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Ulcerative Colitis
David J. Maron, MD, FACS
Assistant Professor of Surgery
Division of Colon and Rectal Surgery
University of Pennsylvania School of Medicine
Philadelphia, PA
Epidemiology and Etiology
Ulcerative colitis (UC) is an idiopathic chronic inflammatory disease affecting the mucosa of the rectum extending proximally to affect a variable length of the colon. In the United States and Northern Europe, the incidence varies between 2 and 10 cases per 100,000 person per year, with a prevalence of between 35 and 100 per 100,0001. The disease may affect all ages, but it predominates in young adults 20-40 years of age. Males and females are affected equally.
Inheritance may often play a role in the etiology of UC. Investigators have reported a positive family history in as high as 29% of individuals with UC2. Ulcerative colitis is not inherited in a Mendelian pattern, however genetic predisposition may be influenced by diet, smoking cessation, breast feeding, and oral contraceptive use3-5. History of appendectomy may also influence the development of UC. Compared with patients without prior appendectomy, appendectomy before diagnosis delays disease onset and gives rise to a milder disease phenotype in ulcerative colitis6. Cigarette smoking has also been shown to affect the incidence of ulcerative colitis4. While smokers tend to have a higher incidence of developing Crohn's disease, non-smokers and former smokers appear to be at increased risk of developing UC.
The pathogenesis of ulcerative colitis remains unknown, but it has been theorized that it is triggered by an environmental stimulus7. An enormous amount of work has been dedicated to identify the antigen(s) that trigger the immune response, however, no specific pathogen has been isolated consistently. Many theories have been presented including infection, autoimmune mechanisms, and allergy to dietary components.
Clinical Presentation
The most common symptoms of ulcerative colitis include diarrhea and rectal bleeding. Patients may also complain of crampy abdominal pain, fever, malaise, passage of mucus, weight loss, and symptoms related to extraintestinal manifestations. The severity of the patient's symptoms typically correlates with the severity of the disease. Physical findings are usually nonspecific and depend on the severity of the disease. Development of abdominal distention, tachycardia, fever, and leukocytosis may signify the onset of toxic megacolon.
Ulcerative colitis begins in the rectum and progresses proximally. Macroscopic changes are generally most severe in the rectum, unless the rectum has been treated with steroid or 5-ASA enemas. With severe inflammation, the mucosa appears granular, friable, and may show areas of pronounced deep ulcerations. Pseudopolyps may be present as a result of regenerating epithelium, and represent islands of intact mucosa that become elevated secondary to ulceration of the surrounding mucosa. Progression from the rectum to the colon is variable; in study of 1116 patients, 46% had proctosigmoiditis, 17% had left-sided disease (to the splenic flexure), and 37% had pancolitis at the time of presentation1. Patients in this study presenting with pancolitis were more likely to develop refractory symptoms, toxic megacolon, malignancy, and extraintestinal manifestations.
Microscopically, the lamina propria, crypts, and surface epithelium are infiltrated by polymorphonuclear leukocytes (PMNs). Cryptitis occurs when PMNs are present within the epithelium of the crypts, and crypt abscesses form from aggregates of PMNs within the crypt lumina. Several other features may help to establish a diagnosis of UC or to evaluate the severity of the condition, including mucosal atrophy, mucin depletion, Paneth-cell metaplasia, and diffuse thickening of the muscularis mucosa. Fulminant ulcerative colitis may show deep ulcers that extend into the muscularis propria and may be associated with muscle necrosis.
Management of ulcerative colitis will vary depending on the severity of the attack, and it is therefore important to assess the extent and severity of the disease with each presentation. A system to categorize attacks as mild, moderate, or severe was proposed by Truelove and Witts8. The degree of severity is based on six clinical signs: diarrhea, presence of blood in the stool, fever, tachycardia, anemia, and elevated erythrocyte sedimentation rate. A scoring system developed at the Mayo Clinic based on stool frequency, rectal bleeding, findings of flexible proctosigmoidoscopy, and the physician's global assessment is often used in determining the response to treatment in study groups9.
The diagnosis of ulcerative colitis is based on the combination of clinical presentation, endoscopic appearance, and biopsies of the colonic mucosa. Proctoscopy or flexible sigmoidoscopy is often sufficient in obtaining tissue for diagnosis. Colonoscopy may result in perforation during the acute attack and is therefore relatively contraindicated, however patients should undergo full evaluation by colonoscopy or barium enema once recovered from the acute presentation. Stool cultures should be obtained to rule out an infectious cause of colonic inflammation, and biopsy specimens should be analyzed by a pathologist to conform the diagnosis of UC. If the diagnosis is still in doubt, a small bowel series or CT enterography should be performed to asses the remainder of the intestine for lesions characteristic of Crohn's disease. Approximately 15% to 20% of patients with severe ulcerative colitis have an associated "backwash ileitis", characterized by a fixed, patulous ileocecal valve and a dilated, granular terminal ileum on double-contrast barium studies10 or colonoscopy.
The differential diagnosis of ulcerative colitis includes Crohn's disease, infectious colitis, pseudomembranous colitis, ischemia, radiation colitis, and collagenous colitis. It is imperative to obtain a detailed medical history to achieve a correct diagnosis. It may be very difficult to differentiate between UC and Crohn's disease, however rectal sparing and a history of perianal sepsis may help, and small bowel involvement obviously indicates Crohn's. Infectious colitis secondary to E. coli, Campylobacter, Salmonella, or Entamoeba histolytica, is typically characterized by a sudden onset and a self-limited course. Pseudomembranous colitis secondary to C. difficile overgrowth results in yellowish, plaque-like membranes on the inflamed mucosa which may be seen on sigmoidoscopy. A history of recent antibiotic use and identification of the C. difficile toxin in the stool aid in diagnosis. Ischemic colitis is typically seen in older patients, has a sudden onset, and is often painful; rectal involvement is rare. Collagenous colitis also tends to occur in older patients, and results in watery diarrhea. The colonic mucosa in patients with collagenous colitis appears grossly normal, but histologic examination shows an eosinophilic band of subepithelial collagen and a mild chronic inflammatory infiltrate in the lamina propria.
Extraintestinal Manifestations
Extraintestinal manifestations of ulcerative colitis include primary sclerosing cholangitis (PSC), erythema nodosum, pyoderma gangrenosum, arthritis, ankylosing spondylitis, and ocular complications such as episcleritis and uveitis. PSC occurs in as high as 7.5% of patients with UC, and results in fibrosis of the intra- and extrahepatic bile ducts. It is more common in men and tends to occur in patients under the age of forty. Ulcerative colitis patients with either the HLA-B8 or HLA-DR3 haplotype have been estimated to have a 10-fold increase in the relative risk of developing PSC11. Proctocolectomy has not been demonstrated to alter the course of PSC12. Erythema nodosum is a classical dermatological manifestation which presents as inflamed, red, and tender nodules, mainly in the anterior part of the lower legs. It has been reported that the prevalence of erythema nodosum in UC is between 10%-20%13. Development of pyoderma grangrenosum is related to active colonic inflammation; the lesions begin as plaques or pustules, afterwards ulcerating and becoming very painful. This is a rare condition, occurring in only 1%-2% of patients with UC. Joint involvement in enteropathic arthritis has been divided in two patterns: (1) peripheral arthritis, and (2) axial involvement, including sacroiliitis with or without spondylitis14. In one study, 3.6% of all patients with UC had more than one episode of arthritis15. Peripheral arthropathy tends to coexists with the underlying bowel disease activity and is associated with an increased incidence of erythema nodosum and uveitis. Ophthalmologic manifestations of UC are reported in 1.6% to 4.6%16. Uveitis presents as a painful eye, with blurred vision, headache and photophobia; episcleritis presents as a red, painful eye without loss of vision17. These occur in less than 10% of patients with ulcerative colitis.
Colorectal Cancer in Ulcerative Colitis
One of the most serious sequelae of ulcerative colitis is the development of colorectal carcinoma. The most important risk factors include prolonged duration of the disease, pancolonic disease, continuously active disease, and the severity of the inflammation. The cumulative risk for cancer increases with the duration of the disease, reaching 2% at 10 years, 8% at 20 years, and 18% at 30 years18. Patients with disease confined to the left side of the colon have a lower risk of developing carcinoma than those patients with disease involving the entire colon.
There is considerable debate regarding the optimal method of surveillance colonoscopy in patients with ulcerative colitis. The American Cancer Society recommends surveillance colonoscopy every one to two years beginning 8 years after the onset of pancolitis and 12 to 15 years after the onset of left-sided colitis. Several studies have recently suggested that at least 30 biopsies be obtained to rule out the presence of dysplasia.
A recent meta-analysis of twenty prospective studies was performed to determine the relative risk of developing cancer in patients with low-grade dysplasia19. When low-grade dysplasia was detected on surveillance, a nine-fold risk of developing cancer was seen, and there was a twelve-fold risk of developing an advanced lesion. Patients therefore need to be counseled about the potential for dysplasia so that they can rationally take part in their management. When high-grade dysplasia is found and has been confirmed by a second independent pathologist, proctocolectomy should be recommended. This is also true for patients who harbor a dysplasia-associated lesion or mass (DALM). If low-grade dysplasia is confirmed, strong consideration should also be given to proctocolectomy.
Medical TherapyMedications remain the primary treatment of ulcerative colitis. The goal of treatment is directed at inducing and maintaining remission of symptoms and mucosal inflammation. The approach to therapy is determined by the extent of involvement and the severity of the disease at the time of presentation. Several types of medications are useful in treating ulcerative colitis. These include aminosalicylates (sulfasalazine, olsalazine, mesalamine, balsalazide), corticosteroids (prednisone, budesonide), and immunosuppressants (6-mercaptopurine, azathioprine, cyclosporine, infliximab).
The mainstay of treatment of patients with disease limited to the rectum is 5-ASA suppositories. Mesalamine suppositories 1-1.5 g/day have been shown to be superior to oral 5-ASA therapy and to steroid enemas20. For patients who do not respond within 4 to 6 weeks, combination therapy with a topical corticosteroid (foam or enema) has been shown to be superior to either therapy alone21. For patients who are not able to tolerate topical therapy, oral mesalamine can be used as an alternative.
Mild to Moderate Distal ColitisMild to moderate involvement of the distal 30 to 40 cm of distal colonic mucosa is best treated with 5-ASA enemas or hydrocortisone enemas. Treatment is initiated with a single nightly mesalamine enema 4g/60 ml and remission rates average 70% within 4 weeks. If symptoms persist, an additional mesalamine enema or hydrocortisone enema may be added in the morning. Combination therapy with mesalamine enemas and hydrocortisone enemas has also been shown to be superior to either therapy alone22. Corticosteroid enemas include hydrocortisone foam or enemas containing budesonide, a second generation corticosteroid with a high first-pass metabolism in the liver which has fewer steroid-related side effects; both are equally effective23. For those patients who do not tolerate or refuse topical therapy, oral 5-ASA preparations are an effective alternative.
Mild to Moderate Extensive Colitis
Patients with mild to moderate extensive or pancolitis with require pharmacologic therapy with an oral 5-ASA medication. Oral sulfasalazine at dosages of 2-6 g/day will achieve remission is as high as 80% of patients, however a substantial number of patients are unable to tolerate high doses of the medication. Newer formulations of 5-ASA are better tolerated, and have been shown to be equally effective24. Topical mesalamine or topical corticosteroids may be added to control rectal symptoms. For patients with more severe colitis who do not respond to oral 5-ASA, oral corticosteroids may be added in an effort to achieve remission. In patients who do not respond to oral corticosteroids, treatment with 6-MP or azathioprine may be considered. Therapy is usually initiated with a dose of 50 mg/day, and steroids should be maintained initially because a therapeutic response may not occur for three to six months.
Severe or Fulminant ColitisPatients with fulminant colitis typically present with high fever, severe abdominal pain, tenderness, tachycardia, and leukocytosis. These patients require hospitalization with intravenous hydration, bowel rest, high-dose intravenous steroids, and broad-spectrum antibiotics. Infectious colitis should be ruled out by obtaining stool cultures and C. diff toxin. Intravenous hyperalimentation may be useful depending on the patient's nutritional status and length of illness prior to the fulminant episode. Patients should be closely monitored with serial abdominal exams, abdominal radiographs, and leukocyte counts. Deterioration or lack of improvement within 48 to 72 hours of the initiation of medical treatment warrants an urgent procedure, as the mortality is increased four-fold in patients with colonic perforation.
Intravenous cyclosporine can also be used in the treatment of severe, steroid-refractory ulcerative colitis. It is typically given as a continuous infusion of 2-4 mg/kg/day, and has been shown to have a response rate as high as 82%25. Cyclosporine should not be administered to patients with active infection or a history of seizures.
Infliximab, a monoclonal antibody against tumor necrosis factor, has also been shown to be effective in the treatment of severe ulcerative colitis. Two large, randomized, double-blind, multicenter trials (ACT 1 and ACT 2) were conducted in which patients received placebo or infliximab (5 or 10 mg/kg) intravenously at weeks 0, 2, and 6 and then at eight week intervals26. At week 8, between 64-69% of patients receiving 5 mg/kg infliximab and 61-69% of patients receiving 10 mg/kg infliximab demonstrated a clinical response, versus 29-37% of patients who received placebo. In addition, patients treated with inflixmab were more likely to have a clinical response at week 30. Ongoing trials are evaluating the use of infliximab and other anti-TNF antibodies in maintenance therapy of ulcerative colitis.
Surgical Therapy
Emergent Surgery Fulminant disease occurs as the initial presentation of UC in up to 50 percent of cases27,28, and up to twenty percent of patients will require urgent or emergent surgery for acute complications29. Potentially fatal complications of UC necessitating surgery include fulminant colitis, toxic megacolon, and massive hemorrhage. Toxic megacolon is a life-threatening variant of toxic colitis in which the dilation of the colon has progressed to the point of imminent perforation. Massive hemorrhage from UC is a less common complication, occurring in up to 4.5 percent of cases30, and approximately 10 percent of all emergency colectomies for patients with UC are performed for massive hemorrhage31.
Although the safety of a single-staged ileoanal reservoir in the acute setting has been reported32, both proctectomy and anastomosis are generally contraindicated in the acutely ill patient with an unprepared bowel. Total proctocolectomy in the urgent setting carries a prohibitively high mortality rate28,33, and the leak rate from a primary anastomosis is unacceptably high34,35. A total abdominal colectomy with ileostomy is therefore the preferred operation for these situations. This procedure can be expeditiously performed with relatively low morbidity and mortality, and it is a non-committal procedure that serves the main purpose of removing the diseased colon while leaving the rectum behind. Moreover, this is particularly important in patients in whom the diagnosis of UC is unclear (indeterminate colitis) and a subsequent ileoanal reservoir might be contraindicated.
The "blowhole" procedure was a popular procedure for the treatment of toxic megacolon prior to the availability of intensive care units and parenteral nutrition. This technique involved the creation of a loop ileostomy with an antimesenteric transverse colostomy36. This procedure limited handling of the bowel and thus the chance for fecal contamination during dissection, but was contraindicated in the presence of free perforation.
Elective Surgery Indications for elective surgery for ulcerative colitis include intractable disease, complications of medical therapy, dysplasia, carcinoma, and occasionally for attempted improvement of extraintestinal manifestations. Patients with intractable disease have persistent symptoms such as crampy abdominal pain, frequent bowel movements, and stool urgency which may result in the deterioration of patient's social and professional lives37. Complications of long-term steroid therapy, such as diabetes mellitus, avascular necrosis of the femoral head, cataracts, psychiatric problems, osteoporosis, and weight gain are a frequent indication for surgical resection, despite the fact the patient's UC may be under control. The finding of carcinoma is an absolute indication for surgery; patients who are found to have any dysplasia or carcinoma should be treated by colectomy38,39.
A less common indication for elective surgery in UC is for the treatment of debilitating extraintestinal manifestations of the disease. Pyoderma gangrenosum, erythema nodosum, peripheral arthritis, and uveitis should regress spontaneously postoperatively, however, sclerosing cholangitis and ankylosing spondylitis will not. Therefore, elective surgery should be considered in patients with colitis and significant extracolonic manifestations refractory to nonoperative measures40.
Elective surgical options for UC include total proctocolectomy with either an end ileostomy or continent reservoir (Kock pouch), total abdominal colectomy with an ileoproctostomy, or a restorative proctocolectomy with an ileoanal reservoir. Each procedure has its advantages and disadvantages, and selection of a specific operation must take into account the age and overall health of the patient, the presence of dysplasia and risk of carcinoma, the status of the patient's anal continence, and the certainty of the diagnosis of UC.
Total Proctocolectomy with End IleostomyTotal proctocolectomy has the advantage of removing all possible diseased mucosa, thereby preventing further inflammation or the potential for progression to dysplasia or carcinoma. Total proctocolectomy with end ileostomy was one of the earliest operations performed for UC, and despite advances in sphincter-saving procedures continues to have a role. Elderly patients, those with poor sphincter function, and patients with carcinomas in the lower rectum may be candidates for this procedure.
Total Proctocolectomy with Continent IleostomyThe continent ileostomy was introduced by Kock in 196941 and became very popular in the 1970s as it offered patients with an ileostomy control over evacuation. Its creation involves suturing several limbs of ileum together to create a reservoir; the pouch becomes continent by intussuscepting the outflow tract to create a valve. As the pouch distends, pressure over the valve causes it close and retain stool, allowing patients to wear a simple bandage over a skin level stoma. Between two and four times per day, the patient introduces a tube through the valve to evacuate the pouch.
The major problem with the Kock pouch is the high reoperation rate, required in up to 50 percent of patients42. The most common surgical procedure required is revision of the nipple valve43, typically when one side of the valve "slips," or loses its prolapsed position within the pouch. This leads to either the inability of the pouch to remain continent or the inability to intubate the pouch leading to spontaneous emptying of the pouch as it overflows.
Despite the high complication rate, a limited role still exists for the continent ileostomy. The most frequent current indication is conversion of a failed ileoanal reservoir in a patient who refuses a Brooke ileostomy. The Kock procedure should not be performed in obese patients, debilitated patients, or any patient with physical or mental handicap that would not allow them to safely catheterize the stoma.
Total Abdominal Colectomy with Ileorectal AnastomosisA third alternative in the surgical management of UC is total abdominal colectomy with ileorectal anastomosis. Many of the intrinsic complications of total proctocolectomy are not experienced with this procedure because there is no mobilization of the rectum. This procedure has been shown to be safe, with an anastomotic leak rate of less than 2% in several large series44,45.
Functional results after ileorectal anastomosis are variable. In one series, over ninety percent of patients had fewer bowel movements per day postoperatively than preoperatively, and forty percent had three or fewer per day46. Other authors, however, have reported increased bowel frequency with up to 6 to 10 bowel movements per day. Failure of this procedure is usually due to continued inflammation in the rectum. Another disadvantage of ileorectal anastomosis is the risk of subsequent rectal carcinoma. The risk of carcinoma varies with time and by reported series, but can reach as high as 6% at 20 years, 15% at 30 years, and 18% at 35 years47. Patients with cancer or severe dysplasia in the resected colon are therefore not candidates for total abdominal colectomy with ileorectal anastomosis.
Despite the risk of carcinoma and the potential for persistent inflammation leading to failure, ileoproctostomy may be an attractive option, especially for young male patients with UC who wish to avoid the risk of impotence involved with proctectomy. Residual inflammation in the rectum in patients undergoing this procedure may be adequately treated with topical 5-ASA or topical corticosteroids.
Total Proctocolectomy with Ileoanal ReservoirRestorative proctocolectomy with ileoanal reservoir has become the most common definitive procedure in the elective treatment of UC. The procedure involves a near-total proctocolectomy with preservation of the anal sphincter complex. The mucosa of the distal anal canal can be stripped off the internal sphincter with the aim of preventing recurrence of symptoms or the potential of the development of cancer. A pouch is then fashioned using two, three, or four loops of small bowel (S, H, J, or W configuration) and this is anastomosed to the anal canal48-51. The pouch and anastomosis were traditionally protected with a diverting loop ileostomy, however, there are some proponents of the single-stage procedure without diversion52-57. Others have cautioned against single-stage procedures58-61.
Regardless of the configuration of the pouch, functional results are similar among many reported series48-51,62. The Mayo Clinic evaluated 1193 patients with J-pouches and found that the mean number of bowel movements in a 24-hour period was five63. Similarly, Fleshman, et al.64 reported a mean of 6.2 bowel movements per day in their series of patients. Schoetz et al.65 reported 7.0 bowel movements per day during the first three months following ileostomy closure and 5.1 per day following three months. Other authors have reported similar findings that improvement in function can be expected to decrease bowel movements during the ensuing 3 to 24 months following reestablishment of continuity65,66.
Because the ileal reservoir is anastomosed directly to the anal sphincter mechanism, continence can be affected. Nocturnal incontinence is a more significant problem than daytime incontinence. In the University of Minnesota series, 91% of patients had good control of both solid and liquid stool during the day67. This number dropped to only 76% of patients during the night. Minor spotting occurred in a significant number of patients and almost two thirds wore protective pads. Pemberton, et al.68 reported that almost half of patients had nocturnal leakage at 6 months, but at one year only 20% continued to have leakage at night. Other authors have shown similar improvements in continence with time64,65.
The major complications after ileoanal reservoir are small bowel obstruction (occurring in up to 27% of patients), pelvic sepsis secondary to anastomotic and pouch suture line leaks, pouch-vaginal fistula, and pouchitis. Pouchitis, may occurs in 7% to 33% of patients68-72. It typically presents with increased frequency of stools which may be accompanied by fever, bleeding, cramps, and dehydration. The cause is unknown but may be related to bacterial overgrowth, mucosal ischemia, or other local factors73,74. Episodes will usually respond to rehydration and oral metronidazole, but the diagnosis of Crohn's disease must also be entertained.
In some cases, the preoperative distinction between Crohn's disease and UC can be difficult, and the pathologist may label the disease as "indeterminate" colitis. Crohn's disease is a contraindication to ileoanal reservoir, and published series on ileoanal reservoir performed on patients with Crohn's show very poor results75,76. Pouchitis or ileitis will affect up to 100% of these cases and pouch-vaginal fistulas occur in 33% of females; pouch failure leading to excision of the pouch occurs in more than half of these cases.
Patients with indeterminate colitis who undergo IAR who do not develop Crohn's disease have results that are more encouraging. Yu, et al.77 reported a series of 82 patients with indeterminate colitis who underwent IAR; in comparison with patients with UC who underwent IAR, patients with the preoperative diagnosis of indeterminate colitis had significantly more episodes of pelvic sepsis, pouch fistula, and pouch failure. Fifteen percent of these patients were found to have Crohn's disease, however, and when these patients were removed from the analysis, the rate of complications for the remaining patients with indeterminate colitis was identical to that of patients with chronic UC. Similarly, in a series at the Cleveland Clinic Florida there was no difference in the rates of complications or the functional outcome in patients with indeterminate colitis and UC who underwent double-stapled ileal pouch anal anastomosis78.
The use of laparoscopic surgery for diseases of the colon and rectum began in the early 1990s and has now become standard of care in some disease states. Although early reports noted increased morbidity79, improved techniques and equipment have produced both early and later results that are comparable to those of standard laparotomy80-86. Laparoscopy may afford the advantages of decreased intraoperative fluid loss, shorter postoperative ileus, less pain, and improved cosmesis87-89. A recent meta-analysis demonstrated that patients who underwent laparoscopic total proctocolectomy with ileoanal pouch were able to tolerate oral intake earlier and had a shorter hospital stay90. Time taken to perform the surgeries and overall complication rates were similar in both the open and laparoscopic groups.
Overall, laparoscopy can be selectively applied in patients with UC. In the hands of skilled laparoscopic surgeons, laparoscopic total proctocolectomy with ileal pouch anal anastomosis is a safe and effective procedure. In this setting, the appropriate use of laparoscopy can benefit the proper patients with improved cosmesis, shorter postoperative ileus, and quicker recovery time.
Fertility and Pregnancy
Many female patients who undergo surgical treatment for ulcerative colitis are of reproductive age, and there is therefore concern regarding the impact of pelvic surgery on both fertility and the ability to carry a fetus to term. A majority of patients will have abnormalities on hysterosalpingography following proctocolectomy91, and this may impact the ability to become pregnant92,93. A recent meta-analysis reported that the infertility rate rose from 12 percent preoperatively to 26 percent postoperatively; sexual dysfunction also rose from 8 percent preoperatively to 25 percent postoperatively94.
A majority of women who have undergone proctocolectomy will be able to carry the fetus to term and deliver vaginally. Hahnloser reported that there was no difference in birth weight, duration of labor, delivery complications, vaginal delivery rates, and unplanned cesarean sections95. Although pouch function may worsen, particularly during the third trimester, most studies show that no longer term differences persist, even after vaginal delivery94.
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42 Vernava AM, 3rd, Goldberg SM. Is the Kock pouch still a viable option? Int J Colorectal Dis 1988; 3:135-138
43 Leijonmarck CE, Liljeqvist L, Poppen B, et al. Surgery after colectomy for ulcerative colitis. Dis Colon Rectum 1992; 35:495-502
44 Fazio V, Turnbull RB, Jr., Goldsmith MG. Ileorectal anastomosis: a safe surgical technique. Dis Colon Rectum 1975; 18:107-114
45 Khubchandani IT, Sandfort MR, Rosen L, et al. Current status of ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum 1989; 32:400-403
46 Jagelman DG, Lewis CB, Rowe-Jones DC. Ileorectal anastomosis: appreciation by patients. Br Med J 1969; 1:756-757
47 Aylett SO. Three hundred cases of diffuse ulcerative colitis treated by total colectomy and ileorectal anastomosis. British Medical Journal 1966; 1:1001-1005
48 Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 1978; 2:85-88
49 Fonkalsrud EW. Total colectomy and endorectal ileal pull-through with internal ileal reservoir for ulcerative colitis. Surg Gynecol Obstet 1980; 150:1-8
50 Oresland T, Fasth S, Nordgren S, et al. A prospective randomized comparison of two different pelvic pouch designs. Scand J Gastroenterol 1990; 25:986-996
51 Nicholls RJ, Lubowski DZ. Restorative proctocolectomy: the four loop (W) reservoir. Br J Surg 1987; 74:564-566
52 Del Gaudio A. Ileal j-pouch anastomosis without diverting ileostomy. Coloproctology 1993; 1:31-34
53 Jarvinen HJ, Luukkonen P. Comparison of restorative proctocolectomy with and without covering ileostomy in ulcerative colitis. Br J Surg 1991; 78:199-201
54 Matikainen M, Santavirta J, Hiltunen KM. Ileoanal anastomosis without covering ileostomy. Dis Colon Rectum 1990; 33:384-388
55 Mowschenson PM, Critchlow, J.F., Peppercorn, M.A. Ileoanal pouch operation: long-term outcome with or without diverting loop ileostomy. Arch Surg 2000; 135:463-465
56 Sugerman HJ, Sugerman, E.L., Meador, J.G., Newsome, H.H., Kellum, J.M., DeMaria, E.J. Ileal pouch anal anastomosis without ileal diversion. Annals of Surgery 2000; 232:530-541
57 Gullberg K, Liljeqvist, L. Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients. Int J Colorectal Dis 2001; 16:221-227
58 Galandiuk S, Scott NA, Dozois RR, et al. Ileal pouch-anal anastomosis. Reoperation for pouch-related complications. Ann Surg 1990; 212:446-452; discussion 452-444
59 Rothenberger DA, Wong, W.D., Buls, J.G. The S ileal pouch anal anastomosis. In: Dozis RR, ed. Alternatives to conventional ileostomy. Chicago: Year Book Medical Publishers, 1985; 345-366
60 Sagar PM, Lewis W, Holdsworth PJ, et al. One-stage restorative proctocolectomy without temporary defunctioning ileostomy. Dis Colon Rectum 1992; 35:582-588
61 Tjandra JJ, Fazio VW, Milsom JW, et al. Omission of temporary diversion in restorative proctocolectomy--is it safe? Dis Colon Rectum 1993; 36:1007-1014
62 McHugh SM, Diamant NE, McLeod R, et al. S-pouches vs. J-pouches. A comparison of functional outcomes. Dis Colon Rectum 1987; 30:671-677
63 Kelly KA. Anal sphincter-saving operations for chronic ulcerative colitis. Am J Surg 1992; 163:5-11
64 Fleshman JW, Cohen Z, McLeod RS, et al. The ileal reservoir and ileoanal anastomosis procedure. Factors affecting technical and functional outcome. Dis Colon Rectum 1988; 31:10-16
65 Schoetz DJ, Jr., Coller JA, Veidenheimer MC. Ileoanal reservoir for ulcerative colitis and familial polyposis. Arch Surg 1986; 121:404-409
66 Becker JM, Raymond JL. Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases. Ann Surg 1986; 204:375-383
67 Wexner SD, Jensen L, Rothenberger DA, et al. Long-term functional analysis of the ileoanal reservoir. Dis Colon Rectum 1989; 32:275-281
68 Pemberton JH, Kelly KA, Beart RW, Jr., et al. Ileal pouch-anal anastomosis for chronic ulcerative colitis. Long-term results. Ann Surg 1987; 206:504-513
69 Madden MV, Farthing MJ, Nicholls RJ. Inflammation in ileal reservoirs: 'pouchitis'. Gut 1990; 31:247-249
70 Nicholls RJ. Restorative proctocolectomy with ileal reservoir: indications and results. Schweiz Med Wochenschr 1990; 120:485-488
71 Oresland T, Fasth S, Nordgren S, et al. The clinical and functional outcome after restorative proctocolectomy. A prospective study in 100 patients. Int J Colorectal Dis 1989; 4:50-56
72 Schoetz DJ, Jr., Coller JA, Veidenheimer MC. Can the pouch be saved? Dis Colon Rectum 1988; 31:671-675
73 Levin KE, Pemberton JH, Phillips SF, et al. Role of oxygen free radicals in the etiology of pouchitis. Dis Colon Rectum 1992; 35:452-456
74 McLeod RS, Antonioli D, Cullen J, et al. Histologic and microbiologic features of biopsy samples from patients with normal and inflamed pouches. Dis Colon Rectum 1994; 37:26-31
75 Koltun WA, Schoetz DJ, Jr., Roberts PL, et al. Indeterminate colitis predisposes to perineal complications after ileal pouch-anal anastomosis. Dis Colon Rectum 1991; 34:857-860
76 Deutsch AA, McLeod RS, Cullen J, et al. Results of the pelvic-pouch procedure in patients with Crohn's disease. Dis Colon Rectum 1991; 34:475-477
77 Yu CS, Pemberton JH, Larson D. Ileal pouch-anal anastomosis in patients with indeterminate colitis: long-term results. Dis Colon Rectum 2000; 43:1487-1496
78 Pishori T, Dinnewitzer, A., Zmora, O., Oberwalder, M., Hajjar, L., Cotman, K., Vernava, A.M., Efron, J., Weiss, E.G., Nogueras, J.J., Wexner, S.D. Outcome of patients with indeterminate colitis undergoing a double-stapled ileal pouch anal anastomosis. Dis Colon Rectum 2004; 47:717-721
79 Schmitt SL, Cohen SM, Wexner SD, et al. Does laparoscopic-assisted ileal pouch anal anastomosis reduce the length of hospitalization? Int J Colorectal Dis 1994; 9:134-137
80 Wexner SD, Johansen OB, Nogueras JJ, et al. Laparoscopic total abdominal colectomy. A prospective trial. Dis Colon Rectum 1992; 35:651-655
81 Thibault C, Poulin, E.C. Total laparascopic proctocolectomy and laparascopic-assisted proctocolectomy for inflammatory bowel disease: Operative technique and preliminary report. Surg Laparosc Endosc 1995; 5:472-476
82 Tucker JG, Ambroze, W.L., Orangio, G.R., et al. Laparscopically assisted bowel surgery. Surg Laparosc Endosc 1995; 9:297-300
83 Liu CD, Rolandelli, R., Ashley, S.W., et al. Laparascopic surgery for inflammatory bowel disease. American Surgeon 1995; 61:1054-1056
84 Rhodes M, Sitz, R.W. Laparascopic subtotal colectomy. Seminars in Colon and Rectal Surgery 1994; 5:267-270
85 Marcello PW, Milsom, J.W., Wong, S.K., Brady, K., Goormastic, M., Fazio V.W. Laparascopic total colectomy for acute colitis: a case-control study. Dis Colon Rectum 2001; 44:1441-1445
86 Hasegawa H, Watanabe, M., Baba, H., Nishibori, H., Kitajima, M. Laparascopic restorative proctocolectomy for patients with ulcerative colitis. Journal of Laparascopic & Advanced Surgical Techniques 2002; 12:403-406
87 Hildebrandt U, Lindemann, W., Kreissler-Haad, D., Feifel, G., Ecker, K.W. Laparscopically assisted proctocolectomy with ileoanal pouch in ulcerative colitis. Zentralbl Chir 1998; 123:403-405
88 Santoro E, Carlini, M., Carboni, F., Feroce, A. Laparascopic total proctocolectomy with ileal J pouch-anal anastomosis. Hepatogastroenterology 1999; 46:894-899
89 Dunker MS, Bemelman, W.A., Slors, J.F., van Duijvendijk, P., Gouma, D.J. Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study. Dis Colon Rectum 2001; 44:1800-1807
90 Tan JJ, Tjandra JJ. Laparoscopic surgery for ulcerative colitis - a meta-analysis. Colorectal Dis 2006; 8:626-636
91 Oresland T, Palmblad S, Ellstrom M, et al. Gynaecological and sexual function related to anatomical changes in the female pelvis after restorative proctocolectomy. Int J Colorectal Dis 1994; 9:77-81
92 Gorgun E, Remzi FH, Goldberg JM, et al. Fertility is reduced after restorative proctocolectomy with ileal pouch anal anastomosis: a study of 300 patients. Surgery 2004; 136:795-803
93 Olsen KO, Joelsson M, Laurberg S, et al. Fertility after ileal pouch-anal anastomosis in women with ulcerative colitis. Br J Surg 1999; 86:493-495
94 Cornish JA, Tan E, Teare J, et al. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review. Dis Colon Rectum 2007; 50:1128-1138
95 Hahnloser D, Pemberton JH, Wolff BG, et al. Pregnancy and delivery before and after ileal pouch-anal anastomosis for inflammatory bowel disease: immediate and long-term consequences and outcomes. Dis Colon Rectum 2004; 47:1127-1135


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Enjoy a romantic getaway this Valentines weekend with your loved one with a stay at The Clarence. Starting from €259 for on overnight stay on Friday February 13th or Saturday February 14th, a cocktail in our Octagon Bar and a delicious breakfast in Cleaver East the following morning.
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subset: commoncrawl


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(07-25-2012 02:04 PM)rsteeves Wrote: Well forget it then. It would take me hours to list my hockey and Baseball. I am still trying to figure out how to list Reg. RU and Autio's. and that has been a chore. Thanks Again and sorry to waste your time.
(07-26-2012 01:53 PM)rsteeves Wrote: To be honest I think Beckett OPG is a waste of money. I but the big book once a year it covers everything I need. I do not have excel. How about open office? I don't want you to think I am rude like others have suggested. am far from it. I trade and trade some more I despise Flebay might as well burn my cards cause that is what value you get there. Just like OPG some cards they put a value that is so far out of the worrl. I think they pass a fish bowl around w/prices on them and that is whet they value the card at. Like a 2012 Press Pass Ignite Profile #P4 Danica Patrick SP $12.00 $30.00 I have yet to see one sell for $12.00 I saw one sell for 4.00 last week. BUT that included shipping. I just do not get it. But LMK about open office. :0]


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Sharp underrated everywhere but Blackhawks' locker room
BY MARK POTASH email@example.com May 12, 2013 7:12PM
Patrick Sharp, Patrick Kane, Michal Handzus
Article Extras
Updated: May 12, 2013 11:09PM
It was no surprise that Patrick Kane and Jonathan Toews scoring zero goals in the first round series against the Minnesota Wild was a hotter angle than Patrick Sharp scoring five.
Kane and Toews are neon-like emblems of the Blackhawks' rise from the muck of the NHL to Stanley Cup championship elite status. Kane is the playmaking wizard with the puck. Toews seemingly is around every good thing that ever happens to the Hawks.
Patrick Sharp is just Patrick Sharp. He wasn't a bally-hooed draft pick. He arrived in town without fanfare. He never was a teenage prodigy. He was neither the goofy kid nor the mature-beyond-his-years, 22-year-old captain. He doesn't win awards. All he he does is act his age and score goals.
And even when you inquire about the secret to his success, it still comes out — perhaps unwittingly — like a bit of a backhanded compliment.
''He knows how to get open. And when he does, he doesn't miss often,'' Kane said. ''He's always finding himself good chance, whether it's around the net or in the slot.''
Kane stopped himself. ''I don't want to pump his tires too much,'' he quickly added. ''But he's a good teammate, a good friend. He's been awesome in the first round.''
Nobody wants to pump anybody's tires on this team — it seems to be an inside joke in the Blackhawks' locker room. But rarely is anyone asked to even try with Sharp. He would be the go-to star in a lot of NHL locker rooms. But with Toews and Kane around, Sharp easily blends into the background.
''Those are things that I can't really control what outside influences have to say or think about our team,'' Sharp said. ''Those are two elite players you're talking about. They get a lot of attention and that's fine. That's the way things are. That doesn't bother me one bit.''
In a way, it helps Sharp keep his edge. ''It's always nice to read things about yourself and hear compliments about yourself. But it doesn't do me any good,'' he said. ''I feel like I play my best when I'm motivated and ready to go out there.
''And we have a good team. The [championship] belt that we have [which is awarded by a teammate to a teammate after each victory] gets passed around to a lot of different people for a lot of reasons.''
Even as a goal-scorer, Sharp is well-rounded. He
s fast and has a big, quck shot but he scores ugly goals when the team needs them most. It was Sharp who smartly tested Wild third-string goalie Darcy Kuemper with a 50-foot slap shot in Game 4 and struck gold. He's more versatile than he looks.
''I've always been proud of the fact that I can play in all situations,'' said Sharp, who has scored 199 regular-season goals in the NHL — the first against former Hawk Ed Belfour in 2004. ''I broke into the league as a fourth-line player, as a penalty killer — that's something I take pride in. Given the opportunity, I feel I can do that. I get a lot of credit for putting up points and scoring goals, but I like to think I can play in all situations.''
Unlike the Kane and Toews, who were targeted for stardom as teenagers, Sharp has been fighting for recognition throughout his NHL career. A third-round draft pick by the Philadelphia Flyers in 2011, Sharp helped lead the AHL Philadelphia Phantoms to the Calder Cup in 2005, with a sweep of the Chicago Wolves. But as a Flyers prospect he was far down a list that was headed by teammates Mike Richards and Jeff Carter. Sharp — who wore five different uniform numbers in 66 games with the Flyers — ultimately was deemed expendable. He was traded to the Hawks in 2005 for Matt Ellison because Flyers general manager Bobby Clarke and coach Ken Hitchcock didn't know what they had.
''Patrick is a natural center, not a wing, and we have too many centers,'' Hitchcock told reporters after the trade.
Ellison played five games and was sent to the minors and ended up playing seven total games for the Flyers. Sharp quickly was moved to right wing and became a star. Well, not a star. He became a scorer with a knack for avoiding the spotlight.
Sharp led the Hawks with 36 goals in 2007-08, but that was the debut season of Kane and Toews. In a turning-point victory over the Vancouver Canucks in Game 4 of the Western Conference semifinals, Sharp had a goal and three assists — but Toews scored a hat trick and had five-point game in a 7-4 victory that gave the Hawks a 3-2 series lead and propelled Toews into Conn Smythe Award contention. In Game 6 of the Cup Finals in 2010, Sharp scored the goal that tied the game at 2-2 — trumped by Kane's game-winner, of course.
Sharp has not been ignored as a Blackhawks star. But the 2010 postseason run to the Stanley Cup remains a shining example of his ability to find the shadows. Sharp was second on the team in goals (11), third in points (22), second in plus/minus (plus-10) and fifth in assists (11) in the playoffs. He led the team in shots-on-goal — an underrated statistic.
And no Hawks player was more consistent: He scored in 15 of 22 games. He never went more than one game without a point. He was a minus player in only four games. Six of his last seven goals either tied the score or gave the Hawks the lead. In the Finals, he had four goals, six points and was a plus-7 against the Flyers. Yet he literally was not in the conversation for the Conn Smythe Award. Toews was a deserving winner. Duncan Keith, Antti Niemi or Dustin Byfuglien could have won it as well. But Sharp had a heluva postseason resume to not even be considered.
''He's always been pretty underrated ever since I came here, maybe one of the most underrated guys in the league,'' Kane said. ''And I don't know if that's because we have so many players here or what. But it's always been kind of unfair to him, I guess. He's a great player, a huge part of the team and always seems to score timely goals.''
With five goals in the opening-round victory over the Wild, Sharp can't be overlooked forever. Well, he can. But like everybody else in hockey, Sharp plays to win championships no matter how it's done. If the Hawks win another Stanley Cup, Sharp gladly will live with being the guy who knows how to get open.


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(Bloomberg) Credit Suisse Group AG is close to resolving a U.S. tax-evasion probe with an agreement that might include a penalty of more than $1 billion, after creating a separate entity last year to house the businesses involved.
All Accounting Today articles are archived after 7 days. REGISTER NOW for unlimited access to all recently archived articles, as well as thousands of searchable stories. Registered Members also gain access to exclusive industry white paper downloads, web seminars, podcasts, blog discussions, and conference discounts. Registered members may also choose to receive our exclusive Tax Pro Today e-newsletters covering the latest breaking news, opinions from industry leaders and developing trends.


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27 Oct
While some of us have been lovingly hand-sewing Halloween costumes since Memorial Day, the rest of us are stuck sticking stainless steel colanders on our kids' heads and making them trick-or-treat as "robots." Last year we mentioned several DIY Halloween costumes—from the Cold Weather Bandit to the Glad Bag. (Yes, that's right—we actually recommended dressing your kid as a garbage bag.)
What brilliant last-minute ideas were we able to come up with this year?
Baby burrito. Swaddle your baby in a white blanket, letting some lettuce or cabbage leaves peak out at the edges. Variations on this theme include baby spring rolls, baby eggrolls, or baby turkey wrap. Here a doll is modeling this look, which took just one minute to create.
Striped baby bug. If you can get your hands on some antennae—or make some out of pipe cleaners or something—then you can dress your baby in various striped garments for this look.
Gnome. Last year Audrey put on a brown tweed skirt and coat she had received as a gift. She wore striped tights and carried a tin watering can to collect her treats. I did need to sew a pointy green hat out of an old curtain, which took me about an hour or longer (because I am such a bad sewer), so this isn't a completely last-minute costume option.
Charlie Brown. Is your baby bald? Do you have a yellow onesie and some brown shorts? Can you draw a passable zigzag pattern with a felt-tip marker? Then you can dress your baby as Charlie Brown.
Old Man. Again—is your baby bald? Do you have some baby-sized glasses, some sort of "old man" hat and maybe a sweater vest? If you answered "yes" to any of the questions above, you might be able to dress your baby as an old man this year.
Alien. Dress your baby or child all in white and use a black eyeliner pencil to create huge alien-eyes.
Dick Cheney. One of our Green Baby Guide consultants came up with this one. "Another great costume idea for babies is the 'Dick Cheney,'" he says. "Dress them up in a little blue business suit and add a cheap pair of reading glasses and some white hair around the sides via cotton balls for a look that will delight Democrats and Republicans alike!"
ZZ Top. This costume idea brought to you from the mastermind behind the "Dick Cheney." All you need is a set of twins, some fake beards, sunglasses, and grungy old hats.
Baby Grecian. Another Green Baby Guide consultant suggested fashioning a toga out of a piece of fabric and crowning your baby with leaves. Brilliant!
Check this site out for baby costumes (including a baby muscle man and Sasquatch!) that require some actual crafting and sewing skills.
If worse comes to worst, you can always stick your baby in a cardboard box, bucket, or other baby-sized receptacle. What is this costume, exactly? "Baby in a box," "baby in a bucket," etc. All right, I'm clearly running out of inspiration. What are your best DIY Halloween costume ideas?
Making my own costumes out of household odds and ends works for me! For more Works for Me Wednesday ideas, head on over to We are THAT Family!
I happen to love the idea of "Flashdance Baby." All you need is an oversized baby shirt (to be worn off the shoulder, of course), some tights, and some adult sized socks that can quickly be adapted into leg warmers. The baby headband worn straight across the forehead would be the perfect finishing touch. Bring on the music!
My favorite last-minute Halloween costume as a child was "gypsy girl." A onesie or leotard is the base of the outfit. Simply ad a belt and stick in it many colorful swatches of fabric for a skirt-like effect. Add gaudy costume jewelry if available. This look could be adapted for a "pirate" costume as well. Instead of the leotard, use a brown shirt. Add a rag to the head for a finishing touch.
I LOVE all your ideas, but Dick Cheney might be too scary for the kids! The best ideas are spawned right out of your garage or toy box. Happy Halloween!
I am so late on this but just had to share that my son's idea of the perfect costume was the traditional ghost – a sheet with holes cut out for the eyes. In a trial run we found out that it isn't very safe as the sheet didn't stay put on his silky hair. So I cut out the entire face and then attached it to a regular hat. We used face paint to make his face white and his eyes black. He looked adorable and many adults commented on what a cool "retro" costume it was.
For my daughter we dug into the dressup and she wore a long white dress (former snow queen costume) a bridal veil and then we painted her face white and put white stuff in her hair. She was the ghost bride – poor thing, died on her wedding day.
We loved the burrito idea, here's our little bean done up in his swaddle, a green hat, and some tissue paper I saved from a gift bag:
That is absolutely adorable! We will have to feature your little burrito in one of next year's Halloween posts!


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Fri, Sep 18, 09 at 5:13
I know we aren't supposed to post advertising but I found this and felt it might be of interest to many... I haven't seen any other sources for someting like this.
http://www.survivalunlimited.com/deepwellpump.htm Might save someone the cost of a generator. |
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Thank you for this web site!! |
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NBA / Oct 24, 2011 / 4:00 pm
The NBA's All-Time Best No. 8 Seeds
I have no problem saying Burger King makes the best fries. But McDonald's won't send me back home shuffling through my refrigerator at 2 a.m. on a Saturday night either. One version is crispier. The other feels like it needs another two minutes in the oven. Both do the job. Both taste really good. Try comparing NBA teams. It's nearly impossible when those squads are coming from differing situations. From the players, ownership, the fans and even the style of play or storylines surrounding a team, no two situations will be entirely alike. You can't compare style. Playoff teams? We've seen 65-win juggernauts, lousy 40-win teams getting in only because their timing was so good, and then everything in-between. Read More »


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Wednesday, March 24, 2010
Social justice comes under attack
Demagogues often prosper under the rules of democracy, intimidating the moderate and preying on the weak-minded. But in a healthy society, such figures cannot cross a final threshold of decency without jeopardizing their own status—and today's right-wing nihilists seem to be on the verge of doing just that.
When Elizabeth Cheney, the daughter of the former vice president, questions...


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My Profile
Trissy Tomato
Grapevine, Texas
Member since Jan 2005
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Reviewed Waffle of Insane Greatness
Sep 15, 2013 in Food Network Community Toolbox on FoodNetwork.com
"We are not huge breakfast for dinner fans, but these waffles were delicious. The only reason I gave them 4 stars instead of 5 is that they got soggy very fast. I stacked them in a warm oven while I was making the batch, but by the time I was done making the 6 waffles this recipe made in my waffle iron, the ones in the oven were not crispy anymor""
Reviewed My Big, Fat Chocolate Chip Cookies
Jun 28, 2011 in Food Network Community Toolbox on FoodNetwork.com
"These cookies were very good. We did not find them cakey at all, but very moist and chewy, with a nice lightly crusty bottom. I made them with about 2 1/4 cups of semi-sweet chips, since that is what I had in the house. I will definitely make them again. ""
Reviewed Jam Thumbprint Cookies
Jun 26, 2011 in Food Network Community Toolbox on FoodNetwork.com
"These cookies were light, buttery and delicious! I used morello cherry and blueberry jam, and they turned out fabulous. My 4 year old even helped roll and dip the dough balls. It was a fun and yummy project for the whole family.""


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Tue, Aug 24, 10 at 14:19
Today as I was doing some cleaning I noticed something inside the glass cover of a light fixture. Thinking it was some bugs that needed cleaning I removed the cover only to realize it was small (dusty looking) pieces of rust. I noticed that one of the nuts that holds the fixture to the ceiling also had rust on it. From what I could see it looks as if at some point some water dripped through around the screw and into the glass cover. There are no water stains at all around the fixture.
Almost 4 years ago we had a bad windstorm that caused shingles to come off and water leaks in that bedroom. Since then the roof has been replaced and as far as we know there are no leaks. It's possible that we haven't changed the bulbs in that time since we don't use that fixture very often. My question is this: Is there anything else that could cause rust? I really don't know if this is a new problem or not, but wanted to make sure we check out any potential problems that could cause this. There is no plumbing or pipes that run over this room. Thanks! |
Follow-Up Postings:
- Posted by ronnatalie (My Page) on Tue, Aug 24, 10 at 17:59
Excessive humidity can also cause rust. Cheap fixtures can rust even at normal humidity levels. As long as the wiring and the components themselves are intact without corrosion and the thing is more or less mechanically sound, there isn't really anything but an aesthetic issue. If you live by the ocean, you often find it impossible not to have rust in things. |
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Sun, Nov 18, 12 at 21:44
I am putting together a baby quilt. The top is cotton and the backing is flannel. Do I need batting between the two or can I omit it? I've heard both ways.
What do you think? Darlene |
Follow-Up Postings:
- Posted by toolgranny (My Page) on Sun, Nov 18, 12 at 22:02
I think it is your call. The flannel makes a heavier quilt so leaving out batting is probably okay. If you don't want the thickness of batting, I think I'd put an extra layer of flannel inside for batting if it were me. I think you need some body when you quilt it. Just my 2cents. |
- Posted by teresa_nc7 (My Page) on Mon, Nov 19, 12 at 7:07
What is the climate for the recipient? If it's the warmer Southern states or SoCal, I'd say you don't *have* to put in a batting. You could tie or do a decorative machine stitch to tie the top and bottom together and call it a summer blanket. But if you want to machine quilt this project, then you might want a thin batt or flannel in the middle as toolgranny mentioned - add my 2cents worth to hers. Teresa |
And don't forget to prewash the flannel! Three cents! Theresa |
Here's another 2 cents' worth. I almost made the mistake of omitting batting when I had a top with a lot of white in it and a darker backing. In order to hide the seam allowances and get the white to "pop," you need a light-colored batting. This is especially true if you are using thinner fabrics for the top. |
Thanks everyone. I think I'm going put flannel in the middle. I'll post a picture when it's done. Darlene |
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Django Unchained
Community Activity
Add a CommentA great film , a homage to Westerns. Director Tarantino did a great job. Loved the Photography of the film, i felt like u'r were in 1858.
I liked parts of this movie. A bonus point awarded because I had the theme music stuck in my head for about three months.
I appreciated the style more than the content. That is, I enjoyed the cinematography and some the light humor throughout the film. Unfortunately, the end was anticlimactic; the demise of Django's foes comes all too quickly and easily.
Tarantino unfortunately sets a high bar for his movies. Django fell short. The editing felt sloppy, the camera lingering on scenes too long, making explicit things that would have been more powerful implied or left to the reader's imagination. For example, in one scene, a cruel slave trader is left injured and surrounded by his slaves. Rather than show them glaring at the trader as he starts to beg and bargain in panic and move on, Tarantino stays until you see what happens, and it is not as good as what I would have imagined. This happens a few times. The soundtrack, usually a powerful component, feels clumsy. And finally, women are reduced to cliches -- the beautiful (but helpless) object of love and the reason for the quest (Kerry Washington) never seems fully realized, for example. Disappointing coming from the director who gave us "Kill Bill" and "Foxy Brown."
But even with all these flaws, a Tarantino movie is still thought provoking, surprising, and cinematic. He draws powerful parallels between bounty hunting and slavery, and no character escapes moral compromise. With some hilarious moments, such as the KKK complaining about how hard it is to see under their prototypical hoods.
As always with Taratino, lots of gore, but there is also a bit of wit. Although not much social commentary.
Best movie I have seen in awhile...bloody tho. Taratinio did not disappoint , this was a great thing to see that slaves fought for freedom.
My husband and I enjoyed this very much. Tarantino is a master at his craft. I didn't love the gore, but I would just close my eyes for a moment. Great acting and a great story.
I put off watching this one for a long time, because of the supposed gore. Without commenting on the amount of gore - which is, after all, a Tarantino trademark - I have to say I really liked the story; it was great!
+Tarintino makes his B Class-like Movies seem like they could be, S Class Movies; and he does it like no one else ever even could. In other words, he makes legendary B Class Movies of his seem as legendary, S ranked-echelon-status movies. +Gobs of altruism and alliteration galore... much and many more... +Loved the good doctor and splendid side-kick character for their brilliance and lucid look into roles of becoming more masterful than most mere mortal men... and even then, and when, and while especially under scrutinizing, pressurizing scenes to deliver lines of whit amongst chaotic, simpleton, simian-thinking, authoritative men, and their monkey minded, madmen, henchmen. +I loved the getting into character class roles, coming from the heroes' actions as to when they encountered, foolish, slave-trader factions; I loved seeing the KKK event when while for the first time and having it unfold; and when while they, the KKK, were attempting to rally and organize themselves, they were sinfully comical by being as belligerently bold; I loved how the slave owners attempted to tackle the sticky issues and situations of there being a free blackman standing right before them; of this I thought and felt it to be wickedly awesome and witty thru their, the slave-traders' farcical, failing approaches that they heinously held; and while the slavers' antics were seemingly noble enough to their own selves in their own real time, those moments had become knowingly then to us as wily, clever tactics to tackle juxtaposition between that of them, they, the said bad dudes, to that of us and our supposed, said, modern human behaviors; add now then, this is our method as to how we all justify just about anything to ourselves for just about any reason... and this is reason now enough, to see... individual story of yours, mine, and ours, is yours, mine, and our mutually inclusive story; and thus, this story shown from afar… through the infamous, fourth wall of one's window frame of time and space, (such as thru: television screen, movie projector, computer screen, and especially the eye of human mind), we are then able to perceive through this device, a glimmer of our unlearning curves, a glimmer of our unlearning lives, and a glimmer of our selfish selves; and by this strategic device, we can then achieve and perceive cosmic-like clarity; we can then see of our own silly inane and insane, said or unsaid, sickly-society, of our own sickly selves, and of our own sickly notorieties; and we can become more than ably apt; we can become more than ably ameliorated; we can become more than ably augmented; we can become more than ably adept in at seeing our own current unaware selves through cosmic-like, lenses of clear-like, comparison; and so by this comparison of ourselves, we may have means of viewing other characters and their stories that they exist in and about; and we can compare these characters with our own selves to see mirrors of our own reflecting, phantom selves, being reflected back at us and our selves. +An awesome, somatic flick; it flavored with whimsical characters and crafted wit; way to go Tarintino... and way to go to all who made this wonderful, wunderkind, cinematic, cowboy, remix. From a Devourer of Diligent Men's, Organized and Masterful Opuses; Rating: 6.0/5.0; -Xandor Who; (Edited and Augmented for more common courtesy and for more clerical clarity). (4-23-14).
Add Age SuitabilityQuotes
Add a QuoteBig Daddy (putting his bag/mask on): "Damn! I can't see f**king sh*t out of this thing!"


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Showing 1-14 of 14 items found in Events
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Dec 31
Holiday Lights Train
The Holiday Light Train is Pete's biggest event of the year. The park is decorated for the Holidays. See over 250,000 lights in various displays. Giant toy soldiers, candy canes, cascading snow flakes, flying reindeer, and swans swimming, just to name a few of Pete's displays!
CITY: Waterman
Feb 15
The Who's Tommy at Paramount Theatre
Set in the 1940's, Tommy is the story of a little boy who witnesses his father murder his mother's lover upon his surprise return home after being released from a prisoner of war camp. Find out the rest for yourself, be a part of the greatest rock opera ever written. Rated PG-13
CITY: Aurora
The Underpants
Play set in Dusseldorf, Germany on 1910, Louis Maske inadvertnetly drops her ill-fitting drawers in the middle of town square during a parade to honor the king.
CITY: DeKalb
18 - 21
This festival is attended by approximately 50,000 during the course of the weekend. PrairieFest events are held throughout Oswego with the main festival grounds located at PrairieFest Park, 91 Plank Road. The event features main stage entertainment, children's performers, expo village, petting zoos, pony rides, camel rides, children's activities, parade, bed races, touch a truck event and more. The event is free, compliments of our generous business sponsors.
CITY: Oswego
23 - 24
Hinckley Germanfest
Planned activities include a craft show, a dance contest, stein holding contests, antique tractor show, races, a church service and delectable international food and much more!
CITY: Hinckley
Apr 26
Paramount Theatrical Production: Les Misérables
This monumental novel comes to life in one of the greatest musicals of all time. It's the story of ex-convict Jean Valjean and his journey for redemption. On that road, he encounters the never-wavering love of a mother, the innocence of a child, the steely determination of a hunter and the passion of youthful freedom fighters.
CITY: Aurora
Brad Paisley in Concert
Tickets ON SALE Friday, November 22nd for February 5, 2015! Country music superstar BRAD PAISLEY has announced the extension of his Country Nation World Tour presented by KRAFT Cheese through March 2015. The last leg of the tour will include the NIU Convocation Center on February 5th, 2015. Special guests on the tour will include Parmalee and The Swon Brothers. The show will start at 7:30pm and doors will open at 6:30pm. Tickets for Brad Paisley will go on sale Friday, November 22nd at 10:00am. Tickets are $39.75 and $59.75. All seats are reserved. Tickets can be purchased at the Convocation Center box office, all Ticketmaster Outlets, Livenation.com, or by phone 800-745-3000. Special guests on the tour will be Stoney Creek Records family band Parmalee and Arista Nashville recording duo The Swon Brothers.
CITY: DeKalb
Monster Truck Show
Feb 22nd, 2015's visit is the first time monster trucks will return to the Convocation Center in 10 years. Tickets Buy tickets Tickets on sale now! $17; $20; $32 Advance Tickets:$17.00 Day of Show Tickets: All Seats $20.00 A Limited number of $32 GOLD CIRCLE SEATS available while supplies last. Advance Tickets on sale October 31st by visiting the Convocation Center Box Office, charge by phone at (800)-745-3000 or online at these two sites: www.ticketmaster.com & www.MonsterTruckNationals.com NIU Convocation Center • DeKalb www.niuconvo.com
CITY: DeKalb
Team Dance Illinois State Championship
February 14th Team Dance Illinois State Championship NIU Convocation Center • DeKalb www.niuconvo.com
CITY: DeKalb
John Lithgow at Paramount Theatre
The Tony®, Emmy® and Golden Globe® Award winning actor offers a touching and humorous reflection on storytelling as the tie that binds humanity. Invoking memories of his grandmother and father before him, Mr. Lithgow traces his roots as an actor and storyteller, interspersing his own story with two great stories that were read to him and his siblings when they were children. STORIES BY HEART provides ample evidence of the power of storytelling, the magic of theatre, and the talents of one of our greatest actors.
CITY: Aurora
Poi Dog Pondering at the Paramount Theatre
POI DOG PONDERING comes back to their suburban home-away-from-home in Aurora for one night only. It's Frankie, Susie, Max, Dag, Ted and the rest of the POI family together for a sensory-overload experience. Plus, they're bringing some very special and talented guests to join them on the enormous Paramount stage. If you've seen POI at the Paramount, then you know exactly why they sell out here every year. If you've never seen POI DOG PONDERING live, then now is the time to experience these amazing artists.
CITY: Aurora
David Sedaris
David Sedaris is one of America's preeminent humor writers. Just check out any of his New York Times bestsellers including Let's Explore Diabetes with Owls, Me Talk Pretty One Day, Dress Your Family in Corduroy and Denim and When You Are Engulfed in Flames – which is just a partial list of his works that have sold over 7 million copies. But there's nothing like seeing and hearing this one-of-a-kind artist in person share stories, observations, works-in-progress and readings from some of his pieces.
CITY: Aurora
You've seen them…you just might not have known it. They stunned the world at the Academy Awards with their shape-shifting performance behind the screen. They've done numerous car commercials that leave your jaw on the ground. They've been on Conan, Oprah and over 100 other TV shows. They're the dance group that defies gravity, taxes muscles beyond conceivable limits and adds an element of unforgettable beauty through dancing. All of this from a group whose name means "a phototropic fungus that thrives in farmyards." Seeing is believing. See Pilobolus.
CITY: Aurora
The Chicago Rat Pack "One Swingin' Night"
Egyptian Theatre - DeKalb, IL. For over 18 years, the unforgettable trio (Frank, Sammy and Dean) excited audiences nightly at the Copa Room and the Sands Hotel and Casino in Las Vegas, Nevada. These wonderful performances have been recreated with remarkable accuracy. Critics all proclaim "One Swinging Night" as being as close as any person could come to experiencing the original Rat Pack. With so much talent on stage together, these wild wonderful performers would set the standard tone for all those who came to Vegas throughout the Swinging 60's. How could these performances be anything less than historical? The Chicago Rat Pack's show, "One Swinging Night" is perhaps one of the few special productions that shall become as timeless as the actual counterparts (Sammy, Frank and Dean). This fantastic show transports its audiences to a time when life was a lot less complicated. "One Swinging Night" is a brilliant reenactment of the "Summit." This was the period at which all three of the magnificent super-stars were at the prime of their wonderful careers. At times, these three actors seem to transcend reality by totally becoming the characters they portray. Along with this and the fact that each member of this cast is very talented in his own right makes "One Swinging Night" a show that must be seen!
CITY: DeKalb
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Fri, May 6, 05 at 19:36
I've always been a big fan of hard to grow items, here are 2 pictures of my banana trees. Each in a different spot in the yard. These bananas have always been in pots and the 2 that you see are offshoots that I snipped away from the main banana tree that I purchased a few years ago. The reason that I decided to plant these outdoors is to see how big they can get in the ground. They have weathered a recent snow a few weeks ago and temps down close to 32 degrees. I have kept them covered with a heavy blanket at night for protection. Looking at weather.com, I see that we're in the clear for SW-PA. I have a 3rd banana plant in a pot, and will use suckers from that to re-plant year after year. I'm going to keep a photo log of monthly pictures to compare growth. As you can see from the banana pics, they are small and stubby. In the previous summers, they've been outside in pots. They tended to get very tall with few off-shoots. When bringing them in for the winter, they tend to sprout multiple off-shoots and growth rather stubbly, with each new leaf growing in before the other has attained sufficient height. Why this is, I have no idea. I've also watered them, after planting them outside with a good amount of fertilizer and use hot water via a hose connected to a spicket in the basement because of the colder nights. With the oncoming warmer weather, I don't think this will be necessary. Anyone care to take a stab at what kind of banana this is??? : ) |
Follow-Up Postings:
- Posted by Billie_ann 6b PA (My Page) on Fri, May 6, 05 at 20:35
Gardenguy, I've only had two varieties, one is the musa basjoos and the other had burgundy spotches on the leaves. I didn't want to bring in the burgundy in so I gave it to a nursery. This looks like the musa basjoos but I really don't have a clue. Maybe someone on the Banana Forum could identify. This will be my third Summer with the basjoos. It's been planted in the ground since I got it. The first year it grew to about 5 feet tall. Last Summer it reached 7 or 8 feet tall. It's in a raised bed so it has good drainage, heats up early in the season and is even taller in the raised bed. There were 4 offshoots and 4 of the old stalks started to grow back from the center. I thought the old stalks had turned to mush like the previous year. Don't know if it's due to the past Winter weather, thicker mulch or more established root system that they started growing back at the centers. I chopped off most of the offshoots for neighbors and friends. I kept the main stalk and 1 offshoot. I'll try to remember to take a picture of what's left growing out back tomorrow. I also grow Angelica archangelica, which looks like a giant celery plant. It looks a little jungley out there. Billie |
- Posted by Billie_ann 6b PA (My Page) on Thu, May 12, 05 at 6:35
Gardenguy, The picture is a little hard to see that the center is growing back. Last years stalk was about 5 or 6" so I'm wondering if this will grow to that size. Don't think that you can see but another offshoot popped up. Billie |
Here is a link that might be useful: banana resprouting
- Posted by gardenguy_ z6a PA (My Page) on Thu, May 12, 05 at 9:41
I know each banana set has about 2 main stems and a few litle offshoots growing out of the main corm. These always get this way when I bring the banana in for the winter. I'll have a nice main stem, then that will die back for some reason while a multitude of stems grow up from around the main stem. The above pictures are what they looked like when I took them out of the pot. Since yesterday, we've had some warm weather, I can now see a new leaf from each plant has unfurled and grown out. The main stems are also pushing up again. |
It's amazing what a warm day or two can do! My Basjoo is still inside but it's soaking up every sunny day and sprouting new leaves again. After this weekend I think it's going out for the season.... I just have to dig up a spot for it. GGuy - I always have a similar experience with the dwarf cavendish, no matter how hard I try the main stem would never make it through the winter. |
- Posted by gardenguy_ z6a PA (My Page) on Thu, May 12, 05 at 22:57
Check out this link: http://davesgarden.com/pf/go/532/ According to the link, What in the world is that all about? |
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United Methodist Church Marks 14 Years of Persecution of Marriage Equality with Church Trial
Almost 14 years to the day since the United Methodist Church convicted and defrocked Jimmy Creech for performing a "holy union" ceremony for a same-sex couple, the largest mainline Protestant denomination in the United States has convicted another pastor for performing the marriage of a same-sex couple. Rev. Frank Schaefer was convicted at a church trial in Spring City, PA on Monday, November 18th, for presiding at his son's marriage to his male partner. See the full report here.
One of Soulforce's first direct actions was at the trial of Jimmy Creech, held November 17th, 1999. Creech was convicted and defrocked at a church trial in Grand Island, NE. Soulforce activists were arrested as they held vigil in front of the church where the trial would take place, blocking the entrance in protest. (Creech went on to serve as co-chair of the Soulforce board of directors.) Soulforce has supported or been witness to various church trials of pastors for performing marriages for same-sex couples since then, including the trial of Rev. Steven Van Kuiken in 2003 in the Presbyterian Church (USA), and the trial of Rev. Janie Spahr in the same denomination in 2010.
Soulforce continues its support of those who nonviolently resist oppression of LGBTQ people in their congregations and denominations and is currently working with activists in the United Methodist Church who are reviving the tradition of nonviolent direct action. More on this to come!


text: Scholarships are available to students based upon their academic performance, community service, residency and other criteria as defined by the founder or donor of the award. Both the State of Tennessee and the Chattanooga State Foundation provide scholarships for qualified students. In this section you will find a comprehensive list of scholarships available at Chattanooga State.


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Civil rights groups are demanding that the FBI solve a 28-year-old California murder long thought to be the work of Jewish extremists.
Alex Odeh, the Palestinian-American regional director of the Arab-American Anti-Discrimination Committee, was killed in October 1985 by a pipe bomb that exploded when he opened his office door. No one has ever been charged in the case.
Now, the Arab-American Anti-Discrimination Committee has launched a campaign to draw attention to the unsolved killing, in cooperation with other civil rights groups and members of Congress.
"Twenty-eight years is a long time, and, with all due respect, too long a time," said Michigan Congressman John Conyers on a conference call announcing the effort.
NAACP president Ben Jealous and ADC president Warren David spoke on the call, as did Jewish Voice for Peace executive director Rebecca Vilkomerson.
Though officially unsolved, press reports have named a handful of suspects in Odeh's murder over the past three decades, often sourcing the reports to FBI officials. An FBI spokesman said in the immediate aftermath of the murder that it believed the Jewish Defense League was responsible for the bombing, though officials later would only say that they suspected Jewish extremists.
Reports in 1990 by Robert I, Friedman, a Village Voice journalist who has since died, named Jewish Defense League members then living in Israel as suspects.
Founded in 1968 by Rabbi Meir Kahane, who went on to found the banned Kach party in Israel, the JDL was a Brooklyn vigilante group with an underground terrorist wing. JDL members bombed Soviet targets in the United States in the early 1970s to protest the treatment of Soviet Jews. A smoke bomb it set in 1973 ended up asphyxiating a young Jewish secretary employed by a Sol Hurok, a Jewish performing arts promoter who managed concert tours for Soviet classical musicians.
Kahane moved to Israel in 1971, but the group continued its U.S. activism and its terrorist violence without him. The day after the Odeh murder, JDL chairman Irv Rubin brushed off the attack.
"I'm certainly not going to lose any sleep over it," Rubin said. Later, Rubin was harsher. "No Jew or American should shed one tear for the demise of Mr. Odeh," Rubin said. "Regarding the death of Mr. Odeh, unfortunate as it may be, as they say, 'What goes around comes around."'
In a television interview the day before the bombing, Odeh said that Palestinian Liberation Organization head Yasser Arafat was not involved in the hijacking of the cruise ship Achille Lauro days before, and that Arafat was a "man of peace." Arafat maintained at the time and throughout his life that he was not involved in the Achille Lauro hijacking, though some have questioned his account.
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