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Publications (129)280.83 Total impact
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ABSTRACT: We compared cure rates and complication rates in patients who had undergone primary or recurrent (secondary) surgery for stress urinary incontinence (SUI). A retrospective cohort study that included patients who underwent surgery to treat SUI in a tertiary referral center was carried out. All patients had, predominantly, SUI. Exclusion criteria were patients with a neurogenic bladder or a neobladder and patients without postoperative follow-up (FU). The primary objective was to assess the success rate, defined as cured SUI or improved SUI at six weeks and at the latest available moment of FU. The secondary objective was to assess complications. A total of 541 women with SUI underwent surgery for SUI between 2002 and 2010. After exclusion of 102 patients a total of 242 patients with primary SUI and 197 patients with recurrent SUI were identified. The success rate at first FU was 89 %. At last FU (median 205 days) the success rate was 83 % (P < 0.01). There were no significant differences in success rate between primary and recurrent surgery at first FU. The overall success rate of primary surgery was 86 %; for recurrent surgery it was 79 %. During surgery, 27 bladder injuries occurred (6.2 %), with no significant difference between the two groups. At last FU, 11 patients (2.6 %) had persistent residual volume, necessitating prolonged clean intermittent self-catheterization. The results of recurrent surgery to treat recurrent or persistent SUI are still good in experienced hands and do not significantly differ from results of primary surgery. The complication rates are comparable to those of primary surgery.International Urogynecology Journal 03/2015; DOI:10.1007/s00192-015-2627-7 · 2.16 Impact Factor
- Obstetrical and Gynecological Survey 01/2015; 70(1). · 2.36 Impact Factor
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ABSTRACT: Estrogens are known to have a major role in the function of the lower urinary tract although the role of exogenous estrogen replacement therapy in the management of women with lower urinary tract dysfunction remains controversial. Whilst for many years systemic and vaginal estrogen therapy was felt to be beneficial in the treatment of lower urinary and genital tract symptoms this evidence has recently been challenged by large epidemiological studies investigating the use of systemic hormone replacement therapy. Consequently the role of estrogen in the management of postmenopausal women with Overactive Bladder (OAB) remains uncertain. In addition the evidence base regarding the use of exogenous estrogen therapy has changed significantly over the last decade and has led to a major changes in current clinical practice. The aim of this article is to review the evidence for the role of estrogen therapy in the management of OAB focusing on current knowledge with regard to both systemic and local estrogen therapy as well as investigating the emerging role of combination therapy with antimuscarinic agents. Neurourol. Urodynam. © 2013 Wiley Periodicals, Inc.Neurourology and Urodynamics 01/2015; 70(1). DOI:10.1002/nau.22464 · 2.46 Impact Factor
Article: Utility of urodynamics before surgery for stress urinary incontinence: response to editorial by Lose and KlarskovInternational Urogynecology Journal 05/2014; 25(7). DOI:10.1007/s00192-014-2403-0 · 2.16 Impact Factor
Article: 21 Vergelijking van uitkomsten van primaire chirurgische behandeling versus herhaalde chirurgische behandeling van stressincontinentie bij vrouwen[Show abstract] [Hide abstract]
ABSTRACT: Van de vrouwen die chirurgische behandeling voor stress urine-incontinentie (SUI) hebben ondergaan, ondergaat 8 tot 17% een tweede ingreep binnen acht tot tien jaar.05/2014; 4(3):77-78. DOI:10.1007/s13629-014-0035-2
Article: Collagen type III alpha 1 polymorphism (rs1800255, COL3A1 2209 G > A) assessed with high-resolution melting analysis is not associated with pelvic organ prolapse in the Dutch population[Show abstract] [Hide abstract]
ABSTRACT: The rs1800255, COL3A1 2209 G>A polymorphism in the alpha 1 chain of collagen type III has been associated with an increased risk of pelvic organ prolapse (POP). In one of our previous studies however, polymerase chain reaction-based restriction fragment length polymorphism (PCR-RFLP) misdiagnosed rs1800255, COL3A1 2209 G>A in 6 % of cases. The high-resolution melting (HRM) analysis on the contrary obtained a 100 % accordance for this specific polymorphism and was used in the present study to validate this risk factor for POP. In this case-control study, women with and without symptoms of POP were included and compared. DNA was extracted from blood samples. HRM analysis was used to assess for the presence of the homozygous rs1800255. Groups were compared using the Pearson chi-square, Mann-Whitney, and t tests. The discrepancy between HRM and PCR-RFLP results was investigated using PCR-RFLP results available from our previous study. The study included 354 women: 272 patients with POP and 82 controls; 18 (7 %) cases versus 3 (4 %) controls had a homozygous rs1800255, COL3A1 2209 G>A polymorphism (odds ratio 1.9, 95 % confidence interval 0.5-6.9, compared to the wild type), and thus no association between POP and the homozygous polymorphism could be demonstrated. A discrepancy between HRM and PCR-RFLP results was found in 8 % of the samples. The previously found statistically significant association between the rs1800255, COL3A1 2209 G>A polymorphism as measured with PCR-RFLP and POP could no longer be demonstrated. This raises concerns regarding the results of other association studies using PCR-RFLP.International Urogynecology Journal 04/2014; 25(9). DOI:10.1007/s00192-014-2385-y · 2.16 Impact Factor
Article: Bladder function after radical hysterectomy for cervical cancer: Bladder Function after Radical Hysterectomy[Show abstract] [Hide abstract]
ABSTRACT: To report the effects of radical hysterectomy and nerve-sparing techniques on lower urinary tract function in women. A literature search was performed in Pubmed and Medline using the keywords bladder after radical hysterectomy, nerve sparing radical hysterectomy, and urinary dysfunction following radical hysterectomy. Significant results and citations were reviewed manually by the authors. The sympathetic and parasympathetic systems innervating the lower urinary tract may be disrupted due to resection of uterosacral and rectovaginal ligaments, the dorsal and lateral paracervix, the caudal part of the vesico-uterine ligaments, and the vagina. This supports the neurogenic etiology of early and late bladder dysfunction after radical surgery. Bladder disorders are also related to the extent of radical surgery. The neuropathopysiology of lower urinary tract symptoms after radical hysterectomy is not fully understood. Recent data have highlighted the role of urethral sphincter pressure in the etiology of postoperative incontinence. Various surgical approaches have been developed to preserve autonomic pelvic innervation. Nerve-sparing techniques appear to improve bladder function without compromising overall survival. Studies comparing the effects of nerve-sparing radical hysterectomy with standard surgery yielded encouraging results in respect of postoperative lower urinary tract function. Clinical trials with a long period of follow-up are required for better comprehension of the complex pathophysiology of bladder dysfunction after radical hysterectomy. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc.Neurourology and Urodynamics 02/2014; 34(4). DOI:10.1002/nau.22570 · 2.46 Impact Factor
Article: Authors' Response Re: Do Preoperative Urodynamics Still Have a Role in Female Stress Urinary Incontinence? Neurourol Urodyn 2013;32:1144-5Neurourology and Urodynamics 11/2013; 32(8). DOI:10.1002/nau.22339 · 2.46 Impact Factor
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ABSTRACT: The objective of this study was to correlate dynamic magnetic resonance imaging (MRI) with Pelvic Organ Prolapse Quantification (POP-Q) measurements and pelvic floor symptoms in order to determine the value of dynamic MRI for evaluating vaginal vault prolapse both before and 6 months after laparoscopic sacrocolpopexy. This was a prospective, single-center cohort study in 43 patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone-anchor fixation and synthetic mesh. The study included dynamic MRI, POP-Q staging, and validated questionnaires before and 6 months after laparoscopic sacrocolpopexy. To assess MRI data, the pubococcygeal reference line and specifically defined anatomical landmarks for the separate compartments were used. Differences between pre- and postoperative measurements were evaluated with the Wilcoxon signed-rank test, and correlations at the 0.05 level were considered to be significant (Pearson correlation, two tailed). At 6 months, a statistically significant improvement was seen in POP-Q staging for all compartments. Dynamic MRI measurements only revealed a significant improvement after surgery for the apical compartment. The correlation between (changes in) MRI measurements, POP-Q measurements, and validated questionnaires was poor. The value of dynamic MRI for evaluating and documenting changes in vaginal vault support and position after laparoscopic sacrocolpopexy is limited due to the poor correlation with both POP-Q staging and pelvic floor symptoms.International Urogynecology Journal 10/2013; 25(4). DOI:10.1007/s00192-013-2254-0 · 2.16 Impact Factor
Article: In Reply.Obstetrics and Gynecology 10/2013; 122(4):905. DOI:10.1097/AOG.0b013e3182a79e07 · 4.37 Impact Factor
Article: Inter- and intraobserver reliability for diagnosing levator ani changes on magnetic resonance imaging[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVES: The aim of this study was to assess the inter- and intraobserver reliability for diagnosing pubovisceral muscle avulsions and measurements of the levator hiatus on magnetic resonance (MR) imaging. Women with recurrent POP or in whom there was a discrepancy between clinical signs and symptoms of pelvic floor dysfunction were potentially eligible to participate. METHODS: Magnetic resonance imaging datasets of the pelvic floor of 262 women were obtained and scored by two observers. A random sample of 100 patients was reviewed a second time by one of the observers. Intraclass correlation coefficient with 95% confidence interval (ICC 95%CI) of all measurements were calculated. Furthermore, mean differences with accompanying limits of agreement were calculated to estimate agreement between two measurements and to detect possible systematic biases. RESULTS: Good interobserver reliability for pubovisceral muscle avulsions was found (ICC 0.76 - 0.79) and excellent agreement for measurements of the levator hiatus (ICC 0.85 - 0.89). The intraobserver reliability for pubovisceral muscle avulsions and other levator hiatus measurements also showed to be excellent (ICC 0.80 - 0.97). A significant systematic bias was observed in the mean difference of levator hiatus transverse diameter when measured by both observers, however, narrow limits of agreement were observed. CONCLUSIONS: Pubovisceral muscle avulsions and levator hiatus measurements can be assessed with good to excellent reliability.Ultrasound in Obstetrics and Gynecology 09/2013; 42(3). DOI:10.1002/uog.12462 · 3.14 Impact Factor
Article: A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVES: Despite extensive research aimed at clarifying (failing) pelvic organ support, the complete aetiology of pelvic organ prolapse (POP) is still not fully understood. During vaginal delivery, the pelvic floor can be irreversibly traumatised, resulting in pubovisceral muscle avulsions. The aetiology of these avulsions is discussed in this pictorial overview. Normal female pelvic floor anatomy is described and variations are exemplified using magnetic resonance (MR) images. The clinical relevance of detecting pubovisceral muscle avulsions is specified. METHODS: T2-weighted MR imaging has multiplanar capabilities with high diagnostic accuracy allowing for detailed visualisation of the pelvic floor. Together with the use of a three-dimensional (3D) post-processing program, the presence and severity of pubovisceral muscle avulsions can be quantified. RESULTS: Pelvic floor MR imaging is a non-invasive method that enables adequate identification of pubovisceral muscle avulsions which are known risk factors for the development of POP. They can be scored with good to excellent inter- and intra-observer reliability. CONCLUSIONS: Radiologists and urogynaecology subspecialists should be familiar with MR imaging findings of pubovisceral muscle avulsions as this birth-related trauma is observed in over 36 % of vaginally parous women. TEACHING POINTS: • Pelvic organ prolapse (POP) is a growing problem for both patients and for our healthcare system • Pubovisceral muscle avulsions are known risk factors for pelvic organ prolapse (POP) • T2-weighted MR imaging visualises pubovisceral muscle avulsions adequately • Pubovisceral muscle avulsions are scored with good to excellent inter- and intra-observer reliability.06/2013; 4(4). DOI:10.1007/s13244-013-0261-9
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ABSTRACT: AIMS: This study focused on the changes in urinary incontinence (UI) rates pre- and postoperatively and identified risk factors which predict the presence of symptoms of urgency urinary incontinence (UUI) or stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) without concomitant or previous anti-incontinence surgery. METHODS: All consecutive women who underwent POP surgery without concomitant or previous anti-incontinence surgery in the years 2004-2010 were included. Assessments were performed preoperatively and at 1-year follow-up, including pelvic organ prolapse quantification score and a standardized urogynecological questionnaire (Urogenital Distress Inventory, UDI). Primary outcome of this study was stress and/or urgency UI postoperatively. Furthermore, this study measured the improvement or worsening of UI following surgery using the UDI. Univariable- and multivariable logistic regression with forward selection procedure was used to identify the risk factors. RESULTS: Nine hundred seven patients were included. De novo SUI appeared in 22% and de novo UUI occurred in 21% of the women. At 1-year 42% were cured for UUI and 39% were recovered from SUI by POP surgery alone. The best predictor for the occurrence of postoperative SUI or UUI was the presence of preoperative SUI or UUI. BMI and chronic obstructive pulmonary disease (COPD) were identified as independent risk factors for postoperative SUI. A recurrence in the anterior compartment protected against SUI postoperatively. CONCLUSIONS: Preoperative SUI or UUI is the most important predictor of SUI and UUI postoperatively. BMI and COPD were identified as important risk factors for SUI. Neurourol. Urodynam. © 2012 Wiley Periodicals, Inc.Neurourology and Urodynamics 06/2013; 32(5). DOI:10.1002/nau.22327 · 2.46 Impact Factor
Article: Value of Urodynamics Before Stress Urinary Incontinence Surgery A Randomized Controlled Trial[Show abstract] [Hide abstract]
ABSTRACT: : To estimate whether a strategy of immediate surgery was noninferior to a strategy based on discordant urodynamic findings followed by individually tailored therapy in women with stress urinary incontinence (SUI). : A multicenter diagnostic cohort study with an embedded noninferiority randomized controlled trial was conducted in six academic and 24 nonacademic Dutch hospitals. Women with predominant SUI eligible for surgical treatment based on clinical assessment were included between January 2009 and November 2010. All patients underwent urodynamics. In patients in whom urodynamics were discordant with clinical assessment, participants were randomly allocated to receive either immediate surgery or individually tailored therapy based on urodynamics. The primary outcome was clinical improvement assessed by the Urogenital Distress Inventory 12 months after baseline. Analysis was by intention to treat; a difference in mean improvement of 5 points or less was considered noninferior. : Five hundred seventy-eight women with SUI were studied, of whom 268 (46%) had discordant findings. One hundred twenty-six patients gave informed consent for randomization and were allocated to receive immediate surgery (n=64) or individually tailored therapy (n=62). The mean improvement measured with the Urogenital Distress Inventory after 1 year was 44 points (±24) in the group receiving immediate surgery and 39 (±25) points in the group receiving individually tailored treatment. The difference in mean improvement was 5 points in favor of the group receiving immediate surgery (95% confidence interval -∞ to 5). There were no differences with respect to cure or complication rate. : In women with uncomplicated SUI, an immediate midurethral sling operation is not inferior to individually tailored treatment based on urodynamic findings. : ClinicalTrials.gov, www.clinicaltrials.gov, NCT00814749. : I.Obstetrics and Gynecology 05/2013; DOI:10.1097/AOG.0b013e31828c68e3 · 4.37 Impact Factor
Article: Comparison of two trocar-guided trans-vaginal mesh systems for repair of pelvic organ prolapse: a retrospective cohort study[Show abstract] [Hide abstract]
ABSTRACT: INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare failure and complication rates in patients who underwent a trocar-guided vaginal mesh repair with either a non-absorbable or a partially absorbable mesh. METHODS: Retrospective analysis of prospectively collected data from consecutive women undergoing either non-absorbable or partially absorbable mesh for symptomatic stage 2 prolapse or higher were evaluated at 12 months. Outcome measures included objective and subjective failure rates, patient's satisfaction, complications and perioperative outcomes. RESULTS: Five hundred and sixty-nine women (347 with non-absorbable mesh, 222 with partially absorbable mesh) were included. Failure rates were similar in the two groups; the re-operation rate in the untreated compartments was higher in the non-absorbable mesh group compared with the partially absorbable mesh group (5 % vs 1 %). Mesh exposure rate in the non-absorbable mesh group was 12 % and in the partially absorbable mesh group it was 5 %. Other complication and patient satisfaction rates were similar. CONCLUSIONS: Non-absorbable and partially absorbable mesh demonstrated similar outcome rates at 12 months. The risk of reoperation was lower for partially absorbable mesh. The mesh exposure rate was significantly lower for the partially absorbable mesh group compared with the non-absorbable mesh group.International Urogynecology Journal 05/2013; 24(10). DOI:10.1007/s00192-013-2098-7 · 2.16 Impact Factor
Article: Surgical treatment of pelvic organ prolapse: a historical review with emphasis on the anterior compartment[Show abstract] [Hide abstract]
ABSTRACT: INTRODUCTION AND HYPOTHESIS: The objective of this work was to collect and summarize a detailed historical review of the surgical treatment of pelvic organ prolapse (POP) in which we specifically focused on the anterior compartment. METHODS: A literature search in English, Dutch, and German was carried out using the keywords pelvic organ prolapse, anterior colporrhaphy, cystocele, and interposition operations in several databases (e.g., PubMed and HathiTrust Digital Library). Other relevant journal and textbook articles were found by retrieving references cited in previous articles and textbooks. RESULTS: Probably the first explanation of the treatment of POP dates from 1500 B.C. The Egyptians gave a description to "falling of the womb" in the Kahun Papyrus. More than a millennium later, Euryphon, a contemporary of Hippocrates (400 B.C.) described some interesting therapeutic options, from succussion (turning a women upside down for several minutes) to irrigating the displaced uterus with wine. A wide range of techniques has been attempted to repair the prolapsing anterior vaginal wall. By 1866, Sim had already performed a series of operations very similar to a modern anterior repair. The first reviews about the abdominal approach to correcting a cystocele were in 1890. The first description of using mesh to cystoceles was the use of tantalum mesh in 1955. In 1970, the first report of collagen mesh in urogynecology was described. Nowadays, robot-assisted surgery and cell-based tissue engineering are the latest interventions. CONCLUSION: Many surgeons have tried to find the ideal surgical therapy for anterior compartment prolapse, but to date, this has not been achieved.International Urogynecology Journal 03/2013; 24(10). DOI:10.1007/s00192-013-2074-2 · 2.16 Impact Factor
Article: Does the method of dissecting in anterior colporraphy lead to a difference in thickness of removed vaginal tissue?[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVE: To evaluate the difference in thickness of the anterior vaginal wall removed after different surgical dissecting techniques of anterior colporrhaphy. STUDY DESIGN: In patients undergoing primary anterior colporrhaphy, trimmed vaginal tissue was taken following different surgical techniques of vaginal wall dissection. Tissues were preserved in formalin and stained with hematoxylin-eosin and elastica-van Giesen stains. The examiner was an experienced pathologist blinded to the surgical technique. The specimens were examined for the epithelial thickness (ET), lamina propria thickness (LPT), muscular layer thickness (MT) and total thickness (TT). RESULTS: Tissue was analysed in 93 women who underwent anterior compartment pelvic organ prolapse surgery. There was no difference between the different surgical techniques in thickness measured in the three histological layers and for the total thickness. The use of hydrodissection was the only independent factor leading to thicker removed vaginal tissue. CONCLUSIONS: Dissecting the vaginal wall as thin as possible does not result in a thinner vaginal layer than dissecting in the most optimal surgical plane. The use of hydrodissection provides a thicker trimmed tissue.European journal of obstetrics, gynecology, and reproductive biology 01/2013; 168(1). DOI:10.1016/j.ejogrb.2012.12.028 · 1.63 Impact Factor
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ABSTRACT: The value of urodynamics (UDS) in the preoperative workup of women with complaints of stress urinary incontinence (SUI) is in question. A previous underpowered randomized controlled trial (RCT) by the same group compared a strategy of UDS and a strategy of immediate surgery in the preoperative workup of women with SUI. Those data showed no benefit of UDS in these women. This multicenter cohort study was designed to determine whether a strategy of immediate surgery is noninferior to a strategy based on urodynamic findings followed by individually tailored therapy in women with SUI. The study was conducted at 6 academic and 24 nonacademic hospitals in the Netherlands between January 2009 and November 2010. All participants enrolled in the study had predominant SUI and were candidates for surgical treatment based on clinical assessment. All subjects underwent UDS according to International Continence Society standards. The primary study outcome was clinical improvement as measured with the Urogenital Distress Inventory (UDI) at 1 year after baseline. A difference in mean improvement of 5 points or less in the UDI urinary incontinence subscale score was considered noninferior. Among 578 women included in the intention-to-treat analysis, 268 (46%) had urodynamic findings discordant with clinical history and physical examination. Study subjects with discordant UDS who consented to take part in a nested randomized trial received either immediate surgery (n = 64) or individually tailored therapy based on UDS (n = 62). After 1 year, the mean improvement measured on the UDI was 44 points (±24) in the group receiving immediate surgery and 39 (±25) points in the group receiving individually tailored treatment. The 5-point difference in mean improvement in the group receiving immediate surgery confirms noninferiority for either 1 of both treatment strategies. The mean improvement of the randomized subjects was also not different from those of the cohort of women for whom UDS was concordant with their clinical diagnosis of SUI. There were no differences between all groups with respect to subjective or objective cure or in the complication rate. These findings show that an immediate midurethral sling operation in women with uncomplicated SUI is not inferior to individually tailored treatment based on urodynamic findings. The data suggest that UDS can be omitted before stress incontinence surgery in women with uncomplicated SUI.Obstetrical and Gynecological Survey 01/2013; 68(8):565-566. DOI:10.1097/01.ogx.0000433840.24794.b5 · 2.36 Impact Factor
Article: Laparoscopic sacral colpopexy versus total vaginal mesh for vault prolapse; comparison of cohorts[Show abstract] [Hide abstract]
ABSTRACT: The surgical treatment of vaginal vault prolapse can either be performed by the vaginal or the abdominal (laparoscopic) route. The objective of this study was to compare the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM) for vaginal vault prolapse. This study compared a prospective cohort of LSC with bone-anchor fixation and mesh limited to the apex to a prospective cohort of TVM as treatment modalities in patients with a symptomatic vaginal vault prolapse (pelvic organ prolapse-quantification (POP-Q) point C ≥ −3). Primary outcome was failure in the apical compartment after 6 month follow-up, defined as POP-Q stage ≥ II with prolapse complaints or re-treatment in apical compartment. Based on an overall failure in all compartments of 23 % in the LSC group and 57 % in the TVM group, 29 patients would be needed in each group with a power of 80 % and alpha 0.05. Ninety-seven women were included, 45 LSC and 52 TVM. The failure rate of symptomatic vault prolapse was 1 (2 %) in each group (p = 0.99). The failure rate (POP stage ≥ II) in any compartment was 23 (51 %) in the LSC group and 11 (21 %) in the TVM group (p = 0.002). Each technique had its own type of complications. Short-term failure rates in the apical compartment after TVM and LSC were similar. In case of anterior or posterior prolapsed, additional mesh insertion or additional vaginal colporrhaphy is indicated in LSC surgery.Gynecological Surgery 01/2013; 10(2). DOI:10.1007/s10397-013-0786-4
Article: Correlating signs and symptoms with pubovisceral muscle avulsions on magnetic resonance imaging[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVE: To correlate signs and symptoms of pelvic organ prolapse (POP) with pubovisceral muscle avulsions on magnetic resonance (MR) imaging. STUDY DESIGN: In this retrospective cohort study of 189 women with recurrent POP or unexplained symptoms of pelvic floor dysfunction, we reviewed T(2)-weighted pelvic floor MR images and categorized defects as minor or major avulsion, or as no defect present. Outcomes were correlated to quality of life questionnaire scores and data on obstetric and surgical history, together with pelvic organ prolapse quantification (POP-Q) measurements. Multivariable ordinal logistic regression analysis with manual backward elimination was applied to calculate odds ratios (ORs). RESULTS: Major pubovisceral avulsions were diagnosed in 83 (44%) women, minor avulsions in 49 (26%) women, while no defects were seen in 57 (30%) women. Women with a history of episiotomy or anterior vaginal wall reconstructive surgery had a higher OR for more severe pubovisceral muscle avulsions (adjusted OR 3.77 and 3.29, respectively), as well as women with symptoms of POP (OR 1.01, per unit increase) or higher stage POP of the central vaginal compartment based on POP-Q measurement "C" (OR 1.18). Women with symptoms of obstructive defecation were more likely to have no defect of the pubovisceral muscle on MR imaging (OR 0.97, per unit increase). CONCLUSIONS: The variables episiotomy, previous anterior vaginal wall reconstructive surgery, POP-Q measurement "C", and symptoms scored with the Urogenital Distress Inventory "genital prolapse" and Defecatory Distress Inventory "obstructive defecation" subscales are correlated with pubovisceral muscle avulsions on pelvic floor MR imaging.American journal of obstetrics and gynecology 12/2012; 208(2). DOI:10.1016/j.ajog.2012.12.006 · 3.97 Impact Factor
Top Journals
Radboud University Medical Centre (Radboudumc)
Nymegen, Gelderland, Netherlands
- Department of Human Genetics
Radboud University Nijmegen
Nymegen, Gelderland, Netherlands
- Department of Obstetrics and Gynecology
St. Antonius ZiekenhuisNieuwegen, Utrecht, Netherlands
Erasmus Universiteit Rotterdam
Rotterdam, South Holland, Netherlands
- Department of Obstetrics and Gynaecology
Erasmus MC
Rotterdam, South Holland, Netherlands
- Department of Obstetrics and Gynaecology
Het Oogziekenhuis RotterdamRotterdam, South Holland, Netherlands
NL Agency, Netherlands's-Gravenhage, South Holland, Netherlands
West Georgia Obstetrics and GynecologyGeorgetown, Georgia, United States


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Tip of the Day
Moving photos from main timeline into albums in iOS 8
The main Photos timeline view in iOS 8 is a nice way to display all of your photos, but if you're often taking special purpose photos — such as screenshots — it can sometimes get a bit cluttered. As we discussed in our previous tip, you can hide photos so that they disappear from the timeline, which will place them in a default hidden album. But you can also effectively move photos from your timeline into specific photo albums.
To do this, simply take the photos you want to remove from your timeline, and first add them to an album — this can be a brand new album or an existing album. Once you've done this, hide them by tapping-and-holding and choose the "Hide" option from the popup menu that appears.
The photos will disappear from your timeline, but will still be shown in any albums that you've manually placed them into, which you can find from the "Albums" view. Despite being hidden, you can also still remove them from this album, find them in the "hidden" album and "All Photos" views, and assign them to different albums — they still work like normal photos, but simply don't appear in the main "Photos" timeline. As an added bonus, if you're using iCloud Photo Library, these changes all sync to your Mac and your other iOS devices as well.
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A few quick changes can make your visitors feel like they're living the luxe life.
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White birch trees shade a Sutherland sofa and love seat on the rooftop terrace; the cushions and pillows are covered in Perennials fabrics, and Booth designed the lattice screening.
What a perfect place to have Sunday brunch! Surrounded by a lush garden, this is an ideal spot for a sunny dining area.
What's Hot! March 2008


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There are lots of cold, hard facts in this book, which is great for those interested in statistics. For people who want a view of the day beyond the numbers, dates and times, to... Read morePublished on September 12, 2011 by Lauren
I've been reading everything I can on 9/11 lately, and sorry to say this one was one of the worst. I just find it terribly written and organized. Read morePublished on February 17, 2009 by blibberinghumdinger
While this book was OK, I found too much about bin Laden within the pages. I felt that part should be a separate book. All-in-all it was a fast read and somewhat informative. Read morePublished on September 1, 2006 by Nose in a Book
I found this book to be very good. It introduces you to many people involved to day.....from Mohammed Atta to the pilot of flight 11 to firefighters. Read morePublished on January 31, 2006 by P. Miller
This is,without doubt,the best book I've come across about that dastardly act committed on 9/11.We have all watched many hours of televised newscasts and specials covering this... Read morePublished on January 26, 2005 by J. Guild
The beginning of this book is very difficult to stomach. Although it has been almost two years since this horrific event, it still seems like yesterday to me. Read morePublished on August 13, 2003 by A. Vegan


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What does └«ñ.└«à.└«¬└»ï.└«ò stand for?
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Hamburg, Hamburg, Germany
75% response rate · Last login 8 days ago
Join Couchsurfing to see Malte's full profile. It's free!View Full Profile
H e y, y o u !
I am Malte, 24 years old, open minded, ambitious, active and outgoing. I am a communicative and tolerant person, curious to hear what other people have to say or what stories they can tell. Always trying to get some traveling, surfing or hosting going on.
I love hanging around with honest, funny people. And I love traveling... well I guess that's what I'm here for. Likewise, I am really into music & movies! And sports. These are my biggest passions for now, but I'd like to learn about passions, activities and hobbies other people have.
My goals: meet great people and see more beautiful places!
Please check what others are saying about me in my references. It will probably add up to a more detailed description of my person than my own written text :-)
Please check my couch description. I can offer you a couch/mattress to sleep on but I don't have a free room for CS guests in my apartment.
Of course, you're welcome to contact me if you're coming to Hamburg. Maybe I can give you some helpful recommendations, show you around the city or we can meet for a drink.
I started Couchsurfing when I was travelling in Canada & the US with my best buddy back in 2010, thus a few recommendations on my profile have been written for 2 people, in case you wondered. Together we did an amazing road trip starting in Summer from the West Coast of Vancouver, B.C., until we reached New York City in cold winter. In between we made a lot of interesting and mostly great couchsurfing experiences. On a different trip to South America, I also had a really good time couchsurfing in Florianopolis. I'd love to return to South America to travel to other places besides Brazil.
I went to a local Couchsurfing event once while I was visiting Ottawa. It was a potluck party and I met lots of fascinating travellers there.
By welcoming Couchsurfers to my hometown Hamburg, I try to innervate the great idea behind couchsurfing. Also, I love the way how couchsurfing guests can mix up your daily routine. It's like the pizza guy bringing great stories by cool people from distant places to your front door.
I feel glad that I could enjoy such variety of couchsurfing experiences so far. I want to keep on with the couchsurfing, wherever I go. It's the best way to travel!
So far I've enjoyed and contributed to the benefits of Couchsurfing in...
Hamburg, Germany
Calgary, Canada
Halifax, Canada
Ottawa, Canada
Montréal, Canada
Philadelphia, U.S.A.
Boston, U.S.A.
Florianopolis, Brazil
I hope there's a lot more to come.
Meet people, get around, see awesome places, sports & games, read, watch movies, listen to music, make music, talk about movies, music, books and more, more, more.
Drive, Moonrise Kingdom, The Big Lebowski, Fight Club, GoodFellas, Casino, The Godfather, Trainspotting, Seven, Pulp Fiction, Departed, Memento, Boogie Nights, Inception.
... but also more independent productions like La Haine, The Act of Killing, Waltz with Bashir, The Congress, Donnie Darko, Napoleon Dynamite, Do The Right Thing, Night on Earth,
... still so much to add here.
Her, Snowpiercer, Interstellar are some of my recent favorites.
I dig a lot of different styles. Starting from Funk and Soul music (70s/80s/Motown) to Rap music (A Tribe Called Quest, MF Doom, Mos Def, Wu Tang, De La Soul), some classic rock (Pink Floyd, Queen, Led Zeppelin), some smooth Jazz (Dave Brubeck, Miles Davis)... The Black Keys, Ratatat, Beach House, Little Dragon, King Krule, Future Islands, SOHN, The XX..., Âme, Dixon, Ten Walls, Mano Le Tough and so on.
Paul Auster, David Foster Wallace, Hakan Nesser, Martin Suter, (and also many more here...)
"If I never meet you in this life,
let me feel the lack.
A glance from your eyes,
then my life will be yours."
- James Jones
Antigua and Barbuda, Argentina, Belgium, Brazil, Canada, Czech Republic, Denmark, France, Hungary, Italy, Luxembourg, Netherlands, Puerto Rico, Saint Lucia, Spain, Sweden, Switzerland, United States
Canada, Germany
Join Couchsurfing to see Malte's full profile. It's free!View Full Profile


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- 396Promote
Wall Clock
Catch of the dayby Budi Kwan
Available in natural wood, black or white frames, our 10" diameter unique Wall Clocks feature a high-impact plexiglass crystal face and a backside hook for easy hanging. Choose black or white hands to match your wall clock frame and art design choice. Clock sits 1.75" deep and requires 1 AA battery (not included).
Excellent! Love the negative space
So creative!
Cute and cool
great job Budi!
so cute!
Thank you
super cute!
Beautiful work!!
wow!!!! i love it :))))))))wonderful ♡
soooo gooood!!!!! colors!!!!!
good stuff!
This is so cute. :D
Love the simplicity of this piece. Very nice illustration.
your work is funny, beautiful with great idea ! bravo :)
Well done! Awesome!
See More Comments


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ACR appropriateness criteria (R) adjuvant therapy for resected squamous cell carcinoma of the head and neck
ABSTRACT Locoregional recurrence following surgical resection alone for stage III/IV head and neck cancer is common. Adjuvant radiotherapy has been shown to improve post-operative locoregional control when compared to pre-operative radiotherapy for head and neck cancers. Following surgical resection, adverse pathological features determine the need for adjuvant therapy. High-risk pathologic features include extranodal tumor spread and involved surgical margins. Other adverse pathologic features include T 3-4 tumors, perineural invasion, lymphovascular space invasion, low neck adenopathy, and multiple tumor involved cervical lymph nodes. The standard adjuvant therapies are post-operative radiation therapy or post-operative chemoradiotherapy. Post-operative chemoradiotherapy yields superior locoregional control, progression-free survival, and in some studies, overall survival compared to post-operative radiotherapy for high-risk patients in multiple randomized studies. Pooled analyses of randomized data demonstrate that post-operative concurrent chemoradiotherapy is associated with overall survival benefits for patients with involved surgical margins as well as those with extranodal tumor spread. Post-operative radiotherapy concurrent with cisplatin at 100 mg/m(2) every 21 days is the current standard chemoradiotherapy platform adjuvant head and neck cancer treatment. Post-operative radiotherapy and post-operative chemoradiotherapy radiation treatment volumes are not standardized and should be designed based on the risk of recurrence and clinically occult involvement of head and neck subsites and nodal regions. Evidence supports a post-operative radiotherapy and chemoradiotherapy radiation dose of at least 63 Gy for high-risk patients and at least 57 Gy for low risk patients.
- SourceAvailable from: europepmc.org
Article: The Effect of the Surgical Margins on the Outcome of Patients with Head and Neck Squamous Cell Carcinoma: Single Institution Experience[Show abstract] [Hide abstract]
ABSTRACT: To assess the impact of close or positive surgical margins on the outcome, and to determine whether margin status influence the recurrence rate and the overall survival for patients with head and neck cancers. Records from 1996 to 2001 of 413 patients with primary head and neck squamous cell carcinoma (SCC) treated with surgery as the first line treatment were analysed. Of these patients, 82 were eligible for the study. Patients were followed up for 5 years. Patients with margins between 5-10 mm had 50% recurrence rate (RR), those with surgical margins between 1-5 mm had RR of 59% and those with positive surgical margins had RR of 90% (P=0.004). The 5-year survival rates were 54%, 39% and 10%, respectively (P=0.002). Unsatisfactory surgical margin is an independent risk factor for recurrence free survival as well as overall survival regardless of the other tumor and patient characteristics.03/2012; 9(1):29-33. DOI:10.3969/j.issn.2095-3941.2012.01.005
Article: Perineural Spread in Head and Neck Malignancies: Clinical Significance and Evaluation with F-18-FDG PET/CT1[Show abstract] [Hide abstract]
ABSTRACT: Certain tumors of the head and neck use peripheral nerves as a direct conduit for tumor growth away from the primary site by a process known as perineural spread. Perineural spread is associated with decreased survival and a higher risk of local recurrence and metastasis. Radiologists play an important role in the assessment and management of head and neck cancer, and positron emission tomography/computed tomography (PET/CT) with 2-[fluorine 18]fluoro-2-deoxy-d-glucose (FDG) is part of the work-up and follow-up of many affected patients. Awareness of abnormal FDG uptake patterns within the head and neck is fundamental for diagnosing perineural spread. The cranial nerves most commonly affected by perineural spread are the trigeminal and facial nerves. Risk of perineural spread increases with a midface location of the tumor, male gender, increasing tumor size, recurrence after treatment, and poor histologic differentiation. Focal or linear increased FDG uptake along the V2 division of the trigeminal nerve or along the medial surface of the mandible, or asymmetric activity in the masticator space, foramen ovale, or Meckel cave should raise suspicion for perineural spread. If FDG PET/CT findings suggest perineural spread, the radiologist should look at available results of other imaging studies, especially magnetic resonance imaging, to confirm the diagnosis. Knowledge of common FDG PET/CT patterns of neoplastic involvement along the cranial nerves and potential diagnostic pitfalls is of the utmost importance for adequate staging and treatment planning. © RSNA, 2013.Radiographics 10/2013; 33(6):1717-1736. DOI:10.1148/rg.336135501 · 2.73 Impact Factor


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Top 7 Best Skateboarding Elbow Pads In 2015
Skateboarding is a sport that is entertaining, fun, but it also comes with its risks. Though skateboarding is entertaining, skaters will normally have falls. Yes, this is part of the sport and especially if you are at the beginners stage. However, in an effort to ensure that


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To see more of my contemporary landscape oil paintings, visit NikiGulley.com.
Niki's Blog
Art Treks, contemporary garden paintings, France, Giverny, Monet's water lilies, Niki Gulley paintings, Paris art classes, photo tours, photography lessons, plein-air painting workshops Europe
Art Fair on the Square
Saturday, July 11 • 9am – 6pm
Sunday, July 12 • 10am – 5pm
Madison, WI • Capital Square
Booth #143 on Carroll St. between State and W. Washington
State Street Area Art Fair
Wed. July 15 • 10am – 9pm
July 16 & 17 • 10am – 9pm
Sat. July 18 • 10am – 6pm
Ann Arbor, MI • Booth #B214
on N. University between Thayer & State St.
Cheesman Park Art Fest
Sat. July 25 • 10am – 9pm
Sun. July 26 • 10am – 9pm
Denver, CO • Cheesman Park at
E. 8th Ave. and N. Williams St.
Booth #A7
Autumn and Art
Friday, Sept. 18 • 10am – 7pm
Saturday, Sept. 19 • 10am – 7pm
Sunday, Sept. 20 • 10am – 5pm
Bradley Fair Parkway • Wichita, KS
The Good Art Company Gallery
218 West Main St.
Fredericksburg, TX
Davis & Co. Fine Art Gallery
200 Main St.
Old Town Spring, TX
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Posted| Updated
Police say they have grave fears for an 88-year-old woman who has gone missing on the New South Wales far south coast.
Topics: police, batemans-bay-2536, malua-bay-2536, bega-2550
A risk analysis expert says while the New South Wales far south coast is vulnerable to a tsunami; it is unlikely there would be a big loss of life.
Topics: disasters-and-accidents, batemans-bay-2536, bega-2550, eden-2551, wollongong-2500
Community organisations on the New South Wales far south coast are set to receive thousands of dollars from the State Government.
Topics: government-and-politics, community-and-society, community-development, community-organisations, bega-2550, batemans-bay-2536, north-narooma-2546, narooma-2546, moruya-2537
Posted| Updated
The Federal Member for Eden-Monaro, Mike Kelly, says university related organisations in the New South Wales south east will need to change their financial practices if the Government's planned changes to education funding are passed.
Topics: education-industry, education, government-and-politics, bega-2550, batemans-bay-2536
The New South Wales Government says ensuring the safety of motorists is the main reason behind the decision to close a major Eurobodalla road for maintenance.
Topics: road-transport, business-economics-and-finance, travel-health-and-safety, batemans-bay-2536, canberra-2600, braidwood-2622
The Liberal candidate for Eden-Monaro in the New South Wales south east, Peter Hendy, has defended the Coalition's broadband policy.
Topics: internet-technology, bega-2550, batemans-bay-2536, cooma-2630, jindabyne-2627, moruya-2537, queanbeyan-2620
A Eurobodalla Shire Councillor says there is confusion surrounding predicted sea level rises due to global warming.
Topics: environmental-impact, environmental-management, bega-2550, batemans-bay-2536
Nurses from the New South Wales south east have joined their colleagues from other regions outside State Parliament to win better conditions and improved pay.
Topics: health-administration, unions, bega-2550, batemans-bay-2536, cooma-2630
A major bowling club on the New South Wales far south coast is set to close later this month.
Topics: bowls-and-petanque, community-and-society, batemans-bay-2536
Surf lifesavers on the New South Wales far south coast say even though the beach-season is coming to an end, swimmers still need to take care.
Topics: swimming, surf-life-saving, broulee-2537, batemans-bay-2536, bega-2550
New statistics have revealed the percentage of women working in Clubs on the New South Wales far south coast is higher than the state average.
Topics: hospitality, community-and-society, work, family, batemans-bay-2536, narooma-2546, bega-2550, merimbula-2548
The south east's major telecommunications provider says it is working to improve mobile coverage in the region.
Topics: information-and-communication, wireless-communication, batemans-bay-2536, broulee-2537, merimbula-2548
A climate change expert says the New South Wales south east is becoming hotter and drier due to global warming.
Topics: weather, climate-change, bega-2550, batemans-bay-2536, cooma-2630, jindabyne-2627, bombala-2632
Police say motorists have to stop blaming a highway in the New South Wales south east and look at their own driving to prevent serious accidents.
Topics: road, nelligen-2536, batemans-bay-2536, bega-2550
A council in the New South Wales high country says it cannot understand why a multi-million dollar higher education project is not being funded by the Federal Government.
Topics: regional-development, jindabyne-2627, batemans-bay-2536, cooma-2630, bega-2550
Nurses and midwives in the New South Wales south east have begun voting on whether they approve of proposed changes to staff ratios and wages.
Topics: health-administration, bega-2550, batemans-bay-2536, moruya-2537, pambula-2549, cooma-2630
Posted| Updated
The New South Wales south east's theatre industry has been recognised at an awards ceremony on the weekend.
Topics: arts-and-entertainment, awards-and-prizes, cooma-2630, bega-2550, batemans-bay-2536, merimbula-2548
Environmental activists in the New South Wales south east say a review of forestry contracts in the region is urgently needed.
Topics: forestry, environmental-policy, corruption, bega-2550, batemans-bay-2536, nowra-2541, tumbarumba-2653, tumut-2720
Posted| Updated
The general manager of the Eurobodalla Health Service on the New South Wales far south coast, Lisa Kennedy, says it will review a proposal to merge the shire's two hospitals.
Topics: healthcare-facilities, batemans-bay-2536, moruya-2537, bega-2550
The President of the Australian Surfboat Rowers League says doping in surf lifesaving on the New South Wales far south coast could have occurred.
Topics: doping-in-sports, bega-2550, tathra-2550, batemans-bay-2536, moruya-2537
The State Government has announced natural disaster declarations for parts of the New South Wales south east, after last month's damaging bushfires.
Topics: disasters-and-accidents, bega-2550, batemans-bay-2536
Posted| Updated
The Member for Monaro, John Barilaro, says reforms to the way retirement villages are operated is good news for people in the New South Wales south east.
Topics: aged-care, bega-2550, batemans-bay-2536, cooma-2630, jindabyne-2627
A specialised learning organisation in the far south coast is chalking up a milestone.
Topics: adult-education, bega-2550, batemans-bay-2536
Posted| Updated
Seniors in the New South Wales south east are set to benefit from an enhanced training program launched by the State Government.
Topics: computers-and-technology, bega-2550, batemans-bay-2536, cooma-2630, jindabyne-2627
The Federal Member for Eden-Monaro, Mike Kelly, says the arrest of former Labor MP Craig Thomson will not affect the Government's election chances.
Topics: government-and-politics, courts-and-trials, bega-2550, cooma-2630, batemans-bay-2536, jindabyne-2627


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Installing nvidia-kernel-legacy
Hello !
I have GeForce4 MX 440 AGP 8x and kernel linux-126.96.36.199-rt31and kernel source
I installing driver and get error log:
/usr/bin/make -f debian/rules clean
|All times are GMT -5. The time now is 09:33 AM.
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1999 Chrysler Sebring Q&A
1999 Chrysler Sebring Question: Leak in Radiator ???
I replaced my transmission cooler with a universal. When poking the attachment things thru the A/C radiator thing and thru the radiator, I have a leak. Coming from the front of the car to the back, 1st is the tranny cooler, then 2nd a radiator thing, and 3rd another radiator thing. What is the #2 thing in my description, cause that is what now is leaking thru a fin. Need to know what kind of sealer to get for what peice of the car. HELP PLEASE! Thank you. You have helped me tremendously with other questions. XXOO Thank you, Robbin Young - onyxteacup
Answer 1
There is no way to seal the leak without replacing the part. Sorry. The A/C condenser is probably the item in front of the engine coolant radiator. You don't mention what's leaking! That's pretty important... You need to find a Chrysler specialist for some help here. If you want to find a specialist, here's our directory link for you: https://repairpal.com/directory?address=32536&car_brand_names=Chrysler - Superbob
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We have a slow water leak. I've checked hoses and radiator cap and all seem fine. About once/month I need to add about a quart of antifreeze or water.
I was Told prev owner and blown heads twice prior to me buying this car....shop told me i had a slow leak in radiator. Ive had car 9mo...now the car overheats if i drive it more than 2 to 5 miles O...
Temp gauge reads just below the 1/2 mark. After a few miles coolant is boiling out the overflow tube. I tried the heater and it will only blow hot after a min or two at 1500 rpm or higher. The r...
coolant in recovery tank boiling. replaced thermostat, drained all air. replaced with new radiator. ran gas test, neg for cracked head or blown head gasket. temp gauge at less than half and bottom ...
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More used needles are being found in Portland. Click here for photos.
Photos: More used needles found in PortlandUPDATED 1:54 PM EDT Apr 09, 2014
Slideshow Central
CommentsThe views expressed are not those of this site, this station or its affiliated companies. By posting your comments you agree to accept our terms of use.blog comments powered by Disqus


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Enroll your child online today.
The latest classes, events, and much more, in PDF.
Read All About It!
Read Previous Editions!
Temple Emanu-El Preschool is thrilled to bring you Adventure TK, a program designed specifically for children who will be turning five in the fall of 2015. Kids will learn through experience, exploring the city's historical landmarks with a focus on Jewish culture and values. We have two teacher positions open. Please review both job descriptions and if you meet the qualifications, we welcome you to apply!
Adventure TK Lead TeacherAdventure TK Jewish Resource Teacher
We need your help! As part of the larger effort of Congregation Emanu-El listening to your needs, we have crafted the following survey about our Adult Education offerings. We would love to hear your honest feedback.
The results of this survey will help us craft the Adult Education schedule for the coming academic year. Your responses are completely confidential. The survey will only remain active for two weeks, closing on Friday, July 3. Thank you in advance!
Please take the survey.
Read our membership renewal letter for 2015. Review the diagrams we added that provide a snapshot of our past year's operating revenue and expenses.
Visit our Events Calendar for a complete listing of upcoming events and programs
Attend Cantor Barak's last Friday night service! July 3, Main SanctuaryDon't miss Cantor Roslyn Barak co-officiating her last Shabbat service at Emanu-El!
Since 1987, AIDS Walk San Francisco has raised $84 million for HIV programs and services in the Bay Area, and has grown into the largest AIDS fundraising event in Northern California. In 2015, AIDS Walk San Francisco will benefit Project Inform and dozens of other organizations that work to stop new infections and support people living with HIV/AIDS.
Can't walk? Consider supporting an Emanu-El team walker with a donation!
Register today to join our team
Invigorate your study of Hebrew at a relaxed pace with a captivating master. Lawrence Kushner will lead four sessions of instruction, each spaced two weeks apart throughout the summer, providing an opportunity to absorb the language at a more languid summer's pace.
"This course changed the way I relate to torah....even the the most basic material opened a world of meaning hidden just beneath the surface of the letters."
- David Goldman, Executive Director, Congregation Emanu-El
In addition to being our resident scholar, Rabbi Kushner is also the author of The Book of Letters, in which he wrote about the Hebrew alphabet being more than just symbols.
Join Emanu-El and the wider Bay Area Jewish community at the annual Giants Jewish Heritage Night! Your Special Event Package includes a seat in one of the Jewish Heritage sections (View Reserved Infield, 317), for the game versus the Milwaukee Brewers, a limited-edition Jewish-themed Giants item, and admission to the Jewish Heritage Night party from 5:00 - 7:00 pm prior to the game!
Congregants register here
Non Members register here
June 22 - July 4Highlights include guided tour of Neot Kedumim, the Bilbical Nature Reserve, hiking up Masada in time for sunrise, floating in the Dead Sea, traveling along the Jordan River Valley to the Upper Galilee, optional wine tasting at the Bahat winery, swimming in the Kinneret at the "Luna Park," exploring the mystical city of Zefat, including ancient synagues and Jewish Quarter, and so much more!
See photos from the 2013 Emanu-El Israel trip!
Search Site:
Access all our sermons in the sermon archive
6:00 pm : ONE SHABBAT - Main Sanctuary
9:15 am : Torah Study – Library10:30 am : Shabbat Morning Minyan - Martin Meyer Sanctuary
View full Worship Calendar
© 2012 Congregation Emanu-El 2 Lake Street, San Francisco, CA 94118 Phone: (415) 751-2535 Fax: (415) 751-2511 firstname.lastname@example.com


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G2D Games
Most Played Games
New Games
Dressup Games
Makeover Games
Girls Games
Celebrity Games
Cool Games
Cooking Games
Baby Games
Fun Games
Game Name
The Fame Chloe Grace Moretz
Makeover Games
Game Tags
Make up,Celbrity,Actress,Hollywood,Beauty,Stylish,Modern
Click Here to Play
Game Details :
We remember her roles in the romantic comedy "500 Days of Summer" and the vampire drama "Let Me In". We are talking about the young star of Hugo; Chlo Grace Moretz is so excited for the Oscar Awards! Because you know, the Hugo movie has got the greatest score with 12 award nominations! Let's make her the most stunning teen actress of the red carpet!
New Games
Winter Streetshot Anim
Barbie Princess Design
Hot 16 Dress Up
Kitty Princess
Peach Princess
Black Laces
Seeing Jewelry
Loose Denim Anime
Bikini Season
Neutral Pastel
Comfy Cozy Anime
Pleated Fashion


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Willis Group to Merge With Towers Watson in $18 Billion Deal
June 30, 2015
• Consider hiring someone in human resources specifically to track and manage the contingent workforce.
• Classify workers carefully and be sure they meet federal and state criteria for independent contractor status.
• Choose the staffing agencies that supply your workers carefully, and make sure your contract with them protects you from legal liability.
• Check the backgrounds of contingent workers as thoroughly as for regular employees.
Workforce Management, May 2011, p. 14 -- Subscribe Now!


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Erin McCann | July 1, 2015 | 11:15 AM | Meaningful Use, Financial/Revenue Cycle Management, Analytics
Patrick Soon-Shiong, businessman, surgeon, scientist and founder of health IT company NantHealth announced he plans to take the company public by the end of the year. More
Carl Natale | July 1, 2015 | 10:52 AM | ICD-10 & Coding, Financial/Revenue Cycle Management, Compliance & Legal
Arguably just as important as ICD-10 readiness come time for October is also focusing on what's to happen afterward. And not all of what you hear is necessarily true. Much of it is myth. More
CHICAGO | Mike Miliard | July 1, 2015 | 09:23 AM | Data Warehousing, Network Infrastructure, Privacy & Security
Once upon a time, security was simpler. Now it's a different world -- a more dangerous one, with omnipresent risks to patient data. That theme was driven home again and again at the Healthcare IT News Privacy & Security Forum on Tuesday. More
CHICAGO | Mike Miliard | July 1, 2015 | 09:02 AM | Electronic Health Records, Network Infrastructure, Privacy & Security
The numbers should shake any provider still blissfully ignorant of privacy threats out of their complacency: Two-thirds of health organizations polled by HIMSS for its latest cybersecurity survey say they've recently experienced a "significant... More
Healthcare IT News | July 1, 2015 | 06:10 AM | Quality and Safety, Clinical, Compliance & Legal
Healthcare IT News' focus is primarily on IT within the healthcare space, but there's also so much happening now within the broader realm of healthcare. Our headlines watch list is updated daily, so check back in with us for regular updates. More
Erin McCann | June 30, 2015 | 10:56 AM | Business Intelligence, Financial/Revenue Cycle Management, Accountable Care
As healthcare providers shift away from fee-for-service toward value-based payment models, they're hitting some serious roadblocks -- one of them being that the majority of them lack sophisticated IT tools and analysis to support these new models. More
Tom Sullivan | June 30, 2015 | 10:20 AM | Business Intelligence, Network Infrastructure, Policy and Legislation
In the national discourse about interoperability, much of the focus is on enabling a doctor using one electronic health record to access patient information residing in a different hospital's EHR, even when another vendor built it. But is that really the... More
Anthony Vecchione | June 30, 2015 | 09:29 AM | Network Infrastructure, Quality and Safety, RFID/RTLS
The University of Vermont Medical Center in Burlington, Vt., announced recently that five million medications have been tracked using radio frequency identification technology. "It's cutting down on medication errors," says its CMIO. More
Erin McCann | June 29, 2015 | 11:06 AM | Workforce, Financial/Revenue Cycle Management, Accountable Care
In the newest payer-provider ACO partnership, UnitedHealthcare has teamed up with an eight-hospital health system to launch another accountable care organization, covering 12,300 individuals. More
Erin McCann | June 29, 2015 | 10:52 AM | Mobile, Clinical, Patient Engagement
The LGBTQ community is the focus of a new study that will tap Apple's clinical research platform as a tool to identify health disparities. More
Mike Miliard | June 29, 2015 | 10:30 AM | Mobile, Privacy & Security, Quality and Safety
New geographic information system technology from the U.S. Department of Health and Human Services aims to help community health agencies and emergency management officials protect patients who rely on electricity-dependent medical equipment. More
Kaiser Health News | June 26, 2015 | 11:11 AM | Claims Processing, Financial/Revenue Cycle Management, Policy and Legislation
In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges -- including one resolved Thursday -- and dozens of repeal efforts in Congress. But its long-term future still isn't... More


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Data recorder recovered; could hold key insights
Posted: March 19, 2003
Search crews walking a grid near Hemphill, Texas, have found the shuttle Columbia's orbiter experiments recorder, or OEX, a tape recorder that stored key data about the shuttle's performance during re-entry. The recorder was found essentially intact, according to a spokeswoman for the Columbia Accident Investigation Board, but the device may have suffered heat damage and in any case, the condition of the data tape inside is not yet known.
But if data on the tape can be recovered, NASA investigators could find a gold mine of information shedding more light on the aerodynamic forces acting on the spacecraft as its flight control system struggled to keep the doomed ship on course.
"We have no way of knowing whether the data's in a condition where it can be recovered or not," said Laura Brown, a spokeswoman for the CAIB. "They suspect there may be heat damage. We just don't know what condition it might be in."
The OEX recorder was found essentially intact on the ground about seven miles from Hemphill. Seventeen years ago, divers recovered tapes from the submerged wreckage of the shuttle Challenger and managed to extract data despite extensive damage. Engineers are hopeful they can recover data from Columbia's recorders as well.
"They're taking it to JSC (Johnson Space Center) for analysis," Brown said. "They'll clean it and they're developing a testing plan for it. They want to be as careful as they can with it so they don't lose any data."
The recorder stores data on aerodynamic pressure, temperature, vibration and other variables. Only Columbia, NASA's original space shuttle, is equipped with an OEX recorder as part of a complex system used to collect data during the ship's initial test flights. The OEX recorder should not be confused with the shuttle's operational recorders, which store additional flight data as well as voice traffic from the crew's intercom. The OPS recorders have not yet been located.
Here is a bit of background on the OEX recorders from NASA's shuttle reference book.
"The support system for the orbiter experiments was developed to record data obtained and to provide time correlation for the recorded data. The information obtained through the sensors of the OEX instruments must be recorded during the orbiter mission because there is no real-time or delayed downlink of OEX data. In addition, the analog data produced by certain instruments must be digitized for recording.
"The support system for OEX comprises three subsystems: the OEX recorder, the system control module and the pulse code modulation system. The SCM is the primary interface between the OEX recorder and the experiment instruments and between the recorder and the orbiter systems. It transmits operating commands to the experiments. After such commands are transmitted, it controls the operation of the recorder to correspond to the experiment operation. The SCM is a microprocessor-based, solid-state control unit that provides a flexible means of commanding the OEX tape recorder and the OEX and modular auxiliary data system.
"The PCM system accepts both digital and analog data from the experiments. It digitizes the analog data and molds it and the digital data received directly from the experiments into a single digital data stream that is recorded on the OEX recorder. The PCM also receives time information from the orbiter timing buffer and injects it into the digital data stream to provide the required time correlation for the OEX data.
"The SCM selects any of 32 inputs and routes them to any of 28 recorder tracks or four-line driver outputs to the T-0 umbilical; executes real-time commands; controls experiments and data system components; and provides manual, semiautomatic and automatic control.
"The recorder carries 9,400 feet of magnetic tape that permits up to two hours of recording time at a tape speed of 15 inches per second. After the return of the orbiter, the data tape is played back for recording on a ground system. The tape is not usually removed from the recorder."
Gemini 7
Gemini 7: The NASA Mission Reports covers this 14-day mission by Borman and Lovell as they demonstrated some of the more essential facts of space flight. Includes CD-ROM.
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On the road to the moon, the mission of Apollo 9 stands as an important gateway in experience and procedures. This 2-DVD collection presents the crucial mission on the voyage to the moon.
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Looking for a fabulous gal to help out with a 22 year high functioning female with a brain injury. This will be a relationship that you will not want to pass up. This young lady is fun, very social, and enjoys life!! We do have a small pooch but he will be your best friend after your first 5 minutes of meeting. Would love the find the right gal to work with our family in a relaxed and upbeat environment.


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I had a beautiful baby girl at 28 weeks gestational because of an incompetent cervix from what they believe. Born at 2 lbs 8 oz and 14.5 inches long she is a fighter and is growing everyday!
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TV Info
Episode PremiereApril 01, 2013
GenreComedy, Romance
Show Period2013 - 2014
Production CompanyWarner Bros. Television
Cast and Crew
DirectorPatrick Norris
ScreenwriterHenry Alonso Myers
Main Cast
- AnnaSophia Robb as Carrie Bradshaw
- Austin Butler as Sebastian Kydd
- Ellen Wong as Mouse
- Katie Findlay
- Stefania Owen
- Brendan Dooling
- Freema Agyeman
- Matt Letscher
- Chloe Bridges as Donna LaDonna
Additional Cast
- RJ Brown
When Carrie (AnnaSophia Robb) inadvertently complicates things with Sebastian (Austin Butler), she tries to fix it by taking him to Madonna's "The Virgin Tour" launch party - but in her quest for the perfect night, only makes things worse. Despite Mouse's (Ellen Wong) best efforts to avoid West (guest star RJ Brown), she can't seem to deny the romantic sparks flying between them. Dorrit (Stefania Owen) turns to Donna LaDonna (Chloe Bridges) for advice about her budding love life. Meanwhile, Tom (Matt Letscher) has an awkward encounter when he spends the night somewhere new.


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Authorities search for identity of homicide victim
Milwaukee police are still trying to determine the identity of a man shot to death a week ago in a church parking lot on the city's south side, the Milwaukee County Medical Examiner's Office said Tuesday.
The man was shot shortly before 8:30 p.m., Oct. 2, at S. 14th and W. Becher St. in the parking lot of St. Hyacinth Catholic Church.
Anyone with information on the victim or the shooting should contact Milwaukee police. »Read Full Blog Post


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Your voice was heard. Meet the new class of AMPC members and other elected officials.
Journal of Vision
Using psychophysics to ask if the brain samples or maximizes
Accuracy Assessment of Intra- and Intervisit Fundus Image Registration for Diabetic Retinopathy Screening
Why Do People (Still) Go Blind from Glaucoma
Tufts UniversityBoston, Mass.
Kellogg Eye Center, University of MichiganAnn Arbor, Mich.
University of WisconsinMadison, Wisc.
May 1 - 5, 2016Washington State Convention CenterSeattle, WA.
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Detroit, MI (Sports Network) - Jimmy Howard made 33 saves for his first shutout of the season to help Detroit snap a skid with a 4-0 win over Nashville.
Niklas Kronwall had a goal and two assists while Daniel Cleary, Drew Miller and Tomas Tatar all scored for the Red Wings, who broke a five-game losing streak.
"He made a great save at the end and made plenty of saves for us when the game was still on the line," said Detroit head coach Mike Babcock about Howard. "He's been solid for us all year long and I'm happy that he got the shutout."
Pekka Rinne gave up all four goals on 27 shots for the Predators, who have dropped four of their last five and have been blanked in consecutive games.
"When you come into this building you have to bring your best game with you," said Nashville head coach Barry Trotz. "I thought we played well at times, but they were just better than us tonight."
Detroit jumped out to a 1-0 lead at the 5:11 mark of the first period when Kronwall blasted a shot from the left point and Miller tucked in the rebound from in front for his second of the year.
The score stayed that way until 2:58 into the second when Tatar snuck in a rebound from the right side off a rebound shot from Joakim Andersson for a 2-0 lead.
Detroit made it 3-0 with 4:27 to play in the third as Kronwall flubbed a one- timer from the slot, but the puck knuckle-balled into the net for his second of the season.
Skating on the power play, the Red Wings put the game away as Kronwall's shot from the high slot was deflected into the net by Cleary.
Howard finished off his 12th career shutout with nine saves in the third.
Detroit hosts Vancouver on Sunday ... Nashville hosts Dallas on Monday ...
Nashville had taken a 4-3 win in overtime at home against Detroit on Tuesday
... Detroit was 1-for-2 on the power play while Nashville was 0-for-2.
Former Heisman Trophy winners Matt Leinart, Eric Crouch and Rashaan Salaam are among 76 Football Bowl Subdivision players on the ballot for election into the 2016 class of the College Football Hall of Fame.
The regular season in the NASCAR Sprint Cup Series has reached its midpoint, with 13 races completed and 13 to go before the championship Chase begins.
The Houston Texans have signed defensive lineman Brandon Deaderick, who played last season with the New Orleans Saints.
The Toronto Blue Jays activated catcher Dioner Navarro from the 15-day disabled list following a 2-0 loss to the Washington Nationals in the opener of Tuesday's doubleheader.
Sacramento Kings forward Carl Landry underwent surgery on Tuesday to repair a torn ligament in his right wrist, the team said.
The Montreal Canadiens revealed on Tuesday that defenseman Jeff Petry has agreed to terms on a six-year contract extension.


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One out of 75 Americans have experienced some sort of panic disorder, and according to a global survey conducted by Nielsen, over 50 per cent of women living in the United States are stressed out. On the surface stress might not sound startling; however, scientific evidence shows women with anxiety age faster.
Researchers at Brigham and Women's Hospital have linked stress with aging. They say their studies demonstrate that a common type of stress called "phobic anxiety", associated with shorter telomeres could speed up the aging process in middle-aged women.
The Effect of Anxiety on Brain Function
Telomeres are DNA protein at the end of chromosomes. During cell division they protect genetic information. Telomeres are indicators of cellular aging. Previous research has linked shortened telomeres to diseases such as cancer, dementia, and heart disease.
The research team at Brigham and Women's Hospital took blood samples of over 5 thousand women between the ages of 42 and 69 to conduct their analysis. They measured the telomere lengths and asked the ladies questions about phobic symptoms. Having a high level of "phobic anxiety" seemed to coincide with shorter telomeres. To put it in perspective, the researchers estimate that it means an additional 6 years added onto a woman's life.
The findings support previous research indicating that stress can impair DNA and lead to higher levels of damage in the blood.
Anxiety and the Body
If you've been taking antacids regularly, you'll be shocked to know antacids destroy healthy stomach acid that's vital for digestion.
For real relief from heartburn and acidity, you need to protect your stomach lining without disrupting normal acid levels.
Researchers have formulated a natural breakthrough that does just that. Studies show the ingredients in this formula helped to reduce heartburn in 89% of people who tried it.
To know more about this amazing formula, Click Here.
According to the National Institute of Mental Health, brain function plays a major role in our general well-being. When you experience stress your hormones and nerve chemicals release, your muscles tense, you breathe faster, and your brain uses more oxygen. This can boost your immune system over the short term; however over the long-term your immunity is lowered and your nervous system, digestive system, excretory system all stop working properly. This is when we get ill. Many people in the scientific community believe there is a link between illness and aging.
Anxiety and Sleep
Chronic stress and anxiety often leads to difficulty sleeping. Studies show that more women suffer from insomnia than men do. Researchers at the University of Chicago Medical Center state that sleep loss impacts metabolic function, and can alter hormones thus stimulating the effects of aging. Aside from the aging factor, studies show that sound sleep is required to ensure proper brain function. Women with insomnia often complain about difficulty concentrating, as well as constant memory loss.
RELATED READING: What Cheese is Doing for Your Nightmares
There are many ways you can beat the stress. For example, exercise and relaxation techniques are often used to lower the impact of stress on the human body. Chemicals are released in the brain during physical activity that can help you feel better. As for relaxation techniques, they distract you from the issues that are causing you anxiety. If stress is taking over your life don't be afraid to ask your doctor for suggestions as well. Millions of women are right there with you, fighting off the anxiety.
Related Reading: Breathing exercises for anxiety, asthma and more


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You can now invite anyone to meet at your favorite Starbucks.
Limited-time feature
26 year old woman | Philadelphia, PA, USA | Seeking men 25-35 within 50 miles
A huge heart with so much to give..looking for that funny, sensible person who I can seek adventure with and make memories for a lifetime.
Motivated, ambitious, kindhearted, sweetheart,funny, silly, intelligent, creative are the words my friends use to describe me. A college graduate, business woman, musician, animal lover, traveler, gamer and an awesome cook. I seek someone who is motivated about life, confident and good natured. I have a sweet spot for comedians and those that love to travel. I desire someone who cannot only be a great lover but instead also a great friend.
Alumni connections , Coffee and conversation , Business networking , Cooking , Dining out , Hobbies and crafts , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Nightclubs/Dancing , Performing arts , Travel/Sightseeing , Video games , Volunteering , Wine tasting
Aerobics, Billiards / Pool, Bowling, Dancing, Martial arts, Tennis / Racquet sports, Walking / Hiking, Yoga
I exercise 1-2 times per week.
I have Cats
I have a black cat named Dante :)
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What she is looking for
|5'3" (160cms)
|3'0" (91cms) to 8'11" (271cms)
|Body type:
|Slender, About average, Athletic and toned, A few extra pounds, Stocky
|Black, Blue, Brown, Grey, Green, Hazel
|Dark brown
|Auburn / Red, Black, Light brown, Dark brown, Blonde, Salt and pepper, Dark blonde
|No Way
|No Way, Occasionally
|Social Drinker
|Never, Social Drinker
|Administrative / Secretarial
|Administrative / Secretarial, Artistic / Creative / Performance, Executive / Management, Financial / Accounting / Real Estate, Labor / Construction, Legal, Medical / Dental / Veterinary / Fitness, Political / Govt / Civil Service / Military, Sales / Marketing, Education / Teacher / Professor, Technical / Science / Computers / Engineering, Travel / Hospitality / Transportation, Nonprofit / Volunteer / Activist, Law enforcement / Security / Military, Fashion / Model / Beauty, Architecture / Interior design
|$50,001 to $75,000
|$35,001 to $50,000, $50,001 to $75,000, $75,001 to $100,000, $100,001 to $150,000, $150,001+
|Never Married
|Never Married
|Have kids:
|Wants kids:
|Definitely, Someday
|Latino / Hispanic, White / Caucasian
|No preference
|Christian / Catholic
|Christian / Catholic, Christian / LDS, Christian / Protestant, Spiritual but not religious, Christian / Other
|Bachelors degree
|Bachelors degree, Graduate degree, PhD / Post Doctoral


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Prices and availability are subject to change from the time and date that you print this page.
7/6/2015 10:37:51 PM. For Customer Service, please call 800.933.9904
The only thing round about our Modern Cube Table Shade and Lamp Base is their ability to round out the look of your décor. The base features diagonal white stripes, and is made from rich mango wood. Pair it with the clean cube shade or any of our table shades for a squared away look.
Modern Cube Stripe Table Lamp Base 8"Wx8"Dx11"H
Details, details
- Designed exclusively for us by Joy Cho
- Part of the Oh Joy! for Nod Collection
- Shade and base sold separately
- Shade was designed to fit our Modern Cube Lamp Base
- Shade and Base can also be used with any individually sold table bases or table shades from The Land Of Nod
- Spider attachment inside of shade (does not have a harp)
- 13W CFL bulb included with base; also accommodates a 60W max. incandescent bulb (not included) learn more
- Bulb not included with shade
- Lamp base features 70" clear cord, socket switch and polarized plug
- UL-listed learn more
- Shade and Base together measure 18"h
Show 'em what you're made of
- Shade: cotton shade with metal spider
- Lamp Base: hand-painted, distressed mango wood
At The Land of Nod, nothing is more important to us than providing safe, high-quality products to you and your family. We believe that kids' products should be able to handle everything kids throw their way (literally and figuratively). That's why all of our products have an 18-year quality guarantee. And, hopefully, your kids will no longer be sleeping in bunk beds by then.
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YMMV: Harriet the Spy: Blog Wars
- Alternative Character Interpretation: Because Harriet is a teenager in this adaptation, she comes off more than just a little developmentally arrested, especially since she's so dependent on her nanny...that, and she does become just a tad bit obsessive with Skander. Throw in how she's practically invisible to her parents and Golly leaving just when things start to get out of hand and this suddenly becomes a view into the mental descent of a young girl losing her only real human contact and one of the darkest Disney Channel movies of all time.
- Crowning Moment of Funny: Harriet making up with Janie and Sport.
- Iron Woobie: Marion seems to be the most cold hearted teenaged girl ever until you notice that shes truly scared that shell lose all her friends because Harriet is more popular than her. May also be a Jerkass Woobie, considering how she treats said friends.
- Moment Of Awesome: Harriets father refusing to allow Skander to stop his daughter from blogging. Also counts as a Crowning Moment of Heartwarming.
- Sports finally dunking a basketball.
- Narm: Harriets mother can ruin any scene.
- Paranoia Fuel: Everything about Harriet and Skander before the ending sequence.
- Unintentionally Unsympathetic: Harriet is a self-absorbed brat. At least the original Harriet had the excuse of being 11.


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Pursuing Uncommon Life in Jesus
"We are not called to go to church but rather to BE THE CHURCH wherever we go."Learn More
Latest From The Blog
Father's Day
Father's Day
Father's Day swirls with pipe smoke memories, the pungent menagerie of gasoline, and Aramis, and the turnstile of time revolves as I stand on the platform awaiting the unstoppable train. Another child prepares to venture into the world, and I know, at best, they are clothed in hole-covered jeans with a backpack of empty promises the world has offered.
The measure of […]
Ask For More
From the Archives…
While Pastor Jeff is on sabbatical, we will open the vault and take a look back into his past sermons, personal musings, leadership postings and Warrior Poet devotionals.
Sermon Ask for More
July 24, 2011
Do you see God as a "glass half-empty God?" Are you waiting for the other shoe to drop, or do you ask […]
Warrior Poet : Ecclesiastes 11:1
Ecclesiastes 11:1 Ship your grain across the sea; after many days you may receive a return.
Dear Warrior Poet,
Our investments eventually return. We measure what's important to us and we become what we measure. If we desire wealth and fame and power and success then we will measure that in relation to others or some standard the world offers, but if we desire Jesus' […]
Warrior Poet : Acts 9:22
Acts 9:22 Yet Saul grew more and more powerful and baffled the Jews living in Damascus by proving that Jesus is the Messiah.
Dear Warrior Poet,
Saul immediately began to testify. Time and time again the compulsion to testify in Scripture is the evidential sign of life change. We will be His witnesses and too often we are silent, the painful reminder that we […]


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Currently no vegetarian restaurant listed. If you know of a veg restaurant, please add it here.
Vegan / Vegetarian Restaurants: (0 Listing)
Health Food Stores, Vegan Shops, Vegan Bakeries, Vegetarian B&Bs, Veg Catering, Veg*n Organizations: (4 Listings)
Health Basket - ClermontBe first to review!
Small health food store with a juice bar, opened since November 2012. Stocks a wide range of natural food and nutritional supplements.
Health Hut1 review
Health food store stocks herbs, health foods, aromatherapy, supplements, and homeopathics. Accepts credit cards.
Clermont Organic Co-op2 reviews
Collectively purchasing seasonal organic foods by the case to make the prices more affordable for each member. See website for pickup days and location.
Green Savings Organic Produce Co-op3 reviews
Members co-operative. Order organic produce, natural and organic herbs, personal care items, cleaning products, supplements, and more for pickup in Clermont. See website details.
OR see more results on Google Local.
Please help us improve this Clermont vegetarian restaurant guide:
- Add health food stores, cafes, or a vegetarian restaurant Clermont, FL.
- Report technical difficulty.
- Phone ahead before you visit any listing in this restaurant directory.
- Please let these businesses know you found them on HappyCow