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Family Birthday Cards

Debbie and I created some birthday cards this past weekend and I wanted to share them with you.

McKaylas bdt card  Isn’t this card darling?  Debbie created this card for her second cousin’s upcoming second birthday.  This is done all with punches!  I love the rhinestones in her tiara and the glitter on her wings.  The little curls are punched from the “string” of a balloon punch!  Great card for a perfect little girl!

Deb's brother card Happy Birthday to Debbi’s brother, Russ!  When he was a teenager, Russ wore only black, gray, silver and white.  His room was limited to black, gray, silver and white.  With this in mind, Debbi created a masculine card that is black, gray, silver and white.  Thanks to the Big Shot, a Texturz plate and Quick Kutz metal sheets, Debbi was able to add silver highlights to her brother’s card.

Russ bdt card 2This was my card for Russ.  I had an idea in mind, but as Debbi had taken all the punches to prepare for our upcoming Punch-a-Bunch Stamp Camp on September 10th and 11th, I was “punchless!”  However, I found the new large scallop circle punch she had left, and I was able to use that to create my interest point.  I used one of the retired silver brads in the center to help carry the silver theme through.  5/8” gray satin ribbon with an overlay of the new 1/8 taffeta ribbon finished off my color scheme.  Happy Birthday Russ!


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Best Cheap Car Insurance in 2018 – Easiest Way to Try to Cut Your Rate in Half

If You Have a Car Insurance Policy, This is the Easiest Way to Try to Cut Your Rate in Half

Best Cheap Car Insurance in 2017 - Easiest Way to Try to Cut Your Rate

Closely inspect your insurance bill before you pay it.

Two shocking studies prove that insured drivers have significantly overpaid. This is the Cheap Car Insurance trick your auto insurer does not want you to know.

Out of all 246 insurers, we found just 7 that will give you an extremely high discount if you drive less than 25 miles per day. Also, there is a select group of insurers that will give a discount for zero DUIs and Cheap Car Insurance if you live in a qualified zipcode. Has your agent told you these discounts?

ALSO READ: Homeowners Are In For A Big Surprise In During 2017 – Rates Still Near Historic Lows!!

The mistake most drivers make is failing to shop around for the best premium and simply accepting an insurer’s renewal quote, which is likely to be much higher.

Thanks to recent reforms to compensation payouts, motorists face a 10 per cent – around $859.00 – hike in their car insurance premiums.

Piling on more pain, from June, bill payers will also see an extra $929.00 added to bills thanks to a rise in insurance premium tax to 12 per cent.

Consumer Fed has warned that 45% of major insurers unfairly hike up loyal customers’ rates just to maximize profits – insurers call it “price optimization.”

This means your insurer will keep barely increasing your rate so it’s statistically unlikely that you’ll leave – this way your insurer makes a higher profit. The rule to fight back is simple.

To get the biggest savings, compare discounted rates from a vast network of insurers (that are licensed in your area).

ALSO READ: Simple Trick To Effectively Solve Your IRS Tax Debt Issues Fast

Therefore, it is now more important than ever to make sure you are not overpaying for your car insurance.

There are a handful of ways to help reduce your car insurance costs? Whether you are male or female, old or young, follow our ten steps to lower premiums.

This is why it’s a no-brainer – you will likely lower your payment, possibly shorten your term, AND can also get cash even on IRSThis is how powerful that little word called “interest” is. The middle class never sees “breaks” like this. So this is your chance to get “in”. Calculate your new payment without HARP »

Recent survey of 1,000 zipcodes shows that the average driver may save $859.00 a year by finding the right insurer. During June — 1,008 U.S. drivers have trusted this to get extreme insurance discounts.

There are 246 auto insurers — Which insurer will give you the best and Cheap Car Insurance rate?

Step 1) Choose your driver and mileage discounts below.

Step 2) After you’ve entered your zipcode and complete the 60 second questionnaire, you’ll have the opportunity compare the best rates in your area to possibly save hundreds per year.

Get discounts in your zipcode from licensed insurers

71% of respondents that shopped said they obtained quotes online. Most shoppers got 2-3 quotes.

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Plans for the 2014 Spring Session

Plans are currently being made for the 2014 Spring Session of Parent University-Effingham. The session will be held on Saturday, April 5, 2014 at the Effingham County Middle School.  Registration and Continental breakfast will begin at 8:00 a.m.  Featured guest will be Shiona “Shi” Curry.

Shiona Curry “Shi” is 9 years old and has a natural approach to cooking. She shares a special message to children about eating healthy while enjoying their food. Since the age of four, Shi has been fascinated by cooking shows and has kept busy reading every cookbook she could get her hands on. She encourages children to take charge of their lives at a young age.

Shi has recently begun taping episodes for her upcoming cooking show entitled “S.N.A.C.’ it up!” S.N.A.C. stands for Shi’s Natural Approach to Cooking. “Shi” speaks that her cooking show will be on television where she can reach children of every race. She has written the S.N.A.C.’ it up! Cookbook and it will be available in October 2013.

“Shi” regularly conducts a series of workshops at schools in her local area. The workshops entitled “Has This Food Come Here From Outer Space?” and “S.H.A.R.E.W.I.T.H.” address different aspects of health (i.e. exercise, water, and healthy thoughts). For these students, “Shi” has become a household name. Recently, Shi was able to clearly see her mission when during one of her workshops, a child with food allergies, was excited to find that she too could participate in a taste testing because all of the ingredients were natural.snac-logo

When “Shi” is not cooking, she enjoys chess, knitting, watching cooking shows, playing with her brothers, and singing. Her overall desire is to continue spreading the message of health and hope everywhere she goes.

The general session will begin at 9:00 a.m. Breakout sessions will begin at 9:30 a.m. Kidz Academy will provide age appropriate activities for children grades PreK – 5. Youth Leadership classes will be provided for students grades 6 – 12. The children’s curriculum will include sessions on test taking tips and a presentation from our featured guest. Various vendors will be available during the day. The program will conclude with lunch and door prizes.

Parent University-Effingham promises to meet the needs of all attendees! The mission of Parent University is to educate, inspire and empower parents to meet the needs of their children by becoming their first and most important teacher. Our goals support Family Literacy by providing services that make sustainability changes in the family. Even though Parent University’s main focus is to provide information for parents, there are learning opportunities for non-parents also.

Parent University-Effingham is sponsored by the Springfield Central High School Association, Inc. and the Effingham County Board of Education. Parent University-Effingham is a non-profit organization with 501 (c) (3) status.

Drawing for all Expense Paid Vacation to the Golden Isles

  • 2 nights and 3 days for 2 adults and 2 children
  • Free passes to Georgia Sea Turtle, Summer Waves, and Lighthouse on St. Simon Island
  • Sponsored by Days Inn

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Parkes Skippycoin ICG

New South Wales

Community, Business and Visitor Town Portal

Parkes Trades and Services Directory, Asphalt

Advertise your Business or Community Group with Parkes best Australian family owned local directory. Replace this entire page with your Advertisement. You can create Ads, Events and Articles for Parkes instantly or have us do it for you

List your Business     List your Community Group

Advertise in Parkes

We are NEW and the Australian Regional Network is over 1000 town and city websites that you can harness for your cause or Parkes promotions that work in hand WITH social media and if you read this message the absolute Top Directory Spot in the Asphalt Category in the Trades and Services Directory is available! Your First Ad or Event is Free! Creating Articles for Parkes community on www.parkes.town website is Free! Full featured Asphalt listings are cheap and Business Article Marketing for Parkes is the best value. Promote "Australian" in Parkes. Login instantly with your Australian mobile, create your Asphalt content and do let us send visitors and new customers to you.

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Promote your Parkes Trades and Services Business, Product or Organization Today
Publish your essential contact information with Phone, Email, Website, Logo, Message, Video and Map to direct Customers, Members or Sales to YOU 24 x 7 with no expensive PPC! Automatically include Facebook and over 300 business and social networking backlink services with Local Community or Australia Wide Advertising through your SEO capable Smart Ad on To build your Parkes listing instantly Create an Account or LOGIN here to all web sites in the ARN Superportal simultaneously to unleash your Easy and Value Community Marketing Platform
Your listing is sorted by timestamp with minimal Ads on the first page therefore early supporters can secure the top spots! Community Portal Finder, Banner Design Tool, More Inside!
If you want us to build Ads for you first create an account
Visit LIST YOUR BUSINESS for more info

Help your favorite business owner find Parkes Trades and Services Directory.
If you know them personally Click Here to send this page to your friend.

The historical radio telescope dish which actively took part in the 1969 first landing of man in the moon located in Parkes
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| 01904 806 500
Ebor Academy Trust Logo

Grovestock and Berri

A big shout out for Rebecca Robbins (aka Berri) and Chris Farrell who performed a number of cover songs including Rebecca’s/Berri’s famous 1995’s version of ‘I want to see the sunshine after the rain’. Thank you Chris for stepping into the role at the last minute – both Rebecca and Chris serenaded us all on Friday at the Grovestock camp out and got that festival vibe certainly a rocking – there was no Kum Ba Yah in sight!

Rebecca is always sooooo modest about her amazing achievements to date, she has a wonderful voice with an amazing range – Rebecca is a natural when she has a mic in her hand and also makes a great DJ! We will probably get told off for posting this 😂 but hey ho.

See below for what she has created to date

About the Author


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18th August 2020

5 of the best places to visit this Autumn

The best places to see the Autumn leaves in North Devon

Everyone knows that autumn days and evenings can be some of the most beautiful, with bright, changing leaves and fiery sunsets. Dramatic displays of autumn foliage appear in abundance around North Devon.  If you’re searching for rust coloured leaves, chestnut landscapes and autumnal photo opportunities, these are the places to visit.

As the temperature falls, enjoy the warmth of the autumn colours with our guide to seeing North Devon’s autumnal beauty at its best.

RHS Rosemoor

Crunching leaves, admiring the autumn colours, learning about the beautiful array of plants, there is plenty to discover at RHS Rosemoor Gardens. The rich scents and colours of the Upper Woodland Walk make this a magical place in autumn, and the thinning canopy allows increasing views over Rosemoor House and across the valley. As the trees start to show off their autumn wardrobe, it's the perfect time to come and explore Rosemoor. Please note, booking is essential. Pre-booked admissions only.

Rock Park

Located just opposite The Park Hotel, Rock Park in Barnstaple is a great place to embrace the autumnal atmosphere. Whether you choose to wander along the river bank and feel the leaves crushing beneath your feet or to simply pick a bench or spot to sit under the trees with an autumn picnic on a warmer day - visitors of all ages can take a break from the rest of the world in the delightful surroundings of our local park.

Arlington Court

The autumn colours always put on a spectacular show at Arlington. Did you know there are over twenty miles of paths on the Arlington estate? Plenty of room to enjoy the autumn vibes and the patchwork of red, gold, oranges and browns. Whether you’re looking for a 5-mile hike or a gentle afternoon stroll, all routes have awesome autumn scenery to enjoy. Our favourite part? In autumn the Deer Park walk provides a chance to see the elusive Red Deer who roam the parkland. Please note, booking is essential. Pre-booked admissions only.

Heddon Valley

On the fringes of Exmoor, you’ll discover the ancient woodland at Heddon Valley will allow you to walk alongside the River Heddon, kicking piles of crisp autumn leaves as you go. Emerging where the sea meets the coastline, towering cliffs on either side of you, take in all the unbeatable views along the way. Feeling more adventurous? Continue the walk to Woody Bay.

Valley of the Rocks

When you visit North Devon, you’ll fall in love with the picturesque Valley of The Rocks. The Valley of Rocks provides a dry valley walk pinned against a backdrop of unique coastal views - the dramatic landscape makes it worthwhile whatever the weather (but especially in Autumn). With pleasant weather, fewer crowds and those beautiful autumnal colours, it’s the perfect place to visit. Wrap up warm and savour the beauty of the natural world, where the air is crisp, the ground is crunchy, and the Valley of Rocks is blanketed in a rainbow of colours.

                                               * * *

Lace-up your walking boots and head to the woods, park or local gardens for an autumn walk. During Autumn, you can save up to 30% on an Autumn Escape and join us for a 2-night break from £116 per person (B&B). Book today! Please check our website for live availability or call us on 01271 372166 to arrange your stay.


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Note: Freight displayed may be higher than actual shipping costs. Items with core charges will be charged additional shipping for a return label to be issued in order to send the core to Keno Tractors. Keno Tractors will always ensure you get the lowest freight possible! Please call if you have concerns.

Orders placed after 1pm PST will be processed the next business day.


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THIS FITS YOUR 2004 Toyota Sienna Reset Vehicle

Roof Racks, Ski/Snowboard Attachment. Ski Rack.

PT27889062 Product Image
Part Number: PT27889062
Supersession(s): PT278-89062

Aluminum attachment features two padded rubber profiles to securely hold your equipment in place. Integrated locks keep your skis/snowboards in the attachment and on the rack. Carries two pairs of skis or two snowboards. Fits on all Toyota Fixed Roof Racks together with a Adaptor Set.  See your Dealer for a complete list of parts required.

Fits 4Runner, FJ Cruiser, Highlander, Land Cruiser, Matrix, RAV4, Sequoia, Sienna, Tacoma, Venza

  • Note: Fits on all Toyota Fixed Roof Racks together with an Adaptor Set:
    • P/N PT278-89061: 4Runner, RAV4, Highlander, Matrix, Sequoia, Sienna, Land Cruiser
    • P/N PT278-35061: Tacoma
    • P/N PT278-35064: FJ Cruiser
    • P/N PT278-48032 : GX/IS/LX/RX

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All prices are Manufacturer’s Suggested Retail Prices and do not include any applicable tax and/or installation charges. Dealer sets actual price.

Additional dealer discounts may apply.
Product Fitment Notice

While every reasonable effort is made to ensure the accuracy of this data, we are not responsible for any errors or omissions contained on these pages. Please verify any information in question with a Toyota sales representative. Before purchasing, please check your vehicle Owner’s Manual or contact your participating Toyota dealer to ensure that the accessory(ies) you have selected are the correct fit for your vehicle.


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COVID-19 UPDATE - OUR SHOP IS NOW OPEN FOR CUSTOMERS TO COME IN AND BROWSE. We will continue to operate a click and collect service for customers who prefer to preorder through the website. Collection is only during shop opening hours Mon-Fri 9am-5.30pm & Sat 9am-5pm. If you require helium filled balloons please put a note on checkout to say what date & time you wish to collect. If you wish to contact us outside of these hours please send a WhatsApp message to 07787 835442. We would like to thank you all for your continued support and hope you all stay safe during these difficult times.

90's TV Host Kit

Look every inch the cheesy TV Host with this instant kit! With a ginger wig and glasses, you’ll have party fever in this cheeky get-up!


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ACA Reporting Software: Tech Support

Tech Support

Hello again,

For those businesses required to file Affordable Care Act information returns, Passport Software’s Tech Support can make your ACA reporting easier.

Our customer service staff is well-trained and informed about our ACA compliance software.  Although we do not give legal advice, we can point you to specific information for complying with the logistics of the ACA.

We have received a lot of “thank-yous” in terms of making business owners’ lives easier with our ACA reporting software and knowledgeable tech support.

One example of our support staff expertise is that we recently helped a client select the correct codes in order to simplify their reporting process.

Our tech support staff is knowledgeable about our software as well as ACA reporting logistics. We can point you in the right direction during the actual reporting process with our software–much more than an average tech staff would be able to.

Our ACA reporting software is a professional level solution, so generally, Passport Software’s Partners will visit the site and implement it for you. This assistance is another way we make your ACA reporting process easier.

Passport Software developers researched the Affordable Care Act in depth, created comprehensive software, and our helpful and informed support can answer your questions about the capabilities of our comprehensive Affordable Care Act software.

Learn more about our ACA Reporting Software or Contact Us – We are here to help.

Contact Us

Find out more about our business solutions!

Login to our secure portal at the bottom of our Partners' page.

Great advice, easily explained
for you to grow your business!


text:
A.J. (sneaky_in_red) wrote in passion_perfect,

  • Location:
  • Mood:
  • Music:
Title: (still no title)
Pairing: Em/JJ, JJ/Will (I swear I want to kill that man!)
Rating: PG
Disclaimer: Don't own them at all. Just borrowing
Archiving: Take it. I don't know if it even worth reading anyway. LOL.

This was intended to be a one-shot fic, but I think my muse changed her mind. :) So here's

Emily woke up with a start. She felt a sharp pain on her head and groaned. She cursed herself for drinking too much the night before. Her head was spinning when she tried to get up so she tried not to move at all.

She thought about the night before. The music, the drink, the pain, the cry, and the realization that she had lost the only person that meant the world to her. She sighed. She could feel tears began to well up in her eyes and she blinked angrily. Get a grip, Prentiss! She scolded herself. She jumped out of the bed, completely ignoring the pounding in her head. She was about to take a shower when she realized that the pounding was not in her head at all. It was the door.

The brunette glanced at the alarm clock on her bedside table and frown. Who in the hell came at this hour? She walked downstairs and opened the door without peeping through the hole.

“You didn’t call me last night! I was worried sick!” an angry Penelope Garcia stormed into her living room.

“Why, good morning to you, too, Penelope,” Emily greeted. She closed the door behind her and followed the blond.

Garcia was about to say something when she saw how pale Emily was. She sighed. She knew something was so wrong with Emily, but the taller woman was a very private person. She doubted she could dig anything out of her, unless Emily herself was willing to open up to her. She watched the brunette walked past her to the kitchen.

“Coffee?” Emily offered. She was too tired to think of the reasons why Garcia came to her place. “I have some cereals in case you haven’t eaten.”

The blond snorted causing Emily to turn. “Cut the crap, Prentiss. What is the hell wrong with you?”

Emily tilted her head. She frowned. “What do you mean?” She asked.

Garcia cursed inside. She knew that Emily wouldn’t crack a thing to her. But she continued anyway, “What do I mean? You know what I mean! You were drunk last night. And you went away without saying anything. You said you were gonna call, but you didn’t. Now you ask me what I mean! You tell me!”

Emily said nothing. She leaned against the wall. Her head was still pounding and she felt like a wreck. But she still looked so calm on the outside that Garcia really wanted to rip that mask off her face. She took a sip of her coffee. “I drank too much,” Emily finally said calmly.

“Right,” Garcia mocked. “That’s new.”

“And I forgot to call,” the older woman continued as if Garcia hadn’t said anything.

Garcia sighed in frustration. “Whatever,” she said. There was no use trying to make an Emily Prentiss to tell her anything she didn’t want to. She knew too well that her friend was well trained for it. And she personally blamed Elizabeth Prentiss for damaging her daughter like that.

Emily shrugged. She put her mug on the counter. “I have to get ready for work,” She pointed. The slender woman walked upstairs, completely ignoring her friend.

Garcia sat on the leather couch, staring blankly at the marvellous view outside the window. The conversation didn’t turn out well, but she had expected that. Emily was always so warm towards everyone in the team, she was always there for them, but what did they know about her life? Besides the fact that her mother is the Ambassador, nothing. The woman felt rather guilty about that. Was she being a good friend? She thought.

It didn’t take long for Emily to get ready. She put on her most ‘FBI like’ outfit, clipped her gun, made sure that she had put that extra foundation to hide the black circle under her eyes, and headed downstairs. “Let’s go,” she called.

Here goes nothing.

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9ct Yellow Gold Ceylon Sapphire & Diamond Pendant

9ct Yellow Gold Ceylon Sapphire & Diamond Pendant

Regular price $1,299.00
Tax included.

Only 1 items in stock!
  • Ceylon Sapphire 4.5mm round
  • Diamond Total = 0.12ct
  • 9ct Yellow Gold
  • This piece is made to order and will take approx. 28 days
  • NOTE: This design is available in 9ct OR 18ct yellow, white OR rose gold, and a variety of gemstones - price will vary (please contact us for further details)

 We offer free shipping on all orders. .

All parcels are shipped through registered Australian post mail.

At this stage Paton's Place is shipping Australia wide and does not ship internationally.

Items are typically sent within 2-4 business days after receipt of payment, unless otherwise stated. This may vary during busy periods however we always aim to get your item to you as soon as we can! From date of purchase, you should expect to receive your parcel within 5-10 business days.

 Here at Paton's Place we are confident that you will love our products. However we understand that under some circumstances you may want to return your purchase.

You are able to return all articles bought from the online Paton's Place shop within 14 days of receipt.

Please send the articles through registered mail to the following address and keep the dispatch receipts for any potential queries.

Paton's Place PO BOX 645 Craigieburn Central, Craigieburn, 3064

Alternatively you may visit us in store at Paton's Place Jewellers Craigieburn, where we can refund your purchase directly onto the card it was originally purchased from.

For articles to be refunded, they must be returned to us with any tags attached, in their original packaging and original condition. All items must be returned brand new, unworn and unscratched. Any items that are not returned to us in the condition that they were sent out will not be refunded. It will be at our discretion to determine whether the condition the item has come back in qualifies for a refund.

The item being returned remains your responsibility until it reaches us back at Paton's Place Jewellers. Paton's Place Jewellers is not liable for any loss or damage to products whilst in transit.

Once we have received your return, we will inform you via email. Returns are usually processed within 10 working days, although during busy periods this may vary. Refunds will always be processed onto the same debit or credit card used for purchase. Refunds may take up to 10 working days to appear on your card.

For any further queries on shipping and returns, please feel free to give us a call, or email us

Contact us +61 (03) 9333 0415 9am-5pm Monday – Friday

Email: craigieburn@patonsplace.com.au

We pride ourselves on providing you with the best quality jewellery that lasts you a lifetime. In order to help you keep your stunning pieces retain their lustre, we have created a list of jewellery industry tips.

  • Remove jewellery before entering any aquatic environment, while conducting cleaning tasks or while doing exercise.
  • Thoroughly dry your jewellery with a soft cloth once it has been exposed to water.
  • Do not expose your jewellery or watches to hot water.
  • Only use jewellery cleaning solutions, when specified for the particular type of material (i.e. gold or diamond) and ensure that it is not corrosive.
  • Makeup, Perfume and hairspray can damage your jewellery. Gently wipe your jewellery clean to remove skin oils and makeup.
  • Make sure that your accessories are the last to be put on and the first thing to come off before getting undressed.
  • Do not wear your jewellery to bed.
  • Get your jewellery professionally cleaned and replated (white gold) every year.
  • Keep all jewellery separate from one another. As pearls are porous, keep in a separate pouch.

Shop BOO-20
Craigieburn Central Shopping Centre,
340 Craigieburn Road,
Craigieburn VIC 3064

Phone: (03) 9333 0415
Email: craigieburn@patonsplace.com.au

Facebook: www.facebook.com/patonsplacecraigieburn

Instagram: Patons Place Jewellery

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10:00am - 5:00pm

 Please note: products online and in our Craigieburn store may differ.


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Magnanni Bartolo Leather Sneakers
Item # 13602 NAVY 8
$325.00 $130.00
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Extremely lightweight and comfortable shoes, made in Spain of luxe, lustrous, Italian calfskin. Cool, perforated lining, leather innersoles, flexible rubber soles, stay-flat lace slots.
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07/04/09 - The setting sun creates a brilliant sky over the Charlotte, North Carolina, skyline. New skyscrapers and highrise buildings pop up on the skyline each year, changing the look of this popular Southern city. Charlotte Photographer Patrick Schneider has an extensive gallery of Charlotte skyline photography. See more at http://pa.photoshelter.com/c/patrickschneider/gallery/Charlotte-Skyline-Photos/G0000hrADf9pmHvk/.


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Paper Models
Flyers, Posters & Other Resources
Interactive Animations
Coloring Books
Education Corner
Guide to Understanding PDB Data
Structural Biology Highlights
PDB & Data Archiving Curriculum
3D Printing
COVID-19 Pandemic Resources

Exploring PDB structures in 3D with Mol* (MolStar)

This tutorial offers an introduction to exploring the PDB structures using the rcsb.org website (sections 1-3), introduces the molecular viewer Mol* (sections 4-6), gives an overview of Mol* operations on components (sections 7-11), introduces Mol* operations on custom selections (sections 12-14) and offers tips for saving images (section 15).

To access the individual sections, click on the link below and hit “Play” on the YouTube video. The video will start playing at the indicated time.

Detailed Mol* documentation is available.


text:
By Spencer Graves

Daniel Ellsberg

The greatest threat to U.S. national security (and the future of humanity) is the U.S. nuclear arsenal. Both

Robert McNamara, U.S. secretary of defense during the Cuban Missile Crisis, and Daniel Ellsberg, a nuclear war planner advising McNamara during that crisis, have said that (a) the world is extremely lucky that that crisis didn’t end in major nuclear war, and (b) it’s only a matter of time until such a nuclear war occurs unless we destroy our large nuclear arsenal first.

Ellsberg, in his 2017 book The Doomsday Machine, further says a major nuclear war would loft so much soot into the stratosphere, where rain clouds rarely form, that such a nuclear war would almost certainly lead to a nuclear winter. That would prevent 70 percent of the sunlight from reaching the surface of the earth, which would lead to death from starvation for roughly 98 percent of the people who survive the nuclear exchange. Reliability engineering computations suggest a probability of over 10 percent of such a nuclear war and winter in the next 40 years, killing in that way at least half of the people alive today. For details, see my Wikiversity article “Time to extinction of civilization”

—Spencer Graves, a member of the PeaceWorks Board, is licensed as a professional engineer in Missouri.


text:
Punchy Sonic Depth

Crystal Beat's unparalleled tonal (and visual) clarity delivers a one-two punch for a new breed of power players. Precision molded, seamless acrylic shells in a variety of available sizes and finishes for an unmistakable drumming signature.

Crystal Beat Shells
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Application of the Yamaguchi criteria for classification of “suspected” systemic juvenile idiopathic arthritis (sJIA)

Many children with sJIA may have a delayed onset of arthritis and so fail to fulfil the ILAR criteria for sJIA. This study was undertaken to determine whether the Yamaguchi criteria (for adult onset Still’s disease) is useful in classification of children with systemic juvenile idiopathic arthritis (sJIA) particularly in “pre-arthritic”, pure systemic, phase of the illness. A secondary objective was to determine the time delay between disease onset and onset of arthritis in our sJIA cohort.

Retrospective chart review all patients with a diagnosis of systemic juvenile arthritis in our department from Jan 1, 2004 to Jan 1, 2010.

Twenty boys and eleven girls formed the study cohort. Thirteen patients were diagnosed with “suspected” sJIA due to typical systemic features but an absence of arthritis. Overall, the Yamaguchi criteria was fulfilled in a higher number of patients in the study (n=23) as compared to the ILAR criteria (n=18). Among the 13 “suspected” sJIA patients, 12 fulfilled the Yamaguchi criteria. Overall, either ILAR criteria or Yamaguchi criteria was fulfilled in 30 patients (96.8% of patients). The degree of association between the two criteria was poor (Phi coefficient = -0.352, p=0.05). Eleven out of eighteen patients with arthritis gave a history of delay in onset of arthritis (range=15 days to more than a year; median=30 days). Thus a total of 24 patients (75%) had a delay in onset of arthritis at onset of disease.

Patients with sJIA can have a significant period during their course (particularly at onset) when they do not have arthritis. The Yamaguchi criteria may be useful in this subset of patients in the “pre-arthritic” phase of the disease. Future criteria should incorporate the strengths of both, the Yamaguchi and the ILAR criteria.

In comparison to the other diseases which are jointly grouped under the term juvenile idiopathic arthritis (JIA), systemic juvenile idiopathic arthritis (sJIA or Still’s disease as it was previously known) has many distinct features[1]. One important difference is that, at least in a subset of sJIA patients, arthritis may be a non-prominent and/or a delayed manifestation. Patients have been reported to have a delay of up to 10 years before the onset of arthritis[2].The International League Against Rheumatism (ILAR) criteria require the presence of arthritis to classify a patient as having sJIA[3]. Since morbidity and mortality may develop early in sJIA patients[2], a strict adherence to the ILAR criteria may lead to an unacceptable delay in diagnosis. Recent research in a small cohort from a single centre has demonstrated that sJIA patients prior to the onset of arthritis (“suspected sJIA”) appeared clinically and immunologically similar to patients fulfilling the ILAR criteria for sJIA[4].

Still’s disease (a.k.a. sJIA) is also known to occur in adults, in whom the disease is labeled as Adult Onset Still’s Disease (AOSD). Most studies comparing AOSD and Still’s disease in children have not found significant differences in the clinical features at presentation[59]. None of the criteria available for the diagnosis of AOSD depend heavily on the presence of arthritis. Among the different criteria available for the classification of AOSD, the Yamaguchi criteria are the most sensitive (96%)[10] and still manage to retain a high degree of specificity (92%)[11]. The Yamaguchi criteria have been compared to the ILAR criteria in Table 1[3, 10]. The present study was undertaken in an attempt to determine the utility of the Yamaguchi criteria in the classification of children presenting with typical systemic features of sJIA who had still not developed arthritis (labeled as “suspected” sJIA). We also wished to determine the time lag between onset of fever and onset of arthritis among sJIA patients in our cohort who had fulfilled the ILAR criteria at presentation to our hospital.

Table 1 Comparison of the features of the ILAR and Yamaguchi criteria

The study was a retrospective chart review conducted in the pediatrics department of a tertiary level teaching hospital. Electronic medical records were mined using key words “arthritis”, “JIA” and “JRA”. All patients with these keywords mentioned anywhere in their notes, and had been diagnosed between Jan 1, 2004 and Jan 1, 2010 were identified. Their detailed case records were reviewed and those patients finally diagnosed by the treating pediatrician (SK, LR and others) as “definite” sJIA (fulfilling the ILAR classification criteria) or “suspected” sJIA (not fulfilling the ILAR criteria) were included. Accuracy of diagnosis was confirmed by the first author (SK). For inclusion in the cohort, the patients had to have been investigated at length to rule out infections and malignancies as causes of fever of unknown origin (FUO).

The chart review was conducted independently by two of the authors (SK and DKR). Any differences were resolved by consensus. The fulfillment of the various variables in both the Yamaguchi criteria and the ILAR criteria were identified in each patient at the time of first presentation to our institute. Exclusionary components of the criteria set were also considered. (Refer Table 1 for the criteria) Variables representing symptoms (characteristic fever, arthralgia, and sore throat,) were considered positive irrespective of whether they had it at presentation to our institute or at any time in the past during the course of the disease.

Laboratory criteria (leukocyte count, liver function test, serositis and negative ANA, RF) and clinical signs (typical rash, splenomegaly, hepatomegaly, and lymphadenopathy) were considered positive only if they had been performed/observed in our department at the time of presentation and had been fulfilled. For the presence of arthritis, either physician documentation at presentation, or patient/parent report were considered sufficient to be graded positive. However, in case of parent/patient reported arthritis, the child was considered to have had arthritis only if in addition to arthralgia the patient had had either significant swelling which had been documented by a doctor or any 2 of the following physical findings: limitation of range of motion/deformity, pain on motion leading to limitation of motion or increased warmth over the joint.

The time duration between onset of fever and onset of arthritis as reported by the patients or their parents (based on information available in the charts or information obtained via a telephonic interview) was also recorded. The statistical significance of any difference was inferred using the Fisher test for nominal values and the independent t test for continuous variables. The coefficient of association between the criteria was calculated using the Phi coefficient. Approval for the study was obtained from the Institutional Ethics Committee.

Thirty-four patients were diagnosed with sJIA (definite or suspected) in the last 6 years. Three patients (all girls) were excluded due to insufficient data in their medical records. Twenty boys and eleven girls (n=31) formed the study cohort. All of the patients were DMARD naïve at presentation and none had received steroids for more than 2 weeks. Thirteen patients failed to fulfill the ILAR criteria, all of them due to a lack of arthritis. The mean age of children who fulfilled the ILAR criteria (11.9 years) was significantly higher than patients who did not fulfill the ILAR criteria (6.9 years, p=0.006) (Table 2).

Table 2 Characteristics of the cohort comprising sJIA and “suspected” sJIA cohort

Among the 13 patients who did not fulfill the ILAR criteria, nearly all children (12 patients) fulfilled the Yamaguchi criteria. Among the 18 patients who fulfilled the ILAR criteria, 7 patients did not fulfill the Yamaguchi criteria (Table 3). The association between a fulfillment of ILAR criteria and fulfillment of Yamaguchi criteria was evaluated. The Phi coefficient was -0.352 (p=0.05). Thus the total number of patients who fulfilled the Yamaguchi criteria was 23 (74%), compared to only 18 patients (58%) who fulfilled the ILAR criteria.

Table 3 The number of patients who fulfilled the Yamaguchi criteria and the ILAR criteria

The exclusionary components of both the ILAR and the Yamaguchi criteria were absent in all of the patients. The number of patients fulfilling the different components of the ILAR criteria and the Yamaguchi criteria are shown in the Figure 1. All of the patients fulfilled both the Yamaguchi criteria component as well as the ILAR criteria component for fever. The second most commonly fulfilled component was “Arthralgia> 2 weeks” (Yamaguchi criteria) which was seen in 28 patients (which included patients with arthritis as well). In contrast only 18 out of 31 patients had arthritis at presentation.

Figure 1

The percentage of patients fulfilling the different component criterion of the ILAR and Yamaguchi criteria in our cohort. Actual numbers of patients are in brackets.

A comparison of the baseline lab characteristics of patients who fulfilled the ILAR criteria and those with “suspected” sJIA has been shown in Table 2. The difference in characteristics was tested using the Fisher’s exact t test for nominal values and the independent t test for continuous variables. During the initial disease presentation, all patients, in addition to a detailed evaluation for an infectious cause, had undergone a bone marrow aspiration. The bone marrow study had been reported as normal in every child.

A higher proportion of patients who fulfilled the ILAR criteria had received steroids, though the mean dosage of steroids (among patients who had received them) was higher in the “suspected” sJIA group. Among the children who had received steroids, (n=10), 8 patients had arthritis and 6 had the typical sJIA rash. In comparison, among patients who had not received steroids (n=21), 10 patients had arthritis and 12 patients had typical rash.

Among the 13 patients with “suspected” sJIA, 6 patients had neither arthralgia nor arthritis and 7 patients had arthralgia without ever having had arthritis. The presence of various clinical features in patients grouped according to the presence or absence of arthritis and arthralgia is shown in Table 4. On comparison none of the differences between the groups were statistically significant.

Table 4 The number of patients with various clinical features divided according to the presence of arthritis and arthralgia

All patients with “suspected” sJIA, after extensive evaluation for infection and malignancy, received treatment with systemic corticosteroids for more than a month for the persistent and unexplained systemic inflammatory illness. During followup (until the end of the study), 3 patients with “suspected” sJIA developed arthritis. One patient developed a transient arthritis a month after initial presentation. The arthritis was present in a single joint and lasted for 3 days. The other 2 patients developed a persistent oligoarthritis. One child developed 2 active joints and the second patient develop arthritis in 4 joints. The delay between first presentation and development of arthritis was 3 months and 7 ½ months, respectively.

Each of the18 patients who had arthritis at presentation fulfilled the ILAR criteria. However, upon careful interviewing it was revealed that 11 of these patients had a history of delay between onset of systemic features and onset of their arthritis. The duration of the delay varied from 15 days to more than a year [median=30 days; mean +/- (SD) =69.3 days +/- 104.6 days]. The delay between the onset of fever and the onset of arthritis in these 11 patients is depicted in Figure 2.

Figure 2

Figure depicting the delay between onset of fever and onset of arthritis in the eighteen patients who fulfilled ILAR criteria at presentation to our department. Cumulative number of patients with arthritis is plotted on the y axis against the number of days (in geometric progression) since they developed fever on the x-axis.

Characteristics of the patients who fulfilled the ILAR criteria but failed to fulfill the Yamaguchi criteria are depicted in Figure 3. All seven patients had fever and arthritis. All patients had a negative ANA as well as a negative RF. Thus they required the presence of another 2 components for fulfillment of the Yamaguchi criteria. However none of the patients fulfilled more than one additional component.

Figure 3

Characteristics of patients who fulfilled the ILAR criteria but failed to fulfil the Yamaguchi criteria. (Total n=7) All patients had fever and arthritis.(components of both Yamaguchi and ILAR criteria). None of the patients had a positive ANA nor RF (Component of Yamaguchi criteria). Further components of Yamaguchi criteria are in black and of the ILAR criteria are in grey.

The change in terminology from Still’s disease to sJIA described in the ILAR criteria leads to situations where children clearly have this disease, but are unable to be classified as sJIA due to the absence of arthritis. Since the ILAR classification criteria were published in 2004, there has been extensive research on the pathogenic mechanisms involved in sJIA. The 2 most important findings, i.e. , the role of interleukin-1 beta and interleukin-6 in sJIA, has translated not only into a better understanding of the disease but has also lead to the use and approval of newer and possibly more effective therapeutic agents (anakinra and tocilizumab respectively)[12, 13].

Basic research has continued to uncover other cytokines and biomarkers which are characteristically increased in sJIA. These include myeloid-related proteins 8 and 14 (MRP 8/14)[1416], interleukin-18 (IL-18)[1719], macrophage migration inhibitory factor (MIF)[20, 21], S100A12 protein[22], soluble IL-2 receptor[23], NK cell function[24], and others. These biomarkers have been studied regarding their utility in diagnosing patients with sJIA, both individually[16, 18, 19, 21, 22] and as part of a panel[18, 25]. Initial results have been quite promising.These biomarkers may also be helpful in distinguishing children with systemic JIA from patients suffering from either other subtypes of JIA, other inflammatory diseases (like Kawasaki disease) or from infections. The baseline clinical characteristics, the mean value of many of the above biomarkers , and the response to therapy of 5 “suspected” sJIA patients without arthritis were described in the work of Vastert et al.[4]. These “suspected” sJIA patients had baseline clinical characteristics and mean value of many of the above mentioned biomarkers similar to a comparison group of 15 sJIA patients fulfilling the ILAR criteria. In addition, the “suspected” sJIA also had a comparably robust improvement on anakinra. Unfortunately, these biomarkers are not routinely available in clinical practice. On the other hand, the Yamaguchi criteria for AOSD are a relatively simple tool with clinical and basic laboratory features[10].

Including the seminal publication of Cabane et al[5] in 1990, there have been 6 publications[69, 26] comparing children and adults with Still’s disease. Most of these studies have revealed a lack of any significant difference between the two groups with respect to the systemic features[59], the articular manifestations, or sequelae[5, 79]. However, a few significant differences between pediatric and adult patients have been pointed out by Pay et al. with respect to clinical and laboratory features[26]. Lin et al. has also noted differences between AOSD adults and sJIA children in articular outcomes[6].

Pay et al. showed significant differences with respect to the frequency of fever, rash, myalgia, weight loss, sore throat, LFT abnormalities and neutrophilia which were all higher in patients with AOSD. The pattern of joint involvement was also slightly different. Patients with sJIA had a higher rate of involvement of knee, ankle, elbow, metatarsophalangeal joints, hip joints as well as the cervical spine. However, in spite of these differences, given the large number of similarities the authors conclude that AOSD and sJIA may still be the same disease, and children may simply be reacting differently[26]. This may be true given the fact that, with the exception of this one publication (Pay et al.[26]), the other five publications revealed a lack of any significant difference between the two groups with respect to the systemic features or the articular manifestations at presentation[59].

Thus, it appears to be a widely-held belief that sJIA and AOSD are the same disease, albeit with slight differences. Given the similarities, it would be reasonable to expect that sJIA patients would fulfill diagnostic criteria for AOSD. In fact, in the study by Luthi et al as well, all 9 of their sJIA patients fulfilled the Yamaguchi criteria[7]. Thus the fact that the Yamaguchi criteria were fulfilled in 74% of patients in our cohort was not as surprising as the fact that only 58% of patients fulfilled the ILAR criteria for sJIA. The performance of the ILAR criteria in the present cohort was comparable to that reported in a previous cohort from a multicenter registry in the state of Pennsylvania, USA (PASOJAR cohort). In the PASOJAR cohort, only 31% of patients (42/136 sJIA patients) fulfilled the ILAR criteria[27]. The failure of ILAR criteria in our cohort was mainly due to the absence of arthritis.

Data pertaining to the delay in (or absence of) arthritic manifestations of sJIA is scarce. A cohort of 46 patients with “probable” Still’s disease (as defined by the Taplow group criteria) was published in 1962. These children were followed for a mean period of 5.9 years. Ten of these patients who did not evolve into any disease had unique features and were labeled as “benign systemic disease” due to the fact that all had fever with rash but none had persistent arthritis. Arthralgia was present in all of them and 7 of them had arthritis lasting only 2 to 3 days[28]. In the PASOJAR cohort, it was reported that 12% of their patients did not have arthritis[27]. Even in the study by Pay et al, in which all sJIA patients ultimately fulfilled the ILAR criteria, 5/25 (20%) sJIA patients did not have arthritis at initial presentation. The frequency of arthritis or arthralgia was not significantly different between sJIA and AOSD patient groups in the same cohort[26]. Uppal et al reported that 30% of their patients with juvenile onset Still’s disease did not have arthritis and of these only 17% of patients had arthralgia[9]. These numbers are lower than what was found in our cohort. This could possibly be presumed to be due to the fact that patients without arthritis are more likely to be referred to a tertiary level hospital.

As part of the effort to develop consensus based treatment plans and a standardized assessment schedule for sJIA, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) in the US conducted a case-based online survey prior to a consensus meeting. Among the 63 pediatric rheumatologists who completed the survey the majority (87.9%) found the initiation of treatment in sJIA acceptable in the absence of arthritis based on fever and systemic features such as characteristic rash, serositis, and adenopathy, provided that infection and malignancy had been excluded. The final operational definition of sJIA developed by CARRA for initiating treatment in patients was different from the ILAR classification criteria for sJIA. The opinion of the consensus group was that the ILAR criteria were “too stringent” and might often lead to exclusion of patients who need to be treated as sJIA[29]. Despite fulfilling the apparently more stringent ILAR criteria, 7 patients in our cohort failed to fulfill the Yamaguchi criteria. The components of the two criteria fulfilled by these patients are shown in Figure 3. In comparison to the entire cohort, the ILAR criteria appeared to be more sensitive in patients with arthritis. The ILAR criteria require the presence of any one extra feature (apart from fever and arthritis) for fulfillment of the classification criteria. However, in the same patients, three additional features (apart from fever and arthralgia due to arthritis) were required to fulfill the Yamaguchi classification criteria. It appears that in patients with arthritis the "ILAR criteria are more commonly fulfilled (100%) than the Yamaguchi criteria (61%). The Yamaguchi criteria seem to be more efficacious in the absence of arthritis (12/13) compared to patients with arthritis (11/18) (Table 4). It is also interesting to note that one patient was diagnosed as “suspected” sJIA based on splenomegaly, typical fever along with the typical sJIA rash.

One of the features typical of sJIA is the characteristic evanescent rash[2, 29]. The prevalence of rash in previous sJIA cohorts reported from Europe or North America has been quite high. (~80%)[27, 30]. Previous JIA cohorts from India have demonstrated that the prevalence of rash, in Indian sJIA patients, vary between 27 to 57%[31, 32]. Similarly, in our cohort only 18 patients (58%) had the typical rash associated with sJIA. The lower incidence of rash in studies in India may be due to darker skin color that makes the rash harder to see. This difficulty may represent a further limitation of the ILAR criteria in ethnicities associated with darker skin colors.

The ILAR criteria for JIA have been criticized on various counts. One of the criticisms has been the lack of consideration or integration of adult criteria for diseases, like Still’s disease, psoriatic arthritis and spondyloarthropathy, which occur in both children and adults. The utility of such integration was tested in a single cohort of 683 JIA patients in whom 157 patients had been grouped under undifferentiated as per the ILAR (Durban) criteria. A hierarchal tree approach with use of validated adult criteria reduced the number of patients in the undifferentiated category to zero[33]. Analogous to this, in our cohort, when both criteria (ILAR criteria and Yamaguchi criteria) were used in an “either/or” combination, nearly all the patients (30 out of 31) could be classified as sJIA.

During development of the CARRA consensus treatment plans for new-onset sJIA, there was extensive discussion over the fact that patients in the early part of sJIA do not fulfill the ILAR criteria (probably due to lack of arthritis) and “yet need treatment”[29]. The response of early pre-arthritic or “suspected” sJIA patients to anakinra in the study by Vastert et al., suggests that treatment of these “suspected” sJIA patients, may help us to utilize a window of opportunity, and possibly prevent some of the morbidity associated with sJIA[4].

There are many limitations to this study. The data was retrospectively obtained from a small cohort of patients diagnosed at a single centre. Being a tertiary level referral hospital, the cohort may not be representative of patients in the community. Telephone interviewing to recall the gap between arthritis and systemic features is a crude method at best. The lack of controls (other inflammatory diseases like Kawasaki disease or inflammatory bowel disease; malignancies and infections) prevents a determination of the specificity of the two criteria. Parts of the Yamaguchi criteria such as sore throat could probably have reduced specificity in children. The peak incidence of sJIA is between 1 and 5 years of age[34]. Children at this age are less likely to complain of “arthralgia” or “sore throat”. The patients in the cohort were investigated at length and infections and malignancies were ruled out as possible causes of their symptoms . However, none of the patients were investigated for autoinflammatory diseases which are known to mimic sJIA. Since the prevalence of autoinflammatory syndromes is quite low with only case reports from India, it is unlikely that patients with these disorders could have formed a considerable number in the cohort. Nevertheless, it is possible that patients fulfilling the Yamaguchi criteria alone may have had a distinct disease which is similar to sJIA but not the same. Another limitation was the fact that long-term followup data was not part of the present study. It is possible that patients in our cohort with suspected sJIA may evolve into other rheumatologic disorders on long-term follow up. In the cohort of “probable” sJIA by Ansell et al., 20 out of 43 patients evolved into another disease on followup. Thus it is prudent to point out that given all these above limitations, the results pertaining to the primary objective of the study should only be viewed as hypothesis-generating.

As is evident from the present cohort as well as previous cohorts, patients with sJIA are a heterogeneous group[35]. A subset of patients may not have arthritis for a significant period at the onset of the disease, but may still have elevated biomarkers associated with sJIA[4]. Some of these new biomarkers have been found to specific to sJIA and could represent future diagnostic markers[16, 18, 19, 21, 22, 25]. Initial evidence seems to suggest that the subset of patients without arthritis, or with minimal arthritis, may respond to therapy equally well, or better, than patients with prominent joint involvement[4, 35]. Modification of the ILAR criteria with inclusions of these biomarkers, would help in classification of sJIA patients without arthritis, enable them to qualify for enrollment in trials as well as become eligible for treatment. However, these tests are not yet available outside the research setting and are likely to be expensive when they do become available. In the meantime, the use of the Yamaguchi criteria, with suitable modifications, in a hierarchal fashion, along with the ILAR criteria (analogous to that used in a previous Italian cohort[33]), might prove to be a useful strategy to help classify “suspected” sJIA patients in resource poor settings.

There is a subgroup of sJIA patients in whom arthritis is absent or quite delayed and in this group, the diagnosis may be very challenging. Comparison of the ILAR and Yamaguchi criteria in our cohort of sJIA patients suggests that some changes to the ILAR criteria for sJIA are probably necessary to make it more inclusive. Possible inclusion of recently described biomarkers or application of the Yamaguchi criteria (which do not consider arthritis as an essential feature), might enable the criteria to be more sensitive and clinically useful. These changes may facilitate early and timely diagnosis of children with sJIA and thus, allow early treatment.

Adult onset still’s disease

Disease modifying anti-rheumatic drugs

International league of associations for rheumatology

Fever of unknown origin

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We would like to thank the EULAR committee; which awarded a travel bursary to Divya Kunhiraman which enabled her to present the research in the annual EULAR conference in Rome in June 2010.

We also wished to thank Sujata Sawhney for her help in reviewing the article and suggesting changes.

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Correspondence to Sharath Kumar.

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Competing interest

The authors had no conflicts of interest.

Author contributions

SK developed the concept for the study, was involved in data collection and wrote and reviewed the manuscript. He had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. DSK was involved in data collection and analysis and reviewed the manuscript. LR was also involved in conceptualizing the study, as well as in critical review of the manuscript. All authors read and approved the final manuscript.

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Kumar, S., Kunhiraman, D.S. & Rajam, L. Application of the Yamaguchi criteria for classification of “suspected” systemic juvenile idiopathic arthritis (sJIA). Pediatr Rheumatol 10, 40 (2012).

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  • Diagnosis
  • Arthritis
  • Juvenile idiopathic
  • Criteria
  • Adult-Onset Still’s disease
  • sJIA
  • Systemic JIA


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Systematic review on treatment of juvenile idiopathic arthritis – associated uveitis

Juvenile idiopathic arthritis (JIA) is commonly complicated by chronic uveitis that frequently leads to visual loss.

Review of the current literature on the treatment of JIA - associated uveitis.

Therapy of JIA-associated uveitis is guided by the severity of inflammation and complications. Topical corticosteroids are generally used as the initial treatment. Severe uveitis is commonly treated with immunosuppressive drugs. Methotrexate is presently the first-choice agent. If uveitis is not responding, another immunosuppressive agent or biological is applied. Currently, adalimumab is the preferred TNF-inhibitor. In refractory disease, other biologicals are used (e.g., rituximab, tocilizumab or abatacept). Ocular corticosteroid injections / - implantations are considered as “rescue therapy”.

Controlled studies are warranted to offer most effective and safe therapy for children with JIA - associated uveitis. Better knowledge of the basic mechanisms underlying the disease and of the molecules that are important for regulating inflammation may help to create new and more specific treatment approaches, and to improve disease monitoring.

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None declared.

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Correspondence to Arnd Heiligenhaus.

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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Heiligenhaus, A. Systematic review on treatment of juvenile idiopathic arthritis – associated uveitis. Pediatr Rheumatol 12, I6 (2014).

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  • Corticosteroid
  • Methotrexate
  • Juvenile Idiopathic Arthritis
  • Uveitis
  • Adalimumab


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Fishing, Ghoul Style

“Just one more and I’ll have my limit,” old Herb chuckles.

The large pond sitting in the northwest corner of the cemetery is off-limits for fishing. To everyone except Fred that is. He doesn’t know the meaning of the word. The spring-fed pond is there, loaded with tasty Largemouth Bass waiting to jump on the surface plug he works through the shallows. Night: the best time to catch them because they hit with abandon, and no one can see him as well.

“If God didn’t want people catching these tasty critters, why did he have someone stock them here?” Fred muttered. “The dead can’t fish, but I certainly can.”

The Ghoul watches with amusement. To him, this man is playing with his food. A cat and mouse kind of game.

He smiles. ‘I suppose that’s what I do now that I eat the flesh of the living,’ he thinks. ‘They suffer; I back off a little; this gives them hope, but as soon as they try to escape their fate, I start slowly feeding on them again, enjoying their pain. I’m a real bastard. Oh, that I am.’

Remorse. He should have some; he has a soul, twisted perhaps, but he has one. Yet all the years of being relegated to the status of a scavenger and bone picker, has made him bitter. God created him as well as these humans but gave them an elevated position.

Many years ago, in what is now Germany, he was doing what was commanded of him when a few grave-robbers happened upon him in the act. He scared the shit out of them, but they returned with a mob, carrying torches, axes, and pitchforks. Yes, he was immortal, but it would still cause him a great deal of pain if they were able to whack off a few body parts. Damn! He didn’t know if he could regenerate new ones. What good was being immortal if he was in pieces? The worst kind of living Hell!

So he vanished off into the night and found a new home, one safe from rabble-rousing villagers bent on his destruction. Now, a few homes later, he finds himself in this decrepit but homey cemetery. As long as he’s careful, no one should be any the wiser to his existence.

This so-called high-tech era doesn’t believe in the actuality of his kind. Monsters. Yeah, merely myths. Nobody in their right mind would accept that gibberish. No pitchforks in this day and age. Nowadays, the one who cried ‘wolf’ would be escorted to the closest looney bin.

A huge splash shatters the quiet and Fred rears back, setting the hooks into a real lunker.

“Hot damn!” he shouts out. “This is a monster!”

The battle between man and fish goes on for quite a while, the Ghoul enjoying the show happening before his eyes almost as much as Fred is in seventh heaven pitting his skills against the great fish. Twice Fred stumbles in the brush bordering this section of the pond, but in the end, he slides his thumb and forefinger into the mouth of the huge Bass and lifts him from the water, getting away from the edge of the water as fast as he can so his prize will not escape him.

“Wow! This is my biggest Bass ever! He must be at least eight pounds. What a night!”

Fred’s exuberance is cut a little short by a horrendous odor drifting down from the cemetery’s edge, causing him to gag, the taste refusing to leave his tongue. He retches on the grass, not at all in control of his faculties. Never before has anything this vile attacked his senses. From sheer euphoria one moment to abject disgust and intestinal pain the next.

“Not a pleasant sight, you rolling around on the grass barfing your guts out.”

Fred looks around him, trying to put person and voice together, but his vision’s blurred and he is having difficulty focusing on much of anything. Something big is here. That and the fact it has an un-Godly stench is foremost in his mind. The big Bass plops around and smashes into his head; he barely takes notice.

“I don’t take too kindly to you reacting to my presence like that,” the Ghoul says. “In fact, you are pissing me off!”

The beast walks down-wind and allows fresh air to move in so Fred can breathe easier. His vision slowly returns and he sees the monster for what it truly is. The long hair over his naked frame makes him appear to be some sort of a huge erect wolf at first, but little by little the creature takes on the form of a man-like entity.

What in the name of all that’s holy is this thing?

“These fish. Are you going to eat them?” the monster asks. “You were going through a lot of work to get them out of the water, but you seemed to be having fun.”

Fred is in too much shock to utter a word. He stares at the demon, wondering what it’s up to, afraid to move. Whatever it is, it can talk.

“I can tell you’re not going to answer me, so I will tell you what I think. You enjoy capturing these fish, even though the poor things must be in pain. To you, it is sport, a game. You inflict pain and eat your prize catch.”

Fred can merely nod his head and watches in disbelief and horror as this monstrosity reaches down and picks up the fish. Holding it by its eyes, he slowly tears the meat off it, leaving only the tail and head. Then, with a huge guffaw, it snaps the head from the backbone and devours that as well.

“Is this the way you do it, or do you apply heat to it like your kind does and cook it? Yes, that’s what you do. A real man would eat these things the way I do. But you’re not a real man, are you? You grovel at my feet, too scared to say a word, your clothes soiled by the release of your excrement. Poor baby. Did the big bad Ghoul scare you?”

Reaching down to check, Fred discovers the demon is right. He is covered in shit and piss. Of what matter is that now, though? He has to get the hell out of here, away from this beast; he must warn the townspeople. Yet, will they believe him? Will they come back and destroy this thing?

“Oh, you are not thinking good thoughts, are you, Fred? Yes, I know your name. What you view as unkempt body hair are actually sensors… receptors that touch your mind, relaying your thoughts to me. And your impractical decision to flee is not going to work. See, if you escape, more of your kind will come to try to kill me. I wouldn’t appreciate that.”

“I won’t tell anyone anything!” Fred is finally able to say. “I promise.”

Laughing, the Ghoul says, “Sorry, Fred, I do not trust you. And besides, just as the fish were to be your meal, you are to be mine. Ah, you think it incomprehensible that I would devour you, but you took no pity on the fish. Why should I take pity on you?”

Fred pleads with his eyes, but the monster picks him up and carries him to the edge of the pond. Staring at him as he does it, the Ghoul takes the plug on the end of the line, jams it into Fred’s mouth, and rears back to set the hooks.

A wail of pain escapes his lips as blood pours out of his mouth and down his cheeks. The delighted fiend laps it up before tossing Fred into the pond.

The beast picks up the pole and hollers to Fred, “I’m giving you the same chance you gave those fish. Fight for your life, damn it!”

He reaches to his mouth to get the hooks out but only manages to get his hands caught on them as well, the Ghoul jerking back on the rod just as Fred has hold of the plug. Secured the way he is now, it is impossible for him to put up much resistance and the heavy line he has on his reel is sufficient to hold him.

The demon reels him up to shore and kicks him back again. “C’mon! That fish put up a better fight than you. This is your last chance.”

Once more, Fred is easily brought to shore. The monster tears the plug out of Fred’s mouth, leaving chunks of flesh on the hooks, and throws him onto the grass, quickly lapping up the poor fisherman’s blood and feasting on the rest of his face.

In unbelievable pain, Fred is powerless to resist and has no will to do so, almost asking for the end to come, but his demise will not be quick. The Ghoul removes his clothing as he feeds, eating those areas which will not cause him to die first, enjoying the struggle, albeit a feeble one from this weakling.

The point is reached where not enough blood is left in Fred’s body to keep him alive, and the demon tears his heart out from his chest and swallows it whole. Feasting on his warm dinner with calm deliberation, the Ghoul soon leaves nothing but bone.

Once the skeletal remains are buried in the fresh dirt of a recently dug grave, he returns to the pond and eats the other fish.

“These really are good. Not as tasty as humans, but they make a fine dessert.”

He looks at the fishing rod and picks it up.

“If Fred could catch these fish, simpleton that he was, I can do it.”

On his third cast a Bass hits, and the Ghoul brings him into shore. No catch and release for the big guy. He eats it while the plug is still in its mouth. This is almost too easy. Though these fellas are good eating, Fred was the catch of the day.

~ Blaze McRob

© Copyright 2014 Blaze McRob. All Rights Reserved

38 thoughts on “Fishing, Ghoul Style

  1. You never cease to amaze with your angling acuity. Your words slide off the bone in a substantive feast of horror. And I hear a book is just about ready for the main course. Hmm mighty fine indeed. I do like mine cooked.

    1. I love your poetic prose in describing my tale, Leslie. I’m not much for raw fish myself, but my Ghoul on the other hand . . .

      Main courses abound off the bow of SS Blaze. 🙂

  2. Here’sm a scary synchroniocity. I was just at a cemetery the other day, my daughter and I marveling at the size of the fish in the big pond and wondering if anyone ever dropped a line in there to pluck them out. And then I read this. Crazy. Great story. I love the Ghoul. I demand more!

    1. I used to fish in cemetery ponds at night, Hunter. Under cover of darkness, of course. I caught some mighty big Bass. There was always something wonderful about trying to hide from the cops and enjoying the ambiance of my my surroundings. Took my angling to a whole new level.

      Glad you like my Ghoulish tale. More to come!

    1. Thank you, Thomas! I think you might be on to something! Short stories like this lend themselves well to comic books/graphic novels. Now you have the cogs turning in my head. 😀

  3. Hmmm… something fishy here, Blaze! lol – Another Ghoul tale to inspire all those who hunt for their dinner at night! How old is your Ghoul? He speaks of townfolk and pitchforks – and continually eludes to ‘relocating’ to his current digs. Where be this beastie from??? Fun spin, Blaze – our Ghoul on Fire! 😀

    1. Ah, Nina, I can’t let the Ghoul out of the bag, so to speak. Think of timeless, present before the coming of humans. Flaming Ghouls are the best kind, my friend. Thank you for your kind words. 🙂

  4. Many apologies for my late comment, Blaze, my schedule has been completely out of whack…but on to the good stuff, and what can be better than FISHING, GHOUL STYLE!!?? 🙂 It’s interesting that you made a comment to Thom that this story, and stories like this in general, could lend itself to a comic book/graphic novel type of style – that is precisely the imagery I had in my head as I read this. Greatly enjoyed as usual, my friend; viva la Ghoul!!! 😉

    1. Thank you, Joseph. Glad you like my Ghoul. 🙂 Yes, after Thom made that statement, I’m seriously thinking of making this series a comic/graphic novel project. This can go so many ways and last a while.

      Viva la Ghoul!

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text: package XS::Typemap; =head1 NAME XS::Typemap - module to test the XS typemaps distributed with perl =head1 SYNOPSIS use XS::Typemap; $output = T_IV( $input ); $output = T_PV( $input ); @output = T_ARRAY( @input ); =head1 DESCRIPTION This module is used to test that the XS typemaps distributed with perl are working as advertised. A function is available for each typemap definition (eventually). In general each function takes a variable, processes it through the OUTPUT typemap and then returns it using the INPUT typemap. A test script can then compare the input and output to make sure they are the expected values. When only an input or output function is provided the function will be named after the typemap entry and have either '_IN' or '_OUT' appended. All the functions are exported. There is no reason not to do this since the entire purpose is for testing Perl. Namespace pollution will be limited to the test script. =cut use parent qw/ Exporter /; require XSLoader; our $VERSION = '0.18'; our @EXPORT = (qw/ T_SV T_SVREF T_SVREF_REFCOUNT_FIXED T_AVREF T_AVREF_REFCOUNT_FIXED T_HVREF T_HVREF_REFCOUNT_FIXED T_CVREF T_CVREF_REFCOUNT_FIXED T_SYSRET_fail T_SYSRET_pass T_UV T_IV T_INT T_ENUM T_BOOL T_BOOL_2 T_BOOL_OUT T_U_INT T_SHORT T_U_SHORT T_LONG T_U_LONG T_CHAR T_U_CHAR T_FLOAT T_NV T_DOUBLE T_PV T_PV_null T_PTR_IN T_PTR_OUT T_PTRREF_IN T_PTRREF_OUT T_REF_IV_REF T_REF_IV_PTR_IN T_REF_IV_PTR_OUT T_PTROBJ_IN T_PTROBJ_OUT T_OPAQUE_IN T_OPAQUE_OUT T_OPAQUE_array T_OPAQUEPTR_IN T_OPAQUEPTR_OUT T_OPAQUEPTR_OUT_short T_OPAQUEPTR_IN_struct T_OPAQUEPTR_OUT_struct T_ARRAY T_STDIO_open T_STDIO_open_ret_in_arg T_STDIO_close T_STDIO_print T_PACKED_in T_PACKED_out T_PACKEDARRAY_in T_PACKEDARRAY_out T_INOUT T_IN T_OUT /); XSLoader::load(); =head1 NOTES This module is for testing only and should not normally be installed. =head1 AUTHOR Tim Jenness Et.jenness@jach.hawaii.eduE Copyright (C) 2001 Tim Jenness All Rights Reserved. This program is free software; you can redistribute it and/or modify it under the same terms as Perl itself. =cut 1;


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