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Published: August 2010
Crystal-induced arthropathies are a group of disorders that involve deposition of crystals into joints and soft tissues, resulting in articular and periarticular inflammation and injury. Examples of such crystals are monosodium urate (MSU), calcium pyrophosphate dehydrate (CPPD), hydroxyapatite, and calcium oxalate. The crystals most commonly involved in joint inflammation and seen in synovial fluid analysis are the MSU crystals involved in gout and the CPPD crystals involved in pseudogout.
Gout is a crystal deposition disease characterized by the supersaturation and precipitation of MSU crystals in tissues resulting in inflammation and, consequently, tissue damage. Gout is characterized by acute or subacute attacks of joint or soft tissue inflammation resulting from MSU crystal deposition. The clinical course of gout can be summarized into the stages of acute intermittent gout and chronic tophaceous gout.
Hyperuricemia is the underlying metabolic aberrancy in gout and is defined as the serum urate level, in body fluids, above which urate precipitates into monosodium urate crystals. A urate level greater than 6.8 mg/dL is considered hyperuricemia.
Gout is a fairly common disease, more common in men than women, and rare in premenopausal women. There have been few studies on the incidence or prevalence of gout and even fewer on CPPD arthropathy. In a population of medical students with a median age of 22 years, the cumulative incidence of gout was reported as 8.6%.1 In this same study, body mass index (relative risk [RR], 1.12), excessive weight gain (RR, 2.07), and hypertension (RR, 3.26) were identified as risk factors for developing gout.1
Overall, the prevalence of gout in the U.S. population increased between 1990 and 1999,2 and factors such as lifestyle habits, obesity, diet, alcohol intake, comorbid diseases such as hypertension, and the use of diuretics were identified as potential contributing factors.3 A study done in the United Kingdom, examining the epidemiology of gout, reported the prevalence of gout to be 1.4% in 1999 and as high as 7% in men older than 65 years.4 Reviews have found that epidemiologic investigations suggest that incidence of gout is on the rise worldwide.5
The annual incidence of gouty arthritis is about 5% at serum urate levels of 9.0 mg/dL or higher and less than 1% at urate levels of 7 mg/dL and lower.6
Gout is an inflammatory crystal arthropathy that results from the pathogenic effect of MSU crystals in the joints and soft tissue. Uric acid in body fluid, at pH 7.4, exists in the urate form. Thus, when referring to uric acid in physiologic fluid it is preferable to use the term urate.
Uric acid comes from the metabolism of purine nucleotides. Purine metabolism leads to inosine then hypoxanthine. Hypoxanthine is metabolized to xanthine and xanthine to uric acid. These two last steps are catalyzed by the enzyme xanthine oxidase, which is the major site for pharmacologic intervention by allopurinol. Uric acid, in humans, is the final product. Human beings lack the ability to degrade urate further.7
Minimal amounts of urate are eliminated through the urinary and intestinal tracts. Therefore, when the human body is unable to eliminate large burdens of urate, hyperuricemia develops. As urate levels increase and saturate the synovial fluid or soft tissues, crystals precipitate, leading to tissue damage and the development of tophi. After urate crystals deposit in soft tissues and joints, monocytes and macrophages are activated in an attempt to clear the crystals by phagocytosis. This then leads to the release of proinflammatory cytokines and chemokines into the surrounding area, triggering a cascade of acute inflammatory reaction and influx of neutrophils into the joint, for example.7,8
The mechanism leading to the self-limited inflammatory process is not fully unveiled. The innate anti-inflammatory processes, mediated by anti-inflammatory cytokines, possibly are called into action and interrupt the inflammatory process.8 Thus, the natural course of gout is one that would resolve spontaneously in 1 to 2 weeks on average.7
An additional proposed mechanism has been elucidated in research work indicating the role of an inflammasome and interleukin 1 (IL-1) in the pathogenesis of inflammation induced by monosodium urate (the crystal in gout) and calcium pyrophosphate dehydrate (the crystal in pseudogout). Cryopyrin inflammasome detects MSU and CPPD crystals, resulting in an inflammatory cascade by activation of IL-1.9 These IL-1–mediated inflammatory effects of MSU crystals could potentially be blocked by IL-1 inhibitors, such as anakinra. This presents opportunities for the management of patients with gouty arthritis who are otherwise intolerant of or inadequate responders to standard anti-inflammatory therapies. Large randomized, controlled trials are required to assess the benefit and safety of blocking IL-1 in the management of polyarticular gouty arthritis.
The cascade of pathologic events leads to acute inflammation of the joint or soft tissue. The clinical manifestations of gout include arthritis, direct soft tissue damage, and accumulation of MSU crystals, known as tophi, in soft tissue and bones. Hyperuricemia can also result in uric acid nephrolithiasis and possible nephropathy if uric acid accumulates in the renal interstitium and tubules.
The arthritis in acute gout usually manifests as asymmetric monoarticular or oligoarticular inflammation, lasts 3 to 10 days, and resolves spontaneously. Eventually the attacks occur more frequently, last longer, and do not resolve completely, leading to chronic gouty arthropathy. Gouty arthropathy can lead to erosions and joint destruction, but it is distinguished from rheumatoid arthritis by the absence of joint space narrowing and absence of periarticular osteopenia.
In general, joints involved in gout include the lower extremity joints as well as those of the upper extremities. Inflammation in joints such as the first metatarsophalangeal (MTP) joints is termed podagra and is highly suggestive of gout. Any joint in the feet, ankles, knees, hands, wrists, or elbows may be involved. Acute gout can occur in bursae, such as the olecranon or prepatellar bursae, causing bursitis.
Occasionally, a gout attack triggers a systemic inflammatory response manifesting with fevers, leukocytosis, elevated sedimentation rates, and elevated C-reactive protein (CRP).
Acute attacks can be precipitated by several factors, such as increased alcohol consumption (especially beer), trauma, use of diuretics, dehydration, cyclosporine, diet (organ meat, shellfish), and any drug that can lead to sudden changes (increase or decrease) in urate levels, such as hypouricemic agents.10,11
When urate accumulates in a supersaturated medium, it can deposit in soft tissue or bones and form a tophus. Tophi can be present over the helices of the ears, extensor areas of the limbs, pressure areas such as the finger pads, and over the Achilles tendons. Occasionally, they are not seen on physical examination but are noted on x-ray films as cystic or masslike lesions. In general, a tophus on radiographic films is radiolucent, but when it occurs over a calcified nodule it may be seen as radioopaque.12
Synovial fluid analysis is the gold standard for diagnosis,and one should attempt a synovial aspiration for microscopic analysis whenever feasible.
Synovial fluid analysis offers a valuable diagnostic tool for evaluating patients with gout or pseudogout. Once the fluid is aspirated, it can be examined grossly for color and turbidity. In general, transparent synovial fluid in the syringe is more suggestive of a noninflammatory condition, whereas fluid that appears turbid or purulent is more suggestive of inflammation or infection (e.g., rheumatoid arthritis, gout, septic arthritis). However, gross appearance alone is by no means diagnostic.
To confirm or rule out infection, the fluid needs to be processed for Gram stain and culture. It is possible to have concomitant gout and septic arthritis at the same time. On microscopic examination, the number of white blood cells (WBCs) per high-power field can be estimated. The WBC count may be a useful adjunct in estimating the degree of inflammation present.13 With gout, synovial fluid analysis reveals leukocytosis, a nonspecific finding of inflammatory arthritis including infectious and crystalline causes.
Crystal analysis is done with compensated polarized light. An accurate diagnosis can be made by a trained observer by detecting and identifying MSU crystals or CPPD crystals.14
MSU crystals are birefringent, with strong negative elongation when viewed under compensated polarized light. CPPD crystals are weakly birefringent and rhomboid or rod shaped. CPPD crystals might not be as evident and thus possibly missed, especially if the analysis is not done by a trained examiner.13-15 In addition to shape and birefringence, MSU and CPPD differ in color depending on the axis of orientation with respect to the polarizer. When the axis of the MSU crystal is parallel to the polarizer it appears yellow, and when it is perpendicular it appears blue. The CPPD crystal is the reverse of that, so when the CPPD crystal is parallel it appears blue and when perpendicular it appears yellow (Table 1).13
|Needle-like, sharp edges
|Rhomboid, rod-like
|Color parallel to polarizer
|Color perpendicular to polarizer
CPPD, calcium pyrophosphate dehydrate; MSU, monosodium urate.
Urate levels are not helpful in the acute gouty attack because they fluctuate and may be normal, low, or elevated. In chronic gout, a urate level is helpful in determining hypouricemic therapy. Once a hypouricemic agent is started, the dose should be adjusted according to urate blood levels (see later).
Other blood tests, such as a complete blood count, a creatinine, and transaminases are useful for assessing contraindications to a drug, to evaluate for other comorbid diseases, and for monitoring drug toxicity after initiating therapy. For example, colchicine is not indicated if the patient has evidence of bone marrow suppression. If there is any evidence of renal insufficiency, therapy with uricosuric medications (such as probenecid or sulfinpyrazone) would not be effective because they require functional renal apparatus to excrete excess urate. In addition, the dose of allopurinol will have to be decreased, and colchicine should be avoided.
A 24-hour urine test for uric acid levels is necessary when considering a uricosuric agent, such as probenecid or sulfinpyrazone. Because results are partly affected by diet, it is best to repeat the test twice on two separate occasions. If the 24-hour urine levels are abnormally elevated, then uricosuric agents should not be used so as to avoid an increased risk of urate stones.
Changes of arthropathy take years to develop, but findings of erosions can appear sooner. Distributions of affected areas include most commonly the feet, ankles, hands, wrists, and elbows. Well-defined erosions with sclerotic margins and overhanging edges are classic in gout. Little or no joint space narrowing and no periarticular osteopenia can differentiate gout from rheumatoid arthritis.12
Once the diagnosis of gout has been made, other associated medical conditions need to be considered, such as alcoholism, the metabolic syndrome, myeloproliferative disorders, and possible medication triggers (diuretics, cyclosporine). Any comorbid disease should be appropriately managed as clinically indicated.
Differential diagnosis of monoarticular arthritis includes infection, pseudogout, atypical rheumatoid arthritis, trauma, and fracture. The differential diagnosis should be considered based on the history and clinical presentation. Thus, the best approach starts with a good history and physical examination. If the history and clinical examination do not indicate a history of trauma or fracture, then a synovial aspiration, as discussed earlier, is performed, rather than an x-ray of the joint.
Erosive gouty arthropathy can mimic rheumatoid arthritis or CPPD arthropathy. Often, patients with advanced gouty arthropathy, especially of the hands, are mistakenly treated for rheumatoid arthritis.
Treatment depends on the clinical presentation and findings. The aim in treating gout is to treat the acute attack, prevent future attacks, and prevent chronic joint and soft tissue mutilation from chronic tophaceous gouty arthropathy. As discussed earlier, gout is characterized by the acute or subacute attacks of joint or soft tissue inflammation resulting from deposit of MSU crystals. Hyperuricemia and gout may be divided into three stages: asymptomatic hyperuricemia, acute intermittent gout, and chronic tophaceous gout.
There are no sufficient data to support treatment of asymptomatic hyperuricemia with hypouricemic agents. In general, initiating such therapy in asymptomatic persons is not recommended, but one should consider investigating the underlying comorbid conditions and treating those conditions as clinically indicated.
The acute attack can be managed with colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroids (intra-articular injection or systemic). The choice of agent is dictated by the patient's tolerance of those medications and the presence of any comorbid diseases that prevent the use of such drugs. Younger, otherwise healthy patients who can tolerate NSAIDs or colchicine may be treated with either. NSAIDs should be avoided in patients who are intolerant of such drugs or in whom such drugs are contraindicated. NSAIDs are contraindicated in renal disease, insufficiency, or failure; gastrointestinal bleeding, ulcers, or gastritis; high risk of cardiovascular disease; and history of allergy to the drug. Occasionally, in an acute gouty attack, when all of these medications are contraindicated, narcotics may be used to relieve pain until the acute attack has resolved.
Although indomethacin has been traditionally used for acute gout, most other NSAIDs can be used as well. NSAIDs provide rapid symptomatic relief within the first 24 hours. Indomethacin can be given at a dose of 150 mg (in three divided doses) daily for the first 3 days then 100 mg (in two divided doses) for 4 to 7 days.16
NSAIDs should be avoided in patients who are intolerant of such medications or who have other comorbid conditions contraindicating their use. Avoid NSAIDs in patients at risk for gastrointestinal (GI) bleeding, GI intolerance, or gastropathy; renal failure; hepatic failure; congestive heart failure; asthma; or hypersensitivity to NSAIDs. Avoid NSAIDs in the third trimester of pregnancy.
Adverse effects of NSAIDs should be discussed with the patient. These include potential GI intolerance, GI bleeding,17 GI ulceration or perforation, nephrotoxicity, prolonged bleeding, fluid retention, risk of cardiovascular events, Stevens-Johnson syndrome, and others.
Colchicine originates from the autumn crocus plant; it works as an anti-inflammatory agent.18 Early on, colchicine blocks microtubule assembly in neutrophils, which attenuates phagocytosis and the transport of MSU crystals to the lysosome.6 Colchicine impedes the activation of neutrophils in the vicinity of MSU crystals by blocking the release of chemotactic factors, thus diminishing recruitment of polymorphonuclear leukocytes to the inflamed joint.18
Colchicine offers the best response when initiated within the first 48 hours of acute gout. Patients usually notice improvement within 48 hours of therapy. During acute gout, oral colchicine can be started at 0.6 mg three or four times daily (taken preferably every 8 hours or in doses separated by at least 1 hour) for 2 days, then decreased to twice daily. Colchicine should not be prescribed to be taken until diarrhea develops, because this will only add more ailment to the patient already suffering from marked pain. Once symptoms resolve, colchicine may be stopped. However, colchicine may be continued at a dose of 0.6 mg every 12 hours to prevent further attacks.
Intravenous colchicine should be used only by experienced rheumatologists and reserved for hospitalized patients, if absolutely necessary, who are unable to take oral colchicine. Caution must be used with dosing, which must not exceed 3 mg per dose. Intravenous colchicine carries a high risk of myelosuppression, can be caustic, and has been associated with fatalities.
Onset of action (pain relief) is 24 hours after the first oral dose. Colchicine requires dose adjustment with decreased renal function and should not be used in dialysis patients because it is not dialyzable.
Adverse effects of colchicine include diarrhea, abdominal cramping, bone marrow suppression, axon-loss neuropathy, myopathy (especially in renal insufficiency), potential liver toxicity, arrhythmia, shock, and skin rash (uncommon). Use caution in patients with biliary obstruction, hepatic failure, or renal insufficiency or end-stage renal disease and in pregnant women, neutropenic patients, and transplant patients on cyclosporine. Concomitant use of colchicine with cyclosporine can lead to rapid-onset myopathy and increased myelosuppression.16,18
It is best to consider steroids in the absence of concomitant infection. In the case of systemic infections or septic arthritis, steroids should be avoided if possible. Corticosteroids may be used locally as an injection or systemically (orally, intramuscularly, or intravenously). Corticosteroids are usually very effective, and response is noticed within 24 hours of beginning therapy.
Oral corticosteroids can be used in the form of a methylprednisolone pack or prednisone starting at 40 mg or less, with a gradually tapering dose.6,16,18 Systemic steroids are the preferred agents in patients with renal failure in whom NSAIDs and colchicine are contraindicated. Local steroid injections may be the best alternative route of administration in patients who are unable to tolerate systemic therapy with steroids, NSAIDs, or colchicine. Steroids, however, are not usually the first line of therapy because of their potential adverse effects such as hyperglycemia, gastrointestinal diseases, weight gain and fluid retention, muscle weakness, immune suppression, and long-term effects such as those on bone resorption. The potential adverse effects need to be considered when making the decision of treating acute gout.
The main goal of treatment is to decrease urate levels to less than the level of precipitation, which is 6.8 mg/dL. The therapeutic target level should be less than 6 mg/dL, at which level risk of gout attack is decreased and so is the formation of tophi (for which urate levels of <5 mg/dL are preferred).
The decision to start a hypouricemic agent needs to be considered on a patient-by-patient basis, taking into consideration factors such as the absence of definite reversible causes of hyperuricemia, the number of attacks (two or more acute gouty attacks), the degree of hyperuricemia, and the presence of tophi. The decision should be clearly discussed with the patient, because treatment with a hypouricemic agent is usually lifelong and compliance is crucial.16 Hypouricemic therapy should be started only after the acute attack has completely resolved so as to avoid exacerbation of the attack. Prophylactic agents (colchicine, NSAIDs, or systemic steroids) should be initiated concurrently with hypouricemic drugs to decrease the risk of an acute gouty attack. Hypouricemic drugs include xanthine oxidase inhibitors (e.g., allopurinol), uricosuric agents (e.g., probenecid, sulfinpyrazone, benzbromarone), and new agents (febuxostat and PEG-uricase).
Allopurinol inhibits xanthine oxidase, the enzyme responsible for the conversion of hypoxanthine to xanthine to uric acid. Steady doses of this drug thus result in decreases in the serum urate levels and dissolution of tophi. Before starting allopurinol, a thorough discussion with the patient is necessary regarding potential adverse effects. The patient must be cautioned about early signs and symptoms of hypersensitivity reactions.
Potential adverse effects of allopurinol include rash, nausea, vomiting, renal failure or impairment, and, less commonly, nephrolithiasis, bone marrow suppression, angioedema, bronchospasm, exfoliative dermatitis, pancreatitis, hepatitis, peripheral neuropathy, Stevens-Johnson syndrome, and toxic epidermal necrolysis.19 Allopurinol hypersensitivity syndrome can manifest with erythematous rash, fever, hepatitis, eosinophilia, or acute renal failure. Allopurinol hypersensitivity is a serious and potentially life-threatening reaction to allopurinol. If hypersensitivity is suspected, the drug should be discontinued immediately and the patient should be followed closely for failure of symptoms to resolve and for any progression of symptoms. Hypersensitivity can occur in patients with renal insufficiency; therefore, a low starting dose, 25 to 50 mg, is recommended in this patient population.
Drug interactions occur with oral anticoagulation (such as warfarin), azathioprine, mercaptopurine, cyclophosphamide, cyclsoporine, and iron supplements. Allopurinol, azathioprine, and mercaptopurine share the same enzyme, xanthine oxidase, and could therefore increase the levels of those drugs, leading to exaggerated marrow suppression. Caution is necessary with the use of allopurinol in patients treated with cyclosporine, because this combination can lead to an increase in the serum levels of cyclosporine.
The recommended starting dose is 100 mg a day, increasing gradually every 2 weeks to reach a target serum uric acid level of less than 6 mg/dL. In patients with renal impairment, it is safer to start at 25 to 50 mg a day.
Uricosuric agents available in the United States are probenecid and sulfinpyrazone; benzbromarone is not available in the United States. These agents inhibit the urate-anion exchanger in the proximal tubule that mediates urate reabsorption, leading to increased urate excretion through the kidneys. It is advisable to maintain good urine volume and avoid dehydration in patients taking those agents.
Before starting uricosuric agents, a 24-hour urine excretion of uric acid should be checked. These drugs are avoided in patients who have overproduction of urate. In addition, these drugs should be avoided in patients with a history of urate nephrolithiasis.
For probenecid, as with all hypouricemic drugs, it is advisable to start at a low dose and increase gradually to the target serum urate level. The starting dose is 250 mg twice a day. The maintenance dose varies and on average is 500 to 1000 mg two or three times a day. The maximum effective dose is 3000 mg a day.
For sulfinpyrazone, the starting dose is 50 mg twice a day, and the average dose varies, depending on serum urate levels, from 100 to 200 mg three or four times a day. The maximum effective dose is 800 mg a day.
Adverse effects include rash, precipitation of acute gouty arthritis, GI intolerance, and uric acid stones. Probenecid, in particular, increases urinary calcium excretion in gouty patients and thus is contraindicated in patients with a history of calcium or urate nephrolithiasis.
Drug interactions with probenecid include interference with penicillin and ampicillin excretion and autoimmune hemolytic anemia.
Febuxostat and PEG-uricase (Puricase) might have an advantage with their potential role in patients who are allergic or refractory to treatment with allopurinol. However, this specific indication has not been fully investigated.
Febuxostat is a nonpurine selective inhibitor of xanthine oxidase20 that has undergone phase I, II, and III trials for treating hyperuricemia in patients with gout.21 It earned approval from the U.S. Food and Drug Administration (FDA) in February 2009. Current data indicate that it is a potent inhibitor of the enzyme that leads to significant urate reduction and is comparable with allopurinol.22
In a study comparing febuxostat with allopurinol in patients with gout and urate levels of at least 8 mg/dL, urate levels dropped to less than 6 mg/dL in 53% of patients who received 80 mg of febuxostat, whereas this level was achieved in only 21% in the allopurinol group.22 The response was more impressive in the group taking 120 mg of febuxostat. This response was also consistent with reduction in tophus size in both groups.
This study proves the superiority of febuxostat to 300 mg of allopurinol, and it also emphasizes the importance of titrating the dose to reach target levels instead of using a standard dose of 300 mg in all patients. Furthermore, after cessation of prophylaxis (colchicine or naproxen was used), after week eight of starting febuxostat or allopurinol, the incidence of gout flares doubled in the group taking 120 mg of febuxostat and tripled in the group taking 80 mg of febuxostat and 300 mg of allopurinol.22 This result supports the concept of necessary long-term prophylaxis for acute gout attacks when hypouricemic therapy is initiated.
Febuxostat is well tolerated, even in patients with mild renal impairment, without the need for dosage adjustment.
The most frequently reported adverse effects are diarrhea, back pain, headaches, and arthralgias and patients should monitored for thromboembolic events and increase in hepatic transaminases. Adverse effects were not increased in subjects with moderate renal insufficiency (creatinine 1.6-2.0 mg/dL). The doses used in trials were 40, 80, and 120 mg orally daily; however the dose to be used in clinical practice may be closer to 80 mg.22a
PEG-uricase is the pegylated form of uricase, the enzyme that catalyzes conversion of urate to allantoin. This enzyme is naturally lacking in human beings, and thus we are unable to catabolize urate naturally. The enzyme itself is highly immunogenic.
This drug has been used in the past, as Rasburicase, to treat tumor lysis syndrome. However, serious allergic reactions resulted after repeated infusions of this drug, which has limited its use to a one-time infusion. To make the drug less immunogenic, it was pegylated. Pegylation prevented production of antibodies to the uricase protein.
It has been given intravenously or subcutaneously in the studies and has been shown to be safe so far; larger studies are under way. Puricase is promising, and it is probably the most impressive drug used in decreasing tophi burden. However, more data are needed to assess its long-term safety and tolerability.23
During treatment with a urate-lowering agent, urate levels fluctuate, leading to increased risk of gout attacks. The best prevention is caution using prophylaxis therapy. Colchicine is the most popular prophylaxis. However, in patients who are unable to take colchicine, NSAID therapy or low-dose steroids may be helpful.
Colchicine prophylaxis helps decrease the risk of recurrent flares. Ample data suggest benefit from treating patients with colchicine during initiation of allopurinol therapy. Prophylactic therapy should continue for 6 months to 1 year, if possible.22,24
Foods and beverages have long been known to cause gout and gouty attacks. Diet can have some influence on hyperuricemia and gouty attacks, but dietary factors are not sufficient to explain the majority of gout attacks. Patients are encouraged to follow healthy diets sufficient in dairy products; to avoid excessive consumption of alcohol (especially beer), shellfish, and organ meats; and to consume other protein-rich foods in moderation.10,11 Patients whose diets are poor in dairy products have a higher risk of developing gout attacks than those who consume more dairy products.11,25
Gout or hyperuricemia in an adolescent or child is invariably a manifestation of an underlying metabolic or inherited enzyme deficiency. Therefore, gout in the young, although rare, should trigger a workup for such diseases.
Gout is not uncommon in postmenopausal women. Estrogen has natural uricosuric effects in premenopausal women. However, after menopause the uricosuric effect is lost and risk of developing gout is increased. Therefore gout in postmenopausal women is more common and tends to involve the upper extremities more often.26
Use allopurinol with caution in patients taking azathioprine (in the cases of transplant patients and patients with systemic inflammatory diseases who require azathioprine). The combination of azathioprine and allopurinol increases the levels of azathioprine in the blood, and this increases the risk of bone marrow suppression.27 Moreover, cyclosporine, another agent used commonly in transplant patients, can increase urate levels.
The metabolic syndrome needs to be considered and identified in patients with hyperuricemia. In this case, it is essential to treat the underlying conditions, such as hypertension, overweight, dyslipidemia, and insulin resistance, in addition to treating gout. When an antihypertensive is being considered, losartan offers an advantage because it has mild hypouricemic properties. Prevention of obesity and hypertension might decrease the incidence of gout and morbidity.1
Pseudogout is a clinical syndrome in which calcium pyrophosphate dehydrate (CPPD) crystals deposit in joints and soft tissue, resulting in inflammation and tissue damage. The clinical presentation resembles gout in its acute attacks of crystal synovitis, thus the term pseudogout. When calcification of cartilage is apparent under radiographic examination of joints, the syndrome is called chondrocalcinosis. Although CPPD crystal deposition and chondrocalcinosis are seen in pseudogout, not all patients with chondrocalcinosis or CPPD crystal deposition present with pseudogout.
Limited studies published in the literature have specifically addressed the epidemiology of pseudogout. Epidemiologic studies regarding pseudogout or CPPD arthropathy have not been consistent in using universal investigative methods. Some looked at the prevalence of CPPD arthropathy described radiographically by the finding of chondrocalcinosis in degenerative joint diseases,28 and others looked at synovial fluid analysis.
This discrepancy creates limitations in extrapolating these data to patients with the clinical constellation of symptoms of pseudogout. A study that looked at age distribution of patients with CPPD by radiographic examination reported the prevalence to be 15% between the ages of 65 and 74 years and higher than 40% after the age of 84 years.28
Genetic factors have been investigated and are believed to cause familial autosomal dominant CPPD chondrocalcinosis. Studies are looking at mutations of the chondrocalcinosis ANKH gene, but its functional role is not fully understood.29
This disease is not commonly encountered at a younger age without a previous history of trauma or surgery. The disease is seen more commonly after age 50 years, and it has no definite ethnic or gender predilection.30
Although the pathogenesis of CPPD deposition and pseudogout is not as well understood as the pathogenesis of gout, there is probably excessive pyrophosphate production in cartilage resulting in calcium pyrophosphate supersaturation and the formation of CPPD crystals.31,32
Chondrocalcinosis and pseudogout may be associated with certain underlying diseases such as trauma to the joint, hyperparathyroidism, hypomagnesemia, hypophosphatasia, hypothyroidism, and hemochromatosis.33 This highlights the importance of addressing other possible underlying diseases when evaluating the patient with pseudogout and chondrocalcinosis.
Although CPPD crystal deposition disease encompasses a variety of clinical manifestations ranging from asymptomatic to goutlike (pseudogout), rheumatoid arthritis–like (pseudo-rheumatoid arthritis) or osteoarthritis-like (pseudo-osteoarthritis), pseudogout is distinguished by acute attacks of synovitis mimicking gout. These acute or subacute attacks can involve one or multiple joints, commonly not more than four or five joints at one time.34 Pseudogout, like gout, however, can manifest with more systemic features such as fevers, malaise, leukocytosis, and elevated acute phase reactants (sedimentation rate and CRP). Acute attacks may be indistinguishable from acute gout. In fact, it is often difficult to differentiate both without a synovial fluid analysis. Patients have joint pain, synovitis with joint tenderness, and swelling. Pseudogout and gout can share similar joint predilection, but pseudogout affects larger joints more commonly than gout (knee joints) and less so the smaller joints (first metatarsophalangeal joints). It also affects the elbow, shoulder, wrist, and metacarpophalangeal joints.
Because pseudogout closely resembles gout, the definite diagnosis of pseudogout often necessitates synovial fluid analysis. Synovial fluid should be microscopically analyzed for cell count and crystal analysis under compensated polarizing microscopy. In addition, fluid should be examined for Gram stain and culture, especially if crystals are not found.35 On synovial fluid polarization, CPPD crystals might not be as evident as MSU crystals. They are weakly birefringent under polarized light and have a rhomboid or rod-shaped appearance. They are seen either intracellularly or extracellularly, and detection might not be as accurate if fluid analysis is delayed.15 In addition, because pseudogout and gout can coexist, MSU crystals might also be observed. White cell counts can range from a few thousand cells up to 80,000 to 100,000 per high-power field.
Radiographs can show chondrocalcinosis in the joint involved and other more typical joints even if pseudogout is not clinically active at the time of presentation. They are helpful in confirming the clinical impression (especially the knee joints, wrists, and anteroposterior view of the pelvis) and extent of joint degeneration; however, radiographs are not required to make the diagnosis once CPPD crystals are seen under polarized light. Chondrocalcinosis is seen in the knees (hyaline cartilage and menisci), the wrists (fibrocartilage), and other joints such as intervertebral discs and symphysis pubis. Other radiographic features include joint space narrowing, subchondral new bone formation, normal mineralization, cysts more prominent than in osteoarthritis, bilateral preponderance, and osteophyte formation.12,36 Certain metabolic conditions associated with CPPD disease, such as in hemochromatosis, have characteristic findings such as joint narrowing of the metacarpophalangeal joint spaces, squaring of the bone ends, subchondral cysts, and hook-like osteophytes on the radial aspects of the metacarpal heads, especially the second and third metacarpophalangeal joints.37
Most of the differentials mentioned with gout can be considered here. Infection is always a major differential, especially in the patient presenting with new acute monoarticular arthritis. In addition, septic arthritis can coexist in the joint that has been or is involved in an acute pseudogout attack. Thus, it is important to aspirate the involved joint whenever possible for microscopic examination of the synovial fluid and Gram stain and culture. Other differentials include trauma, bleeding, and other crystal-deposit diseases. Calcium pyrophosphate deposition disease mimics polymyalgia rheumatica.38
The optimal therapy is one that promptly treats an acute attack, prevents further attacks, and prevents or reverses the degenerative joint disease associated with CPPD arthropathy. Unfortunately, there is no proven therapy that fits this description.
The treatment of pseudogout is mostly tailored to the manifesting symptoms. In patients presenting with one or two points of acute synovitis, rapid relief of pain and inflammation is accomplished with joint aspiration and steroid injection, if no infection is present. In fact, patients often find relief from the joint aspiration itself. When more than two joints are involved it is not feasible to inject all the joints, so treatment is directed more toward systemic therapy. The side effects and toxicities of NSAIDs, colchicine, or systemic glucocorticoids are similar to those discussed for gout. Colchicine at a dose of 0.6 mg once or twice daily may be effective as a prophylactic measure to reduce the number of attacks in a year,39 especially in patients who experience three or more attacks a year. Unlike gout, however, there are no hypouricemic equivalents to improve the long-term control of pseudogout and to prevent or reverse CPPD crystal deposit disease.
The outcome of patients with pseudogout is influenced by genetic predisposition, extent of crystal deposition and joint degeneration, and aggravating factors from the underlying associated diseases. A study looked at the outcomes of 104 patients with pyrophosphate arthropathy for a mean of 4.6 years and found that patients presenting with acute attacks have a good prognosis, and some patients might not have a progressive disease.40
Because CPPD deposition disease is associated with variety of underlying conditions,33,41 I recommend screening for hyperparathyroidism, hypothyroidism, hypomagnesemia, hypophosphatasia, and hemochromatosis. Blood should be tested for intact parathyroid hormone, calcium, phosphorous, thyroid-stimulating hormone, magnesium, ferritin, iron transferrin, and alkaline phosphatase. Treatment of associated diseases is recommended. However, it is unclear if treatment of comorbid conditions would decrease the chondrocalcinosis or reverse joint degeneration.
Crystal deposition disease is a fairly common condition. It is encountered by rheumatologists and other physicians. Gout and pseudogout are the most commonly encountered, but one needs to be aware of the presence of other types of crystal arthropathy, such as hydroxyapatite crystal deposition disease. In this case, crystals might not be seen on classic synovial analysis.
Gout and pseudogout can manifest with similar symptoms, and their signs might not be distinguishable; thus, it is essential to aspirate the affected joint or bursa for synovial fluid and crystal analysis whenever possible. Cell count, Gram stain, and culture, in the right clinical setting, should be sought.
Once the diagnosis is made, treatment for acute attack should be commenced using the least-toxic agent. Treatment should be initiated while taking into consideration other comorbid conditions, such as renal disease, gastric disease, organ transplant, drug interactions, and others, because these will dictate the choice of therapy. In the case of gout, once the acute disease has resolved, the patient should be followed to assess for indications and need for hypouricemic therapy.
New drugs are on the horizon for managing chronic tophaceous gout. Febuxostat has been approved by the FDA, and PEG-uricase could soon earn FDA approval. Keeping on the lookout for new research data, indications, contraindications, and criteria for use of these drugs is essential, because these drugs might come with different criteria for initiating therapy.


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Unfortunately, the right's obsession with masculinity,...
Posts tagged "aaron schock"
Gender Caricatures
How are ideas of masculinity created and enforced? Are the political and Christian right less tolerant of a spectrum of male behavior than those on the left? What about Boehner's crying and Obama's killing? From Amanda Marcotte's article at The Guardian, "The soft underbelly of the right's hard abs":

subset: commoncrawl


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Timeless Singer Whitney Houston Dead at 48 in Beverly Hills, No Good Bobby Brown In Shock
My heart is heavy tonight. It is with sad heart that I must report one of the most beautiful voices of our lifetime has passed away. Whitney Houston is dead at 48.
Whitney Houston is what you call a real singer. No autotunes or lip-syncing was necessary for Whitney Houston. She was all natural, like a cup of sweet milk carmel mocha. She could put you to ease on the roughest day with a voice that was truly from God.
Houston had 7 singles in a row go Billboard #1, was a multi Grammy winner and even ventured out into an acting career. She was raised in church and her movie "The Preacher's Wife" reflected that fact, as well as cross-overs songs she did with gospel artist CeCe Winans.
Many consider the negative turning point in Whitney Houston's life to be when she married the hipped hopper Bobby Brown. He was in a band named New Edition and is really what I'd call a 'Fly By Night' personality. Many people think that Whitney's relationship with the 'bad boy' Bobby Brown drove her into her life's main destructive choice: doing drugs.
Whitney entered a dark period of no new music and repeated victimization of what insiders say was an abusive relationship by Bobby Brown. In that relationship, Houston did become a mother, but overall the toll her time with Brown took on the singer ruined her career.
When Whitney finally emerged from 'the darkness', her voice was different, eaten by drugs. But somewhere within her, there was that voice we all loved from the 80s. It is sad that we've lost yet another talented singer, only weeks after Etta James. Women who can actually sing and be popular for their voices, and not flaunting themselves around like little dime Vegas sluts, are becoming more and more rare. And it is with that, that we mourn the loss of Whitney Houston.
May angels lead you in, Whitney Houston, and may your songs continue to endure as a representative of what real talent from our lifetime sounds like. In other news, Katy Perry will flash her fleshmounds next week to gain attention for her 'singing'.
This is a song that speaks to my heart.
- Excited
- Fascinated
- Amused
- Shocked
- Sad
- Angry


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No reprints will be available from the author.
Treatment and diagnosis of a dog with fulminant neurological deterioration due to anatoxin-a intoxication
Version of Record online: 15 SEP 2010
DOI: 10.1111/j.1476-4431.2010.00578.x
© Veterinary Emergency and Critical Care Society 2010
Journal of Veterinary Emergency and Critical Care
Volume 20, Issue 5, pages 518–522, October 2010
Additional Information
How to Cite
Puschner, B., Pratt, C. and Tor, E. R. (2010), Treatment and diagnosis of a dog with fulminant neurological deterioration due to anatoxin-a intoxication. Journal of Veterinary Emergency and Critical Care, 20: 518–522. doi: 10.1111/j.1476-4431.2010.00578.x
The authors declare no conflict of interest.
Publication History
- Issue online: 18 OCT 2010
- Version of Record online: 15 SEP 2010
- Submitted November 9, 2009; Accepted August 17, 2010.
- Abstract
- Article
- References
- Cited By
- blue-green algae;
- charcoal hemoperfusion;
- convulsant;
- cyanobacteria;
- LC-MS detection
Objective – To describe the clinical features, treatment, diagnostic work-up, and outcome of a dog with acute neurologic signs subsequent to algal toxin exposure.
Case Summary –
A Golden Retriever was presented for evaluation of acute onset of paraparesis after swimming in a man-made pond in early June and ingesting algae from a nearby bucket. The dog was anxious, had mild ptyalism, and when excited, developed generalized self-limiting tremors that progressed to generalized fasciculations and lateral recumbency. The dog was treated with activated charcoal and crystalloid fluids. Two hours after the presentation, the dog acutely decompensated and was ultimately euthanized. Gastric contents, bucket contents, pond water, bile, and urine were positive for anatoxin-a.
New or Unique Information Provided – Anatoxin-a intoxication is rarely confirmed in dogs but should be considered as a differential diagnosis in any dog with acute neurologic signs. We report the first successful detection of anatoxin-a in urine and bile of a dog exposed to blue green algae. This new test provides an enhanced diagnostic tool in suspect cases and has possible therapeutic implications in dogs.


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DAREDEVIL Patricia Glave will mark her 80th birthday in style - by jumping 2,000 feet from a plane.
Patricia, of Wakefield Road, Athersley, will take part in a skydive in celebration of her birthday on March 3.
"It's something I've wanted to do for years and I've never got to do it. If I don't do it now, I never will," she said.
Patricia had to get her GP to sign a form to say she was fit to do the jump.
Patricia will pay to take part in the skydive, but is inviting charities and individuals to collect for their own charities in her name.
She will do the skydive at Hibaldstow, North Lincolnshire, on March 2.
Most read news stories


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Counterfeit Gangster
|Counterfeit Gangster
|GTA Chinatown Wars
|Chan Jaoming
|East Island City, Dukes, Liberty City
|Unlocked by
Counterfeit Gangster is a mission in Grand Theft Auto: Chinatown Wars given to protagonist Huang Lee by Chan Jaoming.
Chan Jaoming has got some problems with the FIB. They will be coming to search his "Goods" and when they find out they are counterfeits they will arrest Chan again. Chan wants Huang to dispose of his "Goods".
This mission is pretty straight forward. You need to destroy all of Chans goods before the FIB discover them. This mission is timed, you have 6 minutes and 15 seconds to complete it. The first bunch of "Goods" are right in front of Chans place. Shoot, run over, or blow them up to destroy them. There are some Molotov Cocktails around the corner. Next take a vehicle and head to the nearest bunch of goods near the docks. Destroy/Shoot/Blow up these crates and then head to the next bunch. These are cars, you will need to use a crane to pick them up and dump them in the water. The Crane controls are pretty simple. Use the black joystick to move the crane around and pick cars up, dumping them in the water. The next part involves pushing a number of cars into the water using a Bulldozer. After they are all gone the mission is complete.


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WOODLAND, Calif. – Oregon senior attacker Shannon Propst earned the first Offensive Player of the Week honors of the 2014 season as announced by the Mountain Pacific Sports Federation office Monday evening (Feb. 17). This is the third player of the week award for Propst who earned it twice before, once during her junior campaign and once during her sophomore year.
Propst was voted the MPSF Offensive Player of Week after she scored five goals with 11 assists and 16 points her first two games. The Bel Air, Md., native was also 5-of-6 shooting from the field (.833), including a perfect shots on goal percentage and went 2-for-2 in free position opportunities to go along with her 3 ground balls.
The senior eclipsed the Oregon all-time career assist record of 78 in the season opener, dishing out nine assists in the 20-3 win over Stetson. Propst tacked on two more assists in the Ducks' win over Coastal Carolina to finish with 11 assists and 81 in her career at Oregon.
Her nine assists also broke the eight-year old single-game assist record for Oregon (6) set by Alison Leiner in 2006 and tied the MPSF single-game assist record set by Jill Remenapp of Denver last season. Propst's 10 points against Stetson also broke the single-game record at Oregon while tying her for sixth all-time on the MPSF all-time single-game points list.
The following day against Coastal Carolina, the senior attack also displayed her offensive capabilities tying the game-high with four goals in Oregon's 23-3 victory over the Chants.
Propst and the Ducks next take the field on March 1 in Philadelphia, Pa., to open their second two-game road trip with Temple at 10 a.m. (PST).


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In the Online Work/Leave System (OWLS), supervisors have read-only access. The role of the supervisor is to review and ensure the accuracy of employee leave records in the unit. As a supervisor, you will receive Post Entry Review Messages (PERMS) each time the timekeeper submits monthly entries.
Any errors, discrepancies, or questions about an employee's OWLS record should be directed to your unit's timekeeper.
To access OWLS, you will be required to log in with your UW NetID and password.
OWLS is intended for use by authorized employees only, and authorization for use is solely at the discretion of department management. In order to protect the privacy and integrity of the records in OWLS, you must log out or password-protect your computer screen whenever leaving your desk.
To review your employee work list, log in to OWLS as follows:
1. Navigate to the OWLS home page and click on the "OWLS Log in" button.
5. The OWLS disclaimer regarding appropriate use of the system will appear. Once you read and understand it, click the "I agree" button to enter OWLS. The list of employees to whom you are assigned as supervisor will appear. NOTE: Do not bookmark this page; doing so will cause future log in errors.
To learn about the additional pages you can view in an employee's record, please visit the Viewing an Employee record page.
Problems logging in? Please contact the OWLS support team at email@example.com.
In order to obtain OWLS record supervisor access, ask your department's timekeeper to add you as a supervisor to an employee's record.
After logging into OWLS, you can click on "OWLS Report" to generate a report of employees' leave balances.
When selecting employee OWLS records, you may choose to display or not display their prior records by clicking on "Include Prior Records."


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How did the Gold Rush change the ethnic makeup of California's population and culture?
What impact did the influx of new inhabitants have on the daily life and politics of rapidly growing towns?
How did the general lack of law enforcement affect daily life?
These images of crime, revenge, and drug dens show why California was often called part of the "Wild West." With few actual law officers or courts to enforce the law, many people took it upon themselves to impose their own varying ideas of justice.
The Gold Rush era was marked by lawlessness: duels, murders in broad daylight, public hangings, jail breakouts, and vigilantism were everyday occurrences. The images in this group are a vivid record of those times. Included here are photographs of convicted murderers like James Egan, who was sent to San Quentin for 35 years for killing a man in a saloon brawl; and John "Chicken" Devine, who beat a man to death with a rock. A newspaper article reports that former Chief Justice of the Supreme Court of California David. S. Terry killed US Senator David C. Broderick in a duel, and a half-page drawing depicts the crime. Men weren't the only criminals: pickpockets Jennie Hastings and Dolly Mickey are also represented here.
Law officers were in short supply, and laws were not uniformly enforced. Some men — such as those in the photograph "Sharpshooters of the Vigilante Committee" — took the law into their own hands, enforcing "justice" as they saw fit. They posted public notices like the "Warning!" sign, which threatens hanging as retribution for "pilfering, robbing, stealing, or any act of lawless violence." Several images portray individuals "rescued from the authorities" and hanged — before being tried or even given a hearing for the crimes of which they were accused.
Drugs were also part of Gold Rush communities. As several images show, people sometimes smoked opium in underground opium dens. And, as one photograph makes clear, opium smoking crossed racial and cultural boundaries. Eventually, law-abiding citizens grew weary of the uncontrolled murder and mayhem in their rapidly growing communities. As the Gold Rush era drew to an end, people felt that existing legal and judicial institutions had to be strengthened.California Content Standards
1.0 Writing Strategies: Research and Technology
2.0 Writing Applications
2.3 Write information reports.
2.0 Speaking Applications
2.2 Make informational presentations.
2.0 Writing Applications
2.3 Write research reports about important ideas, issues, or events.
2.0 Speaking Applications
2.2 Deliver informative presentations about an important idea, issue, or event.
4.3 Students explain the economic, social, and political life in California from the establishment of the Bear Flag Republic through the Mexican-American War, the Gold Rush, and the granting of statehood. (4.3.3)
4.4 Students explain how California became an agricultural and industrial power, tracing the transformation of the California economy and its political and cultural development since the 1850s.
5.8 Students trace the colonization, immigration, and settlement patterns of the American people from 1789 to the mid-1800s, with emphasis on the role of economic incentives, effects of the physical and political geography, and transportation systems. (5.8.4)
3.0 Historical and Cultural Context Understanding the Historical Contributions and Cultural Dimensions of the Visual Arts. Students analyze the role and development of the visual arts in past and present cultures throughout the world, noting human diversity as it relates to the visual arts and artists.
6C's of Primary Source Analysis (PDF) (Source: UCI History Project)
Photographs (PDF) (Source: Library of Congress)
Posters/Visuals (PDF) (Source: Bringing History Home)
Written Documents (PDF) (Source: NARA)
Primary Source Activity (PDF) (Source: Library of Congress)


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Marfan syndrome
Other Names for this Disease
- Marfan syndrome type 1
- Contractural arachnodactyly
See Disclaimer regarding information on this site. Some links on this page may take you to organizations outside of the National Institutes of Health.
mutations in the FBN1 gene, which provides instructions for making a protein called fibrillin-1. Marfan syndrome is inherited in an autosomal dominant pattern. At least 25% of cases are due to a new mutation.[1][2] Treatment is symptomatic and supportive.[2]Marfan syndrome is a disorder of the connective tissue. Connective tissue provides strength and flexibility to structures throughout the body such as bones, ligaments, muscles, walls of blood vessels, and heart valves. Marfan syndrome affects most organs and tissues, especially the skeleton, lungs, eyes, heart, and the large blood vessel that distributes blood from the heart to the rest of the body (the aorta). It is caused by
Last updated: 2/9/2016
- Marfan Syndrome. Genetics Home Reference (GHR). March 2012; http://ghr.nlm.nih.gov/condition/marfan-syndrome.
- Chen MA, Zieve D. Marfan syndrome. MedlinePlus. May 13, 2014; https://www.nlm.nih.gov/medlineplus/ency/article/000418.htm.
GARD Video TutorialsLearn how to find information on treatment, research, specialists, and more.
Your Questions AnsweredView questions about this condition answered by GARD Information Specialists. You can also submit a new question.
On this page
Basic Information
- Genetics Home Reference (GHR) contains information on Marfan syndrome. This website is maintained by the National Library of Medicine.
- MedlinePlus was designed by the National Library of Medicine to help you research your health questions, and it provides more information about this topic.
- The National Heart, Lung, and Blood Institute (NHLBI) provides leadership for a national program in diseases of the heart, blood vessels, lung, and blood; blood resources; and sleep disorders. Since October 1997, the NHLBI has also had administrative responsibility for the NIH Woman's Health Initiative. Click on the link to view information on this topic.
- The National Human Genome Research Institute's (NHGRI) mission encompasses a broad range of studies aimed at understanding the structure and function of the human genome and its role in health and disease. Click on the link to view the information page on this topic.
- The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on research progress in these diseases. Click on the link to view information on this topic.
- The National Organization for Rare Disorders (NORD) is a federation of more than 130 nonprofit voluntary health organizations serving people with rare disorders. Click on the link to view information on this topic.
- A Positive Exposure program called FRAME has an educational film about Marfan syndrome that was created to change how medical information is presented to healthcare professionals. FRAME stands for Faces Redefining the Art of Medical Education. Positive Exposure is an organization that uses photography, film, and narrative to transform public perceptions of people living with genetic, physical, intellectual, and behavioral differences.
In Depth Information
- The Monarch Initiative brings together data about this condition from humans and other species to help physicians and biomedical researchers. Monarch's tools are designed to make it easier to compare the signs and symptoms (phenotypes) of different diseases and discover common features. This initiative is a collaboration between several academic institutions across the world and is funded by the National Institutes of Health. Visit the website to explore the biology of this condition.
- Online Mendelian Inheritance in Man (OMIM) is a catalog of human genes and genetic disorders. Each entry has a summary of related medical articles. It is meant for health care professionals and researchers. OMIM is maintained by Johns Hopkins University School of Medicine.
- Orphanet is a European reference portal for information on rare diseases and orphan drugs. Access to this database is free of charge.
- PubMed is a searchable database of medical literature and lists journal articles that discuss Marfan syndrome. Click on the link to view a sample search on this topic.
Other Names for this Disease
- Marfan syndrome type 1
- Contractural arachnodactyly
See Disclaimer regarding information on this site. Some links on this page may take you to organizations outside of the National Institutes of Health.


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Debonair Jacket
Now available for purchase,
This pattern has been completely rewritten and resized and now includes 8 sizes.
If you had previously purchased this pattern through Ravelry or Knitpicks and would like a copy of the new version please email me at email@example.com with the pattern file attached and I will send you a complimentary updated copy.
A plush cabled cardigan worked in City Tweed with modified drop shoulder sleeves and a wide shawl collar. Guaranteed to keep any guy happy and warm on the coldest days this cardigan pulls double duty as a jacket in the spring and an indoor sweater in the winter. The cables are striking and linear without being fussy and the color is deep, dashing, and indeed debonair.
NOTE: this pattern has been rewritten to include shoulder seams.
Shown in size 47
Chest: 34.5(39, 43.25, 47, 50.75, 56.25, 59.5, 65) inches circumference
Length: 24 (24.5, 25.5, 26, 27, 27.5, 28.5, 29) inches from shoulder seam to hem
Knit Picks City Tweed HW 55% Merino wool, 25% Superfine Alpaca, 20% Donegal tweed; 164 yards/100 gram ball; color: Blue Blood 9(9, 10, 10, 11, 12, 14, 15) balls.
1 set US #8/5mm straight needles OR 1 US #8/5mm 24-inch circular needle
1 US #8/5mm 47-inch circular needle
Cable needle or DPN
Tapestry needle, 5 buttons (1 inch diameter), sewing needle and thread to match buttons, sewing pins (optional)
17sts/20 rows = 4" square in stockinette stitch
13sts/22 rows = 4" square in seed stitch
18sts/21 rows = 4" square over charted cable pattern


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Now in its eighth year, Saturday's Inspiring Abilities Expo, sponsored by Families United for Support and Encouragement, brought families with children with special needs from all over central Indiana under one roof to connect with service providers, agencies, nonprofits and product vendors. This year, the expo featured nearly 60 exhibitors.
In addition to vendors and exhibitors, the expo featured several experts who consulted with area families about topics ranging from nutrition tips to understanding Medicaid waiver services.


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heavenlyHosts&&love.. love.. love..these hosts only know love♪
Character Compilations Thread
Out Of Character Thread
H e a v e n
There's a place right next to a bar
sounds kind of shadycalled Heaven.
It's not really Heaven, but you will see angels. These angels
they're actually gorgeous guysare the hosts of the Heaven Host Club.
Women occasionally like to go to Heaven, to be able to relish in their beauty, but these male hosts have utterly no interest in them.
For you see, well, they all prefer guys.
It might be because they don't have a choice, but either way, they have no thoughts of it being unfair.
These hosts are programmed to like males. They're androids living as humans.
But these androids run on batteries. And batteries are meant to go out one day, right?
N o w , T h e R u l e s F o r T h e R P e r s
1. Listen to what I say.
2. Do not God-Mod.
3. Please keep it PG-15 (I know it might be hard, but please try! No sex scenes.)
4. Each post has to be at least 2 lines. One line is too short.
5. I won't limit characters, but make sure you don't make too much that you can't handle.
6. Please try to post within a 2 week timeline. Unless you have plans - notify me beforehand.
7. Romantic relationships are allowed - but remember, this is a YAOI roleplay.
8. When/If your character swears, please use ***.
9. Make sure to check the OCC occasionally.
10. Have fun with the RP!
╔ . . . t h e s e n i g h t t i m e a n g e l s . . . ➸➸ . . . h o s t s of h e a v e n . . . ╝
This RP is still under construction. Do not post.


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Bright Lipstick Challenge - Applying Lipstick Artistically
This entry was posted on March 26, 2013.
This spring your challenge is to wear your bright lipstick artistically and beautifully. You may be wondering what artistic makeup is all about and what it means. To us it means allowing your bright lips to look fabulous paired with your fabulous outfits and it also means finding complementing shades of lipstick that will go with your locks. Meet these challenges and your lips will be uber-complete (and yes we just made that up) paired with your hair extensions. ;)
Exfoliate Your Lips
The first thing you need to know is that bright lipstick will draw attention to your lips, so it's important to exfoliate them first. Exfoliating your lips will make them smooth and lipstick will be easier to apply with your lips are smooth. If your lips are in tip top shape before applying bright lipstick your lips will shine.
Fill Out Your Lips Entirely
Whether you use lip liner is up to you, but with bright lips the general consensus is that you should fill out your lips all of the way with bright color, just not part of them. Don't be afraid to apply your lipstick a little bit outside your lip line as well, because this will make your lips full of color and not to mention you will have the perfect pout! Use common sense though - you don't want so much lipstick that you're looking like a clown.
Complement Your Outfit to Your Lips
Since your bright lips will be the focal point it's a good idea to make your outfit fairly simple, or at least incorporate your bright lipstick color with one stand - out color that's on your outfit. For example, if you are wearing a plum skirt bright plum lips will look outstanding paired with your ensemble! Or, if you have a black dress wear red - hot lipstick. Use your best judgement and have fun with your outfit without overwhelming it with color since you already will have colorful lips.
Look for Lipstick that has Hyaluronic Acid
Bright lipstick highlights lip wrinkles if you do have lip wrinkles, so a tip is to look for lip colors that have hyaluronic acid. This acid will plump up your lips, hiding your wrinkles. Fuller and smoother lips is the goal and this can be better accomplished by finding lip products that come with this key ingredient.


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I've been to the pyramids in Egypt. I touched the side of their rough stones and it was amazing. What amazes me more is the we have an unbelievable number of pyramids right next to us in Mexico. And how many have you seen - or touched?
The pyramids in Mexico were used for anything from physical sports games, elaborate temples, sacrificial sites and even to beg for fertility. In most states you can visit several significant pyramids in a single day! The major civilizations that built these pyramids were the Olmec, Teotihuacan, Toltec, Aztec and the Mayan. Most of us are familiar with the Mayan calendar :)
Some of the sites have museums, stores and other interesting artifacts. If you don't know where to start, start with some of the top five sites:
- Teotihuacan
- Palenque
- Chichen Itza
- Uxmal
- Monte Alban
So when is the best time to visit these sites?
Central Mexico: April, August & October
Chiapas: October - May
Gulf Coast: November - April
Oaxaca: October - March
Yucatan: November - April


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Fresno State: All-America and John Mackey Award Candidate in his senior season ... returning first-team All-WAC player, the only Bulldog in school history to earn that honor ... projected by most college preseason magazines as one of the top tight ends in America ... one of the hardest working players on the team ... well-built yet athletic player who came to Fresno State as a quarterback and switched to tight end ... has developed into a major offensive weapon and big-play maker... has shown big-play capability, notably a 75-yard touchdown catch against Hawaii in 2006 ... a very smart football player who has made immediate contributions as a blocker, receiver and special teams star early in his career ... one of the strongest tight ends ever to play the position at Fresno State and as a devastating blocker on the line ... has blocked four kicks in his career, two last season ... has 893 career receiving yards ... will go down as one of the best to ever wear a Bulldog uniform. (2007) First-team All-WAC selection after finishing second on the team with receptions (45) and yards (553) despite missing one game and parts of two others with an injury ... on the Mackey Awards Watch List ... had four touchdowns and average 12.3 ... tied a modern day Bulldog record with three touchdown catches at No. 23 Texas A&M ... blocked two kicks during the season ... averaged over 30 yards per catch in the season opener against Sacramento State ... coming off a six-reception game, one shy of his career high, against Georgia Tech in the Roady's Humanitarian Bowl ... suffered an injury against Utah State that limited his availability for the next three games and forcing him to miss the Kansas State contest ... appeared on the kick return team and the PAT/FG block units on special teams. (2006) Emerged as a receiving weapon with 22 receptions for 307 yards and two touchdowns ... averaged 14 yards per reception, fifth-best average in the WAC ... had two receptions for a career-high 95 yards against Hawaii, including a 75-yard touchdown ... finished the season with a career-high seven receptions for 87 yards against San Jose State ... started all 12 games and had at least one reception in every game ... (2005) Played in all 13 games and started three ... had five receptions for 34 yards with a long play of 12 yards. (2004) Redshirted ... earned the scout team offensive player of the year awards at the team's postseason banquet.
High School: A big, physical quarterback who is one of the top all-around athletes in the Valley ... selected the 2003 East Yosemite League Offensive Player of the Year and was named all-area after guiding his team to a 16-4 record over the last two seasons ... guided Granite Hills to the 2002 EYL title ...accounted for 1,851 total yards and 16 touchdowns as a senior and nearly 3,500 yards and 33 touchdowns over two seasons ... was a first-team All-East Yosemite League basketball player as a junior ... also played outside linebacker ... played in the EYL in the shot and discus, placing sixth in the Valley championships in the discus as a junior ... also an accomplished rodeo roper.
Personal: Born Feb. 23, 1986 ... parents' names are Julie and Sean Pascoe ... has one brother, Ryan, and one sister, Sara ... enjoys calf roping ... lists his favorite athlete as Green Bay Packers QB Brett Favre ... his given name is McKenna Sean Pascoe, but he goes by Bear, a name given him by his family as a toddler because of his size ... grew up on a cattle ranch and is a champion roper.
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Season tickets for the upcoming women's basketball season are now available for purchase, offering a variety of packages and enhanced benefits for both new and existing season ticket holders.
Women's season ticket holders are assured of receiving the best available seats inside Maples Pavilion, complete with benefits such as cost savings off single-game prices, priority access to purchase single-game and postseason tickets, ability to resell or transfer unused tickets online or by mobile device and an exclusive season ticket holder e-newsletter.
Women's basketball season tickets range from $280 ($250 for faculty and staff) for upper sides reserved to $394 ($350 faculty and staff) for lower reserved areas. Fans also have the option of purchasing a General Admission Flex Plan, which for $125 includes 25 vouchers good for any game except for Tennessee on Dec. 21.
The women's home slate will feature 14 regular-season games and one exhibition (Nov. 3 against Vanguard). On top of the nine Pac-12 home contests, the non-conference schedule is headlined by a visit from Tennessee on Dec. 21 and tips off Nov. 15 against 2013 Big West champion and NCAA Tournament participant Cal Poly. Additional non-conference opponents include UC Davis (Nov. 17), West Coast Conference champion Gonzaga (Dec. 14) and New Mexico (Dec. 17).
The lone doubleheader on the schedule is set for Dec. 14, with the men facing UC Davis while the women host Gonzaga. Game times have yet to be determined.
Additionally, this year's Maples Pavilion experience will be further enhanced with new and improved concessions, offering a variety of menu options for all fans.
Stanford face at least four NCAA Tournament teams from a season ago during the 2013-14 non-conference season. The Cardinal opens the new campaign on the road Saturday, Nov. 9 at Boston College before facing defending national champion Connecticut at the XL Center in Hartford Monday, Nov. 11. Other 2013 NCAA Tournament teams on the non-conference schedule include Tennessee, Gonzaga and Cal Poly.
The slate also includes trips to Texas and Fresno State as well as a trip to Puerto Vallarta for the 2013 Hardwood Tournament of Hope. Stanford's three opponents at the tournament are still to be determined.
"Our non-conference schedule follows our philosophy that preparation for the unique demands and challenges of the NCAA Tournament begins in November," said Setsuko Ishiyama Director of Women's Basketball Tara VanDerveer. "We look forward to visiting and hosting some of the best competition from around the nation, which will prepare us for another competitive Pac-12 season and the postseason."
The Cardinal's full schedule, which will include TV broadcast information as well a finalized Pac-12 slate, is expected to be available in early September. Non-conference dates and times are also subject to change, and fans are encouraged to continue checking www.gostanford.com for updates.
Stanford, 13-time defending Pac-12 champion and winners of seven straight conference doubles (regular season and tournament titles in the same season), returns from its opening weekend in New England to pull the curtain on its 2013-14 home slate, hosting 2013 Big West champion Cal Poly (Nov. 15) and UC Davis (Nov. 17). Next, Stanford embarks on a four-game trip which takes the team to Austin to battle Texas on Nov. 23 then to Puerto Vallarta for three games in three days over Nov. 26-28.
The final four games of the non-conference season will keep the Cardinal in California, beginning with a three-game homestand against Gonzaga (Dec. 14), New Mexico (Dec. 16) and Tennessee (Dec. 21) and concluding Dec. 28 at Fresno State.
The 2013-14 season will feature many highlights for the Cardinal, among them the final collegiate season for two-time All-American and national player of the year candidate Chiney Ogwumike and head coach Tara VanDerveer closing in on becoming just the fifth women's basketball coach to win 900 career games. VanDerveer enters this season with a career mark of 894-203, needing just six wins to join Pat Summitt, Jody Conradt, Sylvia Hatchell and C. Vivian Stringer in the 900-Win Club.
Ogwumike meanwhile is coming off of a dominant 2012-13 season in which she was named a consensus All-American and national player of the year finalist. The Cypress, Texas native also claimed her first Pac-12 Player of the Year after becoming the first player to capture the Pac-12 Triple Crown, leading the loop in scoring (22.4 ppg), rebounding (12.9 rpg) and field-goal percentage (58.6). She was also the only player in the nation to rank in the NCAA's top seven in all three categories, finishing fourth in field-goal percentage, fifth in rebounding and seventh in scoring.
The Cardinal also returns four starters from a year ago as All-Pac-12 Team pick and junior point guard Amber Orrange (10.8 ppg, 4.08 apg in 2012-13), senior shooting guard Sara James (5.3 ppg, 1.9 rpg) and fifth-year senior forward Mikaela Ruef (4.2 ppg, 6.6 rpg) join Ogwumike back on The Farm.
Stanford 2013-14 Non-Conference Schedule (all times Pacific)
Sat., Nov. 9 – at Boston College – 10 a.m.
Mon., Nov. 11 – at Connecticut – 4 p.m.
Fri., Nov. 15 – Cal Poly – 7 p.m.
Sun., Nov. 17 – UC Davis – 2 p.m.
Sat., Nov. 23 – at Texas – TBD
Tues., Nov. 26 – vs. TBD – TBD (Puerto Vallarta, Mexico)
Wed., Nov. 27 – vs. TBD – TBD (Puerto Vallarta, Mexico)
Thurs., Nov. 28 – vs. TBD – TBD (Puerto Vallarta, Mexico)
Sat., Dec. 14 – Gonzaga – TBD
Mon., Dec. 16 – New Mexico – TBD
Sat., Dec. 21 – Tennessee – TBD
Sat., Dec. 28 – Fresno State – TBD


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Barnsley captain Stephen Dawson has been named as one of the seven footballers arrested in connection with spot-fixing yesterday.
The 28-year-old Irishman, who joined the Reds in January 2012 and has made 78 appearances, is understood to have been interviewed by police as part of an investigation into alleged bribery and money laundering. The exact details and dates of the alleged offences have not been revealed.
The Oakwell club is expected to release a statement today.
Six players from Preston North End were also arrested yesterday while six were re-arrested.
A statement by the National Crime Agency, who made the arrests, said: "In December 2013 the NCA arrested six men in connection with an investigation into individuals suspected of Conspiracy to commit acts of Bribery and Money Laundering relating to conduct during football matches.
"Officers from the NCA have been actively pursuing a number of lines of inquiry in this ongoing investigation.
"The NCA have re-arrested the six original suspects based upon new evidence, along with a further seven footballers aged between 18 and 30 suspected of potential involvement in these offences. The seven men arrested in addition to the original six are from Football League clubs based in the North West of England. All 13 individuals are being interviewed at police stations across the country.
"The investigation began following receipt of material from the Sun on Sunday. It remains ongoing and we cannot provide further detail at this stage."


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Former Minister of Public Works Atty. Samuel Kofi Woods attributed that excruciating economic conditions currently undermining the livelihood are issues that unveil poverty and a deep sense of injustice.
The Attorney-At-Law said the high cost of living, increase in exchange rate that is affecting disposable income and savings, lack of clear economic plan of action, are issues that unveil not only poverty, but it shows a deep sense of injustice.
Making the assertion at a press conference Thursday July 11, 2014 in Monrovia, Atty. Samuel Kofi Woods, Consultant, Liberia Law Society, said the Liberian people are losing faith in the their leaders for failing to proactively address the teetering problems facing the country.
"This situation needs to be addressed irrespective of our political, social and economic persuasions, and as a result of that, we need a national consultative process to manage and address what is becoming a national discontent," the former Public Works Minister said.
Atty. Woods noted that, with the current national discontent regarding the country's natural resources relate to various concession agreements, there is an ardent need to revisit the concession agreements earlier negotiated by the government.
He renewed call to investigate how the country's new-found natural resource (oil) has been managed and collectively take corrective actions where necessary to assure proper management and application of proceeds to the broad-based development of the country for the benefit of its people.
"All current and future intentions to sell additional oil blocks must be discouraged. With ordinary Liberians already bearing the brunt of economic mismanagement and financial managers failing to offer solutions and a plan to address the situation," he added.
The Attorney-At-Law maintained that the least the government wants to embark on is to hassle press freedom and silence the media and other critical voices of reason which are only serving as messenger and not the author of the multiple messages of poor planning, corruption, nepotism, cronyism and indifference to the plight of the people.
Atty. Woods, who was also former Minister of Labor, pointed out that since the commencement of oil exploration in Liberia, there have been continuous arguments in various quarters not only regarding the commercial viability of the samples that have been found so far, but also the management of resources that have accrued as a result of the sale of oil blocks with almost little or no consideration for local content.
"It must be stated now and for the record that if care, prudence, proper judgment and collective interests are not the guiding principles accompanying the process leading to the full discovery of oil in commercial quantity, we run the risk of being one of the most corrupt and least transparent," he warned.
He used the occasion to also renew call for the audit of both the Ministries of Planning and Economic Affairs and Finance, noting that he cannot be deterred or intimidated by anybody.


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Welcome, Bay Area Mozilla Testers, Developers & Users!
Invitation to Meetup & Hackathon Night at AT&T Park!Register at http://soc.att.com/1r5JIab and use this coupon code: BAMOZ to attend the event for free. As part of "Shape, an AT&T Tech Expo", AT&T is inviting us and other... Learn more
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Jul 31, 2014 · 6:30 PMCome prepared to explore the world of Mozilla at our QA Fair
Hello - The Mozilla QA team will all be in town, and we are hosting a QA Fair style event. Come and learn more about the team and what we work on. Here is a list of the... Learn more
Jun 24, 2014 · 6:00 PMIntro to Web Testing event
Please join us for an exciting Introduction to Web testing event in our Mozilla SF space. Some of the topics we will cover include: • Ways to start testing • Find a... Learn more
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Mozilla has developed a testing framework from scratch to support automated UI testing of Firefox OS. Zac Campbell of Mozilla QA has been involved since the beginning... Learn more
May 20, 2013 · 6:30 PMDemo: WebRTC in Mozilla Firefox
WebRTC (Web Real-Time Communication) is an API definition being drafted by the World Wide Web Consortium (W3C) to enable browser-to-browser applications for voice... Learn more
Feb 23, 2012 · 6:30 PMWebQA Test Day
We're inviting web testers from all skill levels to our San Fransisco space to learn hands-on how we test our websites! Bring your laptop, pick a project that interests... Learn more
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Professor Polsky, who joined UNC Law School in 2010, teaches tax courses and writes primarily in the areas of tax and business law. Before entering into law teaching, Professor Polsky practiced tax law in the Miami office of White & Case LLP. From 2001 to 2006, Professor Polsky was an associate professor of law at the University of Minnesota Law School. While at the University of Minnesota, he was named the Vance K. Opperman Scholar for the academic year 2005-2006. From 2007 to 2010, Professor Polsky was the Sheila M. McDevitt Professor of Law at the Florida State University College of Law. During the academic year 2007-2008, while on leave from FSU, Professor Polsky served as the Professor in Residence in the IRS Office of Chief Counsel in Washington, D.C.
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Aug 25, 2008 12:09 PM
Look even better as you blow past the competition when you don these Nike Air Stab Premium Shoes ($100). With a rubber outsole for gripping tough terrain and Nike's signature encapsulated "air" cushioning, this is one sneaker that fits. (And the hot colors and sexy design don't hurt anything, either.)
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Vehicle stolen in Farms; man faces multiple charges
Brad Lindberg Staff Writer
write the author
February 14, 2013
GROSSE POINTE FARMS - A longtime criminal being prosecuted for car theft lit up the municipal courtroom wearing buglight-yellow pants and matching pull-over from the Wayne County Jail.
His future's much dimmer than his county-issued outfit, according to police compiling evidence against Frederick Alex Schmerheim, 36, of St. Clair Shores.
"He's back in jail for two reasons," said Lt. Richard Rosati, head of the Grosse Pointe Farms Public Safety Department detective bureau. "He's a parole absconder, so the Michigan Department of Corrections has a hold on him. He's also bound over for trial for our stolen vehicle."
On Wednesday, Feb. 6, Schmerheim waived his right to a preliminary examination in Farms court.
The case moves to Wayne County Circuit Court.
Schmerheim, with the tattoo of a wizard on his lower right arm, needs more than a talisman when proceedings resume downtown at 9 a.m. Wednesday, Feb. 13.
He was arrested on Detroit's eastside during the late afternoon of Saturday, Jan. 26, in a red 2007 Ford Escape reported stolen about two hours prior from behind Irish Coffee, 18666 Mack.
Rosati said Schmerheim denied stealing the car.
"He said he crack-rented it," Rosati said. "He said he gave a guy at a dope house six rocks of crack (cocaine) for the car. That was in his confession."
The theft victim, Linville Stover, 87, of the Farms, was allowed to testify during the otherwise-waived prelim last week rather than travel downtown.
"We wanted to put some things on the record and preserve his testimony for later use and the balance of the exam," explained Gary Bresnehan, principal attorney at the Wayne County Prosecutor's office.
Stover testified to parking the car at about 2 p.m., leaving it unlocked with the keys on the front seat.
Upon returning at 4 p.m. "It wasn't there," Stover said, adding that police returned it the next day.
Judge Matthew Rumora maintained Schmerheim's $50,000 bond.
"That'll conclude the hearing," Rumora said.
Schmerheim's 20-year criminal history started in 1993 with receiving and concealing stolen property, according to Rosati.
In 1995, Schmerheim began the first of eight terms of incarceration for such crimes as home invasion, dealing drugs, car theft and fleeing police, according to state records.
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Many women experiencing menopause have questions about the symptoms and the most common is how long menopause symptoms last and when can they look forward to moving past the sometimes troubling aspects of this life stage. Although general estimations can be made, just as each woman is an individual, the symptoms of menopause may vary in intensity and duration.
Perienopause is the transitional stage in a natural menopause when the body begins to change due to hormonal changes which signal the onset of menopause. The endocrine system is involved as the production of estrogen slows and eventually ceases. This can be marked by irregular periods and other symptoms of menopause such as hot flashes, mood swings and a range of other symptoms. This stage can continue for an average of four years but can be extended beyond six years, and has lasted up to 15 in some women, and in others, only 2 to 3 years. When there is an absence of menstrual cycles for 12 months, this signals the end of the phase and that menopause has been reached.
Age range for the onset of perimenopause
Perimenopause which begins prior to age 40 is considered to be outside of the normal or expected age range for this event to occur. The causes can be genetic factors, disease, or be medically induced by surgeries or treatment with chemotherapy and other drugs. The average age range is somewhere between the mid-40s to mid-50s.
How long will the symptoms last?
Again, this is a natural biological occurrence in women which may be as different as the individual. In general, the symptoms come and go and range in intensity. Most women report that the symptoms will increase in intensity and they decrease for periods of time. Some do not experience intense discomfort during this phase, while others must seek medical intervention to control the symptoms until this stage completes. There is no concrete answer to the length of time that perimenopause will last, nor for the range or intensity of the symptoms.
Duration of hot flushes
Hot flushes are a common symptom which receive a lot of attention from women enduring them. They generally last for a few moments, but can in rare instances go on for up to ten minutes. What makes them problematic for some women is that they can be frightening, bringing on panic attacks with a rapid heartbeat, sweating, and anxiety creating a stress reaction that can lead to increases in anxiety that becomes cyclic. In general this symptom is sporadic and varies in intensity, and may end when menopause is completed, however; the majority of women report that they still have occasional flushes for up to a year after menopause has been reached.
The onset and completion of menopause is a natural biological event that women all face, and generally complete within four years. It's important to understand that these are only averages, and what is normal for you may vary one way or the other. The duration of menopause symptoms is as individualized as the unique women experiencing this phase, and although there is no way to predict the exact duration, troubling symptoms may be addressed with your physician as there are currently effective treatment methods available to help you manage them. Bear in mind that this is a normal part of life, and certainly is nothing to fear.


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When you think of Jeeps, images of bucking, olive green Army buggies or rugged, off-road Wranglers might come to mind. But if that's what you think, you don't know the new Grand Cherokee. The Kansas City Automotive Examiner recently had the chance to spend some time behind the wheel of a newly redesigned 2014 Jeep Grand Cherokee Sport 4X4. And as you will see, there is nothing here to remind you of the rock-crawling kidney-killers of the past.
Well, there is one thing. If you look closely, the left headlight and steering wheel have little badges that proclaim "Since 1941," and the right headlight has a small, chrome silhouette of that original General Purpose vehicle. That's a great little nod to history, and it also hints to the hidden potential that lies beneath this luxurious facade.
The most exciting part about this particular test vehicle can be summed up in four letters: H-E-M-I. In the new Grand Cherokee, this optional mill is good for 360-hp and 390-lb/ft of torque. Even at more than 5,200-lbs, this bus ran like a Challenger. It may be an SUV (crossover, if you prefer), but it is easy to forget that you're not driving a muscle car. Drop that gear selector down into "Sport" mode, and you really have a stop light screamer.
This lovely power plant is mated to a new eight-speed transmission. This, plus cylinder deactivation technology, is meant to increase fuel mileage. And it is better than last year. Jeep claims 14/city, 20/highway, and 16/combined. The computer in our test vehicle was just over 15-mpg at the end of the week, but it hadn't been reset since the driver cruised to Kansas City from Texas. The point is, for what it is, it does pretty well. It's obviously no Prius, but sometimes you have to pay to play.
Even the air suspension was trick. It could be raised or lowered manually depending on what you were trying to accomplish, or it would hunker down in the lowest position on the highway or in Sport mode. The four-wheel-drive system had settings for rock, sand, mud, and snow, and it has a hill-descent feature for serious off-roading. Like most people, we never left the pavement during our brief test drive. But even as an on-roader it did what it was supposed to. The ride wasn't punishing at all, and it was perfectly comfortable both on the open road and down side streets.
SRT excluded, the Summit model like this one is top-of-the-line for 2014. And it shows. The rich interior was finished in dark Grand Canyon Jeep Brown leather, and it had a nice array of leather, French stitching, and modern wood grain throughout. Even the visors and headliner were covered with soft, expensive looking material.
Many of the vital functions were controlled through the 8.5-inch touch screen. Of course it had Sirius/XM Satellite Radio, voice activated/syncable phone capabilities, and navigation. There was also a huge panoramic sunroof, adaptive cruise control, and dazzling 20-inch wheels.
This particular Jeep had a sticker price of $54,685. Now while that's not chump change, most people guessed that it would be higher. Considering everything you get here, and compared to similar vehicles by other manufacturers, that number didn't seem all that unreasonable. Everything's relative, you know.
The 2014 Jeep Grand Cherokee Sport was a surprise from start to finish. It was loaded with features; loaded with luxury; and loaded with performance. If the idea of a muscle car that can haul a huge load of people and gear to an off-road camping trip in style and comfort appeals to you, give this vehicle a look.
To learn more about the new Jeep Grand Cherokee, visit http://www.jeep.com/en/2014/grand_cherokee/.
And for more from this author, including car show coverage, automotive reviews, and automotive history, be sure to check out http://www.hovermotorco.com/.
Finally, for a comprehensive photo slideshow of our 2014 Jeep Grand Cherokee test vehicle, click this link.


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TIKI CHECK IN 7/19 --Dance, Baby, Dance!
Tuesday, July 20, 2010
Since July 12, I have succeeded in accomplishing:
Activity wise:
2 walks: total 2 miles (I wish backpack tracking included a 20-30 pound pack, because for about 15 minutes, 1/4 mile or so I carried the too-tired tot home. She's heavier than the under 10-pound pack in the tracker. Man, I rocked that downhill hill with her too.)
Getting on my physioball more days than not and wiggling my hiney, stretching my lower back and keeping active at my desk. (pretty much everyday I think). It fits me better than my desk chair, I've learned.
A snatched set of frog squats in the bathroom!
More lower body work while reading to the little one in bed (whoa, did I feel the burn!)
An awesome upperbody ST resistance band video (2 sets) with the Wonder Cutie Nicole Nichols. I moved to my medium resistance too.
I got lots of veggies in with a wonderful batch of summer ragout! Man that felt yummo-awesome.
I really put my fear in the fire with making lots of phone calls and contacting people, stepping outside my comfort zone to get things on the ball with my family's insurance, income and supplemental grocery needs. I really hate making phone calls to unknown entities, so making multiples of these in ONE week is a really big deal for me. (You can see how this can be a big disabling issue in a work setting for a professional who has to make first contacts. oy)
BUT, between now and Friday, July 23- I plan on pushing beyond my boundaries by tackling:
AT LEAST 3 (THREE) Nicole Videos For ST
I also plan on taking good care of my body in the summer heat by doing these 3 things:
Keeping a pitcher of water in the fridge to remind me to drink that instead of other stuff.
Do cardio inside and not make excuses about the heat, humidity and pollen.
Enjoy the summer bounty of tomatoes, squashes and cucumber in lots of yummy salads and light summer saut�s and stir-fries!!
This week, the best way to encourage me is to stop by my page and tell me to keep on dancing and to keep eating clean, that I am worth it.
And when I find myself getting weak or giving in to temptation, I will remember that my body is a temple. Everything I am doing for it should be sacred, not profane. That the week leading up to my birthday can be a special one, because what would a piece of cake mean if I had dessert every day?
This week's cardio is going to be inspired by Allyn, Meraina, Chacha and my dancing princess kidlet and I'm going to do some DANCING, spontaneous, find some Zumba instruction videos, some oldies, anything inspiring.
This week's strength workouts are going to be inspired by Nichol Nicoles and I'm going to do stretch my limits with the resistance band workouts, find new ways play ball, and review her Pilates stuff.
This week's stretching is going to be inspired by Loonette the Clown and I'm going to do fun, silly, spontaneous clock stretches like she did on The Big Comfy Couch.
This week's rest time is going to be inspired by the birds and I'm going to turn off the TV at 9:30 to start my bedtime routine earlier.
The one thing that I am NOT going to do between now and midnight on Friday is:
Eat out.
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Salads are WIN!
Sounds like you are keeping right on track!
You CAN beat the summer heat and still look fab!
Go you!
2164 days ago
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Awesome job so far! I know how you feel about the phone calls, they suck, but good for you because you got them done! You keep on dancing, YOU ARE WORTH IT!!!
2167 days ago
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"A snatched set of frog squats in the bathroom! "
I have NO IDEA what this is, but it made me giggle. :) I like the idea of starting your bedtime routine earlier. You're not saying "I will go to bed by X time!" but you're acknowledging that starting earlier might help you fall asleep earlier. Good plan.
Sounds like you have a great week planned out for yourself. Keep it up with those Coach Nicole videos!
2167 days ago
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