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Specialty Gynecology
ICD-9-CM 617.0
ICD-10 N80
Endometriosis is a condition in which tissue that normally grows inside the uterus (endometrium) grows outside it. Most often this is on the ovaries, fallopian tubes, and tissue around the uterus and ovaries; however, in rare cases it may also occur in other parts of the body. The main symptoms are pelvic pain and infertility. Nearly half of those affected have chronic pelvic pain, while in 70% pain occurs during menstruation. Pain during sex is also common. Infertility occurs in up to half of women affected. Less common symptoms include urinary or bowel symptoms. About 25% of women have no symptoms. Endometriosis can have both social and psychological effects.
Retrograde menstruation theory
Pain quantification
Other medication
Comparison of interventions
Treatment of infertility
The cause is not entirely clear. Risk factors include having a family history of the condition. The areas of endometriosis bleed each month, resulting in inflammation and scarring. The growths due to endometriosis are not cancer. Diagnosis is usually based on symptoms in combination with medical imaging. Biopsy is the most sure method of diagnosis. Other causes of similar symptoms include pelvic inflammatory disease, irritable bowel syndrome, interstitial cystitis, and fibromyalgia.
Tentative evidence suggests that the use of combined oral contraceptives reduces the risk of endometriosis. Exercise and avoiding large amounts of alcohol may also be preventive. There is no cure for endometriosis, but a number of treatments may improve symptoms. This may include pain medication, hormonal treatments, or surgery. The recommended pain medication is usually an NSAID such as naproxen. Taking the active component of the birth control pill continuously or using an intrauterine device with progestogen may also be useful. Gonadotropin-releasing hormone agonist may improve the ability of those who are infertile to get pregnant. Surgical removal of endometriosis may be used to treat those whose symptoms are not manageable with other treatments.
Endometriosis is estimated to occur in roughly 6–10% of women. It is most common in those in their thirties and forties; however, can begin in girls as early as 8 years old. It results in few deaths with this being estimated at 200 globally in 2013. Endometriosis was first determined to be a separate condition in the 1920s. Before that time endometriosis and adenomyosis were considered together. It is unclear who first described the disease.
Although 20–25% of women with endometriosis have no symptoms, pain and infertility are common signs.
A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping or stabbing pain that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. The amount of pain a woman feels correlates poorly with the extent or stage (1 through 4) of endometriosis, with some women having little or no pain despite having extensive endometriosis or endometriosis with scarring, while other women may have severe pain even though they have only a few small areas of endometriosis. Symptoms of endometriosis-related pain may include:
dysmenorrhea – painful, sometimes disabling cramps during the menstrual period; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis
chronic pelvic pain – typically accompanied by lower back pain or abdominal pain
dyspareunia – painful sex
dysuria – urinary urgency, frequency, and sometimes painful voiding
Throbbing, gnawing, and dragging pain to the legs are reported more commonly by women with endometriosis. Compared with women with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down. Individual pain areas and pain intensity appears to be unrelated to the surgical diagnosis, and the area of pain unrelated to area of endometriosis.
Endometriosis lesions react to hormonal stimulation and may "bleed" at the time of menstruation. The blood accumulates locally, causes swelling, and triggers inflammatory responses with the activation of cytokines. This process may cause pain. Pain can also occur from adhesions (internal scar tissue) binding internal organs to each other, causing organ dislocation. Fallopian tubes, ovaries, the uterus, the bowels, and the bladder can be bound together in ways that are painful on a daily basis, not just during menstrual periods.
Also, endometriotic lesions can develop their own nerve supply, thereby creating a direct and two-way interaction between lesions and the central nervous system, potentially producing a variety of individual differences in pain that can, in some women, become independent of the disease itself. Nerve fibres and blood vessels are thought to grow into endometriosis lesions by a process known as Neuroangiogenesis.
Many women with infertility may have endometriosis. Among women with endometriosis, up to half may experience infertility.
Other symptoms include diarrhea or constipation, chronic fatigue, nausea and vomiting, headaches, low-grade fevers, heavy and/or irregular periods, and hypoglycemia.
In addition to pain during menstruation, the pain of endometriosis can occur at other times of the month. There can be a pain with ovulation, pain associated with adhesions, pain caused by inflammation in the pelvic cavity, pain during bowel movements and urination, during general bodily movement like exercise, pain from standing or walking, and pain with intercourse. The most severe pain is typically associated with menstruation. Pain can also start a week before a menstrual period, during and even a week after a menstrual period, or it can be constant. The pain can be debilitating and the emotional stress can take a toll.
There is an association between endometriosis and certain types of cancers, notably some types of ovarian cancer, non-Hodgkin's lymphoma and brain cancer. Endometriosis is unrelated to endometrial cancer.
Genetic predisposition plays a role in endometriosis. Daughters or sisters of women with endometriosis are at higher risk of developing endometriosis themselves; low progesterone levels may be genetic, and may contribute to a hormone imbalance. There is an about six-fold increased incidence in women with an affected first-degree relative.
It has been proposed that endometriosis results from a series of multiple hits within target genes, in a mechanism similar to the development of cancer. In this case, the initial mutation may be either somatic or heritable.
Individual genomic changes (found by genotyping including genome-wide association studies) that have been associated with endometriosis include:
Changes on chromosome 1 near WNT4.
Changes on chromosome 2 near GREB1.
Changes on chromosome 6 near ID4.
Changes on chromosome 7 in the 7p15.2 region.
Changes on chromosome 9 near CDKN2BAS.
Changes on chromosome 10 at region 10q26.
Changes on chromosome 12 near VEZT.
In addition, there is a weaker association with changes in the fibronectin gene as well as in the 2p14 region of chromosome 2.
In addition, there are many findings of altered gene expression and epigenetics, but both of these can also be a secondary result of, for example, environmental factors and altered metabolism. Examples of altered gene expression include that of miRNAs.
Several studies have investigated the potential link between exposure to dioxins and endometriosis, but the evidence is equivocal and potential mechanisms are poorly understood. A 2004 review of studies of dioxin and endometriosis concluded that "the human data supporting the dioxin-endometriosis association are scanty and conflicting", and a 2009 follow-up review also found that there was "insufficient evidence" in support of a link between dioxin exposure and women developing endometriosis. A 2008 review concluded that more work was needed, stating that "although preliminary work suggests a potential involvement of exposure to dioxins in the pathogenesis of endometriosis, much work remains to clearly define cause and effect and to understand the potential mechanism of toxicity".
While the exact cause of endometriosis remains unknown, many theories have been presented to better understand and explain its development. These concepts do not necessarily exclude each other. The pathophysiology of endometriosis is likely to be multifactorial and to involve an interplay between several factors.
The main theories for the formation of the ectopic endometrium are retrograde menstruation, müllerianosis, coelomic metaplasia and transplantation, each further described below.
The theory of retrograde menstruation (also called the implantation theory or transplantation theory) is the most widely accepted theory for the formation of ectopic endometrium in endometriosis. It suggests that during a woman's menstrual flow, some of the endometrial debris exits the uterus through the fallopian tubes and attaches itself to the peritoneal surface (the lining of the abdominal cavity) where it can proceed to invade the tissue as endometriosis.
Retrograde menstruation alone is not able to explain all instances of endometriosis, and additional factors such as genetic or immune differences need to be invoked to account for the fact that many women with retrograde menstruation do not have endometriosis. Researchers are investigating the possibility that the immune system may not be able to cope with the cyclic onslaught of retrograde menstrual fluid. In this context there is interest in studying the relationship of endometriosis to autoimmune disease, allergic reactions, and the impact of toxic materials. It is still unclear what, if any, causal relationship exists between toxic materials, autoimmune disease, and endometriosis. There are immune system changes in women with endometriosis, such as an increase macrophage-derived secretion products, but it is unknown if these are contributing to the disorder or are reactions from it.
In addition, at least one study found that endometriotic lesions differ in their biochemistry from artificially transplanted ectopic tissue. This is likely because the cells that give rise to endometriosis are a side population of cells. Similarly, there are changes in for example the mesothelium of the peritoneum in women with endometriosis, such as loss of tight junctions, but it is unknown if these are causes or effects of the disorder.
In rare cases where imperforate hymen does not resolve itself prior to the first menstrual cycle and goes undetected, blood and endometrium are trapped within the uterus of the woman until such time as the problem is resolved by surgical incision. Many health care practitioners never encounter this defect, and due to the flu-like symptoms it is often misdiagnosed or overlooked until multiple menstrual cycles have passed. By the time a correct diagnosis has been made, endometrium and other fluids have filled the uterus and fallopian tubes with results similar to retrograde menstruation resulting in endometriosis. The initial stage of endometriosis may vary based on the time elapsed between onset and surgical procedure.
The theory of retrograde menstruation as a cause of endometriosis was first proposed by John A. Sampson.
Stem cells: Endometriosis may arise from stem cells from bone marrow and potentially other sources. In particular this theory explains endometriosis found in areas remote from the pelvis such as the brain or lungs.
Environment; Environmental toxins (e.g.; dioxin, nickel) may cause endometriosis.
Müllerianosis: A theory supported by foetal autopsy is that cells with the potential to become endometrial, which are laid down in tracts during embryonic development called the female reproductive (Mullerian) tract as it migrates downward at 8–10 weeks of embryonic life, could become dislocated from the migrating uterus and act like seeds or stem cells.
Coelomic metaplasia: Coelomic cells which are the common ancestor of endometrial and peritoneal cells may undergo metaplasia (transformation) from one type of cell to the other, perhaps triggered by inflammation.
Vasculogenesis: Up to 37% of the microvascular endothelium of ectopic endometrial tissue originates from endothelial progenitor cells, which result in de novo formation of microvessels by the process of vasculogenesis rather than the conventional process of angiogenesis.
Neural growth: An increased expression of new nerve fibres is found in endometriosis, but does not fully explain the formation of ectopic endometrial tissue, and is not definitely correlated with the amount of perceived pain.
Autoimmune: Graves disease is an autoimmune disease characterized by hyperthyroidism, goiter, ophthalmopathy, and dermopathy. Women with endometriosis had higher rates of Graves disease. One of these potential links between Graves disease and endometriosis is autoimmunity.
Most endometriosis is found on these structures in the pelvic cavity:
Ovaries (the most common site)
Fallopian tubes
The back of the uterus and the posterior cul-de-sac
The front of the uterus and the anterior cul-de-sac
Uterine ligaments such as the broad or round ligament of the uterus
Pelvic and back wall
Intestines, most commonly the rectosigmoid
Urinary bladder and ureters
Rectovaginal or bowel endometriosis affects approximately 5-12% of women with endometriosis, and can cause severe pain with bowel movements.
Endometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision, known as "scar endometriosis." Risk factors for scar endometriosis include previous abdominal surgeries, such as a hysterotomy or cesarean section, or ectopic pregnancies, salpingostomy puerperal sterilization, laparoscopy, amniocentesis, appendectomy, episiotomy, vaginal hysterectomies, and hernia repair.
Endometriosis may also present with skin lesions in cutaneous endometriosis.
Less commonly lesions can be found on the diaphragm. Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may inflict the cyclic pain of the right shoulder just before and during a menstrual period. Rarely, endometriosis can be extraperitoneal and is found in the lungs and CNS.
A health history and a physical examination can lead the health care practitioner to suspect endometriosis. Although doctors can often feel the endometrial growths during a pelvic exam, and these symptoms may be signs of endometriosis, diagnosis cannot be confirmed by exam only. Use of pelvic ultrasound may identify large endometriotic cysts (called endometriomas). However, smaller endometriosis implants cannot be visualized with ultrasound technique.
Laparoscopy, a surgical procedure where a camera is used to look inside the abdominal cavity, is the only way to officially diagnose endometriosis as it permits lesion visualization unless the lesion is visible externally, e.g. an endometriotic nodule in the vagina. If the growths are not visible, a biopsy may be taken to determine the diagnosis. Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time.
To the eye, lesions can appear dark blue, powder-burn black, red, white, yellow, brown or non-pigmented. Lesions vary in size. Some within the pelvis walls may not be visible, as normal-appearing peritoneum of infertile women reveals endometriosis on biopsy in 6–13% of cases. Early endometriosis typically occurs on the surfaces of organs in the pelvic and intra-abdominal areas. Health care providers may call areas of endometriosis by different names, such as implants, lesions, or nodules. Larger lesions may be seen within the ovaries as endometriomas or "chocolate cysts", "chocolate" because they contain a thick brownish fluid, mostly old blood.
Frequently during diagnostic laparoscopy, no lesions are found in women with chronic pelvic pain, a symptom common to other disorders including adenomyosis, pelvic adhesions, pelvic inflammatory disease, congenital anomalies of the reproductive tract, and ovarian or tubal masses.
Surgically, endometriosis can be staged I–IV by the revised classification of the American Society of Reproductive Medicine from 1997. The process is a complex point system that assesses lesions and adhesions in the pelvic organs, but it is important to note staging assesses physical disease only, not the level of pain or infertility. A person with Stage I endometriosis may have a little disease and severe pain, while a person with Stage IV endometriosis may have severe disease and no pain or vice versa. In principle the various stages show these findings:
Stage I (Minimal)
Findings restricted to only superficial lesions and possibly a few filmy adhesions
Stage II (Mild)
In addition, some deep lesions are present in the cul-de-sac
Stage III (Moderate)
As above, plus the presence of endometriomas on the ovary and more adhesions.
Stage IV (Severe)
As above, plus large endometriomas, extensive adhesions.
An area of research is the search for endometriosis markers.
In 2010 essentially all proposed biomarkers for endometriosis were of unclear medical use, although some appear to be promising. The one biomarker that has been in use over the last 20 years is CA-125. A 2016 review found that in those with symptoms of endometriosis and once ovarian cancer has been ruled out, a positive CA-125 may confirm the diagnosis. Its performance in ruling out endometriosis; however, is low. CA-125 levels appear to fall during endometriosis treatment, but has not shown a correlation with disease response.
Another review in 2011 identified several putative biomarkers upon biopsy, including findings of small sensory nerve fibers or defectively expressed β3 integrin subunit. It has been postulated a future diagnostic tool for endometriosis will consist of a panel of several specific and sensitive biomarkers, including both substance concentrations and genetic predisposition.
Typical endometriotic lesions show histopathologic features similar to endometrium, namely endometrial stroma, endometrial epithelium, and glands that respond to hormonal stimuli. Older lesions may display no glands but hemosiderin deposits (see photomicrograph on right) as residual.
Immunohistochemistry has been found to be useful in diagnosing endometriosis as stromal cells have a peculiar surface antigen, CD10, thus allowing the pathologist go straight to a staining area and hence confirm the presence of stromal cells and sometimes glandular tissue is thus identified that was missed on routine H&E staining.
The most common pain scale for quantification of endometriosis-related pain is the visual analogue scale (VAS); VAS and numerical rating scale (NRS) were the best adapted pain scales for pain measurement in endometriosis. For research purposes, and for more detailed pain measurement in clinical practice, VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the clinical global impression (CGI) and a quality of life scale, are used.
Limited evidence indicates that the use of combined oral contraceptives is associated with a reduced risk of endometriosis.
While there is no cure for endometriosis, there are two types of interventions; treatment of pain and treatment of endometriosis-associated infertility. In many women menopause (natural or surgical) will abate the process. In women in the reproductive years, endometriosis is merely managed: the goal is to provide pain relief, to restrict progression of the process, and to restore or preserve fertility where needed. In younger women, surgical treatment attempts to remove endometrial tissue and preserve the ovaries without damaging normal tissue.
In general, the diagnosis of endometriosis is confirmed during surgery, at which time ablative steps can be taken. Further steps depend on circumstances: a woman without infertility can be managed with hormonal medication that suppresses the natural cycle and pain medication, while an infertile woman may be treated expectantly after surgery, with fertility medication, or with IVF. As to the surgical procedure, ablation (or fulguration) of endometriosis (burning and vaporizing the lesions with an electric device) has shown a high rate of short-term recurrence after the procedure. The best surgical procedure with much less rate of short-term recurrence is to excise (cut and remove) the lesions completely.
Conservative treatment consists of the excision of the endometrium, adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible. Endometrioma on the ovary of any significant size (Approx. 2 cm +) -sometimes misdiagnosed as ovarian cysts- must be removed surgically because hormonal treatment alone will not remove the full endometrioma cyst, which can progress to acute pain from the rupturing of the cyst and internal bleeding. Laparoscopy, besides being used for diagnosis, can also be used to perform surgery. It's considered a "minimally invasive" surgery because the surgeon makes very small openings (incisions) at (or around) the belly button and lower portion of the belly. A thin telescope-like instrument (the laparoscope) is placed through one incision, which allows the doctor to look for endometriosis using a small camera attached to the laparoscope. Small instruments are inserted through the incisions to remove the endometriosis tissue and adhesions. Because the incisions are very small, there will only be small scars on the skin after the procedure, and all endometriosis can be removed, and women recover from surgery quicker and have a lower risk of adhesions.
55% to 100% of women develop adhesions following pelvic surgery, which can result in infertility, chronic abdominal and pelvic pain, and difficult reoperative surgery. Trehan's temporary ovarian suspension, a technique in which the ovaries are suspended for a week after surgery may be used to reduce the incidence of adhesions after endometriosis surgery.
Conservative treatment involves excision of endometriosis while preserving the ovaries and uterus, very important for women wishing to conceive, but may increase the risk of recurrence.
Endometriosis recurrence following conservative surgery is estimated as 21.5% at 2 years and 40-50% at 5 years.
A hysterectomy (removal of the uterus) can be used to treat endometriosis in women who do not wish to conceive. However, this should only be done when combined with removal of the endometriosis by excision, as if endometriosis is not also removed at the time of hysterectomy, pain may persist.
For women with extreme pain, a presacral neurectomy may be very rarely performed where the nerves to the uterus are cut. However, this technique is almost never used due to the high incidence of associated complications including presacral hematoma and irreversible problems with urination and constipation.
Progesterone or Progestins: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. Progestins are chemical variants of natural progesterone. An example of a Progestin is Dienogest (Visanne).
Avoiding products with xenoestrogens, which have a similar effect to naturally produced estrogen and can increase growth of the endometrium.
Hormone contraception therapy: Oral contraceptives reduce the menstrual pain associated with endometriosis. They may function by reducing or eliminating menstrual flow and providing estrogen support. Typically, it is a long-term approach.
Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes.
Gonadotropin-releasing hormone (GnRH) agonists: These drugs are thought to work by decreasing hormone levels. A 2010 Cochrane review found that GnRH agonists were more effective for pain relief in endometriosis than no treatment or placebo, but were no more effective than danazol or intrauterine progestagen, and had more side effects than danazol.
Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.
NSAIDs: Anti-inflammatory. They are commonly used in conjunction with other therapy. For more severe cases narcotic prescription drugs may be used. NSAID injections can be helpful for severe pain or if stomach pain prevents oral NSAID use.
Opioids: Morphine sulphate tablets and other opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called "endorphins". There are different long acting and short acting medications that can be used alone or in combination to provide appropriate pain control.
Following laparoscopic surgery women who were given Chinese herbs were reported to have comparable benefits to women with conventional drug treatments, though the journal article that reviewed this study also noted that "the two trials included in this review are of poor methodological quality so these findings must be interpreted cautiously. Better quality randomised controlled trials are needed to investigate a possible role for CHM [Chinese Herbal Medicine] in the treatment of endometriosis."
Pentoxifylline, an immunomodulating agent, has been theorized to improve pain as well as improve pregnancy rates in women with endometriosis. A 2012 Cochrane review, however, found that there was not enough evidence to support the effectiveness or safety of either of these uses. Current American Congress of Obstetricians and Gynecologists (ACOG) guidelines do not include immune-modulators, such as pentoxifylline, in standard treatment protocols.
Angiogenesis inhibitors lack clinical evidence of efficacy in endometriosis therapy. Under experimental in vitro and in vivo conditions, compounds that have been shown to exert inhibitory effects on endometriotic lesions include growth factor inhibitors, endogenous angiogenesis inhibitors, fumagillin analogues, statins, cyclo-oxygenase-2 inhibitors, phytochemical compounds, immunomodulators, dopamine agonists, peroxisome proliferator-activated receptor agonists, progestins, danazol and gonadotropin-releasing hormone agonists. However, many of these agents are associated with undesirable side effects and more research is necessary. An ideal therapy would diminish inflammation and underlying symptoms without being contraceptive.
The overall effectiveness of manual physical therapy to treat endometriosis has not yet been identified. There is no evidence to support nutritional therapy as effective.
Medicinal and surgical interventions produce roughly equivalent pain-relief benefits. Recurrence of pain was found to be 44 and 53 percent with medicinal and surgical interventions, respectively. Each approach has advantages and disadvantages. Manual therapy showed a decrease in pain for 84 percent of study participants, and a 93 percent improvement in sexual function.
Evidence on how effective medication is for relieving pain associated with endometriosis is limited.
The advantages of surgery are demonstrated efficacy for pain control, it is more effective for infertility than medicinal intervention, it provides a definitive diagnosis, and surgery can often be performed as a minimally invasive (laparoscopic) procedure to reduce morbidity and minimize the risk of post-operative adhesions. Efforts to develop effective strategies to reduce or prevent adhesions have been undertaken, but their formation remain a frequent side effect of abdominal surgery.
The advantages of physical therapy techniques are decreased cost, absence of major side-effects, it does not interfere with fertility, and near-universal increase of sexual function. Disadvantages are that there are no large or long-term studies of its use for treating pain or infertility related to endometriosis.
Surgery is more effective than medicinal intervention for addressing infertility associated with endometriosis. Surgery attempts to remove endometrial tissue and preserve the ovaries without damaging normal tissue. In-vitro fertilization (IVF) procedures are effective in improving fertility in many women with endometriosis.
Proper counseling of women with endometriosis requires attention to several aspects of the disorder. Of primary importance is the initial operative staging of the disease to obtain adequate information on which to base future decisions about therapy. The woman's symptoms and desire for childbearing dictate appropriate therapy. Not all therapy works for all women. Some women have recurrences after surgery or pseudo-menopause. In most cases, treatment will give women significant relief from pelvic pain and assist them in achieving pregnancy.
The underlying process that causes endometriosis may not cease after a surgical or medical intervention. Studies have shown that endometriosis recurs at a rate of 20 to 40 percent within five years following conservative surgery, unless hysterectomy is performed or menopause reached. Monitoring of women consists of periodic clinical examinations and sonography.
Vaginal childbirth decreases recurrence of endometriosis. In contrast, endometriosis recurrence rates have been shown to be higher in women who have not given birth vaginally, such as in cesarean section.
Complications of endometriosis include internal scarring, adhesions, pelvic cysts, chocolate cyst of ovaries, ruptured cysts, and bowel and ureteral obstruction resulting from pelvic adhesions. Endometriosis-associated infertility can be related to scar formation and anatomical distortions due to the endometriosis.
Ovarian endometriosis may complicate pregnancy by decidualization, abscess and/or rupture.
Thoracic endometriosis is associated with recurrent pneumothoraces at times of a menstrual period, termed catamenial pneumothorax.
Endometriosis can affect any female, from premenarche to postmenopause, regardless of race or ethnicity or whether or not they have had children. It is primarily a disease of the reproductive years. The number of women affected is between 6–10%. It is more common in women with infertility and chronic pelvic pain (35–50%).
Incidences of endometriosis have occurred in postmenopausal women, and in less common cases, girls may have endometriosis symptoms before they even reach menarche.
Endometriosis was first discovered microscopically by Karl von Rokitansky in 1860, although it was documented in medical texts more than 4,000 years ago. The Hippocratic Corpus outlines symptoms similar to endometriosis, including uterine ulcers, adhesions, and infertility. Historically, women with these symptoms were treated with leeches, straitjackets, bloodletting, chemical douches, genital mutilation, pregnancy (as a form of treatment), hanging upside down, surgical intervention, and even killing due to suspicion of demonic possession. Hippocratic doctors recognized and treated chronic pelvic pain as a true organic disorder 2,500 years ago, but during the Middle Ages, there was a shift into believing that women with pelvic pain were mad, immoral, imagining the pain, or simply misbehaving. The symptoms of inexplicable chronic pelvic pain were often attributed to imagined madness, female weakness, promiscuity, or hysteria. The historical diagnosis of hysteria, which was thought to be a psychological disease, may have indeed been endometriosis. The idea that chronic pelvic pain was related to mental illness influenced modern attitudes regarding women with endometriosis, leading to delays in correct diagnosis and indifference to the patients' true pain during the 20th century.
Hippocratic doctors believed that delaying childbearing could trigger diseases of the uterus, which caused endometriosis-like symptoms. Women with dysmenorrhea were encouraged to marry and have children at a young age. The fact that Hippocratics were recommending changes in marriage practices due to an endometriosis-like illness implies that this disease was likely common, with rates higher than the 5-15% prevalence that is often cited today. If indeed this disorder was so common historically, this may point away from modern theories that suggest links between endometriosis and dioxins, PCBs, and chemicals.
As recently as 1995, reports found that over 50% of women with chronic pelvic pain had no organic cause, with women still often being considered mentally unstable. Self-help groups say practitioners delay making the diagnosis, often because they don't consider it a possibility. In the US, as of 2007, about 27% of women with endometriosis had had the symptoms for at least six years before it is diagnosed.
The economic effects associated with endometriosis are substantial and are similar to that of other chronic diseases such as Crohn's disease, diabetes, or rheumatoid arthritis. This economic burden is attributed mostly to the inability to consistently work and predicted by decreased quality of life.
Endometriosis Wikipedia
Endometriosis of ovary
Kashi from Village
César Augusto Blanco Gramajo


The teacher will talk to the child about his\her behavior and put the child on a time out chair. If the child continues to repeat the same behavior, they will be sent to the office. Ms. Evelyn will talk with the child and if necessary contact parents.
8422 Elvaton Road • Millersville, MD 21108 • 410-647-3224 • Copyright © 2008, Elvaton Academy. All rights reserved.


There are several brands of filler paper, as well as the covers that are used. The greatest thing about using filler paper is that you could easily remove the pages without tearing them up. This is made possible through unlocking the chains by gently moving both sides of the opening to the opposite area, and then allowing the sheets to pass through the metallic link. You can remove a certain page, and possibly even all of the pages.
Papers are fragile materials that could be torn, crumpled, or soiled once they are not put in a hard container. With filler papers however, it usually comes with hard cases and thus you can be assured that the sheets inside are kept as neat and clean as possible.
Given that these sheets ought to be removable and transferrable, they are most definitely thicker than a lot of the papers out in the market. This is perfectly reasonable, given that papers that are thinly manufactured can't withstand being removed and added on a regular basis, as they could most definitely tear and be rendered un-attachable to the metal rings.


It would be really helpful if a plugin were to exist where one could specify an object's properties that would differ per team.
For example, a box that could have the drivethrough option applied to it, but for the rabbit team only, for the rabbit to temporarily escape to, or use a shortcut. Or a pyramid that would have the death effect phydrv applied to it, but only affect the blue team, while the red team would be safe when touching it.
I believe this would open up new potential strategies for map and game play creation.
Plugins cannot do that. That would be a protocol-breaking change that would require changes to the client and server.
The concept does sound somewhat similar to what others have proposed over the years.
While, if I remember correctly, in '2.99', there was work to only allow certain teams or shots go through teleporters, this was pretty much as far as it go in terms of 'per-team' attributes to objects.
Not to sound discouraging in any way, but API at the time of this writing have no 'ability' to control or adjust objects.
The tangability feature would have allowed some interesting aspects to be made, but this was for the '3.0' edition, which was never released.
Although you are not able to adjust any of the 'arguments' an object has with the API, there is something you can do.
The part of having a 'death' object only affecting certain teams is pretty much the only thing which can be done be simulated with a plug-in.
However, my implementation of it was inefficient and left a lot to be desired, but it is unlikely I'll be revising it anytime soon due to other projects taking priority at the moment.
Still, the source is there and you are free to use or update it.


Special Olympics Ireland - What do you see?
In June 2003 Ireland hosted the Special Olympics World Summer Games. For two weeks, as a nation we were enthralled and inspired by the determination, bravery, skill and abilities of the 7,000 athletes who travelled from 168 countries.
Staging the 2003 Special Olympics World Games opened our eyes to many things. We saw people with an intellectual disability in a new light, as individuals who could achieve far more than we ever thought possible. We came to see people with an intellectual disability for what they could achieve rather than what could not.
Staging the Games revealed a lot about ourselves too, both as individuals and as an island: we came to experience a 'can do', an 'everything is possible' feeling throughout the island of Ireland not felt before or since. In short our eyes were opened to possibilities which before we thought were beyond us.
To celebrate this and the 2003 World Games and what it stood for and also to acknowledge the legacy that still is impacting people's lives throughout the country Special Olympics Ireland is asking the people of Ireland to remember and celebrate that special time in 2003 by challenging themselves to do something that they had never done before.....in the same way people with an intellectual disability are doing every day of their lives in Special Olympics.
We'd love to hear your story from the 2003 Special Olympics World Summer Games, Share you story either on our website, email it to us on eteam@specialolympics.ie, or share it on our Facebook page here.


Campbell-by-the-Freeway, CA /DenounceNewswire/ -- February 28, 2002 -- eBay, Inc. (NASDAQ: EBAY) today announced the release of Zero-Click, a patented system for enabling its 40-million users to bid and buy items instantly, without having to even click a button on their mice.
"Zero-Click represents a huge leap forth in usability for our site," said Meg Whitman, eBay's Chief Executive Officer. "Sellers will be thrilled with the increased activity for their items, and bidders will find they're bidding on things they had no idea they bid on!"
The technology behind Zero-Click is simple: when a user moves his or her mouse cursor over a certain area of the screen, the eBay system recognizes this and records the activity as a bid request or as a "buy it now" request, depending on what area of the screen the user mouses over. Every five minutes, the website pops up a window describing all the things a user has bid on or bought. There is no way to back out of a Zero-Click bid or buy-it-now transaction. Users who do not pay are banned from the site and permanently exiled to Yahoo Auctions as punishment.
To prevent users from using the Zero-Click capability by accident, eBay has made available an opt-out feature, available by sending a stamped, self-addressed postcard to eBay's customer support division in Utah and waiting six to eight weeks for activation.
"I can't believe how many things I've bought!" said one eBay buyer, who asked to remain anonymous lest her spouse find out. "It's scary! What used to be just browsing is now buying, by simply moving the mouse around the search results page!"
Some eBay customers are not so happy with the new feature, and have disconnected their mice from their computers. "We're not too concerned about these users," says Whitman. "By next week we'll have ten thousand more customers ready to take their place and buy, buy, buy!"
"It's an interesting feature," quipped Indu Strypundit, an industry pundit. "And good timing -- they had to do something quick to distract Wall Street from their blowing it in the Japanese market."


text:
Oxbridge Academic Programs
A pre-college summer experience in two of Oxford's finest colleges, Pembroke and Corpus Christi
Oxbridge Academic Programs has been offering summer programs in England to adventurous students in grades 8-12 for over 30 years. Students enjoy a genuine Oxford University experience by living and studying in Pembroke College and Corpus Christi College, two prestigious constituent colleges of Oxford University, located close to the famous Christ Church Meadows.
Two four-week courses are available: The Oxford Prep Experience (grades 8-9) and The Oxford Tradition (grades 10-12), while the Oxford Summer Seminars offer programs of a week or more. Students choose two subjects — a Major and a Minor — from a wide range of courses available. Outside of class, students can choose from a wide array of elective extra-curricular activities, as well as guest speakers, workshops, and field trips.
Oxbridge Academic Programs are renowned for their expert academic faculty, which they publish on their website.
Live, dine and study in Corpus Christi College or Pembroke College, Oxford
Enjoy teaching from distinguished faculty members
Immerse yourself in all the sites and sounds of Oxford during free time
Make friends from all over the world!
All tuition and class materials
Accommodation, breakfast and dinner
Full cultural and activities programme, including excursions
Room upgrades to single or ensuite rooms
Single or shared rooms, shared bathrooms
View Provider Website
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Live and study in a prestigious Oxford University college
Teaching in small classes with esteemed academics
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You want a longer stay in Oxford (4 weeks) studying a combination of subjects of your choice with expert faculty members.
Since 2014, Oxbridge has been a part of WorldStrides, a global leader in educational travel and experiences since 1967. We're additionally backed by the resources and knowledge of Envision, an organization that has spent more than 30 years educating high-aspiring elementary- to college-aged students through career, leadership, and technology programs. When you participate in an Oxbridge program, you can rest assured knowing our team has spent five decades establishing a network of support to provide a safe and enriching experience.
Silver Standard Provider
10+ years of running summer schools
Student reviews widely available
Excellent Oxford campuses, including university, boarding school or study centres
Learn with qualified tutors
No. Students: 2000+
Accommodation: Oxford College
Age Range: 14 - 18
Hours of Tuition / wk: 15+
Typical Duration: 4 Weeks
Fees from: £$10,395
Dates: July
Oxford Summer Seminars
Fees: $5,995.00 / 2 Weeks
Dates: July 29, 2023 - August 12, 2023
Destination: Oxford
These twin seminars are condensed versions of our 4-week Tradition program. Participants experience life inside the University of Oxford at…
The Oxford Tradition
Fees: $10,495.00 / 4 Weeks
Dates: July 2, 2023 - July 29, 2023
The program we started in 1986 remains our flagship today. OxTrad students live in the same colleges as undergraduates during…
The Oxford Prep Experience
The Oxford Prep Experience offers all the discovery and learning of the Tradition program to students in grades 8 and…
The Cambridge Tradition
Fees: $5,995.00 / 2 or 4 Weeks
Dates: July 9, 2023 - August 6, 2023
Destination: Cambridge
The Cambridge Tradition is based in Jesus College, whose buildings date back to the twelfth century. Students choose two courses…
The Cambridge Prep Experience
The Cambridge Prep Experience offers all the discovery and learning of the Tradition program to students in grades 8 and…

redpajama_set_name: RedPajamaCommonCrawl


Home Activities & Fun Child Hobby Gives Opportunity To Express Themselves!
Child Hobby Gives Opportunity To Express Themselves!
Does your child have hobbies? Does he participate in extra curricular activities?
Child hobby brings much pleasure to the children around the world.
Children are benefited from child hobby in many ways.
Child hobby gives opportunity to express themselves. It also allows your child to discover himself and build self esteem.
Children having hobbies follow the parents' foot steps. So set a good example by pursuing your own hobby.
Need space for child hobby! Your child needs space for the hobbies. Allot an area designated specifically for child hobby so that he can work there. Some times hobbies can be really messy; you should be ready for the messes.
Once you allot separate area for child hobby, the messy things will not be disturb you and your child can enjoy his work.
Educational tools! Child hobbies are great educational tools. If your child is interested in writing stories, he learns about proper grammar and sentence structure. If your child is interested in rock collecting, he learns geology and science.
Child hobby helps to teach your child to set and achieve goals, make decisions and solve problems. Schools can set the course of your child's interest or careers for what he wants to become later in life.
Be available! You should be available to your child to provide guidance, encouragement and support while he is working with his hobby. You can teach strong work habits, such as proper planning, organization, setting goals and following directions closely as it is a great time for your child.
Nothing is easy! You have to show them that nothing is easy especially when they begin to become frustrated with their advancement. Teach personal responsibility as it is a good time. Show and explain your child that it is important to take care of the work area and the tools of the trade.
Encourage! Encourage your child with child hobby by limiting the activities like playing video games and watching television. When children reach the teenage, they spent more time watching television than sitting in a class room.
You can set the example which is crucial now. Instead of watching a foot ball game on television, switch off the television and work on your own hobby. Your child will join you or works on his own child hobby as a result.
Hobbies can be anything like gardening, music, playing sports, and drawing. Hobbies are rewarding and enrich your child's life.
So, encourage your child to explore his hobbies and allow him to find a hobby of his own. If your child starts pursuing a hobby from young age, he will have outside interest throughout the life.
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When we touch a single piano key, we hear not a single string, but the rich sound of many strings vibrating in harmony. When we touch a single life, the harmony that spreads enriches the lives of many. At Seasons Hospice Foundation we feel privileged to be able to provide help to our patients and their families at such a precious time in their lives.
Our Seasons Hospice teams frequently encounter patients and families whose needs and wishes fall outside of what Medicare, Medicaid and private insurance covers. The examples are many. The cost of airfare to bring an unemployed son to the bedside of his dying mother. Or money to pay utility bills for a family who is desperately trying to care for their dying child and fears a cold home may cause needless suffering. Or orchestrating the quiet celebration of a couple's final anniversary together.
We have learned through the years that you cannot underestimate the huge impact these acts of kindness have on someone's dignity and quality of life. Treating the spirit and the soul are essential in bringing peace and comfort to end of life care.
The Foundation's mission is to meet these unique needs and is made possible through the generous gifts of compassionate donors like you. In doing so, we all touch and enrich the lives of patients and their families.


You can calculate your Kilowatt Hour costs for lighting from your energy bill summary based on a simple formula. Survey your home or business and calculate each lighting fixture power output in kWh and cost associated with them per month. In most cases, the power company will penalize you for using power during peak months and peak hours. Read on to find out how to calculate kWh used for lighting throughout your home or business.
You can calculate how much this single light bulb cost you on your bill. 16.2 kWh x $0.141509 = $2.292446 or about $2.29 used by the light bulb in a 30 day period.
When you are breaking down the cost of your lighting, remember to count all light bulbs if you have a light fixture with multiple light bulbs. Example: A fixture has 5 light bulbs that produce 60 watts. 5 x 60 = 300 watts total for the fixture You can plug this into Step 2 and Step 3 to calculate the kWh use and cost for the total light fixture.
Shaun Juan worked in sales for 10 years before writing full time. He has published articles in Brighthub, Demand Studios, and eHow. He obtained his Bachelor of Science degree in psychology in 2003.
Juan, Shaun. "How to Calculate kWh for Lighting." Sciencing, https://sciencing.com/how-to-calculate-kwh-for-lighting-12195286.html. 26 September 2017.


A marvelously entertaining and moving historical novel, set in rural Prince Edward Island in the nineteenth century, that imagines the young life of spinster Marilla Cuthbert, and the choices that will open her life to the possibility of heartbreak—and unimaginable greatness. Plucky and ambitious, Marilla Cuthbert is thirteen years old when her world is turned upside down. Her beloved mother dies in childbirth, and Marilla suddenly must bear the responsibilities of a farm wife: cooking, sewing, keeping house, and overseeing the day-to-day life of Green Gables with her brother, Matthew and father, Hugh.


A lifelong learner and optimist, Parker developed software for Martin Marietta Aerospace and JPMorgan. He then co-founded financial risk technology company, RiskMetrics Group, unique among Wall Street with the mantra: Change the World, Have Fun and Make Money — In That Order. His next move? He is now CEO of a tech startup called NextThought, an education platform built to connect learners with quality content, a social community, and an environment that encourages and enhances collaboration.


text:
TCU hosts AFC Champions
The TCU football team has gotten accustomed going to bowls. In 2011, TCU is already guaranteed a role in one of the nation's biggest. Justin White has the story.
TCU will take part in a different kind of bowl game in 2011.
The Horned Frogs will lend their facilities to the National Football Leagues's
AFC champion when the Super Bowl comes to North Texas.
Bill Lively, the president and CEO of the North Texas Super
Bowl XVL Host Committee, visited campus Wednesday morning to talk about TCU's
involvement with the process. The AFC champion will stay at the Omni Hotel and
practice at TCU, while the NFC champion will stay in Irving, Lively said.
The committee chose TCU because of the good football
program, indoor practice field and accessible facilities, Lively said.
"It's a good place," he said. "There was no debate about it.
It was an easy choice for the NFL."
This will be the first Super Bowl to split the teams'
practice sites into two different cities, Lively said. The Super Bowl will be a
way of uniting Fort Worth and Dallas together, he said.
"If I-30 is a football field, Fort Worth is the West goal
post and Dallas is the East goal post," he said. "The stadium and Arlington are
the fifty yard line."
Lively spoke as a part of the Neeley School of Business'
Tandy Executive Speaker Series. David Dipple, Director of Development for the
Neeley School, said it will be a great opportunity for TCU.
"I think TCU is going to be on the map for a lot of people
in the community, and much more so than ever before," Dipple said.
Super Bowl XVL is scheduled to be played at Cowboys
Stadium on Sunday, Feb. 6, 2011
See the entire Bill Lively speech athttp://blip.tv/file/2701854
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text:
UKSEDS UK Students for the Exploration and Development of Space
Space Careers
http://www.montauk-monster.com/pharmacy
UKSEDS is looking for a new Exec member!
by Steph Williams on 13th November 2018 in Executive Commitee
YouTube stream: https://www.youtube.com/watch?v=GC7mJ55cVqc
Voting: https://ukseds.org/vote
Andrew, one of our At-Large members of the Executive Committee has stepped down. This means there is an opening on the team, and we'll be holding an Extraordinary General Meeting (EGM) on Thursday 6th December 2018. All UKSEDS members are invited to attend, meet the candidates, and vote.
Notice is hereby given of an Extraordinary General Meeting (EGM) of the Membership of UKSEDS for the election of a member of the Executive Committee in accordance with Sections 11 and 12 of the UKSEDS Constitution.
Joseph Dudley is the returning officer, which means he's running the election but can't vote. Contact him at [email protected] or [email protected] if you have any queries.
The EGM will take place online on 6th December 2018 at 7pm, and will be streamed on YouTube. You will be able to ask questions of the candidates and vote.
If you can't make it, you can still participate by voting. Voting will be open for 48 hours until 8th December at 8pm. Manifestos from all candidates will be shared after the meeting.
The agenda is very simple:
Review of the minutes of the AGM held on 4th March 2018 (this is a formality)
Election of a member of the Executive Committee
Candidates for the role will give a short speech stating why they'd be good for the role and their vision for UKSEDS.
What is the role?
The Exec are in charge of UKSEDS and set our strategy and vision. It's a unique opportunity to gain new skills and build a network and your reputation in the space sector. But it's also hard work, and requires a significant time commitment. If you're interested and would like to know more, you can ask one of the current Exec at [email protected]. You can also find out more about the role here.
How can I vote?
Any member of UKSEDS will be able to vote at ukseds.org/vote
How do I vote if I can't attend?
If you can't attend, but would like to vote you can either:
Appoint a proxy, which means you tell someone to vote in your place.
Vote electronically after the event (you will be able to watch the YouTube recording and vote for 48 hours after the event ends)
How do I run for election?
If you decide you'd like to run, you'll need to prepare a short manifesto explaining why you'd like to run and any skills you can bring to the role. You can either submit your manifesto in advance, or just say it at the meeting. You will also need two other Members to support your nomination.
Applications should be received in this Google Form.
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Almost every small Southern town in America has its go-to burger joint where folks can gather to partake of delicious, juicy hamburgers with all the fixin's, but there are a few burger joints that stand out among the rest – burger joints that have received legendary status among their patrons throughout the years.
If you don't mind going a little off the beaten path for a great burger, then head to Fredericksburg, Texas, to tackle one of the giant burgers at Alamo Springs Café. Regulars suggest trying your burger on a jalapeno bun, and if you're really hungry, try taking the Jefe Challenge, which comes with six half-pound patties, cheese, lettuce, tomatoes, onions, pickles, mustard, and mayo on the famous jalapeno bun. The cost is $25, but if you can eat this monster of a burger in 30 minutes or less, it's completely free. You'll also get an "Honorary Jefe" t-shirt, and your photo will be posted on the Glutton Wall of Fame.
You'll find the best burger in Arkansas at a rustic mercantile store turned restaurant in little town called Scott. Cotham's is best known for its Hubcap Burger – a burger so big (at almost a foot in diameter) that it puts other burgers to shame. As you might imagine, the meat patty is thick, and is placed atop purple onions, tomatoes slices and iceberg lettuce and whatever condiments you choose. While you're there, do yourself a favor, and try the fried pies too.
At Chris Madrid's in San Antonio, Texas, you'll find a restaurant that is part Tex-Mex and part burger joint. This self-proclaimed, "Mecca for burger lovers" does not disappoint. Try the Tostada Bean Burger made with refried beans, onions, and melted cheddar cheese on top of a delicious meat patty, all topped with homemade hot sauce. The Cheddar Cheezy Burger is also a crowd favorite. It's got the toppings of a traditional cheeseburger with mustard, lettuce, tomatoes, onions and pickles, but it's the overflowing mound of Cheddar cheese that sets this one apart from just your average cheeseburger.
Dirty Martin's is exactly what you'd expect of a classic burger joint in Texas, and its got the history to go with it. Dirty Martin's has been serving burgers since 1926. Their meat, bread, and produce, are freshly delivered each day, and their classic, old-fashioned style fits their classic "Kum Bak Burger," named after the original restaurant "Martin's Kum-Bak" and also to honor all their costumers who just keep coming back. The Kum Bak Burger is your classic, greasy, delicious burger with all the trimmings.
If you've never tried a deep-fried hamburger, then just add that to your bucket list, and head to Dyer's Burgers on Beale Street in Memphis, Tennessee. At Dyer's Burgers, they keep it plain and simple, serving up deep-fried beef patties with cheese, mustard, and a pickle. It's the same way they've always done it since they opened in 1912. Sure, eating their burgers may shorten your lifespan, but you'll be hard pressed to find a better tasting burger.
Stepping into Latham's Hamburger Inn in New Albany, Mississippi, is like stepping back in the 1920s with its long counter, swivel stools, and antiquated interior all salvaged from Latham's original railroad dining car location. At Latham's you can expect a deep fried, "doughburger." Don't ask them to share their secret recipe though, because they aren't telling. The only thing better than eating Latham's Famous Hamburger is paying for it. At $2.50 it's a steal of a deal.
Tolly-Ho Restaurant in Lexington, Kentucky, is a favorite of University of Kentucky college students and fans. It's everything a Southern burger joint should be with its pinball machines, laidback atmosphere, and greasy, yet delicious, burgers. Diners can choose from four different signature burgers – the Tolly Ho (a single burger), the Super Ho (a double burger), the Mega Ho (a triple burger) or the Big Tolly (a stacked burger with two pieces of beef and one bun in the middle). All the burgers are served "Ho Style" with Ho sauce, mustard, ketchup, lettuce, and onion. As long as you don't have any beef with UK, you should fit right in.


This small area southwest of Siena encompasses in just a few square kilometres some of the most beautiful cities in Tuscany: Pienza, Monticchiello, San Quirico D'Orcia. Less well known than Chianti, this wonderful valley was declared a World Heritage centre by UNESCO in 2004, and has inspired the most famous Sienese painters from Duccio to Lorenzetti. Among imposing medieval towers, Renaissance masterpieces and some of Tuscany's real jewels of the Middle Ages such as the Abbey of St. Antimo, Val d'Orcia also offers other attractions to the visitor. For example, Bagno Vignoni, famous for its spas and its health centres, and also Montalcino, where they produce the famous Brunello, one of the most celebrated wines in the world. Montalcino Dominated by an imposing castle, Montalcino has preserved its walls, gates and towers of the XVI century, recalling the days when it was the main ally of the Republic of Siena. Montalcino, however, owes its fame mainly to red wines, particularly the Brunello di Montalcino, famous throughout the world. 9 kms from the village is the magnificent Abbey of Sant'Antimo, one of the main Cistercian abbeys in Italy. San Quirico d'Orcia Located in the heart of the beautiful Val d'Orcia, San Quirico d'Orcia is a fortified city well worth a visit. A must see is the Collegiata dei Santi Quirico e Giulietta featuring the beautiful Gothic-Romanesque portals, the churches of Santa Maria di Vitaleta and Della Misericordia, the Praetorian Palace and the Palazzo Chigi. To complete the tour, the Leonini Gardens are splendid examples of Italian gardens, which were created in 1540 by Diomede Leoni. Pienza Pearl of the Italian Renaissance, from an artistic point of view Pienza is the most important city in the Val D'Orcia. Transformed in 1462 as the summer residence of Pope Enea Silvio Piccolomini (Pius II), Pienza is a perfect example of the realization of philosophic and architectural theories of the Renaissance, aimed at creating the "ideal city". Since 1996 Pienza is a UNESCO World Heritage Site. Among the major monuments, the Cathedral and the 15th century buildings (the beautiful Palazzo Piccolomini, Palazzo Borgia and Palazzo Comunale) overlook the splendid Piazza Pio II. This town is also famous for having hosted the sets of famous movies such as "Romeo and Juliet" and "The English Patient." Do not miss the walk on the walls overlooking the Val D'Orcia, a taste of the famous local cheese, and the "pici", which are traditional home-made pasta. Montepulciano Montepulciano, the most important town of the western Val di Chiana, is old and charming, and is built around the beautiful medieval Piazza Grande. Among the most important buildings are the Palazzo Comunale, the Church of St. Augustine and the Tempio di San Biagio by Antonio da Sangallo the Elder, whose dome was inspired by the Renaissance dome of St. Peter. Montepulciano is also famous for its wines, particularly the "Nobile di Montepulciano, known since the eighth century AD and defined in 1549 as "the perfect wine" by the bottler of Pope Paul III Farnese.


Festetics Palace, museum and Helikon library.
The pictures on this page were taken while we were on our cycle tour in Hungary. We cycled south along the western border of Hungary with Austria and arrived at Heviz, famous for its giant outdoor thermal bath, and thence to Keszthely town at the west end of Lake Balaton. The highlight of the sightseeing in Keszthely was the visit to the Festetics Palace, museum& and Helikon library. Surrounded by extensive lawns to the front and a large classic English garden layout at the rear, the imposing building with over 100 rooms, faces east. From the front door you may walk to the right, direct into Keszthely high street.
Entering the building visitors must put on special soft overshoes to protect the wooden floors. The famous Helikon library is upstairs with many old books, plus details about papermaking and book binding.
2. Soft slippers provided to cover your outdoor shoes helps to protect the wooden floor.
3. Painting of horses outside the Palace.
7. One of the many lavishly decorated rooms we visited.
8. Small detail of large ornament. The horse appears to have webbed feet and a tail.
10. Possibly the Queen ?
14. More Books in the Helikon library. There were some very large atlas type books also.
16. There was a small section of the museum devoted to the skills of book making and the repair of old books and manuscripts.
17. The chapel, as seen from the landing in the Festetics Palace.
18. Historic painting in substantial gold frame.
19. My hero with sword, wearing a kilt.
20 White cushioned chair with rounded back.
22. Highly decorated chair and flower vase.
23. Beautiful wood floor, where the public walks, thus the reason for everyone to wear soft covers on their shoes.
24. English style formal garden and flowerbeds at the rear of the Festetics Palace.
26. Keszthely town centre. This is the view directly outside the gate at Festetics Palace. There are a number of pavement cafes and shopping opportunities.


text:
'JAMMEH'S ATTACK ON MANDINKAS CAUSED HIS DOWNFALL'
By Omar Bah
The caretaker leader of the opposition Alliance for Patriotic Reorientation and Construction has for the first time admitted that former President Jammeh contributed to his own downfall after his tribal attacks on Mandinkas.
Speaking on The CheckPoint, a new GRTS programme Fabakary Tombong Jatta said: "Yes, I have to admit that Jammeh's tribal attacks, especially on the Mandinkas contributed dearly to his downfall and that of the APRC in the last Presidential election."
FTJ further disclosed that this unfortunate episode was used to full advantage "by the opposition and haters of the APRC especially those on social media who used it as a propaganda tool during the campaign to tarnish the image of the party and its leader."
'Those remarks by Jammeh seriously eroded the Mandinka support base from the APRC. But notwithstanding I have to say that, Jammeh was not only attacking the Mandinkas, because as a leader he has the right to tell any group or tribe what he feels about them, be it good or bad," FTJ said.
Bad advisers
According to FTJ, the remarks Jammeh made about Mandinkas among other things were only possible because he was wrongly advised by some disgruntled people who were only interested in saving their positions and not the country or the party.
"Even for the smallest mistake, there is someone waiting to report you to the office of the president; even cleaners were at some point reported there. So, these among so many other things misled the former president," FTJ added.
The APRC leader said Gambians should understand that the former government and the system that everyone is blaming the APRC for, was not built by the APRC alone, but others who are opposition to the former regime but were working under Jammeh.
Contact with Jammeh
On whether they are communicating with Jammeh, Mr Jatta said that will remain private but he was quick to say that former President Jammeh until now, has not contributed a single butut to the running of APRC.
He said APRC is running smoothly and that there is no power struggle or whatsoever in the party.
"It will surprise you to know that, we are very proud to be in the opposition, because it will give us the chance to assess others in government so that if we return, we will be able to rectify our mistakes," he said.
On his assessment of the coalition government so far, Mr Jatta said it is regrettable that the government is not taking advantage of the opportunities availed to them.
He said the only thing the Barrow administration can be proud of is their ability to secure funding from the West, "but it is sad to say that the effects of those funds are not seen yet."
Jatta said the only thing APRC regret is the fact that they were not able to empower the party faithful to give Jammeh the right advice.
Former President Jammeh, Mr Jatta said was not as difficult as many people thought he is, "because if you talk to him he will listen especially if you have your facts."
ATTACK .MANDINKAS
jammeh's
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text:
Proud Lion Heaton Underlines Clarets' Strength
Tom Heaton believes international calls show Burnley progress as captain prepares for first England start
Tom Heaton believes the booming number of international players at Turf Moor proves the Clarets are going places as he prepares to make his first England start.
Heaton will line up against France in Paris tonight as the Burnley goalkeeper and captain wins his third cap for his country.
Heaton's promotion to Gareth Southgate's starting line-up follows a full England debut for team-mate Michael Keane earlier in the season.
That bridged a 43-year gap since Martin Dobson became the last Burnley player to start a game for England.
And a proud Heaton is delighted to be following in their footsteps as the Clarets continue to grow on the international stage.
"It's a good marker," he told FATV.
INTERNATIONAL | Tom Starts For England
Tom Heaton speaks with FATV. [Full Interview]
"Since I signed four years ago, the club has moved on in leaps and bounds.
"We had a successful season in the Championship and then got relegated from the Premier League, but as a club we were moving things forward.
"There were a lot of things going on in the background with the infrastructure and planning, and I think that stood us in good stead to go and win the Championship and retain our Premier League status this season.
"We have a lot of internationals at the club now, which is a good sign."
The calf injury sustained by Keane during the end-of-season run-in has kept him out of the current round of international games.
But last weekend Clarets' striker Sam Vokes won his 50th cap for Wales and Burnley had four starters in the Republic of Ireland side which drew with Austria in a World Cup qualifier.
Heaton was on the bench as England drew 2-2 in Scotland but Southgate confirmed that the 31-year-old will replace Joe Hart and play the first half of Tuesday night's friendly at the Stade de France.
Heaton's promotion after winning two previous caps as a substitute follows an 'outstanding season' – according to England boss Southgate – and comes just seven years after he was loaned out by Manchester United to League Two side Rochdale.
"I am a big believer in everyone takes their own journey," added Heaton, who became Sean Dyche's first signing as a Burnley manager when he arrived on a free transfer from Bristol City in May, 2013.
"That certainly feels true for me. I am a little bit older coming into the set-up but I try not to let that hold me back.
"I have played across all four divisions but it never left me, that hunger and ambition to play for England.
"It may have felt a long way off for other people at certain times, playing down in League Two, but I never lost that belief.
"It's a different sort of journey from a lot of other lads but I am quite proud of that journey.
"I like to think it stands me in good stead in terms of experience and perhaps the mental side of it.
"When you set out in a career in football, playing for England encapsulates what you visualise and I am certainly no different from that.
"Belting out the national anthem with that shirt on will be a fantastic moment. It's a really proud moment.
"It (the goalkeeping department) is strong at the moment and I'm delighted to have got the nod. I'm really excited and looking forward to the game."
Tom Heaton


text:
Crnoštica (Servisch cyrillisch Црноштица; Bulgaars Църнощица) is een plaats in de Servische gemeente Bosilegrad. De plaats telt 190 inwoners (2002).

Plaats in Servië

redpajama_set_name: RedPajamaWikipedia


While his best-known work is featured in New X-Men, he has a very diverse repertoire, moving between traditional pencils and inks to fully painted panels. Because of his speed as an artist, at his peak, he was producing artwork for three or four monthly books at the same time.
Igor Kordey (born 1957) is a Croatian comic book artist.
His artistic output has been relatively light in recent years. He was announced to be joining Chris Claremont (with whom he has collaborated on X-Treme X-Men) on a 2004 relaunch of Excalibur, but was replaced by Aaron Lopresti before its debut, even though he was already well into drawing the second issue. He has suggested that it may have had to do with disagreements with management.


text:
const fs = require('fs');

function summarizeFilesInDirectorySync(directory) {
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exports.summarizeFilesInDirectorySync = summarizeFilesInDirectorySync;

redpajama_set_name: RedPajamaGithub


text:
Seeking the Cave
A Pilgrimage to Cold Mountain
James P. Lenfestey
"Lively and profound." —GARY SNYDER
Born and raised with the kind of expectations that often accompany privilege, Jim Lenfestey approached his thirtieth birthday in a state of acute anxiety. A young family and a demanding work life on one hand, and a burgeoning love for poetry on the other.
When an independent bookseller discerns Lenfestey's difficulties, and prescribes for a remedy the poems of a Chinese hermit named Han Shan, Lenfestey's life is changed forever. After "swallowing the poems like aspirin" for the next thirty years, a spirited embrace of this ancient poet called Cold Mountain—the poet he has come to see as a guiding light in his life—prompts Lenfestey to travel to China on a pilgrim's search for his cave. Along the way, this quest takes our author first to Tokyo, where he visits with the foremost translator and scholar of eastern poetry, Burton Watson, and from there across China, from the enormous chanting hall of ten thousand Buddhas in Bailin Temple to the birthplace of Confucius.
A singular combination of travel writing, memoir, translation, and poetry, Seeking the Cave is both deeply personal and universally illuminating. "Uniting our brief literary life with the ancient richness of Chinese culture" (Robert Bly), this extraordinary book evokes the transformative power of poetry, and the way it breathes meaning into our lives.
ancient, asian poetry, buddhist nuns, chinese culture, chinese history, chinese poetry, cold mountain poems, cultural landmarks, foodstuffs, friendships, geography, han shan, heavenly landing, hermit, identity, inner life, japan, kyoto, landscapes, language, literary backcountry, literary history, Midwest, mythical, narrative, personal memoir, pilgrimage, poet, prose, quest, road trip, scholars, shrine, solitude, spiritual journey, tang dynasty, tiantai mountains, tokyo, translators, travel books, travelogue, voyage, writer, zen temples
Watch: Behind the Book: James Lenfestey on Seeking the Cave | Milkweed Editions
James P. Lenfestey is the author of Seeking the Cave: A Pilgrimage to Cold Mountain, a Minnesota Book Award finalist, and multiple collections of essays and poems, including A Marriage Book. He is chair of the Literary Witnesses poetry series, teaches at the Mackinac Island Poetry Festival, and lives in Minneapolis with his wife.
"A lively, profound, and profoundly personal book. It's very captivating, warm and friendly, personal, unguarded, idiosyncratic, pointed but also finally apolitical, and eminently charming."
"A beautifully crafted volume of personal discovery, travel, and poetry."
Shelf Awareness
"Full of vivid characters and poetry and coincidence, delivered against the landscapes of a foreign culture, James P. Lenfestey's delightful story of pilgrimage to the source of Cold Mountain's poetry possesses great bravado, attentiveness, and honesty."
Tony Hoagland
"James P. Lenfestey's ranging, big-hearted book of pilgrimage and quest recounts the meeting of two poets, one a twentieth-century American, the other a surprisingly gregarious Tang Dynasty hermit known for both his poems of deep solitude and the warmth of his friendships. Seeking the Cave intertwines landscape and language, poetry and prose, foodstuffs and culture, and above all, the explorations of inner life made outward, step by step, on the steep paths of China's cities and mountains."
Jane Hirshfield
"Seeking the Cave is part travelogue, part literary history, and part spiritual journey. James P. Lenfestey is a lively and entertaining tour guide. Modest, funny, curious, and wide open to the world, he gives us perceptive glimpses of Chinese culture, ancient to contemporary, and into what it means to be a poet, both now and twelve centuries ago. The account of his quest to find Han-shan's cave is a delight from beginning to end."
Chase Twichell
A Marriage Book
From James P. Lenfestey, a collection of poems that lends delicacy and gentle humor to durable, long-lasting love.
Elizabeth Rush
An astonishing, vital book about Antarctica, climate change, and motherhood from the author of Rising, finalist for the Pulitzer Prize in General Nonfiction.
A Darker Wilderness
Erin Sharkey
A vibrant collection of personal and lyric essays in conversation with archival objects of Black history and memory.
Rising weaves the firsthand accounts of those who are living through sea level rise today with eyewitness reporting from our shoreline's disappearing places.
Juliet Patterson
A sublimely elegant, fractured reckoning with the legacy and inheritance of suicide in one American family.
Kazim Ali Wins the 2022 Banff Mountain Book Award for Environmental Literature
0c44c2bab1abf6bf28463a4b8441eba26dccd851.jpg Milkweed Editions is thrilled to announce that Northern Light: Power, Land, and the Memory of Water by Kazim Ali...


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I don't know how other writers work, but my revision process is not linear—especially not once I get outside feedback from my critique partners (CPs). Lately I've found myself nearly getting lost in iterative loops as I keep refining chapters. I can hardly remember what I've added (or subtracted) where, and which clarifications have been made to allow a later section to make sense as originally written (or did that section already get cut out anyway?).
It's those blasted fuller descriptions that are at fault. It all makes sense to me; why does a reader need to be told? (Oh yeah… That whole "outside my head" thing again.) You mean someone actually wants to read the details that I purposely glossed over during my hurried first draft and failed to elaborate on later because I didn't make any notes? Bother. Well, fine. I can do that. I'll just add a little something here. Don't worry—I've added something in an earlier chapter to fix that other problem, so this fix will make sense here, even though it's not as much as you wanted.
The problem with iterative revisions, I've found, is that I go in so many circles in a single chapter that I lose the overall thread of the story—or at least of character development. Sprinkling breadcrumbs back through previous chapters doesn't necessarily leave me with a coherent trail because I've scuffed over the turf so often.
So now what? Well, I've decided it's time to try larger circles—a bigger chunk of text as the piece that gets polished as a single entity. Instead of working on single chapters consecutively, going back to previous ones as I get feedback until I'm changing details within minutes of CP comments (not necessarily as productive as it might sound!), I'm going to bite off a chunk of several previously revised chapters instead.
The idea is that with a larger segment of the overall story arc to consider, I'll be better able to see the direction of its flow. Did I leave a huge sandbar in the middle where the narrative runs dry, only to pick up on the other side, rushing ahead without looking back? Or have I meandered so far off course I've created an oxbow bend that could just as well have been bypassed entirely?
Whatever the case, I hope the ride smoothes out; I'm getting awfully dizzy.
Posted on 11 June 2013, in Writing Process and tagged Fantasy, Fiction, Revision, Writing. Bookmark the permalink.	Leave a comment.


T2-weighted sagittal MRI of lumbosacral spine: Shown is tract in subcutaneous layers (left) and intramurally (right).
Cutaneous dimple of dermal sinus tract: Shown is the dimple of a dermal sinus tract just above the gluteal fold.
The cutaneous dimple is removed by elliptically incising the dermal layer around it. The incision is then extended down to the spinal fascia taking care not to cut through the sinus tract.
The spinous processes and lamina overlying the intramural portion of the dermal sinus tract are then exposed.
The lamina can be freed from the lateral elements of the spine in a fashion that allows their reattachment at the time of wound closure.
The dura is opened elliptically around the sinus tract and then extended rostrally to expose the length of the intramural component of the sinus tract.
After the tract is removed the film terminale is sectioned.
The dura is closed. The lamina can be reattached to the spine and the incision then is closed in the routine manner.


The Xperia L received the Android 4.2.2 update today. Android 4.2.2 15.3.A.0.26 firmware is a major update for the Xperia L, the previous version of the handset was android 4.1.2 15.0.A.2.17 firmware, and it is confirmed in regions such as Indonesia, India, Philippines, Central Europe and is available over PC Companion as well as via SUS.
The Xperia L will contain all the stock android 4.2.2 features which other Xperia smartphones got in this 700 Mb update, as well as updated media apps such as a new camera app, Walkman, Album and a UI refresh.
Add more widgets in home screen and lock screen now.
Superior auto mode ( auto scene recognition ) and Burst Mode feature added in Camera interface. Camera is certainly improved a lot in this update.
Transparent status bar and dock at the bottom part on home screen.
Users who are hoping for an Android 4.3 update in the near future will also take into consideration the fact that the Xperia L is a mid-range handset, so don't get your hopes up just yet.
Thank you Xperia Guide and NextPowerUp for providing us with this information.


The beautiful maiden motif on this Pewter Butter Dish is pure Art Nouveau. The design is found on silver by Kate Harris for William Hutton of Sheffield. Some of Harris's designs were later produced by Huttons in pewter, with Connels of Cheapside being retailers for Hutton. Marked 'Connell' to underside.
With lid and glass liner, Circa 1910.
Stephen Pudney, "Katie Harris: Mystery Woman of English Art Nouveau." The Journal of the Decorative Arts Society 1850 – the Present, no. 39, 2015, pp. 40–57. The maiden motif illustrated on a silver vase, p. 40.


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Powder Mill Group; Kallander Creek Volcanics
Basalt, andesite and lesser rhyolite flows. Basalt flows near base of the formation contain plagioclase phenocrysts, some in radiating clusters
Middle Proterozoic
Lithologic constituents
Igneous > Volcanic > Mafic-volcanic > Basalt (Flow)Basalt, andesite and lesser rhyolite flows. Basalt flows near base of the formation contain plagioclase phenocrysts, some in radiating clusters
Igneous > Volcanic > Mafic-volcanic > Andesite (Flow)Basalt, andesite and lesser rhyolite flows. Basalt flows near base of the formation contain plagioclase phenocrysts, some in radiating clusters
Igneous > Volcanic > Felsic-volcanic > Rhyolite (Flow)Basalt, andesite and lesser rhyolite flows. Basalt flows near base of the formation contain plagioclase phenocrysts, some in radiating clusters
Davis, D.W., and Green, J.C., 1997, Geochronology of the North American Midcontinent rift in western Lake Superior and implications for its geodynamic evolution: Canadian Journal of Earth Sciences, v. 34, pp. 476-488.
Zartman and others, 1997, U-Th-Pb zircon ages of some Keweenawan Supergroup rocks from the south shore of Lake Superior: Canadian Journal of Earth Sciences, v. 34, p. 549-561.
Cannon, W.F., Kress, T.H., Sutphin, D.M., Morey, G.B., Meints, Joyce, and Barber-Delach, Robert, 1997, Digital Geologic Map and mineral deposits of the Lake Superior Region, Minnesota, Wisconsin, Michigan: USGS Open-File Report 97-455 (version 3, Nov. 1999), scale 1:500,000.
https://pubs.er.usgs.gov/publication/ofr97455
NGMDB product
NGMDB product page for 10177
Ashland - Bayfield - Iron


Polycarbonate not Acrylic like others on the market.
Installs in minutes without any cutting or drilling.
Keep the rain and unwanted noise out without losing your rear vision. Constructed from Durable Hard-Coated polycarbonate, the cab back is contoured for a custom fit. Reduces dust and swirl in the cab. Tool-less removal and installation in minutes.
Pair it with the EMP® Hard-Coated front windshield # 13083. Also, works with the factory plastic top.
NOTE: on the General 1000-4 (four seater) you will not be using the bottom two clamps.


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Where to Stream the 2020 Oscar-Nominated Movies
There were snubs aplenty this year, but there are still a bunch of movies worth your time.
By Brady Langmann and Adrienne Westenfeld
Wouldn't it be nice if someone would collect all of the Oscar-nominated movies in one tidy, easily-streamable place? It sure would, but until that happens, we'll all be stuck cobbling together our "to watch" lists from various streaming platforms. If you're looking to get caught up before the Oscars on February 9th, look no further—here's how to stream everything you need to watch. But, while you're at it, don't forget to also stream the incredible films snubbed by the Academy this year.
Nominated for Best Actor (Adam Driver), Best Actress (Scarlett Johansson), Best Supporting Actress (Laura Dern), Best Score, Best Picture, and Best Original Screenplay.
Nominated for Best Supporting Actor (Al Pacino), Best Supporting Actor (Joe Pesci), Best Cinematography, Best Costume Design, Best Director (Martin Scorsese), Best Editing, Best Picture, Best Production Design, Best Visual Effects, and Best Adapted Screenplay.
Nominated for Best Actor (Jonathan Pryce), Best Supporting Actor (Anthony Hopkins), and Best Adapted Screenplay.
Once Upon A Time...In Hollywood
Nominated for Best Actor (Leonardio DiCaprio), Best Supporting Actor (Brad Pitt), Best Cinematography, Best Costume Design, Best Director (Quentin Tarantino), Best Picture, Best Production Design, Best Sound Editing, Best Sound Mixing, and Best Original Screenplay.
Nominated for Best Actor (Joaquin Phoenix), Best Cinematography, Best Costume Design, Best Director (Todd Phillips), Best Film Editing, Best Makeup & Hairstyling, Best Original Score, Best Picture, Best Sound Editing, Best Sound Mixing, and Best Adapted Screenplay.
Nominated for Best Actress (Renee Zellweger) and Best Makeup & Hairstyling.
Hulu Amazon iTunes
Nominated for Best Animated Film.
Nominated for Best Animated Film and Best Original Song.
Nominated for Best Documentary.
Nominated for Best Documentary and Best International Film.
Nominated for Best Cinematography.
Nominated for Best Visual Effects.
Nominated for Best Original Song.
Nominated for Best Sound Mixing.
Adrienne Westenfeld Assistant Editor Adrienne Westenfeld is a writer and editor at Esquire, where she covers books and culture.
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