Pronto team, consisting of students Alice Jia, Olivia Liberatore, Ryan Nadeau, Jonathan Okun and Marco Wai, won first place and the BDO New Venture Cup.
Our entire team is thrilled about winning the BDO New Venture Competition, said Okun. Throughout the year, we have worked hard to develop our initial idea into a viable new venture by performing market research, contacting industry professionals and crafting a strong business plan. Each step along the way has allowed us to learn the value of strong teamwork and true dedication.
We want to thank the sponsors, faculty, staff and alumni who have put in the time and effort to offer such an exciting opportunity for us in our first year of the BBA program, and to the Laurier community as a whole for its amazing support throughout.
The runners-up included:
- Intelife, second place, a student time-management app
- ThermaTint, third place, a coffee sleeve with a heat indicator
- KinPower, finalist, a social venture massage service for students during exams
- EZ Park Tech, finalist, a parking reservation service
- Pedalz, finalist, an under-desk accessory to promote daily physical activity in elementary schools
Following the final presentations and judges deliberations, students had the opportunity to hear from Canadian entrepreneur and Laurier alumnus, Ryan Smolkin (BBA `95), founder of Smokes Poutinerie. In three years, Smolkin created a National Poutine Empire of over 43 locations. Smokes Poutinerie recently received the Pinnacle Award through Foodservice and Hospitality as the Canadian company of the Year.
View all Communications, Public Affairs & Marketing news
View all Laurier news


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Step 1: Gather Supplies
Send your kids on a hunt for stray alphabet blocks and ask them to gather a few that they would like to turn into Christmas ornaments. While they're searching through the toy bins and under the bed, you'll need to gather glue, glitter, yarn, a knitting needle and a drill.
Step 2: Drill Holes
Start with the parent-only task of drilling holes in each block. Use a power drill to create a small hole through one corner of each block as shown above. Then using a knitting needle (if you have an older child they can do this part), thread yarn through the block's hole. Cut the yarn at a length long enough to hang it on a tree branch and then knot the two ends together.
Step 3: Prepare for Sparkles
Let your child line one side of each block with glue, simply add glue to the block in any pattern she likes.
Step 4: Glitter!
Then sprinkle glitter onto the gluey portions or pat each block, glue side down, into a plate of glitter. Repeat, adding glue and then glitter to each side of each block. Keep on going until you've created enough ABC block ornaments for your tree.
Step 5: Hang Your Blocks
Hang the sparkling recycled ABC block Christmas ornaments on your tree and enjoy! You'll especially appreciate these keepsakes as your children grow older and most of their other toys and blocks have been passed on to other children.


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- KCII Radio - http://kciiradio.com -
Public Hearing for B4 Building Purchase
Posted By Community On @ 6:24 am In Today's Local News | Comments Disabled
The Kalona City Council is holding their regular meeting tonight. They will be discussing with the public the proposed purchase of the B4 Building, which currently houses Grandma's Corner Shop. The city wants to turn the building into a "well defined public space". They will also hear a second reading of a gas franchise agreement with Interstate Power and Light Company. The discussion of new FEMA Mapping will continue at this meeting after being discussed in several previous meetings. They will receive a TIF Application for Stables Subdivision as well. The meeting begins at 7:30 tonight.
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This board in particular seems to be infected with a lot of delusional conservatives that are wrapped up in confirmation bias because they are in the company of other like minded fools.
Sure, but I've seen liberal boards that are just as bad.
quote:Does Rush covers his party loyality? Hannity? Bill Kristol?
See how easy that is?
Goddamnit VOR, even George F*cking Stephanopoulos claims there is no bias. Stephanopoulos claims there is NO BIAS!
Conservatives are so butt hurt from losing so many elections, they've become so paranoid that they think everyone is against them. TV media, print media, pollsters, poll analyzers, betting websites, Columnists, movies, tv shows, actors, snopes, political fact checkers, scientists. Anyone and everything that disagrees with them. Even conservative media like Frum or Brooks. And when evryone is right and conservatives are proven wrong, then they claim it's a conspiracy. It's rigged. It's bought and paid for. Conservatives cannot bring themselves to even consider that they might be wrong about anything. So they only watch and read conservative media which makes a fortune feeding them crap they want to hear. Drudge, Rush, Breitbart, Colter, Murdoch...make a fortune telling them stuff they want to hear. Doesn't matter if it's the truth. Conservative media are the modern day snake oil salesman.
Pot meet kettle!
Frum and Brooks...Conservative! Mmm huh...and Obama REALLY DID order his team to give the Benghazi four all they needed to help.
Dialogue becomes pretty useless when one side becomes so delusioned that their assessments of reality are basically clinically insane. Savage nailed it..."Liberalism IS a mental disorder".
Elections! Yeahhh! Like the Red States are going to lay down their God-given Freedom to the hoards of Obama Phone Lady types!
Theater of the absurd! Monty Python material. Snopes...don't even matter. Mama Nature will sort this one out.
But I do feel better seeing that a couple of other posters agree about the predominant point of view from this board. Not even saying it's a bad thing. It is what it is.
quote:An example of his comments on that specific issue
I've never seen his comments on that specific issue.
quote:Interesting that matter never arose with Russert.
I suggest that the fact that we know his background and experience colors (even if it's subconscious) our interpretation of his comments and our evaluation of the program.
Well...it all started when Mett threw that 2nd downer in the dirt!
Million dollar arm, ten cent head. It's like JL/JJ were the George W. Bush of LSU quarterbacks and Mett is the Ogump
Well, that 10 seconds tells me a lot.
When Stephanopoulos said "I don't", was he lying?
quote:You saw the context. A reporter walked up to him at the GOP convention, asked the question, and Stephanopoulos answered. PERIOD. That's it. That is the context.
NC, I'm not being "cute" here, but I'd like to see more of the context.
Carville calls White House chief of staff Rahm Emanuel.
Emanuel calls ABC News Chief Washington Correspondent George Stephanopoulos.
A bit later, CNN commentator Paul Begala, who is not quite the early bird that his friends are, will complete the circle with a rapid set of calls to all three.
"I refer to it as the 17-year-long conference call," said Emanuel, who starts calling his friends at 6 a.m. "You can tap into it anytime you want."
In that sense, the morning calls — no single one of which usually lasts more than a few minutes — among this gang of four is the headwaters of at least one major tributary of Washington politics.
Under other circumstances, the morning calls between Emanuel, Carville, Stephanopoulos and Begala — pollster Stan Greenberg is another frequent member of the core group, a kind of "fifth Beatle" — might be a Society of Has-Beens, reliving ancient glories from the Little Rock "War Room."
It was Emanuel's ascension into Barack Obama's inner circle — even as Carville and Begala remained closely linked with the defeated Clinton political machine — that saved the group from irrelevance.
The calls "are about what's happening, what the implications are of what's happening and what's going on," said Emanuel.
Begala's own interest, as a former speechwriter, is in rhetoric — what is likely to be the sound bite that will echo through the news cycle.
Carville is the wild card, "a genius," in Begala's view, "who can look at the same operative facts as everyone else and come to a different conclusion."
Stephanopoulos' role is as the analyst and the skeptic. "George is really a big-systems thinker," Begala said. "As a journalist, he is half of a political scientist, and because he's not in the partisan battles anymore, he sees things differently."
It is a sensitive point for Stephanopoulos, who shot to fame as a Bill Clinton retainer and has worked hard to fashion a reputation as an independent journalist.
He said he does not surrender that role when he gets on the calls, nor does he surrender personal feelings that go back nearly 20 years.
"We are all good friends," he said. "We just like talking to each other, and I learn a lot from it ... and that's why we have been doing it for so long."
Still, the line between journalism and politics is not always bright. Begala said he often can't remember the originator of any particular insight: "We talk so much — was this my idea that James changed, or was this George's observation that Rahm tweaked?"
I don't find that they lean left.
quote:Any examples?
so they didn't care much when I would like stuff from Snopes with my reply to them
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Seven U.S. Marines were killed and at least seven others were injured when a powerful 60mm mortar exploded during a training exercise in Nevada, the Pentagon said today.
The survivors of the blast are being treated at Renown Hospital in Reno for injuries that includes trauma fractures and vascular injuries, hospital spokeswoman Stacy Kendall told ABC News.
Five patients are listed in serious condition, one patient is in fair condition and one patient has been discharged from the hospital, according to Kendall.
The Marines were all from the 2nd Marine Division based at Camp Lejeune, N.C., and were participating in a mortar firing exercise at the Hawthorne Army Depot 140 miles southeast of Reno, Nev. The blast occurred just before 10 p.m. MST on Monday, according to a statement from the Marines.
It takes several Marines to fire a 60mm mortar and they must "work together to provide constant and accurate high-angle suppressive fire," according to the Marines' website.
Several defense officials said this incident did not appear to involve a round landing on the troops.
The mountainous desert terrain of the 230 square mile depot is used as a training location for special forces since it "provides a realistic simulation of the situation in Afghanistan," according to the depot's website. The depot is also used as a storage site for ammunition awaiting demilitarization.
Maj. Gen. Raymond C. Fox said it was important to remember the courage and sacrifice of the Marines.
"We send our prayers and condolences to the families of Marines involved in this tragic incident. We remain focused on ensuring that they are supported through this difficult time," Fox said in a statement.
The Marine Corps is notifying families before releasing the identities of those who were killed. The explosion is under investigation.
ABC News' Sabina Ghebremedhin contributed to this report
- Military & Defense
- Politics & Government
- Hawthorne Army Depot


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This profile drawing of an unknown cabinet maker was drawn in Sydney. Lambert modelled the head to vividly capture the young man's alert expression and his thick mane of hair.
Lambert believed that line is capable of embodying vitality and rhythm, signifying life. In drawings such as this he captured variations of texture and showed a range of line from the delicate and sinuous to a heavy staccato.
As with a number of Lambert's best portrait drawings the work has a generic title. This suggests that Lambert made the drawing because he was interested in the face of his subject rather than because he was commissioned to do so.


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Larry G. Bundy
MADISON, Wis. - Larry Bundy, age 69, passed away on Monday, July 8, 2013 at Agrace Hospice Care.
Larry was born on December 21st, 1943, in Red Bud, Illinois, the son of Lacy and Martha (Asselmeier) Bundy. He was raised on a grain and livestock farm in southern Illinois (Monroe County) where he attended public elementary and secondary schools. He received B.S. and M.S. degrees from the University of Illinois, served in the U.S. Army from 1969 to 1971 and received a Ph.D. degree in soil chemistry from Iowa State University in 1973.
Larry dedicated his career to improving economic returns for Wisconsin farmers and minimizing environmental impacts through nutrient management. From 1973 to 1982, Larry worked in industry as a soil scientist for Libby, McNeill & Libby and Nestle Enterprises, Inc.
He joined the Soil Science faculty at the University of Wisconsin-Madison in 1982, where he was a Professor and Extension Soil Scientist for 25 years until retirement in 2007. Larry conducted research and educational programs on understanding and managing soil and fertilizer nutrients in crop production while minimizing nutrient losses to the environment. He authored over 80 research publications and over 250 Extension articles. He also served as a major professor for three Ph.D and 13 Master's degree students in Soil Science. Larry was a fellow of the American Society of Agronomy and the Soil Science Society of America, as well as a Wisconsin Certified Soil Scientist.
In retirement, Larry enjoyed fishing, gardening, and reading mystery novels. He also continued to write for scientific journals. Larry and wife Susan enjoyed travelling, spending time with children and grandchildren, attending Badger basketball games, and attending concerts including the Madison symphony.
In addition to Susan, his wife of 46 years, survivors include his son Christopher (Heather) Bundy and their son Julian and his son Jonathan (Maria) Bundy and their children Tyler and Elliana.
A celebration of Larry's life will be held at Cress Funeral Home at 6021 University Avenue in Madison July 26 from 1-4 p.m. In lieu of flowers, memorials may be made to the Larry Bundy Graduate Student Fund through the UW Foundation at 1848 University Ave., Madison, WI 53726 or Agrace Hospice Care at 5395 E. Cheryl Parkway, Madison, WI 53711.


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James Madison "Matt" Elmore, 87, of New Liberty passed away Monday, Aug. 13, 2012, at the New Horizons Medical Center.
Born Oct. 1, 1924 in the New Liberty community of Owen County, he was the son of the late James Madison and Janie Brock Elmore.
Mr. Elmore was a tobacco farmer, had worked for the Brite Lite Tobacco Warehouse in Carrollton as a buyer and office personnel. He was also a devout member of the New Liberty Christian Church where he was church treasurer until two years ago. He served in that capacity for 70 years.
Richard Wayne Hawkins, 66, of Monterey, passed away Sunday, Aug. 12, 2012, after a long illness.
He is preceded in death by his parents, Florian and Katherine Reynolds Hawkins.
Survivors include his sister Vicki Melford of Owenton and brother Steve (Kimberly) Hawkins of Owenton.
A memorial service is planned for Thursday, Aug. 23, 2012, from 6 to 8 p.m. at the home of his brother, Steve Hawkins, at 2915 Claxon Ridge Road, Owenton. All friends and family are invited to attend.
The McDonald and New Funeral Home is in charge of all arrangements.
Joann Walker, 66, of Worthville, passed away Sunday, Aug. 12, 2012, at the Signature Healthcare of Trimble County.
She was the daughter of the late Lawrence and Virginia Roberts Agrue.
Survivors include her husband, James Walker and her daughter Donna Sue Winnies of Ghent.
A graveside service was held Tuesday, Aug. 14, 2012, at the Wheatley Cemetery.
McDonald & New Funeral Homes was in charge of arrangements.
Louis C. "Bud" Conrad, 87, of Dry Ridge, passed away Saturday, Aug. 11, 2012, at Saint Elizabeth Medical Center in Grant County.
Survivors include his wife, Sylvia K. Conrad; one son, David Conrad of Smyrna, Tenn.; one stepson, Mark Kyle of Carrollton; and two stepdaughters, Geraldine Utz of Lexington, and Mona Ammerman of Dry Ridge.
The funeral services were held Tuesday, Aug. 14, 2012, at Eckler-McDaniel Funeral Home in Dry Ridge. Burial was in Jonesville Cemetery.
Daphne Marlene Howard Manns, 69, of Owenton, passed away Friday Aug. 3, 2012, at her residence.
She was the daughter of the late Clarence and Virgie Johnson Howard.
Survivors include her husband Cornelius Manns; a son, Rodney Riddle of Owenton; a daughter, Tina Smoot Boyle of Frankfort; and two stepchildren, Timmy Manns and Carla Manns Turner, both of Frankfort.
The funeral services were held Tuesday, Aug. 7, 2012, at 1 p.m. in the Seminary Street location of McDonald and New Funeral Home. Burial was in the Owenton Cemetery.
Karen Sue Wilhoite, 66, of Frankfort, passed away on Friday, July 27, 2012.
She was the daughter of the late Willard and Virginia Ruth Rose Riddle.
Survivors include her sons, Willis Wilhoite of Monterey and Brian and Rusty Wilhoite of Frankfort
The funeral services were held Tuesday, July 31, 2012, at the Main Street location of McDonald & New Funeral Homes. Burial was in the Frankfort Cemetery.
Mae Magline "Tag" King, 64, passed away Wednesday, July 25, 2012, at the University of Kentucky Chandler Medical Center.
She was the daughter of the late Burchell and Elizabeth Taylor Wagers.
Survivors include her husband, Horace King of Lexington; two sons, Phillip Hamilton of Carrollton and Thomas King of Owenton; and two daughters, Martha J. wagers of Owenton and Christina King of Lexington.
The family received friends at the Main Street location of McDonald and New Funeral Homes July 27.
William Howard Adams, 85, of Owenton passed away Wednesday, July 18, 2012, at his home.
He was the son of the late Joseph Andrew and Mary Liza Huff Adams.
Survivors include his wife, Hannah Johnson Adams; and his children, Mary Elizabeth (Charles) Catron of Stamping Ground, Bonnie Marie Glass, Joan Gayle (Terry) Kincaid, Patsy Ann Marshall all of Owenton and William Ray (Lynn) Adams of New Castle.
The funeral services were held Saturday, July 21 at the Main Street location of McDonald & New Funeral Homes. Burial was in the Stamping Ground Cemetery.
Floyd Mikel Smith, 17, of Owenton, passed away Tuesday, July 10, 2012.
He was the son of Floyd Smith (Crystal Goodrich) of Owenton and Kim Williams Smith of Owenton.
He was going to be a senior at the Owen County High School this year. He was employed at McDonalds.
He is also survived by his brothers, Jacob and Phyllip Smith; his sisters, Melinda and Autumn Smith; his grandparents. Danny and Linda Williams of Owenton and Donald Arnold of Lockport; and his great-grandmother, Lenora Kelly Olds of Owenton.
Dallas L. York, 66, of Sanders, passed away Monday, July 9, 2012, at his home.
He is survived by his wife, Evalina; daughters, April and Christy York; and his stepchildren, Richard Hardesty and Candy Gibson
The funeral services were held Thursday, July 12, 2012, at the Seminary Street location of McDonald & New Funeral Homes
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The Owenton News-Herald is your source for local news, sports, events and information in Owen County and Owenton, KY, and the surrounding area.