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"2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia." has been saved, and will be accessible from the My NGC page.
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Hyperuricemia (gout)
Patients with gout
The search of PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) from the 1950s to the present for articles on gout, used a search strategy based on the Cochrane Highly Sensitive Search Strategy for identifying randomized trials, and search terms related to gout, hyperuricemia, tophi, and arthritis, described in the text. Limits included English Language and the exclusion of "animal only" studies. The exact search terms included: ("gout"[mh] OR gout*[tw] OR "Hyperuricemia"[mh] OR hyperuricemia[tw] OR hyperuricaemia[tw] OR toph*[tw] OR arthritis uric*[tw] OR arthritis uric*[tw] OR uric acid dis*[tw]) AND English[lang] NOT ("animals"[MeSH] NOT "humans"[MeSH]). The first search (9/25/10) retrieved 5,380 articles from PubMed and CENTRAL. As schematized, the review was divided into three stages: titles, abstracts, and manuscripts. Each phase required two team members to assess the items individually for relevancy, and items were rejected if they fulfilled explicit exclusion criteria, such as studies not done in gout patients. Discordant assessments between reviewers were resolved with direct discussion between the two raters. Remaining disagreements were adjudicated by a third party arbitrator. Of the 5,830 titles, 192 duplicate titles and 82 non-English titles were excluded, with an additional 3,729 titles excluded based on pre-defined criteria – leaving 1,827 titles, of which another 1,699 were excluded in the manuscript abstract review phase. Of the 128 manuscripts reviewed, there were 41 eligible manuscripts on non-pharmacologic measures (such as diet and alcohol, etc.) in gout patients, but none were randomized, controlled trials and all were excluded. The remaining 87 manuscripts met the inclusion criteria for pharmacologic agents in gout patients, but 40 of these were excluded because they were not controlled trials. Subsequently, the systematic review was updated by repeating the search with the same criteria to include any articles that were published between 9/25/10 and 3/31/11. Recent meeting abstracts from the American College of Rheumatology and European League Against Rheumatism (EULAR) were searched for any randomized controlled trials that were yet to be published, before presentation to the Task Force Panel (TFP) in the evidence report. The supplemental search resulted in 4 additional manuscripts, and 5 meeting abstracts on pharmacologic agents. The gout literature was reviewed until April 20, 2012.
A total of 51 manuscripts and 5 meeting abstracts were reviewed.
Level of Evidence
Level A: Recommendations supported by multiple (i.e., >1) randomized clinical trials or meta-analyses
Level B: Recommendations derived from a single randomized trial or nonrandomized studies
Level C: Consensus opinion of experts, case studies, or standard of care
The RAND/University of California at Los Angeles (UCLA) method requires a core expert panel (CEP) that provides input into case scenario development and preparation of a scientific evidence report. The CEP consisted of leaders for each domain (see Supplemental Figure 2, available in the online version of this guideline at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658 ). Pharmacologic approaches and diet, lifestyle, and nonpharmacologic measures (e.g., weight loss, exercise) were addressed within each domain. Although a previous systematic review for gout has been performed by the European League Against Rheumatism (EULAR), as a prime example, a new systematic review of pertinent literature was performed.
The Core Expert Panel (CEP) performed its own systematic review of pertinent literature. The resultant scientific evidence report was given to the Task Force Panel (TFP) in conjunction with clinical scenarios representing differing degrees of disease activity (see the "Methods Used to Formulate the Recommendations" field). There were multiple questions of interest and alternative options presented for each case scenario.
The level of evidence supporting each recommendation was ranked based on previous methods used by the American College of Cardiology and applied to recent American College of Rheumatology (ACR) recommendations.
Of the reviewed literature, 21 manuscripts were on urate-lowering therapy (ULT), and were presented to the TFP in the evidence report. Abstracts presented at ACR or EULAR meetings (including case series, single center trials) were graded as level C evidence, unless a multicenter randomized controlled trial. The majority of the meeting abstracts reviewed were subsequently published as full manuscripts in the open literature, with evidence level of these studies subsequently re-graded, as appropriate.
Project Design and Development of Recommendations
The overall design of the project is schematized in Supplemental Figure 1 (available in the online version of the original guideline document at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658 ). The RAND/University of California at Los Angeles (UCLA) consensus methodology, developed in the 1980s, incorporates both Delphi and nominal group methods, and was successfully used to develop other guidelines commissioned by the American College of Rheumatology (ACR). The purpose of this methodology is to reach a consensus among experts, with an understanding that published literature may not be adequate to provide sufficient evidence for day-to-day clinical decision making. The RAND/UCLA method requires two groups of experts: a core expert panel (CEP) that provides input into case scenario development and preparation of a scientific evidence report, and a task force panel (TFP) that votes on these case scenarios. The CEP consisted of leaders for each domain (see Supplemental Figure 2, available in the online version of the guideline at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658 ). Pharmacologic approaches and diet, lifestyle, and nonpharmacologic measures (e.g., weight loss, exercise) were addressed within each domain. The CEP leaders communicated with an international panel of gout experts and the principal investigators to develop initial case scenarios that reflected broad differences in severity of the disease and its clinical manifestations. In addition, there were weekly interactive teleconferences between the domain leaders and principal investigators to refine case scenarios. The scientific evidence report was given to the TFP in conjunction with clinical scenarios representing differing degrees of disease activity. There were multiple questions of interest and alternative options presented for each case scenario.
By ACR mandate, the TFP had a majority of members without a perceived potential conflict of interest, and had diverse experience and expertise, as described in detail in Supplemental Figure 2 (available in the online version of this article at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658 ). The TFP included seven rheumatologists (including one Chair of Internal Medicine and one Internal Medicine Residency Training Program Director), two primary care physicians, a nephrologist, and a patient representative. There were two rounds of ratings, the first anonymous, with the members of the TFP instructed to rank each of the potential elements of the guidelines on a risk/benefit basis ranging from 1–9 on a Likert scale using the Delphi process, followed by a face-to-face group discussion and then revoting of the same scenarios. A vote of 1–3 on the Likert scale was rated as inappropriate (risks clearly outweigh the benefits), a vote of 4–6 was considered uncertain (risk/benefit ratio is uncertain), and a vote of 7–9 was rated as appropriate (benefits clearly outweigh the risks). Samples of votes taken and results are provided in Supplemental Figure 3 (available in the online version of the original guideline document at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658 ). Votes on case scenarios were translated into recommendations if the median voting score was graded 7–9 (appropriate) and if there was no significant disagreement, defined as no more than 1 of 3 of the votes graded as inappropriate for the scenario. The final rating was done anonymously in a two-day face-to-face meeting, facilitated by an experienced moderator. During the face-to-face TFP meeting, some case scenarios were clarified for content or verbiage and revoted on by the TFP.
Clinical Case Descriptions
The TFP evaluated clinical scenarios with differences in frequency of acute gout symptoms and differences related to the presence or extent of chronic findings (tophi, synovitis) on physical examination, similar to what a clinician might see in a busy practice. Scenarios were divided into mild, moderate, and severe disease activity in each of three distinct "treatment groups" (see Figures 1A and B in the original guideline document). In generating these nine fundamental clinical case scenarios, mild disease activity levels in each treatment group were meant to represent patients at the lowest disease activity level for which most clinicians would consider initiating or altering a specific medication regimen. Conversely, the severe disease activity level was intended to represent patients with disease activity greater than or equal to that of the "average" subject studied in a clinical trial. The case scenarios were not intended to serve as classification criteria. To allow the TFP to focus on management decisions, each case scenario had the assumption that the diagnosis of gout was correct. In addition, it was assumed that there was some clinical evidence of gout disease activity. This included intermittent symptoms of variable frequency, specifically presented to the TFP as episodes of acute gouty arthritis of at least moderate to severe pain intensity. Other clinical evidence of gout disease activity, presented to the TFP in specific case scenarios, was tophi detected by physical examination, or alternatively, chronic symptomatic arthritis (i.e., "chronic arthropathy" or "synovitis") due to gout, with or without confirmed joint damage (e.g., deformity, erosion due to gout on an imaging study) (see Figure 2 in the original guideline document). Hyperuricemia was defined here as a serum urate level >6.8 mg/dl. All aspects of case scenario definitions were determined by a structured iterative process, using regular e-mail and teleconferences at least once per month. Multiple revisions to the proposed parameters were carried out, until accepted by the CEP domain leaders.
Key Assumptions in the Process Applied to Develop the Recommendations
Definitions of Pharmacologic Therapeutic Agents
Medication classes evaluated in the case scenarios were defined as follows: xanthine oxidase inhibitor (XOI) refers to allopurinol or febuxostat, and uricosuric agents were defined to include agents available in the U.S. (probenecid and off-label use [as uricosuric therapy] of fenofibrate and losartan), but did not include sulfinpyrazone or benzbromarone. Other agents and modalities were self-explanatory. Evaluation by the TFP of effectiveness of a given therapeutic option assumed that patients in the case scenarios received the maximum tolerated typical dose for a period of time sufficient to accurately assess therapeutic response, unless otherwise indicated.
Not applicable
The RAND/University of California at Los Angeles (UCLA) methodology utilized for this project did not allow the guideline authors to address the important clinical practice and societal implications of treatment costs, which clearly impact patient and provider preferences for gout management options recommended by the task force panel (TFP) as effective. For example, the authors recognize the potential cost issues of the urate-lowering therapy (ULT) recommendations presented, since, for example, febuxostat is substantially more expensive than allopurinol or probenecid. The guideline authors note that a recent single technology appraisal with cost analysis done by an independent evidence review group of the National Institute for Health and Clinical Excellence concluded that febuxostat should be recommended for ULT in gout only in patients with contraindications or intolerance to allopurinol. Conversely, polymerase chain reaction (PCR)-based human leukocyte antigen (HLA)–B*5801 pharmacogenetics screening for allopurinol is a one-time test and relatively inexpensive, but raises new questions about the added costs to gout management, particularly for populations where the risk of allopurinol hypersensitivity syndrome (AHS) is low. Last, third-line ULT with pegloticase is an expensive biologic therapy approach for gout, and additional biologic agents for gout therapy are currently being developed and investigated. Cost-effectiveness trials and analyses are particularly timely for emerging therapies in gout.
Peer Review of Recommendations
After the draft recommendations were submitted, the American College of Rheumatology (ACR) invited peer review, prior to journal review, done by the ACR Practice Guidelines Subcommittee, the ACR Quality of Care Committee, and the ACR Board of Directors.
Note from the National Guideline Clearinghouse (NGC): The American College of Rheumatology (ACR) guidelines for management of gout focus on 4 specific domains in gout management. Two of these domains are addressed herein, i.e., urate-lowering therapy (ULT) and chronic gouty arthritis with tophaceous disease detected on physical examination (designated by the ACR with the terminology "chronic tophaceous gouty arthropathy" [CTGA] and specifically represented in the fundamental case scenarios 7–9 described herein). The remaining 2 domains (analgesic and antiinflammatory management of acute gouty arthritis and pharmacologic antiinflammatory prophylaxis of attacks of gouty arthritis) are addressed in part 2 of the guidelines as a separate article (see the NGC summary of the ACR guideline 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis).
The levels of evidence supporting the recommendations (A-C) are defined at the end of the "Major Recommendations" field.
Primary Principles of Management for All Gout Case Scenarios
The task force panel (TFP) generated recommendations for a systematic nonpharmacologic and pharmacologic management approach intended to be applicable to all patients with gout, which is summarized in Figure 3 in the original guideline document. This was based on the assumption that the diagnosis of gout was correct before initiation of management. The approach highlighted patient education on the disease and treatments and their objectives, and initiation of diet and lifestyle recommendations, including the particular role of uric acid excess in gout and as the key long-term treatment target (evidence B). The TFP also recommended, on a case-by-case basis, careful consideration of potential elimination of serum urate–elevating prescription medications that might be nonessential for the optimal management of comorbidities (e.g., hypertension, hyperlipidemia, or major organ transplant) in a given patient. Prime examples of urate-elevating medications are thiazide and loop diuretics, niacin, and calcineurin inhibitors (evidence C). However, the TFP, without a specific vote, recognized the particular benefits of thiazides for blood pressure control and outcomes in many patients with hypertension. Although low-dose acetylsalicylic acid (aspirin ≤325 mg daily) elevates serum urate, the TFP did not recommend discontinuation of this modality as cardiovascular disease prophylaxis in gout patients. In discussion, without a specific vote, the TFP viewed the relative risks specifically attributable to the modest effects of low-dose aspirin on serum urate as negligible in gout management.
The TFP recommended that clinicians consider causes of hyperuricemia for all gout patients, and recommended a specific comorbidity checklist (evidence C) (see Table 2 in the original guideline document). In doing so, the TFP specially recommended consideration, and if indicated, medical evaluation of certain agents and disorders that cause uric acid underexcretion or overproduction, which thereby could merit laboratory investigations such as urinalysis, renal ultrasound, a complete blood cell count with differential cell count, or urine uric acid quantification, as indicated. In this context, the TFP specifically recommended screening for uric acid overproduction (by urine uric acid evaluation) in patient subsets with gout clinical disease onset before age 25 years (evidence C) or a history of urolithiasis (evidence C).
The TFP provided guidance for referral to a specialist, with caution to avoid appearing self-serving. Although limited by the absence of outcomes data on potential benefits of referral, the TFP recommended that gout case scenarios including any of the following should be among those where referral to a specialist is considered (evidence C for all): 1) unclear etiology of hyperuricemia; 2) refractory signs or symptoms of gout; 3) difficulty in reaching the target serum urate level, particularly with renal impairment and a trial of xanthine oxidase inhibitor (XOI) treatment; and 4) multiple and/or serious adverse events from pharmacologic ULT.
Clinical Evaluation of Gout Disease Activity and Burden
The TFP recommended clinical evaluation of gout disease symptom severity and burden in individual patients by history and a thorough physical examination for symptoms of arthritis and signs such as tophi and acute and chronic synovitis (evidence C). To be actionable by clinicians, the authors without a specific TFP vote suggested that clinicians can work with patients to record and estimate the number per year and severity of acute attacks of gouty arthritis per year.
Core Recommendations for Nonpharmacologic ULT Measures in Gout
The TFP recommended certain diet and lifestyle measures for the majority of patients with gout (evidence B and C for individual measures) (see Figure 4 in the original guideline document). Many of the diet and lifestyle measures were recommended for decreasing the risk and frequency of acute gout attacks and lowering serum urate levels, but the primary emphasis of the TFP recommendations in Figure 4 of the original guideline document was on diet and lifestyle choices for promotion and maintenance of ideal health and prevention and optimal management of life-threatening comorbidities in gout patients, including coronary artery disease and obesity, metabolic syndrome, diabetes mellitus, hyperlipidemia, and hypertension.
Dietary recommendations were grouped into 3 simple qualitative categories, termed "avoid," "limit," or "encourage" (see Figure 4 in the original guideline document). This approach, with rare exceptions, reflected a general lack of specific evidence from prospective, blinded, randomized clinical intervention trials that linked consumed quantities of individual dietary components to changes in either serum urate levels or gout outcomes. Notably, the replication of hazardous lifestyle risk factors in a conventional clinical research trial would potentially pose both design and ethical difficulties. As such, the TFP deliberated on evidence regarding the impact of exposures to alcohol or purine-rich foods in a short timeframe. The evidence sources were epidemiologic studies of hyperuricemia and incident gout, including long-term prospective analyses and internet-based case-crossover studies of specific exposures. The TFP recommended that gout patients limit their consumption of purine-rich meat and seafood (evidence B) as well as high fructose corn syrup–sweetened soft drinks and energy drinks (evidence C), and encouraged the consumption of low-fat or nonfat dairy products (evidence B) (see Figure 4 in the original guideline document). The TFP voted to encourage vegetable intake in gout patients (evidence C) (see Figure 4 in the original guideline document), having considered evidence in healthy subjects for lowered serum urate levels and urine urolithiasis risk factors associated with dietary vegetable intake. However, there was no specific TFP vote on the question of avoidance of excess purine intake from food sources other than meat and seafood, such as vegetables and legumes, in gout patients. The TFP recommended reduced consumption of alcohol (particularly beer, but also wine and spirits) and avoidance of alcohol overuse in all gout patients (evidence B) (see Figure 4 in the original guideline document). The TFP further recommended abstinence from alcohol consumption for gout patients during periods of active arthritis, especially with inadequate medical control of the disorder and in CTGA (evidence C). Significantly, in discussion by the TFP, without a specific vote, the TFP recognized that diet and lifestyle measures alone provide therapeutically insufficient serum urate–lowering effects and/or gout attack prophylaxis for a large fraction of individuals with gout. For example, some clinical trials on diet and fitness have reported only an approximately 10%–18% decrease in serum urate. In further discussion by the TFP, again without a specific vote, the TFP viewed this degree of serum urate level lowering as beneficial for all case scenarios, but insufficient to achieve an effective serum urate target in those with sustained hyperuricemia substantially above 7 mg/dl.
Core Recommendations for Pharmacologic ULT, Including the Serum Urate Target
Here, and with all other recommendations for drug therapy in parts 1 and 2 of the 2012 ACR guidelines for gout, the recommendations assumed a lack of contraindications, intolerance, serious adverse events, or drug–drug interactions for given agents. The TFP recommended gout with chronic kidney disease (CKD) stage 2–5 or endstage renal disease as an appropriate indication, by itself, for pharmacologic ULT (evidence C) in patients with prior gout attacks and current hyperuricemia. In pharmacologic ULT, certain treatment choices (e.g., probenecid) and drug dosing decisions (e.g., allopurinol) are impacted by the creatinine clearance. The TFP, without a direct vote, discussed and recognized the clinical value of accurate measurement of creatinine clearance, not simply the serum creatinine, in ascertaining the degree of renal impairment. However, the scope of the project did allow for detailed prescriptive recommendations regarding specific ULT drug doses, usage of individual agents in the presence of a given degree of either renal impairment, or other comorbidities such as hepatic impairment.
TFP recommendations for pharmacologic ULT, shown graphically in Figure 3 of the original guideline document, included recommendation of XOI therapy with either allopurinol or febuxostat as the first-line pharmacologic approach (evidence A). The panel did not preferentially recommend either XOI over the other XOI drug. In doing so, the TFP weighed the lack of published safety data for febuxostat in the setting of stage 4 or worse CKD. Probenecid was recommended as an alternative first-line pharmacologic ULT option in the setting of contraindication or intolerance to at least 1 XOI agent (evidence B). However, the TFP did not recommend probenecid as a first-line ULT monotherapy in those with a creatinine clearance below 50 ml/minute.
The TFP recommended that pharmacologic ULT could be started during an acute gout attack, provided that effective antiinflammatory management has been instituted (evidence C). The TFP recommended regular monitoring of serum urate (every 2–5 weeks) during ULT titration, including continuing measurements once the serum urate target is achieved (every 6 months; evidence C). The TFP weighed this measure as particularly useful to monitor adherence, given that poor adherence to ULT is a common problem in gout patients.
The TFP recommended that the goal of ULT is to achieve a serum urate level target at a minimum of <6 mg/dl in all gout case scenarios (evidence A). Moreover, the TFP recommended that the target serum urate level should be lowered sufficiently to durably improve signs and symptoms of gout, including palpable and visible tophi detected by physical examination, and that this may involve therapeutic serum urate level lowering to below 5 mg/dl (evidence B).
Recommendations Specific to Allopurinol Dosing and Pharmacogenetics
TFP recommendations for use of allopurinol in gout are summarized in Table 3 in the original guideline document. Importantly, the TFP recommended that the starting dosage of allopurinol should be no greater than 100 mg per day (evidence B), consistent with prior Food and Drug Administration (FDA) and European League Against Rheumatism (EULAR) guidelines. The rationale of the TFP was partly that a low allopurinol starting dose could reduce early gout flares after ULT initiation, and partly as a component of risk management with respect to the potential for severe hypersensitivity reaction to allopurinol, discussed in further detail below. The TFP recommended gradual upward titration of the allopurinol maintenance dose every 2–5 weeks to an appropriate maximum dose for gout, in order to treat to the serum urate target appropriate for the individual patient (evidence C).
The TFP weighed robust evidence that allopurinol monotherapy at doses of 300 mg or less daily failed to achieve the serum urate level target of <6 mg/dl or <5 mg/dl in more than half of the subjects with gout. The TFP reviewed small studies in which the allopurinol dose was titrated above 300 mg daily in gout with overall success in achieving the serum urate target. Importantly, in doing so, the TFP also recommended that the maintenance dosage of allopurinol can be raised above 300 mg per day, even in those with renal impairment, provided there is adequate patient education and regular monitoring for drug hypersensitivity and other adverse events, such as pruritis, rash, and elevated hepatic transaminases, as well as attention to potential development of eosinophilia (evidence B).
The TFP next considered the issue of measures to reduce the incidence of severe allopurinol hypersensitivity reactions, here termed allopurinol hypersensitivity syndrome (AHS). TFP discussion recognized the potential for hospitalization and severe morbidity and the reported mortality rate of 20%–25% in AHS. The estimated incidence of AHS is approximately 1:1,000 in the U.S., and its spectrum includes not only Stevens-Johnson syndrome and toxic epidermal necrolysis, but also systemic disease with a clinical constellation of features such as eosinophilia, vasculitis, rash, and major end-organ disease. Concurrent thiazide use and renal impairment have been implicated as risk factors for AHS. A widely employed risk management strategy has been a non–evidence-based algorithm for allopurinol maintenance dosing, calibrated to renal impairment (evidence C); importantly, the TFP did not recommend this strategy.
In their evaluation of the allopurinol starting dose as a component of risk management strategy, the TFP first weighed evidence that the highest risk of severe allopurinol hypersensitivity reaction is in the first few months of therapy. A recent case–controlled retrospective analysis of AHS and allopurinol starting dose further supported the aforementioned recommendation by the TFP of a starting dose of allopurinol of no more than 100 mg daily, and the TFP recommendation of an even lower starting dose of allopurinol (50 mg daily) in stage 4 or worse CKD (evidence B).
The TFP also weighed the rapidly emerging area of pharmacogenetics to screen for AHS, and recommended that, prior to initiation of allopurinol, human leukocyte antigen (HLA)–B*5801 testing should be considered in select patient subpopulations at an elevated risk for AHS (evidence A). Those with HLA–B*5801 and of Korean descent with stage 3 or worse CKD (HLA–B*5801 allele frequency approximately 12%), or of Han Chinese or Thai extraction irrespective of renal function (HLA–B*5801 allele frequency approximately 6%–8%), have been highlighted in the literature as prime examples of subjects at high risk for AHS, marked by HLA–B*5801 hazard ratios of several hundred. Such high-risk individuals were recommended to be prescribed an alternative to allopurinol if HLA–B*5801 positive (evidence A). The TFP recommended that the HLA–B*5801 screening be done by the rapid, widely available polymerase chain reaction (PCR)–based approach (evidence A) that, in only approximately 10% of tests, requires more cumbersome followup HLA–B*5801 sequencing for inconclusive results. Significantly, the TFP did not recommend universal HLA–B*5801 allopurinol screening. Current evidence informing this TFP decision included that whites with an HLA–B*5801 prevalence of approximately 2% had a substantially lower HLA–B*5801 hazard ratio and negative predictive value of the test than in the aforementioned Asian subpopulations.
Recommendations Specific to Primary Uricosuric Urate-Lowering Monotherapy
Under conditions where uricosuric monotherapy was employed as a primary ULT modality (see Table 3 in the original guideline document), probenecid was recommended by the TFP as the first choice among uricosuric drugs currently available in the U.S. (evidence B). The TFP recommended that a history of urolithiasis contraindicates first-line use of a potent uricosuric agent for ULT (evidence C), given that probenecid (and benzbromarone, which is unavailable in the U.S.) was associated with an approximately 9%–11% risk of urolithiasis. Specific TFP recommendations for risk management in uricosuric ULT also included initial measurement and monitoring of urine uric acid, and that an elevated urine uric acid level indicative of uric acid overproduction contraindicates uricosuric ULT. There was no TFP consensus on assay of undissociated urine uric acid, or use of Simkin's Index and similar calculation on spot urine, in risk management in uricosuric therapy. The TFP did recommend that when initiating uricosuric ULT, patients should also be instructed to increase fluid intake and consider urine alkalinization (e.g., with potassium citrate; evidence C for all), but no quantitative parameters were voted on for these measures, in view of lack of evidence.
Recommendations on Pharmacologic ULT Decision Making in Gout, Including Case Scenarios with Mild, Moderate, or Severe Disease Activity or CTGA
The TFP voted on clinical decision making in each of the 9 case scenarios when the serum urate target had not yet been met and under circumstances where gout remained symptomatic (i.e., where there were 1 or more continuing clinical signs and symptoms of gout, such as recent acute gout attacks, tophi, and chronic gouty arthritis) (see Figure 5 and Table 4 in the original guideline document). In doing so, the TFP, in limited voting scenarios, first considered the potential role of imaging in the evaluation of disease burden and clinical decision making on ULT gout. The TFP recommended the utility of high-resolution ultrasound, computed tomography (CT), or dual-energy CT (evidence B) to detect tophi, and the utility of plain radiographic findings consistent with tophi (such as characteristic bone erosion; evidence C). The TFP also voted that the ultrasound "double contour sign" was consistent with nontophaceous urate crystal deposition on the surface of articular cartilage (evidence B). However, the TFP did not recommend use of the double contour sign as a sufficient indicator for initiating or increasing the intensity of ULT, given that the sign was detected in joints of approximately 25% of subjects with asymptomatic hyperuricemia in a recent study. Conversely, in a recent study, the double contour sign was not universally detectable (i.e., absent in approximately 33% of subjects in an ultrasound survey of multiple joints in each subject) in patients with early gout not receiving ULT.
For all 9 case scenarios when the serum urate target has not been met, the TFP recommended upward dose titration of 1 XOI (allopurinol or febuxostat) to the respective maximum appropriate dose for the individual patient (evidence A) (see Figure 5 and Table 4 in the original guideline document). The maximum FDA-approved dose of allopurinol is 800 mg daily, and for febuxostat is 80 mg daily. Given the request for an international frame of the gout guidelines by the ACR, the TFP recommended increasing febuxostat up to 120 mg daily, a dose approved in many countries outside the U.S., in the specific scenario of active disease refractory to appropriately dosed oral ULT (evidence A). The TFP further recommended, and broadly so in the 9 case scenarios, that if upward titration of the initial XOI agent was not tolerated or did not achieve the serum urate target, substitution of another XOI was an appropriate first-line option (evidence C).
Notably, the TFP recommended probenecid and other agents with clinically significant uricosuric effects, such as fenofibrate and losartan, as therapeutically useful in a comprehensive ULT program in refractory disease (evidence B). Specifically, the TFP recommended a combination oral ULT approach (i.e., 1 XOI agent [allopurinol or febuxostat] and 1 uricosuric agent [probenecid, fenofibrate, or losartan being the currently available agents in the U.S.]) as an option when the serum urate target has not been met across the 9 case scenarios (evidence B) (see Figure 5 and Table 4 in the original guideline document).
Last, the TFP recommended pegloticase as appropriate only in the case scenarios with severe gout disease burden and refractoriness to, or intolerance of, appropriately dosed oral ULT options (evidence A) (see Figure 5 and Table 4 in the original guideline document). In 2 large placebo-controlled randomized clinical trials, pegloticase 8 mg every 2 weeks was effective in reducing the serum uric acid level to <6 mg/dl in 42% of patients versus 0% in the placebo group at 6 months. In addition, 45% of patients receiving pegloticase 8 mg every 2 weeks had complete resolution of 1 or more tophi versus 8% in the placebo group, with significant improvement in chronic arthropathy and health-related quality of life. Importantly, the TFP did not recommend pegloticase as a first-line ULT for any case scenarios. The TFP also did not achieve consensus on the appropriate duration of pegloticase therapy once decreased symptoms and signs of gout, including decrease in size (or resolution) of tophi on clinical examination, had been achieved.
The original guideline document provides a clinical algorithm for baseline recommendations and overall strategic plan for patients with gout.
The type of supporting evidence is identified and graded for most of the recommendations (see the "Major Recommendations" field).
Appropriate management of gout using systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia
Adverse effects of therapeutic agents
Limitations of the Guidelines
An implementation strategy was not provided.
Not applicable: The guideline was not adapted from another source.
Supported by a research grant from the American College of Rheumatology and by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH (grant K24-AR-063120).
Task Force Panel
Panel Members: Dinesh Khanna, MD, MSc, Puja P. Khanna, MD, MPH, Blake Roessler, MD: University of Michigan, Ann Arbor; John D. FitzGerald, MD, Sangmee Bae, MD, Shraddha Prakash, MD, Marian Kaldas, MD, Maneesh Gogia, MD, Daniel E. Furst, MD, Neil Wenger, MD: University of California, Los Angeles; Manjit K. Singh, MD: Rochester General Health System, Rochester, New York; Tuhina Neogi, MD, PhD, FRCPC, Hyon Choi, MD, DrPH: Boston University Medical Center, Boston, Massachusetts; Michael H. Pillinger, MD: VA Medical Center and New York University School of Medicine, New York; Joan Merill, MD: Oklahoma Medical Research Foundation, Oklahoma City; Susan Lee, MD, Robert Terkeltaub, MD: VA Healthcare System and University of California, San Diego; Fernando Perez-Ruiz, MD, PhD: Hospital Universitario Cruces, Vizcaya, Spain; Will Taylor, PhD, MBChB: University of Otago, Wellington, New Zealand; Frédéric Lioté, MD, PhD: Université Paris Diderot, Sorbonne Paris Cité, and Hôpital Lariboisière, Paris, France; Jasvinder A. Singh, MBBS, MPH: VA Medical Center and University of Alabama, Birmingham; Nicola Dalbeth, MD, FRACP: University of Auckland, Auckland, New Zealand; Sanford Kaplan, DDS: Oral and Maxillofacial Surgery, Beverly Hills, California; Vandana Niyyar, MD, Danielle Jones, MD, FACP: Emory University, Atlanta, Georgia; Steven A. Yarows, MD, FACP, FASH: IHA University of Michigan Health System, Chelsea; Gail Kerr, MD, FRCP(Edin): Veterans Affairs Medical Center, Washington, DC; Charles King, MD: North Mississippi Medical Center, Tupelo; Gerald Levy, MD, MBA: Southern California Permanente Medical Group, Downey; N. Lawrence Edwards, MD: University of Florida, Gainesville; Brian Mandell, MD, PhD: Cleveland Clinic, Cleveland, Ohio; H. Ralph Schumacher, MD: VA Medical Center and University of Pennsylvania, Philadelphia; Mark Robbins, MD, MPH: Harvard Vanguard Medical Associates/Atrius Health, Somerville, Massachusetts
Managing Perceived Potential Conflicts of Interest (COI)
Perceived potential COI was managed in a prospective and structured manner. Specifically, all participants intellectually involved in the project, whether authors or not, were required to fully and prospectively disclose relationships with pharmaceutical companies with a material interest in gout (see Supplemental Figure 2 and Appendix A, available in the online version of the original guideline document at http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)2151-4658 ). Disclosures were updated every 6 months, and for the principal investigators, core expert panel (CEP), and task force panel (TFP), updated just prior to the face-to-face meeting. A summary listing of all perceived potential COI was disseminated to all participants in the project. Based on the policies of the American College of Rheumatology (ACR), which are aligned with those of many medical societies, no more than 49% of the project participants could have a COI at any given time. It was required that the project principal investigator remain without perceived potential COI prior to and during the process.
Dr. Dinesh Khanna has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Novartis and Ardea and (more than $10,000 each) from Takeda and Savient, and has served as a paid investment consultant for Guidepoint. Dr. Puja P. Khanna has received speaking fees (less than $10,000) from Novartis and (more than $10,000) from Takeda, and has served on the advisory board for Novartis. Dr. Pillinger has received speaking fees and/or honoraria (less than $10,000 each) from the RA Investigator Network, NY Downtown Hospital, Winthrop Hospital, and Einstein College of Medicine. Dr. Perez-Ruiz has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Novartis, Menarini, and Savient, and (more than $10,000) from Ardea. Dr. Lioté has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Novartis Global, Novartis France, and Ipsen, and has served as a paid investment consultant for Gerson Lehrman Group. Dr. Choi has served on the advisory boards (less than $10,000 each) for Takeda, URL, and Savient. Dr. Singh has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Ardea, Savient, Allergan, and Novartis, and (more than $10,000) from Takeda, and has received investigator-initiated grants from Takeda and Savient. Dr. Dalbeth has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Takeda, Ardea, and Novartis, has received research funding from Fonterra, and holds a patent from Fonterra for milk products for gout. Dr. Niyyar has received honoraria (less than $10,000) from the American Society of Nephrology. Dr. Kerr has served as a study investigator (more than $10,000 each) for Savient and Nuon. Dr. Edwards has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Savient, Takeda, Ardea, and Regeneron, and (more than $10,000) from Novartis, and has given expert testimony for Novartis. Dr. Mandell has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Savient, Novartis, and Pfizer. Dr. Schumacher has received consultant fees (less than $10,000 each) from Pfizer, Regeneron, West-Ward, and Ardea, and (more than $10,000) from Novartis. Dr. Terkeltaub has received consultant fees (less than $10,000 each) from Takeda, Savient, Ardea, BioCryst, URL, Regeneron, Pfizer, Metabolex, Nuon, Chugai, EnzymeRx, Ajanta, Anadys, Celgene, Isis, and Prescription Solutions, and (more than $10,000) from Novartis, has received grant support from the VA San Diego Healthcare System and the National Institutes of Health (NIH), and has served as a paid investment consultant for Leerink Swann, Medacorp, and Guidepoint.
Electronic copies: Available from the American College of Rheumatology Web site .
Supplemental figures and Appendix A are available from the Arthritis Care and Research Web site .
The following is available:
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
This NGC summary was completed by ECRI Institute on December 27, 2012. The information was verified by the guideline developer on January 17, 2013.
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Andrew Luck Out for Sunday, Hasselbeck Expected Starter for ColtsThe Colts will be without their star quarterback and their potential starter for Sunday is also hurt
Will The Texans Take a Shot At A Franchise QB In 2016?Jason Cole from Bleacher Report joined Mad Radio to discuss the future of the QB position for the Texans, the risks of playing Andrew Luck and the gloomy future of Colts head coach Chuck Pagano
With Four Games To Go, Texans Control Their Own AFC South DestinyAfter 12 games of the 2015 NFL regular season, the Houston Texans are 6-6 and tied for first place in the AFC South Division. However, they would lose the tiebreaker to the Indianapolis Colts currently due to a head-to-head Week 5 loss.
Andrew Luck Out 2-6 Weeks With Lacerated KidneyAndrew Luck's tough season took an even bigger hit Tuesday when the Colts announced he would miss two to six weeks with a lacerated kidney and a partially torn abdominal muscle.
Hammond: Alabama Belongs In Top 4, Baylor And TCU Don't
Rosenfels: Texans Have A Chance At The Playoffs Right NowFormer Texans QB Sage Rosenfels joined Mad Radio and they talked about the Texans heading into the bye week, Andrew Luck's issues, Peyton Manning and the Broncos and his thoughts on Ken Whisenhunt getting fired by the Titans.
O'Brien Switched QBs Too EarlyNFL game analyst Jim Miller joined Mad Radio and they talked about the quarterback situations for the Texans, Bengals, Jaguars, Broncos, and Colts.
Hammond: Astros Are Better After Tough ALDS Loss To Royals
Hammond: For Andre Johnson, Texans-Colts Should Be Personal
REPORT: Matt Hasselbeck Will Start For The Colts On Thursday Night
It's A Make-Or-Break Week For The Texans In Week 5As the Houston Texans prepare to host the Indianapolis Colts on Thursday Night Football this week, it's key to recognize this may be the Texans' last chance to make a statement in 2015.
Houston Texans Face Uphill Battle Against Struggling Indianapolis ColtsA Houston Texans win over the Indianapolis Colts on Thursday Night Football could move them into first place in the AFC South.

subset: commoncrawl


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Chinese Drywall Settlement Reached
A major settlement in the Chinese drywall saga was reached on Thursday in New Orleans.
A federal judge there signed off on an agreement between some homeowners and importers, manufacturers and distributors of Knauf Plasterboard Tianjin (KPT) Chinese drywall, alleged to emit corrosive sulfur fumes that damage electrical wiring and metal pipes. KPT and Knauf Gips KG, a building products company based in Germany, and other Knauf entities are named as defendants in the lawsuits. Knauf argues it was named in many suits because its products were clearly marked, unlike some others.
The plasterboard manufacturer, suppliers and insurers agreed to completely remove and replace KPT drywall, as well as all the electrical wiring, gas tubing and appliances from 300 homes in four states. They also agreed to pay relocation expenses while the houses, in Alabama, Mississippi, Louisiana and Florida, are repaired, which could take several months. The cost of remediation, excluding relocation, is estimated at $40-$80 per square foot. The insurers are providers of commercial liability policies.
The agreement is expected to provide a template for resolving thousands of other pending lawsuits against the manufacturer in multidistrict litigation consolidated in federal court in the Eastern District of Louisiana, as well as hundreds of other lawsuits filed in state courts across the U.S.
The settlement approved by Judge Eldon Fallon closely follows a protocol for remediation issued by the federal Consumer Product Safety Commission and the Department of Housing and Urban Development months ago.
Rich Kampf, 57, a homeowner in Cape Coral, Fla. whose home allegedly was built with KPT drywall, said the KPT settlement was "hopeful" for people whose homes have been remediated already, or who have been chosen for the repairs but, "I worry about those with Knauf drywall who have not been selected," he says.
Colleen Stephens, 42, a homeowner in Virginia Beach, Va. whose home allegedly was built with drywall from a different Chinese manufacturer not covered by the settlement said, "There are so many people who have gone bankrupt and been foreclosed upon already. They have lost their homes already. The settlement is a good step forward but we need more help than that. It's going to take a coordinated government as well as a legal effort to help these families."
KPT did not admit to product liability as part of the settlement, says Gregory J. Wallance of Kaye Scholer, LLP, one of the attorneys for the defendant company. The settlement also did not address allegations that the problem drywall causes health effects including headaches, bloody noses and eye irritation. Health claims have been set aside until later, the attorneys said. KPT contends that its investigation found the product was not harmful to health.
"The company has looked at the issue and doesn't believe there is merit to those claims. Specifically, the company requested that the Center for Toxicology and Environmental Health conduct tests on this issue and they found that the drywall, KPT's drywall did not present a health risk and we are not aware of any governmental study that has found that KPT drywall affects environmental health. But home remediation will greatly facilitate resolution of those claims," Mr. Wallance said.
An attorney for the homeowners, Russ Herman of Herman, Herman, Katz & Cotlar, L.L.P., said "it is true they don't admit the drywall is defective, and they don't admit jurisdiction in the federal court, or that they are controlled by Knauf entities in Germany. That will be the subject of the trial after we complete depositions in New York, Frankfurt, London and Beijing," he said.
Knauf Gips KG, a has long maintained that it is not the parent of the Chinese manufacturer but only an affiliate. But court documents filed recently in connection with a state court suggested otherwise. Louisiana-based Interior/Exterior Building Supply, the Louisiana Homebuilders Indemnity Trust, QBE Insurance Group and State Farm Insurance and other Knauf entities also signed the agreement.
Thousands of lawsuits have been filed against KPT and other Chinese manufacturers of problem drywall, which was installed in thousands of homes nationwide during the mid-2000s when domestic materials were scarce. More than 3,600 complaints about metals corrosion and possible health effects have been filed to date with the federal Consumer Product Safety Commission in connection with problem drywall, including a small number of cases involving American companies. The majority of cases were from Florida, although complaints have come from 39 states.
The CPSC's chief spokesman, Scott Wolfson, said the commission would not comment on the settlement. The CPSC is continuing to conduct indoor air testing focused on a small number of homes that have reported products with non-Chinese drywall.


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A Holiday Boutique Show
Imagine a marketplace with a festive atmosphere that invites you to stroll among colorful booths displaying exquisitely handcrafted wares, a marketplace that inspires you with beautiful pieces of art that are created by local artists. For one day only, local patrons of the arts have conceived of such a marketplace that combines the artistry and creativity of our local talent with community outreach and support to give the gift of art.
"Imagine nourishing your creative spirit and spreading the joy of giving gifts made with passion and love," expresses jeweler Silvia Peluso, the boutique coordinator. She is looking forward to a fun day with her fellow artisans and encourages shoppers to embrace their joy of giving. You are invited to stroll among the treasures and find a richly colored silk scarf for an aunt, admire captivating wire wrapped jewelry for a friend, and dig among artfully arranged succulents for the hostess of a holiday event. Discover vibrantly painted ceramic goods or beautifully assembled mosaics for your home and browse among frames, cards and ornaments to chance upon a unique treasure to give. Grab a fashionably trendy and brightly colored fashionista homie hat, or a cool silver cuff for your impossible teen and charm new mothers with adorable baby outfits and matching accessories. Treat yourself to an extravagant fashion ensemble and soothe your night with an herbal dream pillow. Celebrate a successful day with hot cider and delicious homemade treats.
"Art transforms everybody's home, decorates everybody's wall and lives in everybody's soul," suggests designer Stefani Conniff, the show curator. As a special treat 14 local artists are invited to enhance the creative flair of the marketplace. The curator chose artworks representative of the local mood, as well as a few pieces with a unique flair. Beautifully painted familiar landscapes, luscious flowers, somber surfers or delicate ballerinas are waiting to decorate your blank walls. Intricate local photo collages, or lacy coffee grain creations are sure to inspire vivid conversations at your next event. Express your love to your special someone by giving the memory of an everlasting piece of art.
You are invited to share this delightful day in the essence of giving to all whom you love and to your community that you live in. "In true holiday spirit the art community of Redondo Beach will host the First Annual Creative Holiday Boutique to celebrate local talents and creativity, contribute to the beauty of our city, share a day of exploration of unique crafts and arts, color and texture, and a sense of a community working together to enrich each others life," reflects artist Nina Zak Laddon, the show organizer. This event will help pay for a public art project that is part of the esplanade beautification design. Two local artists are envisioning mosaic patterns on the bollards that are placed in front of the inclines to the beach. Be proud to have contributed to the beauty of your town by giving beauty to whomever you treasure.
HOLIDAY BOUTIQUE - SAT NOVEMBER 6th -9am-6pm- 710 Diamond Street, RB


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Ones to Watch: WBA
by Ashley Houghton
Take at look at some of the Baggies' biggest threats.
West Brom's club captain is just seven games away from 200 appearances for the Baggies.
And, since his move from Sheffield Wednesday back in 2007, Brunt has been ever-present in Albion's progress, which has seen them finish in the top 11 in the Barclays Premier League in the previous two campaigns.
Northern Ireland international Brunt has garnered a reputation for a sweet-left foot that has contributed to the majority of his 33 goals for West Brom.
Sunderland are all too aware of Brunt's quality - the midfielder has turned out two man-of-the-match performances against the Black Cats as well as scoring in the 3-0 defeat at the Hawthorns back in April 2009.
James Morrison
The former Middlesbrough man is the Baggies' longest serving player, making 161 appearances since joining from Teesside back in 2007 – a week before Brunt.
Morrison, who, despite rising through England's youth teams, chose to be a full international for Scotland, showed his versatility during his first season at The Hawthorns with a string of sparkling displays across the midfield.
And, those displays have continued throughout his time with West Brom and he was runner-up in the Baggies' Player of the Year award for the 2008-09 season.
Morrison scored in both fixtures between the two sides in the 2011-12 season – scoring the second in the Baggies' 4-0 win at the Hawthorns and West Brom's first as Sunderland came from two behind to draw 2-2 back in October 2011.
Romelu Lukaku
The on-loan Chelsea starlet has made a huge impact on West Brom's success under Steve Clarke; with ten goals in 24 games the Belgian international has proved an instant hit with the Baggies fans.
It's hard to believe that Lukaku, who made his professional debut for Anderlecht a week after turning 16, is still only 19.
And, it was as an 18-year-old that Lukaku made a reported £13m move to Stamford Bridge, signing a five-year contract.
First-team opportunities were limited for the 6'3" Belgian in his first year in London, prompting West Brom to take him on loan for the 2012-13 campaign.
He became Albion's youngest ever scorer when he scored in the Baggies' 3-0 victory over Liverpool on the opening day of the 2012-13 season.


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OHO – Free to Flee
October 9th, 2011
"Free to Flee" is new from French group OHO. The excellent track navigates a lane between classic French pop/electro (think Air) and more modern beat-driven music (Ratatat, Bonobo, etc) and is framed by a great Nouvelle Vague-esque female vocal. Result. OHO – Free to Flee OHO (Official) (Facebook) Rating 8.5


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IDC says European consumers are shunning ultrabooks
Intel's marketing millions are not doing the trick
INDUSTRY WATCHER IDC reports that ultrabooks are being shunned by European consumers despite Intel's marketing spending.
Intel has set aside $300m to market ultrabooks that have svelt designs and promise all day battery life, two factors that should make the units popular with punters. However IDC says that consumers are shunning ultrabooks, favouring smartphones and tablets instead of buying ultrabooks that look very much like four year old Apple Macbook Air laptops.
IDC wasn't very keen on ultrabooks, saying that the market is sensitive to prices - meaning that vendors will have to cut prices to tempt punters. The firm said the impending launch of Microsoft's Windows 8 will see OEMs push revamped ultrabook designs.
Intel's ultrabook drive isn't all about marketing, with the firm championing with its own money the use of solid-state drives and better screens in laptops. Even with Intel's millions spent, the biggest problem is that companies such as Dell, with its impressive XPS 13 ultrabook, simply cannot undercut the equally impressive Macbook Air.
Previously NPD said that ultrabooks were gaining popularity in the US premium laptop market, accounting for 15 per cent of laptops sold that cost more than $700. However it seems that IDC's European data suggests that laptop makers are not enjoying the same sort of success across the Atlantic. µ
INQ Latest
Snoopers' Charter: Open Rights Group pushes for post-Brexit postponement
A country with no prime minister should probably pause plans
Chrome bug makes film and TV piracy easy
Bad news for Hollywood, good news for GoT fans
Windows 10 Build 14372 brings Evernote extension to Microsoft Edge
Yep, there's another one
Microsoft to stop making Surface 3 range as it looks to Surface 5
Expect a successor in early 2017


text:
A year ago today:
Internal Rhode Island Economic Development Corporation documents released to The Providence Journal give no indication whether agency executives heeded an employee's warnings about loaning money to video-game company 38 Studios.
5 years ago today:
The National Weather Service confirms a small tornado tore through Rhode Island and Southeastern Massachusetts two days ago.
25 years ago today:
State Rep. John M. Skeffington Jr. supports gun shop owner Donn DiBiasio, who shot and killed Wayne Costa after Costa smashed a car into the front door of D-B Guns and D & B Electronics in Providence. DiBiasio was then charged with murder. "I am just outraged that Mr. DiBiasio is being charged for protecting his business and his life," Skeffington said.
Location, ST | website.com


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| Hi, my name is Kyle Willis.
I am a self taught multi-media artist with zero formal art education. I am constantly inspired by geek culture and I am infatuated with all things nerdy.
I dabble in digital media, and can create logos and concept designs, but my heart is deeply rooted in portraiture. I offer my skills to original commissions, I also sell prints, original paintings and illustrations as well as puzzles and other oddities. In my gallery you will find some examples of my work.
Thank you for taking the time to look through my artwork and my website, don't hesitate to contact me if you are interested in commissioning me or have a project you want to see if we can work together to create. I am always open to trying new things.


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The Little Book of Merida Doors
Ralf Hollmann
A small collection of doors from the city of Merida, Yucatan, Mexico!
Freelance Writer
Comment posted.
elmaloso says
Thank you Janet!
posted at 10:20AM Aug 02 PST
JanetSpaun says
How nice to see someone else appreciates old doors. They are great . Janet
posted at 08:36AM Aug 02 PST
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or create an account to post a comment.
The Uayalceh Hacienda
A Henequen Plantation in Ruins
Published February 05, 2012
The Little Book of
Chunkanaan Cenotes
Published August 02, 2011
Blurb Sites


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Ellen DeGeneres Loves Your Pets! She Is Offering You Free Halo Pet Food!
Animal advocate (and Halo, Purely for Pets co-owner) Ellen DeGeneres says "If you love your animals as much as I love mine, you'll feed them Halo!" Now you can get your first can for FREE! What's better than that? Halo, Purely for Pets' mission is to provide pet parents and their pets with honest information and wholesome products to better the lives of animals and the people who love them. Halo is committed to creating the healthiest and highest all natural quality pet food!
The Halo Pet Foundation's mission is to enhance the well-being of pets and the people who love them. Inspired by their love for animals, they reach out to educate people on responsible pet ownership, eliminating animal abuse and reducing the overpopulation of uncared for pets. And that's something we all can bark about!
Ellen DeGeneres' movie, Shelter Me, raises donations to shelter pets in need! The film follows the journey of two stray dogs, from the day they are picked up on the streets and brought to the shelter until the day they became a beloved family pet. It also focuses on a women's prison where inmates train shelter dogs to become service animals for people with disabilities, and shelter pets that are helping returning war veterans cope with PTSD. The main theme of this public awareness movie is to encourage society to adopt the remaining nearly four million dogs and cats that are euthanized every year in the United States.
Halo is also the sponsor of Freekibble.com, a pet related trivia site that has donated more 7.6 million meals to shelter pets. Halo became the official sponsor of Freekibble.com and Freekibblekat.com in August 2010. Created in 2008 by 14-year-old Mimi Ausland when she was just 11 years old. By simply answering the daily trivia questions on Freekibble.com or Freekibblekat.com, right or wrong, 10 pieces of kibble are donated to homeless dogs and cats!
Pick up your free Halo, Purely For Pets Furtastic Finds Giveaway, a free can of pet food courtesy of Ellen DeGeneres by clicking on this link: http://www.halopets.com/coupon/
For more information visit: www.halopets.com
For the Best that Pet Lifestyle and Animal Welfare has to offer follow Wendy Diamond on Facebook, Twitter, and right here at AnimalFair.com!


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- Watch This video
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This gallery contains images of unsafe sex practices, also known as barebacking. Engaging in sexual practices without the use of a condom is a risky and unnecessary behavior. There are a lot of studios including the one listed on this page that film bareback or have bareback scenes in their content libraries. The images presented below should only be used for fantasy and you should not deceive yourself into thinking that "everyone is doing it." Further, you should not assume that just because you see photos or film content of barebacking that sexually transmitted diseases have been miraculously cured. HIV and other sexually transmitted diseases are very real and potentially lethal. Please practice safe sex in your own life and educate yourself regarding the dangers of not wearing a condom before having sexual encounters. Visit AMFAR for more information about safer sex.
There are 14 comments on this gallery
DraperSeptember 24, 2011 - 09:50:12 | See all My Comments
Mmmm, sexy uninhibited fluid sharing
allied8May 08, 2011 - 13:44:02 | See all My Comments
Prefer Nash as a bottom getting his tight ass stuffed full of dick.
JiminOrlandoJanuary 02, 2010 - 16:15:29 | See all My Comments
Nash is THE hottest man in porn right now!
freedieselDecember 30, 2009 - 16:05:24 | See all My Comments
Some powerful stuff going on there!
CuriousTopDecember 29, 2009 - 16:12:39 | See all My Comments
LANSING. . .I LOVE YOU!!!! Well. . .at least I seriously lust after you!! I have been a member of ChaosMen for about 3 months now. This is ONE HOT WEBSITE and more than worth the $$. The guys are hot, fresh, and really seem to enjoy the sex. I can not say enough about this site and the hot guys. . .Lansing is my favorite by far, but there is someone here for everyone. Lansing. . if you are reasing this. ..MARRY ME !!
Luv_TrailDecember 28, 2009 - 18:21:44 | See all My Comments
MaraisMecDecember 28, 2009 - 14:31:11 | See all My Comments
Both guys are uber-hot...
Nash IS perfection... a god among men.
fordboyDecember 28, 2009 - 04:42:18 | See all My Comments
nash is easily the hottest guy on at cm - he's vers, built, and HAIRY !!
lansing is just getting hotter and hotter - looove seeing him btm raw - HOT
afterhoursDecember 27, 2009 - 17:22:40 | See all My Comments
Aw ...this is so hot I want to be fucked HARD by that man!!!
hotmestizoDecember 27, 2009 - 10:06:31 | See all My Comments
what i wanted to see is someone who can really rip and fucked harder like a real manly man Lansing's very hungry hole 'till he begs to STOP and cum like there's no tomorrow. Lansing baby you are just fucking HOT! keep up the good work.
CroynanDecember 26, 2009 - 07:37:22 | See all My Comments
has nash been ill? he looks terrible. maybe he celebrated too much during the holidays.
watersign69December 26, 2009 - 06:55:00 | See all My Comments
Nash in anything and I want to see it.
More please.
wizardoDecember 26, 2009 - 06:15:45 | See all My Comments
Very nice. But I greatly prefer Nash as a bottom.
RicanKicksDecember 26, 2009 - 05:47:14 | See all My Comments
Damn!! just looking at his pix i can feel him inside me lmfao wtf!! damnn i wanna fuck tha bottom too
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Live music for Newcastle match
- 17 August 2013 18:04
- Posted by @porter_mcfc
Popstar Cleo Higgins will be performing a special rendition of Blue Moon live on the pitch before City face Newcastle on Monday night.
The Voice star will be giving a new twist to the terrace classic as we prepare for kick off in the opening game of the season.
There will be more live music on stage in BT City Square from Hunter and the Bear, who will be getting you in the mood pre-match.
Plenty more is on offer in BT City Square, featuring special guests Shaun Goater, Paul Dickov and Uwe Rosler who will all be answering questions on stage.
Former Arsenal and Scotland keeper Bob Wilson will also be there pre-match to share memories of Bert Trautmann, as part of the club's tribute to the City legend.
As well as all that, the City playmakers are back and there are some great competitions on offer for you to win fantastic prizes.
So make sure you get down early to enjoy everything on offer ahead of the big match!


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The five Democratic candidates who square off in Tuesday's primary for attorney general all promise to take a hard line on public corruption, help prevent another Wall Street meltdown and protect the rights and welfare of average New Yorkers.
The office, with some 700 lawyers, defends the state in lawsuits, protects consumers, files civil suits, monitors charities and sometimes conducts investigations and prosecutions.
The five are former insurance superintendent and assistant attorney general Eric Dinallo, Assemblyman Richard Brodsky, former federal prosecutor and trial attorney Sean Coffey, Nassau County District Attorney Kathleen Rice, and state Sen. Eric Schneiderman.
The winner faces Staten Island District Attorney Dan Donovan, the Republican candidate, on Nov. 2.
Democratic Attorney General Andrew Cuomo, like his predecessor Eliot Spitzer, gathered headlines in major investigations and settlements and launched a bid for governor.
Rice, 45, from Locust Valley, now in her second term, has reported the most campaign donations and appeared to have the quiet support of gubernatorial front-runner Cuomo, who hasn't formally endorsed anyone. She has said her first initiative would be a legislative push to give the attorney general's office primary jurisdiction in public corruption cases.
Dinallo, 47, from Manhattan, headed the attorney general's Investor Protection Bureau that developed the strategy under Spitzer to use New York's anti-fraud Martin Act to go after big financial companies and force large settlements. He plans to ask the next governor to grant a broad mandate for investigating public officials.
Coffey, 54, a former naval aviator and assistant U.S. attorney from Westchester County, has won major shareholder settlements from failed telecommunications giant WorldCom and from JPMorgan.
Brodsky, 64, from Westchester County, said he's spent years as a legislator facing down powerful interests like the Metropolitan Transportation Administration and the New York Yankees and promised to continue as the state's top lawyer on behalf of average New Yorkers. He's giving up his Assembly seat.
Schneiderman, from Manhattan, is giving up his legislative seat after 12 years to run. He led the investigation this year that forced the expulsion of Sen. Hiram Monserrate, a fellow Democrat convicted of misdemeanor assault in a domestic incident. He has promised to create an elite unit to force reforms in the consumer debt and mortgage markets.
By MICHAEL VIRTANEN,Associated Press Writer
Copyright 2010 The Associated Press.


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Virus Clean Up Using Panda Rescue USB Drive
No matter how many precautions one takes, the only given is that at some point everyone will be affected by malware (a virus). The only way you can prevent being infected is to never connect your computer to the internet and never open any file on your computer. The reality is that not being connected to the internet or never open any files, pretty much eliminates the need for a computer, So knowing that at some point you will be cleaning your pc, should mean that you need to prepare yourself.
One of the items in my bag of tricks to clean malware is the Panda Rescue USB Drive. The problem with doing malware clean up is that some of the malware files created trick Windows into thinking they are important, so when you go and try delete the offending malware you get a message that says "Unable to delete – File is in use". The benefit of using tools like the Panda Rescue USB drive is that the tool checks your computer without actually booting into Windows, so that any offending file can be successfully removed.
Panda has posted instructions on creating and using the Panda Rescue USB drive on their Panda Security page.
I highly recommend creating one of these Rescue Drives and keep it handy just in case.
Source: Panda Security – How to disinfect viruses with Panda Rescue USB drive (http://www NULL.pandasecurityusa NULL.com/support/cards/1678/)


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Where did the time go? This Sunday is already "The Walking Dead" Season 4 finale! On Wednesday, March 26, Reddit posted spoilers for the upcoming finale, episode 16 "A," and it looks like the TV show will be following the comics. Spoilers are ahead if you are not caught up to "The Walking Dead" or wish to not know anything that's to come.
The official synopsis for episode 16 is, "Many paths collide; Rick faces sheer brutality; the group struggles to survive." At first, this synopsis told us close to nothing, but now we can easily break it down to spoilers.
The many paths that will be colliding are obviously all of the groups that have been making their way to Terminus. For sure, Rick and Daryl's group will be meeting – and the results won't be pretty. Check out spoilers and images for that here. There haven't been any trailers or images leaked that reveal any of the other groups seeing each other. But it can't just be Rick and Daryl's, since the synopsis says "many."
Second, the group will struggle to survive because Terminus is not what they thought it would be – this comes as no surprise to us fans. However, the much speculated cannibal theory remains to be seen. One thing is for sure though, it won't be a warm welcome. Check here for more spoilers on that.
Lastly, and here is the major spoiler, "Rick faces sheer brutality," things are gonna get ugly. According to the source, one of the guys from Daryl's group is going to harass Carl, as in sexually harass. I know, this could be the reason the rumors of AMC being afraid of the second half could be about. In the comics, Carl is harassed by one of the guys. Fortunately, Rick saves him in time [self-explanatory what the guy was trying to do to Carl]. Rick is not at all happy. What does he do? Rips out the guy's throat…with his teeth!
Not sure if they will show all of that on the TV show, but this forum has photos of a guy holding Carl at knife point and another photo of Rick's mouth and face covered in blood. Check out the conversation for that here.
The final episode of "The Walking Dead" Season 4, episode 16 "A," airs Sunday, March 30 on AMC. Like us on Facebook and follow us on Twitter to catch the latest spoilers on your newsfeed!
Some great Twitter accounts to follow for everything 'The Walking Dead':
For more "The Walking Dead" check out:
- More spoilers for Season 4 finale 'A'
- Robert Kirkman's spoiler teases: Beth and Cliffhanger
- 'The Walking Dead' spoilers: Two important deaths coming!
- 10 spoilers for "The Walking Dead" back-half of Season 4
- 'The Walking Dead': Why is AMC worried about second half?
- Season 4 spoilers: Episode 9 – 16 titles and synopses
- Morgan to return this Season 4?
©Sandra Perez, All Rights Reserved. No part of this article may be reproduced without prior permissions from the author and proper credit. A piece of the article may be reproduced with proper credit and link back


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Rated 4.3 out of 5 by 4 reviewers.
Rated 5 out of 5 by LaLaG I love it!! This rug does not look or feel like recycled plastic bottles. It feels like a good quality wool! The colors are true to the picture. It's easy to clean, resists stains, and just looks great. It's the perfect size to anchor two gliders and 1 chaise on my screened porch. I wish it came bigger than 8x10 for my bedroom! It has gotten wet in storms several times since I put it out and seems no worse for it. Dries quickly, unlike a lot of the natural fiber rugs like jute or sisal. August 4, 2014
Rated 5 out of 5 by Fifi Beautiful rug! This is an excellent quality indoo/outdoor rug with an eclectic appearance. Vivid colors, that go with most anything! I LOVE it, although the first time it gets rained on I may cry! LOL! It will hold up very well. I couldn't be more thrilled! April 24, 2014
Rated 5 out of 5 by adjectivebear Perfect This rug is absolutely lovely. The colors are vibrant, it feels wonderfully soft underfoot, and it's just so cool that it's made of recycled bottles, of all things--none of my guests believe it when I tell them! I do wish I could have found one a few feet larger so that my couch wouldn't be blocking so much of the view (by necessity--I bought it so the feet of the couch wouldn't damage my floor), but that's really neither here nor there. I may just have to get some felt pads to put under the couch so I can see more of my beautiful rug! March 17, 2014
Rated 2 out of 5 by Lucinda Poorly made rug I bought the 5x8 size. The tassels aren't attached well and are coming off and one was missing when we unwrapped it. There are pulls in the weave also. I loved the fact that it's made of recycled material but am very disappointed in the quality of this rug and wouldn't recommend it to anyone. We don't wear shoes in the house and have tried not to step on the tassels so that isn't the reason they are coming off. April 9, 2014
1-4 of 4


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The Panthers had the opportunities, but when the game was on the line, the Cardiac Cats once again couldn't convert.
"It was a misunderstanding," Panthers QB Cam Newton said of their failed fourth quarter comeback. "One of the receivers didn't run the right route, but it is still my job to fix it. You know, I'm not here to point the finger, or I'm not here to bash myself, but that is just unacceptable. It shouldn't have even been fourth down. I think I could have scored on a lot of them. It was an excellent play call by coach on the naked, and I just have to make that throw. It's professional football, and you have to hit open targets, wide-open targets when the opportunity presents itself."
When asked about the team's overall trouble in the red zone, Newton didn't know right off hand how to fix the Panthers' problems.
"I don't know," Newton said. "Really, I don't know. It hurts leaving the field with three points. I think it is self-inflicted. Whether it is a penalty, whether it is a bad decision, you just have to get it right, and we are going to get it right. I'm not the person to sit up here and say 'well, we have next time.' I want to get it right, and I'm going to get it right right now."


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The Feed
By Stephanie March
Foodie File
By Dara Moskowitz Grumdahl
The Host
Harvest Beer Festival
Mpls.St.Paul Event
Restaurant Week
Party Patrol
By Parties Editors
The Morning After
By Tad Simons
Arts Off The Cuff
by Arts & Nightlife Editors
Ali Shops
By Allison Kaplan
ASID MN Showcase Home
Exceptional Properties
By Edina Realty
Super Real Estate Agents
Super Mortgage Professionals
Outstanding Nurses
Fit Fest
The FAM
The FAM Editors
Featured Promotion
Prep Schools
Aisle File
By Emily Howald Sefton
Real Brides
By Real Brides-to-Be
Diamond Awards
Introducing: RC's BBQ at the MN State Fair
By: Stephanie March | Posted: 11/26/2013
Does your neck feel sore from the whip lash? It's a bummer to report this, but it looks like UMAMI, the West Broadway dim sum shop, will close by the end of the year.
The Asian concept from the Travail boys was originally created as a pop-up. It was supposed to be open for about a month to earn a little extra cash while the guys were working on building out their new Travail/Rookery digs. Initial ticket offerings sold out like hotcakes. Not soon after, the Travail Kickstarter Phenomenon dialed everyone into a state of frenzy and the boys decided to use a little of the cash to keep Umami open as a real shop, albeit with a twist to the concept focusing it on dim sum.
But things haven't been going as they had hoped or planned. "It just really doesn't have legs for us right now" Mike Brown told me. "The way it was set up was meant to be temporary and right now to make it work means more time and energy than we have at this time." In truth, Brown said, it has started to jeopardize the Travail project and they just can't allow that to happen. They've just spread themselves too thin.
BUT ... he also said Umami will rise again, maybe not as an Asian concept, and definitely not in the back of a strip mall, "our whole mission is to open restaurants in spaces that we can someday own outright". But they want to come back to the neighborhood with something they have time to work through and plan, having worked at the Broadway Farmers Market, they've connected with enough of the neighborhood to know that they can create something that will work in the area.
As for all the guys who were hired for Umami, including Geoff Hausmann who left the helm of Sample Room to return to the fold, they will be absorbed into the Travail/Rookery project which is hot under way to debut in the New Year.
Umami will be open through brunch on Dec. 22, after which it will go dark for good. Tickets for the last few weeks are on sale now. Get your dumpling on.
Here is the official presser from the gang. UMAMIbyTravail1126pressrelease
Stephanie March is Mpls.St.Paul Magazine's food and dining editor. See bio
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- Screen Capture Utility (By Progency Software)
Screen Rip32 is a
program that allows you to easily cut and paste images from any
document. This can be used to capture charts and graphs from the
Executive Summary for use in your own custom reports or
we have used this program and not had any problems, please keep in
mind that this is freeware. The Survey of Organizational
Excellence does not support it, nor take responsibility for any
damage it may cause. Some options (such as printing) may be
nonfunctional or buggy. For more information on this software
or the company - visit www.progency.com
Screen Rip32
Screen Rip32 Help File
Screen Rip32 Zipped File
(includes both files)
Instructions for use: (see help file for
detailed instructions)
1. Open the Executive Summary PDF file.
2. Double Click the SRip32.exe file.
3. Select the "Capture Image" menu and Select "Grab
Rectangular Area".
The SRip window will disappear and your PDF file should appear.
5. Select the area which you wish to copy - a rectangular tool
will indicate the area you are copying.
The image will appear in the SRip32 window.
7. Use the Save options to create a
picture file in the desired format.
Survey Data
Benchmarks Promoting
Excellence Celebrating
Online Resources
Other Services Contact Us
Survey of Organizational
Excellence Home Page
Resources Home
Last Update: February 28, 2002
Questions and comments to: firstname.lastname@example.com
School of Social
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Copyright © Survey of
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Sports Medicine
Children's Hospital Colorado: Real Colorado Soccer's Preferred Healthcare Provider
Children's Hospital Colorado and Real Colorado Soccer formed a partnership to promote the health and wellness of the entire Real Colorado community.
The links below will guide you to all that Children's Hospital Colorado has to offer to Real families, from a certified athletic trainer, to injury and weather guidelines and more.
Injury Database
Common Soccer Injuries and Conditions
Sports Medicine Resources for soccer players, parents and coaches
- Sports Medicine Resources for soccer players, parents and coaches
- Urgent Care vs. Emergency Room Guide
Emergency Action Plans
Weather Guidelines – These guidelines are recommendations specifically related to training sessions when officials are not present. As weather conditions can vary from area to area, it is up to the coaches and referees to make best case decisions to whether matches should be postponed, delayed or played.
Concussion Guidelines
Hydration and Young Athletes


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Middle Eastern Lamb Stew
This brothy stew is boldly flavored with a blend of characteristic Middle Eastern spices and finished with fresh spinach and fiber-rich chickpeas. Economical lamb shoulder tenderizes beautifully when leisurely cooked in a slow cooker. If you can't find boneless shoulder stew meat, do not substitute more-expensive lamb leg—it tends to dry out during slow cooking. Instead, purchase lamb shoulder chops and debone them. Serve over bulgur and accompany with a salad.Yield: 8 servings, about 1 cup each
Active Time: 40
Total Time: 255
- 1 1/2 pounds boneless lamb stew meat, (shoulder cut) or 2 1/2 pounds lamb shoulder chops, deboned, trimmed and cut into 1-inch chunks
- 1 tablespoon olive oil, or canola oil
- 4 teaspoons ground cumin
- 1 tablespoon ground coriander
- 1/4 teaspoon cayenne pepper
- 1/4 teaspoon salt
- Freshly ground pepper, to taste
- 1 large or 2 medium onions, chopped
- 1 28-ounce can diced tomatoes
- 3/4 cup reduced-sodium chicken broth
- 4 cloves garlic, minced
- 1 15- or 19-ounce can chickpeas, rinsed
- 6 ounces baby spinach
- Place lamb in a 4-quart or larger slow cooker. Mix oil, cumin, coriander, cayenne, salt and pepper in a small bowl. Coat the lamb with the spice paste and toss to coat well. Top with onion.
- Bring tomatoes, broth and garlic to a simmer in a medium saucepan over medium-high heat. Pour over the lamb and onion. Cover and cook until the lamb is very tender, 3 to 3 1/2 hours on high or 5 1/2 to 6 hours on low.
- Skim or blot any visible fat from the surface of the stew. Mash 1/2 cup chickpeas with a fork in a small bowl. Stir the mashed and whole chickpeas into the stew, along with spinach. Cover and cook on high until the spinach is wilted, about 5 minutes.
Tips & Notes
- Make Ahead Tip: Prepare the stew, omitting the spinach, cover and refrigerate for up to 2 days or freeze for up to 4 months. Add spinach after the stew is reheated. | Prep ahead: Trim lamb and coat with spice mixture. Chop onions. Combine broth, tomatoes and garlic. Refrigerate in separate covered containers for up to 1 day.
- For easy cleanup, try a slow-cooker liner. These heat-resistant, disposable liners fit neatly inside the insert and help prevent food from sticking to the bottom and sides of your slow cooker.
Nutrition Per Serving
|15 g (5 g sat, 6 g mono)
|92 mg
|15 g
|30 g
|5 g
|494 mg
|238 mg
Nutrition Bonus Vitamin C (30% daily value), Vitamin A (25% dv), Iron (20% dv).
Carbohydrate Serving 1
Exchanges 1/2 starch, 1 vegetable, 3 lean meat
From EatingWell January/February 2008


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Buy The DVD
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Microtransactions if you're not familiar with them are items (skills, buffs, gear, toys, etc.) that can be purchased inside a game. Most give an advantage of some type over players that only use the 'free' items.
World of Warcraft has a subscription based system with a modified microtransaction system. You can purchase pets to play with inside the game but actual gear that can help you become better, stronger and faster is not directly available. (Before you say it, yes I know there are mounts and other items that can be purchased that technically can enhance your gameplay).
I have been a member of Facebook for about 5 years now. And up to now I've never spent a penny on games such as Farmville, Cookville, Monkeyville and others. It boggled my mind just why someone would pay good hard earned money for a completely fake item. Even in Warcraft you could find ways of spending hard earned greenbacks to obtain gold. (Hopefully if you have read any of these entries that are on this site then you never ever have to buy from a gold vendor again).
But recently I've had a slight change of perspective. The one thing that has made me hesitant to spend my hard earned Georges (I have other names for them) is that I spend 15 dollars a month just to get access to a game. The idea of opening up a game to let the rich become more powerful and the less fortunate end up having to work twice to three times as hard to get there.
My suggestion that if a micro transaction system is created and the free to play system implemented by Blizzard is that there be a cap on the amount of real money able to be spent. I expect that soon (perhaps next year) that there will be a rise in the subscription cost to play World of Warcraft. If a hard cap of 20 dollars real money is placed on what can be purchased for any account it keeps the playing field even, but still allows players a lot more diversity on what they purchase.
Warcraft has a large fan base that stays loyal to the brand even through the large amount of 'WOW Killers' that take their shot at the King. So a conversion to a micro transaction system can generate the same revenue and still allow players to continue to play in Azeroth.
Good Luck and Good Hunting
The New Face of Opportunity
Bring Out Your Pets
Bring On The Next Wow Killer
The Value of Material Assets
PVP Sales Are Not Kind To Me
Finding A New Ryhthm
Breaking The Million Gold Barrier
Bye Bye... I Will Take Your Gold Now
Post Patch 5.3: The Lineup
Patch 5.3: It's here... well tomorrow
Patch 5.3: Preparing for the Arrival
Patch 5.3: Grasspicking World Order
Patch 5.3: Bring Out Your Miners
Enchanting add-on for quick flips
Prepping for 5.3: Profit lines


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Unique invitations and announcements with personal service
my list
800.421.9521 facebook
Naptime Productions Sinatra 40th wedding anniversary party invitation is personalized with your custom wording and monogram placed behind your text to create simple elegance. We can print for any year.Coordinating rsvp card, thank you note, save the date card and sharing (memory) enclosure card.Personalized with Garamond Antiqua/Berthold Script typestyle on 80 lb. ivory card stock and includes an ivory envelope.Custom printing in English, Spanish, French or Italian. Proof is highly recommended for foreign languages.Optional return address printing available. Request during ordering process.
It's All Custom!


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Program Name: OST to PST Freeware
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text:
- Products
- Company
- Technical Data
- Dealer Locator
- Promotional Products
Spectro® Oils is one of the world's foremost manufacturers and packagers of premium – quality lubricants.
Our products are engineered to provide the highest levels of performance across the full range of full-synthetic, semi-synthetic and petroleum lubricants for all types of power-sports engines and transmissions. Spectro® provides unsurpassed strength and endurance to protect your engine against wear and tear.
The Spectro® line also includes superior suspension fluids, fork oils, brake fluids, coolant, chain lubes, filter cleaners/oils, and appearance products.
We've added some new features to the site; these include an updated "dealer locator", photo galleries and a customer Q&A section.
COMING SOON: Spectro Lubricant Consultant.
These elements were added to provide our visitors with an extremely user-friendly environment, one that enables Spectro® to supply detailed and helpful information across more topics, more often.
Spectro Performance Oils – Engineered Excellence!


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Bachmann Says Romney an Easy Choice vs. Obama
Portsmouth, Va.
Michele Bachmann proclaimed her support for Mitt Romney at a campaign stop here, endorsing her onetime rival in the Republican primaries despite some harsh criticism earlier in the race.
Mrs. Bachmann said she will "lend my voice and my endorsement to Mitt Romney as our president and take the country back." She added: "I think for all of America, this is a very simple proposition this November — President Barack Obama, President Mitt Romney. You decide. Very easy."
Back in January, Mrs. Bachmann had said that she didn't think Mr. Romney could beat Mr. Obama. The tea-party favorite ended her own campaign after she placed sixth in the Iowa caucuses.
Many of Mr. Romney's challengers have taken their time endorsing the presumptive GOP candidate. On Wednesday, another primary challenger, Newt Gingrich, dropped out the race officially but didn't endorse Mr. Romney.
The congresswoman wooed supporters last year with her willingness to go on the attack and stake out a clear space on the right. Those same attributes often limited her wider appeal.
Danny Yadron contributed to this article.


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My name is Michael Locke, instructor, designer, brand developer and creative leader specializing in all areas of the web. I have over 15 years of web design experience with high proficiency in front-end web development (XHTML/CSS), UI/UX design, brand development, internet marketing, social media marketing, video marketing, photography, SEO concepts and traditional print design among other things.
I currently work for ADP as a Lead UX Designer. Prior to ADP, I worked for CBS Interactive, Yahoo!, FOX, Cars.com and Thomson Reuters. In addition to my full-time career, I teach web design through my weekly video blogs and my online web design training course. I have a huge passion for helping people succeed. I believe with the right training and direction, I can help people reach their dream of having a long and successful web design career. A career in web design is one of the best ever and its a passion of mine to help people experience what I live everyday.
Browse around my site, take a peek at my portfolio, watch my videos and get inspired! And don't hesitate to contact me if you have any questions.
~ Mike


text:
In Stock
You Save $314.03
item#: 429635
Questions? Call us 866-740-9830
Phone Code: N/A
Increase your storage options with the BBF Series A 42"W Corner Hutch. A perfect fit for the 42"W Corner Desk, this convenient Hutch offers open storage with two fixed shelves and four adjustable shelves. The perfect accompaniment for desktop privacy, the 42"W Hutch provides extra storage where you need it. This desktop option fits perfectly in a small space or in a collaborative office with a fully finished interior and back panel. Solid construction meets ANSI/BIFMA test standards in place at time of manufacture; this product is American Made and is backed by BBF 10-Year Warranty.
|Series A
This consumer rating is based on 58 reviews of all BBF products. The Bush BBF Series A 42W Corner Hutch in Hansen Cherry has not yet been reviewed, be the first!


text:
Available for Adoption:
4 Years
American Staffordshire
Pet ID Number: C25768
How to adopt
All pets over 12 weeks are spayed or neutered.
We give a free spay/neuter certificate to those adopting kittens or puppies.
| Emerald is a calm, gentle girl who is crate trained. She is truly a gem.
EMERALD has received monthly sponsorship care from loving donors. Zack, Jennifer, Aniston, Audrey and Hank Woods are sponsoring EMERALD. Thank you, Zack, Jennifer, Aniston, Audrey and Hank for your loving support!