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MEMPHIS — As this surprisingly successful Trail Blazers season chugs along and the victories continue to accumulate, an unexpected trait is emerging within a franchise that is supposed to be young and rebuilding.
These baby Blazers sure are clutch.
The Blazers eked out yet another nail-biting win Friday night at FedExForum, defeating the Memphis Grizzlies 86-84 in a gritty, grinding slugfest before 15,823.
With the win, the Blazers improved to 8-2 in games decided by six or fewer points. Add that to the fact that they're 4-0 in overtime games and 13-1 when leading or tied heading into the fourth quarter and the Blazers are developing a knack for excelling in pressure-packed, do-or-die situations.
"When we are in close games, I do believe ... there's a belief that we're going to find a way to win the game," Blazers coach Terry Stotts said. "Not to say that we're going to win all of them, but the belief is certainly there."
Wesley Matthews scored 21 points and LaMarcus Aldridge added 19 points and 11 rebounds, but the Blazers' narrow escape Friday was courtesy of defensive dominance down the stretch. The Grizzlies did not make a field goal over the final 3 minutes, 10 seconds as the Blazers' stingy defense forced them into misses on their final nine attempts.
The most harrowing and important of the misses came in the closing seconds, when the Grizzlies had three opportunities to win the game in what was a wild finish. With the Blazers leading 85-84, Rudy Gay launched a 12-foot turnaround jumper under duress with 16.9 seconds left but missed. Marc Gasol snared the rebound and worked it to Mike Conley, who drove the lane and missed a contested layup.
Nicolas Batum wrestled away the rebound for the Blazers along the baseline and — with Stotts screaming for a timeout from the bench — was forced out of desperation to throw the ball off Conley's leg as he was falling out of bounds. Stotts didn't get his timeout, but the Blazers were awarded the ball with 4.8 seconds left.
They worked it to Aldridge out of an inbound play and he was fouled with 2.1 seconds left. But he only made one of two free throws and the Grizzlies had one final chance to win or force overtime.
The Grizzlies set up a play for Gay out of a timeout, and, with Batum attached to his hip, Gay sprinted left across the middle of the court and launched a 22-foot pull-up jumper. Brick. Game over.
The dramatic defensive stands by the Blazers epitomized their stout defensive play during the pivotal fourth quarter. Memphis scored just 12 points, made just 5 of 22 field goals and committed four turnovers in the fourth. And throughout the solid stretch, virtually every Blazers player did something to fuel the run.
"I thought we played very good team defense," Aldridge said. "I thought we played tendencies very well down the stretch. We had talked about it all game, about knowing what (Memphis) wanted to do, and I thought down the stretch, we guarded those tendencies."
Case in point: The final play. Batum had been studying video of Gay's tendencies since the Blazers arrived into Memphis on Thursday, and he noticed that Gay was nearly unstoppable in clutch situations when he went right before elevating to shoot. So as Batum steadied himself for the final defensive stand, he knew he had to do everything he could to force Gay left and away from his bread-and-butter move.
"I knew if he goes right, he's going to make it," Batum said. "In the videos, when he got the last shot, he goes right and he make it almost every time. So I just tried to push him left to have a better chance for him to miss. He's a great player, so if he makes it, he makes it."
But he didn't. And the Blazers (17-15) pulled off another shocker. It was their ninth win in the last 12 games and their second in three games of a four-game trip. A team that couldn't buy a win on the road has now defeated the New York Knicks and Grizzlies — teams with combined 26-7 home records — over a four-day span.
JJ Hickson had 19 points and 11 rebounds and Damian Lillard added 11 points, eight assists and five rebounds for the Blazers, who overcame the rugged play of Maurreese Speights (22 points, 13 rebounds) and held Gay (19 points, nine rebounds) to just two points in the second half.
"It was a gritty win," Stotts said. "Memphis is used to playing these types of games. We haven't. And to win a game in that style says a lot about our growth as a team."
Notes: The game featured 21 lead changes and nine ties. ... Former Blazers forward Zach Randolph was a late scratch because of flu-like symptoms. ... Memphis dropped to 20-10 on the season. ... Batum (417) moved past Steve Blake (415) and into fifth place on the Blazers' all-time three-point shooting list with three threes against the Grizzlies.
—Joe Freeman; follow him on Twitter


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'Gittisham - the ideal English village'
HRH Prince Charles
Combe House Devon is committed to a focus on green initiatives and green policies, by monitoring and reducing consumption levels, converting environmental efforts into cost-reduction and revenue generating opportunities, whilst promoting the Combe House Devon corporate and social responsibilities mandate contained below.
Our CSR policy is supported by all our staff who assist in identifying and implementing eco-friendly policies.
Combe House Devons corporate and social responsibility policy sets out the principle and standards for the business.
Accessibility for all
Combe House Devon understands that every guest has different needs and we aim to make our hotel facilities available and accessible to all of our guests equally. In rare instances where this is not possible we will endeavour to offer a range of facilities for guests with a perspective on disability (see Access Statement in Hotel Directories and on website) including:
Community support
Combe House Devon is supportive of specific local community projects and assistance to local charities. Each request is given due consideration. All sponsorships contribute to the our objective of supporting local charities (the list of charities changes on a rotation basis).
Overview of the Strategy and Action Plan
At Combe House Devon we regularly review each area of our environmental policy. The main focus is on reducing consumption and improving efficiency in our Energy and Waste Management processes. Our strategy is to investigate and implement new technology or practices, to reduce levels and to agree ongoing best practice and improvement in our overall environmental impact.
We work towards continuous improvement in environmental management and performance by staff and to encourage support from all stakeholders. (See Environmental Policy in Hotel Directories and on website.)
Our approach to the environment is guided by a number of principles.
The Environment Policy is everyones responsibility from kitchen porter, housekeeping to the Green Team, and sets out the responsibility for environmental performance and develops and maintains an adequate system of management, measurement and improvements.
Standards Management
The Chairman of the Green Team is responsible for the overall environmental performance, which is reported to the Combe House Devon owners.
Reduce the use of water and materials through awareness programmes and through designing efficiency into buildings, equipment and working practices.
Set and meet targets for the reduction of utility consumption. Monitor, report and update this annually.
Reduce, Reuse or Recycle solid waste where economically and environmentally sensible. When these options are not available, dispose of solid waste in the most environmentally responsible manner.
Set targets for the reduction of waste produced. Monitor, report and update these annually.
The following is a selection of initiatives that Combe House Devon adopts to help Reduce, Reuse and Recycle:
Daily actions
On a day to day basis the staff at Combe House Devon take the following actions in their contribution to helping the environment:
Hazardous substances
Reduce the use of hazardous or non-degradable chemicals. We work with our supplier partners to encourage use of environmentally friendly soaps and detergents for laundering bed linen and towels. Where the use of such substances is unavoidable, train staff in their handling and disposal and take precautions to minimise the impact of spillage.
Reduce the use of ozone depleting substances in supplied packaging materials, refrigerants and fire suppression systems by specifying new equipment that is free of such materials and replacing existing systems as directed by legislation. Staff are COSHH trained.
Working with our local communities
Reduce as far as commercially practicable the level of harmful or nuisance emissions.
Collect used cooking oil and recycle it through a licensed contractor.
Carry on business in a responsible manner with due regard to the hotels immediate environment, particularly at unsociable hours and in relation to noise, odour, lighting, litter, uncollected waste or deliveries and collections.
Maintain building exteriors, outdoor equipment and grounds to create a positive visual impact within the hotel's community.
Introduce contingency plans for major incidents to reduce their environmental impact.
Local Support
A selection of actions of ways in which we support our local environment, services and suppliers:
Our Corporate & Social Responsibility Policy
Combe House, nr Exeter, Devon
somewhere different, somewhere special
Combe House DevonVisitors always most welcome for coffee, lunch, tea or dinner.
Dining at
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If you're looking for a restaurant that serves great food and offers exciting wines, specially selected by passionate wine lovers, you will love the Restaurant at Combe House - click here to learn more
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subset: commoncrawl


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Cleveland County deputies arrest burglary victim's relative
Police noticed suspect wearing ring stolen from victim's homeUPDATED 10:26 PM CDT Aug 22, 2013
Cleveland County Sheriff's deputies said they arrested a woman after a family member noticed she was wearing a ring stolen from the victim's home on Aug. 16.Video Transcript
CASH.. JEWELRY AND FLAT SCREEN T-V'S. A NORMAN FAMILY GOES ON VACATION, TO FIND SOME OF THEIR MOST VALUABLE POSSESSIONS GONE. AND TONIGHT, DEPUTIES SAY THEY MADE A SHOCKING ARREST. THEY BELIVE A FAMILY MEMBER IS BEHIND THE CRIME. HERE AGAIN IS KIM PASSOTH. 2:23:21 hey did you see anything weird last night? 2:23:23 THAT'S THE QUESTION LEXI WILLIAMS WAS ASKED BY HER NEXT-DOOR- NEIGHBORS. OVER THE WEEKEND SOMEONE BROKE INTO THEIR HOME, WHILE THEY WERE OUT OF TOWN. THE BURGLARS ONLY HIT CERTAIN AREAS WHERE VALUABLES WERE HIDDEN. 2:27:34 not like a typical burglary b/c we got hit years before and they dumped everything out 2:27:39 RUSSELL CLARK SUSPECTED SOMEONE HE KNEW WAS BEHIND THE BREAK -IN... BUT HAS A HARD TIME ACCEPTING HIS OWN DAUGHTER WAS ARRESTED FOR THE CRIME. 2:29:43 it pretty well tore me and her mom both up 2:29:47 INVESTIGATORS SPOTTED JESSICA CLARK WEARING ONE OF THE STOLEN RINGS... 2:29:19 it was :20 my mothers wedding ring 2:29:21 DEPUTIES SEARCHED HER HOME AND CAR AND FOUND SOME OF THE 60 THOUSAND DOLLARS WORTH OF STOLEN JEWELRY... MONEY... AND ELECTRONICS. 2:14:43 she had a backpack with her that contained the 16,900 in cash 2:14:46 NOW THIS BROKEN HEARTED DAD IS HOPING SOMEONE CAN HELP HIM FIND A FAMILY HEIRLOOM STOLEN BY HIS OWN DAUGHTER. 2:30:35 i'd just really love to have my grandfather's ring back 2:20:38 HE SAYS THE 32ND DEGREE MASON RING THAT LOOK SIMILAR TO THIS.,, CANNOT BE REPLACED.... AND NEITHER CAN THE TRUST HE ONCE HAD IN HIS DAUGHTER. 2:30:18 i dont know where it goes from here 2:20:19 RUSSEL SAYS HIS DAUGHTER WOULD HAVE INHERITED MUCH OF THE JEWELRY, HIS DAUGHTER IS ACCUSED OF STEALING. SHE'S ALSO FACING DRUG CHARGES. BRAND NEW AT TEN...
CommentsThe views expressed are not those of this site, this station or its affiliated companies. By posting your comments you agree to accept our terms of use.blog comments powered by Disqus


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Grindz™ removes lingering residue inside your grinder by absorbing and loosening the coffee particles and oils that get left behind. Using Grindz™ is as easy as grinding coffee beans – just grind the tablets through your grinder, with no disassembly required.
Designed for:
Grindz™ Grinder Cleaner is a patented, completely all-natural and food safe way to regularly clean the burrs and casings of your grinder without disassembly.
For Use on Burr Grinders
1. Empty all coffee from grinder.
2. Add one packet of Grindz™ Retail Grinder Cleaner to hopper.
3. Adjust grinder to medium setting and operate.
4. To purge, repeat above process twice with coffee. Repeat if desired.
Note: Dust may develop during grinding and is harmless. Wipe particulates from hopper, spout, and doser. Keep container tightly closed and dry.
Ingredients: Proprietary formulation containing grains and cereals, and pharmaceutical grade binders. Gluten Free and Organic.
Why use Grindz™?
Cleaning a grinder is a challenge because water cannot be used on the burrs or around electric motors. The process of opening or disassembling a grinder can also be intimidating due to the small parts and electrics inside the machine. Grindz™ eliminates these concerns because it is as simple to use as grinding coffee. Simply grind the cleaning tablets through your grinder to remove the coffee residue and oil, ensuring great tasting coffee.
How often do I clean my grinder?
We recommend using Grindz™ once a month, to ensure that there are no stale or rancid coffee oils and particles inside your grinder. This residue can negatively affect the taste and quality of your next brew, so avoid a bad cup by keeping your grinder properly cleaned. Grindz™ should be used when switching between flavored and non-flavored coffees, as well as caffeinated and decaffeinated coffees.
Why was Grindz™ Grinder Cleaner developed?
Cleaning a grinder has always been a challenge since water cannot be used on the burrs or around electric motors. The process of opening a grinder can also be very intimidating due to the small parts and precision involved in positioning burrs. Finding a way to clean a grinder without opening the machine became a valuable product concept. After extensive field testing and evaluation, Grindz™ was successfully launched in 2005 and patented in 2012.
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When ground through your coffee grinder, the product gently dislodges coffee particles while absorbing coffee oil residue.
Is Grindz™ Grinder Cleaner a "chemical?"
No. There are only food safe and edible ingredients in this product. As a result, the product presents no risk if the residue is consumed, and it will be flavor neutral to your coffee.
How do I learn more about safety of this product?
A full material safety data sheet (MSDS) for each product can be downloaded here: Download


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Nobody likes Tax day…. except probably the people over at TurboTax. Their service is now the default way of filing taxes.
I really like how on their pricing page they have speech bubbles so you can easily self-identify with a the best TurboTax plan for your needs. It is really hard to cater to the masses.. but TurboTax does it extremely well, they are able to cater to low AND high income earners as well as students, military personnel, and business owners.
When I was on this page, my eyes went right to the speech bubbles. I remember even saying, "Yes" a few times in my head as I was scanning which package I should get.
What is interesting is that it isn't just the simple short text, it is also the design. The speech bubbles make it look like you just said it.
What do you think of the speech bubbles – did they work on you?


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"Lindsay went to the hospital to visit a friend," says her rep. "She is in rehearsal today for her film Labor Pains."
Lohan and Ronson were spotted at Century City Hospital in Los Angeles on Thursday evening
Later, Lohan briefly accompanied Ronson to her deejaying gig at West Hollywood's Goa.
Like this story? Click on the Yahoo Buzz! button below to Buzz it up!


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Note: Some images can be enlarged, clicking over them.
| Agoncillo. (La Rioja)
"Castillo de Aguas Muertas".
Castle built in XVth century, recently restored. In the middle ages, several feudal strifes took place there: in 1334 the last lord of Cameros was executed in the castle.
|Aguilar de Campoo. (Palencia)
Ruins of a castle built between XII and XIV centuries. Donated by Enrique II to the Manrique family (as part of the donations known as "bienes enrique±os"), it returned later to the Crown, being given by Enrique III to D¬ Aldonza de Castila. Nowadays, it belongs to the Town Council of Aguilar de Campoo.
|Almenar. (Soria)
Castle of arab origin, modified in XV century. It belonged to several noble families (Bravo de Sanabria, Saravia, RĒos). The Spanish romantic poet Gustavo Adolfo Bķcquer placed here two of his stories. The wife of the poet Antonio Machado was born here.
| Ampudia. (Palencia)
One of the best conserved castles in the province of Palencia. Built at XV century, it was assaulted by the rebels during the War of the Communities (1520-1521). At XVII century it belonged to the Duke of Lerma (Prime Minister of Felipe III), who was also Count of Ampudia. Now, it belongs to the Fontaneda industrial family.
| Arenas de San Pedro. (Avila)
"Castillo del condestable Dßvalos" or "Castillo de la Triste Condesa".
Built between 1393 and 1423 by Don Ruy L¾pez Dßvalos, lord of the town, it belonged to the constable of Castile, D. Alvaro de Luna and, after his death, to his widow, Juana de Pimentel: "la triste condesa" (the Sad Countess), who gave her name to the castle. Now, its tower is being restored.
| Arķvalo. (Avila)
Castle made at XIV century with stone and brick, modified at XV and XVI centuries. There, the king Pedro I confined his wife Blanca de Borb¾n. Afterwards, it was a State Prison.
| Arg³eso. (Cantabria)
Placed near the town of Fontibre (in the Northern region of Cantabria), it has two towers,built between XII & XIV centuries, and a central body built later. The mother of the marquis of Santillana (a famous medieval poet) lived here.
Atienza. (Guadalajara)
Castle of XII century, built on a 200 m. high rock, over a previous arab castle which was conquered by the castilians in 1085 (when Alfonso VI conquered Toledo). In 1162, king Alfonso VIII of Castile, still a child, was sieged by his aunt, Fernando II de Le¾n, and escaped while his men celebrated a holyday to distract the Leonese, this holyday is still celebrated in the town.
|Batres. (Madrid)
Built between XV and XVI centuries, it is almost completely conserved. There, was banished the knight Fernßn Pķrez de Guzmßn, where he wrote "Mar de Istorias" and his famous "Generaciones y Semblanzas". Afterwards, the poet Garcilaso de la Vega, brother of the Lord (Pedro Lasso de Guzmßn) lived there.
| Belmonte de Campos. (Soria)
Ancient castle, in the border between the kingdoms of Castile and Le¾n. Only the Main Tower (XV-XVI centuries) is conserved in the present days. It belonged to D. Juan Manuel de Villena, being adquired in 1.622 by the familiy Manrique, marquises of Belmonte.
| Berlanga de Duero. (Soria)
Arab castle of X century, reconquered by Fernando I and rebuilt at XV century by Tovar family. Many modifications at XVI century, in order to adapt it to the use of artillery. Close to it, there were a palace and Renaissance garden, both of them destroyed during the Napoleonic invasion.
|Castle of Las Caba±as de Castilla. (Palencia)
Near the town of Osorno la Mayor, this castle was built at XV century by the family Casta±eda. It has been restored by his owner, who lives there.
| Caracena. (Soria)
Built in XV century, over a more ancient castle (about XII century). It is placed between two precipices, over the town of the same name.
|Castrourdiales. (Cantabria)
XIII century Gothic castle, at the northern region of Cantabria. Nowadays, it lodges a lighthouse.
| Cifuentes. (Guadalajara)
Built after 1324 by the prince don Juan Manuel, who lived there some time; Fernando de Antequera & king Juan II of Castile also lived in this castle, while the first one was waiting for the decission of the Parliament of Caspe (which made him king of Arag¾n). It was owned to the Silva family, counts of Cifuentes. In the War of Sucession of Carlos II, the city supported the Archduke Charles, and in the Spanish War of the Independence (Peninsular War), it was occuped two times by the Empecinado's guerrillas.
|Clavijo. (La Rioja)
Castle placed 15 km far from Logro±o, in the same place where the king of Asturias Ramiro I defeated the Moorish in 844, helped, following the legend, by St. James.
Coca. (Segovia)
Brick-made castle, of "mudķjar" style. Built by the archbishop of Seville don Alonso de Fonseca, during the reigns of John II & Henry IV. It belgons today to the dukes of Alba, and is used by the Autonomous Government of Castilla y Le¾n as School of Forest Science.
|Cuķllar.. (Segovia)
Built at XV century by D. Beltrßn de la Cueva, favourit of the king Henry IV, and first duke of Alburquerque. It was finished by his descendants at XVI century, being still propierty of the Dukes of Alburquerque, it lodges the Archive of their House, as well as a Public Secondary School and cultural celebrations.
|Encinas de Esgueva (Valladolid)
Built at XIV century, it belonged to the Aguilar family, who were counts of Encinas and lords of the castle. Now, it belongs to the spanish Ministry of Agriculture, who used it as a cereals storage.
| FrĒas (Burgos)
The actual castle is a mixture of buildings of XII, XIII, XV & XVI centuries. Probably the most impresionant rock castle at northern Castile, it was adquired by the Crown in 1202. In 1446 king Juan II left it to Pedro Fernßndez de Velasco, comstable of Castile & Duke of FrĒas.
|Fuensalda±a. (Valladolid)
Built at XV century by Vivero family (Lords of the town). Currently is the building of the Autonomous Parliament (Cortes) of the region of Castile & Leon.
Fuente el Sol (Valladolid)
Built at XV century, by D. Alvaro de Bracamonte.
Fuentes de Valdepero. (Palencia)
"Castillo de los Sarmiento".
Built at XV century, this castle is being rebuilt now. It belongs to the Province Council of Palencia, which has planned to lodge there its Historical Archive.
|Gormaz. (Soria)
Arab castle (started at 956, under the Caliph Al-Hakam II), it is the biggest and oldest castle of Western Europe: it has a perimeter of 1 km and 400 m between its two sides. It presents many reforms, because it was conquered several times during the "Reconquista" (978-981 by the count GarcĒa Fernßndez, 983 by Almanzor, and 1059, by Fernando I.
|Iscar. (Valladolid)
There is first reference on a castle in Iscar, from 939, when it was destroyed by troops of Caliph Abd-el-Rhaman III. The town was repopulated in 1089, by count MartĒn Alfonso. later, it belonged to the Z·±iga family, being the castle reformed in 15th century, by Pedro de Z·±iga. Nowadays, it is being restored, and it is planned to lodge a museum.
|La Adrada. (Avila)
Ruins of a XIV century castle, built in the same place o f the romance between Alfonso VI & Zaida, the daughter-in-law of Al-Mutamid of Seville. On a strategic position, between Old Castile & Toledo, it was cause of several strifes between the counts of Villena and the Pimentel & Mendoza families.
Manzanares el Real (Madrid).
Built, at the end of XV century by the first duke of el Infantado, don Diego Hurtado de Mendoza , over a previous castle, which had been built by another Diego Hurtado de Mendoza (1365-1404), this one Admiral of Castile.
|Medina del Campo. (Valladolid)
Built in 1440 by king Juan II of Castilla, in mudķjar style, was designed by Fernando Carre±o and Alonso Ni±o, and built by Abdalla & AlĒ de Lerma. It was a royal residential palace (queen Isabel I lived there her last years), then it became prison of the Kingdom. Now completely restored, it belongs to the Regional Administration ("Junta de Castilla y Le¾n"). Apart from being a museum, it can provide facilities for courses and workshops, including housing.
|Medina de Pomar. (Burgos)
Castle of "Las Torres" or "Alcßzar de Medina de Pomar".
Built between 1370and 1380 by D. Pedro Fernßndez de Velasco, lord of the city by gift of the king Enrique IV. It is conserved completed and restored.
|Mironcillo. (Avila)
Castle of "Aunqueospese" or "del risco"
Castle started in 1490 by Pedro Dßvila, captain of the Duke of Alba, over a land propierty of the Community of ┴vila. The construction was stopped, after the complain of the city council, being finished by the son of Pedro Dßvila, esteban, in 1504.
Molina de Arag¾n. (Guadalajara)
It was built at XII century over an ancient Arabic castle.
|Mombeltrßn. (Avila)
"Castillo de los duques de Alburquerque".
Built about 1470 by D. Beltrßn de la Cueva, favourit of the king Enrique IV and first Duke of Alburquerque. The interior of the castle was reformed at XVIII century. It still belongs to the Dukes of Albuquerque.
|Monteagudo de las VicarĒas. (Soria)
Castle built at 15th century, near the frontier between Castile and Arag¾n, probably being part of the frontier defensive system of Castile. It is placed on a side of a walled town. It has been recently restored.
Montealegre. (Valladolid)
Castle built at the end of XIII century or beginnig of XIV century by Alfonso de Menezes, as new main fortress of the family (being Villalba de los Alcores the prvious one). Nowadays, it belongs to the Ministry of Agriculture.
|Monz¾n de Campos. (Palencia)
Castle of XIV or XV centuries, probably built by the Rojas family, ancient lords of the place. It has been restored by the provincial Council of Palencia, and lodges a hotel and a restaurant.
Narros de Saldue±a (Avila).
"Castillo del duque de Montellano".
Mudķjar castle, built on 15th century, by the family Valderrßbano. It is still used as residence by its owners.
|Las Navas del Marquķs. (Avila)
Castillo-Palacio de Magalia
Built during the first half of XVI century, by the first Marquis of Las Navas, Don Pedro Dßvila y Z·±iga, and over a previous castle. Nowadays, it belongs to the Spanish Ministry of Culture and is used to lodge courses and cultural events.
|Olmillos de Sasam¾n. (Burgos)
"Castillo de los Cartagena"
Built about 1440 by D. Pedro de Cartagena, a nobleman of Jew origin (the original name of the Cartagena family was LevĒ). Now, it lodges a museum, and a future hostal of the "Camino de Santiago".
|Osma. (Soria)
Remains of an ancient castle, from X-XI centuries, and placed over a long hill between Ucero & Avi¾n rivers. Near the ancient Roman city of Uxama. Following the legend, on October 6th, 1469, the future king Ferdinand the Catholic tried to enter the castle, disguised as a trademan (he was coming to Castile to marry Isabella). The guradian of the castle shot him an arrow that, fortunately, didn't hurt him.
| Pedraza de la Sierra. (Segovia)
Built between XIV & XVI centuries. It belonged to the families Herrera & Velasco (dukes of FrĒas). The sons of king Francis I of France were hostages here. Now, it belongs to the descendants of the painter Zuloaga, who use it as residence and museum.
Pe±afiel. (Valladolid)
Built in the XV century by Pedro Gir¾n, Master of the Order of Calatrava, over the ruins of a previous castle. Tpday, it lodges a Museum of Wine: the region around Pe±afiel is the place of origin of the wines of "Ribera del Duero". The castle is famous too because it was the place where the Prince Don Juan Manuel (one of the top figures of Spanish Medieval Literature) wrote his books.
Pe±aranda de Duero. (Burgos)
Built at XV century, by the first Count of Miranda de Casta±ar, Don Diego de Z·±iga y Avellaneda, with the same plant as the castle of Pe±afiel.
| Pioz.. (Guadalajara)
Moslem castle. Only the outern walls are conserved.
|Portillo. (Valladolid)
Built between XIV and XV century, it was a royal prison, some of its prisoners being the count of Benavente, Suero de Qui±ones & Enrique EnrĒquez, king Juan II of Castile and his comstable Alvaro de Luna. In the present days, it belongs to the University of Valladolid.
| Poza de la Sal. (Burgos).
Castle built in 14th century by the family Rojas. It was part of the defensive system of the salt mines of the place.
| Riba de Santiuste.. (Guadalajara)
XII-XIII centuries castle, it belonged to the bishops of Sig³enza.
San Esteban de Gormaz. (Soria)
Ruins of an arab castle, near the more famous castle of Gormaz (see above). it was a veryimportant fortress during the Middle Age, because it defended the bridge over the Duero river, which was one of the entrance ways to Castile. At this castle, the daughters of El Cid refugeed after being abandoned by the sons of the Count of Carrion.
| San MartĒn de Valdeiglesias. (Madrid)
"Castillo de la Coracera".
XV century castle, it belonged to D. Alvaro de Luna, favourite of Juan II of Castile. It has been restored by its owners, recovering the Homage Tower.
| Segovia."El alcßzar".
There is a first document about a castle in Segovia, in 1122. It was residence of kings like Ferdinand III, Alphonso X, Henry IV, Philip II .... The present building was built by the kings of Trastßmara dinasty, at XV century. It was destroyed by fire in 1862, and rebuilt in 1882. Currently it belongs to the Spanish Ministry of Defence, lodging a Museum of Artillery, the Military Historical Archive .... The city of Segovia has been declared World Heritage Site.
More information here
Sig³enza. (Guadalajara).
"Castle/Palace of the bishops".
Castle built at 12th century, after the Christian conquest of the city. It presents many modifications. The frontal area (photograf), dates from 14th century, and was built by the bishop D. Sim¾n Gir¾n de Cisneros. Today, it lodges a hotel of the National Net of "Paradores"
Simancas. (Valladolid)
Built at XV century by the Admirals of Castile (EnrĒquez family). Later, it was a royal propiety, and it was (and is actually) used like General Archive of the State Files.
|Sotopalacios. (Burgos)
"Palacio del Cid".
One of the biggest and best conserved castles at the province of Burgos (origin of Castile). built between XIV & XV centuries, near the ancient lands of "El Cid".
| Tiedra. (Valladolid)
There is first reference on a castle of Tiedra, of the times of El Cid (he was charged by Sancho II with and interview with Princess Urraca, in this castle), but the present castle is a construction of XIII century, built by Pedro ┴lvarez de Asturias. It was used by the rebel Don Tello Tķllez de Meneses, during the minority of Alfonso XI. Tiedra belonged to Le¾n, until it was given to Castile as compensation for the divorce of Alfonso IX & D¬ Berenguela. It is on sale.
Torija. (Guadalajara)
Templar castle, whose actual structure dates from XV century. It was conquered by the Marquis of Santillana and the bishop of Toledo, in 1452. During several centuries belonged to the Mendoza family, who controled the Royal Road. During the Peninsular War, it was blown by the guerrillas of el Empecinado. Recently restored, it lodges the museum of "Viaje a la Alcarria", the novel of C.J.Cela, where personal souvenirs of this Nobel Prize are shown.
Torrelobat¾n. (Valladolid)
"Castillo de los Comuneros".
Built about 1420-1426, by Alfonso EnrĒquez, (future Admiral of Castile). During the War of the Communities (1519-1521), it was assaulted by the rebel troops of Juan de Padilla, who used it as Headquarters of his army. After the war, it was rebuilt (1538).
|Ucero (Soria)
Built at XIV century, in one of the most exciting landscapes of the province of Soria: over the town of Ucero, the river of the same name and the Canyon of the Lobos River (Natural Park). A secret passage connects the castle and the river.
Urue±a. (Valladolid)
Built, like the walls, between XIII & XIV centuries. Urue±a was part of the "Infantazgo de Valladolid", a land disputed by Castile & Le¾n, being the main fortifications built by Alfonso VIII of Castile. After the union of both kingdoms, the fortifications lost importance, recovering it by a while during the civil wars of the reign of Pedro I El Cruel.
| Villafranca del Condado. (Segovia)
"Castillo de Castilnovo".
Castle of mudķjar style, built at XIV-XVI centuries. It belonged to the comstable Alvaro de Luna, the St·±iga family and the dukes of FrĒas, lodging royal characters like the princes Ferdinand & Leonor (future kings of Arag¾n), Henry IV, the Catholic kings and the sons of the king of France (Francis I) as hostages, after the battle of PavĒa. Restored in XIX-XX centuries, it belongs to the Spanish-Mexican Cultural Association.
|Villafuerte de Esgueva. (Valladolid)
One of the best example of the "School of Valladolid", being built on 15th century by Garci Franco de Toledo, a nobleman of Jewish origin, and Lord of Vellosillo. Today, it belongs to the Spanish Society of Friends of Castles, who are restoring it.
|Villaviciosa. (┴vila)
Built between XV & XVI centuries by Nu±o Gonzßlez del ┴guila y Guzmßn, it is conserved complete & restored, lodging a hotel.
| Villaviciosa de Od¾n. (Madrid)
Built after 1496, by the Marquises of Moya, Andrķs Cabrera & Beatriz Fernßndez de Bobadilla. Destroyed by the Communard rebels in 1520, it was rebuilt by D. Diego Fernßndez de Cabrera y Bobadilla. In the presents days, it lodges the Historical Archive of the Spanish Air Force.
|Vozmediano. (Soria)
Castle of an ancient origin, most of its contruction dates from XII-XIV centuries. The castle occupies a strategic position on the Moncayo mountain, a region highly disputed by Castile, Aragon & Navarre, from its reconquest by Alfonso I of Arag¾n (12th century) until the deffinitive fixing of the border in 1437.


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Top Definition
An animal which is cross between a giraffe and a polar bear. It is considered an insult because of the way it is pronounced and is an extension of the word jar.
I hate you so much! You're so annoying! You're such a jarbear.
بواسطة ilovejarbears مارس/آذَار 8, 2013
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Can you define these popular missing words?


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From the Department of Surgery, University of Louisville School of Medicine, and the Trauma Program in Surgery, University of Louisville Hospital, Louisville, Ky.
Medical error is a prominent public issue today. Surgeons, for many decades, have conducted regular and meaningful reviews of most untoward events, which deserve improvement. "Near-miss" is a useful focus for such a conference, in that it avoids a focus on ultimate personal guilt and minimizes exposure to litigation (ie, a nonevent).
The converging realities of medical error, the demand by the public and purchasing community for greater accountability by health care providers, and the need to incorporate quality improvement education into residency training pose a formidable challenge, in addition to new restrictions on resident duty hours.1 Reengineering conference time to maximize educational content is an essential component of meeting this challenge and improving patient care and safety. The traditional Morbidity and Mortality Conference has been a genuine learning conference for surgical residents for generations.2 To use conference time more efficiently, the conference has been altered to reflect educational needs while meeting weekly for 1 hour. All deaths and complications are previewed by a faculty member with the presenting resident. The best teaching cases are selected for formal presentation and in-depth discussion. Emphasis is placed on evaluating complications and deaths in the context of literature experience with similar situations and with the goal of optimizing patient care to minimize future treatment-related complications.
In addition, a "near-miss" case is chosen for presentation and discussion. As noted by Spencer,3 the near miss provides a free lesson (ie, a picture of a problem that was corrected so as to avoid or limit its consequences). This represents a new area of discussion at the retitled Quality Improvement Conference.
The focus of this report is to review some of these near misses with the goal of trying to improve patient safety via this internal reporting format. Four examples follow. These near-miss cases demonstrate 4 completely different types of problems, all of which are common.
A middle-aged woman presented to our surgery clinic with a large breast tumor. She was diabetic and had chronic renal failure; her creatinine level was 2.5 mg/dL (221 µmol/L). A computed tomographic scan of her abdomen and chest, with intravenous contrast, was ordered as part of her pretreatment examination. The ordering physician had missed her creatinine value in the outpatient clinic medical record. The technologist in the Radiology Department noted the problem and alerted the ordering physician, and the imaging study was changed to a magnetic resonance imaging scan, which provided the desired anatomical information. A modified radical mastectomy was subsequently performed, without complications.
This demonstrates the potential problem of intravenous contrast-induced renal failure in a patient with preexisting chronic renal dysfunction. From an institutional perspective, it illustrates the need for adequate safeguards to prevent iatrogenic injury resulting from diagnostic tests, when safer alternatives exist in certain situations.
A young healthy man was admitted to our emergency surgery service at 4 AM after being involved in an automobile crash while intoxicated from alcohol. His emergency department examination revealed a grade 1 splenic laceration, and he was admitted for observation. The computerized patient list failed to include his admission. The surgical team changed at 7 AM, and the patient was literally lost in the "handoff." Because he also did not appear on the computerized patient list, he was not seen by a surgeon for nearly 36 hours. His presence in the hospital only became known to the surgical residents when his nurse asked one of them for diet orders. He tolerated a regular diet, had stable hemoglobin and hematocrit levels, and was discharged from the hospital early the next day.
The missed handoff is attributable to the changes in house staff work hours, which have diminished continuity of patient care, coupled with a data entry problem in our hospital's computerized patient listing. Local solutions to this problem have been implemented to minimize recurrence.
An obese middle-aged man with a long history of cigarette smoking sustained fractured ribs from blunt trauma and was treated with an epidural catheter in the intensive care unit (ICU). He was stable and was transferred out of the ICU after postinjury day 2. He was noted to be tachypneic by the surgical residents during regular rounds the following day, although he was otherwise stable, including having an oxygen saturation rate of 92% to 94%. He was returned to the ICU. Despite optimal respiratory care, he tired quickly and required intubation in the ICU several hours later. He eventually recovered, without further difficulties.
This case illustrates the serendipitous timing of rounds and an alert resident who noticed the early signs of respiratory decompensation in a patient at high risk for such an event. The prompt actions taken thereafter averted the possibility of a catastrophic event. In further evaluating this case, the nurse-patient ratio is raised as a potential quality-of-care issue. Successful management of similar cases outside of the ICU demands attentive care by skilled nurses who have appropriate workloads.
A healthy middle-aged man was admitted to the emergency surgery service after sustaining chemical burns to his leg, penis, and lower abdomen. On postinjury day 2, he was taken to the operating room with a planned operation of excision and split-thickness skin grafting of the wounds. Despite healthy-appearing tissue at the base of the excised wounds, skin grafting was deferred. The wounds subsequently required 2 additional operative debridements to remove later-appearing residual necrotic tissue before allowing successful split-thickness skin grafting.
This last case addresses the issue of clinical judgment based on knowledge. This man's chemical burns looked good enough that serious consideration was given to early excision and skin grafting. Understanding the nature of chemical burn injuries led to the decision to delay skin grafting. This decision was validated by the subsequent manifestation of deeper tissue injury requiring further operative debridement before grafting.
The introduction of near-miss cases into a conference forum offers a rich and previously overlooked teaching opportunity. These cases provide students, residents, faculty, hospital administrators, and nurses a vehicle for evaluating and improving quality-of-care delivery locally. These cases also introduce students and residents to the concept of systems thinking (system-based learning) through the evaluation of health care delivery as a series of interlinked processes that are best broken down into component parts and changed to effect improvement in health care delivery. Last, by publicizing specific near misses and considering the causes, external reporting potentially serves to help other institutions address problems that have yet to be recognized.4
Corresponding author: Michael H. McCafferty, MD, Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292 (e-mail: email@example.com).
Accepted for publication June 29, 2003.
Box Section Ref ID
Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
Millenson ML. Demanding Medical Excellence. Chicago, Ill: University of Chicago Press; 1997.
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One of the most important things I've learned over the years is that weight management for most people is an ongoing challenge. We don't struggle to reach our goal weight then simply "coast" for the rest of life. Far from it. At the same time I can tell you that achieving and maintaining a healthy weight is easier with some solid knowledge about food and nutrition, self-awareness, motivation, and successful strategies.
I can put on weight faster than just about anyone else I've ever met. My gender, height, and age are not working in my favor. I'm a woman, which typically means having a slower metabolism than a man of the same height, age, and weight. I'm short and that translates to a slower metabolism than someone taller. I'm getting older and so I am affected by the inevitable metabolic slowdown that begins around the age of 40.
However, the one thing I do have control over is exercise. Sometimes I get the exercise I need and sometimes I don't.
How about you? How do you fare with metabolism? Do you understand how it works, what your metabolic needs might be, and how to keep your metabolism running smoothly? If not, I would encourage you to read a series I wrote on what we currently know about metabolism.
It must be my metabolism: Part One
My basal metabolic needs hover around 1200 calories. That's what I need to keep my organ systems functioning well even if I were at complete rest for 24 hours. If I do anything at all, but am mostly sedentary, my total caloric needs are just 1400 calories per day. That's why I write a lot about low calorie diets. I have to watch what I eat and make sure I get the exercise or other physical activity I need. Not being vigilant can mean putting on weight FAST.
Fortunately, I've learned many things over the years in my work as a Nutritionist that helps me manage weight more easily. I'll share some of the things I've discovered in recent years that have helped me a LOT. Maybe you'll find a tip or two that will work for you. I'll also share some of the ways I could improve.
Some Lessons Learned and Heeded
One of the most important lessons I've learned with respect to what I have on hand to eat is the need to have "enough" lean or low calorie protein foods. Striking the right balance is a bit of a challenge because if I have too much on hand, I end up with waste. Not having enough means I may not get the protein I prefer to have to not only meet my basic needs with respect to physiology but also to keep me feeling full and satisfied.
At the beginning of each week I decide which lean protein foods I will be purchasing. Most of the protein foods I buy will get incorporated into meals. This might include a lean cut of meat, poultry, fish, eggs, or beans.
I also have protein foods for quick, easy, and nutritious low calorie snacks. One week it might be a carton of low fat cottage cheese. Another week it might be lean slices of chicken or turkey. Or I might choose to boil 4-5 eggs at the beginning of the week to have hard-boiled eggs readily available in the refrigerator. There are plenty of other choices but these are some of my current favorites. Having some kind of quick-to-eat lean protein matters.
In addition to having lean protein available for meals and snacks, I need to have other healthy low calorie snack foods on hand such as fruit or raw cut veggies. Something else I've been enjoying recently are my own homemade nutrition bars made of peanut butter, dried fruit, oatmeal, a little honey, seeds, and sometimes nuts.
Although I like these bars, I'm still experimenting with coming up with the right mix of ingredients. I make each bar small to keep the calorie count down. I find them to be very satisfying as well as nutritious. I also keep one or two small commercially prepared snack bars such as Larabars in my purse. This way I have something handy to eat if I'm away from home and hunger hits but there's nothing available that's low calorie or healthy.
Best Nutrition Bars for Women: Part One
Another tip is to avoid having tempting snack foods at my desk. Having something available for those times when I'm too busy to break away to eat properly is important. BUT if I have too much of what I like, I can easily get carried away eating it at times when I'm not necessarily hungry.
I keep a small amount of almonds and a carton or two of soymilk near my desk but in a location I cannot see. I only rely on these if I am actually hungry but cannot stop work to go eat.
Here are a few more changes I've made in recent years:
I now eat whole fruit most of the time rather than drink juice. For example, I gave up on drinking orange juice quite a while ago because I get more dietary fiber and other nutrients when I eat a whole orange.
When eating out I've learned to look for lean cuts of meat, skinless poultry, or fish without breading or high calorie sauces. In addition, I choose to substitute the carb part of the meal such as white potatoes, white rice, or pasta with an extra serving of veggies. If the portion size is very big, I'll only eat half and take the rest home. By doing these things it helps me to cut down on calories and lowers my overall carb intake for the day.
I do plan for one or two cheat meals each week when I am allowed to have whatever I want. If you try this strategy, I encourage you to plan for something that's really tasty and satisfying (otherwise why bother?). In addition, you need to eat slowly so that you recognize when you are full and stop before overeating!
What have YOU learned about yourself or your way of eating that is making things easier for you now? Please share!
My Ongoing Challenges
The one challenge I struggle with more than anything else is overestimating how many calories I burn when I exercise. By doing this I have a tendency to allow myself to eat larger portions and less than healthy foods because I THINK I have burned lots of calories.
Something I experimented with this past year to avoid this problem is the BodyMedia Fit armband. In a previous article, I shared how much I learned about the calories I burn each day. What an eye opener! When I stop wearing the armband, in just a short 2-3 months I begin to forget. I may need to wear the armband for a few days 2-3 times a year as a gentle reminder of my caloric needs.
Something else I find to be very helpful if I actually use it is a pedometer.
I also need to work on limiting the number of potential treats and less than healthy foods in my house. I do buy some of these items but my dear husband tends to bring home more of the things I would rather not have around. My current solution is to at least put the food where I do not see it every time I walk into the kitchen!
What kinds of things are you struggling with? Would you be so kind as to let me know in the comments? Thanks!
Novel Idea for Motivation
I came across an intriguing idea in a USA Today article for weight loss motivation. The tip was to hang up a pair of skinny jeans in a place you see often, possibly even the kitchen! Now this could work for any outfit that you'd like to fit into soon. Choose one that might fit better with the loss of just a few pounds (1-5). I think that's a creative idea!
For more ideas on doing what works for YOU, you may want to read the article Weight Loss Advice: Tips from Others that I wrote not too long ago.
O.K. these are just a sampling of my recent experiences and ideas. I hope I've inspired you enough to get you thinking about the past year with respect to what is working for you and what isn't when it comes to achieving or maintaining a healthy weight. What might you change?
Wishing you the very best for Happy Holidays! I will be off Christmas week visiting my mother and other family. I hope to be back publishing sometime the first week of January. Happy New Year!


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Sony TV Launching Arabic Versions of Everybody Loves Raymond and The Voice
Also, Who Wants to Be a Millionaire?By Andre Tartar
Also, Who Wants to Be a Millionaire?By Andre Tartar
Once upon a time, Craig Rowin asked the Internet for a million dollars. It didn't happen, but he got one more chance in the hot seat at Who Wants to Be a Millionaire.By Eliot Glazer
Meredith Vieira gives you permission to laugh.By Amanda Dobbins
Also: 'Blue Valentine' opens two days earlierBy Bryan Hood
Watercooler conversation topics ain't the same as they used to be, folks.By Mark Graham
"When I was asleep, I kept hearing that name."By Mark Graham
Our note? More slumdogs!By Mark Graham


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Author Affiliations: Division of Dermatology (Drs Matsukura, Walsh, and Shear) and Department of Pharmacy (Ms Knowles), Sunnybrook Health Sciences Center and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada. Dr Matsukura is now with the Department of Dermatology, Yokohama City University Medical Center, Yokohama, Japan.
This article was corrected | View correction
Background There is increasing evidence that a single cycle of rituximab (375 mg per square meter of body surface area once weekly for 4 weeks) is efficacious in patients with severe pemphigus. The approved protocol in rheumatoid arthritis is 1 g on days 1 and 15. We report herein on the efficacy and safety of this latter protocol for rituximab in 9 patients with pemphigus.
Observations Nine patients with recalcitrant pemphigus were treated with prednisone, immunosuppressive agents, and/or intravenous immunoglobulin. Rituximab, 1 g, was infused on days 1 and 15. Each patient was observed for a minimum of 6 months. Reepithelialization of at least 50% of the affected areas occurred in all patients within 16 weeks. Three of 6 patients (50%) discontinued intravenous immunoglobulin therapy. A significant decrease in the pemphigus severity score and the mean dosage of prednisone was observed at 3 and 6 months. Relapses were observed in 4 patients between 5 and 13 months after rituximab treatment; these patients completed a second cycle of rituximab. There were no serious adverse effects observed during the follow-up period.
Conclusions A single cycle of rituximab, 1 g on days 1 and 15, is an effective treatment for pemphigus. Further studies are needed to determine the efficacy and safety of repeated treatment courses in patients who experience recurrences.
Pemphigus is a rare, life-threatening, autoimmune, blistering disease affecting the skin and mucous membranes. This group of diseases is mediated by autoantibodies directed against desmogleins 1 and 3 and results in the loss of cell-cell adhesion of keratinocytes through acantholysis. Patients with severe pemphigus often require long-term, high-dose corticosteroid therapy to maintain disease control. However, adverse effects frequently accompany this dosing regimen, such as glaucoma, metabolic abnormalities, and hypothalamic-pituitary-adrenal axis suppression. Thus, immunosuppressive agents (eg, azathioprine sodium, cyclophosphamide, and methotrexate sodium) and intravenous immunoglobulin (IVIG) therapy are often used concomitantly as corticosteroid-sparing agents.1- 6 Despite the use of these potent drugs, there are patients whose disease is resistant to therapy and others who are intolerant of these agents.
Rituximab is a chimeric murine-human monoclonal antibody that targets the CD20 antigen found on B cells and results in rapid depletion of this cell population. It is approved for the treatment of non-Hodgkin B-cell lymphoma and rheumatoid arthritis; in addition, rituximab has been shown to be effective in other autoimmune diseases, such as systemic lupus erythematosus, multiple sclerosis, and pemphigus.7- 10 In published studies of pemphigus, the dosing schedule for rituximab is similar to that indicated for nonHodgkin B-cell lymphoma, namely, 1 cycle of 4 weekly infusions of rituximab at a dose of 375 mg per square meter of body surface area (BSA). In contrast, rituximab has been approved7,9 for rheumatoid arthritis at a dosage of 1000 mg on days 1 and 15. We hypothesized that the 2-dose protocol would be effective and safe in the treatment of pemphigus. We report herein on the efficacy and safety of rituximab therapy in 9 patients with recalcitrant pemphigus who were treated using this alternative protocol.
Patients with a confirmed diagnosis of severe pemphigus vulgaris or pemphigus foliaceus were eligible to receive rituximab if they met at least one of the following conditions: (1) relapsing disease that was resistant to treatment, including the use of systemic corticosteroids, immunosuppressive agents, and/or IVIG; (2) contraindication to the use of systemic corticosteroids; or (3) recalcitrant disease that affected more than 50% of the BSA. Patients were assessed according to a pemphigus severity score11 (Table 1). Outpatient medical records were reviewed to identify demographic information, the extent of disease involvement, and the use of corticosteroids, immunosuppressive agents, and IVIG.
All patients had a confirmed diagnosis of pemphigus vulgaris or pemphigus foliaceus. Diagnoses were based on severe mucosal erosions, superficial blisters, and/or erosions on the skin that formed a histologic picture of intradermal acantholysis and/or deposition of IgG complement component 3 on the keratinocyte membrane, which was detected by direct immunofluorescence. Indirect immunofluorescence studies were performed for most patients at diagnosis. This type of study uses monkey esophagus for the substrate and applies antihuman IgG–fluorescein isothiocyanate conjugate. Serial dilutions are performed if the initial dilution (1:40) is positive for circulating IgG autoantibodies directed against the cell surface of keratinocytes or if the patient is known to have had positive test results previously. Eligible patients were identified by the treating dermatologist (S.W. and N.H.S.). This study was approved by the Sunnybrook Health Sciences Centre and Women's College Research Ethics Board.
Rituximab, 1 g, was administered as an intravenous infusion on days 1 and 15 along with methylprednisolone sodium succinate, 100 mg, before each infusion, according to previous recommendations.6 All patients received the treatment in a local hospital or in an outpatient infusion center between January 1 and August 31, 2008. Therapy with corticosteroids, other immunosuppressive agents, and IVIG was maintained during rituximab treatment. When rituximab infusion was completed, these treatments were decreased or discontinued if a remission occurred.
Each patient was observed for a minimum of 6 months. The extent of disease was evaluated at 1, 3, and 6 months after rituximab treatment was completed. Primary end points were a change in the pemphigus severity score, the dosage of corticosteroids used (ie, prednisone), whether IVIG therapy was discontinued, the time from the start of rituximab treatment to partial or complete remission, the number and length of relapses, and the adverse effects of treatment, including infections. Secondary end points were whether the immunosuppressive agents (other than corticosteroids) were decreased and results of an immunological evaluation of the pemphigus antibody. Partial remission was defined as the epithelialization of more than 50% of the lesions; complete remission was defined as the epithelialization of all skin and mucosal lesions.
Basic descriptive statistics were used to characterize the patient population. The percentage of change in the prednisone dosage at 1, 3, and 6 months after rituximab infusion was calculated. Single-sample paired t tests were performed to determine the significance in mean values between treatment time frames. All statistical tests were performed using Microsoft Excel 2003 software (Microsoft Corp).
Nine patients (6 men and 3 women; 8 with pemphigus vulgaris and 1 with pemphigus foliaceus) were included in this study (mean [SD] age, 41.3 [11.5] years). Patient characteristics are given in Table 2. Two patients had skin lesion involvement of more than 50% of their BSA. Two patients had had recalcitrant, severe oral mucosal lesions for more than 2 years. Three patients experienced at least 2 cutaneous or mucosal relapses while corticosteroid dosages were being decreased. The use of corticosteroids was contraindicated in 1 patient owing to uncontrolled hypertension and osteopenia.
Before rituximab treatment, 8 of the 9 patients were treated with high dosages of prednisone (mean [SD] dosage, 58.1 [49.7] mg/d). Immunosuppressive agents used included mycophenolate mofetil hydrochloride (6 patients), azathioprine (1 patient), methotrexate and mycophenolate mofetil (1 patient), and cyclophosphamide (1 patient). Intravenous immunoglobulin was administered monthly in 6 patients.
We found a significant decrease (P < .05) in the average pemphigus severity score at 3 and 6 months compared with the mean score at baseline (Figure 1). Partial remission occurred in all patients between 4 and 16 weeks (mean [SD], 7.5 [3.1] weeks) after rituximab treatment (Table 3). Complete remission was seen in 4 patients between 16 and 24 weeks (18.0 [4.0] weeks).
Figure 1. Pemphigus severity score before and after rituximab treatment. A significant decrease (P < .05) was observed in the mean score (red curve) of 9 patients at 3 and 6 months compared with the mean score at baseline.
Eight patients were taking prednisone at baseline (mean [SD] dosage, 58.1 mg/d). The mean percentages of decrease in the prednisone dosage were 39% at 1 month (mean [SD] dosage, 35.1 [22.3] mg/d), 67% at 3 months (21.7 [11.9] mg/d), and 74% at 6 months (15.6 [3.7] mg/d) (Figure 2). One patient's prednisone dosage was increased at 6 months because of disease recurrence at 5 months. We noted a significant (P < .05) decrease in the mean prednisone dosage at 3 and 6 months compared with baseline.
Figure 2. Effect of rituximab treatment on the prednisone dosage in 8 patients. A, Most had a dramatic decrease in the prednisone dosage except 1 patient who discontinued its use at 3 months but started again at 6 months because of disease recurrence. B, A significant (P < .05 [*]) decrease (↓) in the mean prednisone dosage at 3 and 6 months was observed compared with the mean dosage at baseline. The percentage of change in the prednisone dosage was measured from baseline.
Six patients received monthly IVIG therapy prior to rituximab treatment. Two patients discontinued IVIG therapy at 3 months and 1 patient at 5 months. Three patients continued monthly IVIG treatments during the follow-up period.
Patients received immunosuppressive agents, such as mycophenolate mofetil (Figure 3A), azathioprine and cyclophosphamide (Figure 3B), and methotrexate (Figure 3C). The use of these agents was generally reduced after the prednisone dosage was decreased. The dosage of mycophenolate mofetil was decreased in 2 patients at 3 and 6 months. The cyclophosphamide dosage was decreased in one patient (75 mg/d at 1 month reduced to 50 mg/d at 3 months), and the methotrexate sodium dosage was decreased in another (22.5 mg/wk at baseline reduced to 5 mg/wk at 6 months). The dosage of azathioprine was decreased in a third patient at 6 months. All other patients remained on the same dosage of these agents after undergoing a decrease in their prednisone dosage.
Figure 3. Change in the dosage of each immunosuppressive agent after rituximab treatment in 8 of our 9 patients. A, Mycophenolate mofetil hydrochloride. B, Azathioprine sodium and cyclophosphamide in patients 5 and 9, respectively. C, Methotrexate sodium in patient 7. Our usual protocol is to taper the corticosteroid dosage first and then decrease or withdraw intravenous immunoglobulin therapy followed by immunosuppressive agent tapering. Most patients stayed on the same dosage of their immunosuppressive agent during the study period.
The peripheral-blood B-lymphocyte (CD19+ B-lymphocyte) count was examined in 3 patients. The rate of B cells in all 3 patients decreased dramatically to undetectable levels (<1000/μL [to convert to cells ×109 per liter, multiply by 0.001]) at 4 weeks and remained undetectable during the follow-up period. In addition, the circulating antipemphigus antibody level was measured in 3 patients at baseline and 6 months. Two patients' titers became negative at 3 and 6 months after rituximab treatment. One patient had a flare at 5 months; his titer was 1:320 at baseline, 1:80 at 3 months, and 1:160 at 6 months after treatment.
Four patients experienced disease recurrence: 1 at 5 months, 2 at 12 months, and 1 at 13 months. All 4 patients completed a second cycle of rituximab intravenous infusion, 1 g, on days 1 and 15. One of our 9 patient developed bacterial pneumonia 7 months after rituximab treatment; his condition improved after standard antibiotic therapy. No other adverse effects, including infusion reactions, were noted.
To our knowledge, this is the first report to describe the use of an alternative dosing regimen for rituximab in patients with pemphigus. In previously published reports, rituximab was administered intravenously at a dosage of 375 mg per square meter of BSA once weekly for 4 infusions per course.6- 8 The 2-dose regimen was administered to our patients because it was an approved dosing regimen for rheumatoid arthritis (1 g administered on days 1 and 15), it was more convenient for patients because it decreased the number of clinic visits they needed to attend to receive their infusion, and the cost of the rituximab was decreased, on average, by about 35%.12
Rituximab has been shown to provide clinical benefit in patients with pemphigus vulgaris or pemphigus foliaceus that is treatment resistant, widespread, or both.10- 14 A recent review article summarized the case reports in the literature to December 2008.10 In all, 136 patients with pemphigus were treated with rituximab. In 79 of the 103 patients with pemphigus vulgaris (77%), rituximab treatment resulted in the healing of all lesions; in 41 (40%), all immunosuppressants were discontinued. Thirteen patients (13%) had a relapse that required a second course of rituximab treatment. In our report of 9 patients, all had a partial response initially between 4 and 16 weeks after rituximab treatment. At 6 months, 4 patients (44%) had a complete response and 4 (44%) had a partial response; 1 patient (11%) had a recurrence at 5 months. At the end of the observation period (a minimum of 6 months), 3 of the 9 patients (33%) were in complete remission, 3 (33%) were in partial remission, and 4 (44%) had a recurrence requiring a second cycle of rituximab. The relapse rate is similar to the study by Joly et al,8 who described 9 of 21 patients (43%) who experienced disease relapse after a mean (SD) of 18.9 (7.9) months.
In our study, the dosage of prednisone was decreased 74% compared with baseline at 6 months after rituximab treatment. In addition, of the 6 patients who were receiving IVIG therapy prior to rituximab, 3 patients discontinued therapy after 6 months. For 6 of the 8 patients receiving mycophenolate mofetil, no change in dosage was noted at the end of the observation period. Azathioprine treatment was decreased in 1 patient.
We observed no serious adverse effects during the study period. One patient developed pneumonia at 7 months, which resolved with a course of oral antibiotics. Reported adverse effects of rituximab in the treatment of pemphigus include 1 patient who developed pyelonephritis8 and 1 death from septicemia at 18 months.8 Another report15 describes 2 deaths in a cohort of 25 patients who received rituximab for refractory mucous membrane pemphigoid. One patient was receiving cyclophosphamide and prednisone, and the other was receiving azathioprine, cyclosporine, and prednisone. The authors hypothesized that there was an increased risk of death associated with continuing immunosuppressive treatment following administration of rituximab. In our patient population, the prednisone dosage was decreased on completion of the rituximab infusions. Treatment with other immunosuppressive agents is usually continued until some improvement is observed. We did not find that continuation of immunosuppressives resulted in increased adverse events. However, it is still important to monitor for potential adverse effects of immunosuppressive therapy, such as serious infections and late-onset neutropenia. We may not have observed any serious adverse effects because of the small number of patients studied or because of our simplified protocol.
In conclusion, a single cycle of rituximab administered as 1 g on days 1 and 15 is an effective and safe treatment for patients with recalcitrant pemphigus. A larger study is needed to assess the long-term benefits and risks of this treatment and to determine the optimal dosing regimen (2 doses vs 4 doses) of rituximab for patients with pemphigus. Further studies are also needed to establish criteria for subsequent infusions of rituximab. Our study provides encouraging results for the use of an alternative regimen that requires only 2 infusions.
Correspondence: Setsuko Matsukura, MD, PhD, Department of Dermatology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan (firstname.lastname@example.com).
Accepted for Publication: December 8, 2011.
Published Online: February 20, 2012. doi:10.1001/archdermatol.2011.3320
Author Contributions: Drs Matsukura and Shear and Ms Knowles had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Matsukura, Knowles, Walsh, and Shear. Acquisition of data: Matsukura, Knowles, and Shear. Analysis and interpretation of data: Matsukura, Knowles, and Shear. Drafting of the manuscript: Knowles and Shear. Critical revision of the manuscript for important intellectual content: Matsukura, Knowles, Walsh, and Shear. Statistical analysis: Matsukura and Knowles. Administrative, technical, or material support: Matsukura and Knowles. Study supervision: Knowles and Shear.
Financial Disclosure: None reported.
This article was corrected for errors on August 20, 2012.
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By ROGER ROSENBLATT; Roger Rosenblatt, the author of ''Children of War,'' is the editor of U.S. News & World Report.
Published: July 9, 1989
FROM BEIRUT TO JERUSALEM By Thomas L. Friedman. 525 pp. New York: Farrar, Straus & Giroux. $22.95.
With America's attention fixed on China and the Soviet Union these days, it is odd to remember how long and steadily we have gazed at news from the Middle East. Events thought ineradicable at the time they occurred now have to be recalled deliberately: the Israeli invasion of Lebanon in the spring of 1982. The P.L.O.'s retreat from that country. The suitcase-bomb assassination of the President of Lebanon, Bashir Gemayel, in September 1982. Shortly afterward, the massacre of over 200 Palestinian men, women and children by units of Phalangists in the refugee camps of Sabra and Shatila. The suicide bombing of the American Embassy in Beirut in April 1983. The suicide attack on the Marine headquarters in October 1983, in which 241 servicemen were killed. The hijacking of a T.W.A. jetliner to Beirut, and the brutal, casual murder of an American seaman on board, his body dumped from the plane like a sack of mail. The Achille Lauro hijacking, and the murder of the wheelchair-bound Leon Klinghoffer. Countless killings, kidnappings and bombings among the sects and factions in Lebanon. Most recently, the Palestinians in the occupied West Bank and Gaza Strip hurling stones at Israeli soldiers, and the retaliating Israelis wielding clubs and firing guns.
For nearly a decade from 1979 to 1988, such explosions formed the routines of Thomas L. Friedman's journalistic life. ''From Beirut to Jerusalem'' is an account of those years - the most intelligent and comprehensive account one is likely to read. It is a story of how the past cripples the present and confounds the future. And it is also the story of a particular kind of character in pursuit of an all-devouring subject. One learns early on that the author is a golfer, a key to appreciating the narrative. Mr. Friedman has the golfer's serene fanaticism, incomprehensible persistence and a lovable insufferability.
He says himself, ''I was insufferable,'' describing his high school passion for Israel and things Israeli. In Minneapolis, where he grew up, he created a slide show for his classmates on the Six-Day War of 1967. When 13 Jews were arrested in Syria, young Mr. Friedman went around wearing a button that read: ''Free the Damascus 13,'' which ''most of my high-school classmates thought referred to an underground offshoot of the Chicago 7.'' Mr. Friedman's first story for his high school paper was about a lecture given at the University of Minnesota by a then obscure Israeli general by the name of Ariel Sharon.
From Minneapolis to Brandeis University, where he studied both Hebrew and Arabic. From Brandeis to St. Antony's College, Oxford, and a master's degree in Middle East studies. From Oxford to Beirut in 1979, first with United Press International, then, in 1982, with The New York Times, which posted him to Jerusalem in 1984 after almost five years in Beirut. While with The Times, Mr. Friedman won two Pulitzer Prizes for his coverage of the inflammable world of his dreams.
In a way, Lebanon and Israel have constituted the world of everyone's dreams for the past several years. For Americans at home, the story of those places has seemed a surrealistic work in progress, or regress, full of strange, brooding characters (Menachem Begin, Yasir Arafat, General Sharon) and bizarre episodes always involving death, dismemberment, deep wailing in the streets. Mr. Friedman is different when writing of Beirut than he is when writing of Jerusalem. When he arrives in Jerusalem for the second stage of his assignment, and for the second half of the book, he becomes the political and historical analyst. Reporting from Beirut, he is, for the most part, Pandemonium's correspondent, detailing scenes of pathos and hysteria.
After an Israeli bomb flattened an eight-story apartment house, a Palestinian woman returned home to find her entire family buried in the rubble. ''She immediately tried to fling herself onto the ruins,'' Mr. Friedman reports, and a photograph was taken of her struggling toward her smothered family. About an hour after that picture was taken, the same woman was standing beside a car parked across from the Ministry of Information. A small bomb planted in the car exploded, and the woman was killed at once.
''Eventually, after seeing enough car bombs,'' Mr. Friedman writes, ''I started focusing on the leaves. When a car packed with one hundred sticks of dynamite explodes on a crowded street, the force of the blast knocks all the leaves off the trees and the road is left choking with them like an autumn lawn. My friends in the Lebanese Red Cross still tell the story of a man they found at a car bombing near the Ministry of Information whose chest was blown open. They knew he was still alive because, through the blood that filled his mouth, little air bubbles kept surfacing. The thing they remembered most, though, was that two leaves had come to rest gently on his face - one on each eye.''


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The families and friends of the four teenage Scouts who were killed in a tornado at an Iowa Boy Scout camp are trying to cope with the loss of the young leaders, while others are hoping for the full recovery of the injured.
In Omaha, Neb., on Thursday night, hundreds gathered, many of them in Scout uniforms, for a candlelight vigil to remember the four: Aaron Eilerts, 14, of Eagle Grove, Iowa; and Josh Fennen, 13; Sam Thomsen, 13; and Ben Petrzilka, 14, all of Omaha -- all of whom had been selected as leaders in their local troop and had been invited to attend the special week-long training.
Click play to hear comments from Lloyd Roitstein, an executive with the Mid-America Council of the Boy Scouts of America, as scouts, friends and family gather together to honor the four at a candlelight vigil.
Now, family members are preparing for funeral services. A memorial service will be held for Josh Fennen on Saturday, but his funeral and burial will be in Texas. On Monday, Aaron Eilerts' funeral will take place and on Tuesday, funerals for Ben Petrzilka and Sam Thomsen at their local Catholic churches.
Coping through Prayer, Action
The family of Sam Thomsen is relying on faith to cope with his death, and their church in Omaha is rallying around them, according to the family's pastor.
Pastor Jim White of the Southwest Church of Christ said many people have been extending their love and support to the grieving family. He said that church members and friends had blessed their home with food - and lots of prayer.
White recalled Sam as active leader in Sunday School, saying he recently attended a national youth church program and delivered a sermon at the church on Samuel from the Bible after his return.
Sam's mother, Sharon Thomsen, believes her son's life had a purpose.
"It's been a real blessing to see all the people that Sam impacted just rallying around us. It's very touching, the storie that are coming out. And we know that he had a purpose. Has a purpose still. We're very confident of that," she told ABC News.
The family of another victim, Ben Petrzilka, set up funds at two banks to raise money to build underground storm shelters at the Little Sioux Scout Ranch, said John Nordmeyer, Petrzilka's uncle.
Wrong Spot, Wrong Time
"It's hard to wrap your brain around it," scoutmaster Doug Rothgeb said of the horrific tornado that tore through the elite camp on Wednesday night.
"It's something that as parents and scouters, we know the risks. We know the boys know what they're doing. Those four boys ended up in the wrong spot at the wrong time. It's all Mother Nature."
The bodies of the four fallen scouts were found near the collapsed stone chimney of the multipurpose building where Scouts gathered to socialize, said Lloyd Roitstein, an executive with the Mid-America Council of the Boy Scouts of America.
The 145 mph tornado had destroyed the building where the boys had taken shelter.
At least 12 people remained hospitalized late Thursday, including four who were in serious but stable condition at Mercy Medical Center in Sioux City, Iowa.
'They Know What to Do'
Dozens of the Scouts, ages 13 to 18, are being praised as heroes for their acts of bravery and resourcefulness.
"There were some real heroes at this Scout camp," Gov. Chet Culver said, adding that he believes the Scouts saved lives while they waited for paramedics to cut through the trees and reach the camp a mile into the woods.
The 93 boys had taken part in a mock emergency drill with 25 staff members just a day before the twister hit.
"They knew what to do, they knew where to go, and they prepared well," Roitstein said.
Homeland Security Secretary Michael Chertoff toured the camp. He said it appeared that the Boy Scouts "didn't have a chance" and that the tornado came through the camp "like a bowling ball."
Hailed as Heroes
In the meantime, tales of valor emerged from the camp.
Roitstein said a group of Scouts pulled the camp ranger and his family from their destroyed home. Scoutmaster Rothgeb said his 15-year-old son emerged from a ditch where he had taken cover, then joined other Scouts to break into the equipment shed.
Fourteen-year-old Zach Jessen remembered that before the tornado hit, someone noticed a rotation in the clouds and that an alarm went off in the multipurpose building. A short time later, someone began shouting to get under the tables, Jessen said.
"All of a sudden, the tornado came and took the building," he said. "It sounded like a giant freight train going right over the top of you."
Another scout, 16-year-old Charles Bowerman, recalled taking cover under a table and watching chairs go airborne. The very force of the twister sent Bowerman flying across the floor and out onto the grass.
"I was going to the Lord's side, and I was going to go there flying," he told the New York Times."It felt like I was about to be lifted up. I just hugged the ground as much as I could."
The governor declined to address inquiries as to whether the Scouts should have stayed at the campground after severe weather alerts were issued.
"There's always lessons learned from any natural disaster, from any tragedy," Culver said. "We need to focus on the victims, the families affected."
The 1,800-acre camp is located in the Loess Hills in westernmost Iowa, not far from the Nebraska line, about 40 miles north of Omaha.
Source: The Associated Press, New York Times, ABC News
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