Rheumatoid arthritis (RA) is a common disease that affects about 1% of the population worldwide. Women are affected almost 3 times as often as men. The prevalence increases with advancing age, and 4% to 6% of the white population older than 65 years may have RA. Although the cause is unknown, evidence suggests an association between severe RA and HLA, particularly to alleles coding for a shared epitope on the HLA-DRB1 molecule.

Major features of active disease include symmetrical polyarthritis with joint swelling and tenderness and morning stiffness lasting for an hour or longer. Subcutaneous nodules, presence of rheumatoid factor (in about 80% of patients with RA), and radio graphically evident erosions or juxta-articular osteoporosis in or adjacent to the involved joints are further characteristics of RA.

The onset and clinical course of RA are variable. Gradual onset is most common. About 20% of patients will have a monocyclic course, which will abate within 2 years, whereas the rest will have a polycyclic or progressive course.¹ The long-term prognosis of patients with abrupt onset of disease is similar to that for patients with gradual onset of disease.²

Rheumatoid arthritis is one of the most common causes of disability. After 12 years of disease, more than 80% of patients with RA are partially disabled, and 16% are completely disabled.³ Life expectancy is shortened by an average of 7 years in men and 3 years in women, an outcome equivalent to the increased mortality of patients with Hodgkin disease, diabetes, and stroke.⁴ Factors contributing to the poor prognosis include the presence of extra-articular disease and infections, as well as complications of treatment such as gastrointestinal (GI) toxic effects of nonsteroidal anti-inflammatory drugs (NSAIDs).

MANAGEMENT PRINCIPLES

The goals of therapy for RA are to alleviate pain, control inflammation, preserve the ability of the patient to function in activities of daily living and work, and prevent joint destruction. Appropriate and timely therapeutic intervention after accurate diagnosis diminishes not only the symptoms but also the progress of RA. The primary care physician has a crucial role in this process by early recognition of the symptoms of RA, leading to its diagnosis and use of the resources necessary to establish a successful treatment program to achieve these goals, and by participating in the ongoing management of the patient with RA.Early in the course of RA, education on the disease and vocational, lifestyle, and family counseling must be provided. Patients are best served by a multidisciplinary team that includes a rheumatologist and other specially trained medical personnel, including nurses and occupational and physical therapists skilled and knowledgeable about RA. Physical modalities such as joint protection, orthotics and other adaptive devices, and exercises improve the symptoms, function, and well-being of the patient. Adequate rest reduces the fatigue associated with active RA, and resting the involved joints lessens the symptoms of inflammation.

THERAPY

Nonsteroidal anti-inflammatory drugs reduce inflammation and help relieve pain but seldom completely eliminate signs and symptoms of active arthritis. They inhibit 1 or both types of cyclooxygenase (COX). Cyclooxygenase-1 is constitutively expressed in the GI mucosa, kidneys, platelets, and vascular endothelium. Cyclooxygenase-2 is functionally expressed and promotes the elaboration of prostaglandins in inflamed tissues.

Selective blockage of COX-2 may lead to an improved safety profile for these agents. Celecoxib and rofecoxib are the first such agents available in the United States that selectively block COX-2. Rofecoxib is withdrawn from the market due proven increase in cardiac risk.  Of importance, the efficacy of these COX-2 inhibitors does not differ substantially from that of conventional NSAIDs. Their putative advantage is principally because of a reduced rate of adverse events, especially upper GI bleeding.⁵ Cyclooxygenase-2 inhibitors should be considered in patients at high risk of GI bleeding, including those older than 65 years and those with a previous history of GI bleeding. Despite advantages, these drugs may be associated with important adverse reactions, including allergy and fluid retention, and like other NSAIDs should be used with caution in patients with renal insufficiency.

Glucocorticoids are the most potent suppressors of inflammation and may be needed to control severe polyarticular disease until disease-modifying antirheumatic drugs (DMARDs) have been added and become effective. At that point, the glucocorticoids should be tapered and discontinued. Glucocorticoids should not be used alone in the management of RA. Oral prednisone or an equivalent is given in dosages typically ranging between 2 and 15 mg/d, often in divided doses (eg, 2 mg twice a day). A split-dosing regimen is frequently necessary because the anti-inflammatory effect is relatively short. It is preferable, but often not possible, to avoid long-term glucocorticoid therapy in patients with RA because of the well-appreciated adverse effects of these drugs. Systemic extra-articular manifestations such as rheumatoid vasculitis may require treatment with initial prednisone dosages of 40 to 60 mg/d, tapering according to response.⁶ Intra-articular injection of glucocorticoids is an effective means for reducing pain and inflammation in individual recalcitrant joints.

Disease-modifying antirheumatic drug therapy is associated with reduced morbidity and mortality in patients with RA.⁷ It should be used when the diagnosis of RA has been established and before erosive change appears. Disease-modifying antirheumatic drugs are usually given with NSAIDs and glucocorticoids, if needed. The DMARDs currently in use are listed in Table 1. The mechanism of action of most of these agents is diverse and to a variable extent overlapping. For many of the agents, the mechanism of action is defined incompletely, whereas for some, including the new class of tumor necrosis factor (TNF) blockers, it is better understood.

For patients with mild disease, hydroxychloroquine is often the first drug of choice because of ease of use and its favorable toxicity profile. Retinopathy due to hydroxychloroquine rarely develops when appropriate dosages are used. The onset of antirheumatic disease activity occurs in about 3 to 4 months in almost 50% of patients, although 6 months may be needed for the full benefit to be realized. For patients with moderately active or severe newly diagnosed disease, methotrexate or sometimes sulfasalazine is a preferred initial choice. In patients with continuing active established disease, methotrexate may be used in combination with other agents including hydroxychloroquine, sulfasalazine, or both or cyclosporine, azathioprine, and the more recently available DMARDs.⁹

For patients with acute and severe disease, a combination of DMARDs, prednisone, and an NSAID may be initiated; the dose of prednisone should be tapered during the ensuing weeks to months as disease control improves.

Because of its favorable efficacy and toxicity profile, methotrexate is regarded by many rheumatologists as the anchor therapy for RA. The initial dosage is usually 7.5 to 10.0 mg/wk, titrated upward to an average dosage of 12.5 to 15.0 mg/wk, although dosages of 20 to 30 mg/wk (if tolerated) may be necessary to realize this drug’s therapeutic potential before the response is deemed “inadequate.” Methotrexate may be given in tablet or liquid form; the liquid form is substantially less expensive than tablets, and injection may be associated with less stomatitis and GI upset. Appropriately managed, methotrexate can be used effectively for long periods to control RA. Although generally well tolerated, methotrexate can cause GI upset and hepatotoxicity including liver fibrosis and cirrhosis. Concomitant alcohol use is an important risk factor for methotrexate-related hepatotoxicity, and thus alcohol should not be used by patients taking this drug. Methotrexate can also cause a syndrome of pulmonary hypersensitivity manifested by dyspnea, cough, and fever and should not be used in patients with hepatic or renal insufficiency or severe lung disease. Supplemental folate (usually 1 mg/d) seems to reduce the occurrence of other adverse effects, including stomatitis, hair thinning, and bone marrow suppression. In patients taking methotrexate, physicians should avoid prescribing antifolate drugs such as sulfamethoxazole for sinusitis or cystitis, which may precipitate pancytopenia.

Use of DMARDs has substantially improved disease control and the long-term outlook for patients with RA. Their use may be associated with a lower incidence of extra-articular disease manifestations such as systemic vasculitis. In a series of more than 3000 patients monitored for up to 20 years, patients who had received DMARD therapy had a 30% reduction in long-term disability and improvement in survival compared with patients who had received NSAIDs alone.⁷ Despite these successes, major challenges exist. For example, DMARDs are becoming more accepted among practicing physicians and their patients¹⁰ however, adverse effects or failure of the drug to produce long-term disease control often leads to a change in DMARD treatment.

To improve disease control, therapies that contain combinations of DMARDs are often used. About 50% of patients with RA treated by rheumatologists are prescribed combination therapies with either 2 or 3 DMARDs. The combination of methotrexate, hydroxychloroquine, and sulfasalazine is among the most popular regimens. Methotrexate is often combined with other DMARDs including cyclosporine, but many other combinations of DMARDs have also been used.

In addition to hydroxychloroquine and methotrexate, other traditional DMARDs include penicillamine, gold, and sulfasalazine. Sulfasalazine was among the first drugs to be developed for the treatment of RA and may be chosen as the initial DMARD for patients with no allergy to sulfa, rather than hydroxychloroquine or methotrexate. The use of gold or penicillamine is seldom recommended because of the limited efficacy and the pronounced incidence of adverse effects associated with these drugs.

Three to 6 months may be needed before agents such as gold, hydroxychloroquine, and even sulfasalazine are effective. If the response is inadequate after 6 months of treatment, a second DMARD should be added or the DMARD regimen should be changed.

In the past year, 3 new DMARDs, etanercept, infliximab, and leflunomide, have been approved for the treatment of patients with RA.^11,12 Etanercept and infliximab are TNF-α antagonists that have powerful anti-inflammatory effects in patients with RA. Tumor necrosis factor is a potent inflammatory cytokine expressed in increased amounts in the serum and synovial fluid of patients with RA. It promotes the release of other proinflammatory cytokines, particularly interleukin (IL) 1, IL-6, and IL-8 and stimulates protease production. Etanercept consists of fusion monoclonal antibody composed of 2 identical chains of recombinant human TNF-α receptor fused with the Fc portion of human IgG1. In vitro it binds to soluble TNF. About 70% of patients receiving subcutaneous etanercept at dosages of 25 mg twice a week have substantial improvement in the extent of joint inflammation, often within 1 to 2 weeks after initiation of therapy. This improvement can be enhanced by combination with methotrexate. Adverse effects of etanercept are influenza-like symptoms and reactions at the injection site, which usually abate after the first few injections. The efficacy of infliximab, a recombinant TNF receptor fusion protein, seems to be roughly equivalent to that of etanercept. Infliximab is given intravenously once every 8 weeks, a regimen that may be more convenient for some patients. Potential long-term risks of these TNF-α antagonists have not been established. Infliximab may be associated with development of autoantibodies such as antinuclear antibodies. To date, neither drug has an increased risk of malignancy, autoimmune disease, or infection, issues that are the subject of ongoing postmarketing surveillance. The cost of these drugs is about $10,000 to $12,000 a year, generally higher for etanercept than infliximab. The available TNF-α antagonists should be considered in patients with recalcitrant disease not controlled by methotrexate.

Leflunomide is a pyrimidine synthesis inhibitor with clinical efficacy generally equivalent to methotrexate.¹³ Adverse effects reported include rash, alopecia, allergy, weight loss, thrombocytopenia, and diarrhea. Diarrhea often occurs early in the course of treatment and may abate, but discontinuation of the drug is necessary when the diarrhea cannot be ameliorated with dose reduction or concomitant use of antidiarrheal agents.

Serious extra-articular disease manifestations including vasculitis, scleritis, and recalcitrant serositis generally require systemic glucocorticoids and may necessitate the use of immunosuppressive agents such as cyclophosphamide. In my opinion, the only indication for cyclophosphamide in the treatment of RA is severe extra-articular disease, especially vasculitis.

Of importance, the decision about the use and aggressiveness of DMARD therapy should not be based solely on the presence or absence of the rheumatoid factor. Early in the course of RA, the rheumatoid factor may be absent, whereas in patients with established poly articular arthritis, absence of the rheumatoid factor is not invariably associated with mild disease and good disease outcome. Treatment must be tailored to the disease manifestations and needs of the individual patient. Consultation with a rheumatologist is helpful for patients who are pregnant or considering pregnancy because many antirheumatic drugs have severe fetal toxic effects including teratogenicity. Management suggestions for several clinical scenarios involving patients with RA are listed in Table 2.

When the symptoms of RA are well controlled, the glucocorticoids should be tapered, and the NSAIDs may also be tapered or used as needed. As a generalization, DMARD therapy should be continued indefinitely; however, if the patient does well and has no signs of active disease for at least 1 year, DMARD therapy could be carefully tapered. With combination DMARD therapy, one of the DMARDs could be tapered if the patient has been in remission for at least 6 months. Methotrexate can be considered as an “anchor” therapy and generally continue this drug for the longest period. Of note, less than 5% of patients with bona fide seropositive RA remain in long-term disease-free remission.

Rheumatoid arthritis is a serious disease. Follow-up early in the course of disease and in patients with poorly controlled disease should be every 2 to 6 weeks. Patients with well-controlled disease may be seen every 3 to 6 months. The primary care physician has an important role in the management of RA and can effectively guide and monitor routine therapy, with periodic consultation by a rheumatologist as needed. Assessment of disease activity and treatment efficacy is enhanced substantially with serial use of standard outcome measures, including duration of morning stiffness, severity of fatigue, presence and degree of joint pain and stiffness including joint counts, global and disease-specific health assessment instruments such as the modified Health Assessment Questionnaire, erythrocyte sedimentation rate, and radiographs of involved joints.

Appropriate medical care for patients with RA includes immunization and prompt treatment of infections. Patients with RA have a high risk of infections even if they are not taking DMARDs but particularly when they are taking immunosuppressive drugs. Several medications used to manage RA, including NSAIDs, cyclosporine, and glucocorticoids, may cause or exacerbate hypertension. Rheumatoid arthritis is associated with an increased incidence of pulmonary disease, and patients who smoke have an especially high rate of lung disease. In patients at high risk of GI bleeding, including elderly women and those with a previous history of GI bleeding, prophylaxis is achieved with agents such as proton pump inhibitors and misoprostol. As a general principle, use of NSAIDs should be avoided when possible and certainly discontinued when symptoms diminish. Virtually all patients with RA have or develop osteoporosis as a complication of the disease or its treatment. Adequate intake of calcium (1200-1500 mg/d) and vitamin D (400 IU/d) is important. In all patients receiving long-term corticosteroid therapy, including men, an antiresportive agent such as bisphosphonates or calcitonin should be considered. In postmenopausal women, estrogen replacement therapy or agents such as raloxifene may be considered. Finally, mouth and eye moisturization is necessary for patients with sicca complex symptoms.

Understanding the relationship of disease susceptibility and severity with genetic factors may provide an avenue for individualized treatment of patients with RA in the future. It may be possible to treat patients lacking genetic markers of severe disease with milder agents, while those with markers of severe disease may be treated more aggressively. More than 80 drugs are currently being developed for treatment of RA; thus, further advances in the management of the disease are forthcoming.

Questions About Treatment of RA

1. Which one of the following would be an acceptable therapeutic program for a patient with early mild RA?

1. Hydroxychloroquine with an NSAID
2. Hydroxychloroquine, methotrexate, and an NSAID
3. Methotrexate and prednisone at 5 to 15 mg/d
4. Etanercept and prednisone
5. Leflunomide and sulfasalazine

2. Which one of the following regimens would be appropriate for a patient with RA and new-onset systemic vasculitis?

1. Azathioprine, hydroxychloroquine, and prednisone at 10 to 15 mg/d
2. Prednisone, 20 mg/d, and methotrexate, 25 mg/wk
3. Prednisone, 40 to 60 mg/d, and cyclophosphamide
4. Cyclosporine and prednisone at 20 to 30 mg/d
5. Prednisone, 40 to 60 mg/d, and immunoabsorption column treatment

3. Which one of the following situations is not a relative contraindication to the use of etanercept?

1. Patient with history of tuberculosis exposure
2. Patient with history of lymphoma
3. Patient with active chronic infection
4. Patient with newly diagnosed RA
5. Patient with established RA receiving hydroxychloroquine and methotrexate

4. Which one of the following statements about the clinical course of RA is false?

1. The median life expectancy of patients with RA is the same as that for the general population
2. Most patients with RA have some disability after 12 years of disease
3. Predictors of poor outcome in patients with RA include the extent of radiographic erosions, female sex, and functional class
4. Patients in whom the rheumatoid factor is present have a worse prognosis than those with seronegative disease
5. Disease-free remission is unusual

5. Which one of the following statements about COX is true?

1. Cyclooxygenase-1 is constitutively expressed in the gastric mucosa, kidney, and platelets
2. Use of the currently available selective COX-2 inhibitors is safe in patients with renal failure
3. Currently available selective COX-2 inhibitors have been proved in multiple clinical trials to be safe in patients who are taking warfarin
4. Cyclooxygenase-1 is functionally expressed and promotes the elaboration of prostaglandins important in the inflammatory cascade
5. Selective COX-2 inhibitors are not associated with risk of GI bleeding Correct answers: 1. a, 2. c, 3. e, 4. a, 5. a

REFERENCES

1. Masi AT. Articular patterns in the early course of rheumatoid arthritis. Am J Med. 1983;75(suppl 6A):16-26.
2. Jacoby RK, Jayson MI, Cosh JA. Onset, early stages, and prognosis of rheumatoid arthritis. BMJ. 1973;2:96-100.
3. Sherrer YS, Bloch BA, Mitchell DM, Young DY, Fries JF. The development of disability in rheumatoid arthritis. Arthritis Rheum. 1986;29:494-500.
4. Mitchell DM, Spitz PW, Young DY, Bloch BA, McShane DJ, Fries JF. Survival, prognosis, and causes of death in rheumatoid arthritis. Arthritis Rheum. 1986;29:706-714.
5. Wolf MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 1999;340:1888-1899.
6. Matteson EL, Conn DL. Extraarticular manifestations of rheumatoid arthritis. In: Weisman MH, Weinblatt ME, eds. Treatment of the Rheumatic Diseases. Philadelphia, Pa: WB Saunders Co; 1995:52-67.
7. Fries JF, Williams CA, Morfeld D, Singh G, Sibley J. Reduction in long-term disability in patients with rheumatoid arthritis by disease-modifying antirheumatic drug-based treatment strategies. Arthritis Rheum. 1996;39:616-622.
8. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for monitoring drug therapy in rheumatoid arthritis. Arthritis Rheum. 1996;39:723-731.
9. Borigini MJ, Paulus HE. Rheumatoid arthritis. In: Weisman MH, Weinblatt ME, eds. Treatment of the Rheumatic Diseases. Philadelphia, Pa: WB Saunders Co; 1995:31-51.
10. Ward MM, Fries JF. Trends in antirheumatic medication used among patients with rheumatoid arthritis, 1981-1996. J Rheumatol. 1998;25:408-416.
11. Weinblatt ME, Kremer JM, Bankhurst AD, et al. A trial of etanercept, a recombinant tumor necrosis factor recepton:Fc fusion protein, in patients with rheumatoid arthritis receiving methotrexate. N Engl J Med. 1999;340:253-259.
12. Moreland LW, Baumgartner SW, Schiff MH, et al. Treatment of rheumatoid arthritis with a recombinant human tumor necrosis factor receptor (p75)-Fc fusion protein. N Engl J Med. 1997;337:141-147.
13. Mladenovic V, Domljan Z, Rozman D, et al. Safety and effectiveness of leflunomide in the treatment of patients with active rheumatoid arthritis. Arthritis Rheum. 1995;38:1595-1603.

1. die .NET Beginners Roadshow richtet sich, wie es im titel steckt, an beginner. erste erfahrungen im programmieren sind gemacht und ev. auch auf der .NET plattform wurde der erste schritt schon gemacht - dann bist du hier richtig. das event findet in innsbruck, salzburg, graz und wien statt, start ist in 2 wochen. ich bin wahrscheinlich in innsbruck, salzburg und wien anzutreffen
2. das DEVcamp richtet sich an erfahrende entwickler auf .NET technologie. das event wird von 3 microsoft partnern veranstaltet und findet mitte oktober in wien statt. auch microsoft ist als sponsor mit dabei und wird mit einem stand am event als auch mit vorträgen mitwirken.

beides sind kostenpflichtige veranstaltungen, anmeldung über die jeweilige website.

One of the artists exhibiting has close links with Parwich, Liz Salter  is Martin Compton's sister.  Her chief interest is landscape using mixed media such as pastels and other pencils.  Liz has always painted and has exhibited widely Britain and in Ireland. Her work is in private collections in this country and abroad.  You can see her work at the Lime Kiln Pub in Middleton Road.

The festival continues until September 21st with a range of performances and workshops.

Trafficking enslaves 27 million people across the globe. On 23rd September World Vision invites you to

become one of today's abolitionists and use your skills and talents to stand against this human rights crime.

Don't Trade Lives campaigners will unite on this Day of Action to inspire and educate each other on child labour in cocoa production and TAKE ACTION by taking the Don't Trade Lives message to the public.

This is YOUR opportunity to campaign for freedom! Bring along your friends or Vision Group and make a difference!

You will...

• LEARN about Don't Trade Lives' asks of Government and corporations as we launch our campaign policies
• TAKE ACTION and BE CREATIVE in our campaign stunt in Camberwell
• DEVELOP your public speaking skills
• LOBBY Industry and Government to increase their efforts to eliminate child labour
• HAVE FUN with other like-minded campaigners!

Day of Action details
Date | Tuesday 23rd September 2008 (Term 3 Holidays)
Time | 9am - 5.30pm
Venue | Camberwell Baptist Church, 460 Riversdale Rd, Camberwell Junction
Cost | $10 (includes lunch, refreshments and conference materials)
Download the registration form here and send to events@vgen.org (it includes a billeting package for regional delegates)

VGROUP COMPETITION!

See how many VGroup members or friends from your network you can bring along to win a fairtrade chocolate hamper for your next VGroup/Team meeting!

Today's Abolitionists is a fantastic opportunity for people who have supported the 40 Hour Famine and Don't Trade Lives, Vision Group Leaders and members

1. Η ΓΣΕΕ με την ΑΔΕΔΥ καλούνε στις 6μμ στο άγαλμα Βενιζέλου. Το παρόν θα δώσουν το ΠΑΣΟΚ , ο ΣΥ.ΡΙΖ.Α και το ΣΕΚ/ΕΝ.ΑΝΤΙ.Α. . Λίγο πιο δίπλα (Αριστοτέλους και Εγνατίας) θα βρίσκεται το Ελληνικό Κοινωνικό Φόρουμ.
2. Το ΚΚΕ με το ΠΑΜΕ θα βρίσκεται στις 7μμ στη ΧΑΝΘ.
3. Ανεξάρτητη εργατική συγκέντρωση στην Καμάρα στις 6μμ. Συμμετέχει η ΕΣΕ, ο Σύλλογος Υπαλλήλων Βιβλίων & Χάρτου, οι Πολίτες Κατά Του Λιθάνθρακα κλπ.

Let`s rock, baby....!!

Guess what's one of the biggest fests at the beginning of every academic year at Bentley? The Fall Activities Fair! This year more than 100 student organizations will be there, including the Bentley Music Society. Please stop by the BMS table to register for our mailing list, meet with us, and enjoy the BMS-style jam sessions performed by our own e-boarders.

There are several open spots in our e-board this semester. That means we're recruiting new people to jump on board! Open positions include, but not limited to, Freshman Liaison, Sophomore Liaison, and Treasurer Trainee. On the same note, we're also looking for students to join our Marketing Team and the A Cappella Choir.

So, if you want to discover one of your most terrific experiences during your Bentley years, come to the Activities Fair and the next BMS events. We'll be there; and you will, too.

It appears the military will be keeping fifteen brigades of troops in Iraq for the duration of this year. Afghanistan is fast becoming a much more dangerous place and I do hope the violence can be contained there until we resolve the Iraq situation and additional support can reach those currently fighting to bring peace and stability to that region of the world. It is sad that the Canadian death toll in Afghanistan is approaching one hundred soldiers.  Canada had been a solid ally and of great assistance, as always, in contributing to the establishment of a  safer and more stable Afghanistan.  Our thanks and condolences to the families of the three most recent fatalities in the region.

Back here in little Erie,PA~ Brandy ,the abandoned pup, gets spayed thanks to the generous vets at Erie Animal Hospital and her sponsors.  If a home is not found for her by this weekend, she is scheduled to be accepted to the A.N.N.A shelter here in Erie as soon as they have an opening.  We will all miss her in our neighborhood.  Speaking of the neighborhood, we're going to have a get-together to explore forming a watch group and just to familiarize everyone with each other. Papa Joe's Pepperoni Cafe has graciously offered to serve as the host for the meeting in a couple of weeks and hopefully some city officials will be in attendance to offer guidance and insight into what's involved in neighborhood watch and other available programs for the area.  The meeting invitation is being extended to all residents, property owners and managers of rental properties, and anyone interested in attending who lives around the four and five hundred blocks of West 8th and West 7th Sts.  The tentative date is September 17th at 6:30 pm.  Just having people show an interest in meeting one another and looking out for each other is encouraging.  If we do not end up establishing a formal group that will be all right too.  Whatever will be, will be.

Gridley Park's litter problem has returned,  but not as bad, with the start of the school year. I suppose that's to be expected. And the graffitti is still in all the same places as well.  The more things change, the more they remain the same.

Just had to post a photo of my puppy, Cricket as she just walked in the room carrying a light fixure complete with light bulb!!! I haven't a clue where she got it-well, actually I think she ventured in to one of the "Off Limit Restricted Areas" of the basement aka the Fix-It Room and did a bit of exploring on her own! So now, after checking to make sure the fix-it room is secured and she cannot retrieve anything more of a similar ilk, I'm back to the matters at hand. She has been an absolute joy in my life.  She increases my bliss each and every day.  She's an imp and full of playfulness and reminds me that Life is Joy. As the late great Charles Schulz said, "Happiness is a Warm Puppy."

Now, I'm having a senior moment and cannot think of any of the other things I wanted to blog about so I shall call this one Fini!

This is Awesome !!! Adobe is giving out free passes to Adobe RIA Developer Summit for Academia. Please find more details at this URL http://raghuonflex.wordpress.com/2008/09/04/free-passes-for-academia/

Register yourself soon. Passes are given at First Come First Serve basis and the passes are limited :)

Want to demo your Flex/AIR application to audience from various organizations developing awesome Flex/AIR applications? Here is your chance, you can do that in Adobe RIA Developer Summit Demos can be from a organization or an individual.  

Here is what you need to do

Regsiter yourself here http://www.endtoend.in/ete2008/adobe/ria/micro/registration.php

Sig up for the demos here http://raghunathrao.com/announcements/events/DemoRegistrations.html

Once you sign up Raghu will contact you and take it forward. :)

• September 5: Letterman Show Auditions [brownpapertickets.com] [Comedy]
• September 5: Lebowski Fest @ Mezzanine [Lebowskifest.com] [DRINKS, TRIVIA, SCREENINGS]
• September 6: Power To The Peaceful featuring Michael Franti @ GG Park [website] [FREE CONCERT]
• September 6: Bring-your-own-shit- to-be-silk-screened party from 7 to 10 [Mccaig Welles & Rosenthal] [SHIRT SILK SCREENING]
• September 7: SF 49ers host the AZ Cardinals [49ers.com] [PRO FOOTBALL]
• September 7: Grillin 'N' Chillin @ Pier 23 Cafe [going.com] [DAY PARTY]

Weekend Schtuff [SF Schtuff]

make a comment

]]> http://cakedecorating.wordpress.com/?p=72 Fri, 05 Sep 2008 05:47:53 +0000 cakedecorating http://cakedecorating.wordpress.com/?p=72 “Amazing Wedding Cakes,” an all new series, premieres on WE tv on Sunday, September 7 at 10PM ET & PT/9 C.  The six one-hour episode series takes viewers inside the world of high-end cake-making, from larger-than-life designs to the over-the top personalities who create them and features some of the best bakeries in New York, [caption id="attachment_73" align="alignleft" width="158" caption="Photo Credit: We tv"][/caption]Chicago and Los Angeles.  In the first episode, the Cake Divas in LA have their work cut out for them when someone orders a wedding cake that resembles a favorite icon – the convertible car – but they’re up for the challenge.  In Chicago, the Cake Girls encounter a first: a groom who wants to order the wedding cake!  He’s confident, but will he get it right?  Meanwhile, the Cake Atelier has taken on interns to help with their heavy load, but will the extra hands help or hinder their perfectionist personas?

This also means it has given me a firm departure date: the 12th, because the fare ends by the 14th.

So now I need to kick my fundraising into overdrive. I am trying to raise $500 dollars before I go. So, if you can find it in your hearts to donate since I am paying for all of this out of pocket, consider going here to donate via PayPal. Or if you have any advice about fundraising, please share it.

Everyone in the Coeur d'Alene area should say hi if you have any other ideas as to what I should do while I'm there. After that I will be heading on to Montana, so let me know if you're there as well.

Tomorrow I think I'll try to break everything down for you so you can see more about what I'm thinking and where I'd like to go.

The PebbleStorm LA Open House was last night, and it was phenomenal!  (I'm biased, but it's still true.)  We had about 25-30 people and there was just a GREAT energy in the air. I felt a lotta lotta interaction and inspiration.

I knew about 2/3 of the attendees personally, and the rest either came as guests or found PebbleStorm through the group on Meetup.com.  I felt that everyone really was very open, friendly and interested in each other.

LA's My Playground

The second 'stage' of PebbleStorm is "Play", and Los Angeles is my playground for PebbleStorm itself - events and all. There's an enormous creative, entrepreneurial energy here looking for more ways to be channeled and directed.  That (ok plus the fun and weather) is why I moved here! As I experiment and tune PebbleStorm tools, event formats and such, I'll then take them to a few other main areas as well (SF Bay Area - you're next).

Fear Gremlins

I'm not someone that holds much fear of doing or trying new things (as my friends and family know). But even I, when doing a new event format, even with a small group of people, always have those little ego/fear gremlins: Am I missing anything? Will people show up? Will the format work?  Will they enjoy it, get value from it?

Then, once the event starts, whether in person or a conference call, I get into the flow and love it, and it always works out exactly as it should. I know this from experience, and yet the gremlins are there each time I do a new one :)

PebbleStorm Circles

Ah, fear. Everyone experiences fear and loneliness as they start and run a business, especially if you're a single entrepreneur or CEO without a true peer or partner in the business. One of, or the, best antidotes for this common fear and loneliness is connecting with other people going through similar journeys, people who can also help each others' businesses. Community increases the enjoyment and makes it easier to be successful, since you have a group of people helping you out!

A fundamental part of PebbleStorm includes connecting people in supportive communities, both offline and online.  I'm still working on fleshing out the idea of a 'do it yourself kit' for motivated people who want to start their own "PebbleStorm Circle", a small local group of like-minded people that would meet say, at least once a month.  (Interested in finding out more? Send me an email.)

Unique Genius

A topic we spent some time on last night was "Unique Genius"...a unique mashup of your talents, interests and enjoyments combined in a way that adds meaning to your life - usually by helping others in some way. For example, I say "helping people make money through enjoyment" is my unique genius, and PebbleStorm is the manifestation.  I'm getting closer to putting up a real blog post about it (the raw material is on the wiki: unique genius).

Another Open House Post Coming

I'll put up another followup blog post with some more content, pictures, etc. in a few days once I digest everything and ask the group for some stories or impressions I can share here.

Digital Versions of Handouts / Contact Info

If anyone at the event missed my contact information, or would like digital versions of the handouts, you can reach me at: aaron [at] pebblestorm [dot] com

I was baffled at this blog I came across that had alot of facts in regards to Sarah Palin. I was looking for a blog or information that was unbiased about Sarah Palin because I had never heard of her before so I really didn't have an opinion one way or the other. The politics of the world does affect what I do because business is affected by the tides of politics.

I'm not a republican, a democrat, or an independent so I'm detached all the way through. Here is the blog:

http://mudflats.wordpress.com/2008/08/29/what-is-mccain-thinking-one-alaskans-perspective/#comments

Come and join the presence the Lord as we celebrate it together with our families and love ones.

This will be on September 7, 2008. Sunday After worship Service.

Thursday, Sept. 11, 2008 from 6-9pm come and join your fellow Trustfunders for eats, drinks, and great autumn clothing.