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Home > Patients & Visitors > Health Library > Colorectal Cancer Screening (PDQ®): Screening - Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Note: Separate PDQ summaries on Colorectal Cancer Prevention; Colon Cancer Treatment; and Rectal Cancer Treatment are also available.
Based on solid evidence, screening for colorectal cancer (CRC) reduces CRC mortality, but there is little evidence that it reduces all-cause mortality, possibly because of an observed increase in other causes of death.
Colorectal cancer (CRC) is the third most common malignant neoplasm worldwide [1] and the second leading cause of cancer deaths in the United States.[2] It is estimated that there will be 134,490 new cases diagnosed in the United States in 2016 and 49,190 deaths due to this disease. From 2008 to 2012, CRC incidence declined by 4.5% per year among adults aged 50 years and older. However, in adults younger than 50 years, CRC incidence rates have been increasing by 1.8% per year. From 2003 to 2012, mortality from CRC declined by 2.8% per year.[2] The incidence is higher in men than in women. The incidence rates range from 45.9 per 100,000 per year in Hispanic men to 62.3 per 100,000 per year in African American men. In women, the incidence rates range from 31.4 per 100,000 per year in Hispanics to 47.5 per 100,000 per year in African Americans. The age-adjusted mortality rates are 19.1 per 100,000 per year in men and 13.5 per 100,000 per year in women.[3] About 5% of Americans are expected to develop the disease within their lifetime and about 50% of those will die from it.[3] Age-specific incidence and mortality rates show that the vast majority of cases are diagnosed after age 50 years; about 4% of CRC cases occur in patients younger than age 50 years.[4,5]
Among the groups that have a high incidence of CRC are those with hereditary conditions, such as familial adenomatous polyposis and hereditary nonpolyposis CRC (inherited in an autosomal dominant manner). Combined, the two groups account for no more than 6% of CRCs. More common conditions associated with an increased risk include a personal history of CRC or adenomas; first-degree relative with CRC; a personal history of ovarian, endometrial, or breast cancer; and a personal history of long-standing chronic ulcerative colitis or Crohn colitis.[6,7,8] These high-risk groups account for about a quarter of all CRCs. Limiting screening or early cancer detection to only these high-risk groups would miss the majority of CRCs.[9]
Genetic,[10] experimental, and epidemiologic [11] studies suggest that CRC results from complex interactions between inherited susceptibility and environmental or lifestyle factors. Efforts to identify causes led to the hypothesis that adenomatous polyps (adenomas) are precursors for the vast majority of CRCs.[12] In effect, measures that reduce the incidence and prevalence of adenomas may result in a subsequent decrease in the risk of CRCs;[13] however, some CRC mortality may be caused by fast-growing lesions and even lesions that do not pass through an adenomatous phase. Overall, the details of growth rates of adenomas and cancer are unknown; most likely there is a broad spectrum of growth patterns, including formation and spontaneous regression of adenomas.[14]
Fecal Occult Blood Test (FOBT)
In FOBT testing, a person collects stool samples that are analyzed for the presence of small amounts of blood. Collection details vary somewhat for different tests, but they typically involve collection of as many as three different specimens on 3 different days, with small amounts from one specimen smeared by a wooden stick on a card with two windows or otherwise placed in a specimen container.
The guaiac test identifies peroxidase-like activity that is characteristic of human and nonhuman hemoglobin. Thus, the test records blood from ingested meat, upper airway bleeding such as epistaxis, upper gastrointestinal (GI) bleeding, and colonic lesions.
Five controlled clinical trials have been completed or are in progress to evaluate the efficacy of screening utilizing the FOBT. The Swedish trial is a targeted study for individuals aged 60 to 64 years.[1] The English trial selects candidates from lists of family practitioners.[2] The Danish trial offers screening to a population aged 45 to 75 years who were randomly assigned to a control or study group.[3,4]
The Minnesota trial randomly assigned 46,551 men and women aged 50 to 80 years to one of three arms: colorectal cancer screening with guaiac-based, rehydrated FOBT every year (15,570), every 2 years (15,587), or control (15,394). This trial demonstrated that annual FOBT screening decreased mortality from colorectal cancer (CRC) by 33% after 18 years of follow-up (relative risk [RR], 0.67; 95% confidence interval [CI], 0.51–0.83, compared with the control group) and that biennial testing resulted in a 21% relative mortality reduction (RR, 0.79; 95% CI, 0.62–0.97).[5] Some part of the reduction may have been attributed to chance detection of cancer by colonoscopies; rehydration of guaiac test slides greatly increased positivity and consequently increased the number of colonoscopies performed.[6] Subsequent analyses by the Minnesota investigators using mathematical modeling suggested that for 75% to 84% of the patients, mortality reduction was achieved because of sensitive detection of CRCs by the test; chance detection played a modest role (16%–25% of the reduction).[7] Nearly 85% of patients with a positive test underwent diagnostic procedures that included colonoscopy or double-contrast barium enema plus flexible sigmoidoscopy (FS). After 18 years of follow-up, the incidence of CRC was reduced by 20% in the annually screened arm and 17% in the biennially screened arm. With follow-up through 30 years, there was a sustained reduction in CRC mortality of 32% in the annually screened arm (RR, 0.68; 95% CI, 0.56–0.82) and 22% in the biennially screened arm (RR, 0.78; 95% CI, 0.65–0.93). There was no reduction in all-cause mortality in either screened arm (RR, 1.00; 95% CI, 0.99–1.01 for the annually screened arm; and RR, 0.99; 95% CI, 0.98–1.01 for the biennially screened arm).[8] Important information that was not reported includes the treatment of CRC cases by stage by arm and the extent of CRC screening in each arm by FOBT, sigmoidoscopy, or colonoscopy after the completion of the trial protocol.[8,9]
The English trial allocated approximately 76,000 individuals to each arm. Those in the screened arm were offered nonrehydrated guaiac FOBT (gFOBT) testing every 2 years for three to six rounds from 1985 to 1995. At a median follow-up time of 7.8 years, 60% completed at least one test, and 38% completed all tests. Cumulative incidence of CRC was similar in both arms, and the trial reported a RR reduction of 15% in CRC mortality (odds ratio [OR], 0.85; 95% CI, 0.74–0.98).[10] The serious complication rate of colonoscopy was 0.5%. There were five deaths within 30 days of surgery for screen-detected CRC or adenoma in a total of 75,253 individuals screened.[11] After a median follow-up of 11.8 years, no difference in CRC incidence between the intervention and control groups was observed. The disease-specific mortality rate ratio associated with screening was 0.87 (0.78–0.97; P = .01). The rate ratio for death from all causes was 1.00 (0.98–1.02; P = .79).[12] When the median follow-up was extended to 19.5 years, there was a 9% reduction in CRC mortality (RR, 0.91; 95% CI, 0.84–0.98) but no reduction in CRC incidence (RR, 0.97; 95% CI, 0.91–1.03), or death from all causes (RR, 1.00; 95% CI, 0.99–1.02).[13]
The Danish trial in Funen, Denmark, entered approximately 31,000 individuals into two arms, in which individuals in the screened arm were offered nonrehydrated gFOBT testing every 2 years for nine rounds over a 17-year period. Sixty-seven percent completed the first screen, and more than 90% of individuals invited to each subsequent screen underwent FOBT testing. This trial demonstrated an 18% reduction in CRC mortality at 10 years of follow-up,[14] 15% at 13 years of follow-up (RR, 0.85; 95% CI, 0.73–1.00),[15] and 11% at 17 years of follow-up (RR, 0.89; 95% CI, 0.78–1.01).[16] CRC incidence and overall mortality were virtually identical in both arms.
The Swedish trial in Goteborg enrolled all of its 68,308 citizens in the city, who were born between 1918 and 1931 and were aged 60 to 64 years, and randomly assigned them to screening and control groups of nearly equal size. Participants in the control group were not contacted and were unaware they were part of the trial. Screening was offered at different frequencies to three different cohorts according to year of birth. Screening was done using the gFOBT Hemoccult-II test after dietary restriction. Nearly 92% of tests were rehydrated. Individuals with a positive test result were invited to an examination consisting of a case history, FS, and double-contrast barium enema. The range of follow-up times was from 6 years 7 months to 19 years 5 months, depending on the date of enrollment. The primary endpoint was CRC-specific mortality. The overall screening compliance rate was 70%, and 47.2% of participants completed all screenings. Of the 2,180 participants with a positive test, 1,890 (86.7%) underwent a complete diagnostic evaluation with 104 cancers and 305 adenomas of at least 10 mm detected. In total, there were 721 CRCs (152 Dukes D, 184 Dukes C) in the screening group and 754 CRCs (161 Dukes D, 221 Dukes C) in the control group, with an incidence ratio of 0.96 (95% CI, 0.86–1.06). Deaths from CRC were 252 in the screening group and 300 in the control group, with a mortality ratio of 0.84 (95% CI, 0.71–0.99). This CRC mortality difference emerged after 9 years of follow-up. Deaths from all causes were very similar in the two groups, with a mortality ratio of 1.02 (95% CI, 0.99–1.06).[1]
All trials have shown a more favorable stage distribution in the screened population compared with controls (see Table 3). Data from the Danish trial indicate that while the cumulative incidence of CRC was similar in the screened and control groups, a higher percentage of CRCs and adenomas were Dukes A and B lesions in the screened group.[14] A meta-analysis of all previously reported randomized trials using biennial FOBT showed no overall mortality reduction by gFOBT screening (RR, 1.002; 95% CI, 0.989–1.085). The RR of CRC death in the gFOBT arm was 0.87 (95% CI, 0.8–0.95), and the RR of non-CRC death in the gFOBT group was 1.02 (95% CI, 1.00–1.04; P = .015).[17]
Mathematical models have been constructed to extrapolate the results of screening trials to screening programs for the general population in community health care delivery settings. These models project a reduction in CRC mortality or an increase in life expectancy using currently available screening methodology.[18,19,20,21] The anticipated success of such methodology is critically dependent on the appropriate use of the FOBT and an effective clinical management plan.[22,23]
A systematic review done through the Cochrane Collaboration examined all CRC screening randomized trials that involved gFOBT testing on more than one occasion. The combined results showed that trial participants allocated to screening had a 16% lower CRC mortality (RR, 0.84; 95% CI, 0.78–0.90). There was, however, no difference in all-cause mortality between the screened and control groups (RR, 1.00; 95% CI, 0.99–1.02). Furthermore, the trials reported a low positive predictive value (PPV) for the FOBT test, suggesting that most positive tests were false positives. From the trials with nonrehydrated slides (Funen and Nottingham), the PPV was 5.0% to 18.7%, while the PPV in the trials using rehydrated slides (Goteborg and Minnesota) was 0.9% to 6.1%. The report contains no discussion on contamination in the control arms of the trials and no information on treatment by stage.[24,25]
On initial (prevalence) examinations, from 1% to 5% of unselected persons tested with gFOBT have positive test results. Of those persons with positive test results, approximately 2% to 10% have cancer and approximately 20% to 30% have adenomas,[26,27] depending on how the test is done. Data from randomized controlled trials (RCT) are summarized in Table 3.
Newer FOBTs: Nonrandomized Controlled Trial Evidence
The immunochemical FOBT (iFOBT) was developed to detect intact human hemoglobin. The advantage of iFOBT over gFOBT is that it does not detect hemoglobin from nonhuman dietary sources. iFOBT also does not detect partly digested human hemoglobin that comes from the upper respiratory or GI tract. Preliminary studies of several commercially developed iFOBT tests define their sensitivity and specificity compared with concurrently performed colonoscopy. The studies also examine these outcomes for different cut-points, and the benefit of multiple versus single stool samples.[30] Generally, iFOBT testing is more sensitive for cancers than for benign neoplasias. As expected, higher cut points decrease sensitivity and increase specificity.
In one study, 2,188 patients scheduled for colonoscopy because of an elevated risk due to personal or family history of colorectal neoplasm, positive gFOBT result, change in bowel habits, anemia, abdominal pain with weight loss, or anal symptoms were invited to participate in a comparative assessment of iFOBT against colonoscopy findings. After exclusions for health and cognitive reasons, 1,859 patients were offered iFOBT, 1,116 patients adhered to the protocol, and 1,000 patients completed the procedure. Sensitivity and specificity were calculated at various cut-points. At a cut point of 100 ng/mL, sensitivity and specificity were, respectively, 88.2% and 89.7% for cancer and 61.5% and 91.4% for any clinically significant neoplasia (cancer and advanced polyps). At 150 ng/mL the respective sensitivities and specificities were 82.4% and 91.9% for cancer and 53.8% and 95% for any clinically significant neoplasia. Calculations were based on the most severe pathologic finding from colonoscopy and the highest fecal-hemoglobin concentration measured by iFOBT applied to three stool samples collected before the colonoscopy. Stool samples were collected by patients following iFOBT kit instructions and analyzed by the OC-MICRO analyzer (from the Eiken Chemical Company in Tokyo, Japan).[31]
In another study, 21,805 asymptomatic patients received iFOBT based on one stool sample collected by patients following the kit instructions on the day of or the day before the colonoscopy. Stool samples were analyzed using the Magstream 1,000/Hem SP automated system (from Fujirebio Incorporated, Tokyo, Japan), which is based on the HemeSelect system (from Beckman Coulter, Palo Alto, California). Sensitivity and specificity based on subsequent colonoscopy were, respectively, 65.8% and 94.6% for cancer and 27.1% and 95.1% for advanced neoplasm.[32]
Fecal immunochemical tests may vary with regard to numbers of stools tested and cut-off values for a positive result.[30,33,34]
A systematic review to evaluate the comparative diagnostic performance of gFOBT and iFOBT in the context of a decision to introduce screening for CRC in the United Kingdom, included 33 studies evaluating gFOBT and 35 studies evaluating iFOBT, including nine that evaluated both gFOBT and iFOBT. There was no clear evidence for superiority of either gFOBT or iFOBT. Sensitivities for the detection of all neoplasms ranged from 6.2% (specificity 98%) to 83.3% (specificity 98.4%) for gFOBTs and 5.4% (specificity 98.5%) to 62.6% (specificity 94.3%) for iFOBT. Increasing sensitivity entailed adjusting cut-points to decrease specificity. Sensitivities were higher for the detection of CRC and lower for adenomas.[35]
Some studies have utilized the quantitative ability of iFOBT to consider detection and specificity at various test cut-points for defining a positive test. One study [36] found that reducing the cut-point from the standard 100 ng/mL to 50 ng/mL increased the detection of advanced adenomas but had little impact on the detection of cancer. The number of colonoscopies required to detect a single advanced adenoma or cancer increased from 1.9 to 2.3; a 20% increase. Specificity declined from 97.8% to 96%.
Potential false-positive test results due to an increased risk of upper GI bleeding are of concern with FOBT testing and pretest protocols, therefore; low-dose aspirin regimens should be discontinued for a week or more before FOBT. The performance of iFOBT was tested in an ongoing diagnostic study (2005–2009) at 20 internal medicine GI practices in southern Germany. Nineteen hundred seventy-nine patients (233 regular low-dose aspirin users and 1,746 never users) were identified in the records for inclusion in the analysis. All patients provided one stool sample taken within a week before colonoscopy preparation, which was collected according to instructions in a container that was kept refrigerated or frozen until rendered to the clinic on the day of colonoscopy, and the patients agreed to complete a standard questionnaire regarding the use of analgesics and low-dose aspirin (for prevention of cardiovascular disease). Stool samples were thawed within a median of 4 days after arrival at the central laboratory (shipped frozen from the recipient clinics). Fecal occult blood levels were measured by two automated iFOBT tests according to the manufacturer's instructions (RIDASCREEN Haemoglobin and RIDASCREEN Haemo-/Haptoglobin Complex, r-biopharm, Bensheim, Germany) following clinical procedures and blinded to colonoscopy results. Advanced neoplasms were found in 24 aspirin users (10.3%) and in 181 nonusers (10.4%). At the cut-point recommended by the manufacturer, sensitivities for the two tests were 70.8% (95% CI, 48.9%–87.4%) for users compared with 35.9% (95% CI, 28.9%–43.4%) for nonusers and 58.3% (95% CI, 36.6%–77.9%) for users compared with 32% (95% CI, 25.3%–39.4%) for nonusers (P = .001 and P = .01, respectively). Specificities were 85.7% (95% CI, 80.2–90.1%) for users compared with 89.2% (95% CI, 87.6%–90.7%) for nonusers and 85.7% (95% CI, 80.2%–90.1%) for users compared with 91.1% (95% CI, 89.5%–92.4%) for nonusers (P = .13 and P = .01, respectively). For these iFOBTs, sensitivity for advanced neoplasms was notably higher with the use of low-dose aspirin while specificity was only slightly reduced, suggesting that there might be an advantage to aspirin use to increase sensitivity without much decrease in specificity.[37]
The flexible fiberoptic sigmoidoscope was introduced in 1969. The 60 cm flexible sigmoidoscope became available in 1976.[38] The flexible sigmoidoscope permits a more complete examination of the distal colon with more acceptable patient tolerance than the older rigid sigmoidoscope. The rigid instrument can discover 25% of polyps, and the 60 cm scope can find as many as 65% of them. The finding of an adenoma by FS may warrant a colonoscopy to evaluate the more proximal portion of the colon.[39,40] The prevalence of advanced proximal neoplasia is increased in patients with a villous or tubulovillous adenoma distally and is also increased in those aged 65 years or older with a positive family history of CRC and with multiple distal adenomas.[41] Most of these adenomas are polypoid, flat and depressed lesions, which may be somewhat more prevalent than previously recognized.[42]
Five sigmoidoscopy screening RCTs have reported incidence and mortality results. These are the Norwegian Colorectal Cancer Prevention (NORCCAP) trial; the Telemark trial in Norway; the United Kingdom trial; the SCORE trial in Italy; and the U.S. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. Participants were aged 50 to 59 years in the Telemark trial, aged 55 to 74 years in PLCO, and aged 55 to 64 years in the other three trials. Together the trials enrolled 166,000 participants in the screened groups and 250,000 participants in the control groups. Follow-up ranged from 6 to 13 years. Results were summarized in two systematic reviews. There was an overall 28% relative reduction in CRC mortality (RR, 0.72; 95% CI, 0.65–0.80), an 18% relative reduction in CRC incidence (RR, 0.82; 95% CI, 0.73–0.91), and a 33% relative reduction in the incidence of left-sided CRC (RR, 0.67; 95% CI, 0.59–0.76). There was no effect on all-cause mortality.[43,44]
Two case-control studies have been reported that evaluate the efficacy of screening sigmoidoscopy in preventing CRC mortality;[45,46] one study used rigid sigmoidoscopy, and the other used rigid and FS. Both studies were conducted in prepaid health plans and suggested a significantly decreased risk (70%–90%) of fatal cancer of the distal colon or rectum among individuals with a history of one or more sigmoidoscopic examinations compared with nonscreened patients.
There are no strong direct data to determine frequency of screening tests in programs of screening.
Combination of FOBT and Flexible Sigmoidoscopy
A combination of FOBT and sigmoidoscopy might increase the detection of lesions in the left colon (compared with sigmoidoscopy alone) while also increasing the detection of lesions in the right colon. Sigmoidoscopy detects lesions in the left colon directly but detects lesions in the right colon only indirectly when a positive sigmoidoscopy (that may variously be defined as a finding of advanced adenoma, any adenoma, or any polyp) is used to trigger a colonoscopic examination of the whole colon.
In 2,885 veterans (97% male; mean age 63 years), the prevalence of advanced adenoma at colonoscopy was 10.6%. The estimate was that combined screening with one-time FOBT and sigmoidoscopy would detect 75.8% (95% CI, 71.0%–80.6%) of advanced neoplasms. Examination of the rectum and sigmoid colon during colonoscopy was defined as a surrogate for sigmoidoscopy. This represented a small but statistically insignificant increase in the rate of detection of advanced neoplasia when compared with FS alone (70.3%; 95% CI, 65.2%–75.4%). The latter result could be achieved assuming that all patients with an adenoma in the distal colon undergo complete colonoscopy. Advanced neoplasia was defined as a lesion measuring at least 10 mm in diameter, containing 25% or more villous histology, high-grade dysplasia, or invasive cancer.[47] One-time use of FOBT differs from the annual or biennial application reported in those studies summarized in Table 1.
A study of 21,794 asymptomatic persons (72% were men), who had both colonoscopy and fecal immunochemical testing (FIT) for occult blood, compared the detection of right-sided cancers as triggered by different test results. FIT alone resulted in a sensitivity of 58.3% and a specificity of 94.5% for proximal cancer diagnosis. FIT plus the finding of advanced neoplasia in the rectosigmoid colon yielded a sensitivity of 62.5% and a specificity of 93%. Thus, in this trial, the addition of sigmoidoscopy to FIT did not substantially improve the detection of right-sided colon cancers, compared with FIT alone.[48]
The NORCCAP once-only screening study randomly assigned 20,780 men and women, aged 50 to 64 years, to FS only or a combination of FS and FOBT with FlexSure OBT.[49] A positive FS was defined as a finding of any neoplasia or any polyp at least 10 mm. A positive FS or FOBT qualified for colonoscopy. Attendance in this study was 65%. Forty-one cases of CRC were detected (0.3% of screened individuals). Adenomas were found in 2,208 participants (17%), and 545 (4.2%) had high-risk adenomas. There was no difference in diagnosis yield between the FS only and the FS and FOBT groups regarding CRC or high-risk adenoma. There were no serious complications after FS, but there were six perforations after therapeutic colonoscopy (1:336).
Barium Enema
As part of the National Polyp Study, colonoscopic examination and barium enema were compared in paired surveillance examinations in those who had undergone a previous colonoscopic polypectomy.[50] The proportion of examinations in which adenomatous polyps were detected by barium enema was related to the size of the adenoma (P = .009); the rate was 32% for colonoscopic examinations in which the largest adenomas detected were no larger than 5 mm, 53% for those in which the largest adenomas detected were 6 mm to 10 mm, and 48% for those in which the largest adenomas detected were larger than 10 mm. In patients who have undergone colonoscopic polypectomy, colonoscopic examination is a more sensitive method of surveillance than double-contrast barium enema.
Because there are no completed RCTs of colonoscopy, evidence of benefit is indirect. Most indirect evidence is about detection rate of lesions that may be clinically important (like early CRC or advanced adenomas). Some case-control results are available. One RCT of colonoscopy has been initiated.[51]
Evidence about lesion detection rate
In a colonoscopic study of 3,121 predominantly male U.S. veterans (mean age: 63 years), advanced neoplasia (defined as an adenoma that was ≥10.0 mm in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer) was identified in 10.5% of the individuals.[52] Among patients with no adenomas distal to the splenic flexure, 2.7% had advanced proximal neoplasia. Patients with large adenomas (≥10.0 mm) or small adenomas (<10.0 mm) in the distal colon were more likely to have advanced proximal neoplasia than were patients with no distal adenomas (OR, 3.4; 90% CI, 1.8–6.5 and OR, 2.6; 90% CI, 1.7–4.1, respectively). One-half of those with advanced proximal neoplasia, however, had no distal adenomas. In a study of 1,994 adults (aged 50 years or older) who underwent colonoscopic screening as part of a program sponsored by an employer, 5.6% had advanced neoplasms.[53] Forty-six percent of those with advanced proximal neoplasms had no distal polyps (hyperplastic or adenomatous). If colonoscopic screening is performed only in patients with distal polyps, about half the cases of advanced proximal neoplasia will not be detected.
A study of colonoscopy in women compared the yield of sigmoidoscopy versus colonoscopy. Among 1,463 women, cancer was found in one woman and advanced colonic neoplasia was found in 72 women or 4.9% (about 50% of the prevalence compared with men). The authors focused, however, on RR (i.e., RR of missing an advanced neoplasm) as the outcome, instead of absolute risk of such neoplasms, which is substantially lower in women. In addition, the natural history of advanced neoplasia is not known, so its importance as an outcome in studies of detection is not clear.[54]
Analysis of data from a colonoscopy-based screening program in Warsaw, Poland demonstrated higher rates of advanced neoplasia in men than in women. The predominant age range of participants was 50 to 66 years. Of the 43,042 participants aged 50 to 66 years, advanced neoplasia was detected in 5.9% (5.7% among women with a family history of CRC, 4.3% among women without a family history of CRC, 12.2% among men with a family history of CRC, and 8.0% among men without a family history of CRC). Clinically significant complications requiring medical intervention were rare (0.1%) consisting of five perforations, 13 episodes of bleeding, 22 cardiovascular events, and 11 other events over the entire population of 50,148 screened persons. There were no deaths; however, the author reported that collection of 30-day complications data was not systematic; therefore, the data may not be reliable.[55]
Flat or difficult-to-detect lesions include "serrated polyps," which may be more common in the right colon than they are in the left. The term, serrated polyp, is currently used to include hyperplastic polyps, sessile serrated adenomas, traditional serrated adenomas, and mixed serrated polyps.[56,57] The clinical significance of these lesions is uncertain, because the natural history is so difficult to learn for any polypoid lesion. However, the histologic and molecular characteristics of some serrated lesions suggest possibly important malignant potential (mutations in the BRAF gene may be an early step toward carcinogenesis in serrated polyps).[57] This potential, along with the challenges of detecting flat lesions, may partially account for recent reports of a colonoscopy's lesser protective effect in the right colon compared to the left colon.
In 2011, authors of one study reported variability of detection rates for proximal serrated polyps. They studied 15 colonoscopists on faculty at one university and showed, during the years 2000 to 2009, a wide variation in detection rate for proximal serrated polyps, ranging (per colonoscopy) from 0.01 to 0.26, suggesting that many proximal serrated lesions may be missed on routine exam.[56] The overall proportion of polyps that are "serrated" is unknown, in part because these lesions have been unappreciated and/or difficult to identify.
Detection rates in colonoscopy screening vary with the rate at which the endoscopist examines the colon while withdrawing the scope. In one study, there were differences among gastroenterologists in the rates of detection of adenomas (range of the mean number of lesions per patient screened, 0.10–1.05; range of the percentage of patients with adenomas, 9.4%–23.7%) and the times of withdrawal of the scope (3.1–16.8 minutes for procedures not including polyp removal). Examiners whose mean withdrawal time was 6 minutes or more had higher detection rates than those with mean withdrawal times of less than 6 minutes (28.3% vs. 11.8%; P < .001 for any neoplasia and 6.4% vs. 2.6%; P < .005 for advanced neoplasia).[58] In the first 10 years of the German CRC screening program, detection of nonadvanced adenomas increased in men from 13.3% to 22.3% and in women from 8.4% to 14.9%. The great majority of the nonadvanced adenomas, however, were small (under 0.5 cm) and had uncertain clinical significance. The detection of advanced adenomas and CRC increased by a much smaller amount.[59] Overall detection rate of adenomas and cancer may be affected by how thoroughly endoscopists search for flat adenomas and flat cancer. While the phenomenon of flat neoplasms has been appreciated for years in Japan, it has more recently been described in the United States. In a study in which endoscopists used high-resolution white-light endoscopes, flat or nonpolypoid lesions were found to account for only 11% of all superficial colon lesions, but they were about 9.8 times as likely to contain cancer (in situ neoplasia or invasive cancer) compared with polypoid lesions.[42] However, because the definition of flat or nonpolypoid was height less than one-half of the diameter, it is likely that many lesions classified as nonpolypoid in this study would be routinely found and described by U.S. endoscopists as sessile. At the same time, the existence of very flat or depressed lesions (depressed lesions are very uncommon but are highly likely to contain cancer) means that endoscopists will want to pay increasing attention to this problem.[60] Flat lesions may play a role in the phenomenon of missed cancers.[61]
The impact of adenoma detection rates (ADRs) was assessed in a health maintenance organization in follow-up after 314,872 colonoscopies done from 1998 to 2010 by 136 gastroenterologists, each of whom had done at least 300 colonoscopies during that period. The goal was to determine rates of interval CRC, interval advanced CRC, and CRC death and to relate those rates to a gastroenterologist's ADR. There were 712 interval cancers (155 advanced) and 147 CRC deaths. The risk of interval cancer from lowest-to-highest quintile of ADR was 9.8, 8.6, 8.0, 7.0, and 4.8 per 10,000 person-years of follow-up. The adjusted hazard ratio, for physicians in the highest quintile compared with the lowest, was 0.52 for any interval CRC, 0.43 for advanced CRC, and 0.38 for fatal CRC. Each 1.0% increase in ADR was associated with a 3% decrease in risk of cancer, although the CI for each quintile was broad. Limitations of the study include the inability to determine which specific feature of ADR led to reduced interval cancer; for example, it is unclear whether it was due to the following:
Another limitation is that the harms of a colonoscopy associated with ADR could not be measured.[62]
Evidence about colorectal cancer mortality reduction
Although there is no RCT to assess reduction of CRC incidence or mortality by colonoscopy, some case-control evidence is available. Based on case-control data about sigmoidoscopy, noted above, it has been speculated in the past that protection for the right colon might be similar to that found for the left colon. However, a recent case-control study of colonoscopy raises questions about whether the impact of colonoscopy on right-sided lesions might be different than the impact on left-sided lesions.[63] Using a province-wide administrative database in Ontario, investigators compared cases of persons who had received a diagnosis of CRC from 1996 to 2001 and had died by 2003. Controls were selected from persons who did not die of CRC. Billing claims were used to assess exposure to previous colonoscopy. The OR for the association between complete colonoscopy and left-sided lesions was 0.33, suggesting a substantial mortality reduction. For right-sided lesions, however, the OR of 0.99 indicated virtually no mortality reduction.
This difference, which was striking and unexpected, might be explained in several possible ways and has been discussed extensively.[64] Possibilities include the following:
In other words, it is impossible to determine the reason for the dramatically different results on the right side compared to the left side, which are either the result of physician-related and patient-related factors or are the result of the biology of cancer.
Even if it is not possible to determine which reasons may be responsible for the right side versus the left-side difference, the findings beg the question, "What is the degree of mortality reduction from colonoscopy?" While a figure of 90% is sometimes cited as the degree of mortality reduction,[65] the question will not be properly answered until the European study is completed.[51] In the meantime, the results of the study mentioned above [63] question what is known about the degree of CRC mortality reduction provided by colonoscopy. Until there are more reliable results from RCTs, it may be prudent to expect an approximately 60% to 70% CRC mortality reduction, based on consideration of these studies and other data.[64]
Evidence about colorectal cancer reduction
A case-control study assessed CRC reduction (not CRC mortality reduction) in the right side versus the left side. In a population-based study from Germany, data were obtained from administrative records and medical records; 1,688 case patients (with CRC) were compared with 1,932 participants (without CRC), aged 50 years or older.[66] Data were collected about demographics, risk factors, and previous screening examinations. According to colonoscopy records, the cecum was reached 91% of the time. Colonoscopy in the previous 10 years was associated with an OR for any CRC of 0.23, for right-sided CRC of 0.44, and for left-sided CRC of 0.16. While this study does not assess CRC mortality, the results suggest that the magnitude of the right side versus the left-side difference may be smaller than previously found.[63] It would be extremely useful to assess right side-versus left side differences in a RCT.
Virtual Colonoscopy (Computed Tomographic [CT] Colonography)
Virtual colonoscopy (also known as CT colonography or CT pneumocolon) refers to the examination of computer-generated images of the colon constructed from data obtained from an abdominal CT examination. These images simulate the effect of a conventional colonoscopy. Patients must take laxatives to clean the colon before the procedure, and the colon is insufflated with air (sometimes carbon dioxide) by insertion of a rectal tube just before radiographic examination.[67]
A large, paired-design study was conducted by the American College of Radiology Imaging Network group, with 2,531 average-risk people (prevalence of polyps or cancer greater than or equal to 10 mm, 4%; mean age about 58 years) screened with both CT colonography and optical colonoscopy (OC). The gold standard was the OC, including repeat OC exams for people with lesions found by computed tomographic colonography (CTC) but not by OC. Of 109 people with at least one adenoma or cancer ≥10 mm, 98 (90%) were detected by CTC (referring everyone with a CTC lesion of ≥5 mm). Specificity was 86%, and PPV was 23%. There are several concerns from this study, including the following:
Unknowns from the study include the following for either OC or CTC:[68]
Another study reported similar sensitivity and specificity in persons with an increased risk of CRC.[69] In this study, the sensitivity of OC could not be determined because it was done in an unblinded manner. This study suggests that virtual colonoscopy might be an acceptable screening or surveillance test for persons with a high risk of CRC, but this cross-sectional study does not address outcome or frequency of testing in high-risk persons.
Some studies have assessed how well virtual colonoscopy can detect colorectal polyps without a laxative prep. The question is of great importance for implementation because the laxative prep required by both conventional colonoscopy and virtual colonoscopy is considered a great disadvantage by patients. By tagging feces with iodinated contrast material ingested during several days before the procedure, investigators in one study were able to detect lesions larger than 8 mm with 95% sensitivity and 92% specificity.[70] The particular tagging material used in this study caused about 10% of patients to become nauseated; however, other materials are being assessed.
Another study [71] utilized low-fiber diet, orally ingested contrast, and "electronic cleansing," a process that subtracts tagged feces. CTC identified 91% of persons with adenomas 10 mm or larger, but detected fewer (70%) lesions greater than or equal to 8 mm. Patients who received both CTC and OC preferred CTC to OC (290 vs. 175). This study shows that CTC without a laxative prep detects small 1 cm lesions with high sensitivity and is acceptable to patients. Long-term utilization of CTC will depend on several issues including the frequency of follow-up exams that would be needed to detect smaller lesions that were undetected and may grow over time.
Extracolonic abnormalities are common in CTC. Fifteen percent of patients in an Australian series of 100 patients, referred for colonography because of symptoms or family history, were found to have extracolonic findings, and 11% of the patients needed further medical workups for renal, splenic, uterine, liver, and gallbladder abnormalities.[72] In another study, 59% of 111 symptomatic patients referred for clinical colonoscopy in a Swedish hospital between June 1998 and September 1999 were found to have moderate or major extracolonic conditions on CTC. CTC was performed immediately before a colonoscopy and these findings required further evaluation. The extent to which follow-up of these incidental findings benefited patients is unknown.[73]
Sixty-nine percent of 681 asymptomatic patients in Minnesota had extracolonic findings, of which 10% were considered to be highly important by the investigators, and required further medical workup. Suspected abnormalities involved kidney (34), chest (22), liver (8), ovary (6), renal or splenic arteries (4), retroperitoneum (3), and pancreas (1);[74] however, the extent to which these findings will contribute to benefits or harms is uncertain. Two other studies, one large (n = 2,195) and one small (n = 136) examined the moderate or high importance of extracolonic findings from CTC. The larger study [75] found that 8.6% of patients had an extracolonic finding of at least moderate importance, while 24% of patients in the smaller study [76] required some evaluation for an extracolonic finding. The larger study found nine cancers from these evaluations, at a partial cost (they did not include all costs) of $98.56 per patient initially screened. The smaller study found no important lesions from evaluation, at a cost of $248 per person screened. Both of these estimates of cost are higher than previous studies have found. The extent to which any patients benefited from the detection of extracolonic findings is not clear. Because both of these studies were conducted in academic medical centers, the generalizability to other settings is also not clear. Neither of these studies examined the effect of extracolonic findings on patient anxiety and psychological function.
Technical improvements involving both the interpretation methodology, such as three dimensional (3-D) imaging, and bowel preparation are under study in many centers. While specificity for detection of polyps is homogeneously high in many studies, sensitivity can vary widely. These variations are attributable to a number of factors including characteristics of the CT scanner and detector, width of collimation, mode of imaging (two dimensional [2-D] vs. 3-D and/or "fly-through"), and variability in the expertise of radiologists.[77]
Digital Rectal Examination
A case-control study reported that routine digital rectal examination was not associated with any statistically significant reduction in mortality from distal rectal cancer.[78]
Detection of DNA Mutations in the Stool
The molecular genetic changes that are associated with the development of colorectal adenomas and carcinoma have been well characterized.[79] Advanced techniques have been developed to detect several of these gene mutations that have been shed into the stool.[80,81,82,83] Stool DNA testing was recently assessed in a prospective study of asymptomatic persons who received colonoscopy, three-card FOBT (Hemoccult II), and stool DNA testing based on a panel of markers assessing 21 mutations. Conducted in a blinded way with prestated hypotheses and analyses, the study found that among 4,404 patients, the DNA panel had a sensitivity for CRC of 51.6% (for all stages of CRC) versus 12.9% for Hemoccult II, while the false-positive rates were 5.6% and 4.8%, respectively. On this basis, the approach looks promising but would be improved, if possible, by increased sensitivity (perhaps by increasing the number of DNA markers) and by reduced cost.[84,85]
A subsequent study of stool DNA markers utilized a new multitargeted stool test that combined methylation markers for NDRG4 and BMP3, several KRAS mutations, and a human hemoglobin immunoassay. The markers, each quantitated separately, were combined using an algorithm in a prespecified multivariable analysis. The assay's sensitivity and specificity were compared with a commercial FIT test (OC FIT-CHEK Polymedco), using colonoscopy as the gold standard. Among 12,776 participants who had colonoscopy screening, were enrolled from 2011 through 2012 at 90 sites in the United States and Canada, and were aged 50 to 84 years (and weighted toward >65 years), 9,989 had fully evaluable results. There were 65 CRC and 757 advanced adenomas or sessile serrated polyps 1 cm or greater. The sensitivity for CRC was 92.3% (60 of 65 CRC) for the multitargeted test and 73.8% for FIT. Sensitivity for advanced lesions was 42.4% for the multitargeted test and 23.8% for FIT. Sensitivity for high-grade dysplasia was 69.2% for the multitarget test and 46.2% for FIT. Sensitivity for serrated sessile polyps 1 cm or greater was 42.4% for the multitargeted test and 5.1% for FIT. Specificities were 86.6% for the multitargeted test and 94.9% for FIT, using nonadvanced or negative colonoscopy results, and were 89.8% and 96.4% for totally negative colonoscopy results. A receiver operating characteristic (ROC) analysis showed that the multitargeted test has higher sensitivity than FIT alone, even if the FIT "cut-off" is reduced to try to increase sensitivity. A limitation is that there were no data about performance of repeated testing over time and what may be an appropriate testing interval.[86]
Overall, the multitargeted test was more sensitive than FIT for both CRC and advanced precancerous lesions, but the test was less specific.[86]
Adherence to Screening
Benefit from CRC screening can only occur if eligible people are actually screened. There have been problems with screening adherence, particularly for low income and uninsured people. There has also been concern that some people may adhere less to screening with a colonoscopy than with fecal tests. One well-conducted RCT found that, among an uninsured population, mailed FIT-kit outreach and follow-up reminder phone calls resulted in an adherence rate of 40.7%. Mailed colonoscopy invitations and follow-up phone reminders resulted in a 24.6% adherence rate. The usual-care adherence rate in this trial was 12.1%.[87]
Harms are associated with the various modalities used to screen for colorectal cancer (CRC).
Fecal Occult Blood Testing (FOBT)
A systematic review done through the Cochrane Collaboration examined all CRC screening randomized trials that involved FOBT on more than one occasion. The trials reported a low positive predictive value for the FOBT, suggesting that more than 80% of all positive tests were false-positives.[1] A positive test can lead to further diagnostic procedures that include colonoscopy or double-contrast barium enema plus flexible sigmoidoscopy.
Sigmoidoscopy can be an uncomfortable or painful procedure. Women may have more pain during the procedure, which may discourage them from returning for future screening sigmoidoscopies. Sigmoidoscopy can also cause perforation and bleeding, although this is rare.
Clinically significant complications requiring medical intervention are rare but can include the following: perforations, bleeding, cardiovascular events, and other adverse events. The rate of complications may increase among older persons.[2]
Computed Tomographic (CT) Colonography
Extracolonic abnormalities are common in CT colonography. Fifteen percent of patients in an Australian series of 100 patients, referred for colonography because of symptoms or family history, were found to have extracolonic findings, and 11% of the patients needed further medical workups for renal, splenic, uterine, liver, and gallbladder abnormalities.[3] Other areas of extracolonic findings include the chest, ovary, and pancreas. In another study, 59% of 111 symptomatic patients referred for clinical colonoscopy in a Swedish hospital between June 1998 and September 1999 were found to have moderate or major extracolonic conditions on CT colonography. CT colonography was performed immediately before colonoscopy, and these findings required further evaluation. The extent to which the follow-up of these incidental findings benefited patients is unknown.[4]
Sixty-nine percent of 681 asymptomatic patients in Minnesota had extracolonic findings, of which 10% were considered to be highly important by the investigators, requiring further medical workup. Suspected abnormalities involved kidney (34), chest (22), liver (8), ovary (6), renal or splenic arteries (4), retroperitoneum (3), and pancreas (1).[5]
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Updated statistics with estimated new cases and deaths for 2016 (cited American Cancer Society as reference 2).
Evidence of Benefit
Added text to state that in the first 10 years of the German colorectal cancer (CRC) screening program, detection of nonadvanced adenomas increased in men from 13.3% to 22.3% and in women from 8.4% to 14.9%; however, the great majority of the nonadvanced adenomas were small and had uncertain clinical significance; the detection of advanced adenomas and CRC increased by a much smaller amount (cited Brenner et al. as reference 59).
This summary is written and maintained by the PDQ Screening and Prevention Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about colorectal cancer screening. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Screening and Prevention Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Screening and Prevention Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Colorectal Cancer Screening. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/types/colorectal/hp/colorectal-screening-pdq. Accessed <MM/DD/YYYY>.
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.
Contact Us
More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website's Email Us.
Last Revised: 2016-01-15
This information does not replace the advice of a doctor. Healthwise, Incorporated, disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. Learn how we develop our content.
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The global challenge of information security and risk management is constantly changing, and the need to drive information rather than just data points is increasingly important to understand changes in the threat landscape and protect against vulnerabilities.
Our Managed Security Services (MSS) is a step change in the concept of managed security services. Providing insight to understand what is happening at both the network and application layer, NTT Security MSS delivers meaningful information for active threat management.
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Working with NTT Security as your MSS partner increases visibility to the real and potential threats – within the millions of logs and events generated by our systems – so that your organisation can take immediate action and get more from your existing information security investments. With increased pressure on resources, working with an MSS partner is an effective way to reduce the cost of administration and the complexity of maintaining multiple support systems.
By choosing NTT Security MSS, you gain access to our collective global knowledge and systems as well as our highly experienced people. A combination of these two elements applies a layer of intelligence and context across correlated events to increase visibility, understanding and the ability to make informed business decisions regarding your risk profile.
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subset: commoncrawl


text:
Crossing Cultural DividesHow can you cross cultural divides and engage with the strangers next door?
read more
This side is a proud member of the Salem Web Network, a subsidiary of Salem Media Group.
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Godtube.com is a video sharing platform offering online Christian videos with faith-based, family friendly content. Popular video sections on GodTube include; Christian bands and singers in Christian music videos, Christian comedians, funny video clips and inspirational videos.
Be inspired in your walk with Jesus Christ and grow in your knowledge of the Bible with videos highlighting inspirational Bible verses.
Also, check out the political cartoons at Townhall.com!


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MANY lovebirds choose Caribbean beaches or hidden country retreats as their ideal post-wedding venues - but one couple have their eyes on a lamp post on the Castle Green.
Lee Miles and Michelle Hurcombe, both 36, are tying the knot on June 21 – the date which marks the summer solstice.
The day is special to the couple, who both follow the Wiccan rede, as it is the day they first bound - Wiccan tradition.
And after tying the knot next month the couple will return to lamp post 2405 on the Castle Green. The site marks the spot where they first kissed - and they will make their way there for a special blessing performed by Michelle's dad.
"It was a joint idea. We have both been married before and it's something completely unique to our relationship," Lee explained.
"We are going to have a small wedding but the blessing side of it is more important to us because we wanted to do it on summer solstice because that's the date we bound – it's more of a spiritual thing for us."
Michelle's dad will deliver the reading.
"He has written all his own wording – we haven't heard what he'll be saying yet," Lee said.
"But he's a fantastic speaker – the kind of person that could tell you how sellotape works and have you hooked for hours. He's obviously given me permission to marry his daughter and it will be blessing our relationship."
But it has taken a long wait reach the perfect day.
"We have been planning the wedding for about four years. I work at Blackmarston School so we have been waiting for summer solstice to fall on a Saturday," Lee said.
The couple, who first met at Whitecross High School, were reunited in 2007.
"When we left school we went our separate ways,"
Lee added. "Michelle got married and was living in Germany. She had a stroke and was also diagnosed with MS and her marriage broke up."
The pair were reunited after a mutual friend visited the same hospital where Michelle was being treated in Germany. Michelle returned to Hereford where Lee aided her recovery and they fell in love.


text:
Apple Angst
We cannot overlook the daily powerfully negative influence of Apple (AAPL) on this market. Apple represents retail, it represents the conundrum of value, and it represents the angst of the overall market.
As long as Apple goes down, it might just keep taking down the market if we lose the other plays, like Amazon (AMZN) and Google (GOOG)....358 more words left in this article. To read them, just click below and try Real Money FREE for 14 days.
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Trainer Emma Lavelle has confirmed the lightly-raced Claret Cloak an intended runner in the Ladbroke Handicap Hurdle at Ascot on Saturday week.
The five-year-old ended his novice campaign over hurdles with back-to-back victories at Sandown and Newbury and ran a race full of promise when third behind last year's Ladbroke hero Raya Star on his Ascot comeback.
Claret Cloak is set to carry 10st 7lb following the publication of the weights and is a 14-1 shot with the sponsors.
Lavelle said: "The Ladbroke is definitely the target for Claret Cloak but the ground is the crucial thing with him and we are hoping it stays dry.
"He has been in great form since Ascot and seems in really good condition. I was chuffed to bits with his first run and he has definitely come on a little bit.
"There is no doubt that the better the ground, the better he will perform so if we got good ground at Ascot we would be delighted.
"I think they will go a furious pace in The Ladbroke and that will suit him because he has a very high cruising speed. I think 136 is a workable mark as he's only a baby and is still improving physically - I think he is getting better."
Claret Cloak could be reopposed by Raya Star, who currently shares top-weight of 11st 12lb with last weekend's Sandown winner Petit Robin.
Gerry Feilden winner Lyvius (10st 6lb), Haydock scorer Balder Succes (11st 4lb) and Dermot Weld's Irish contender Hisaabaat (11st 5lb) are among the other major players.


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Complete Election coverage
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Simply click here, or visit http://lavote.net/LOCATOR/, and enter your information in the designated fields.
Once done, information regarding your polling place, along with directions and a Sample Ballot will be provided by the Los Angeles County Registrar of Voters.


text: Boys' long-sleeve metallic race car T-shirt Item F6784 Size: All sizes are US sizes. Size Charts Quantity: 1 2 3 4 5 6 7 8 9 Prices do not include taxes. Add to Bag Wishlist Add to Bag Add To Wishlist share: size & fit Product Details From our top-secret graphics lab to their closet...a soft tee featuring a cool metallic race car, courtesy of the creative minds of our crewcuts designers. Cotton. Machine wash. Import. Item F6784.


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The holiday is booked, flights sorted and you have carefully decided on which clothes and accessories are coming with you. However, there is one last hurdle before you reach your destination…the dreaded packing.
We have some great tips to help resolve all your packing issues and rid the pre-holiday stress!
*Lists are NOT for losers
Don't underestimate the value of making a packing list. This will become clear when travelling with the less organised and they are begging for a plaster that you remembered to pack. If you can, a week before start making a list of everything you need to pack then you have a few days to add to it. Check the list before you pack, after you've packed and just before you walk out the door.
*No neat foldingWhen packing your clothes you don't want to neatly fold them individually as you would in your bedroom drawers, this causes creases when compressed. Here are some alternatives:
Rollin' Rollin' Rollin': rolling up your clothes instead of folding has been proven to save space and leave fewer creases.
The flat pack method: place small items on the bottom of the suitcase to create a flat surface, then lay clothes out in one layer across the suitcase adding in curved items such as bras into corners and shoes along the sides. This method reduces wrinkles and saves on space!
*Be ruthless to travel lightLay out everything on your bed that you are considering packing then you can get a real idea about how much you are taking. Remove anything that you don't really need! This will leave extra room in your suitcase for shopping and souvenirs when you are out there.
*Clever accessories
As an alternative to taking an entire extra outfit a few carefully selected accessories will keep you prepared for any holiday occasion. Consider taking a pretty scarf, statement necklace and embellished sandals to add versatility to your looks. Some of our White Stuff scarves double as up as sarongs or glamorous evenings wraps and pack light in the suitcase.
Shop Women's Summer Accessories
"When you figure out your suitcase, you figure out your life,"
- Diane von Furstenberg


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Peyton Manning Children's Hospital to unveil new themed room
Peyton Manning Children's Hospital is set to unveil a new Pacers and Fever themed room on Wednesday.
Indianapolis-based insurance company, Baldwin & Lyons, has committed to providing ten hospital rooms to the hospital over the next five years. The Pacers and Fever room is the second completed room in the commitment. The first was a super hero room created this past summer. The project aims to make the hospital less scary for children.
The Pacers mascot, Boomer, will join the Baldwin & Lyons CEO and the executive director of St. Vincent, at a ribbon cutting at 3:00 p.m. Wednesday.
The Peyton Manning Children's Hospital at St. Vincent now has eleven themed patient rooms, funded by donations from the local community.


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Communications Workers of America Ratify Agreement Covering AT&T Wireline Employees in Southeast
Dallas, Texas, December 07, 2012
AT&T* today announced that wireline employees represented by the Communications Workers of America have voted to ratify a three-year contract for the AT&T Southeast region.
The contract covers about 22,000 AT&T wireline employees in Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, and Tennessee.
AT&T wireline employees represented by the CWA earlier ratified, on Aug. 17, three-year contracts for the Midwest region and AT&T Corp. (CWA Telecommunications and Technology Office). The ratified agreements collectively cover about 40,000 AT&T wireline employees.


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Dinner jackets and elegant ball gowns were never more appropriate than for Clarendon Academy's Year 11 Prom this year, which was themed around British Secret Service agent James Bond.
Pupils dressed up in their best suits and dresses and arrived in a range of luxury sports cars, including an Ariel Atom, for the evening at Cumberwell Park Golf Club last Thursday.
The entertainment included fake roulette wheels, card games and a magician to entertain partygoers, while there were also pictures of the pupils from over the years displayed.
Andy Ridyard, assistant head of sixth form, said: "There was absolute awe at Serge the Magician's card tricks, sheer delight at some of their old photos on display, bucket oads of energy on the dance floor and then almost 500 party poppers going off at the finale.
"The Prom Committee did an amazing job and everyone enjoyed themselves immensely throughout the night.
"I don't think anyone wanted to leave, but what an end to the year for such a wonderful group of Clarendon students."


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HollyPop will be open 6-9 p.m. Wednesday for "The Night of Lights," and it will open again 7 a.m.-7 p.m. Nov. 23 and 24. Fashion-oriented vendors include OFabz Swimwear, The Good Ones Clothing Co., Eternal Youth Clothing Co. and Sharp Dressed Van jewelry.
Kernel Coladas Gourmet Popcorn and Yum-Mee's Bakery will sell food, and Ferocious Quarterly and One Lucky Guitar will have art and design products available.
•By the way, the HollyPop boutique coincides with Small Business Saturday, Nov. 24, when we are all encouraged to patronize local businesses. Keep those dollars local, folks.
•And speaking of Small Business Saturday, that coincides with Holly Trolley Shopping, organized by the Downtown Improvement District. From 11 a.m. to 5 p.m. Nov. 24, free trolley rides will be provided to many downtown shops and attractions. Most of the businesses on the trolley route will offer special holiday items, discounts and refreshments.
Citilink has declared Nov. 24 a free transit day across the entire city, so you can even take a bus downtown and then hop on the trolley. More than 40 gift shops, galleries, attractions, a farmers market and restaurants will participate in Holly Trolley Shopping. Maps will be available on the trolleys and will be posted on the DID website, www.downtownfortwayne.com. Park near your favorite attraction, then wait at a trolley stop sign or flag it down at intersections.
•In addition to the HollyPop boutique, DID and Arts United are coordinating a one-day "pop-up" holiday market 11 a.m.-5 p.m. Nov. 24 at the Arts United Center, 303 E. Main St. The pop-up market will feature farmers market vendors, artists and entertainment.
Foxy Ladies Art Posse will also be in a one-day market 11 a.m.-5 p.m. Nov. 24 at Artlink, 300 E. Main St., in the Auer Center for Arts and Culture. Several local artists and crafters will sell pottery, fiber works, paintings, sewn and knitted/crocheted goods, upcycled materials and crafts, jewelry, handmade soaps, and prints.
For a Holly Trolley map and more information on participating shops, go to www.HolidayFestDowntown.com.This gives Black Friday a whole new meaning.
On Nov. 23 — "Black Friday" — you can get a special deal on dogs and cats with black fur that are up for adoption.
Fort Wayne Animal Care and Control will join with the American Society for the Prevention of Cruelty to Animals and Subaru of America for Subaru's annual year-end "Share the Love" campaign and celebration. Off-site dog and cat adoptions will be held at the Illinois Road Subaru dealership, and adoptable dogs and cats with black fur will be $10 to adopt.
I read somewhere once that black dogs are harder to adopt because they look scary. And you know what they say about black cats.
We have a black dog, a Lab, and she has been a joy to us.
The adoption event will be 11 a.m.-6 p.m. Nov. 23 at Fort Wayne Subaru, 5000 Illinois Road.Oh, brother. We had to know this would happen. The retail madness otherwise known as Black Friday is encroaching on Thanksgiving. Target has announced it is opening at 9 p.m. Thanksgiving night, rather than waiting until 12:01 a.m. Black Friday.
I heard on the news Target employees aren't too happy about it. I don't blame them.From 10 a.m. to 5 p.m. Saturday, the gift shop at the Foellinger-Freimann Botanical Conservatory, 1100 S. Calhoun St., is hosting an open house. The shop will be selling fresh, local wreaths; cut trees; holiday ornaments; and gifts. You can enjoy free hot chocolate while you shop. No admission is required to shop at the conservatory, but to visit the gardens, regular admission applies. Information: 427-6440.Two Fort Wayne business owners and Burmese natives have moved their businesses on Decatur Road to a co-located space. Htay Htay, owner of Htay's Beauty Salon, and Thant Naing, owner of Win-Win PC, are now at 3132 S. Calhoun St.
Htay's Beauty Salon offers hair and nail services, eyebrow waxing, facials, hair extensions, and permanent eyebrows, eyeliner and lip liner. It is open 10 a.m.-8 p.m. Tuesday through Sunday and Monday by appointment only. Phone: 449-5477. Walk-in customers are accepted.
Win-Win PC repairs and installs personal computer systems and builds and sells custom desktop systems. Hours: 10 a.m.-8 p.m. Tuesday through Sunday and Monday by appointment only. Call 755-6226.Kay Jewelers has opened a store at 4602 Illinois Road in Orchard Crossing. Hours: 10 a.m.-9 p.m. Monday-Saturday and noon-6 p.m. Sunday. Phone: 432-4768.Flip Flop Shops will open a store in Glenbrook Square, 4201 Coldwater Road, on Tuesday.
The store will sell "the hottest brands and latest styles of flip flops and sandals," according to a news release.
Know of a store opening, closing or remodeling? Find a good deal? Call Cindy Larson at 461-8284, fax 461-8817, email clarson@ news-sentinel.com or write to: In the Bag, C/O The News-Sentinel, PO Box 102, Fort Wayne, IN 46801. To read other columns, go to www.news-sentinel.com/ section/LARSON.


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Mary just made the 1000th comment since Quilty Pleasures began on the 100 Blocks: One-derful Ideas post and I declare her a surprise winner! I found a (mostly full) bundle of strips from Karen Combs' Belle Fleur line from Avlyn to go with a copy of 100 Blocks.
Here's Karen's block, Square and Diamond, that uses Belle Fleur so you can see the fabric that is coming to you Mary:
Congratulations Mary!


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Matheny focused on leading NL to win in ASG
MILWAUKEE -- Cardinals manager Mike Matheny is enjoying all that has surrounded managing his first All-Star Game, but his main focus will be on finding ways to have the National League come out on top.
"Once that game starts is going to be all about winning," Matheny said. "We're going to make that very clear."
With some of the top players in the game on his squad, Matheny acknowledges that he will have an array of options from which to choose.
"I want to respect everyone that's involved," he said. "We'll try to have some roles listed so the guys can expect what will happen. But once we start competing, we expect those guys to play like their postseason is on the line because, for somebody in that room, it is. I know it can mean a big difference in October."
The National League roster includes three of Matheny's own players: pitchers Adam Wainwright and Pat Neshek and infielder Matt Carpenter. Fans also selected Yadier Molina to the team but the Cardinals catcher is on the disabled list after having surgery to repair a torn thumb ligament.
Matheny has been mum on how he intends to use Wainwright, who pitched seven innings Saturday in a dominating performance against the Brewers. He said he wouldn't be concerned about pitching Wainwright since Tuesday would be his normal day to throw on the side.
When asked whether his ace pitcher has been pushing him for a starting nod in the game, Matheny said, "He hasn't done that much lobbying. He's just a pro. You spend any time around him. He just goes about his business. He just loves to compete."
Matheny indicated Sunday that he has decided who the starting pitcher will be, but wouldn't reveal his decision. "I'm ready," he said.
Rich Rovito is a contributor to MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.


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Don't Touch
NOOK Book(eBook)
The locals call the dockside neighborhoods of Moretown Bay "The Shadows." In The Shadows, drug deals and prostitution don't hold a candle to the magical crimes the locals pretend not to see, because paying attention to what goes on after dark is dangerous business. For one young exotic dancer, noticing too much about her latest customer is more than dangerous -- it just might get her killed.
Product Details
|Thunder Valley Press
|Publication date:
|Sold by:
|NOOK Book
|File size:
About the Author
Annie Reed is a prolific writer with more than thirty short stories in print under her own name and various pen names.
Annie began her fiction career writing Star Trek stories which appeared in the Strange New Worlds anthologies edited by Dean Wesley Smith and Battletech fiction for battlecorps.com. Annie's work has since appeared in Ellery Queen's Mystery Magazine as well as numerous anthologies published by DAW.
Annie's writing has been recognized in the literary arena, where she was awarded a Literary Fellowship in 2004 by the Nevada Arts Council for her speculative fiction story "One Sun, No Waiting," as well as in genre competition when her novel "Pretty Little Horses" was chosen as a finalist in the 2007 Best First Private Eye Novel contest sponsored by St. Martin's Press and the P.I. Writers of America. Annie was also a finalist in the 2004 Lori Foster Novella Contest sponsored by Brava.
Annie lives in Northern Nevada with her husband, daughter, and a varying nummber of high-maintenance cats. (Don't writers usually come equipped with cats?)
Customer Reviews
Average Review


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Don't miss out on a lower price on this hotel
Get an overview of this hotel4-star Munich hotel in Laim with restaurant
Popular property highlights
Located in Laim, this hotel is 0.8 mi (1.2 km) from Augustiner Brau and within 3 mi (5 km) of Marienplatz and Asamkirche. Viktualienmarkt and Church of Our Lady are also within 3 mi (5 km).
Hotel Features
A restaurant, a 24-hour health club, and a bar/lounge are available at this smoke-free hotel. WiFi in public areas is free. Other amenities include a sauna, a 24-hour business center, and self parking.
Room Amenities
All 251 soundproofed rooms feature WiFi and pillowtop beds. Conveniences include refrigerators and coffee makers, and guests will appreciate thoughtful touches like pillow menus and slippers.
Guest Highlights
- Central location
- Proximity to public transit
- Breakfast
- Helpful staff
- Comfy beds and overall room comfort
Sheraton München Westpark Hotel
Hotel Amenities
Hotel Amenities
Sheraton München Westpark Hotel features a 24-hour health club and a sauna. The hotel offers a restaurant. A bar/lounge is on site where guests can unwind with a drink. A computer station is located on site and wired and wireless Internet access is complimentary.
This 4-star property offers access to a 24-hour business center and meeting rooms. Event facilities measure 1087 square feet (101 square meters). This business-friendly hotel also offers tour/ticket assistance, multilingual staff, and coffee/tea in a common area. Parking is available onsite for a surcharge.
Sheraton München Westpark Hotel is a smoke-free property.
- Computer station
- Sauna
- Bar/lounge
- Total number of rooms - 251
- Multilingual staff
- 24-hour front desk
- Dry cleaning/laundry service
- Elevator/lift
- Restaurant
- 24-hour health club
- Luggage storage
- Number of floors - 10
- Meeting rooms 10
- Conference space size (feet) - 1087
- Conference space size (meters) - 101
- Number of meeting rooms - 10
- Self parking (surcharge)
- Smoke-free property
- Breakfast available (surcharge)
- Coffee/tea in common areas
- Free newspapers in lobby
- Concierge services
- Tours/ticket assistance
- Free WiFi
- Free wired Internet
- Safe-deposit box at front desk
- Year Built 1980
- 24-hour business center
- Number of buildings/towers - 1
- Television in common areas
Family Friendly Amenities
- Family Hotel
- Free Wi-Fi
- Soundproofed rooms
- Refrigerator
Available in all rooms: ,
Available in some public areas: Free WiFi , Free wired Internet
Self parking (surcharge)
Room Amenities
- Premium bedding
- Hypo-allergenic bedding available
- Air conditioning
- Blackout drapes/curtains
- Phone
- Refrigerator
- Daily housekeeping
- Private bathroom
- Hair dryer
- Desk
- Satellite TV service
- In-room climate control (air conditioning)
- Coffee/tea maker
- WiFi (surcharge)
- Soundproofed rooms
- Free toiletries
- Slippers
- Shower/tub combination
- Room service (24 hours)
- Down comforter
- Egyptian-cotton sheets
- Pillowtop mattress
- Rollaway/extra beds (surcharge)
- Iron/ironing board
- Wired Internet access (surcharge)
- In-room safe (laptop compatible)
- Pillow menu
Where to Eat
Buffet breakfasts are available for a surcharge and are served each morning between 6:30 AM and 10:30 AM.
Speis und Trank - This restaurant serves breakfast, lunch, and dinner.
24-hour room service is available.
Nearby Things to Do
Recreational amenities at the hotel include a 24-hour health club and a sauna.
If you have requests for specific accessibility needs, please note them at check-out when you book your room.
- Accessible bathroom
- Roll-in shower
- In-room accessibility
Hotel Policies
Minimum check-in age is 18
Check-in time starts at 3 PM
Special check-in instructions:
Check-out time is noon
Payment types
Children and extra beds
- Children are welcome.
- Kids stay free! Children 12 years old and younger stay free when using existing bedding.
- Rollaway/extra beds are available for EUR 40 per night.
- Cribs (infant beds) are not available.
- Pets allowed for an extra charge of EUR 20 per pet, per day
You need to know
Extra-person charges may apply and vary depending on property policy.
- The name on the credit card used at check-in to pay for incidentals must be the primary name on the guestroom reservation.
Optional extras
- Fee for buffet breakfast: EUR 22.00 per person (approximately)
- Fee for in-room wireless Internet: EUR 19.00 per 24-hour period (rates may vary)
- Fee for in-room wired Internet: EUR 19.00 per 24-hour period (rates may vary)
- Self parking fee: EUR 20 per night (in/out privileges)
- Pet fee: EUR 20 per pet, per day
- Rollaway bed fee: EUR 40 per night
Hotel Name
- Hotel München Westpark
- Hotel Westpark
- Hotel Westpark München
- München Hotel Westpark
- München Westpark Hotel
- Sheraton München Westpark Hotel
- Sheraton München Westpark Hotel Munich
- Sheraton München Westpark Munich
- Westpark Hotel München
- Westpark München Hotel
- Sheraton München Westpark
We should mention
This property offers transfers from the airport. Guests must contact the property with arrival details before travel, using the contact information on the booking confirmation. Children 12 years old and younger stay free when occupying the parent or guardian's room, using existing bedding.


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Topic: What to expect?
We've been watching this site for awhile but remained quiet - our Mom was diagnosed over a year ago and told she'd likely have less than 6 months. She chose to have a stent as her only form of treatment and we feel blessed she has done as well as she has. But her time is coming now and signs of liver failure are here. It was like false security with how well she was doing and it is almost like the initial shock of diagnosis is back. She is still at home but might come stay with us prior to inpatient hospice care. I don't want to open any wounds or cause anyone pain but if there is anyone who is comfortable enough to share what to expect now and what we can do to help her be comfortable I could really use it. We have children, too so I am hoping to be as well informed ahead of time so I can make sure they understand as best they can. Thankm you and bless you.


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£95.00 per roll
A wonderfully abundant wallpaper featuring interwoven vine leaves inspired by the Great Vine at Hampton Court Palace. Printed in olive green.
|Pattern Repeat
|53.6 cms (& half drop)
|52 cms x 10 m
Then visit our FAQs
If you cannot find what you are looking for then give us a ring on +44 (0) 1273 495500
To create a new scheme, simply add an item from its page on the site
To save your active scheme and load any previously-saved, enter your email address below and press enter
We also stock the following products in this range.


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Government frontbencher Malcolm Turnbull has defended Tony Abbott against accusations he lied about workers' conditions at SPC Ardmona, saying the Prime Minister has never lied to him and does not lie.
On Tuesday, outspoken Liberal MP Sharman Stone accused Mr Abbott and Treasurer Joe Hockey of ''lying'' when suggesting that workers' conditions at troubled food processor were overly generous.
SPC Ardmona – who last week had their request to the federal government for a $25 million assistance package rejected - has since refuted the claims that workers were over compensated.
On Wednesday, Mr Turnbull defended the Prime Minister during an interview on Fairfax Radio in Brisbane. When asked ''is Tony Abbott a liar?'' the Communications Minister quickly replied: ''Absolutely not. He's an absolute straight shooter''.
When asked if Mr Abbott had ever lied to him, Mr Turnbull replied: ''Never lied to me, no''.
But Mr Turnbull stopped short of criticising Dr Stone for her comments, noting that ''in passionate times, people say passionate things. And sometimes they're not as well considered as they should be''.
He also praised the member for Murray as a ''good friend and good colleague''.
Independent MP Cathy McGowan also weighed into the SPC Ardmona saga on Wednesday, saying more MPs should follow the lead of Dr Stone and engage in fiery debate.
In an address to the Rural Press Club in Melbourne, Ms McGowan applauded Dr Stone, who she described as a ''fantastic'' and ''tenacious'' local member for Shepparton.
On Tuesday, Ms Stone hinted that she may not stay in the Liberal party for the ''long term'' after launching her extraordinary attack on Mr Abbott and Mr Hockey.
''It is exactly what politics should be about. I love that Sharman is a member of the Liberal party and she is able to get up there and have feisty debate with everybody else about what needs to happen,'' Ms McGowan said.
''She wasn't put down, she stood up, she's carrying the flag for her people, she's exactly what we want people to do.''
Ms McGowan, who unseated former Coalition frontbencher Sophie Mirabella in the rural seat of Indi at last year's federal election, called for ''good public policy'' on manufacturing and food production in Australia.
''I think it's such a bad thing to close down debate and what I saw happening was people blaming the workers, or putting blame on people where it didn't belong. That's not the issue. The issue is the future of manufacturing and food production in Australia,'' she said.
As the debate continues over the government's decision not to grant SPC Ardmona $25 million in assistance, Dr Stone has written to Mr Abbott to urge him to reconsider his stance.
Dr Stone said she emailed the Prime Minister on Tuesday.
''I've asked could he please reconsider the cabinet decision on the basis that at that press conference ... he said that if they sort of got their house in order that might be a different story,'' Dr Stone told Channel Nine.
In her address to the Rural Press Melbourne, Ms McGowan also strongly advocated for electronic voting, and said she had spoken to fellow crossbencher Clive Palmer about this issue.
''I think we have moved past pencil and paper for voting . . . pencil and paper are last century . . . Let's get it done quickly and move into the 21st Century.''
She said agricultural production and manufacturing, the environment, telecommunications and public transport were high on her agenda for Indi.


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Eight years ago I was asked if I thought that rat rods and my type of cars would be accepted by the public at an indoor, turn table and mirrors, ISCA sanctioned show. My answer was, "only one way to find out." That first show was The 2003 Cincinnati Cavalcade of Customs, and we put four of "our cars" in a roped off area and piled tons of old rare speed equipment all around and on them. Well, the display was not only accepted, it was a mob scene! The entire weekend the crowd stood Four rows deep surrounding these "weird" cars. By the end of the weekend the ISCA show officials had pulled me into their offices and future plans were made for this new phenomenon. The next year I took four to six traditional hot rods and rat rods on tour to six different cities. I also went to Detroit, and with the help of Race Ruedisueli, Denis Scott and a few others we started the show within a show in the lower level that is now known as Detroit 1953 (Autorama Extreme).
While the public's fascination for traditional hot rods and rat rods has not changed, a few other things have since then. My area's do not require Carpet under the cars any more, or ropes to keep the people away. Also the amount of cars has grown tremendously! At our show in Cincinnati, my first four car area has now grown to an entire wing/corner of the show holding 70 cars, motorcycles and vintage race cars. I named it Survivors Alley, due to the large amount of unrestored race cars and hot rods we find every year to put on display.
This year (2011) was one of the best. I spent many hours on the phone, and searching collections to find "something for everyone." From tractors to Motorcycles, to Model T race cars, to COE haulers, to original untouched turn of the century vehicles, whatever you were into was represented. Another aspect of this year's group of "survivors" is that the majority of the cars are owned, or were built by guys under the age of 35. It was important to me to show people that the history that has been made, and preserved by hot rodders and racers of the past is not going to fade away.
Now its 2011 and almost every Indoor car show has a section for traditional hot rods and rat rods. Whether it's your kind of thing or not, at least take time to realize. Your shinny show car might just end up being drug out of storage one day with years of patina and dust on it only to be marveled at in a section with other survivors. One can only hope so.


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Moderators: Timko, Fritz, Solty, Booter, Blake_T, Frank Delicious
Fightingthetide wrote:Never thrown 9.5/10 Pro Teebird-L, no ink, marked at 175, Rancho and patent number, "TL" marking. There's some surface scuffs from storage, a few TINY (sand grain size) marks on the leading edge, The word "PRO" has been scuffed a little off the top (see 1st pic), and one very small cut on the edge (see 2nd pic)
Any idea what it could sell for?
Sorry for the low quality shots. If anyone wants to see a better one, let me know and I can make it happen.
Users browsing this forum: No registered users and 1 guest


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Did You Know?
Amur Tigers are the biggest cats in the wild, topping out around 600 pounds!
Today is World Oceans Day! Every year on June 8, communities around the world celebrate all that the ocean offers: marine life, seafood, lanes for international trade, and more. Sadly, pollution and over-consumption have hurt many species. World Oceans Day is an important time for us to think about how life depends on our oceans and what we should do to protect them for the future.
We can all make simple lifestyle changes to decrease pollution and over-consumption. Here are a few steps you can take in and around Potter Park Zoo:
1. Reuse water bottles and grocery bags. Whenever you visit the zoo or any other place, bring your own water bottle to fill up at a drinking fountain and your own grocery bag to put items in. The more you do these things, the less plastic is wasted.
2. Buy locally-sourced food as much as possible. Farmers' markets are a great place to do this; find one near you.
3. Explore different modes of transportation. Walk, bike, take public transit, and carpool often. Potter Park Zoo is located along the Red Cedar River, and is easily accessible by bike or foot from the beautiful Lansing River Trail.
"In the end, we will conserve only what we love. We will love only what we understand. We will understand only what we are taught." -Baba Dioum
This is a quote we firmly believe in at the zoo. We hope you'll join us in our mission to conserve the future of oceans and life – today and every day.


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Just a suggestion or two...
1- Create a sponsor link that would list all who have donated for that month. Create a tiered system in which Gold members donate at least X amount, Silver donate at least Y amount and Bronze donate Z amount. Everyone likes to see their name or handle in a favorable light. The alternative would be to list their status under their username, along with or instead of players names.
2- If a dedicated server is involved, could you offer other simple services? Something along the lines of, donate so much per year and get a mail box that has a "email@example.com" address. That would be pretty cool.
In any case, put me down on the list for sponsoring a month's worth of service. Heck, I might be persuaded to take care of two months.


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Emerson Foundation Awards Grant for Ithaca College Office of Civic Engagement
ITHACA, NY — A grant from the Fred L. Emerson Foundation will aid Ithaca College in its efforts to enhance service-learning and volunteerism opportunities for students in the community. The Auburn-based family foundation, which has supported a number of Ithaca College initiatives over the years, has awarded a $500,000 grant for the college's Office of Civic Engagement.
Established in 2012, the Office of Civic Engagement (OCE) serves as the catalyst for all student civic engagement opportunities, including volunteer community service, course-related service learning and community-based research. It is a significant component of the college's IC 20/20 initiative, which seeks to create a seamless experience for students in which every commitment they make — on and off campus — is fully utilized for its educational value.
"This grant is but one example of the commitment the Emerson Foundation has demonstrated through the years to the well-being of the college and to the community that the foundation serves," said Ithaca College President Tom Rochon. "We are grateful for their support as we seek to enhance the impact of our students' service work in the region."
The grant was awarded as part of the college's plans to establish a permanent endowment for the OCE, providing support for personnel as well as for civic engagement activities. Led by Anthony Hopson, assistant vice president for community/government relations and civic engagement, the office
- offers faculty development programs in concert with the Center for Faculty Excellence, to increase the availability of high quality service learning opportunities for IC students as well as provide logistical support to reduce the burden on faculty who teach a service learning course;
- develops cultural competency orientation modules for students to prepare them for effective community engagement;
- collaborates closely with community partners to identify and promote authentic and impactful service partnerships with community agencies and organizations; and
- assesses the effectiveness of various service learning and community service activities both from the perspective of educational value to students and impact on the community organizations.
The college already provides a number of formal volunteering opportunities for students, including Service Saturdays; Project Generations; Student-to-Student Mentoring; Community Plunge; Alternative Spring Break; the MLK Scholar, Park Scholar and Leadership Scholar programs; the IC-Longview Partnership; and Big Brothers-Big Sisters.
"The Emerson Foundation is pleased to assist Ithaca College as it seeks to enrich the opportunities students have to partner with civic organizations in a meaningful way," said Anthony D. Franceschelli, president of the Fred L. Emerson Foundation.
The Corporation for National and Community Service has consistently named Ithaca College to a place on the President's Higher Education Community Service Honor Roll, a designation recognizing colleges and universities that have demonstrated a commitment to volunteering, service learning and civic engagement.
"The Office of Civic Engagement will continue to build upon these successes as we further cement for our students the relationship between learning and its application for the greater public good," said Hopson.
One of the largest institutional contributors in Ithaca's history, the Emerson Foundation made its initial grant to the college in 1975 to establish an endowed scholarship fund. In the nearly four decades since, the Fred L. Emerson Endowed Scholarship and Internship Fund has been enhanced through additional gifts from the foundation and by contributions from friends, parents and alumni, including those who participated as Emerson Scholars. The foundation also provided funding to establish the Emerson Humanities Collaboration Award and the James J. Whalen Young Artist Award.
The Emerson Foundation is a fourth generation family philanthropy based in Auburn, New York. Founded in 1932 by the late Fred L. Emerson, president of the Dunn & McCarthy shoe company, the foundation continues to be a vigilant investor in selected organizations where it can make a critical and significant difference.
For more information on the Office of Civic Engagement, visit www.ithaca.edu/civic-engagement.


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And that's what's wrong with Chicago and the rest of the world!
Judge not lest ye be judged. Who are you to say Chicago and the rest of the world are wrong?
The process of responding to the needs and desires of your constituent base is fundamental to democracy.
Morality goes out the window and then you live by the "Hammer and the Nail" mentality.
Morality is a very flexible value; it can be bent or shaped to meet anyone's personal perspective.