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August 2017 Vol 8, No 8
In the longest follow-up on single-agent nivolumab to date, 5-year overall survival (OS) was 16% in patients with advanced non–small cell lung cancer (NSCLC) in updated results from a phase 1b dose-ranging study (CA209-003).
Using a "double whammy" of 2 HER2-directed therapies achieved a clinical benefit rate of 70% and an objective response rate (ORR) of 30% in patients with heavily pretreated, HER2-positive metastatic colorectal cancer (CRC), according to final results from the phase 2 HERACLES-A trial.
CAR T-cell therapy achieved excellent responses in an updated report on a series of 50 patients with relapsed B-cell acute lymphoblastic leukemia (B-ALL) treated with CAR T-cells at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City.
The novel combination of the investigational IDO pathway inhibitor indoximod plus pembrolizumab led to higher response rates in patients with advanced melanoma than what is seen with pembrolizumab alone, according to interim analysis of a phase 2 clinical trial reported at the 2017 Annual Meeting of AACR.
Preliminary data show excellent and durable responses to atezolizumab in 10% of women with triple-negative breast cancer (TNBC), one of the most aggressive and difficult cancers to treat.
Cancer costs are rising, but the implementation of evidence-based quality improvement strategies in early-stage breast cancer care can reduce costs and improve patient quality of life, according to Angie Meillier, RN, MS, from Abbott Northwestern Piper Breast Center in Minneapolis, MN.
Oral cediranib, an investigational VEGF inhibitor, in combination with a PARP or chemotherapy inhibitor, appears to have a survival benefit in women with relapsed platinum-sensitive ovarian cancer, according to data from 2 studies presented at the 2017 ASCO Annual Meeting.
In the SARC028 phase 2 multicenter trial, reported at the 2017 ASCO Annual Meeting, pembrolizumab achieved encouraging responses in soft tissue sarcoma, especially undifferentiated pleomorphic sarcoma (UPS) and liposarcoma.
Alectinib, a next-generation ALK inhibitor, was called a new standard of care for ALK-positive non–small cell lung cancer (NSCLC) based on results from the phase 3 ALEX clinical trial presented at the 2017 ASCO Annual Meeting.
The PARP inhibitor olaparib significantly improved progression-free survival (PFS) compared with standard chemotherapy in women with HER2-negative metastatic breast cancer with a germline BRCA mutation. Disease progression was delayed by about 3 months with olaparib in the multinational, randomized, open-label phase 3 study known as OlympiAD, reported Mark E. Robson, MD, at the 2017 ASCO Annual Meeting.
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Pagtitistis ng Malaking Bituka at Tumbong (Colorectal Surgery)
Ang pagtitistis o pag-oopera ng malaking bituka (colon)at tumbong (rectum)ay ang pagsasaayos ng mga pinsalang natamo ng alin mang bahagi ng malaking bituka, tumbong, o puwit sanhi ng mga sakit tulad ng kanser, diverticulitis, inflammatory bowel disease (ulcerative colitis and Crohn's disease) at iba pa, sa pamamagitan ng iba't-ibang pamamaraan. Ang mga aksidenteng pinsala, pagbabara, pagkapunit o pagkabutas, mga bukol o peklat na dahilan ng pagbabara ay maari ring mangailangan ng operasyon. Ang pagsasaayos ng mga pinsala ay magpapanumbalik sa normal na sistema ng pagdumi. Ang iba pang mga kundisyon na maaaring mangailangan ng pagtitistis ay almuranas, anal fissures, prolaps, kawalan ng pagpipigil sa pagdumi (bowel incontinence), at kulugo sa puwit (anal warts).
Mga Uri ng Pagtitistis
May iba't ibang pamamaraang ginagamit ang mga siruhano (surgeon) upang gamutin ang mga pinsala ng malaking bituka at puwit. Noong mga naunang panahon, kalimitang ang pagtitistis ay ginagawa sa pamagitan ng isang malaking paghiwa sa tiyan at pagsasa-ayos ng mga pinsala sa bituka. Ang karaniwang ginagawa ay ang pagputol at pagtanggal ng apektadong parte ng bituka (resection) at pagkabitin ang mga hindi napinsalang parte (anastomosis). Ang iba pang klase ng operasyon ay ang pagtahi ng mga punit sa puwit, pagtanggal ng almoranas at pagpapasikip ng spincter muscle.
Karaniwan din noon ang paglalagay ng ostomy. Ito ay ang paglalagay ng butas mula sa loob ng katawan palabas upang tanggalin ang mga ihi at dumi (urine and feces) ng katawan. May mga uri din ang ostomy. Ang colostomy ay ang paglabas ng bahagi ng malaking bituka sa may tiyan upang mailabas ang dumi ng katawan patungo sa isang lalagyan (pouch). Sa ileostomy naman, ang lahat ng parte ng malaking bituka, tumbong at puwit ay inaalis at ang pinakadulong bahagi ng maliit na bituka (ileum) ang siyang nagiging stoma.
Sa kasalukuyan, ang laparoscopic surgery ay ginagamit sa maraming sakit at pinsala ng bituka kabilang na ang mga maagang kanser. Sa ganitong operasyon, ang siruhano ay nagpapasok ng instrumentong may nakakabit na maliit na kamera (laparoscope) sa maliit na hiwa sa tiyan. Ang operasyon ay may mas kakaunting komplikasyon, mas mabilis, mas hindi masakit, at mas may maliit na pilat. Ito ay nangangahulugan din ng mas maikling araw ng pananatili sa loob ng ospital.
Makailan lamang, mayroong mas makabagong pagsulong sa teknolohiya ng pag-oopera. Ito ay ang robotic surgery. Dito, ang siruhano ay gumagamit ng computer na nagkokontrol ng mga maliliit na instrumentong nakakabit sa robot.
Desisyon sa Pagtitistis
Ang ilang mga kondisyon ng may sakit ay maaaring matugunan ng minimally-invasive surgery. Samantala, ang ibang mga sakit tulad ng kanser ay maaring mangailangan ng ostomy, isang mas mabigat na operasyon. Ang desisyon ng doktor upang irekomenda ang operasyon ay nakasalalay sa iba't ibang kadahilanan tulad ng kasaysayang medikal ng pasyente, tindi ng sakit o kirot na nararanasan, at mga resulta ng dyagnostikong ginawa sa kanya.
Mga paghahanda bago ang operasyon
Sasabihin ng doktor ang mga gagawin sa operasyon, ang mga posibleng masamang epekto nito, at ang mga inaasahang mararanasan matapos ang operasyon. Katulad ng kahit anong pagtitistis, ang pasyente ay papipirmahin ng isang kasulatan ng pagsang-ayon o pagpapahintulot (consent form). Bilang paghahanda sa operasyon, ang manggagamot ay maaring humiling ng mga pag-aaral ng dugo at ihi ng pasyente, ganun din ng iba't ibang x-ray at electrocardiograph (EKG). Maari ding mag-alok at magbahagi ang doktor o nars sa pasyente o mga kaanak nito ng mga katuruan patungkol sa pamamahala ng ostomy.
Upang maging malinis ang bituka bago ang operasyon, ang pasyente ay maaring hilingin ng doktor na huwag kumain o uminom ng kahit ano ilang oras bago ang pagtitistis. Maari ding painumin ng mga gamot na pampadumi o gumamit ng labatiba (enema). Maari ding painumin ng antibiotics upang kumaunti ang bakterya sa bituka upang maiwasan ang impeksiyon matapos ang operasyon.
Pangangalaga matapos ang operasyon
Matapos ang operasyon, imomonitor ang presyon ng dugo, pulso, paghinga, at temperatura ng pasyente hanggang ito ay bumalik sa normal. Tuturuan ang pasyente kung papaano susuportahan inoperahang bahagi ng katawan habang humihinga nang malalim at umuubo, bahagi ng ehersisyo matapos ang operasyon. Maaari din siyang bigyan ng gamot sa kirot kung nararapat. Sinusukat din ang lahat ng likidong (liquid) pumapasok at lumalabas sa kanyang katawan. Ang kulay at katas ng sugat ay inoobserbahan. Karaniwang pinapatayo na ang pasyente at pinapaupo sa silya kinagabihan ng operasyon. Karamihan ay nakakalabas na ng ospital makalipas ang dalawa o apat na araw.
Mga panganib
Ang mga potensyal na panganib matapos ang operasyon ay madalas na nangyayari habang ang pasyente ay nasa ospital pa. Ang kanyang pangkalahatang kalagayan ng kalusugan bago ang pagtitistis ay nagpapahiwatig ng mga potensyal na panganib. Dapat bigyang tuon ang mga problema sa puso at mababang immune system ng pasyente.
Normal na resulta
Ang lubusang paggaling ng may sakit na walang anumang kumplikasyon ay inaasahan. Ang panahon ng pagpapagaling ay iba-iba depende sa pangkalahatang kalagayan ng kanyang kalusugan bago ang operasyon. Ang mga pagbabago sa diyeta ay minimungkahi upang maiwasan muli ang pagkakasakit o upang mapangalagaan ang kasalukuyang kalagayan.
Ang mga payo patungkol sa mga pagbabago ng kasalukuyang pangaraw-araw na pamumuhay ay ibinabahagi sa pasyente.
Matapos ang pagpapa-uwi
Ipaalam agad sa manggagamot kung maranasan ang matinding kirot, pamamaga, pamumula, pamamasa o pagdurugo ng sugat. Ipaalam din kung may pananakit ng ulo at kalamnan, pagkahilo, pagsusuka o pagduduwal, lagnat, pagtitibi o pangingitim ng dumi.
Ang impormasyong ito ay hindi pamalit sa mga payong medikal. Magtanong at sumangguni sa mga espesiyalista.
2nd Floor, Podium Building, The Medical City,
Ortigas Avenue, Pasig City, Metro Manila
Tel No. (632) 9881000 or (632) 6356789 ext. 7789
www.colonandrectalspecialists.com , www.crsi.com.ph
Clinic Hours: Mondays to Saturdays – 8:00 AM to 5:00 PM except Wednesdays
Ang Mga Espesiyalista
Manuel Francisco T. Roxas, M.D.
Robert L. Chang, M.D.
Catherine S. Co, M.D.
Carlo C. Cajucom, M.D.
Marc Paul J. Lopez, M.D.
* What are the symptoms of hemorrhoids?
Bleeding from hemorrhoids is usually bright red, often dripping into the toilet bowl, or noticed when wiping. The stools themselves are normal looking, indicating that the bleeding is originating only from the anorectal area. Sludge of dark blood and stool mixed thoroughly together is usually from a source within the small and large intestines and not hemorrhoids. Hemorrhoidal bleeding is painless, and this differentiates it from anal fissures, which is also a very common anal condition that presents with similar bright red bleeding during defecation, but with anal pain.
Hemorrhoids only become painful when they thrombosed or incarcerated. Thrombosed hemorrhoids occur when blood clots within the hemorrhoids, causing very obvious swelling and pain. While surgery for this may be effective during the first 4 days of the attack, if left alone the swelling and pain gradually subside and disappear after 2 weeks. Usually this occurs just once or twice in a person's lifetime, and it is uncommon to have repeated episodes of thrombosis.
Doctors often classify patients as to having either external or internal hemorrhoids. External hemorrhoids are located just outside the anus, and hence are always visible on routine inspection. Many people have them without suffering from any symptoms, and therefore these may be safely left alone. Sometimes external hemorrhoids may make cleaning difficult, allowing sweat and anal discharge to hide between folds, resulting in anal itching.
Internal hemorrhoids arise from inside the anus and are therefore only visible when, because of excessive laxity, they protrude outside. This condition is called prolapsed, and usually occurs during defecation. When internal hemorrhoids prolapsed they may either slip back inside on their own, or require manipulation by the person for it goes back in. When the prolapsed hemorrhoids cannot be returned, they become trapped outside, resulting in pain and swelling. This scenario is called incarcerated hemorrhoids.
* What are the forms of treatment – surgical and non-surgical?
Hemorrhoids only require treatment when there are symptoms. And the type of treatment depends on the severity of symptoms. Mild symptoms may be managed just by eating a lot of fiber and taking in bulk laxatives such as psyllium to improve the consistency of stools and ease bowel movement. Some over-the-counter creams may provide symptomatic relief.
Non-surgical and almost painless treatments for hemorrhoids include injection sclerotherapy, infrared photocoagulation (often mislabeled as "laser treatment"), and rubber band ligation, any of which can be done safely in the clinic as an out-patient procedure. In scientific studies comparing these methods, rubber band ligation was found to be the most effective and cheap, which is why it is the most common non-surgical procedure for hemorrhoids in the world today.
Non-surgical treatment is often ineffective for large, incarcerated or thrombosed hemorrhoids. Surgery is usually recommended in these situations, and also when non-surgical treatment has failed to relieve symptoms. Traditional surgery requires cutting out the hemorrhoid using a variety of instruments such as scissors, knives, cautery, and ultrasonic dissectors. Unfortunately, any wound created in the outer skin of the anus results in often Sever post-operative pain, which is responsible for the reputation of hemorrhoid surgery being one of the most painful of operations.
* What are the advances in hemorrhoids treatment?
Due to this reputation of being a painful operation, advances in hemorrhoid surgery have focused on making it less painful. One such operation is stapled hemorrhoidectomy. Using a specially-designed, single-use stapler instrument (which was modified from the staplers used to reconnect intestines during major abdominal surgery), the hemorrhoids are excised and the anus repaired from the inside, something which is difficult to do with traditional surgery. The end result is that the surgical wound is inside, and no wound is visible outside the anus. Scientific studies have proven that this is less painful than traditional surgery, although with a small recurrence rate.
Stapled Hemorrhoidectomy Transanal Hemorrhoidal Dearterialization (THD)
Another advanced surgical technique is Transanal Hemorrhoidal Dearterialization (THD). Using a doppler ultrasound, the blood vessel supplying the hemorrhoid is identified and ligated with stitches. Deprived of its blood supply, the hemorrhoid then shrinks and shrivels. Again there is no wound outside and is therefore almost painless. However, because it is a new technique, not very many studies evaluating its long-term effectiveness have come out.
All surgical procedures for hemorrhoids, whether traditional or innovative, may sometimes develop complications such as bleeding, infection and stricture. It is important therefore when seeking treatment, to see an expert in anal diseases.
* What are some common misconceptions about hemorrhoid treatments?
One misconception about surgery for hemorrhoids is that it can cause fecal incontinence, or the inability to control farting or defecation. Again this is not true. Properly done hemorrhoid surgery, using any of the techniques discussed previously, does not entail cutting or injuring the anal muscles. Therefore no complication such as incontinence should develop.
Another misconception about hemorrhoid treatment is the use of lasers. A true LASER is defined as Light Amplification by Stimulated Emission of Radiation, and in medical applications is used as a very fine, and precise cutting instrument (such as when in ophthalmology). The technology is very expensive, and therefore using a true laser for hemorrhoid surgery makes the procedure quite prohibitive
There are other misconceptions in the public about hemorrhoid treatment. Unfortunately this is propagated by many false claims and unscrupulous practices. Hemorrhoids are a very common condition that is often bothersome, sometimes very painful, but never life-threatening. All symptoms must be evaluated by a doctor to make sure one truly has hemorrhoids. There are a variety of surgical and non-surgical options, and these should always be discussed first with an expert prior to making a decision on treatment.
* Note: This information is not intended as a substitute for professional medical advice. For any inquiries please Visitor calls your specialists.
MANILA, Philippines - Hemorrhoids are actually present in all individuals whether healthy or not. They are the vascular cushions which surround the general area of the rectum and anus.
The term hemorrhoids is associated with the symptoms when this part of the body becomes enlarged, inflamed, thrombosed or prolapsed.
Many people have them without suffering from any symptoms, and therefore these may be safely left alone. Treatment is usually required for those whose hemorrhoidal symptoms such as excruciating throbbing pain affect quality of life and daily living.
There are many traditional remedies and non-surgical treatments for hemorrhoids. However, if none of these work, surgical procedures may be required as a last resort.
Below are some misconceptions about hemorrhoids treatment and the truth behind each:
*Ano ang kulugo sa puwit?
Ang kulugo sa puwit o tinatawag ding "condyloma acuminate" ay parang mga butlig na nakapalibot sa puwit at maari ring hanggang sa may genital area. Ang sakit na ito ay maaring ituring na sexually transmitted disease (STD) o nakukuha sa pakikipagtalik. Ito ay maaring magsimula nang napakaliliit, parang ulo lang ng aspili o karayom at maaring lumaki nang lumaki at mapuno ang buong paligid ng puwitan. Karaniwang walang mararandamang pagkirot ang mga mayroon nito at maaring hindi mamalayan ang pagkakaroon nito. Kalaunan ay maaring makaranas ng mga sintomas tulad ng pangangati, pagkirot, at pagkakaroon ng mga maliliit na umbok o butlig sa puwitan.
Ano ang sanhi?
Ang kulugo sa puwit ay sanhi ng papilomang birus na pantao (human papilloma virus o HPV). Ito ay naisasalin sa pamamagitang ng direktang kontak mula tao sa tao. Maari rin itong maisalin sa pakikipagtalik. Hindi kailangan ang anal sex upang magkaroon nito.
Dapat bang tanggalin ang mga kulugo?
Oo. Kapag ito ay hindi naalis, ito ay maaring lumaki at kumalat. Pag pinabayaan, tumataas ang panganib na ito ay maging kanser sa lugar na kinaroroonan.
Ano ang mga pwedeng ipanglunas?
Kung ito ay nasa maliit na lugar lamang, maari itong gamitan ng mga pamahid na gamot. Maari ring gumamit ng liquid nitrogen na magpapayelo (freeze) ng mga kulugo. Pwede rin itong tanggalin sa pamagitan ng operasyon (surgery) kung ito ay malalaki na o kaya ay nasa loob ng tumbong (rectum) o puwit. Ang operasyon ay karaniwang paghiwa o pagsunog sa mga kulugo. Ginagamitan din ito ng pampamanhid (anesthesia).
Kailangan bang maospital para sa opersyon?
Hindi. Ito ay karaniwang ginagawa lamang sa klinika bilang out-patient procedure.
Ang impormasyong ito ay hindi pamalit sa mga payong medikal. Magtanong at sumangguni sa mga espesiyalista.
2nd Floor, Podium Building, The Medical City,
Ortigas Avenue, Pasig City, Metro Manila
Tel No. (632) 9881000 or (632) 6356789 ext. 7789
www.colonandrectalspecialists.com , www.crsi.com.ph
Clinic Hours: Mondays to Saturdays – 8:00 AM to 5:00 PM except Wednesdays
Ang Mga Espesiyalista
Manuel Francisco T. Roxas, M.D.
Robert L. Chang, M.D.
Catherine S. Co, M.D.
Carlo C. Cajucom, M.D.
Marc Paul J. Lopez, M.D.
Dione P. Sacdalan, M.D.
The colorectal cancer doctors are in: Dr. Marc Lopez and Dr. Dione Sacdalan are only the 20th and 21st graduates of the 29-year-old PGH program for colorectal cancer specialists. They're available for consult at the country's first outpatient colorectal specialty clinic in the country, located at the MEDICard Lifestyle Center in Makati.
In the Philippines, we can take heart in the fact that we have a lot of competent cardiologists around. And for those with sagging spirits who need a lift somewhere, they can revel in the fact that we do have a lot of very good plastic surgeons/dermatologists. But did you know that there are less than 40 colorectal surgeons in the Philippines, and that MEDICard Lifestyle Center has launched the first outpatient colorectal specialty clinic in the country?
The clinic, which opened only last October, is designed to make cost-effective care for colorectal problems accessible to the public, what with colorectal diseases now the fourth leading cause of cancer deaths globally.
"We can see patients for consult. We can also do out-patient procedures under local anesthesia. We can do endoscopies, minor operations like excisions of hemorrhoids, management of fissures in the operating room of this building," says Dr. Dione Parreño-Sacdalan, one of only two practicing female colorectal surgeons in the country today, the other being Dr. Catherine Sim Co. Both are affiliated with PGH and The Medical City.
Dr. Sacdalan had her post-residency training in colorectal surgery at the Philippine General Hospital (PGH). She also had further training focusing on anorectal diseases and minimally invasive surgery at the Chulalongkorn Memorial Hospital in Thailand and had colorectal observership stints in the University of Minnesota Medical Center in Minnesota and Memorial Sloan-Kettering Cancer Center in New York, USA.
"We're the first organized group of colorectal surgeons offering outpatient clinic services in the country," Dr. Marc Paul Jose Lopez introduces himself. "There are a lot of concerns among a good part of the population about colorectal diseases, anorectal diseases such as hemorrhoids, abscesses (pigsa) and fissures (punit sa puwit). The spectrum goes further down to colorectal cancer, which is at present on the rise."
Dr. Marc Paul Jose Lopez is one of the two male colorectal surgeons in the clinic, the other one being Dr. Carlo Cajucom. Dr Lopez had his post-residency training in colorectal surgery at PGH and his post-fellowship training in advanced laparoscopic colorectal surgery in Vietnam. He also had further training in colorectal surgery specializing in anorectal diseases and laparoscopic colorectal surgery in Thailand. He is currently a consultant at PGH, Asian Hospital and Medical Center, and Manila Doctors Hospital.
While there's no clear shred of evidence on what causes colorectal cancer, the problem is mostly associated with low fiber and high animal fat intake.
Dr. Sacdalan gives us the lowdown: "There are different regions in the gastrointestinal tract. From the mouth, the food goes to the esophagus and then to the stomach. And then it goes to the small intestines, then the large intestines or the colon, and then down into the rectum and out into the anus. In cases of colorectal cancer, we have to differentiate where the mass is because the management differs. That's one of the things we're able to provide to our patients: an in-depth discussion not only of the disease but how it will affect them and their families."
What are the symptoms?
"Still most common when it comes to the colon is abdominal pain; for rectum, it's blood in the feces," Dr. Lopez asserts. "Symptoms of abdominal pain, difficulty in defecation, blood in your stools may already indicate that in all likelihood your tumor may be in an advanced stage or it may already be huge. That's why we advocate screening for the general population when they're not feeling anything yet. The recommendation is that at 50 years of age, particularly for those with no family history of colorectal cancer, without any symptoms, they come in and we can perform a screening procedure on them. It can start earlier if the patient's father or mother has colorectal cancer."
"We catch these patients already in an advanced stage because we don't have a screening program similar to what they have in the States or Australia, where patients have access to medical care," Dr. Sacdalan explains. "And if we recommend colonoscopy, for instance, for an average-risk patient, it would cost a lot. The cost in itself is prohibitive (a colonoscopy generally costs P15,000 to P25,000, depending on who will do it, where it will be done, etc.)."
She points out, "Screening will demonstrate possibly polyps and hinder growth later on. Or if there's a cancerous mass already, we can recommend treatment while it is still at an early stage."
Dr. Lopez laments, "The sad part is that screening is not part of our national health program, even in hospitals, there's no hospital-based screening program. Unfortunately, this being the state of health of the country, we get most of our patients in Stage III already. When in fact we can get them in the earlier stage, of course it follows that the prognosis or outcomes are expected to be better."
Dr. Sacdalan notes with concern, "What's sad is people don't know that screening is needed at age 50, or as early as 40, if there's a history of colorectal cancer in the family."
Sadder still is the fact that today, there are more young people, as young as 20, getting colorectal cancer in an advanced stage.
"There have been studies by one of our colleagues, that for Filipinos, the average age at time of diagnosis is earlier than that of Westerners and that it's more aggressive," says Dr. Sacdalan.
"MEDICard accommodates cardholders who come for screening," Dr. Lopez assures patients.
What took the colorectal clinic so long to open?
Dr. Lopez hastens to reply, "It took long to have this because there's only a limited number of colorectal surgeons in the country. In the society, there are only around 40 colorectal surgeons. Right now, there are only three training programs in the country — one at PGH, Jose Reyes Memorial Medical Center, and a new one in Davao."
Marc and Dione are only the 20th and 21st graduates of the 29-year-old PGH program. The focus should be on prevention, early consult, and early detection.
There comes a ray of hope: "If we catch them in the late stages, there's still very much a chance for cure," Dr. Lopez stresses. "When it comes to survival for colorectal cancer, it's very good now as opposed to, say, when I was just a trainee because there have been a lot of improvements not only in the surgical techniques but also in terms of the other therapies, like chemotherapy and radiation. Even patients in Stage IV whom we would write off already before, now have a chance of even a cure, if not a better life. For Stage I patients, more than 90 percent are doing well in five years. It's really better to catch it early for a better prognosis and there will be better outcomes."
The MEDICard Lifestyle Center Colorectal Clinic is now in the forefront of colorectal care in the Philippines. They utilize the multi-disciplinary team approach of management. "It's not just the surgeon who decides or recommends whatever's needed for the patient," Dr. Sacdalan points out. "We also involve the medical oncologist, radiation oncologist, and other specialties like palliative care if it's Stage IV or a pain specialist. The permutation of options is endless. It's important that all the specialties are around so they can come up with the best approach for this particular patient. We try to tailor the treatment, depending on the patient's preferences, their goals for treatment, their financial capability."
Colorectal Specialists offers diagnostic examinations such as examination for common anorectal conditions, sexually transmitted diseases, endorectal and endoanal ultrasonography. It offers treatments for hemorrhoids and fissures, acute and chronic anal pain, fecal incontinence and constipation, anal abscess/anal fistula, anal warts, inflammatory bowel disease, colorectal tuberculosis. And of course, it specializes in comprehensive management of colon and rectal cancer.
Its staff offers state-of-the-art treatment options for hemorrhoids like rubber band ligation, stapled hemorrhoidopexy and trans-anal hemorrhoidal dearterialization (or THD).
For colorectal cancer which will entail hospital admission, the colorectal specialists offer minimally invasive surgery or laparoscopic surgery, robotic colorectal surgery, and anal sphincter preservation, which can be done at their affiliate hospitals. Some benign anorectal diseases can be managed in the clinic setting under local anesthesia while others can be performed in the operating room but still as a day or out-patient procedure. Not all colorectal and anal problems are managed surgically. Non-operative treatment options may be recommended when deemed necessary.
For any problems, embarrassing as they may seem, down there on your bottom, help is always available since there are colorectal specialists in the house!
It has claimed the lives of famous and powerful people – from local and Hollywood stars, to politicians, models, etc. The fact that they succumbed to this deadly disease is proof that colon cancer does not discriminate between rich and poor, young and old or male and female.
And despite the media exposure it has been getting lately, the number of colon cancer patients continue to rise. In 2008, it has caused 608,000 and experts say this number will continue to grow in the coming years. To date, colon cancer is now the fourth leading cause of cancer deaths globally.
However daunting the scenario may be, there are ways to prevent colon cancer. Awareness, prevention, early detection and screening are the main weapons against this menacing disease. Fortunately, cost-effective care for colorectal problems is easily accessible at Colorectal Specialists, Inc., (CSI) located at the MediCard Lifestyle Center.
CSI is the only specialty clinic in the country where colorectal surgeons are grouped together to offer outpatient clinic services. It is at the forefront of colorectal care in the Philippines, utilizing a multi-disciplinary team approach of management. This means that it's not only the surgeon who decides or recommends what a patient needs. The medical oncologist, radiation oncologist and other specialties like palliative care are involved. CSI at the MediCard Lifestyle Center offers state-of-the-art treatment options for haemorrhoids like rubber band ligation, stapled hemorrhoidopexy and tran-anal hemorrhoidal dearterialization or THD.
"We deal with all kinds of colorectal pathology, from benign to malignant cysts, even anorectal, which means from the anus to the anal canals including haemorrhoids, fistula, fissures, incontinence, constipation and of course colon diseases like infections, inflammations and cancers," says Dr. Carlo Angelo Cajucom, one of four colorectal surgeons in CSI.
Dr. Cajucom earned his medical degree from the University of Santo Tomas and did his general surgery residency at Quirino Memorial Medical Center. He then had his fellowship training in colorectal surgery at the Jose Reyes Memorial Medical Center, as well as post fellowship training in Sydney's Royal Prince Alfred Hospital.
Dr. Cajucom underscores the importance of early detection of signs and symptoms so patients can easily be diagnosed and treated before the disease becomes advanced. This is especially important in a country like the Philippines, where the majority of patients are diagnosed in the very late stages and where there is no screening. Unlike countries like the US or Australia, the Philippines does not have a screening program.
Dr. Cajucom adds that people who belong to the general risk population, meaning those who are not predisposed to having colorectal cancer, must have themselves screened at age 50, every three to five years. Those at high risk must undergo screening at least upon reaching 40 or 10 years before.
"Supposing you have a relative who was diagnosed with colorectal cancer at 38 years old, then you must have yourself screened at 28 years old," explains Dr. Cajucom. He adds that those who are extremely high risk must be screened as early as 10 – 12 years old.
Dr. Cajucom notes that people should watch out for the following risk factors for colorectal cancer: strong family history or genetics, aging, low fiber intake and those who like to eat grilled or red meat. He adds that the symptoms to watch out for include abdominal pain, fecal blood, and difficulty in defecation.
More than being mindful of the risks, Dr. Cajucom encourages people not to feel embarrassed to seek medical attention in case they experience symptoms of colorectal disease. After all, the stigma won't help anyone recover from cancer.
To know more about colorectal diseases and how you can prevent or cure them, visit Colorectal Specialists, Inc. at the MediCard Lifestyle Center, 51 Paseo de Roxas corner Buendia Avenue, Makati City from Mondays through Fridays, 1-7 pm and Saturdays from 9 am – 3 pm. You may also call them 555-0832. Equally competent doctors in the said facility include Dr. Catherine Co, Dr. Dione Sacdalan and Dr. Ancoy Lopez.
MEDICARD recently opened its Colorectal Specialist Clinic - a first in the HMO industry.
Located at the MEDICard Lifestyle Center at the corner of Paseo and Buendia St., Makati, the clinic offers the latest technology and expertise in colorectal healthcare.
This specialist clinic provides comprehensive, advanced and efficient care to wide range of colorectal conditions. Its expertise is in the management of colorectal cancer, diverticulitis, inflammatory bowel diseases, and other benign disorders like hemorrhoids, fissures, fistulae, polyps, constipation, fecal incontinence, sexually transmitted diseases (STDs), and other colorectal problems. It always strives to provide comfort, privacy and total quality service to its clienteles.


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On December 11, 2018, Kazakhstan Celebrated its 27th Anniversary in New York City
"Our earnest desire to build a world without conflict, terrorism, and nuclear weapons, and we set the target date as 2045 – the UN's centennial."
— H.E. Kairat Umarov, Permanent Representative of Kazakhstan to the United Nations
"The Comprehensive Nuclear-Test-Ban Treaty has an essential role within the nuclear disarmament and non-proliferation regime. It fosters international peace and security by constraining the development of nuclear weapons. Our collective security demands that every effort should be made to bring this essential treaty into force." — UN Secretary-General, António Guterres
"The only sure way to eliminate the threat posed by nuclear weapons is to eliminate the weapons themselves." — UN Secretary-General António Guterres
by Bircan Ünver, Head
NGO Representative to the United Nations Department of Public Information
The Light Millennium
Sometimes we may think that we know a country simply based on its name which might have connotations based on what we have read or heard about it over the years.
My main interest in Kazakhstan as a nation actually did not develop because it is the 9th largest country in the world, therefore the largest Turkic country. There is more to it than that such as not the size or cultural background but its core domestic and international policies in connection with peace, global security, food security, cultural diversity, total elimination of nuclear weapons, a world free conflict and terrorism…
Permanent Mission of Kazakhstan to the United Nations' all forms of organized events, led resolutions and run campaigns over the years, in particular, in connection with the Comprehensive Nuclear-Test-Ban Treaty (CTBT). The Mission of Kazakhstan has been the leading of it as an annual base event or High-Level Forum on the CTBT at the United Nations on the International Day Against Nuclear Test (Resolution# A/64/391) adopted by the General Assembly on 2 December 2009. It states the following:
"1. Declares 29 August as the International Day against Nuclear Tests, devoted to enhancing public awareness and education about the effects of nuclear weapon test explosions or any other nuclear explosions and the need for their cessation as one of the means of achieving the goal of a nuclear-weapon-free world;
2. Invites the Member States, the United Nations system, civil society, academia, the mass media and individuals to commemorate the International Day against Nuclear Tests in an appropriate manner, including through all means of educational and public awareness-raising activities.
— 55th plenary meeting 2 December 2009″
Source: http://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/64/35
In connection with the "Global Nuclear Disarmament" goal of the United Nations, Kazakhstan also has been the leading country on both, regional and global levels towards the "Total Elimination of Nuclear Weapons", which goal has also been adopted by the United Nations General Assembly Resolution (#A/RES/68/32). Its background goes back to 1952, which states:
"Achieving global nuclear disarmament is one of the oldest goals of the United Nations. It was the subject of the General Assembly's first resolution in 1946, which established the Atomic Energy Commission, which was dissolved in 1952, with a mandate to make specific proposals for the control of nuclear energy and the elimination of atomic weapons and all other major weapons adaptable to mass destruction. The United Nations has been at the forefront of many major diplomatic efforts to advance nuclear disarmament since then. In 1959, the General Assembly endorsed the objective of general and complete disarmament. In 1978, the first Special Session of the General Assembly Devoted to Disarmament further recognized that nuclear disarmament should be the priority objective in the field of disarmament. Every United Nations Secretary-General has actively promoted this goal."
Source: http://www.un.org/en/events/nuclearweaponelimination/
UNGA's related Resolution on the International Day for the Total Elimination of Nuclear Weapons (#A/RES/68/32) in item# 7 declares the following:
"Declares 26 September as the International Day for the Total Elimination of Nuclear Weapons devoted to furthering this objective, including through enhancing public awareness and education about the threat posed to humanity by nuclear weapons and the necessity for their total elimination, in order to mobilize international efforts towards achieving the common goal of a nuclear-weapon-free world."
I applied through the UN System and had given an opportunity to attend the High-Level Forum on the Total Elimination of Nuclear Weapons on the declared date September 26, during the UN General Assembly Sessions both in 2016 and 2018.
Most people are not aware that the United Nations provides many opportunities such as art and photo exhibits, special film/documentary screenings, book discussions, concerts, musical or art performances along with High-Level Forums, panels, symposiums, regular meetings, conferences, Briefings, side events and many more in numerous forms such as anniversary celebrations, openings and/or UN Days related programs.
In particular, in connection with Kazakhstan's Campaign at the United Nations for the Security Council as a Temporary Member State in 2016, provided several unique opportunities and information to the UN community at large including 25 Milestones of Independence of Kazakhstan for its 25th Anniversary.
Its leading role on CTBT and Total Elimination of Nuclear Weapons in the region and at the United Nations along within overarching concept such as "Global Security and Peace", "Food Security", "Energy Security" and "World Free of Terrorism", these have been in the top agendas, program and activities of the Permanent Mission of Kazakhstan at the UN.
As it is defined the Third Pillar of the UN is the Non-Governmental Organizations, and as a member of the UN.DPI/NGO Family, we have opportunities to participate and follow up such event and programs. Based on my own experience, the United Nations has been, the most effective and enhancing life-long school for me. Because, there is always something new to learn on a daily base that you may never have known or been aware of before. This endless source of information through multiple channels instantly opens up the mind to understand national and regional matters better from each Member State stand point of the UN–in this case Kazakhstan–that contributes to enhancing the general knowledge on the daily basis in a wider-spectrum and multiple dimension through gathered information and observations.
As the 9th largest country in the world in terms of land-size along with the stepping stone to the International Space Agency in Baikonur, Kazakhstan gives the utmost importance to Global Security, Food Security, Water Security, Education, Space, Arts-Culture, and Cultural Diversity as the backbone of its national and international policies. All together, it has been very inspirational and hopeful. In particular, effectively and impactfully bringing all these issues on the top level of the UN Agenda, and regularly campaigning on these, indeed, in terms of the NGOs and Global Community at large, that gives us trust in the UN Vision and Programs along with hope and inspiration for the future generations.
With the above-provided background, I attended the Reception "On the occasion of the 27th Anniversary of the Independence Day of the Republic of Kazakhstan and the End of the Non-permanent Membership of Kazakhstan at the United Nations Security Council" in New York City on December 11, 2018. In this context, I offer sincere thanks for the initial invitation to the Reception through Permanent Representative of the Republic of Kazakhstan to the United Nations H.E. Mr. Kairat Umarov and Mrs. Aigerim Umarov.
The Reception was well attended, in particular, on the Ambassadorial level, UN Staff and Media along with some invited NGO representatives.
"We do wish that others should not suffer the fate that 1.6 million Kazakhs did."
Excerpts from the Welcoming Speech of H.E. Mr. Umarov as follow:
- "We were guided and inspired by the seven verifiable and balanced priorities, which were outlined by my President Nursultan Nazarbayev at the beginning of our term, based on three pillars of the UN's work. We are happy to share with you that we have accomplished them on 150%.
- We strove for disarmament and non-proliferation, working towards a world free of nuclear weapons for we do wish that others should not suffer the fate that 1.6 million Kazakhs did.
- We have advocated for building confidence and trust as the basis for conflict prevention and resolution. It is also our earnest desire to build a world without conflict, terrorism and nuclear weapons, and we set the target date as 2045 – the UN's centennial.
- We put the spotlight on strengthening cooperation in Central Asia with Afghanistan integrated into it, through security and political diplomacy, investments in development. We hope to make this region as a model to be replicated elsewhere in the world.
- Along with counter-terrorism being a major focus of our Chairmanship at the Security Council's sanctions Committees 1267 and 1988, we launched in September 2018 the Code of Conduct for achieving a world free of terrorism, which I am proud to say has been signed by 80 countries already, as a coalition to fight terrorism, and the number is growing.
- Leaving the Council, we left our legacy in the form of flag installation ceremony for incoming members".
Based on the above provided excerpts, Kazakhstan NOT only has left a legacy at the UN Security Council but also has successfully seeded of Kazakhstan's Global Agenda on the "Total Elimination of the Nuclear Weapons" towards "Global Security and Peace", which is the most needed for the sustainability of humankind and the planet Earth at large. In particular, targeting for the "Total Elimination of Nuclear Weapons" by 2045 at the Centennial of the United Nations, indeed, gives utmost importance and hope to be attained by 2045!
– . –
Brief History of the Comprehensive Nuclear-Test-Ban Treaty (CTBT)
The Conference on Disarmament (CD) began its substantive negotiations on a comprehensive nuclear-test-ban treaty in January 1994 within the framework of an Ad Hoc Committee established for that purpose. Although the CD had long been involved with the issue of a test-ban, only in 1982 did it establish a subsidiary body on the item. Disagreement over a mandate for that body blocked tangible progress for years.
– For more information: https://www.un.org/disarmament/wmd/nuclear/ctbt/
– Status of the Ratification:
Article of the President of the Republic of Kazakhstan Nursultan Nazarbayev "Seven Facets of the Great Steppe"
Special Thanks to: Bauyrzhan Kerimkulov
Alternate Political Coordinator/First secretary
Permanent Mission of the Republic of Kazakhstan to the United Nations
#UNSC on the African Union Mission – United Nations Hybrid Operation in Darfur (UNAMID)
Related through Lightmillennium.Org:
2016: "Kazakhstan: Building a Nuclear Safe World"
WELCOME TO THE FUTURE" KAZAKHSTAN – Land of the Great Steppe
Foto Albums through Lightmillennium.Org:
2018 – ASTANA BALLET GALA at Lincoln Center
26th INDEPENDENCE DAY OF THE REPUBLIC OF KAZAKHSTAN
2016 UN HL Informal International Day for the Total Elimination of Nuclear Weapons
2016 -KAZAKHSTAN: UNITED FOR GLOBAL SECURITY – UN Photo Exhibit
– Posted on December 15, 2018.
©Turkish Library Museum is under the umbrella of The Light Millennium Organization, which is officially formed based in New York in 2001.
NGO Associated with the United Nations Department of Public Information since 2005. http://www.turkishlibrary.us | http://www.lightmillennium.org
Social Media: @Bircan.Unver @Bircan.Unver.35 @lightmillennium #lightmillennium @The Light Millennium @TurkishLibraryMuseum #TurkishLibraryMuseum


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Nothing quite says 'summer is here' quite like lounging poolside, picnics and trips to the beach with a frozen drink in hand. Perhaps it's the sound of the blender pulverizing ice cubes, the smell of coconut in the air or those little colorful umbrellas that give summer's arrival confirmation. Whatever does it for you, here are the top five places in LA to get your frozen drink on.
La Velvet Margarita
1612 N. Cahuenga Blvd.
Los Angeles, CA 90028
(323) 469-2000
While margaritas are a year-round cocktail, frozen margaritas just seem to taste better during the summer. The Velvet Margarita has maintained a long reputation of serving unique and delicious margaritas since it opened its doors more than a decade ago. Notable drinks on the menu are the signature frozen Velvet and Premium Velvet Margaritas (which is served in a pineapple). There are also strawberry, mango and pomegranate margaritas that pack quite a wallop.
Related: Best Coffee Houses To Chill At In LA
LAMILL Coffee Boutique
1636 Silver Lake Blvd.
Los Angeles, CA 90026
(323) 663-4441
The heat can be draining and sometimes what you really need is a cup of java to keep going through the day. Instead of grabbing one of those powder-based, mass-produced concoctions, treat yourself to something special. The Lamill Coffee Boutique has something called the blanco y negro. It's made from cold press coffee, frozen beans and handmade vanilla bean ice cream. The prep time for this mind-blowing cup of Joe is about 18 hours. Fortunately, it only takes moments to make.
Liquid Kitty
11780 W. Pico Blvd.
Los Angeles, CA 90064
(310) 473-3707
Liquid Kitty is one of those places that's more authentic dive than hipster dive. Fortunately, while most dive bars don't have a blender, Liquid Kitty does. It only has one frozen drink on the menu, but it's an amazing one. The Kitty Colada is the perfect blend of coconut, rum and a little Midori added for a little extra flavor.
Short Order
6333 W. 3rd St.
Los Angeles, CA 90036
(323) 761-7970
Frozen fun for the whole family, Short Order has some of the best custard and malts in town. Traditional chocolate, vanilla and a vanilla cookie shake are served regularly with daily specials your server will be happy to list. These shakes are the kind of thick and delicious variety you can only find in a burger joint.
Related: Best Juice Bars In Los Angeles


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Encounters with deep-sea creatures
Shell technicians work at extreme depths to recover oil and gas, and their encounters with squid and sharks are helping to increase understanding about deep-sea marine life.
Some two kilometres (1.2 miles) beneath the sea at the Perdido project in the Gulf of Mexico, the camera aboard an underwater, remotely-operated robot captured a glimpse of a big-fin squid for the first time. The robot's operators on the surface were retrieving drilling equipment from the seabed when they saw the creature with its mass of bent tendrils and a large undulating fin hovering near the well.
Deep-sea creatures in the Gulf of Mexico
I and others
you wouldn't believe some of the animals that we see the
on the sea floor and eight thousand feet of water mother nature's done tremendous
things off shore and
summer the that unusual animals that we see one we're installing these
components offshore is extremely amazing and there's always something new that
we've never seen before
during the noble club to go under the previous drilling programs I've seen a
shark on one of the videos on our underwater robots
the same shark that marijuana professors for the university said it had been seen
on a goal for Mexico in years
we've got chemo synthetic communities which are
seafloor colonies life that's it
to the south into the east of us chemo synthetic community
years a colony of like this on the seafloor
Maccabi tube worms it could be quite clams
its certain kinds of crabs there tend to populate
on areas that have unique features so in this case
there feeding on hydrocarbons as they're coming up through the sprouts 0
in some of these areas we have natural seepage is where the hydrocarbons
actually come through the seafloor
on the wrong in those areas we will get
taking a synthetic community that actually works form
and feed of the oil and they're protected so we have to stay away from
when we wake pipelines were when we do seafloor acted
At Shell's Great White field in the Perdido area of the Gulf of Mexico, an underwater robot encountered a Greenland sleeper shark at 2,600 metres (8,530 feet) below the sea. This species was previously thought to live at ocean depths less than about 2,000 metres (6,562 feet). The footage shows the shark as it slowly swims near a wellhead on the seabed before it disappears into the dark.
More in about us
Perdido – overview
Perdido in the Gulf of Mexico was one of our most challenging deep-water projects.
Assembling one of the deepest offshore hubs
Thousands of people from all over the world worked on Perdido, the world's deepest spar, and the second deepest oil and gas production hub.
You may also be interested in
Deep water
Shell has a long history of developing energy projects using its knowledge, experience and proven deep-water technologies to unlock new resources safely and efficiently. Read more about Shell's deep-water work around the world.
Overcoming technology challenges
We develop innovative technologies to find and safely unlock more, and affordable, energy from ever harder-to-reach places.
Technical careers
Human solutions to global challenges: find out how you can develop your career in our technical teams.


text:
By Eddie Lowen
How to untangle boldness, fear, and pride.
I wonder how Pharaoh and his crew sized up Moses when he barged into their presence. Did Moses look "fresh from the farm" after decades of rural ranching? No doubt, age and circumstance had altered Moses' appearance. Those easy childhood years as adopted grandson of an earlier king were long gone.
However, what Moses lacked in fashion and grooming, he overcame with boldness. True, he hedged at the burning bush. Yet something had shifted in him. His presence was amplified by another presence. Aaron went along because Moses lacked confidence as a presenter, but ironically, there is no record of Aaron opening his mouth. Moses struggled in practice, but on game day, he was money.
He didn't bother being diplomatic. Rather, Moses was dominant: "This is what the Lord . . . says: 'Let my people go'" (Exodus 5:1). No wimpy qualifiers. No polite "please."
I have some pity for Pharaoh because I've encountered a few people who brought me messages from God. Oddly, God always wanted exactly what the messenger wanted. Since some claims of divine messaging are questionable, I understand why Pharaoh wanted confirmation.
But Pharaoh was more than prudent; he was insolent (Exodus 5:2), "Who is the Lord, that I should obey him and let Israel go? I do not know the Lord and I will not let Israel go." When you invest a lot of energy and tax revenue promoting your own divinity, it's tough to take orders from other deities.
We know Moses pretty well because we have more narrative from his life than most biblical characters. So, it's not speculative to say Moses was among the boldest people in the Bible. He pronounced judgments. He spoke with great authority. Moses was so confident as God's representative, he made rubble of the stone tablets on which God himself carved the commandments. That's the equivalent of you or me throwing the original manuscript of the Gospel of John into a fireplace to make a point. I wouldn't have the nerve. Moses did.
This and more makes Numbers 12:3 a fascinating and valuable statement. It is one of the most noteworthy compliments ever paid to a human being: "Now Moses was a very humble man, more humble than anyone else on the face of the earth."
King-confronter. Tablet-smasher. Plague-pronouncer. Slave-freer. Judge-appointer. Consequence-bringer. Miracle-worker. God-seer. But still humble.
The Dilemma
Those who dare to lead know the tension between boldness and humility. Not only is there a struggle in the heart of every leader to harmonize these qualities, there is also dogged determination on the part of many critics to highlight (or exaggerate) any sign of pride in us, especially in the church.
Maybe that's why so many pastors project a vibe, not of humility, but of crippling self-doubt. When you combine the weight of past mistakes, frequent criticism, and the Bible's warnings against pride, who can blame a guy for concluding it's safer to loathe himself than like himself?
But the leader who is empty of confidence is avoiding pride at too great a cost—and usually doesn't lead for long. Without some poise and conviction, people won't follow us very far, especially uphill.
There is also a psychological price to pay when a leader is mired in timidity. In his song "Fear," Ben Rector admits that much of his early music career was a lengthy season of deep insecurity. In his lyrics, Rector confesses to being scared of failing and looking like a fool; he writes, "I'd rather quit than risk that I could lose."
That's the theme song of the fearful leader. It's exactly what Paul was pruning from Timothy when he wrote, "For the Spirit God gave us does not make us timid, but gives us power, love and self-discipline" (2 Timothy 1:7).
Before the burning bush, Moses was humming a song of fear. He had wrecked his life morally, legally, and socially. It was safer to remain in the desert muttering at mutton.
But Moses learned it wasn't his vision (freedom for his countrymen) that was in error—it was his methodology. He hadn't been cut. He'd been sidelined for a time of recovery.
Beware Pride
If we could somehow place timidity and pride on opposite sides of a scale that weighed their potential danger, the scale would tip quickly toward egotism. Proverbs 29:23 warns, "Pride brings a person low, but the lowly in spirit gain honor." It's better to live well inside the border of humility than to allow even one foot inside the kingdom of pride.
Blessed are the meek. Empowered are the humble. The Bible says God actively works on behalf of the humble, but personally opposes the proud. I want the advantage of God's approval in my life and work.
The reason pride is so dangerous for leaders is that its impact is multiplied. I spend time with leaders of both smaller and larger churches. I've learned that the percentage of humble leaders and arrogant leaders in large churches is no different than the percentage of each in smaller churches.
Large church leaders are criticized more often, more publicly, and more severely. Some of it is warranted, of course. But much of it is hyperbolic commentary by people with more words than wisdom.
However, there can be no argument that when a larger church leader's spirit is bloated with pride, the negative impact is magnified because of the increased visibility and influence.
A business consultant writing for Harvard Business Review confirmed that the prevailing assumption in many business environments is that confidence is crucial to success. Meekness is often viewed as weakness in high-powered circles. However, after years of observing leaders and their results, CEO and business professor Tomas Chamorro-Premuzic claims that low confidence is better than overconfidence. Employees and leaders who have a confidence deficit are more likely to accept critique, more likely to self-correct, and less likely to foster animosity with coworkers and clients.
Even in your career, if you must fall off one side or the other, choose meekness. A lot has changed in our world, but prideful people still, eventually, fall. When falling, it's better to start close to the ground.
Character More Than Strategy
We live in a day of unbelievable accessibility to resources. The books that have been written for church leaders are incredible. Conferences—good ones!—are multiplying like rabbits. Colleagues and ministry friends can stay in touch daily and share ideas with just a click. Some of the best preachers in the world are willing to share their teaching notes with other preachers! The preaching and church leadership greats of the past would be stunned by the material available to us on our phones.
But regardless of how capable and informed we become, our greatest challenge will always be surrendering our hearts to be shaped by the Holy Spirit. There are no shortcuts for this, and it can't be delegated.
J.R.R. Tolkien groaned when a proofreader suggested Tolkien's initial draft of The Hobbit contained too much silly chatter between characters. To Tolkien, clever dialogue was more interesting and challenging than constant action. Still, he decided to heed the input, informed his publisher the final draft would arrive late, then edited significantly.
Tolkien didn't just trim. He slashed, deleting half the dialogue. As he did, he could feel the pace of the story improving. He also changed a central character's name from Bingo to Frodo. That was a good call by the man of many initials. Giving Frodo the name Bingo would have been akin to J.K. Rowling opting for Old MacDonald over Dumbledore.
Despite his literary talent, Tolkien not only considered a bold critique, he fully embraced it. I assume he sent a thank-you note to his buddy C.S. Lewis for the valuable advice.
Regardless of your giftedness, someone out there can show you a better way—and we all need a better way. Someone out there can inspire you—and we all need to be inspired. There are someone's feet at which you should be sitting and listening. The wiser you and I become, the more we will recognize those people around us.
Milton Rokeach's book The Three Christs of Ypsilanti features the author's experiences with several men in Ypsilanti, Michigan, all of whom believed themselves to be Jesus Christ!
One technique Rokeach used to reconnect the men with reality was to ask each of them questions in front of the others. He would ask one man, "Why did you say that?" The man would answer that God had told him to say it. Then one of the other two men would respond, "I never told you to say that!"
How often do we pretend to know, do, or be what God hasn't asked? God's known qualities are that he knows everything, can do anything, and can be everywhere at the same time. There's a lot of freedom in admitting that we're not even close.
Eddie Lowen serves as lead minister with West Side Christian Church, Springfield, Illinois.


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Secretary of State offices to be closed for 4th of July holiday
LANSING -- Michigan Secretary of State Ruth Johnson reminds residents that all branch offices and the Office of the Great Seal will close on Thursday, July 4 in observance of Independence Day.
The Department of State mails notices to motorists 45 days before their driver's license or license plates expire to give them ample time to renew. Licenses and plates that expire on a day when state offices are closed, such as a holiday or weekend, can be renewed the following day without penalty.
Most people renewing license plates, driver's licenses and ID cards can do business online at www.ExpressSOS.com or by mail. Easy to follow instructions can be found with the renewal notice. Additional services can be done online as well.
License plate tabs can also be renewed at Self-Service Stations, many of which are available around the clock. Visit the Branch Office Locator at www.michigan.gov/SOS to find a Self-Service Station near you.
With the exception of holidays, branch offices are open Monday, Tuesday, Thursday and Friday from 9 a.m. to 5 p.m. Smaller branch offices may close for the lunch hour. On Wednesdays most offices are open from 11 a.m. to 7 p.m., with those in city centers open 9 a.m. to 5 p.m. PLUS offices and SUPER!Centers are open from 9 a.m. to 7 p.m. on Wednesdays. SUPER!Centers also provide Saturday hours from 9 a.m. to noon.


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Emirates competition terms and conditions
1. No purchase necessary. 2. One entry per person, no bulk or third party entries. 3. Competitions are open to all UK residents except employees of Time...
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4. The closing date for receipt of entries is midnight on April 25 2013. Time Out is not responsible for any delay or failure to receive notification for any reason, including inactive email accounts, technical difficulties associated therewith, or the potential winner's failure to adequately monitor any email address.
5. Winners will be notified by Time Out by email within 24 hours of the prize draw closing. Entrants who have not won a prize will not receive notification
6. How to enter: Enter your full name, email address and phone number, and upload a photo of your football team to be entered into the draw. There is a limit of one (1) entry per person per prize during the promotion period. Only entries received by Time Out during the promotion period for the prize in question will be accepted.
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Kai Ryssdal: The box score from the Los Angeles Dodgers game last night was a nifty win. They beat the Braves 6-1 on 11 hits, no errors. But really, nobody was talking about the game. The buzz at the stadium and all over sports last night was about Major League Baseball taking control of team from owner Frank McCourt.
Renee Cantu: It was just a matter of time before it happened.
Dave Serpa: I think it's a good thing; I don't think Frank McCourt was doing a good job with the Dodgers, and we need to find somebody who's going to take care of the Dodgers and their history.
Zak Forbes: Hopefully it will lower ticket prices and raise payroll.
Anthony Gonzales: Have to have death of an old for birth of a new, so we're going to rise up, we're going to get better.
That was Renee Cantu, Dave Serpa, Zak Forbes and Anthony Gonzales at the game last night.
For some thoughts today, we've called Dave Zirin. He's the author of "Bad Sports: How Owners are Ruining the Games We Love." Dave, great to talk to you.
Dave Zirin: Hey, great to be here. Thank you.
Ryssdal: The word that comes to mind when you think about the Dodgers and Frank McCourt is sort of Wall Street-y, actually — it's "leverage." The guy borrowed $145 million to buy the team, he owes $430 million now. What was, though, the straw that broke the camel's back for Bud Selig, the commissioner of baseball?
Zirin: Oh, I think the straw that broke the camel's back for Bud Selig was when Frank McCourt asked Fox Broadcasting, his broadcast partner, for a individual, personal loan so he could make payroll. And this was after Frank McCourt asked Major League Baseball if he could take a business loan to make the payroll, and Major League Baseball said no. So then he did an end-around and said, I want money for a personal loan, and then used it for payroll anyway. I think that was just a bridge too far for Bud Selig.
Ryssdal: He's going to appoint a representative in the next couple of days, the commissioner is. What will that person have the power to do?
Zirin: It's a very good question. Because on the one hand, all the other owners are subsidizing this team. But on the other hand, what do you do if this team is then competitive, if they go on a run and they need to add some parts here and there? Will they have the freedom to do that, even though they would effectively be spending the other owners' money for the purposes of bettering their competitive advantage against other owners? So it's a very tricky situation in terms of what that person is going to be allowed to do, and the only thing we can know by looking at history and by looking at other sports, is that it will in fact be rife with conflict.
Ryssdal: This whole episode has echoes of the financial crisis, a little bit, with the Obama administration stepping in with General Motors and with TARP, and with this top-down type of dictate-from-above, whether it's the government or the league saying, listen, we know what's best, here's what we're going to do. What happens now with the Dodgers?
Zirin: I think it is true to say that the Dodgers are too big to fail, that they would fall under their rubric certainly. But I think the other echo of the financial crisis here is not just seen with the Dodgers, but with all of Major League Baseball. The Texas Rangers, who made the World Series last year, had to be sold in the middle of last season in a bankruptcy auction. Let's remember that the New York Mets, whose fans are already wearing paper bags over their heads just 15 games into the season, are literally bankrupt because their owners leveraged their team towards Bernie Madoff. I mean, the problem really is, really mirrors the economic problems in the United States because so much of baseball has been about real estate over the last 30 years. I mean, you're talking about over $30 billion that have been spent on either refurbishing or building brand new stadiums and parks, which owners then borrowed money on. Now, that was all fine and good when the economic climate was better and the real estate market was good, but now that the real estate market has cratered, you're seeing a lot of teams crater along with that market, as the values of the land and values of the stadiums have actually plummeted.
Ryssdal: What about the fans, though? They're kind of staying away this year, I mean, Dodgers' season ticket sales are down, baseball attendance is down.
Zirin: Yeah. It's a tragic thing, actually, because the Dodgers had the number one attendance mark for 12 straight years, and that's really changed. But that's a story across Major League Baseball. And I would argue that it's happened because Major League Baseball has ignored working-class and middle-class fans for a generation, because they haven't had to cater to those fans, for the simple reason that they were making so money from public subsidies, from sweetheart cable deals and from luxury boxes. But now that those revenue streams are running dry, you really are seeing the chickens come home to roost.
Ryssdal: Dave Zirin, he's a sports editor at The Nation magazine. His most recent book is called "Bad Sports: How Owners are Ruining the Games We Love." Dave, thanks a lot.
Zirin: My privilege, thank you.
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Point 6 of our Realtime Art Manifesto says Don't make games and The rule-based structure and competitive elements in traditional game design stand in the way of expressiveness and summarizes with Express yourself through interactivity. While this has always been more of a guideline and a desire than a factual truth, we have recently found proof for this claim from an unexpected place.
Rod Humble, an executive producer at Electronic Arts, has made a game. Or more to the point, he has constructed a work of art with game rules. It's a very simple game but is has captured the imaginations of at least half a dozen bloggers ( Arthouse Games, Joystiq, Indygamer, TIG Source, Man Bytes Blog, Raph Koster, Jonathan Blow ). Probably precisely because of its explicit purpose of trying to express something -a story, a set of opinions- through game rules only, and its apparent success at doing just that.
I, however, beg to differ.
The first response we had here was to feel pity for Rod's wife. In his game, she is represented as a pink square that gets bigger when she collides with her husband while the latter gets smaller. This may be a naughty reference to human sexuality but nevertheless, it made us worry about their marriage. Later this was confirmed by Raph Koster saying that "He did report that his wife didn't like the rules." I bet she didn't. He just made her look like a self inflating idiot in front of the whole world!
I'm sure that's not what he meant. And this is the core of the problem.
Game rules, by their very nature, live on a very abstract plain. They are mathematical expressions of relationships between objects. These relationships are completely and utterly logical. They have to be. Otherwise the game breaks. This severe logic is detrimental when trying to express something about the human condition with its inherent messiness, contradictions and ambiguity. As a result, game rules are only capable of expressing a very specific story, a story without layers of meaning or freedom of interpretation.
And it gets worse. Because of their extreme abstraction, game rules are only capable of telling this very specific story in very general terms. When you do that, all poetry gets lost and with it all depth and aspiration to universality.
That being said, I applaud the attempt. I want to see it as one step in the right direction. The direction of telling stories through interactivity. And I hope that the failure of The Marriage (which is the name of this game) to express anything but a banal generalisation of something that is obviously of very deep concern to the author, stimulates us to take the next step. To abandon this strange obsession with games and their rules.
Interactivity is capable of so much more than games. New media artists like Lia and Dextro have been working with this for years. And while they share a formal language with Rod Humble to some extent, the work of these internationally renowned artists provokes a lot more rich and diverse emotions.
Not that I am advocating any kind of puritanism in art. I don't think laying bare the very concepts of art and limiting art to its very core is a good idea. The computer gives us a an unprecented array of media that we can all use simultaneously to express things in the most sensuous and spectacular ways ever imagined. Why limit ourselves with this wealth at our disposal?
So as a final example, I want to leave you with the work of Alex Mayhew. Way back in 1997 already, he made a CD Rom in Peter Gabriel's Realworld Studios called "Ceremony of Innocence". Like The Marriage, it uses interaction as a form of expression to talk about a relationship. However, it does not limit itself to the mechanics but touches all your senses at once. Ceremony of Innocence does not limit itself to gameplay either. It allows interactivity to be free. Playful interactions that express so much more than strict game rules can. Alex is still very active today. Visit his website for more information and some beautiful little experiments with interactivity.


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Abstract and Keywords
Between 1903 and 1950, aviation technology was spread around the world and became a key concern of governments and a cultural marker of modernity. After 1903, Asia had to be explored again. Almost as soon as heavier than air flight became possible, French and British fliers began pioneering new routes to Asian cities and developing new maps and new airports along the way. With these new forms of knowledge, the colonial powers quickly moved to tie together their empires. New mapping techniques allowed for new forms of control, including what the British called "air policing," the idea that judicious use of aircraft, and in some cases bombs and poison gas, could cheaply pacify far-flung colonial populations.
Aviation was one field, however, where the Europeans did not have a long lead on Asians. Just as Europeans were using aviation to express their dominance, Asians were using it to express their modernity. Feng Ru was making and flying his own planes in San Francisco by 1912, and Siam had an air force by 1913. Asian social and political elites, who had once traveled by rail and steamship, now preferred to fly instead. "Air-mindedness" became a marker of global citizenship.
Japan was the first Asian country to have an aviation industry. They proved their technological prowess to the rest of the world when they entered World War II. Their pilots bombed cities and fleets across Asia between 1937and 1945. The experience of being bombed as well as the drills and community organizations that grew out of experience ushered in a societal awareness of the military power of airplanes. The war culminated with two atomic air raids and was followed by a scramble to occupy and connect the newly liberated and independent parts of Asia. The post–World War II period led to an intensified effort to tie Asia together with faster transportation
Keywords: aviation, air-mindedness, aerial perspective, colonialism, imperialism, transportation, military
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A group of researchers are developing a tiny foldable robot, to be used as a non-invasive tool in medicine.
Author: Eva Spielvogel
Image of the Week: Eternal Data Archiving
Have scientists just created superman's memory crystal? This glass disc contains 5D data – with a lifespan close to eternal.
Image of the Week: Extraterrestrial Life
This week's image, taken from the International Space Station, is of a flower blossoming in space.
Image of the Week: Closeup of Wine
These beautiful photographs of alcohol under the microscope are a perfect blend of art and science
Image of the Week: Swimming with Grey Seals
This weeks image is of a playful grey seal: an intelligent animal with interesting behaviours…
Image of the Week: Mapping Happiness
What do we know about happiness? This week's image reveals a clue in the quest for happiness.
Image of the Week
The image of the week is a stunning night-time display of cosmic light.


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The impact of tutoring in the digital academic literacy programme on graduate attributes at the University of the Western Cape
Siebrits, Andre
Stoltenkamp, Juliet
Mokwele, Tebogo
MetadataShow full item record
This study reports on the impact of a Tutor Work-Study Programme, within the Digital Academic Literacy Programme (DAL) at the University of the Western Cape (UWC), South Africa. This study was prompted by the need to investigate the impact of peer (student) tutoring initiatives on tutors' learning, academic studies and future career preparation. This paper seeks to make a contribution to the broadening of conceptions regarding impact of tutoring programmes from knowledge gains in the recipients, to gains (and impediments) conferred to tutors supporting the delivery of the material. While the enquiry focuses primarily on the DAL tutors, it also includes an account of the impact of the tutors on the delivery and facilitation of programme, and on the registered UWC students served by it. A mixed-methodology is employed, incorporating qualitative and quantitative data, drawn from questionnaires and interviews. The sample consists the tutors in the programme (second semester, 2014) who agreed to take part in the study, as well as the three facilitators. Data are also drawn from a semester-end evaluation regarding tutoring. Findings reveal that participation in the DAL Programme had a strongly positive impact on the tutors, especially in skills gains and general career preparation. The tutors also had a strongly positive impact on the delivery and the facilitators. Finally, while most students enrolled in the DAL Programme were satisfied with the quality of the support and expertise provided by tutors in class, some areas for improvement are identified. Ultimately, the need to reflect critically on student interventions at Higher Education Institutions must be taken seriously, especially in the context of producing professional, knowledgeable, and employable graduates who are able to meet the demands of the modern information economy. In this context, the results of this research reveal that should the DAL Programme be discontinued or cease to be integrated into the curriculum at UWC, student development would be directly impeded, given the dire need for digital academic literacies.


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Percentage of 2010 births classified as "preterm"
• Alabama: 15.6 percent
• Georgia: 13.8 percent
• Tennessee: 12.9 percent
Note: Preterm is defined as less than 37 complete weeks of gestation
Source: National Vital Statistics Report
First laugh, first crawl, first word -- every year parents fill baby books with familiar accomplishments.
Twelve-month-old Brielle Barnes' parents celebrated much different milestones. First bottle. First night maintaining body temperature. First breath.
Brielle came into the world at 2 pounds, 7 ounces, after only 31 weeks of gestation. On Saturday she celebrated the birthday of her first neighbor and fellow premature baby, Cheyenne Douglas. The two lay next to each other at Erlanger Hospital's Neonatal Intensive Care Unit, where Cheyenne spent the first 110 days of her life.
Their moms shared the ordeal.
"It's hard to relate for someone who had a full-term baby," said Brielle's mother, Nicole Barnes.
"NICU was my full-time job," added Cheyenne's mother, Missy Douglas.
The two spoke of long hours at the hospital, of waiting days to hold their babies for the first time and of seeing both turn gray as their tiny bodies struggled to breathe.
In an effort to give back to the people who helped care for Cheyenne, her parents celebrated her first birthday with a public party at the East Ridge Community Center. The event was a fundraiser for Erlanger's T.C. Thompson Children's Hospital and food drive for the Ronald McDonald House. They also held a blood drive and promoted preemie awareness.
Money donated to the hospital will go toward buying kangaroo chairs -- wide-backed recliners.
Douglas and Barnes explained that holding a baby skin-to-skin promotes bonding in the child and milk production in the mother. Also, a mother's heartbeat is believed to soothe the baby with sounds familiar from the womb.
However, it's difficult to snuggle an infant with a feeding tube, respirator and IVs. Kangaroo chairs, they say, support preemies' unique ergonomic needs and make intimacy much easier.
Wanda Dossantos, a NICU nurse for 20 years and party guest, noted how important parent contact is for all infants, but how difficult it can be with fragile, pre-term babies. She said that caregivers try to include parents as much as possible, even if only to take a child's temperature or change her diaper.
However, even that can be difficult. Barnes said Brielle was so weak she could hold the infant only for 30 minutes every three hours and had to change her diaper through portholes in Brielle's pod.
Food donation
Cheyenne's birthday also featured a table brimming with food to be donated to the Ronald McDonald House. For $10 a night and some help maintaining the facility, parents of sick children can get a bed and a hot meal as well as access to a kitchen and laundry machines. It also offers a place of mutual support for families affected by pre-term births.
The Barnes family lives two hours away from the hospital in Blairsville, Ga. Brielle's father, Brad Barnes, said that his daughter spent 39 days in NICU, and his wife stayed 38 nights at the Ronald McDonald House.
Barnes explained the pressures of trying to support his family financially and emotionally while being helpless to heal his struggling baby.
Pausing to collect himself, he said, "I won't take help for anything, but at a moment when you're not prepared and you have no place to go, [Ronald McDonald House] really takes care of your needs. I can't speak highly enough of how we were taken care of."
Finally, family, friends, preemie parents and hospital staff were encouraged to visit the party's on-site bloodmobile. Douglas explained that even at a birth weight of less than 2 pounds, Cheyenne required six blood transfusions during her hospital stay.
Today, Brielle and Cheyenne are both healthy and happy. The crowd began singing "Happy Birthday," and Dossantos joined in.
When the song ended, she watched Cheyenne taste some frosting.
"I have the best job in the world," she said. "I see miracles happen every day."
Georgia nonprofit One Harvest seeks to fill food box need in Chattanooga
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Jesse Stuart On Education
Editor, J.R. LeMaster (English and American studies, Baylor Univ.), has culled from six of Stuart's autobiographical works segments that express the down-to-earth educational philosophy of the Appalachian novelist, poet, teacher, and school administrator. The selections from works dating from 1938 to 1970 are arranged in a loose chronology of Stuart's life. Each is accompanied by the editor's commentary and evaluation of the work as a whole. LeMaster has done an admirable job of selecting and editing the readings. Not only will this collection save time for education students, for whom Stuart is required reading, it will also help acquaint the contemporary reader with this remarkable man.