text:
The ABC's of the XYZ's
Thursday, September 09, 2010
I'm on my own this week, no featured artist, no featured poet, just me and my library friends, pulling all the strings by ourselves.
Photos are a problem. Not only do I, once again, have a find a way to make old pictures look new, but, since iphoto won't open on my laptop, i've lost half my pictures and have less to work with.
I decided I'm going to try to go the other direction, make new pictures look old. I mention the Texas Big Bend in this issue. I'm using pictures from there, which I did not loose, and will try to make them look like they might be photos Civilian Conservation Corps workers from the 1930s who built Big Bend National Park (and most of our national parks) might have taken with their little box cameras and sent home (with a little stop at the photo lab for hand tinting as was often done in those days). About half the photos are from within the park and the rest are taken along a little two-lane highway that runs from Study Butte, just outside the west entrance to the park, to Presidio. It's about an hour/hour and a half drive sometimes alongside, sometimes above the Rio Grande River. Rough country and no place to be without a good horse and a snakebite kit, but beautiful all the same.
Somebody save my from myself. Send me you photos, your art, your doodles of consequence.
Here's who we are.
Ted Kooser
Walking on Tiptoe
A Happy Birthday
i took a pill
Charles Simic
Evening Walk
the dark
Mary Rose O'Reilly
Clearing Land for the Lotus Pool
The Zen Master's Instructions
what's the big idea
Fu Tianlin
Li Qi
In the Rain
Mei Shaojing
The Greens
no second act
Ursula K. Le Guin
The Lorelei to Heinrich Heine
The Woman in the Attic
a partly cloudy day
R.G. Vliet
After the Lone Ranger Died
For Sex
cowboy movie
Brian Blanchfield
Two Moons
night falls in the mountains
e.e. cummings
intimate moments
William Everson/Brother Antoninus
A Winter Ascent
The Approach
Do You Not Doubt
i start this week with former Poet Laureate of the United States
Ted Kooser
. I have four poems from his book
Delights & Shadows
, published in 2004 by Copper Canyon Press and winner of the Pulitzer Prize for Poetry. This is a book I just picked up today at the used book store.
Kooser is a retired life insurance executive and author of ten books of poetry. In addition to the Pulitzer, he has won a number of literary prizes for his poetry and nonfiction, including two NEA fellowships. He currently lives on an acreage near the village of Garland, Nebraska.
After the funeral, the mourners gather
under the rustling churchyard maples
and talk softly, like clusters of leaves.
White shirt cuffs and collars flash in the shade:
highlights on deep green water.
They came this afternoon to say goodbye,
but now they keep saying hello and hello,
peering into each other's faces,
slow to let go of each other's hands.
She was all in black but for the yellow ponytail
that trailed from her cap, and bright blue gloves
that she held out wide, the feathery fingers spread,
as surely she stepped, click-clack, onto the frozen
top of the world. And there, with a clatter of blades,
she began to braid a loose path that broadened
into a meadow of curls. Across the ice she swooped
and then turned back and, halfway, bet her legs
and leapt into the air the way a crane leaps, blue gloves
lifting her lightly, and turned a snappy half-turn
there in the wind before coming down, arms wide,
skating backward right out of that moment, smiling back
at the woman she'd been just an instant before.
Walking on Tiptoe
Long ago we quit lifting our heels
like the others - horse, dog, and tiger -
though we thrill to their speed
as they flee. Even the mouse
bearing the great weight of a nugget
of dog food is enviably graceful.
There is little spring to our walk,
we are so burdened with responsibility,
all of the disciplinary actions
that have fallen to us, the punishments,
the killings, and all with our feet
bound stiff in the skins of the conquered.
But sometimes, in the early hours,
we can feel what it must have been like
to be one of them, up on our toes,
stealing past doors where others are sleeping,
and suddenly able to see in the dark.
A Happy Birthday
This evening, I sat by an open window
and read till the light was gone and the book
was no more than a part of the darkness.
I could easily have switched on a lamp,
but I wanted to ride this day down into the night,
to sit alone and smooth the unreadable page
with the pale gray ghost of my hand.
I have trouble sleeping because of various aches that get worse the longer I stay in bed. Usually, I put up with it, but sometimes, I really want a good night's sleep and take something.
i took a pill
i took a pill
last night to ease
the nagging aches and pains
that keep me up and down
all night,
favoring this part or that
chair to bed bed to chair
left side right side back,
each sleeping position
good for some aches,
aggravates other -
it is a dance of tender joints
that keep me rocking
and rolling
through the dark hours,
leave me pining
for first hint
of light...
deprived of the stillness
of her kind
leaves me by midnight,
finds her cushion
in the den
and i watch her sleep and
admire the quality of her repose,
and, jealous of a cat, wish i could be her
for just one night
and sleep the sleep of the wild,
sleep with the natural intensity of the beast...
but the pill works
and i sleep like the deep of a storming sea,
undisturbed by surface tensions,
dream the dreams,
disquieting dreams i cannot remember
but feel the sly taste of
like the tingling nerve
that makes a leg want to jump
or an eyelid twitch
that do not end when i wake,
like a shadow
behind my ear, fogging my morning
with a lethargic mist,
a dislocation, a star
off its orbit, circling still
but in a cosmos slightly foreign...
i need another pill, i think,
a pill to break the dreams, a pill
to bring me back to earth
a pill
to wake me
One of my favorite poets, another former Poet Laureate of the United States
Charles Simic
, has a book,
Sixty Poems
, published by Harcourt in 2007. Here's one of them.
Evening Walk
You give the appearance of listening
To my thoughts, O trees,
Bent over the road I am walking
On a late summer evening
When every one of you is a steep staircase
The night is slowly descending.
The high leaves like my mother's lips
Forever trembling, unable to decide,
For there's a bit of wind,
And it's like hearing voices,
Or a mouth full of muffled laughter,
A huge dark mouth we can all fit in
Suddenly covered by a hand.
Everything quiet. Light
Of some other evening strolling ahead,
Long-ago evening of silk dresses,
Bare feet, hair unpinned and falling.
Happy heart, what heavy steps you take
As you follow after them in the shadows.
The sky at the road's end cloudless and blue.
The night birds like children
Who won't come to dinner.
Lost children in the darkening woods.
As the anniversary of the Twin Towers attack came near, I was determined not to write a 9-11 poem, first because I knew everyone would be writing a 9-11 poem and because it's my opinion our country has become obsessed by that single historical event and that, vicious attack that was, the greater national tragedy was not the attack itself, but the unnecessary war in Iraq that it led us into and all the unnecessary death that ensued, many, many more dead, innocents mostly, as were those who died in the towers and the pentagon, than were killed in the event that bought on the cycle mis-directed violence.
But then, there it was 6:30 a.m. on the morning of September 11, 2010, and I was writing a 9-11 poem. Some events are too much in our psyche to be denied.
the dark
i've lived my life
in a doomsday world
where everything is
from razor blades
to the human race
but as i scan ancient times
i see they were also
the beginning
of the end of things
that mattered -
walls breached
at the gate, always,
libraries burned,
people burned for seeing
what others did not,
could not...
today ,
the anniversary
of a specific insanity,
towers burning
racing clouds
of smoke and dust
like death snakes
curling through city streets,
more insanity following,
more buildings burning
more people burning,
children burning,
more death snakes
our children,
boiling in their own
bursting blood,
other children, real children
babes in arms
burning, bursting,
strewn on bloody streets,
theirs, ours
strewn in precious pieces on bloody
imploded, hanging like burnt
meat on bridges,
boiling in the bloody cauldron
of war
while the guilty hide in caves
and plan more
atrocity, watch their plan unfold...
barbarians at the gate,
breaching the walls,
invading our souls
as the dark stain spreads
even among our own,
even within ourselves,
becoming the atrocity,
surrendering to the cave,
the dark
within us that threatens to
become us
I have two poems now by
Mary Rose O'Reilley
. The poems are from her book
Half Wild
, published in 2006 by Louisiana State University Press and winner of the 2005 Walt Whitman Award of the Academy of American Poets.
O'Reilley was born in Pampa, Texas, and educated in Roseville and Saint Paul, Minnesota. She was raised a Catholic, and served as a novice in a religious community. She graduated from the College of St. Catherine and completed graduate work at the University of Wisconsin at Milwaukee. From 1978 to 2006, she taught English and environmental studies at St. Thomas College where she is currently Professor Emeritus. She lives in Saint Paul, Minnesota.
Active in Quaker ministry, she has also taken Buddhist precepts as a lay practitioner.
Clearing the Land for the Lotus Pool
Wherever you lean
on a spade
in this earth of Duras
you strike the shells
of old houses
bones no one remembers
and, if you are quiet,
the spaces between
the bones.
"This land gives birth
to stones,"
my neighbor calls
as I pass
with the dogs.
He tosses the rocks
in a pile.
They roll together,
exchanging the names
of men and women,
stories of wounds,
a few notes of music
stones know.
These red tiles of Duras -
each holds
like a clay cup
the whisper we need
to sustain
our silence.
Do what you've
listened to -
says the cup
in my hands, smiling:
The Zen Master's Instructions
The meadow has become
a like of rime;
another mirror.
In the dry stream bed
a white tail
flags its fear
some young one
unwilling to rest
with whatever rises
before the heart's eyes
as these other
have learned to do.
Stand like the deer
knowing the hunter
is in the woods
knowing here tremor
will bring the shot.
In your stillness
the hunter
over and over.
The temptation of pontification lures everyone who takes pen in hand, a sure path to self-delusion and embarrassment.
what's the big idea
was on the verge
of thinking big thoughts
this morning -
about the seemingly
oxymoronic idea
that young men
are often more willing
to die for a cause
than old men, who,
practically speaking
have fewer years to lose,
but it is that which
makes them
for the more rare a thing is
the more precious
it becomes
and an old man
with few years left
will kill for every living
moment of it
but will not die
for any cause but their own
survival - it is age
that makes cowards
of us all...
but that reminds me
of a Nash Rambler station wagon
i bought back when i was in college -
made it six blocks
from where i bought it
before the engine froze up -
a pile of crap
is what it was, just like most
so-called "big ideas"
except that the Rambler
was a pile of crap
on wheels
while most big ideas,
though they could use
a good set of training wheels,
have no wheels at all,
they just sit there and stink...
it should be hung up on a flagpole
written in fancy big letters -
"if you ain't Einstein,
don't fuck around with big ideas
cause you ain't got it in you" -
reminds me of Bill Moyers,
fairly good preacher, politician
and journalist, with his Southern Baptist
voice on the TV
talking well over his own head,
like he'd never seen that Eastwood movie,
Clint saying,
"a man's got to know his limitations."
but it seems, just like Moyers,
none of us know that, which seems
so simple,
and so we end up, like in
Cool Hand Luke with a "failyorrr
to commicate"
saying things we didn't mean to say
to others
hearing something else
and our big ideas
mostly end up
big embarrassments
like this whole business
of young men being more willing
to die
while old men are willing
to kill
so could you just forget
you ever heard that
from me
and pretend this poem
was about frogs in a pond
or birds in a tree
or bears in the woods
what bears do in the woods,
something simple like that,
not remotely pretending to be a "big idea,"
its just
Next, another anthology. This one,
Women of the Red Plain
, is a collection of contemporary Chinese women's poetry was published by Penguin Press in 1992.
The poems in the book were translated by
Julia C. Lin
The first of the three poets I selected from the book is
Fu Tianlin
Born in Sichuan Province in 1946, Fu graduated from electricity school in 1961, then worked in the orchards while pursuing a writing career. Her first book won a national poetry prize in 1981 and subsequent collections have followed. When this book was published, she worked for the Chongqing Publishing House.
I've praised you with such sincerity
- your glistening sweat!
You're like dewdrops on grass at sunrise
Reflecting sun's radiance
Mirroring hills' jewelled greeness.
I've glorified you with such fervor.
- You glisten with sweat
Like streams cruising through cliffs
You cling yourselves to my forehead,
You slide down my back.
Today tractors dash across the field
A thousandfold more efficient than the hoe!
I see the workers faces sweltering
With the same glistening sweat.
You trudge close to all lives that toil,
Sometimes you're exalted, sometimes disdained.
When hard work is combined with wisdom,
Your round glowing pearls,
When hard work is joined by ignorance,
You are only tears, bitingly bitter.
Next, I have a poem by
Li Qi
Born in the Heilongjian Province in 1956, Li became a chinese instructor in the Athletic College of Harbin upon her graduation from college. She began writing poetry when she was fourteen years old and began publishing in literary journals in 1978 when she was twenty-two. Her first volume of poems was published 1985.
In the Rain
In the chill of an autumn rain
I shivered uncontrollably
Suddenly, overhead
A piece of house eave seemed to fly past -
Behind me, there's a strange girl
Eyes like new moons,
Her umbrella rose pink.
I'm thankful
But she shyly moves out of my sight
As though her arrival
Is as natural as raining
Silently we stroll along
- That opened umbrella
Is like a wheeling sun -
Toward the world before us
Illimitable warmth.
My last poet from the anthology is
Mei Shaojing
, born in 1948 in Chongquing. She worked in the area of Yan'an in the Shaanxi Province after her graduation from the middle school that is affiliated with Beijing University. She enrolled in the Chinese Department of the Shaanxi Teachers' College, but withdrew due to illness. She returned to her former job, doing promotion work for a radio factory. In 1981, six years after publication of her first poem, she was transferred to work for the Federation of Literary and Art Circles in the Yan'an area. Beginning in 1984 she attended the Lu Xun Academy in Beijing as well as the Chinese Department of the Beijing University for advanced studies.
The Greens
Oh this poor, bony land
As fire flares in the black night,
The greens also flare up the day.
When will the greens
Forever sheathe this yellow earth?
A, in those days when even the sky was yellow,
I've fancied
A fabulous green sun.
Great beginnings are always disappointing when they lead nowhere. Sometimes, I'm so pleased when I come up with a great line to start a new poem that I stick with it, even when I have nothing to add to it.
Making lemonade - sometimes that's the best you can do.
no second act
i have a dozen
great first lines running
through my head this morning
but i'm saving them
until someday
when maybe i'll have second
lines to follow -
my situtation much like that
of the religiosos babosos
that used to sit near enough to me
to eavesdrop
on their conversation
great conversations at the beginning
learned discussions,
theological arguments
about matters philosophical
and moral,
bible study for the intellect,
and it was pleasure to listen in
and develop the arguments
in my own mind and in my poems...
but lately,
the guys might as well be cost accountants
or shoe salesman,
football, basketball, baseball
all examined
in their seasons
and church politics
and gossip, like
which voices in which pulpits
are up
and which are down,
who's aheard; who's behind,
who's sleeping with someone
else's dogma
and who's been true to the faith,
who's got a shot at that opening
at Northside Methodist
and who doesn't have a shot
in hell,
he he, they say, figuratively
journeyman talk,
laborers in the field
talking about crop conditions...
like so many of us,
no second act -
that's the problem
Next I have two poems by
Ursula K. Le Guin
. The poems are from her book,
Incredible Good Fortune
, published in 2006 by Shambhala.
As a reader of all science fiction from my very early teens, I had read Le Guin. Though her more fantasy directed style was not my favorite. she was one the writers whose every new book I read. I never knew, in my science fiction world that she was also an accomplished and award-winning poet.
I have two poems from the book, both including a touch of the sensibility that made her great at her kind of science fiction.
The Lorelei to Heinrich Heine
I don't know why I am so sad,
I watch the river ships go by
and see a harmless sailor lad
and call him and he comes to me
into my arms to die
and we sink down and down
he to drown, not I,
for what I breathe is not the air
when I sit lonely in the sun
and comb my hair and comb my hair
till there comes b another one,
some boy a mother had,
to sink with me and die.
O why am I so sad?
The Woman in the Attic
I am the mad woman in the attic,
professionally frantic. Hear my laugh?
Loud, singularly mirthless, automatic.
I am the first and worthless wife.
My heart is not in this poem.
How could it be? My lie
is contingent, like that of the Golem
or the Golden Calf,
on a word written on my forehead,
or a popular belief.
I am boring, I am bored.
Ha ha I say to joy, ha ha to grief.
Sunshine and an old friend return.
a partly cloudy day
overcast skies were mostly cleared
yesterday, a partly cloudy day,
bright sunshine
broken at times by slow-moving clouds,
sending me out for an hour
to my private sunshine spot
in the back yard...
having heard
that a person's buttocks
are the hardest part of the body
to tan, i diligent moon the sun
when it passes from behind a cloud,
then quickly switch over on my back
when a cloud returns, bringing with it
the pleasure of a cool breeze
passing over parts normally sequestered..
i spied my hummingbird again,
wings folded,
on a mesquite branch high over my head,
a tiny creature,
against the morning sky,
meditating, perhaps,
or maybe just wondering about
the return of the pale hulk splayed below,
washed up again on the green shore
of his blue-bright sea
Poet, novelist, playwright, and short story writer
R. G. Vliet
was born in Chicago in 1929. His father was a Naval medical officer, and the family lived in many parts of the U.S., largely in the south, and in American Samoa. R.G. Vliet attended high school in Texas City, Texas, just south of Houston, and attended Southwest Texas State University, where he wrote and acted in his own plays. While at the university, he met his future wife and had one child, a daughter, Brooke. Both he and his wife received their B.S. degrees in Education in 1952. He went on to complete his Master's thesis in 1953, then taught English for two years in central Texas high schools. Even though many of Vliet's novels, plays, and poems would be set in Texas and would win awards from Texan literary institutions, Vliet would not live in Texas again, except for a six-month period near the end of his life, in 1983.
In 1955, after a year and a half studying playwrighting at the Yale University School of Drama, he left to start his own writing career, which began with a string of award winning plays. In 1966, at the age of 37, Vliet published his first book of poetry, then, in 1970, he published a second, both honored by the Texas Institute of Letters. Then, from 1971 to 1982, Vliet worked a small farm in Stamford, Vermont, where he wrote then published his first novel. Despite the novel's relatively low sales, Vliet was paid $25,000 from the sale of movie rights to the work. It was the most money he would earn from any of his literary efforts. He continued to write novels, completing his last one, considered to be his best, shortly before his death from cancer in 1984.
I have two poems from Vliet's book,
Water & Stone
, published by Random House in 1980.
After the Lone Ranger Died
they put him in a cave.
For eight weeks Tonto carried the series
Then the Masked Raider resurrected, a mite slower
than Jesus, perhaps, but just as reliable. The world
unloosed its bindings and straps and I slapped my horse's
rump through the sweet grass and the sour grass.
Such hoof pounding till m feet hurt.
I reared and neighed with the sweet iron bit
in my mouth, I was sexual and the sky burned blue. The white
light of a slake desert hurt my eyes.
I rode up the hill to the hanging tree and the bound
leather- skirted maiden until I was called in to dinner.
For Sex
I could go clear out of myself.
It lights a window in the thickening wood.
White grubs glow at its roots.
The poplar bends in the wind of it,
in wetness shining like a green sleeve,.
When your face turns to me it is
your self, and more than the meaning of yourself,
down birchbright corridors. Such a luminous waste.
The deer stare out of shimmering thickets,
the happy Chinese hermit dances
under the pines and in the steams trout
sing. We are such joyful commoners.
Next I have two of my early poems.
The first is very early, written in 1970, I remember the night I wrote it. I had returned to college after completing my military service and was near to finishing up. I lived in a small trailer on the banks of the Blanco River and had driven into town to wash some clothes at a laundrymat. There was a heavy storm blowing in and I tried to write about that, but it went nowhere. In frustration I did this poem. The poem was finally published nearly 30 years after it was written in 1999 in a print journal,
, which made me very proud, since it was the first poem I had seen published since 1971 and the first since I had returned to writing after my first retirement.
The second poem was published in 2002 in
The Melic Review
. Although I had published several poems in the intervening years, I was especially pleased to see it in print (on-line, actually) because I liked the poem very much. I also used the poem in 2005 book,
Seven Beats a Second
I haven't submitting my work for the past several years because I've been so busy with "Here and Now," plus, my work, as it has developed, is pretty much outside the mainstream of what the journals look for and I doubt it would do much good to submit anyway.
Here are the two poems.
cowboy movie
she said to me
in her low voice
and sighed
as I moved closer
she said to me
into his corner
and sighed
and cried
in the shallow shadows
of his silver sombrero
she cried to me
i'm not
you truly set me burning
when you walked out those swinging doors
in your skimpy white short-shorts
tight cheeks flexing against the soft cotton
like two little monkeys in a velvet bag
waving goodbye
is the word that comes to mind
I'm back to the place in my bookcase where the first books I bought when I started "Here and Now" are stacked. This one,
Not Even Then
, by
Brian Blanchfield
, was published by the University of California Press in 2004.
Blanchfield is currently Adjunct Associate Professor at the Otis School of Art and Design. He has a BA from the University of North Carolina, Chapel Hill, and an MFA from Warren Wilson College. At the time of publication of his book, he taught in the BFA creative writing program at Plat Institute of Art.
I have one poem from the book.
Two Moons
The moon will all but disappear, which is to say the world is in the way
again. It will take two hours to return to full, which is what we, in or
way, call a whole half lit.
The last eclipse I didn't understand what I do now.
I was stunned by lawn sculptures of waves outside the long lobbied
Delano on South Beach, its oceanside wide open, its twenty-five-foot
billowing white drapes sucked to my back and then not and then sucked
again, its cavity fighting mine.
The galaxy is all wring with nine-dollar cosmopolitan. I couldn't get
daylight's alibi. Someone said gimme and O. I said gimme another. We
couldn't get the bartender's attention. Obtundity nearly knocked me
Dennis said he didn't know about lunar ones but the wind that rushes
in when the sun goes out brings the scent of you secret desire.
At Grand Army Plaza, by nine lanes spinning into fewer, I make it to
the middle. The moon is already phased to the size of an eyelash, or
someone's distant hand cupped at his sunned brow, making you out.
Poor white parenthesis, is everything inessential? Should everything
come between? Someone cheer the sidereal.
But no on has outsprinted our coverlet to star in a warmth on rock. I
imagine it new, another tournament beginning, an open, an invitational.
We have a break scheduled in mid-October to the Big Bend National Part. It is beautiful and it is wild and with no TV, internet or cell phone coverage, it is isolated.
I love it while I'm there, but, city boy that I've become, can't take more than two days of it.
night falls in the mountains
night falls in the mountains,
the sun dropping
behind ragged peaks
on one side
of the Chisos Basin
while the moon rises
from behind high ridges
on the other,
dark, light to dark
while your attention
from one to the other...
below the mountains,
on the desert floor,
sunset is a slow
and stately progression,
a soft glide
through all the colors
of yellow and orange,
lying at the end
like a bloody red ball
on the west horizon,
as, in the east, the moon rises
over the flat, dry plain,
soft custodian of the desert night,
it is in it's reflected glow,
like a counterweight to the sun,
bringing paler light to sunburned
sand and night-blooming cactus,
reds and yellows and orange blooms
restating in pastel shades
sunset's vivid
though each within sight of the other,
they are different worlds,
these mountains and this desert,
each bringing it's own rise and fall
to the day
and to its ever-lost companion, the night
I have two poems now by
e.e. cummings
from his collection,
is 5
, published by Liveright in 1985.
I've always enjoyed the fun of cummings, but never appreciated him as a poet until I read some of his intermediate period poems, after his early classicism and before he became the poet-jester of later days. This book and these poems are from the poet-jester period.
this man is o so
this;woman is
please shut that
the pout And affectionate leer
interminable pyramidal,napkins
(this man is oh so tired of this
a door opens by itself
woman.)they so to speak were in
Love once?
her mouth opens too far
and:she attacks he Lobster without
(exit the hors d'oeuvres)
it started when Bill's chip let on to
the bulls he'd bumped a bloke back in fifteen.
The she came toward him on her knees across the locked
room. he knocked her cold and beat it for Chicago.
Eddie was waiting for him,and they cleaned up a few
times-before she she got the info
from a broad that knew Eddie in Topeka,went clean
daffy,and which was very silly hocked
the diamond he gave her. Bill was put wise
that she was coming with his kid inside her.
He laughed. She came. he gave her a shove
...she exactly lay,looking hunks of love
in The Chair he kept talking about eyes
I was asked if I thought a good poem could be written using only dialogue. I responded that I didn't know. Still don't.
intimate moments
that tickles - she says
not exactly the idea - he says -
but it's a start
shall i do it again - he asks
let me get the light - she replies
the dog's watching - she says
what! - he exclaims -
but it's dark, she can't see anything
then it must be the cat - she says -
they can see in the dark,
you know
it is the cat - she says -
i can hear her snoring
then she's asleep - he says -
and can't be watching
she might wake up - she says
so let's be very quiet - he says
shhh- she says
the dog's here, too - she says
how do you know - he asks
she licked my toes - she replies -
she's gonna wake the cat
down, boy - he says
no, not yet - she says
i'll put the dog out - he says
quietly - she says - so you don't
wake the cat
OK - he says - the dog is
you got a snack while
you were out, didn't you - she says
how do you know - he asks
you left the refrigerator door
open - she says - i can see the
i'll go close it - he says
and turn off the fan
in the den - she says
all done - he says - now
where were we, a near-miss
tickle, if i recall
you woke the cat - she says
and she's watching
Brother Antoninus
was born
William Everson
in Sacramento, California in 1912. His Christian Scientist parents, both of whom were printers, raised him on a farm outside the small fruit-growing town of Selma. He played football at Selma High School and attended Fresno State College.
When his book,
The Residual Years
, was first published by New Directios in 1948, he was a young man working in California, not long after he had been released from a work camp for conscientious objectors. While in the camp, he joined with a few other workers and a mimeograph machine to create the Untied Press, publisher of some of the most influential protest poetrry of the Second World War.
He joined the Catholic Church in 1948 and soon became involved with the Catholic Worker Movement in Oakland, California. He took the name "Brother Antoninus" when he joined the Dominican Order in 1951 in Oakland. A colorful literary and counterculture figure, he was subsequently nicknamed the "Beat Friar."
He spent most of his years living near the central California coast a few miles north of Santa Cruz in a cabin he dubbed "Kingfisher Flat". He was poet-in-residence at the University of California, Santa Cruz during the 1970s and 1980s, where he founded the Lime Kiln Press, a small press through which he printed highly sought-after fine-art editions of his own poetry, as well as of the works of other poets, including Robinson Jeffers and Walt Whitman.
He continued to travel, write and perform readings until his death in 1994.
I have three poems from a New Directions re-issue of
The Residual Years
in 1968.
A Winter Ascent
Climbed, ,up stone slope and its runneled rifts,
The shade-heavy side of a winter hill.
Under our feet the rain-ruined flints,
Over our heads the birds scarce in the air
And the air widening,
The air spreading about us -
Time-eaten England, her handing doom
Washed from out brows.
So blood beat;
So backs rising stone over stone
Bore the full sky;
So sight sprang, when, gaining the crown,
Knew in the valley its first farm,
Shrouded, as in some airman's straining eye
The Orkneys, small on the sea, draw him down.
The Approach
Breaking back from the sea we ran through low hills,
The long deserted pavement falling and winding,
Lonesome farms in their locked valleys,
The coastal range, ancient even as mountains,
Moulded by wind,.
Till inland we curved to the far converging city,
Seeing it laid at the hill's heel,
Whirlpooled, the long lines of its power,
Beacons for planes revolving he dusk,
The black trails of concrete slipping down grade
To the first clusters of the city,
Thick in the gloom with its few lights showing,
And its heavy pounding heart.
Do You Not Doubt
Do you not doubt, being lonely of heart,
And bleakly alive on a wrinkling world,
The fate that so forces?
Men doubling on death
Deny with their eyes the job that drew them;
And the cursing girl,
Twisting about her central hurt,
Breathes oath on black oath
Before she fails.
These turn at the crux;
But one whole of mind and firm of flesh,
Flinch as he does his aching eyes,
May yet bear brunt,
Unholy and harsh through it beat against him,
May yet bear brunt.
For the scope, the sweep,
The balancings and continuations of our lives
Extend beyond us.
However we spaniel to wedging fate,
The inherent choices of human attempt
Are opening yet.
What has to be taken take with mind wide,
Dragging wholesale armies into its maw,
Sorting the masses of heaped confusion,
Dealing with doubt and that lonely fear.
And through the spectacular agitation of pain
Quench you at last,
Be yet at last,
Be yet prepared to use as you can
The augmentation and heritage of the race.
The continuity of mind beyond mind
Grappling with truth,
As if all who have hammered against the dark
Beat from your brow -
Then hard-handed force,
The exactitude of that final fate,
Such even as they may be faced.
I'm going to finish this week with one of two poems I had published forty years ago in a little literary journal in Austin. Outside of an annual thing the university did, these were my first published poems.
I spent a year of my military service on the northwest frontier of Pakistan, on the edge of the desert, with the Hindu Kush on the far horizon. The poem is about what I woke up one morning as I crossed the road from our living compound to our operations center, a wondrous sight to my truly foreign eyes.
i awoke one morning and there was a
marching single-file
across my back yard,
the beasts were
and all the trade goods
piled on their backs
made the clatter clang clatter
that had awakened me
they went their way
and i went back to sleep
I'm done.
Until next week, please read the notice posted at the door, i.e. a material presented on this blog remains the property of those who created it. My stuff you can have - though proper credit would be nice.
I'm allen itz, owner and producer of this blog and I sure hope I have a featured poet and someone else's art next week.
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text:
"A reader lives a thousand lives before he dies…The man who never reads lives only one."
For any of my book lovers out there, here are a few books I have already read myself and fell in love with!
Disclosure: This post contains affiliate links, meaning that if you click on one of the product links I will receive a percentage!
Being Mortal: Medicine and What Matters in the End by Atul Gawande, M.D. Gawande gives his experiences of medicine in today's world. He lays out examples of how medicine can be altered to benefit lives of patients in their final days. How when the end of life is near, medicine isn't the only thing that we need. Comfort and care overpower. This book was absolutely extraordinary. From the places he has traveled to hearing of his own life, you are sucked in from the beginning. I recommend this to anyone who is going into the healthcare field to learn more about the importance of care for the elderly. Such a good read!!
When breath becomes air by Paul Kalanithi, M.D. This book will spin your emotions! Being interested in Neuroscience myself, I read this book in two days; I could not put it down. Reading of a Physician in a patient role as well as his triumphs as a neurosurgeon resident, you won't be able to stop reading! You'll laugh and cry, but it will be by far a book that stays with you forever!
If neither of those fancy you, here are the three books I plan to read this summer!
The Brain that Changes Itself by Norman Doidge, M.D. This book was recommended to me by one of my neuroscience professors when we talked about brain plasticity! It's full of stories of patients' lives that were changed by the plasticity of their own brains! The back of the novel talks of a woman with half of a brain, finding ways to rewire itself became fully functioning! So excited for this read!
Confessions of a Surgeon by Paul A. Ruggieri, M.D. This book I found while trolling through my favorite book store! This general surgeon shares his successes and failures inside and outside of the O.R. He shares the secrets of what goes on in the O.R and the challenges that he faces. Wanting to go into surgery myself, this is something I cannot wait to read!
Cutting for Stone by Abraham Verghese This book was recommended by a fellow blogger. She had read this in medical school and said it is a must read! Unlike the books mentioned before, this is more of a novel read. Brothers who go through life with a shared passion for medicine! It takes place in Ethiopia, so I am interested to see the difference in the culture of medicine!
There you have it, a summer reading list for 2017. I'm starting with The Brain that Changes Itself this Friday! If you're reading along, let me know! I'd love to hear your thoughts and chat about the amazing field of Neuroscience! I'll be posting my reading journey on Instagram so you can follow along!
Thanks for reading and of course Happy Reading <3

subset: commoncrawl


text:
Association of primary tumor lymph node ratio with burden of liver metastases and survival in stage IV colorectal cancer
Colorectal cancer (CRC) is the third most common cancer in the United States (1). The most important prognostic factor is the TNM stage and up to 60% of patients with CRC will develop metastases during the course of their disease (2). Outcomes in these patients depend heavily on the nature and extent of distant metastases (3). The significance of primary tumor characteristics, such as lymph node (LN) status on survival in patients with Stage II/III CRC is well established (4,5). The implications of primary tumor draining LN burden are considered less pivotal in the setting of stage IV disease.
National guidelines recommend evaluation of at least 12 LNs for adequate staging in CRC (6). The extent of nodal involvement is a well established prognostic factor in patients with non-metastatic CRC (4,5,7). In addition to conventional LN status, several authors have proposed surrogate methods of nodal assessment for more accurate staging (8,9). Of those, a valuable tool is the lymph node ratio (LNR), defined as the ratio of positive LNs to the total number of nodes harvested. Recently, the significance of LNR has been explored for various neoplasms including CRC. Although some authors have suggested a role for LNR in stage IV CRC (9,10), the relative dearth of such evidence limits its utility in planning multimodality management of these patients.
The majority of patients with stage IV CRC have liver dominant metastatic disease. Outcomes in such patients are defined by the extent of hepatic tumor burden (3,11). Although aggressive primary tumor characteristics portend a high risk for distant metastases (10,11), the correlation between primary tumor biology and the extent of intrahepatic metastatic disease requires further clarification. The biologic significance of nodal staging in patients with liver metastases (LM) may become increasingly important as patients with synchronous disease are more likely to obtain control of their liver disease with more effective systemic regimens and potentially immunotherapy (12). As such, patients who present with synchronous LM are likely to undergo primary tumor resection at some point during the course of their disease (13).
The objective of our study was to assess the impact of primary tumor LNR in stage IV CRC on survival and its association with the extent of hepatic tumor burden. Such associations would confirm the importance of rigorous nodal staging during resection of the primary tumor in patients with disseminated disease. We hypothesized that high primary tumor LNR is associated with more extensive hepatic metastases and worse survival outcomes in stage IV CRC patients. To our knowledge, an association between primary tumor LNR and intrahepatic tumor burden has not been previously reported.
With approval of the Institutional Review Board and in accordance with Health Insurance Portability and Accountability Act regulations, a prospectively maintained Roger Williams Cancer Center tumor database was used. Between 2004 and 2011, 79 patients with stage IV CRC were treated at our institution. We excluded 26 patients who did not undergo resection of the primary tumor. Retrospective chart review was then performed on the remaining 53 patients that met final inclusion criteria. Variables examined included age, gender, primary tumor site, LN status, burden of hepatic metastases, carcinoembryonic antigen (CEA) level, presence of extra-hepatic metastases and surgical intervention.
Odds ratio (OR) calculations were used for quantitative assessment of associations and statistical analysis was derived using the chi-square test. A multiple regression model was utilized to determine multivariate statistical independence on factors that were found to be significant on univariate comparison. LNR was defined as the ratio of primary tumor LN with metastatic carcinoma to the total number of LN retrieved. With the assumption of a normal distribution of data, all the associated variables were tested on a correlation matrix using the Pearson product-moment correlation test. Correlation coefficient was calculated by linear regression. LNR cut-off values were analyzed for predictability using receiver operating characteristic (ROC) curves. Survival curves were generated using the Kaplan-Meier (KM) method and statistical comparison was done using the log-rank test. The cox regression model was used for multivariate survival analysis. All statistical analyses report 95% confidence intervals (CI) and were performed using SPSS for windows (SPSS Inc, Chicago, IL, USA). Significance of difference was assumed at P<0.05.
The decision and timing of surgical resection of primary tumor and LM was based on clinical assessment by a surgical oncologist in conjunction with a multidisciplinary team. Extent and nature of hepatic surgery was similarly individualized for each patient based on rigorous clinicopathologic evaluation. Patients were selected for hepatic resection when complete tumor clearance was possible along with an anticipated adequate liver remnant.
The median number of LNs retrieved was 17 (range, 2–39). Thirty-nine patients (74%) had ≥12 LNs retrieved, consistent with national guidelines. Median follow up was 16 months (range, 0–117 months). The median LNR was 0.25 (range, 0–0.94) and used a cutoff to define patients with a low LNR (L-LNR, ≤0.25) or high LNR (H-LNR, >0.25), as previously reported (8). Among 53 eligible patients, 26 (49%) had H-LNR. Demographic and tumor characteristics with respect to LNR status are outlined in Table 1.
Full table
Age and gender were fairly well distributed within both groups. Most primary tumors were of colonic origin (72%), while the remaining were rectal adenocarcinomas. The median CEA level was 16.5 ng/mL (range, 0.5–2,725 ng/mL). This value was used as a cutoff for comparative analysis. Among all patients, 51% had >3 LM, 51% had bilobar hepatic involvement and 45% had a hepatic metastasis >5 cm. Sixteen patients (30%) had extrahepatic metastases, with lung being the most common site of disease outside the liver. Fourteen patients with extrahepatic metastases (n=16, 88%) did not undergo any hepatic surgery. All patients received chemotherapy either in the neo-adjuvant or adjuvant setting. The dose and timing of chemotherapy was individualized to each patient after a multidisciplinary discussion. Fifteen patients with rectal cancer (n=15, 100%) and 12 patients with colon cancer (n=38, 32%) received neo-adjuvant chemotherapy prior to resection of the primary tumor.
LNR analysis
We did not identify an association between age, gender, primary tumor site or CEA level with LNR (Table 2). We found that H-LNR was associated with the presence of >3 LM (OR: 3.21; 95% CI, 1.04–9.88; P=0.042) and bilobar LM (OR: 4.50; 95% CI, 1.41–14.28; P=0.011). Size >5 cm or the presence of extra-hepatic disease were not significant correlates of LNR. Patients with H-LNR were significantly less likely to undergo surgical resection of LM (OR: 0.25; 95% CI, 0.07–0.81; P=0.021). On multiple regression analysis (Table 2), factors independently associated with LNR included the presence of >3 LM (OR: 2.43; 95% CI, 1.12–8.85; P=0.047) and bilobar disease (OR: 3.94, 95% CI, 1.07–14.49; P=0.039). Surgical intervention for metastatic disease was negatively correlated with H-LNR however it was not statistically significant (Table 3).
Full table
Full table
ROC curves were derived to analyze the predictive value of LNR on liver tumor burden and survival (Figure 1). A cutoff of 0.25 was found to be the most predictive for the presence of >3 LM (sensitivity 63%, specificity 65%), bilobar hepatic metastases (sensitivity 65%, specificity 67%) and overall survival (OS) (sensitivity 63%, specificity 72%). Lower LNR cutoffs increased the sensitivity but decreased the specificity of this parameter and the reverse was noted for higher cutoffs.
Survival analysis
In our group of patients with colorectal LM, with data assumed to be normally distributed, increasing LNR was correlated with worse OS. On linear regression, each increase of LNR value by 0.1 was associated with a decrease in OS by 3.1 months (Figure 2, P=0.009). The median OS for patients with H-LNR was 14 months as compared to 26 months for those with L-LNR (Figure 3). The 3-year OS for H-LNR group was also significantly worse than the L-LNR group (9% vs. 34%, P=0.027). On multivariate analysis of the entire cohort (Table 4), factors independently associated with worse OS included age ≥65 years (HR: 2.33; 95% CI, 1.16–4.82; P=0.022), H-LNR (HR: 2.63; 95% CI, 1.13–6.14; P=0.025), presence of >3 LM (HR: 2.05; 95% CI, 1.13–5.28; P=0.028), and bilobar hepatic metastases (HR: 2.81; 95% CI, 1.25–6.29; P=0.012).
Full table
LNR was also associated with worse OS in patients who underwent resection of LM (Figure 4). In these patients, the median OS in H-LNR group was significantly worse than the low LNR group (13 vs. 27 months, P=0.013). The 5-year OS for patients with L-LNR was 37% while none of the patients in the H-LNR group were alive at 5 years following resection of LM. Seven patients in the H-LNR group (27%) and 4 patients in the L-LNR group (15%) had high risk features defined as the presence of bilobar hepatic metastases, >3 LM along with the presence of extra-hepatic disease. The median survival of H-LNR patients with high risk features was 11 months compared to 21 months for those L-LNR group with high risk features (P=0.029).
The management of patients with stage IV CRC has evolved considerably over the past decade. Advances in multimodal care have led to improved survival outcomes (14). Although LN status serves as a strong prognostic determinant in CRC patients without distant metastases, the significance of primary tumor LNR is not well understood in the context of stage IV disease. Outcomes in such patients are largely defined by the extent and nature of hematogenous metastatic disease (13). We have demonstrated that primary tumor LNR predicted long-term survival following resection of LM and served as an independent predictor of intrahepatic tumor burden.
Currently, national guidelines recommend retrieval of at least 12 LN for appropriate staging in CRC (6). Nodal stage is determined by the number of positive nodes in the current TNM staging system (AJCC 7th edition), as opposed to LNR. Adequate lymphadenectomy enables appropriate staging of patients, which greatly facilitates management decisions in patients with CRC (15). Although adequate nodal staging should be attempted in all patients, a variety of factors can influence the number of LN ultimately retrieved. Appropriate surgical technique along with diligent pathologic examination of resected specimen are required to consistently attain that goal (16,17). Due to variability in surgical technique and pathologic assessment of specimens, recent studies have proposed alternative LN parameters which may be more reliable than standard nodal staging in predicting outcomes (8,9). The most thoroughly investigated alternative nodal staging approach is LNR (18,19).
The prognostic significance of LNR has been well established for several solid organ malignancies (20,21), including CRC (22). Few studies have evaluated the role of LNR in stage IV CRC. Derwinger and Gustavsson (10) reported worse survival outcomes with increasing LNR in patients with stage IV CRC. However, in that study, the median number of nodes assessed was 10, whereas it is 17 in our present report. Furthermore, the authors did not correlate LNR with extent of intrahepatic metastatic disease. Ozawa et al. (23) recently reported a relationship between LNR and survival in patients with metastatic CRC. In our patients, the median survival of stage IV CRC patients was 26 months in the L-LNR group and 14 months in the H-LNR group. Similarly, for patients with high risk features or those who had undergone surgical intervention for CRLM, the 5-year OS was significantly better in the L-LNR group.
Vaccaro et al. (24) showed that LNR >0.25 was an independent prognostic factor for overall and cancer specific survival in patients with non-metastatic CRC. Several other LNR cutoffs have been proposed based on quartiles, means and various other statistical derivations without any reliable consensus (25,26). We used the median LNR as the cutoff as reported by Ozawa and colleagues (23). On ROC analysis, this cutoff value was found to be the most accurate in predicting hepatic tumor burden and survival in our patients. Importantly, we confirmed in our study group that LNR correlated with survival time in a continuous manner, indicating that our results were not dependent on a particular LNR value.
The majority of patients with stage IV CRC present with liver-only or liver-dominant metastatic disease. All of the patients included in our study had LM and 30% had extra-hepatic disease as well. Surgical resection of CRC LM is the preferred approach (27,28) but unfortunately many patients who are diagnosed with metastatic disease are found to be unresectable at the time of initial evaluation (29). Pathological characteristics of the primary tumor, including LNR, predict the extent of metastatic disease and may assist in identifying high risk patients. In our study, LNR was associated with the presence of more than 3 LM and bilobar disease. Both of these factors weigh heavily when a patient is considered for liver surgery (30). This association may be used to identify patients undergoing liver surgery who are at high risk for recurrence and potentially benefit from neoadjuvant therapy or require more intensive surveillance.
Due to the retrospective design, the exact influence of specific confounding variables could not be quantified. We speculate that the longevity in survival seen in patients with low LNR was influenced by favorable tumor biology in general. While adjuvant therapy likely impacted the outcome of patients in our study, our small sample size did not allow us to examine this in stratified fashion. However, the association of survival with LNR remained significant on multivariate model. Due to improvements in multimodality care, patients with LM from CRC are experiencing prolonged periods of disease control. Primary tumor biologic surrogates, such as LNR, may acquire increased relevance in patients with LM who survive for extended periods of time.
With the development of novel therapeutic options, patients with stage IV CRC have improved outcomes. Risk stratification of these patients may further assist in improvement of care and potentially open avenues for further progress. Considering LNR for patients with metastatic CRC who have undergone surgical resection of the primary tumor should be considered a routine parameter in the evaluation of these patients. Our study defines the potential utility of LNR in predicting hepatic tumor burden and survival, which may influence the complex decisions surrounding multimodality management of patients with stage IV CRC. We believe that even in the setting of stage IV disease, if resection of the primary tumor is required, principles of appropriate nodal staging should be practiced.
We would like to acknowledge the contribution of Cheryl Raffel, cancer tumor registrar, for assisting in data acquisition.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The study was approved by institutional ethics board of Roger Williams Medical Center (No. 00000088888) and written informed consent was obtained from all patients.
- National Cancer Institute. Surveillance, Epidemiology, and End Results Program. SEER Stat Fact Sheets: Colon and Rectum Cancer. Accessed: Dec 5, 2015. Available online: http://seer.cancer.gov/statfacts/html/colorect.html
- Van Cutsem E, Nordlinger B, Adam R, et al. Towards a pan-European consensus on the treatment of patients with colorectal liver metastases. Eur J Cancer 2006;42:2212-21. [Crossref] [PubMed]
- Miller G, Biernacki P, Kemeny NE, et al. Outcomes after resection of synchronous or metachronous hepatic and pulmonary colorectal metastases. J Am Coll Surg 2007;205:231-8. [Crossref] [PubMed]
- Le Voyer TE, Sigurdson ER, Hanlon AL, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21:2912-9. [Crossref] [PubMed]
- Gunderson LL, Jessup JM, Sargent DJ, et al. Revised TN categorization for colon cancer based on national survival outcomes data. J Clin Oncol 2010;28:264-71. [Crossref] [PubMed]
- NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Version 2.2016. Available online: https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf
- Johnson PM, Porter GA, Ricciardi R, et al. Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer. J Clin Oncol 2006;24:3570-5. [Crossref] [PubMed]
- Ozawa T, Ishihara S, Sunami E, et al. Log odds of positive lymph nodes as a prognostic indicator in stage IV colorectal cancer patients undergoing curative resection. J Surg Oncol 2015;111:465-71. [Crossref] [PubMed]
- Peschaud F, Benoist S, Julié C, et al. The ratio of metastatic to examined lymph nodes is a powerful independent prognostic factor in rectal cancer. Ann Surg 2008;248:1067-73. [Crossref] [PubMed]
- Derwinger K, Gustavsson B. A study of lymph node ratio in stage IV colorectal cancer. World J Surg Oncol 2008;6:127. [Crossref] [PubMed]
- Rosen SA, Buell JF, Yoshida A, et al. Initial presentation with stage IV colorectal cancer: how aggressive should we be? Arch Surg 2000;135:530-4; discussion 534-5. [Crossref] [PubMed]
- Katz SC, Burga RA, McCormack E, et al. Phase I Hepatic Immunotherapy for Metastases Study of Intra-Arterial Chimeric Antigen Receptor-Modified T-cell Therapy for CEA+ Liver Metastases. Clin Cancer Res 2015;21:3149-59. [Crossref] [PubMed]
- Ruo L, Gougoutas C, Paty PB, et al. Elective bowel resection for incurable stage IV colorectal cancer: prognostic variables for asymptomatic patients. J Am Coll Surg 2003;196:722-8. [Crossref] [PubMed]
- Khoo CK, Vickery CJ, Forsyth N, et al. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 2007;245:867-72. [Crossref] [PubMed]
- Chang GJ, Rodriguez-Bigas MA, Skibber JM, et al. Lymph node evaluation and survival after curative resection of colon cancer: systematic review. J Natl Cancer Inst 2007;99:433-41. [Crossref] [PubMed]
- Prandi M, Lionetto R, Bini A, et al. Prognostic evaluation of stage B colon cancer patients is improved by an adequate lymphadenectomy: results of a secondary analysis of a large scale adjuvant trial. Ann Surg 2002;235:458-63. [Crossref] [PubMed]
- Huh JW, Kim CH, Kim HR, et al. Factors predicting oncologic outcomes in patients with fewer than 12 lymph nodes retrieved after curative resection for colon cancer. J Surg Oncol 2012;105:125-9. [Crossref] [PubMed]
- Ng M, Roy-Chowdhury S, Lum SS, et al. The impact of the ratio of positive to total lymph nodes examined and outcome in colorectal cancer. Am Surg 2009;75:873-6. [PubMed]
- Wang J, Hassett JM, Dayton MT, et al. Lymph node ratio: role in the staging of node-positive colon cancer. Ann Surg Oncol 2008;15:1600-8. [Crossref] [PubMed]
- Bando E, Yonemura Y, Taniguchi K, et al. Outcome of ratio of lymph node metastasis in gastric carcinoma. Ann Surg Oncol 2002;9:775-84. [Crossref] [PubMed]
- Voordeckers M, Vinh-Hung V, Van de Steene J, et al. The lymph node ratio as prognostic factor in node-positive breast cancer. Radiother Oncol 2004;70:225-30. [Crossref] [PubMed]
- Berger AC, Sigurdson ER, LeVoyer T, et al. Colon cancer survival is associated with decreasing ratio of metastatic to examined lymph nodes. J Clin Oncol 2005;23:8706-12. [Crossref] [PubMed]
- Ozawa T, Ishihara S, Nishikawa T, et al. Prognostic significance of the lymph node ratio in stage IV colorectal cancer patients who have undergone curative resection. Ann Surg Oncol 2015;22:1513-9. [Crossref] [PubMed]
- Vaccaro CA, Im V, Rossi GL, et al. Lymph node ratio as prognosis factor for colon cancer treated by colorectal surgeons. Dis Colon Rectum 2009;52:1244-50. [Crossref] [PubMed]
- Rosenberg R, Engel J, Bruns C, et al. The prognostic value of lymph node ratio in a population-based collective of colorectal cancer patients. Ann Surg 2010;251:1070-8. [Crossref] [PubMed]
- Sabbagh C, Mauvais F, Cosse C, et al. A lymph node ratio of 10% is predictive of survival in stage III colon cancer: a French regional study. Int Surg 2014;99:344-53. [Crossref] [PubMed]
- Nordlinger B, Guiguet M, Vaillant JC, et al. Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Française de Chirurgie. Cancer 1996;77:1254-62. [Crossref] [PubMed]
- Scheele J, Stangl R, Altendorf-Hofmann A. Hepatic metastases from colorectal carcinoma: impact of surgical resection on the natural history. Br J Surg 1990;77:1241-6. [Crossref] [PubMed]
- Jones RP, Vauthey JN, Adam R, et al. Effect of specialist decision-making on treatment strategies for colorectal liver metastases. Br J Surg 2012;99:1263-9. [Crossref] [PubMed]
- Fong Y, Fortner J, Sun RL, et al. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 1999;230:309-18; discussion 318-21. [Crossref] [PubMed]


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You don't believe in alternative therapy? Try reading this
Posted: Ralph Stricker
You think only traditional medicine can help you with your daily problems? Well, be assured it's not like that. Alternative therapy can have the absolute same effects on your mind and body as pills do. Psychoanalysis, behaviour therapy or hypnotherapy patients experienced recoveries after the sessions with a specialist. You are wondering how it works? Try looking for the services of any cabinet which offers hypnotherapist practice in Birmingham or any other location. If you are interested in giving it a shot, make an appointment right away and wait for the beneficial results to gradually appear. Here's what you might need to know about one of these techniques:
A brief history of hypnosis
Doctor James Braid tried to make people fall into a trance for better sleeping around the age of 1840. He called it hypnosis (which means going to sleep in Greek). Mesmerism was then used for treating acute pain and illnesses. While trying to treat hysteria, medics from all around the world proposed hypnosis as a new way for therapy. Around 1960 hypnosis will already be called a branch of psychology which is a science, while the British Medical Association considers hypnosis a therapy from now on. How does hypnosis work then? Who is in charge of it? Well, the conscious mind and the unconscious mind are both implied in this kind of therapy. You'll think you are in control of your own mind, when in reality someone else guides you to the right path.
Is it effective?
If you are wondering how well hypnosis works and what benefits it brings, here are some facts you might want to know:
- It treats a vast range of affections: weight loss, relaxation, life improvement in general, sports performance, traumas from the past, lack of motivation, self-confidence boosts, insomnia, anxiety, stress, depression and many other. That's why hypnosis is considered one of the most effective therapies for solving such a wide variety of issues.
- It's not expensive: compared to other means of therapy that you might've use in the past, hypnosis is more affordable than you think. The number of sessions you will need depends on the issue you want to solve and the psychological triggers that you might be exposed to.
- Doctors started to recommend it as an alternative solution. Even though most doctors recommend using hypnosis along with other treatments, they sustain its effects on your health and life in general. Using both of the methods together will surely have the best possible results you might be expecting. Step by step, especially for psychological problems, try basing on hypnosis
- Trances are natural states of mind. If you were worried that something unnatural it's happening to your brain, you should relax. Trances are occurring when routine actions take place and your mind simply wanders around your thoughts, just like fixing your eyes on an object and forgetting about anything else. Drifting thoughts are often occurred even without the intervention of psychology. The difference is you'll be using it for your own good this time.
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My experiment on November 10th did not include confirmation by using a level.
Now I have used a level to confirm that the track I built out of cardboard (the 'trough' of the modular trough leverage device, which has been partially built) conforms to the requirement of including an upwards-oriented slope.
This means the device, even in it's present form, IS capable of recovering all movement, from a position of rest, including some overall upwards movement of the entire apparatus. Although the counterweight moves downwards during that time, the mobile weight is later able to operate the counterweight, compensating it for it's usefulness.
So, according to my observations, even in it's present form, this is an OVER-UNITY DEVICE!
Perpetual motion should be within reach, although I have doubts about my ability to build a full-scale device in my living room any time soon, due to space constraints. I also do not have all of the appropriate building materials presently. Maybe I can order aluminum pipettes online, or maybe they are hard to locate. Either way, there is a space constraint on building a model at the same scale. Larger would be better, but such a device wouldn't even fit in my apartment.
International Society for the Philosophy of Architecture » Ethics and Aesthetics of Architecture and the Environment
Intention and Architecture, by Carolyn Fahey
2 years ago


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Finding the Right People to Get Financial Investment Advice From The fact that the economy can be quite unpredictable is one of the things that you would probably know by now about it but given how it can be unbearably tough sometimes, this is something you need to understand too. One of the most important things you need to do is make wise financial investments especially nowadays where the economy is tough and it appears to be getting tougher with each passing day. When it comes to this however, you will find that with the exception of people that belong to the world of business and have become quite adept in the art of financial investment, there are a lot of people out there that don't have the slightest idea about where to begin when it comes to making financial investments, let alone making wise ones. You should know that compared to the people that actually have money to spend, there are more people out there that are more people out there that practically spend most of their time having no money in their pockets. Because of this, most people don't know what to do when they actually have some money that they can invest into something. If you are among those that have a bit of money in your pocket but you don't exactly know where to begin when it comes to financial investment, then getting some financial investment advice from the right people would be one of the most important things you are going to have to do. The starting point of this matter however, is basically the same as the first obstacle that needs to be solved since most people would also have no idea where to start as far as the right people to get financial investment advice from is concerned. Of course, you would be happy to find that there are actually ways for you to be able to make things simpler on your part and you would be able to learn more about this simply by making sure that you do your research. You should know that as far as getting some wise financial investments is concerned, there are many places out there where you will be able to gather valuable pieces of information about this. You need to know that when it comes to finding the right people where you will be able to get the best financial investment advice from, the internet would be able to provide you with a tremendous deal of assistance. Among the best thing about this is that it will allow you to easily access websites that contain valuable pieces of information as to where you will be able to find the best people to get financial investment advice from. This will be an easy task as long as you do your homework.The Key Elements of Great Services
Category: Health Care & Medical
Learning The Secrets About Professionals
Why One Should Seek The Services Of Worker Compensation Lawyers
When employees are at work they exposed to certain risks and at times injuries which may be caused by the equipment they use and activities they perform. Previously when there were no laws governing employer-employees relationship the workers would get injured without compensation while others would get a career ending injuries condemning them to poverty. But after the law was established, workers who are injured when working they are entitled to compensation, but the process of obtaining the necessary settlement may be challenging. The employer is tasked with ensuring that their employees who are injured get the necessary medical support as well as ensuring that they get a monetary settlement in the case of being injured while working or in extreme cases death occurs while working.
It is not all injuries that one gets while working will qualify for settlements but injuries such as brain damage, back injuries and broken bones will deserve compensation from the employer when one was involved in lifting heavy objects. Some injuries are accidental as they happen suddenly, but there are others that develop over time such as the carpal tunnel syndrome which is caused by constant movements as well as stress. There are some requirements that a worker should meet for them to be compensated by their employer such as informing the company within a given timeline.
There are plenty of activities that are involved when one is out to claim for settlement, and they may prove to be challenging to the victim especially in case they suffered serious injuries hence requiring medical attention. In such cases the employee will need to hire a compensation lawyer who will file the suit on their behalf. The lawyer will file the complaint on behalf of the injured employee without charging them attorney fees. Most of the lawyers will provide the services to the claimant with a view to being paid by use of a certain percentage of the settlement the employee will be awarded as compensation. If the company has been compensating the employee the lawyer will ensure that the compensation is done properly.
Lessons Learned About Lawyers
The lawyer will make sure that their clients get proper medical services such as treatment, therapies and in case of severe injuries surgery as the employee is entitled to the services . It is also the task of the attorney to make sure that the employer will clear the medical bill after the employee is discharged. The lawyer also ensures that the employee will get some employment either in the same capacity or a different one depending on the injury severity. When an employee gets a different job the employer should facilitate the training of the employee. The attorney will also ensure maximum monetary compensation for the employee from the employer or the insurance company. Payment in most cases is done once the agreement has been granted and should not exceed 40 percent of the compensation amount awarded.… Read More
Case Study: My Experience With Options
Ways to choose the best lawn care expert.
It will end up being very good if you have the lawn at your home, it is because there are the lot of things a person can do when you have one. Having your lawn can save you through using manual tools and invest in backbreaking function to consider care and sustain an attractive landscaping that you should keep your grass healthy and well manicured.
To archive all this you need a mower to help you out of which will save your time. In these particular days, managing and keeping a lawn is becoming a lot more convenient, and manageable choice for many houses retains.
The home holders and property directors have more access to neighborly, reasonable, master grass mind arrangements and administrations. If you may have no time or even interest for the task and have limited knowledge and the capability to have a proper lawn maintained, there are garden experts who will offer the best services to your lawn machine.
Questions About Options You Must Know the Answers To
Overwhelmed by the Complexity of Lawns? This May Help
It might be hard to select an expert to care for your lawn and also landscaping can be a bit tricky with many firms offering the same services. You need to consider some factors before hiring a lawn care company.
The principal thing is to search for a certification for their work. You will become more acquainted with when the organization offers 100{91005a36fab468aab82214fb1ba223e0def3d9f4e1f757056567e375ce396042} no risk involved and subsequently they will carry out the occupation done legitimately.
You will have the peace of mind if you have an insurance policy plus work compensation as you may be assured you will end up guarded just in case there is an occurrence of unexpected incidents.
The the second thing to do will be to look for an excellent feedback from previous clients. While you are nevertheless doing your research ask for tips from your contracts plus other persons who may have experienced the service first hand. You can also look up independent reviews sites in order to check the ratings.
At long last, consider the administrations gave. Powerful grass mind and furthermore arranging, pros typically say, is equal amounts of craftsmanship and science. In decide very element of the particular service, from hiring only competent consultant to making use of quality control checklists, this should be well created and executed expertly to ensure the best outcome.
When you decide to choose from among the numerous garden mind specialists it will be less demanding now with these tips. Watering your lawn is extremely important. Ensure that you water your lawn few times in a day . Should you not have a particular time, you should consider buying an automated sprinkling system.… Read More
Lessons Learned About Therapies
Wilderness Therapy Programs For Teens There are a variety of excellent wilderness treatment packages that are offered for troubled adolescents. It really is clear that parents possess a tough time selecting if they desire to ship the youngster overseas to stay a wilderness therapy system. Nevertheless, in case your teenager is on the hazardous route, obtaining him/her about the correct path leading to wellness may conserve them from experiencing these issues through their person lifestyles. It would be considered a comfort for parents experiencing their teenagers' dangerous addictions that these troubled teenager wilderness therapy plans have a substantial success rate in assisting players flip their lives around. As a result, more parents are embracing these applications to assist them out using their struggling teenagers. Different teens have different dilemmas which imply that finding the right plan which will take advantage impression inside their lifestyle and inspire one of the most change is very important. There are some wilderness therapy programs that give attention to particular treatment. Some cope with teens experiencing taking the demise of the family member, some cope with teens who've self esteem problems, and much more.
The Best Advice on Treatments I've found
Within our culture, it is very worrying the quantity of teenagers experiencing medication and alcohol addiction is very large. You will find wilderness treatment applications that aid with that as well. Several years back, such packages were standard wherever one kind of software fits-all teens with diverse problems. Because of this, adolescents that were provided for such programs are often not prepared for therapy also it was tougher for camping team to target their treatment.
Learning The Secrets About Resources
Struggling teenager wilderness treatment applications nowadays often allow it to be a place to organize for that appearance of the struggling teenager to be able to take advantage effect. It's also accomplished to make sure that the moment used by the youth within the software could genuinely be centered on what problems must be addressed. There are many of personal treatment classes in addition to helpful team classes whilst in the plan. Unlike what many people may believe, such therapeutic programs aren't almost hiking, although they're done in a wilderness setting. Through forging a relationship between camp staff and adolescents, the youth who spends time within the software considers it as being a shared voyage and encounter as opposed to being a punishment. Throughout the plan, combined with the therapy for substance and alcohol addiction, they understand a wholesome sort of camaraderie as well as a superior level of particular liability. Some applications may last for as brief like a couple weeks, some may operate for all months. Some possess a summer program, some have packages which have educational things to be able to make certain that the youngster doesn't fall behind within their reports while taking part in the program.… Read More
The Beginners Guide To Renovations (What You Need To Know To Get Started)
All About Renovations: Don't Relocate – Renovate!
You have your own house, and this is always you anted to have ever since, in this way, you may spruce it up. Things do not appear pretty and clean as they used to. This article will present some unique ideas on your home renovation contractors in Toronto.
If you have considered getting a wall chance, bring an engineer. Anytime you are going to knock out a wall, it could affect the integrity of the building. A general contractor may not understand the principles of engineering and so he is not the perfect professional to give advice. It may sound "expensive" to employ a structural engineer, but think about how more you would spend if a single side of your home fell off. Always get your permits. Nothing is apparent than a home addition, no matter how small or insignificant. Even if you can get away with the permit, still home addition is obvious and so you may be able to held liable for fines, penalties, and you may even be demanded that the work be removed and re-done after an inspection.
Study: My Understanding of Remodels
Plan It
The Best Advice on Homes I've found
If you are adding a new extension of your home, it's important to talk with an architect or designer. As you can see, the homes were built in specific area of the country in specific areas. In certain circumstances, an inspector or architect can review the home plans and the original blueprints in order to figure out if the foundation of the first floor is enough to support the second floor.
Your current cooling and heating unit and ducts are set up for the current number of rooms in your home. Consult a good HVAC company to examine your air flow requirements with an addition floor or room. Make sure that your designer will take in all the features of the other homes in your neighborhood: windows, doors, paint, roofs, siding, and elevation. These should all work with the architecture of the home and the surrounding area.
Have It Build
Prepare for the primary disruption of having equipment, workers, and certain materials that will be invading your house. Keep track on all the details if there are disputes or problems down the road.
Make sure that you are well plan and prepared out all certain details ahead of time. You may opt for this kind of look if you really want this.
Adding a wallpaper in your home will be a good idea. Always choose the best professional. Home addition is fun. Keep the project simple, therefore finding something that will go with the colors of paint, as well as the colors in the room and go to work on your undertaking.… Read More


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Instyler Price Islamabad, Lahore, Karachi
Chat now on Whatsapp: +92310-4080037
Product Available
Instyler in Pakistan
(0321-2223646),Clickbuy.pk, The originally Instyler (rotating with iron) is an entirely the new hair straightening device that the aligns wrap and the provides extras shine for the long times. The Instyler consist of the circulating intenses polishing cylinder with the four rows of accurately straights crawl. It's neither the comb nor the tedious iron; it's the INSTYLER circulatings hot iron.
How the Instyler worked:
It is the most advances hair straightening devices ever the manufactured. When you sprints the Instyler through your hairs, the first sets of the crawls smoothly categorize and the segregates the strand of your hairs. Then circulatings intenses polishing the cylinder softly drifts over your hairs. At the end the seconds pair of the crawls sets the finishings touch to your hairs by giving shines and the silkiness. The best parts of the Instyler is its durables design, which prevented your hairs from the breaking. In facts, the Instyler used less heats than the conventionally hot hairs straightening device available in the Pakistan at Clickbuy.pk. It can provides the optimum result, because the softs heating in the circulatings cylinders varies with the regulars motions of the cylinders, resultings in extra shiny and the silky hair.
How to use Instyler in the Pakistan:
Plug the Instyler in Pakistan into an electrics outlet and the press the powers button to start the devices.
Press one the time to get the intenses heat. (190 degree)
Press the second times for the moderate heating (156 degree)
Press for the third times to the get low heating (135 degree)
Press for the fourth times to the turn the device off.
The LED bar will the flash while the devices is heating up. When the temperatured reaches the certain degree, the flashing stop.
Washed the hair proper before the used the Instyler.
Do not apply the any oil and others product to the hair to gets the required designs from the Instyler.
Dry your chairs with the towel before startings the process.
Makes segment of the uppers layers of the hairs. The segment should be abouts 5-7 cm wides and the does not exceeds the wideness of the cylindered.
Always used the Instyler before it is the fully heated to the requires temperatures. Start from the last layers and, first cover the backs and then the front sides.
Repeated the process untills the desired styles is the formed. Do not repeats on the same segment for the longer periods.
After you have finishing , press the buttons until the device is the turned off.


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The Irrigation and Flood Control Department, Manipur is committed for development of i) assured irrigation in the State by construction of Major and Medium Irrigation & Multipurpose projects and ii) management of flood problems in the State with flood fighting/flood control schemes of restoration/improvement and protection works. Apart from Irrigation and management of flood, the department is also creating potentials for water supply and hydro power generation from the Irrigation projects.
Irrigation and Flood Control Department is dealing with all matters relating to Medium and Major Irrigation Projects in the State. In addition, the Department is also looking after matters relating to Lift Irrigation Projects, management of floods, including construction of major dams and drainages, Management and Preservation of Water Resource, investigation of Ground Water Resources in the State.
So far, the IFC Department has taken up 8 (eight) Major and Medium Irrigation & Multipurpose Projects viz i) Loktak Lift Irrigation Project (LLI), ii) Khoupum Dam Project, iii) Sekmai Barrage Project, iv) Imphal Barrage Project, v) Singda Multipurpose Project, vi) Thoubal Multipurpose Project, vii) Khuga Multipurpose Project and viii) Dolaithabi Barrage Project. Out of the above, i) Khoupum Dam, ii) Imphal Barrage, iii) Sekmai Barrage, iv) Loktak Lift Irrigation, v) Singda Multipurpose Project have been completed. The ongoing Projects are i) Khuga Multipurpose Project, ii) Thoubal Multipurpose Project and iii) Dolaithabi Barrage Project. The above 3(three) on-going projects could not be completed in time mainly due to fund constraint in the earlier part coupled with disturbed law and order situation of the State and also issues related to Rehabilitation & Resettlement. The 3(three) projects are included in the PM's Package during November, 2004 and adequate flow of funds has been assured for early completion of these projects. Out of the above 3 (three) on-going projects 2(two) projects viz, i) Thoubal Multipurpose Project and ii) Dolaithabi Barrage Project are now included under the 23 priority projects of the Ministry of Water Resources for completion by 2016-17.
The Revised Annual Plan allocation for 2016-17 under Major & Medium Irrigation is Rs. 335.6860 crores i/c Rs. 275.19 crores (C.A under AIBP), Rs. 24.50 crores for establishment and Rs. 35.9960 crores for state share (Works). The expenditure incurred during 2016-17 upto March, 2017 is Rs. 240.7492 Crores including Rs. 178.8147 crores (C.A. under AIBP).
i) IRRIGATION: -
The status of total Irrigation potentials created up to 3/2017 is 41,168 ha. In addition, 1200 ha. and 900 ha. of low lying areas of Loushipat and Poiroupat respectively has already been reclaimed after having been taken up as a part of Thoubal Multipurpose Project. The Targets and anticipated achievement during the next year 2017-18 is 41,527 ha.
ii) WATER SUPPLY: -
4 (four) MGD of raw water is supplied to the State PHED from Singda Multipurpose Project for water supply.
There is a provision of 5 (five) MGD of raw water to be supplied from Khuga Multipurpose Project to the State PHED. Now, out of this provision, State PHED has been drawing an average of 0.83 MGD for water supply and the Thoubal Multipurpose project will provide 10(ten) MGD of raw water after completion by March, 2018.
On completion of the ongoing projects, an ultimate annual irrigation of 57,460 ha, water supply facility of 15.00 MGD and power generation of 9.75 MW will be achieved. Out of these with the partial completion of the Projects, irrigation potential of 35,018 Ha. water supply of 5 MGD has been created upto the end of 31-03-2017. The targeted potential for the next year 2017-18 is 22,442 ha.


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Chavez is dead. Long live the 'great man' theory
Love him or loathe him, Hugo Chavez was a larger-than-life figure who changed Venezuelan politics forever
In death, as in life, Hugo Chavez, has taken over the ether. Within minutes of TV, radio and the internet simultaneously announcing the Venezuelan president had died, journalist Jonathan Katz re-tweeted "Chavez's last tweet". It read: "Still clinging to Christ, trusting docs & nurses. Then quotes Che & Fidel, adding: 'We will live'."
Slate magazine chimed in with the "fun facts" about the military officer who went on to become president of Venezuela and guiding light of a political ideology he called Bolivarianism: "He was a 9/11 truther and he doubted that the moon landing happened".
They might have added this absolute corker from Caracas – that Mr Chavez was given cancer by the evil West; that it was a plot, a conspiracy.
Chavez's death leaves a gaping hole – in conspiracy theories, just as much as in Venezuelan politics; in stop-start regional attempts to forge ever closer union; and in the eight-year-old, 18-nation Petrocaribe (a good gig for Caricom; a costly attempt at peddling influence by Chavez).
But mostly, of course, Chavez's final removal from the scene – 15 days after he returned to Caracas from a Cuban hospital – raises huge questions about Venezuela's future. Chavez's oversized personality, strident opinions, and absolute certainties made him a hugely controversial and enormously charismatic figure.
He exemplified the Great Man Theory of history, i.e. that a certain time and place in the life of a country can be explained by the impact, both positive and negative, of "great men". For Venezuela, that was the last 14 years.
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