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We investigated the association between cholecystectomy or appendectomy and the subsequent risk of colorectal cancer (CRC) in the Korean population.
A retrospective cohort study was conducted with the National Health Insurance Service–National Sample Cohort of Korea; this sample was followed up from January 1, 2002, until the date of CRC incidence, loss to follow-up, or December 31, 2015. The exposure status of cholecystectomy and appendectomy was treated as a time-varying covariate. The calculated risk of CRC was stratified by follow-up period, and the association between these surgical procedures and CRC was investigated by a Cox regression model applying appropriate lag periods.
A total of 707 663 individuals were identified for analysis. The study population was followed up for an average of 13.66 years, and 4324 CRC cases were identified. The hazard ratio (HR) of CRC was elevated in the first year after cholecystectomy (HR, 1.71; 95% confidence interval [CI], 1.01 to 2.89) and in the first year and 2-3 years after appendectomy (HR, 4.22; 95% CI, 2.87 to 6.20; HR, 2.34; 95% CI, 1.36 to 4.03, respectively). The HRs of CRC after applying 1 year of lag after cholecystectomy and 3 years of lag after appendectomy were 0.80 (95% CI, 0.57 to 1.13) and 0.77 (95% CI, 0.51 to 1.16), respectively.
Colorectal cancer (CRC) is the third-leading cancer in the world and the third-most common cancer in both incidence and prevalence in Korea [1-3]. The age-standardized incidence rate (ASR) of CRC was 30.4 per 100 000 in 2015; it rose by 6.0% annually from 1999 to 2010, and has been decreasing by 4.9% annually since 2010 [3].
Several well-established risk factors are related to CRC [1]. For instance, age is closely associated with the risk of CRC, and diabetes mellitus (DM) and inflammatory bowel disease (IBD) are also known to increase the risk of CRC [1,4,5]. Environmental factors, including smoking, alcohol, and obesity, are associated with an increased risk of CRC [1].
Cholecystectomy and appendectomy are 2 of the most commonly performed surgical procedures in Korea [6], and are similar in terms of being performed under general anesthesia and involving the removal of an inflamed organ within the digestive tract. The association between these procedures and CRC has been of interest due to multiple potential biological mechanisms. Bile acid, which is synthesized in the liver and stored in the gallbladder, is known to be carcinogenic for CRC [7-9]. As a result of cholecystectomy, the exposure time of the intestinal mucosa to bile acid secretions increases, and cholecystectomy enhances negative feedback on bile acid synthesis in the liver [10], which could possibly alter the risk of CRC development. The appendix is thought to have an immune function in the bowel [11]. Because inflammation is considered to be a mechanism through which CRC develops, the risk of CRC may be changed after appendectomy.
Several studies have investigated the association between cholecystectomy and the risk of CRC [12-22]. Some of these studies have reported a modestly increased risk of CRC after cholecystectomy [12-16], but others reported no such association [17-21], and only 1 study reported a decreased risk [22]. The association between appendectomy and the risk of CRC has been studied, and an increased incidence of CRC after appendectomy was found [23-27]. Only 1 study reported no association between appendectomy and CRC [27]. These inconsistent results might be due to differences in dealing with bias. Protopathic bias, also called reverse causation, is a bias in which the exposure occurs as the result of the early manifestation of the targeted disease. To avoid this bias, an appropriate lag time is needed after exposure [28,29]. However, the lag times in previous studies varied, ranging from 0 to 6 years, and no obvious criteria were used to select the lag time. In this study, we investigated the association between cholecystectomy or appendectomy and the risk of subsequent CRC, considering this source of bias by applying an appropriate lag time in the analysis.
Data Source and Study Population
Korea has a single medical insurance claim system that covers over 97% of the Korean population. This system provided a sample cohort, the National Health Insurance Service–National Sample Cohort (NHIS-NSC), for the purpose of research. It comprises approximately 1 million individuals, accounting for roughly 2% of randomly selected health insurance subscribers and Medical Aid recipients in the Korean population, and contains information on demographic factors, medical resource utilization, and regular medical check-up data from 2002 to 2015. The details of the cohort have been presented elsewhere [30].
We designed a retrospective cohort study using the NHIS-NSC, which comprises a total of 1 108 369 subjects from 2002 and 2015. To exclude subjects with a history of CRC, subjects who had any diagnostic code for CRC (C18-C20) from the 10th International Classification of Diseases (ICD-10) before January 2004 were excluded (n=2082). In addition, subjects under 20 years of age at study entry were excluded (n=298 624). Finally, a total of 707 663 subjects remained for analysis. During the study period, 11 362 subjects underwent cholecystectomy, and 16 094 subjects underwent appendectomy. The study population was followed until the end of the follow-up period or until the development of CRC, whichever came first.
The study was exempted from review by the institutional review board of Seoul National University Hospital (H-1508-031-694).
Identification of Colorectal Cancer
We identified CRC cases using ICD-10 codes. Subjects who simultaneously had a diagnostic code of CRC (C18-20) and the claim code for its treatment were identified as CRC cases. The treatments of CRC include surgery, chemotherapy, and radiation therapy, and are listed in Table S1. The incidence rate obtained using our definition was lower than that of the national cancer registry data, but the trends were similar (Figure S1). CRC cases were categorized into colon cancer (C18) and rectal cancer (C19-20), based on the ICD-10 code.
Identification of Cholecystectomy and Appendectomy
Cholecystectomy and appendectomy were identified by the insurance claim codes for these surgical procedures. Cholecystectomy covered cholecystectomy (Q7380) and radical cholecystectomy of gallbladder cancer (Q7410). Appendectomy covered appendectomy-simple (Q2861), appendectomy-perforated (Q2862), and removal of appendiceal abscess with periappendiceal abscess drainage (Q2863). The first date of the claim was defined as the surgery index date. Procedures performed after or simultaneously with the diagnosis of CRC were excluded from the study.
We also extracted the following factors known to be associated with CRC: DM, IBD, smoking status, alcohol consumption, and high body mass index (BMI) [1,4,31]. Individuals who had DM were identified using the corresponding ICD-10 codes (E10-14) with a simultaneous prescription of hypoglycemic agents within the first 2 years after study entry. Individuals who had 2 claims per year of IBD based on the corresponding ICD-10 codes (K50, K51) in the first 2 years were defined as IBD patients. Lifestyle factors, such as smoking status, alcohol consumption, and BMI, were obtained from medical check-up data. These factors were identified based on the data available in the first 2 years of the study, and participants were classified by BMI into 2 groups (<25 kg/m2 or not), based on the World Health Organization classification of overweight. However, medical check-up data were missing for over 70% of the subjects. Because reliable results cannot be obtained with more than half of the data missing, we considered these lifestyle factors not in the main analysis, but in the sensitivity analysis, in which the subjects were restricted to those who had available medical check-up data.
Statistical Analysis
The chi-square test and t-test were used to compare the baseline characteristics between patients who had ever undergone cholecystectomy during the study period and those who had not; the same procedures were also completed for appendectomy patients. We defined the status of cholecystectomy and appendectomy as a time-varying covariant, so that each individual was followed up as a non-exposure of cholecystectomy or appendectomy until the date of surgery.
We calculated the ASRs of CRC separately for the total study population, cholecystectomy patients, and appendectomy patients. ASRs were calculated using the mid-year Korean population in 2010 as the standard population and considering lag periods. The standardized incidence ratio was compared to the incidence in the study population, and 95% confidence intervals (CIs) were calculated by the Poisson distribution.
The risk estimation for CRC was conducted separately for cholecystectomy and appendectomy. A time-dependent Cox proportional hazard regression model was used to calculate the hazard ratios (HRs) of cholecystectomy or appendectomy for the risk of CRC after adjusting for sex, DM, and IBD, and age was chosen as the time scale [32]. Initially, we evaluated the risk of CRC stratified by the follow-up time after cholecystectomy or appendectomy. Then, we applied an appropriate lag period after cholecystectomy or appendectomy in the Cox model and evaluated the risk of CRC after surgery. We also calculated the risk of CRC stratified by anatomical site based on the ICD-10 codes of colon cancer (C18) and recto-sigmoid cancer (C19-20). The proportional hazard assumption was checked by Schoenfeld residual plots. All statistical analyses were performed with SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).
Sensitivity Analysis
Only 181 933 subjects had medical check-ups in the first 2 years of the study. We performed a sensitivity analysis with these subjects to consider lifestyle factors. The baseline characteristics were compared in the same way as in the main analysis. In this analysis, HRs were computed using a time-dependent Cox proportional hazard regression model adjusted for sex, DM, IBD, smoking status, alcohol consumption, and BMI. The CRC risk stratified by anatomical site was also computed in this analysis.
A total of 707 633 subjects were included in the final analysis, with an average of 13.66 years of follow-up time, and 4324 subjects developed CRC during the study period. A comparison of the baseline characteristics between patients who underwent cholecystectomy or appendectomy and those who did not is shown in Table 1. Subjects who underwent cholecystectomy tended to be older and were more likely to have DM than those who did not. Those who underwent appendectomy tended to be younger and were more likely to be free of DM than those who did not.
The truncated ASR of CRC in the study population was 40.93 per 100 000 person-years for adults aged 20 years and older (Table S2). The ASRs after cholecystectomy or appendectomy were 43.52 and 57.88 per 100 000 person-years, respectively. The standardized incidence ratio of CRC after cholecystectomy was 0.97 (95% CI, 0.72 to 1.29) compared to the total study population, and this was non-significant, even when lag periods were applied. The standardized incidence ratio of CRC after appendectomy was 1.43 (95% CI, 1.11 to 1.81) which was only significant with no lag period applied.
Stratified by the follow-up time since cholecystectomy, the risk of CRC was significantly elevated in the first year (HR, 1.71; 95% CI, 1.01 to 2.89) (Table 2). However, it showed no association after 1 year post-cholecystectomy. The risk levels of colon cancer and rectal cancer were also elevated in the first year after cholecystectomy, although not to a statistically significant extent. Since the risk elevation in the first year after cholecystectomy may have been affected by bias, the HR when 1 year of lag was applied was 0.79 (95% CI, 0.56 to 1.10) (Table 3). In the appendectomy cohort, the risk of CRC was elevated in the first year (HR, 4.22; 95% CI, 2.87 to 6.20) and from 2 to 3 years (HR, 2.34; 95% CI, 1.36 to 4.03) after surgery, and this risk elevation was prominent for colon cancer (Table 2). The risk from 1 to 2 years after appendectomy was elevated, but not significantly so (HR, 1.19; 95% CI, 0.57 to 2.50). Since this risk elevation may have been affected by bias, a lag period of 3 years was applied, and no association between appendectomy and CRC risk was found (HR, 0.75; 95% CI, 0.50 to 1.13), even though the risk elevation was significant when no lag periods were applied (Table 3). Stratified by anatomical site, this tendency was more prominent for colon cancer than for rectal cancer (Table 4). The risk could not be calculated in those who had both appendectomy and cholecystectomy because no CRC cases were identified in this sub-population after applying a lag period. The number of participants who underwent both cholecystectomy and appendectomy in the study period was 425. Among them, only 2 cases of CRC developed within 1 year of cholecystectomy or 3 years of appendectomy. For this reason, a risk estimation among patients who underwent both cholecystectomy and appendectomy could not be calculated. Because there was no pattern with time, we could confirm that the risk models fit the proportional hazard assumption for both cholecystectomy and appendectomy.
The characteristics of subjects who did and did not have available medical check-up data in the first 2 years are shown in Table S3. Subjects who had medical check-up data were older and were more likely to be male than those who did not. Additionally, they were more likely to have DM and IBD than those who did not have medical check-up data. A comparison of baseline characteristics among subjects with medical check-up data is shown in Table S4. The cholecystectomy patients were younger than those who were not, and the appendectomy patients were older than those who were not. For lifestyle factors, the patients who underwent cholecystectomy tended to be non-smokers, never-drinkers, and to have a higher BMI, while the patients who underwent appendectomy tended to be non-smokers and current drinkers.
When the sample was restricted to subjects who had available medical check-up data, the results were similar to those of the main analysis (Table S5). The risk of CRC was elevated in the first year of cholecystectomy and appendectomy, and this elevation was prominent for colon cancer. No significant results were found when lag periods were applied in the sensitivity analysis (Table S6).
In this population-based cohort study, the risk of CRC was only elevated in the first year after cholecystectomy and the first 3 years after appendectomy. These results suggest the possibility of protopathic bias. When this bias was considered, associations between cholecystectomy or appendectomy and the risk of CRC were not shown. In the sensitivity analysis considering additional confounding factors, the risk was significantly elevated in the first year after cholecystectomy and appendectomy, as in the main analysis. However, the lag-applied analysis did not show any significant results, which might have been due to the small number of CRC cases.
Previous studies regarding the association between cholecystectomy and CRC have shown inconsistent results. Some previous studies have indicated a positive association between cholecystectomy and the risk of CRC, including 2 meta-analyses [15,16]. One meta-analysis covering 5 cohort studies and 33 case-control studies reported a relative risk (RR) of 1.22 (95% CI, 1.08 to 1.38), but the pooled RR in cohort studies was 0.97 (95% CI, 0.82 to 1.14). The results of the other meta-analysis covering 9 cohort studies showed a modestly increased risk (RR, 1.22; 95% CI, 1.08 to 1.38), and the result was only significant for colon cancer (RR, 1.30; 95% CI, 1.07 to 1.58). Although a positive association was shown in other studies, it was significant only in short-term follow-up periods, as in our study [12,14]. No association was shown in other studies [17,18,20,21], and another study conducted in US using the surveillance, epidemiology, and end results program Medicare data [22] showed a non-significant negative association between cholecystectomy and the risk of CRC (odds ratio, 0.97; 95% CI, 0.92 to 1.02), which is similar to our results. The finding of an elevated risk in the first year after cholecystectomy can be explained by the similar clinical presentation of gallbladder disease and CRC. Furthermore, the misdiagnosis of early signs of CRC as gallbladder disease has been reported [33-35]. In our study, appendectomy increased the risk of CRC, especially in the first year, and this risk elevation was prominent for colon cancer. Although the risk elevation was not statistically significant in the second year of appendectomy, the risk seemed to be increased until 3 years after appendectomy. An elevated risk of CRC was not associated with appendectomy after 3 years. In addition, this risk elevation was significant only for colon cancer. This result might imply that appendicitis, the reason for appendectomy, could be an early sign of CRC, which has also been shown in other studies. The studies conducted by Wu and Colleagues [25,26] reported that the risk tended to be elevated in shorter follow-up periods.
Our study had several strengths. First, this study used nationally representative data sources, and the sample comprised approximately 700 000 individuals over 20 years old. Second, we dealt with time-dependent bias by conducting time-varying statistical analyses [36]. Third, the analysis focusing on the follow-up period provided evidence that protopathic bias was involved in the association. Thus, we found that considering a lag period is necessary when investigating associations between cholecystectomy or appendectomy and CRC.
However, our study also had limitations. Because we used claims data, the identification of CRC might not have been completely precise. However, a comparison of the incidence of CRC between our definition and that of the national cancer registry data showed a similar, but underestimated, trend. This underestimation could have led to undifferentiated misclassification bias. Although we analyzed over 700 000 subjects, there were not enough newly developed CRC cases among cholecystectomy and appendectomy patients, because CRC is a rare disease, and there were not enough surgery cases, which could have been why our results did not show statistical significance. Cholecystectomies and appendectomies performed before 2002 could not be identified in this study. Because these surgical procedures do not need long-term follow-up, it was impossible to obtain patients' histories of these procedures through claims data. For this reason, some cases of surgery may have been present in the non-surgery cohort, rendering the results null. We could not consider other important possible confounding factors, such as colonic polyps or family history. We found that there was little change in the HRs when adjusting for history of DM, history of IBD, and lifestyle factors in the sensitivity analysis. In addition, information about colonoscopy could not be comprehensively collected because our data did not include data on colonoscopies performed for the purposes of screening or without any symptoms. Lastly, the follow-up time after surgery in our study might not have been sufficient for the development of CRC, which needs at least 5 to 10 years for carcinogenic changes [1].
In conclusion, the risk of CRC was not associated with cholecystectomy. However, the risk of CRC was elevated in the first year after cholecystectomy, likely due to gallbladder disease. The risk of CRC after appendectomy was significantly increased when no lag period was applied, but no association was found when applying 3 years of lag. The reason for this may be that appendicitis, which is the reason for appendectomy, could also be an early manifestation of CRC, whereas appendectomy is less likely to be a cause of CRC. To be protected from bias in analyses focusing on exposures such as surgery and CRC risk, including lag periods after surgery is necessary.
This study was supported by Seoul National University College of Medicine (Project no. 800-20170161).
Conflict of Interest
The authors have no conflicts of interest associated with the material presented in this paper.
Table 1.
Table 2.
Table 3.
Table 4.
Supplementary Materials 1-6: Table S1-S6 are available at https://www.jpmph.org/.
Supplementary Materials 7: Figure S1 is available at https://www.jpmph.org/.
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Friday, June 19, 2009
Going on Vacation
Good-bye blog world. I'm going on vacation for a week to San Diego & then traveling to Tulsa for a girls weekend with Wendy & Angel. I'll be back in about 10 days!
Posted by Paige Allen at 8:06 AM
1 comments:
- Enid said...
I hear you are having a blast!
- June 27, 2009 at 11:46 PM
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subset: commoncrawl


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obsessed with the white on white title and the triangles sewn into more triangles..
these photos of Dez. Oh, my heart. Sometimes he's a real turd. And then sometimes... aww.
All stitched up. The only thing I'd change on this page is I would stitch the entire sheet full of half hearts. It looks SO cool in person to see those thick threads taking up the space.
I seriously die for the enamel glasses. (I mean, I don't actually die for them... but, you know.)
How great are all of those little bits and pieces?! I've always been a big Elle's Studio fan, but I think I need to check out the kits more regularly. Such good stuff! So glad I was asked to guest design. What a fun opportunity.


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Millions face new rail chaos as militant RMT union votes for action over pay – but Tories promise new crackdown on strikes
- Hardline RMT union voted 4-1 in favour of strikes after rejecting pay offer
- Rail bosses proposed £500 rise followed by increases in line with inflation
- Comes after new Business Secretary promised crackdown on strike laws
- Transport Secretary Patrick McLoughlin said he condemns industrial action which disrupts 'the travelling public' and wants negotiations
Millions of passengers face a new threat of travel chaos as militant rail workers voted in favour of strike action over pay.
They rejected an offer by Network Rail of a £500 pay rise followed by three years of increases in line with inflation.
Members of the hardline Rail, Maritime and Transport (RMT) union backed the walkouts by 4-1 describing the result as 'overwhelming mandate for action'.
The Transport Salaried Staffs Association (TSSA) is also balloting its members, with the result due over the coming week.
Transport Secretary Patrick McLoughlin said: 'I condemn any industrial action that disrupts the travelling public. I want to see Network Rail and the unions back round the negotiating table, hammering out a deal.
'Rail passengers will not thank the unions for inflicting this unnecessary disruption.'
A strike by union members including signallers, maintenance workers and admin staff, would cripple train services. The unions have to give seven days' notice of any industrial action.
It gives the Conservative government its first major challenge on the industrial relations front and comes just hours after newly-appointed Business Secretary Sajid Javid promised a crackdown on strikes.
The RMT vote was a turnout of 60per cent, beating planned Government thresholds on strike ballots.
Rail workers voted by a bigger margin - 92 per cent - for other forms of industrial action. The result will now be considered by the union's executive.
RMT general secretary Mick Cash said: 'Our members have decisively rejected the pay package offered by Network Rail.
'This is a massive mandate for action and shows the anger of safety-critical staff across the rail network at attacks on their standards of living and their job security.
'It is now down to Network Rail to start taking this issue seriously, to understand the deep-seated grievance felt by their staff and to come forward with a renewed offer which protects pay and jobs.
'The union executive will now consider this overwhelming mandate for action and decide on our next steps aimed at securing pay and workplace justice.'
The RMT and the TSSA are protesting at a pay offer of £500 this year followed by rises matching RPI inflation over the next three years.
A no compulsory redundancy commitment will be extended to the end of 2016 as part of the proposed deal.
Mr Cash added: 'As far as we are concerned the one-off, non-consolidated, lump-sum payment this year is wholly inadequate and fails to recognise the massive pressures staff are working under to keep services running at a time when the company is generating profits of £1 billion.
'It is our members battling to keep Britain moving around the clock and they deserve a fair share from Network Rail for their incredible efforts.
'RMT remains available for talks and we hope that the company will appreciate the anger amongst staff at the current offer on pay and conditions from Network Rail reflected in this ballot result and that they will agree to our call to come back to the table with an improved package.'
Network Rail bosses said the militant RMT rail union of 'holding the country to ransom' and of 'behaving in a way that will cause untold misery to our passengers and will hurt the economy'.
They pointed out that fewer than half of RMT members at Network Rail have voted in favour of strike action.
Mark Carne, Network Rail's chief executive, said: 'It cannot be right that the unions can hold the country to ransom in this way.
'The railways are a vital public service and industrial action would have a massive impact on millions of passengers, as well as freight distribution across Britain. It cannot be right that the unions can hold the country to ransom in this way.
'Our employees have received pay rises eight times higher than other public sector workers over the last four years and have now been offered a deal for the next four years that is unmatched elsewhere.'
Mr Carne said: 'Despite the very clear need to modernise our railways, we have offered a guarantee of no compulsory redundancies for the next two years. The unions have also rejected a number of proposals that would boost productivity, removing our ability to offer them more.
'We will do everything we can to keep our railways moving during these times of uncertainty and to stop the RMT from behaving in a way that will cause untold misery to our passengers and will hurt the economy.'
He noted: 'Fewer than half of RMT members at Network Rail have voted in favour of strike action and we urge union leaders to come back to the table for further discussions.' :
The news comes just hours after Mr Javid, who was promoted to his position from Culture Secretary in David Cameron's Cabinet reshuffle, promised tough action against strike laws.
Mr Javid confirmed that the Queen's Speech on May 27 will include an employment bill, moving to reduce regulation on business while overhauling strike laws.
The Tories will press ahead with changes to the law on strikes which were blocked by the Lib Dems during the coalition which came to an end in last week's general election.
With an overall majority in place, the Conservatives can implement their manifesto commitments in full.
Mr Javid said there would be 'significant changes' to the rules governing walkouts by trade unions.
He told BBC Radio 4's Today programme: 'We've said that there will be a minimum threshold in terms of turnout of 50 per cent of those entitled to vote.
'We've also said that where it comes to essential services, 40 per cent of people need to vote for strike action and we've said we are going to lift the ban on agency staff when strike action takes place.
'That's something we will give more detail on in the Queen's Speech but it will be a priority of ours.'
Under the changes, a strike will only be able to go ahead in key public services like health, education, fire and transport if 40 per cent of all members vote in favour of action, and at least half of those who vote back it.
At least half of the workforce will have to take part in a ballot for industrial action for it to be legal.
Rules on the use of agency workers to replace those on strike will be changed and ballots will be time-limited, to stop strikes taking place based on votes from years earlier.
Network Rail is responsible for 20,000 miles of track across the Great Britain on which 4.5million passengers rely every day.
Some 9,556 out of the RMT's 16,000 membership at Network Rail voted in the ballot - or 60 per cent of the total.
Of these 7,695 voted in favour of strikes, 1,828 against, with 33 spoilt papers.
The yes vote represents 48 per cent of the total eligible to vote, so would have stood under the planned Tory reforms to strike ballots.
To add to commuters' misery, RMT workers on London's Docklands Light Railway have also voted by 4 to 1 to go on strike in a row over pay and conditions.
The RMT said it had been involved in extensive talks with DLR operators Keolis/Amey Docklands over this year's pay review and other issues including the shifting of the pay anniversary date.
Union members employed by DLR contractors Interserve have also voted overwhelmingly in favour of strikes. RMT general secretary Mick Cash said: 'The union will not sit back while core issues on pay and working conditions are left unresolved. '


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Gillian Woollett, MA, DPhil, senior vice president, Avalere Health, explains potential consequences if the United States were to do away with biosimilars.
Gillian Woollett, MA, DPhil, senior vice president, Avalere Health, explains potential consequences if the US were to do away with biosimilars.
If the US were to do away with biosimilars in favor of price regulation for innovative drugs, what might happen to biosimilars in the rest of the global market?
Well, I think we have to start with how totally un-American it would be and I say this as a putative ex-Brit and definitely American. It would be to just do away with a potentially competitive framework. Now, there's no question biosimilars are struggling in the US. Insofar as they're struggling, maybe there's some changes that are needed to the pathway to enable them to actually get to market, get through what's been known as the patent thicket, and then have commercial models. But to unilaterally just dispose of a pathway that's allowed 23 products to be approved, strikes me as awfully premature and probably not helpful for anyone. Now, in terms of the rest of world, I do think there's a bigger sub-question to what you asked. That is, if the US doesn't succeed and doesn't provide the return on investment (ROI) for the substantial dossiers that are being compiled, about $100 million to $500 million it's costing—which is 100 times that of the average generic—if the US is not providing the ROI for a biosimilar, what does that mean for the global market? I think there's a very real risk that the rest of the world cannot provide the ROI that we in the US do, given we're 60% by dollar value of the originator biologics market.


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Book Release Spotlight: Lizzie Borden, Zombie Hunter By Christine (C.A.) Verstraete
Christine (C.A.) Verstraete enjoys putting a little "scare" in her writing. Her latest book, Lizzie Borden, Zombie Hunter, offers a twist on the Lizzie Borden murders. She also is author of a young adult book, GIRL Z: My Life as a Teenage Zombie, and books on dollhouse collecting and crafting, including Dollhouse Decor & More and In Miniature Style II.
Christine's short stories have appeared in various anthologies including: Happy Homicides 3: Summertime Crime, Mystery Weekly, Young Adventurers: Heroes, Explorers and Swashbucklers, Athena's Daughters, Silence in the Library; Feast of the Dead: Hors D'Oeuvres; Darlings of Decay; 100 Doors to Madness; Timeshares, Steampunk'd, and Hot & Steamy: Tales of Steampunk Romance, DAW Books; and The Corner Cafe: A Tasty Collection of Short Stories.
She is an award-winning journalist with stories published in daily to weekly newspapers and in various magazines. Her stories have received awards from local and national newspaper associations and the Dog Writer's Association of America.
She is available for signings or appearances, including a PowerPoint presentation on zombies, writing and the history of Lizzie Borden.
Social Media Links
Blog: http://girlzombieauthors.blogspot.com
Website: http://cverstraete.com
Amazon: http://getbook.at/LizzieBordenZombieHunter
Goodreads: https://www.goodreads.com/book/show/31553183-lizzie-borden-zombie-hunter
Lizzie Borden: Guilty or Innocent?
By C.A. Verstraete
What makes Lizzie Borden so intriguing? Is it the chubby face and dimpled cheeks? The look of innocence? Or is it the idea of a demon lurking behind that smile?
Nearly 150 years later, the spinster Sunday School teacher from the industrial town of Fall River, Massachusetts, remains one of the most infamous, and controversial, women in history. Yet today, camps are still divided on whether she actually killed her father and stepmother that August 4th morning in 1892.
The lack of evidence likely helped convince the jury to declare her not guilty in her trial in June, 1893. But that doesn't mean there wasn't any, though the "not found" column may be more telling as to the results of the trial…
What was found:
* A hatchet head without the handle. Stains were later determined to be rust, not blood.
* Two persons brutally butchered with only one family member and a maid at home.
* In recent years, traces of blood were found running down the walls to the cellar.
What wasn't found or ignored:
* The crime scene wasn't sealed off.
* No fingerprints were taken although the new, developing technology was being used more and more by police departments.
* No witnesses, though reports were made of a man holding some kind of cleaver or weapon seen on the street. They were determined unfounded.
* In the weeks prior to the murders, Lizzie supposedly heard a mysterious visitor arguing at the door with Mr. Borden. The person was never identified or found.
* The uncle (Lizzie's late mother's brother) came from out of town, stayed overnight and then left that morning.
* A possible illegitimate son of Mr. Borden was mentioned.
* No direct evidence was found linking Lizzie to the crime. The case was circumstantial with only her and the maid Bridget Sullivan home with Mrs. Borden until Mr. Borden returned a couple hours after doing errands downtown.
* No bloody clothes were found though a witness later testified about seeing Lizzie burn a dress. When asked about it, Lizzie said that the dress had "paint" on it.
What played a role in the trial:
* Class and social standing. The jurors—all men—likely couldn't see a woman of Lizzie's social standing committing such a brutal, heinous crime. Hence, the verdict of not guilty.
* During a time period when women were still viewed – literally - as the weaker sex, the idea that a woman could commit such a brutal, physical crime that took a lot of strength and stamina also didn't seem likely to jurors.
* Lizzie's inquest testimony was ruled out as evidence in the trial and could not be used. Her testimony answers made no sense, likely due to her being treated with morphine prior to questioning to "relax her nerves."
Rumors flourished about Lizzie's character. Many other theories have been offered today as to why she committed the crime, including that she had epilepsy; was caught in a lesbian relationship; was sexually abused; lived in a dysfunctional family with domestic violence; or that this was a crime of anger fueled by passion and her being "stuck" within the rigid bounds of society.
None of the claims, of course, can actually be proven. The expanse of time allows the horrific crime to be interpreted today in a number of ways. Then, as now, we may never know the real answer. People can choose the method they think fits the crime and decide for themselves whether Lizzie Borden was indeed guilty or not guilty.
If you look at the autopsy reports and photos, however, the question remains as to why the victims had been so viciously attacked and repeatedly hit in the head.
Another View of the Murders
My view is that Lizzie had no choice but to commit the crime since her father and stepmother had become… zombies.
About Lizzie Borden, Zombie Hunter:
Every family has its secrets…
One hot August morning in 1892, Lizzie Borden picked up an axe and murdered her father and stepmother. Newspapers claim she did it for the oldest of reasons: family conflicts, jealousy and greed. But what if her parents were already dead? What if Lizzie slaughtered them because they'd become… zombies?
Thrust into a horrific world where the walking dead are part of a shocking conspiracy to infect not only Fall River, Massachusetts, but also the world beyond, Lizzie battles to protect her sister, Emma, and her hometown from nightmarish ghouls and the evil forces controlling them.
Using actual inquest testimony and events, the book gives an entirely different view of the crime.
* Available in print, Kindle and Kindle Unlimited. (The Kindle is on sale for 99 cents to Dec. 15. Or get a signed print copy (US shipping only) at my website.
Happy reading my book lovers!
Claire xxx
13/12/2016 12:14:48 pm
Thanks Claire for hosting me today! Melanie - yes her home is a B&B- some say it's haunted, too! Thanks for stopping by!
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October 2017


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Tonsillectomy and Adenoidectomy
Tonsillectomy and Adenoidectomy
Tonsillectomy and adenoidectomy (T & A) are surgical procedures to remove the tonsils from the back of the mouth or adenoids from the back of the nasal cavity—both are are part of the lymphatic system, which is responsible for fighting infection. These operations are often performed together and are usually done on children. T & As are the most common childhood operations.
Tonsils are removed (with or without the adenoids) when the child has any of the following conditions:
- obstruction
- sleep apnea. This is a condition in which the child snores loudly and stops breathing temporarily at intervals during sleep
- inability to swallow properly because of enlarged tonsils
- "hot potato" voice (breathy voice) and other speech abnormalities due to enlarged tonsils
- recurrent or persistent abscesses or throat infections
Doctors do not agree completely on the number of sore throats that make a tonsillectomy necessary. Most would agree that four cases of strep throat in any one year; six or more episodes of tonsillitis in one year; or five or more episodes of tonsillitis per year for two years indicate that the tonsils should be removed.
Adenoids are removed (with or without the tonsils) when the child has any of the following conditions:
- alteration of facial growth because of enlarged adenoids
- upper airway obstruction
- development of an irregular bite (dental malocclusion)
- difficult speech or swallowing
T & As are not performed as frequently today as they were in the past. One reason for a more conservative approach is that there is always some risk involved when a patient is put under general anesthesia.
In some cases, a T & A may need to be modified or postponed:
- children with cleft palates should not have the adenoids removed
- bleeding disorders; these must be brought under control before surgery
- acute tonsillitis; surgery should be postponed—usually for three to four weeks—until the infection is gone
Tonsillectomies are hospital procedures. In adults, they may be performed under local anesthesia. Children are usually placed under general anesthesia. The doctor depresses the tongue in order to see the throat and removes the tonsils with a scooplike instrument. The adenoids are usually removed through the nose.
Patients are turned on the side after the operation to prevent the possibility of blood being drawn into the lungs. The patient's vital signs are checked. After the patient is fully awake, he or she can drink water and other nonirritating liquids.
Adult patients are usually warned to expect some bleeding after the operation and a very sore throat. Antibiotics are given to prevent infection. Medications to relieve pain may also be given. For at least the first 24 hours, the patient is fed soft or pureed foods and fluids. If the adenoids alone were removed, the patient may be allowed solid food the day after surgery.
Patients are usually sent home the next day, with instructions to call the doctor if there is bleeding, an earache, or a fever that lasts longer than three days. They are told to expect a white scab to form in the throat between five and 10 days after surgery.
About one in every fifteen thousand tonsillectomies ends in death, either from the anesthesia or from bleeding to death five to seven days after the operation. There is also a chance that children with previously normal speech will develop a nasal-sounding voice. In addition, children younger than five years may be badly emotionally upset by the hospital experience.
Normal results
Normal results include the correction of the condition for which the surgery was performed.
Berman, Stephen, and Ken Chan. "Ear, Nose, & Throat." In Current Pediatric Diagnosis & Treatment, edited by William W. Hay, Jr., et al. Stamford: Appleton & Lange, 1997.
Abscess— A localized area of tissue destruction and pus formation.
Adenoids— Masses of lymphoid tissue that are found in the upper throat.
Sleep apnea— A condition marked by loud snoring during sleep and periodic episodes of suspended breathing.
Tonsils— Oval masses of lymphoid tissue on each side of the throat.


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Hints for notepadqq in main
notepadqq.desktop ⚙ amd64
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The component ID is not a reverse domain-name. Please update the ID to avoid future issues and be compatible with all AppStream implementations. You may also consider to update the name of the accompanying .desktop file to follow the latest version of the Desktop-Entry specification and use a rDNS name for it as well. In any case, do not forget to mention the new desktop-entry in a <launchable/> tag for this component to keep the application launchable from software centers and the .desktop file data associated with the metainfo data.


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"Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean".
This image taken a few years ago in an eaterie in a Scottish Amusement Park always reminds me of a 1982 film directed by Robert Altman (originally a play by Ed Graczyk) which I've never seen but somehow think I should as I'm sure I would enjoy it.
The Disciples of James Dean meet up on the anniversary of his death and mull over their lives in the present and in flashback, revealing the truth behind their complicated lives. Who is the mysterious Joanne and what's the real story behind Mona's son, James Dean Junior ? (see imdb website)
The cast includes Cher, Karen Black and Sandy Dennis. In the film they meet up in in a Woolworth's Five and Dime Store but I don't think they'd have been out of place here……..


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IWSR 2018 Global Beverage Alcohol Data shows growth in spirits, but beer and wine volume is down; market expected to grow by 3% over next five years.Beverage alcohol drinkers across the globe consumed a total of 27.6bn nine-litre cases of alcohol in 2018, but while that number represents a decrease of -1.6% from the year prior, new data from the IWSR forecasts that total alcohol consumption will steadily increase over the next five years, to 28.5bn cases in 2023. In terms of retail value, the global market for beverage alcohol in 2018 was just over $1tn, a number which the IWSR expects to grow 7% by 2023 as consumers continue to trade up to higher-quality products. These figures – and more than 1.5m other points of data – are included in the just-released IWSR Drinks Market Analysis Global Database, which also shows:
Gin was the Leading Global Growth Category in 2018, and Forecasted to Reach 88m Cases by 2023The largest gain in global beverage alcohol consumption in 2018 was in the gin category, which posted total growth of 8.3% versus 2017. Pink gin was a key growth driver, helping the category sell more than 72m nine-litre cases globally last year. In the UK alone, gin was up 32.5% in 2018, and the Philippines (the world's large
st gin market) posted growth of 8%, fueled by a booming cocktail scene and premiumisation of the market. By 2023, the gin category is expected to reach 88.4m cases globally, with particular strong growth in key markets such as the UK, Philippines, South Africa, Brazil, Uganda, Germany, Australia, Italy, Canada and France. Notably, Brazil has emerged as a new hotspot for the categ ory, with volumes there more than doubling last year and forecasted to grow at 27.5% CAGR 2018-2023, as the gin-and-tonic trend has increased in upmarket bars of São Paulo and Rio de Janeiro.


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Announcing The Poetic Pen Best of Show Awards
23 Sandy Gallery is pleased to announce our Best of Show Awards for The Poetic Pen. Since all of the submissions for this incredibly beautiful show far exceeded our expectations, it was a very difficult to choose, but based on a variety of criteria, we have selected four exceptional pieces for their outstanding visual and poetic appeal and mastery of the craft. In no particular order, here is a bit of information about each of our award winners.Read more


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The great variety in sacred architecture in Egypt has tended to be obscured by the standardised plan of the largest surviving structures, though even these are far from uniform. The following table offers access to some of the range of forms. The rectilinear double-ended temple is a hypothetical proposal for the form of the lost temple of the sun-god Ra at Iunu/Heliopolis. That temple and the temple of Ptah at Memphis would have been the two most important religious centres of Egypt across all periods, and present the two greatest gaps in our knowledge of the ancient Egyptian temple.
|circular form
|peristyle form
|terraced form
|lake form
|rectilinear form, single axis
|rectilinear form, double axis
|rectilinear form, double-ended
|rock-cut form
A complex of temples might incorporate more than one form.
An existing temple might be extended in various ways:
Copyright © 2003 University College London. All rights reserved.


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Your hardwood floors should not be disposable!
We here at Evergreen Hardwood Floors are focused on a quality first approach. For the work that we do and the flooring we install. Unfortunately we are noticing an unfortunate trend around our area. Still perfectly good hardwood floors are being ripped out, then installing lesser quality hardwood flooring or even laminate.
There seems to be a lot of misinformation out there regarding the life expectancy of hardwood floors. Good quality hardwood floors should last as long as your home is standing.
The waste and environmental impact is enormous from this practice. The still useful flooring is just thrown into the landfill, where it sits and adds to the pile of garbage. Some of the new flooring installed, it may be hard to tell where your hardwood floors come from, without a lot of research. Some overseas manufacturers have much lower environmental standards and sustainable logging practices are not a concern.
While this may help lower the price, this has a major impact on the worldwide environment but also the environment of your own home. We know you are concerned about the environment now and for future generations, so why not extend that to what goes in your own home!
So what do you do if you have hardwood floors that are worn or out of date? We offer the option of refinishing your hardwood floors. With this practice, the environmental impact is much less. We remove as little as possible of your existing hardwood floors and then we build it up through the use of low VOC stain and finish coats. We are committed to always offering you the best options for your health that also have great durability and longevity for your hardwood floors.
The bonus of the refinishing process is that you can have a direct impact on how your flooring looks. The choices that you can make for regarding the colour of your floor are almost endless so we can really tap into what you want your home to look like!
So if your hardwood floors are looking out of date, within a few days we can get them looking modern again, and you can have a hand in the finished product.
Also, if you need to install new hardwood floors we can help you choose the best option for your home. We do our best to offer flooring from mills that are conscious of their environmental impact. Whether that's an engineered or solid hardwood floor, we want you to love your floors for decades! We would not want you to go through all the inconvenience that come with a renovation, and then have to go through it again with ripping up your floors every few years. I know that may seem far off, but the years seem to fly by.
Contact us today, about your hardwood flooring project, and you may be surprised by the options available to you.


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…How he led operation to rescue two abducted girls
With information not readily available about the living condition of Boko Haram members in the thick forests of North east Nigeria, a 15-year-old boy's experience as a militant recruit and an escapee is nothing but incredible.
Baba Goni, a young man who has lived all his life in rural Borno told the Daily Mail how he was enlisted into the Boko Haram group, his dangerous escape, saving two abused teenage girls and later joining the vigilante groups searching frantically for the missing 276 schoolgirls kidnapped in Chibok, Borno State.
Their faces scratched and bleeding, the pitiful remains of their once-smart school uniforms ripped and filthy, the two teenage girls were tethered to trees, wrists bound with rope and left in a clearing in the Nigerian bush to die by Islamist terror group Boko Haram.
Despite having been raped and dragged through the bush, they were alive – but only just – in the sweltering tropical heat and humidity.
This grim scene was discovered by 15-year-old Baba Goni. 'They were seated on the ground at the base of the trees, their legs stretched out in front of them – they were hardly conscious,' says Baba, who acted as a guide for one of the many vigilante teams searching for the Nigerian schoolgirls abducted from their school last month by Boko Haram – and now at the centre of a concerted international campaign for their freedom.
The horrific scene he and his comrades encountered, a week after the kidnap early on April 15, was in thorny scrubland near the village of Ba'ale, an hour's drive from Chibok, where 276 girls aged 16 to 18 were taken from their boarding school dormitories – with 223 still missing. It was still two weeks before social media campaigns and protests would prick the Western world's conscience over the abduction.
In the days following their disappearance, rag-tag groups such as Baba's, scouring the forests in a convoy of Toyota pick-up trucks, were the girls' only hope.
But hope had already run out for some of the hostages, according to Baba, when his group spoke to the terrified inhabitants of the village where Boko Haram had pitched camp with their captives for three days following the kidnap.
Saviour: 15-year-old Baba Goni helped find two of the schoolgirls
The chilling account he received from the villagers, though unconfirmed by official sources, represents the very worst fears of the families of the 223 girls still missing.
Four were dead, they told him, shot by their captors for being 'stubborn and unco-operative'. They had been hastily buried before the brutish kidnappers moved on.
'Everyone we spoke to was full of fear,' said Baba. 'They didn't want to come out of their homes. They didn't want to show us the graves. They just pointed up a track.'
The tiny rural village, halfway between Chibok and Damboa in the besieged state of Borno in Nigeria's north-east, had been helpless to stop the Boko Haram gang as it swept through on trucks loaded with schoolgirls they had taken at gunpoint before torching their school.
Venturing further up the track, Baba and his fellow vigilantes found the two girls. Baba, the youngest of the group, stayed back as his friends took charge. 'They used my knife to cut through the ropes,' he said. 'I heard the girls crying and telling the others that they had been raped, then just left there. They had been with the other girls from Chibok, all taken from the school in the middle of the night by armed men in soldiers' uniforms.
'We couldn't do much for them. They didn't want to talk to any men. All we could do was to get them into a vehicle and drive them to the security police at Damboa. They didn't talk, they just held on to each other and cried.'
For Baba, a peasant farmer's son who has never been out of rural Borno, it was shocking to see young girls defiled and brutalised by the notorious terrorists he knew so well.
But his own life has been full of tragedy and he told how he had 'seen much worse' than the horror of that day in the forest clearing.
A bright-eyed Muslim boy from the Kanuri ethnic group, proud of a tribal facial scar and nicknamed 'Small' by all who know him because of his short, slim frame, he described a happy childhood with three brothers and two sisters in Kachalla Burari, a collection of mudhouses not far from Chibok.
Without electricity or running water, the children spent their days helping on their father's subsistence farm, planting maize and beans and millet.
Chilling: Another terrifying still from a video by Nigeria's Boko Haram terrorist network which shows the missing girls
Baba and his friends used home-made catapults to shoot birds and in the rainy season fished in the river with bent hooks. But by his tenth birthday, the scourge of the radical Islamist Boko Haram was creeping up on everyone in Borno State.
Baba and his siblings attended a local madrassa, or religious school, where they learnt the Koran, but he had no formal teaching and cannot read or write to this day.
By 2009, Boko Haram were becoming active in his area, peddling their message of hatred to Christians, but also turning on Muslims they branded as informants Nigeria's chaotic military was incapable of defending itself or its citizens.
Baba's village life came under siege. There were attacks on the Christian population in the region, with bank robberies funding the gang. Disaffected, unemployed youths from local families were recruited and neighbours who once lived in peace now spied on one another.
'The girls said they'd been raped andleft there'
One night as he slept in his family's mud house in the village, the gunmen came door to door, looking for informers. 'I heard some noise, I woke up and saw men coming through the door, shooting at my uncle who was in the bed beside mine,' he said. 'That was the end of my childhood, the end of everything. I saw his body covered in blood, I backed away, and the men turned their guns on me. They grabbed me roughly and took me outside to a pick-up truck.
Baba, telling his story confidently and lucidly, wants to skate over the details of his two hellish years in the Boko Haram camp in Sambisa Forest. Today there are special forces soldiers swarming over the vast nature reserve and circling overhead in surveillance aircraft.
For this slight boy, there was no such worldwide interest as he scurried back and forth at the command of a ruthless gang dug into woodland far from any help or rescue.
He remembers many of them lived with women who had come voluntarily into the camp. He never saw any girls abducted. This latest phenomenon is unknown to him. 'There were many abducted boys, but no girls,' he said. 'We were all scared to death and had to do whatever we were told – fetch water, fetch firewood, clean the weapons.
'We couldn't make friends – you didn't know who to trust. I was made to sleep next to the Boko Haram elders, the senior preachers. I had no special boss in the camp, I was ordered around by everybody'.
The men prayed five times a day yet would leap on their motorbikes and trucks to carry out killing sprees.
'I knew they had started out as holy men but now I saw them as criminals, loaded with weapons and ammunition,' he said.
Leader: Boko Haram's Abubakar Shekau
As he got older, he was taught how to use an AK-47, how to strip it down and clean it, and reassemble it.
He could never understand what drove the men. They did not use alcohol or hard drugs, though he sometimes saw them smoking marijuana. They were monsters and he felt convinced they were mad.
'They were wild, even when they prayed so loudly in groups together, making us join in. They were insane, unpredictable, and always planning their next attack. I never wanted to be one of them.
'They slept rough every night, just taking shelter under trees in the rainy season,' he said. 'We all wore the same afaraja [the Nigerian long shift and trousers] day and night. We washed them when we could. We slept on mats made of palm leaves, out in the open with the trucks all parked nearby, ready for a hasty move if necessary.'
He said the fear, and the endless boredom, were his worst enemies. 'They made us work hard so it was easy to sleep. I don't remember crying through homesickness. I think the night when my uncle was killed in front of me did something to my feelings forever. It seems mindless, but I adapted to my life out there.'
Then came the day when he was given a 'special' but sickening task. One of the commanders told him he was going on a journey and would be tested for his loyalty to the group.
'He brought two of his senior men to stand beside me. He said I would be going with them to my family's home and I would have to shoot and kill my father.' Baba had no time to plan. He was sandwiched between the two fanatics as they set off on a motorbike for his village home.
'I pretended I was willing to do the job. I took the ammunition belt I was handed and clung on as we drove through the rough bush. When we were less than a mile from a nearby village, I threw the ammunition belt to the ground and pretended it had slid out of my hands.
'They stopped to let me pick it up. Instead, I ran as fast as I could through the undergrowth. I didn't care about thorns or snakes or anything. They shot at me and I could hear the bullets flying past and hitting the trees, but I was not going to stop for anything. I made it to the village and some kind people let me hide there.
'The shooting would have been heard by local vigilante groups. I think that is why I wasn't followed by the men on the bike.'
The next day Baba went home. He saw his grieving parents and siblings for the first time in two years.
'But I couldn't stay,' he said. 'I was bringing danger to their door and we all knew it.'
Confirmation of that came when Baba soon heard that vengeful Boko Haram chiefs had put a bounty on his head for his defiance of the equivalent of £12,000 – a fortune in the local economy.
'I took a bus to Damboa, to report to the youth vigilante group,' he said. 'I wanted to work with them and I knew I was doing the right thing.'
His family, terrified, abandoned their home soon afterwards and today live in a remote part of Borno, rarely seeing their eldest son. He lives with a cousin who is also under a Boko Haram death threat.
He became a valuable volunteer with the vigilantes. He helps man checkpoints where Baba points out members of Boko Haram to the rest of the team.
But he was soon exposed to brutality of a different kind – this time from the government side. He helped to get one of his captors, a man he only knew as Alaji, arrested and handed to the soldiers.
'It felt good at first, but then they shot him dead right in front of me,' he said.
Now joining the patrols armed with a shotgun and machete, Baba has been able to give valuable intelligence to the Nigerian authorities about Boko Haram's way of life in their camps.
'By now I have seen this violence many times. It never gets better. It will always be an even worse sight than finding those poor schoolgirls in the forest,' he says.
culled from Daily Mail


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Popular Stories
Check This Out:
You may remember Adele Enersen as the brilliant and creative young mother who brought to us some amazingly creative sleeping baby photography some time back.
If you're a fan of that type of artwork, you're in luck. Here are some more amazing baby designs from Adele. This time she combines digital illustration and photography in order to create some stunningly cute baby photos…


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Venezia Arte Guides
Venezia Arte was founded in 2009 by a group of Qualified Guides working in the cultural heritage and tourism sector, who have long been committed to promoting alternative itineraries for a mindful and sustainable tourism. We would like to introduce you to Venezia Arte Guides:
Federica Chiuch
Federica graduated in Oriental Languages and Literature from Ca' Foscari University in Venice. She has lived in Venice for almost thirty years and it is her ideal city. She lived in China and then worked as a tour manager and interpreter both abroad and in Italy. She is passionate about the history and art of Venice, and in 2000 gained her licence as an official tour guide to Venice and its lagoon. She works as a volunteer with the FAI and helps to create documentary material about the safeguarding of Venice. Her free time revolves around dance, travel and the discovery of culinary traditions from around the world.
Diana Cugola
This Venetian is a guide to Venice, the lagoon and the Veneto villas. Diana graduated in Foreign Languages and Literature from Ca' Foscari University in Venice. She loves travel, cinema and visual arts, and has worked in the tourism and film sectors in various countries in Europe and North Africa, spending lengthy periods in Russia. For years she worked at the Venice Biennale (in the Cinema, Architecture and Visual Arts sectors) and for the Teatro alla Scala in Milan, as well as working as a consultant for ABC and National Geographic on their TV programmes about Venice. She loves her work and the extraordinary uniqueness of this city.
Emanuela Favero
Emanuela was born in Venice and obtained her degree in Oriental Languages and Literature from Ca' Foscari University in Venice. She has lived in Japan, where she perfected her Japanese and knowledge of its culture, becoming an aficionado of ceramics and tea ceremonies. On her return to Venice, she focussed on studying Western art. She has been a tour guide since 2000 and loves her work. She has worked for years with the FAI (Fondo Ambiente Italiano) on safeguarding monuments. Her interests include cats, cooking and oriental issues.
Arianna Gambirasi
An authorised guide to Venice and Treviso, Arianna graduated in Art History, specialising in Venetian sixteenth-century art. As well as working as a guide, she is also an art historian: previously at the Correr Museum in Venice and now at the Culture Office of Venice City Council. She has been President of the Associazione Guide del Veneto-Guide di Marca for nine years, and continues to be involved in art history, organising training, conventions, conferences and lessons. She is keen on literature, anthropology and communication, and is also active on the web and social media as a blogger and youtuber.
Corine Govi
A Venice guide since 2000, Corine was born and grew up in Provence. On obtaining her university degree in History of Art and Tourist Techniques, she became an official guide in France before deciding to work as a guide in Venice. She has worked for many years with the most important cultural institutes in Venice (the Venice Biennale, Teatro la Fenice, Ca' Foscari University), with French financial newspapers such as Le Point, and specialist guides such as Le Petit Futé and Rick Steve. She has worked with France 2/Secrets d'Histoire and France 3/Des racines et des Ailes on cultural programmes. Her vocation is to transmit the culture of beauty.
Cristina Gregorin
Cristina has been a qualified Venice guide since 1991, a long period of time in which she has been able to study in depth many aspects of this extraordinary city. She is particularly passionate about what is still alive in Venice today: the artistic craftspeople (about whom she has published a book and numerous articles), young designers and artists, as well as the city's everyday life consisting of unique customs. She was part of a citizens' association for a number of years and campaigned about various serious questions for the city and for the equilibrium of its lagoon.
Elisabetta Morelli
After graduating in Languages from Cà Foscari University in Venice, Elisabetta worked in the world of tourism, working with various agencies and cultural institutes (including the Venice Biennale) before becoming a tour escort. After obtaining her licence, she became a guide to Venice and its lagoon. Since 2000 she has worked with the Rick Steves US agency. Her passion for languages and art suits her job perfectly, allowing her to combine the history of the Serenissima with the everyday life of this unique city.
Caterina Nardin
Caterina lives in Venice, where she graduated in Languages and Literature from Ca' Foscari University. After various jobs in the tourist sector, she obtained her licence as a professional tour guide. She focuses on Byzantine history and history of art, in particular Greek and Roman architecture and late medieval, medieval and post-medieval archaeology, with particular reference to Venetian archaeology and the origins of the city. For the last ten years she has been a volunteer guide with the FAI, taking visitors around the sites of major interest in her city.
Susanna Rodighiero
Susanna's love of travel has led her to work in the field of tourism since she was at university. After graduating in Languages with a specialisation in American Literature, she decided to continue working as a tour manager and then became an official tour guide in 2005. Her passion for this job saw her return to university and in 2015 she graduated a second time, this time in History of Art specialising in Medieval and Byzantine Art.
Laura Sabbadin
Laura was born and bred in Venice, and she will never leave it. After graduating in Modern Languages, she worked as a teacher, translator and interpreter, before deciding to take the official tour guide exam. Laura has worked with organisations such as the Venice Biennale, the BBC, National Geographic, Discovery Channel and the Fai, to name just a few, but since 2000 her main focus has been her work as a tour guide. It is a challenging job, which requires extensive research and a need to keep up to speed. Above all it requires indispensable communication skills in order to offer a memorable and enjoyable travel experience.
Hélène Salvadori
Hélène graduated in History and History of Art from Ca 'Foscari University in Venice, after having spent a few months at Warwick University. In 2000 she obtained her authorised guide licence for the city of Venice, and since then has worked with tour operators, universities, institutes and private clients. As well as her love for art history, which she inherited from her family, she is also interested in contemporary dance and art, cooking and, above all, yoga. She has worked as a consultant with the BBC and ARTE on documentaries about Venice.
Rita Sartori
Rita is a guide of Venice and its lagoon. After graduating in Languages, Art, History and Civilization, and a second degree in Economics and Management of Arts, she is still collaborating with Maclab, a research centre of the Department of Management, at Ca' Foscari University in Venice, with a focus on redundant religious heritage. She is actually a member of the organization Future for Religious Heritage. She has worked as a researcher for RAI, National Geographic Television, BBC and RTI-Mediaset on documentaries on the history of Venice and the environmental issues of the Venice Lagoon.
Sabrina Scaglianti
Sabrina was born and grew up in Venice, but she studied and lived abroad in the USA, Germany and Japan. After graduating in Oriental Languages and Cultures from Ca' Foscari University in Venice with a thesis on the Anthropology of Tourism, she has worked in this sector for over twenty years, first as a tour escort and since 2002 as an official tour guide to Venice. She works with visitors of all ages and nationalities, aiming to create dialogues between cultures, with a particular focus on younger visitors. Her leisure interests include singing, anthroposophy and travel.
Cinzia Trevisan
Cinzia was born and grew up in Venice. She lived for two years in the USA, in California, Texas, and Florida where she worked for a year in Orlando, at EPCOT Center (Disney World). She obtained her first degree in History from Ca' Foscari University in Venice, focussing particularly on Byzantine and Venetian history and art. Since 2000 she has been a licenced tour guide to Venice and the Veneto villas. For years she has devoted herself to initiatives aimed at promoting Venetian culture and safeguarding its artworks. She recently obtained her MA in Economics and Management in Arts and Culture, studying in depth subjects related to the international law and the protection of cultural heritage, UNESCO and sustainable tourism.
Francesca Zanatta
After obtaining her degree in Chinese Language and Literature at Ca' Foscari University in Venice, Francesca's love of the East led her to continue her studies in the relations between Venice and the Far East. Her studies strengthened her love of this city, which in time led her to become a guide, allowing her to take her guests around the intricate labyrinth of culture and cultures, history and stories, art and wonders which only Venice contains.
Giovanna Zane
Giovanna has lived in Venice since she was born, but she never ceases to be amazed by its extraordinary beauty. She graduated in English Language and Literature, and has been an authorised tour guide since 2003. She considers it an enormous privilege to be able to share her immense love for her city with the people she meets. For the last few years she has volunteered with the FAI as part of the Venice delegation, with the aim of making people aware of less famous, but no less significant places. Venice is a magical city and Giovanna feels there is nothing like getting lost in its streets and finding traces of its centuries-old history in every detail.


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Welcome to the American Agriculture Movement Home Page
|American Agriculture Movement Goals:
|American Agriculture Movement's Short Term Goals: 2018 Farm Bill (PDF)
|American Agriculture Movement's Statement of Farm Policy: Click here for details.
AAM Annual Convention (Jan. 6-7, 2023) in Lubbock, TX. Event Agenda
Press Releases: The latest from AAM
"AAM Reporter": Your weekly insight into agriculture news, advocacy and opinions:
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Announcing the AAM Parity Fund. Click here for details.
Calendar of Events |
History of the AAM |
Membership/Order Form | Shop Our Members | Links | Email


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One of the most common uses for digital signage is displaying the local weather. This content works great for digital signage, as it is provides targeted, actionable, and dynamic content to viewers. With easy access to weather forecasts from digital signage displays, viewers can better plan their day by adjusting their schedules for weather related delays, making necessary transport arrangements, or even optimizing their outfit choices.
For an organization using digital signage, one must select a weather widget application to use on the organization's deployed screens. In this article, we detail five weather widget applications and solutions for digital signage, including Screenly's own digital-signage optimized weather app.
Screenfeed offers over 75 content feeds for digital signage in up to 15 world languages. Several of these content feeds from Screenfeed are, of course, weather related. Weather content feeds include weather forecast videos, weather radar maps, and other weather graphic packages. Screenfeed also offers live weather data in XML and JSON, so you are able to add your own creative designs to Screenfeed weather data. Pricing is between $6 and $24 per player, but there are large discounts for organizations with many digital signage screens.
MeteoTV is a digital signage weather service from the Meteoblue company. Notably, MeteoTV is an entirely free service. Weather forecasts from MeteoTV are available globally, and you can choose between a standard 5-day daily weather forecast or a more frequent weather forecast with 3-hour intervals. MeteoTV also provides a weather API for free, so you can code and design custom weather displays for your digital signage solution.
AccuWeather was founded in 1962 and is a major provider of weather-related content, with over 40 billion weather related data requests per day. AccuWeather provides data to over 200 TV stations, 900 radio stations, and 700 newspapers. AccuWeather has several digital signage content programs that include advertising networks and even interactive weather content that can feature live polls and social media feeds. While these large-scale solutions will need to be done through AccuWeather corporate, AccuWeather also provides a free weather widget builder. The AccuWeather widget can be customized by location, viewer size, temperature unit, and language. AccuWeather will then provide a code snippet which can be featured on a webpage and displayed using your digital signage player.
IntelliWeather provides a variety of weather content and weather widget solutions. Their two main solutions are IntelliWeather Web Content and the IntelliWeather NowCaster. For IntelliWeather Web Content, IntelliWeather allows users integrate custom, white-labeled weather widgets into their website. These weather widgets can feature customized sponsor logos or advertisements alongside the weather data. However, this service does come at a price and starts at $99 per month. IntelliWeather also offers a digital signage player for its weather widget called the IntelliWeather NowCaster. This device is a simple dongle the plugs into the HDMI port of a TV screen and displays weather content via a WIFI connection. While this digital signage player is limited to displaying weather content, it is certainly an easy "plug-and-play" solution. However, the IntelliWeather NowCaster is a bit price-prohibitive, especially considering its single feature use, as it comes in at a hefty cost of $199.
Screenly offers a beautiful weather widget in the Screenly App Store for use with Screenly Raspberry Pi digital signage players. Screenly's goal with its digital signage apps is to provide users a way to display third-party content in a way that looks great and works instantly. The Screenly weather app is location-aware and will automatically display the weather associated with your digital sign's location. Also, you can set custom locations for more advanced weather content needs. Additionally, Screenly's weather widget app is optimized for the Raspberry Pi, and the Screenly team has focused on a minimalistic design that has great readability from afar. Screenly's weather widget app is currently free for all users. You can find it in the Screenly App Store here.
As shown, companies have several different options for weather content on their digital signage. Companies must measure the pros and cons of each solution, and they must weigh several factors, such as the solution's ease-of-use, the solution's design, the solution's customizability, and, importantly, the solution's costs. Also, it is important to ensure that the chosen weather widget option works on a versatile digital signage player that can simultaneously cater to your company's other digital signage needs.


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Implant Series Part 1 – The Many Uses of Implants
Implants are used for various ways in dentistry. One is prosthodontics, the field of dentistry that aims at provision of prosthetic replacement of missing teeth and oral tissue, is the major user specialty. They are also employed in various orthodontic treatments, such as temporary anchors within the jaw or palatal bone to support orthodontic devices and implements where suitable anchorage is not already available. Prosthodontic use involves permanent implantation within the jaw bones as a replacement of natural tooth roots, and also makes use of the natural process called ossoeintegration, which is the natural attachment of bone tissue to the implant material and growing around it. Titanium and its alloys have been shown to be the best materials for permitting integration of bone to the implant.
- Strength – A primary requirement of an implant is that it should be strong enough to support the prosthesis it is meant to hold. This means it must be anchored to a sufficiently strong body structure.
- Quality and Quantity of Jaw Bones – The shape and size of the implants depends on the bone structure to which the implant is to be made. If enough bone is not available in the jaw the implant may have to be made to the cheek bone. This will demand a longer size of the implant normally called Zygotic Implant. Properly selected and installed modern implants will give satisfactory service for over a decade.
- Safety – the material used for implant fabrication must be biocompatible, and must not generate any adverse or allergic reactions in its vicinity.
Single Teeth
For replacement of an individual tooth first an abutment is attached to the implant which has already been drilled into its position. This is done with a screw. The crown (the prosthesis) is attached to the abutment in one of various ways. These may be use of cement or a suitably small screw. The crown may also be fused to the abutment during the process of manufacturing.
Multiple Teeth
The same process can be used for a prosthesis involving multiple teeth, but normally a double implant anchored at two points will have to be used, although a cantilever arrangement may have to be made in special cases. The result can be a fixed or a removable prosthesis.
Dental Bridges
Bridges typically connect to more than one implant and may also connect to teeth as anchor points. A bridge supported by an implant (fixed denture) consists of one or more teeth attached to dental implants in such a manner that the prosthesis remains fixed at its position. The supported teeth will normally outnumber the anchor points. Those teeth which are directly over the implants are called as abutments. The in between teeth are called pontics. Bridges supported on implants have to be attached to implant abutments just as in the case of single tooth implant replacement.
Implant Supported Removable Dentures
An implant supported denture may also be made removable. It may also be called as implant supported over denture. The dental prosthesis is attached to the abutments in such a way that the user can safely and easily remove it and reinstall it. The abutment in this case has to be as a small button or ball (or some other suitable shape) which will mechanically mate securely with receptacles of corresponding shapes and inner sizes in the dental prosthesis.
Facial Prosthetics
Facial abnormalities may result from cancer treatment, or from injuries, or may be birth defects. To correct these facial prostheses can connect to implants installed in the cheek bone. Again, the facial implant may be designed for a fixed or removable prosthesis.
Orthodontic Utilization
Orthodontic utilization of implants is for a limited period, or temporary. These implants are not as thick, and because of their function are called Temporary Implant Devices (TAD). They should be able to bear the force necessary for the desired tooth movement and reshaping. As implants do not have a periodontal ligament forces generated will not initiate any bone remodeling. Also their shorter duration of installation will not cause much osseointegration. Hence, removal will be easy when desired.
Be sure to check back for part 2 of our dental implant series where we'll discuss the possible complications or risk factors in having implants put in.


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Should You Get Travel Insurance From Boots?
There are many reasons you could be taking a trip – perhaps for work, perhaps just a holiday to recharge your batteries and re-focus. There are lots of great places to see in the world, and so many things you can do on holiday, but remember to spend a while thinking about the practical things before you go. Boots travel insurance, for example, is worth considering to make sure that should things go wrong, you have something to fall back on.
The Costs Of Traveling
Taking a trip can be expensive – there are lots of things to spend money on, from hotels, to train fares and flights – and then you need spending money while you are away. These expenses quickly mount up and your holiday budget can be gone before you know it.
Since you are going to be spending so much money on traveling already, having Boots travel insurance is a great idea. No matter how much you are spending on your trip, and no matter how much your trip costs, once you spend money on something like a vacation, you don't want to lose that money in any way. There are many ways that money you have already spent can be lost when you travel.
As an example – the hotel could be overbooked, or your flights could be canceled due to bad weather. In cases like those, if you do not have travel insurance, you could find yourself in serious trouble – just imagine having to pay walk-up fares for a hotel while you wait for the airline to sort out a new flight.
Many places have fees that you are going to have to pay if your trip is canceled and it is not your fault. If your airline ticket is bumped, or if you aren't able to get into your hotel room for any reason, having Boots travel insurance could be the thing that saves your money.
What Does It Offer?
Boots travel insurance can be beneficial in a lot of ways. You can buy it just like most other policies – either in the store, or online, and then it will cover you should anything unfortunate occur while you are away.
If you have to pay for something unexpected – such as new reservations or a different hotel room, then the travel insurance will cover you. Should your baggage go missing, or you be robbed while you are on holiday, then Boots travel insurance will help you replace what you have lost, and get you your money back. You can count on Boots travel insurance to look after you while you are away.


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Alina Palmer, CNM
My Specialties:Midwifery; Obstetrics & Gynecology
My Areas of Focus:Complete Women's Health, Obstetrics
Languages:English, Interpreters available for other languages, Spanish
Affiliations:Legacy Health Partners
Where I see patients
Where I see patients
Northwest Women's Clinic, PC Barnes Office
11750 SW Barnes Road
Suite 300
Portland, OR 97225
- 503-416-9922
- 503-416-9970
- 9am-5pm
Northwest Women's Clinic, PC Lovejoy Office
2222 NW Lovejoy Street
Suite 619
Portland, OR 97210
- 503-416-9922
- 503-416-9970
- 9am-5pm
About Me:
Alina L. Palmer, RN, CNM, MN joined Northwest Women's Clinic November 1, 2017. Alina received her Bachelors of Science in Nursing at Oregon Health & Sciences University, while working as a NICU and L & D nurse. She graduated from Oregon Health & Science University in 2005 with her Masters in Nursing, and immediately began working as a midwife. Alina came to NWWC after having had her own midwife practice in Vancouver for over 6 years. Alina believes in empowering women to make informed decisions about their care. Birth is a momentous occasion in all women's lives and that of their family. Alina feels that it is an honor and a privilege to assist all women throughout their pregnancy. She has experience in water birth, nitrous oxide use, and other childbirth options. In her spare time, she loves traveling with her husband and family. She has gotten quite good at short, exciting trips. She also loves to bake for others, and enjoys craft projects, especially intricate needlepoint.
No reviews are available at this time.


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|From: Neil Toronto (neil.toronto at gmail.com)
Date: Sat Feb 18 21:39:36 EST 2012
I've attached my entry into the "lambda + R" prototype series. I went for symmetry on the lambda body, mimicked the round part of the Times New Roman "R", and compromised as little as possible on the angle of the left leg. This is a very tricky logo idea, FWIW. The left-leg angle is always hard to get right, and it's hard to make a round shape that's forceful and balanced but not overbearing. (That's why I deferred to the pros on that part. I think it was a good move.) Neil ⊥ -------------- next part -------------- A non-text attachment was scrubbed... Name: lambda+racket-logo.svg Type: image/svg+xml Size: 6693 bytes Desc: not available URL: <http://lists.racket-lang.org/dev/archive/attachments/20120218/a9fcb464/attachment-0001.svg>
|Posted on the dev mailing list.


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The giant honeybees of East Asia can build impressive open nests measuring a few meters across. The fact that they are always exposed makes them vulnerable to predators, particularly large wasps and hornets that love nothing more than invading hives and stealing grubs. Luckily, the bees have a secret weapon that is as visually mesmerizing as it is effective.
Called shimmering, the unique defensive strategy of giant honeybees involves large numbers of workers raising their rear-ends by ninety degrees and shaking them in unison, creating an effect similar to the well-known Mexican waves seen at stadiums across the world. How hundreds of bees are capable of communicating and producing this highly coordinated response to threats remains unknown, but after 15 years of studying the behavior in the wild, scientists are now convinced that shimmering is a defense mechanism.
Photo: Wikimedia CH (GFDL 1.2)
Naturalists have long assumed that the Mexican wave-like patterns observed on living "bee curtains" in the forests of East Asia were meant to keep predators at bay, but the first conclusive proof came a decade ago, when a team of researchers led by Gerald Kastberger from the University of Graz, in Austria, published a study after 15 years of observing giant honeybees in India and Nepal.
After analyzing videos of shimmering colonies of giant honeybees, Kasterberger and his colleagues concluded that there two types of shimmering – small-scale ones that only involved under a dozen bees and large-scale ones that covered the entire surface of the hive. Small scale shimmering occurred frequently, while the large-scale ones only happened when there were wasps nearby.
Scientists noted that the intensity and frequency of the shimmering increased the closer predators got to the giant honeybee hive, and that the moment it began, nearby wasps or hornets halted their attack and fled. The more bees took part in the mesmerizing Mexican waves, the faster the predators retreated.
While it's still not clear how the shimmering of giant honeybees affects invading wasps, in his study Gerald Kastberger suggests that small-scale waves confuses attackers, making it difficult for them to focus on any one bee, while large-scale shimmering actually threaten them.
Interestingly, large-scale shimmering was observed only when wasps or hornets breached a 50cm safe-zone around the honeybee's hive. They could hover outside this perimeter without triggering the defense mechanism, but as soon as they crossed it, the Mexican waves began.
Shimmering seems to be used solely as a defense against wasps and hornets, while larger threats trigger a different response. For example, in one experiment, giant bees deployed hundreds of defenders when a kite appeared within 20 meters of the bee's hive.
Shimmering is not full-proof, but if any wasp or hornet decides to land on the hive, giant honeybees have another trick up their sleeve. It's called "snow balling" and it involves a group of bees surrounding the intruder and vibrating their wing muscles in unison. This heats the bees' bodies to 45C, a temperature that is harmless to them but lethal to wasps. Basically, they cook the intruder alive.


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Today I am sharing with you one of my most favorite meals ever.
As in it was the meal I requested for my birthday, when I came home from college on break, and any other time my mom said the magic words "What would you like me to make for you?". We call my mom "Cici" for the kids (that's her initials. C. C.) So I call these Cici's Pork Chops.
You may be wondering right now "Jenn, if this is your favorite meal, and you've been blogging since 2006, why have you waited 8 years to share it with us".
Because it just isn't pretty. I mean really–look at my photo up there. It just isn't something that LOOKS good. Not only that but it sounds weird. Sauerkraut and tomatoes? Ew. I admit it, if I didn't know how delicious it was I too would look at that photo and those ingredients and be very, very skeptical. Actually, I've made this meal three times since the new year with the intent to photograph it and share it, but each time it just looks, well, like it does. So I finally gave up and said "self–they are either going to like it or not, there is no way you can be true to how this is cooked and come up with a pleasing photo". So here we are!
The ingredients for this dish are super simple. Pork Chops. Seasoned Salt. Sauerkraut. Stewed Tomatoes. Onions. Really–that's pretty much it. A couple of caveats: I've typically used either the Kosher Sauerkraut, the kind they sell in jars in the refrigerator section of the store, or homemade. These are milder krauts, not as vinegary as some. You can make this with the bagged or canned kraut as well–but if you try it and think the flavor is good just a tad too sour then next time you might want to try the Kosher kind. For the stewed tomatoes I use home canned or the plain, unflavored kind.
I make the chops by first seasoning & browning the meat (I use my Homemade Seasoned Salt and some Pepper), then layering them in my slow cooker with the sauerkraut, stewed tomatoes and sliced onions. Usually I'll get about 2 to three layers depending on the number and size of the pork chops. I'll sprinkle a little more seasoned salt on the middle layer as well. Turn it on low for 6-8 hours and you come back to fall off the bone tender pork. I put all the pork on a platter and then scoop the sauerkraut/tomato mix into a separate bowl to be eaten as a side dish.
If you are in a rush you can skip the browning step (although it adds additional flavor) and you can cover and bake the entire dish in the oven instead of using the slow cooker (I'd say about an hour and then check). I'm sure you could probably make this in a pressure cooker as well, but I haven't tried that.
The leftover broth is very flavorful (but tangy from the sauerkraut). I sometimes will just put the liner in the fridge overnight, scoop off the layer of fat in the morning, stick it back into the slow cooker, toss in some lentils and other odds and ends and make a soup for the next day.
I hope some of you give this recipe a try and let me know what you think!
Cici's Pork Chops
- Pork Chops 4-6
- 1 Quart Sauerkraut (roughly 1 LB or 2 cans)
- 1 Quart Stewed Tomatoes (or 2 cans)
- 2 Onions medium
- Seasoned Salt
- Pepper
Season pork chops with seasoned salt and pepper. Brown in a skillet.
In slow cooker layer 2-3 browned pork chops, 1/2 sauerkraut, 1/2 tomatoes, 1 onion and some seasoned salt--repeat with a second layer.
Cover and cook 6-8 hrs on low.
Serve pork and sauerkraut/tomato separately.
You may skip browning the pork, but this will result in a slight loss of flavor (browning adds a lot!) and a more "gray" look to your meat.
You may use plain salt instead of the seasoned.
You can layer all the ingredients in a casserole dish, cover with foil (or a lid) and bake for an hour in a 350 oven (please check and adjust the time as it will vary depending on the thickness of your pork chops and your individual oven)