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text:
Nacque in un villaggio vicino a Coblenza, e studiò presso l'Università Humboldt di Berlino, dove ottenne il suo dottorato nel 1868. Nel 1875 divenne professore associato di mineralogia a Breslavia, e nel 1880 professore di mineralogia e geologia a Bonn. Lasaulx si distinse per le sue ricerche sui minerali e nella cristallografia, e fu uno dei pionieri della petrografia microscopica. Egli descrisse nel 1878 le rocce eruttive del distretto della Saar e di quello del dipartimento francese della Mosella.

Nel 1880 curò la pubblicazione del "Der Aetna", tratto dai manoscritti di Wolfgang Sartorius von Waltershausen, risultato delle osservazioni realizzate dal geologo tedesco tra il 1834 e il 1869. Fu l'autore di "Element der Petrographie" (1875), "Einführung in die Gesteinslehre" (1885), e "Precis de pitrographie" pubblicato postumo (1887). Morì a Bonn nel gennaio 1886.

Note

Altri progetti

Collegamenti esterni

redpajama_set_name: RedPajamaWikipedia


text:
package com.orientechnologies.orient.core.sql.executor;

import com.orientechnologies.common.concur.OTimeoutException;
import com.orientechnologies.orient.core.command.OCommandContext;
import com.orientechnologies.orient.core.db.record.OIdentifiable;
import com.orientechnologies.orient.core.db.record.ridbag.ORidBag;
import com.orientechnologies.orient.core.exception.OCommandExecutionException;
import com.orientechnologies.orient.core.record.impl.ODocument;
import java.util.Collection;
import java.util.Map;
import java.util.Optional;

/**
 * after an update of an edge, this step updates edge pointers on vertices to make the graph
 * consistent again
 */
public class UpdateEdgePointersStep extends AbstractExecutionStep {

  public UpdateEdgePointersStep(OCommandContext ctx, boolean profilingEnabled) {
    super(ctx, profilingEnabled);
  }

  @Override
  public OResultSet syncPull(OCommandContext ctx, int nRecords) throws OTimeoutException {
    OResultSet upstream = getPrev().get().syncPull(ctx, nRecords);
    return new OResultSet() {
      @Override
      public boolean hasNext() {
        return upstream.hasNext();
      }

      @Override
      public OResult next() {
        OResult result = upstream.next();
        if (result instanceof OResultInternal) {
          handleUpdateEdge((ODocument) result.getElement().get().getRecord());
        }
        return result;
      }

      private void updateIn(OResult item) {}

      private void updateOut(OResult item) {}

      @Override
      public void close() {
        upstream.close();
      }

      @Override
      public Optional<OExecutionPlan> getExecutionPlan() {
        return Optional.empty();
      }

      @Override
      public Map<String, Long> getQueryStats() {
        return null;
      }
    };
  }

  @Override
  public String prettyPrint(int depth, int indent) {
    String spaces = OExecutionStepInternal.getIndent(depth, indent);
    StringBuilder result = new StringBuilder();
    result.append(spaces);
    result.append("+ UPDATE EDGE POINTERS");
    return result.toString();
  }

  /**
   * handles vertex consistency after an UPDATE EDGE
   *
   * @param record the edge record
   */
  private void handleUpdateEdge(ODocument record) {
    Object currentOut = record.field("out");
    Object currentIn = record.field("in");

    Object prevOut = record.getOriginalValue("out");
    Object prevIn = record.getOriginalValue("in");

    // to manage subqueries
    if (currentOut instanceof Collection && ((Collection) currentOut).size() == 1) {
      currentOut = ((Collection) currentOut).iterator().next();
      record.setProperty("out", currentOut);
    }
    if (currentIn instanceof Collection && ((Collection) currentIn).size() == 1) {
      currentIn = ((Collection) currentIn).iterator().next();
      record.setProperty("in", currentIn);
    }

    validateOutInForEdge(record, currentOut, currentIn);

    changeVertexEdgePointer(record, (OIdentifiable) prevIn, (OIdentifiable) currentIn, "in");
    changeVertexEdgePointer(record, (OIdentifiable) prevOut, (OIdentifiable) currentOut, "out");
  }

  /**
   * updates old and new vertices connected to an edge after out/in update on the edge itself
   *
   * @param edge the edge
   * @param prevVertex the previously connected vertex
   * @param currentVertex the currently connected vertex
   * @param direction the direction ("out" or "in")
   */
  private void changeVertexEdgePointer(
      ODocument edge, OIdentifiable prevVertex, OIdentifiable currentVertex, String direction) {
    if (prevVertex != null && !prevVertex.equals(currentVertex)) {
      String edgeClassName = edge.getClassName();
      if (edgeClassName.equalsIgnoreCase("E")) {
        edgeClassName = "";
      }
      String vertexFieldName = direction + "_" + edgeClassName;
      ODocument prevOutDoc = ((OIdentifiable) prevVertex).getRecord();
      ORidBag prevBag = prevOutDoc.field(vertexFieldName);
      if (prevBag != null) {
        prevBag.remove(edge);
        prevOutDoc.save();
      }

      ODocument currentVertexDoc = ((OIdentifiable) currentVertex).getRecord();
      ORidBag currentBag = currentVertexDoc.field(vertexFieldName);
      if (currentBag == null) {
        currentBag = new ORidBag();
        currentVertexDoc.field(vertexFieldName, currentBag);
      }
      currentBag.add(edge);
    }
  }

  private void validateOutInForEdge(ODocument record, Object currentOut, Object currentIn) {
    if (!isRecordInstanceOf(currentOut, "V")) {
      throw new OCommandExecutionException(
          "Error updating edge: 'out' is not a vertex - " + currentOut + "");
    }
    if (!isRecordInstanceOf(currentIn, "V")) {
      throw new OCommandExecutionException(
          "Error updating edge: 'in' is not a vertex - " + currentIn + "");
    }
  }

  /**
   * checks if an object is an OIdentifiable and an instance of a particular (schema) class
   *
   * @param iRecord The record object
   * @param orientClass The schema class
   * @return
   */
  private boolean isRecordInstanceOf(Object iRecord, String orientClass) {
    if (iRecord == null) {
      return false;
    }
    if (!(iRecord instanceof OIdentifiable)) {
      return false;
    }
    ODocument record = ((OIdentifiable) iRecord).getRecord();
    if (iRecord == null) {
      return false;
    }
    return (record.getSchemaClass().isSubClassOf(orientClass));
  }
}

redpajama_set_name: RedPajamaGithub


The City of Oak Grove had a population of 8,075 as of July 1, 2018. Oak Grove ranks in the upper quartile for Population Density when compared to the other cities, towns and Census Designated Places (CDPs) in Missouri. See peer rankings below.
The primary coordinate point for Oak Grove is located at latitude 39.005 and longitude -94.1294 in Jackson County. The formal boundaries for the City of Oak Grove encompass a land area of 6.17 sq. miles and a water area of 0.02 sq. miles. Jackson County is in the Central time zone (GMT -6). The elevation is 879 feet.
The City of Oak Grove (GNIS ID: 2395283) has a C1 Census Class Code which indicates an active incorporated place that does not serve as a county subdivision equivalent. It also has a Functional Status Code of "A" which identifies an active government providing primary general-purpose functions.
The City of Oak Grove is located within Township of Sni-A-Bar, a minor civil division (MCD) of Jackson County.
Alternate Unofficial Names for Oak Grove: Lickskillet.
The table below compares Oak Grove to the other 1,032 incorporated cities, towns and CDPs in Missouri by rank and percentile using July 1, 2018 data. The location Ranked # 1 has the highest value. A location that ranks higher than 75% of its peers would be in the 75th percentile of the peer group.


Americans tend to think of the world in simple terms, and that includes even their nation's history. Third quarter of 20th Century is often seen as the conflict between two forces embodied by two very different US Presidents. The first one of them was John F. Kennedy - great statesman, courageous reformer and embodiment of youthful idealism that was supposed to bring USA into new Golden Age. Opposed to him was Richard M. Nixon - evil, corrupt, reactionary, genocidal and power-hungry paranoid that nearly destroyed American democray. While Kennedy's assassination proved to be one of greatest American tragedies, Nixon's disgraceful removal from the Oval office was one of great American triumphs. This perspective, implanted by 1960s and 1970s salon leftists into Hollywood and the rest of the world, was the reason why NIXON, 1995 biopic directed by Oliver Stone, represents one of the greatest surprises to come from Hollywood in the past decade.
The plot begins in June 1972, at the moment when the infamous "Plumbers" prepare for the Watergate break-in, and ends in August 1974, with the resignation of President Richard Nixon (played by Anthony Hopkins). The well-documented events that unfold in between are intertwined with Nixon remembering the events that marked both his life - traumatic childhood in 1920s California - and the history - Chequers speech, 1960 and 1968 elections, Vietnam War and his foreign policy triumphs.
Four years before this film Oliver Stone in JFK had accepted the traditional "Kennedy-as-saint" gospel, so most people expected Oliver Stone to make a hatchet job of 37th US President in NIXON. Others expected the film to be flooded with wild conspiracy theories. NIXON didn't meet such expectations. Oliver Stone instead gave surprisingly serious, three-dimensional and humane portrayal of disgraced American leader, obviously being fascinated with many contradictory and enigmatic details of his character and biography. While Stone doesn't shy away from showing what brought such infamy to Nixon, he also gives his human side and even some redeeming qualities - his patriotism, dedication to family and the potential for true greatness. But, just like the protagonists of classic tragedies, Nixon failed to meet such potential from his own human weakness. This powerful message, underlined with Stone's clever idea to turn White House into some sort of haunted Gothic castle, is however muddled with Stone succumbing to his old conspiracy theories and sensationalism in the most un-opportune moments. Idea that the same people who had killed Kennedy - the "dark forces" - played part in Nixon's downfall is intriguing; putting those forces in the form of Texas oilman played by Larry Hagman (who had played similar role in 1970s soap DALLAS) makes this idea into parody of itself.
Another problem with the film is casting. Anthony Hopkins tries his best to impersonate Nixon, but the Welsh actor under heavy make-up is simply hard to associate with the real-life president. Joan Allen as First Lady Pat Nixon, Paul Sorvino as Kissinger and Powers Boothe as Alexander Haig don't seem to have such problem (and the Boothe delivers truly chilling performance). Narrative structure of the film also makes things difficult for viewers - in the first hour the plot meanders between June 1972 and December 1973 and goes back to June 1972 only to catch the classic linear structure in last two hours. Movie also suffers because of Stone's desire to make it look "cool" by combining different film stock, using MTV-style editing and putting Chinese and Cyrillic characters in the scenes that feature Nixon's meetings with leaders of China and Soviet Union. Watergate scandal is, on the other hand, carefully recreated in all of its infamy, but those who want to find something more about it could do better if they watch television documentary.
At the very end of the film, when Hopkins' Nixon gets replaced with the documentary footage of 37th President, the audience would get impression that the real character was more intriguing and interesting than the one portrayed in the movie. Some day in the future the lessons from this film will serve the makers of CLINTON.


Background Reaching the therapeutic target of remission or low-disease activity has improved outcomes in patients with rheumatoid arthritis (RA) significantly. The treat-to-target recommendations, formulated in 2010, have provided a basis for implementation of a strategic approach towards this therapeutic goal in routine clinical practice, but these recommendations need to be re-evaluated for appropriateness and practicability in the light of new insights.
Objective To update the 2010 treat-to-target recommendations based on systematic literature reviews (SLR) and expert opinion.
Methods A task force of rheumatologists, patients and a nurse specialist assessed the SLR results and evaluated the individual items of the 2010 recommendations accordingly, reformulating many of the items. These were subsequently discussed, amended and voted upon by >40 experts, including 5 patients, from various regions of the world. Levels of evidence, strengths of recommendations and levels of agreement were derived.
Results The update resulted in 4 overarching principles and 10 recommendations. The previous recommendations were partly adapted and their order changed as deemed appropriate in terms of importance in the view of the experts. The SLR had now provided also data for the effectiveness of targeting low-disease activity or remission in established rather than only early disease. The role of comorbidities, including their potential to preclude treatment intensification, was highlighted more strongly than before. The treatment aim was again defined as remission with low-disease activity being an alternative goal especially in patients with long-standing disease. Regular follow-up (every 1–3 months during active disease) with according therapeutic adaptations to reach the desired state was recommended. Follow-up examinations ought to employ composite measures of disease activity that include joint counts. Additional items provide further details for particular aspects of the disease, especially comorbidity and shared decision-making with the patient. Levels of evidence had increased for many items compared with the 2010 recommendations, and levels of agreement were very high for most of the individual recommendations (≥9/10).
Conclusions The 4 overarching principles and 10 recommendations are based on stronger evidence than before and are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA.
There are several reasons to reconsider the treat-to-target recommendations. When they were developed, several of the items were based on expert opinion or indirect support rather than stringent, direct evidence and, therefore, it was deemed advisable to look out for new pieces of evidence for or against one or more of the items, as also stated as research agenda at that time. Beyond this aspect, some criticism had arisen.29 ,30 While most points of this critique had actually been already quite clearly accounted for in the recommendations or the accompanying text, it indicated that the verbalisation and/or the positioning of some of the recommendations might have not been sufficiently clear. Also, the adherence to the treat-to-target recommendations in clinical practice may be low,31 despite all the evidence regarding the importance of this approach. Therefore, revisiting the formulation of individual recommendations in line with available evidence and/or reassessment of expert opinion seemed desirable. Finally, all recommendations should be revisited every few years for their timeliness, appropriateness and accuracy, especially in the light of new developments in the field. Such reshaping of the recommendations may also help improving adherence of health professionals to the recommendations32 and adherence of patients to therapies they have agreed upon with their physicians.
This endeavour consisted of several stages. Initially, a Steering Committee comprised of rheumatologists from several areas of the world and a patient was brought together in 2012 to discuss the potential need for updating the recommendations. During these deliberations, questions related to the practicability of some of the items; aspects of risks on the way to attain the treatment target; the issue of comorbidities both from the viewpoint of their association with active RA and as potential contraindications for intensifying therapy; the role of work productivity; and reduction or withdrawal of therapy upon achievement of the target were distilled in an iterative discussion process as important themes that had not, or not sufficiently, been addressed in 2010. Also, in the SLR performed for the 2010 recommendations,34 only very few publications had focused on differences between treatment strategies as primary endpoint, namely comparing a treatment strategy towards a particular target with other therapeutic approaches, and these almost exclusively dealt with early but not established RA. As a consequence of these discussions, details for an SLR of studies published between 2008 and 2012 were elaborated and an initial search performed by MSch. When the Steering Committee reconvened at the end of 2012 and discussed these SLR results, it was disappointing to see that evidence for many of the questions addressed was still scarce. Therefore, it was decided to wait for additional information and the re-evaluation of the recommendations was postponed. A new SLR that accounted for the literature accumulated between 2012 and April 2014 was performed in the middle of 2014 by MSt and TS. These results were presented to the Steering Committee.33 Indeed, novel evidence related to the questions posed was found, expanding the data obtained by the initial SLR34 and the SLR performed in 2012.33 At a new meeting, the Steering Committee was informed on the results of the SLRs and subsequently revisited the individual recommendations and performed a preliminary reformulation, where necessary. The committee also evaluated the sequence of the recommendations for logical coherence or risk of being overlooked. Aspects to be discussed in the text accompanying the individual points were documented.
In a next step, the proposal of the Steering Committee was presented to a large Task Force of 33 expert individuals, which comprised rheumatologists from many regions of the world (Australia, Europe, Japan, Latin America and North America), 5 patient representatives who had either been already involved in the development of the original recommendations or were identified as having particular interest in this area of research, and a rheumatology nurse. After presentation of the steering group's proposal and the background for it, three breakout groups were formed to address (a) the overarching principles, (b) recommendations 1–5 and (c) recommendations 6–10. Chaired by a patient representative (group dealing with the overarching principles) and rheumatologists (the other two groups), further discussions took place during these breakout sessions and the proposed wordings reformulated as deemed appropriate, with majority votes where controversy existed. It was agreed that individual items of the 2010 recommendations should only be changed based on new evidence, expansion of knowledge or if the wording appeared not being sufficiently clear. The results obtained by the breakout groups were reported to the whole Task Force, which then discussed these proposals, amended them and arrived at final wordings that were subjected to an anonymous voting process using voting cards. Items that achieved at least a two-third majority (≥67%) were taken as final recommendation in the exact way as they had been worded. Items that did not attain such majority approval straight away were re-discussed, re-formulated and re-voted on, until the majority was achieved.
In a final exercise, the bullet points were sent to each participant and additional members who could not be present at the face-to-face meeting by email to determine the level of agreement using an 11-point numerical rating scale (0=I do not agree at all, 10=I completely agree). At this stage, no changes to the wording could be made unless a mistake had been detected. Also, the final text of the manuscript was sent to all participants for their comments and ultimate approval.
With this database at hand, the steering committee discussed the limitations of the treat-to-target recommendations and potential means to adapt them. Many themes were addressed: clinical versus 'imaging' or 'laboratory' remission (the latter meaning remission by non-clinical means); minimisation of comorbidities, especially cardiovascular, but also the risk that LDA or remission may not be targeted by rheumatologists because comorbidities preclude intensifying therapy; individualised therapy; work productivity and work-force maintenance aspects; and factors confounding the treatment target.
After the discussions on the SLR, its consequences for the recommendations and the rewording and repositioning proposals in relation to the 2010 recommendations as suggested by the steering committee and in the breakout groups all items underwent voting and the resulting recommendations are shown in table 1; for comparative purposes, the old version is presented in small font. Table 2 reveals the results of the ballots, the levels of evidence and grades of recommendation and the levels of agreement.
The treatment of RA must be based on a shared decision between patient and rheumatologist. While this principle remained unchanged, it was discussed that the follow-up of patients with RA and therapeutic dialogues are increasingly also involving other healthcare professionals (HCPs) than physicians, particularly specialist nurses. In healthcare systems where this is already established, the shared decision-making also has to include these HCPs, thus involving the whole team in the care of RA. All 33 participants voted in favour of the statement.
The primary goal of treating patients with RA is to maximise long-term health-related quality of life through control of symptoms, prevention of structural damage, normalisation of function and participation in social and work-related activities. Two changes were made to the previous item B: a minor one, where 'the patient' was replaced by 'patients'; but more importantly, the previous item B ended with '… social participation' which was changed to 'participation in social and work related activities'. It was deemed particularly important to include aspects of work productivity and employment, especially since work participation has been associated with a better quality of life,47 which is also implied by using the term 'through'. Moreover, participation in work is an important part among the categories of the WHO's International Classification of Functioning, Disability and Health.48 Other aspects mentioned while discussing this item were comorbidities, including osteoporosis and cardiovascular risk, and systemic features of RA, but also the role of comorbidities as contraindication to amend therapy. However, it was decided by majority vote to only mention this in the text accompanying this item as an important consideration when treating RA but not to include it in the current wording of the point, especially also because comorbidity is mentioned specifically in one of the current recommendations (recommendation no. 7).
Abrogation of inflammation is the most important way to achieve these goals. This item remained unchanged compared with the 2010 version. As during the deliberations 4 years ago, the term 'abrogation' was discussed and also the question raised if the most important aspect was really inflammation, but at the end of these discussions everyone was convinced that this point should remain as it was since there were no data available allowing to make any other conclusion than that interfering with the inflammatory response was of utmost importance for optimal outcomes.
Treatment to target by measuring disease activity and adjusting therapy accordingly optimises outcomes in RA. Also, this item remained unchanged compared with 2010; there was no further discussion and full agreement within the Task Force (33 positive votes).
Before addressing the recommendations individually, it was decided to add a footnote (asterisk) to the heading of the table to ensure the recognition that the text accompanying each item is an integral part of the recommendations and that any interpretation that does not account for the information provided in the text should be seen as wrong.
The primary target for treatment of RA should be a state of clinical remission. This first item was not changed at all versus 2010 and seen as the cardinal point of the recommendations. Clinical remission has consistently been shown to convey better outcomes than other disease activity states, even low-disease activity.11 ,25 ,26 ,49 Meanwhile, also two studies targeting DAS28<2.6 compared with conventional not DAS28-steered therapy, one in early RA and one in established RA, showed a significant advantage in favour of targeting this activity state.36 ,39 While the Task Force discussed in depth whether the term 'clinical remission' should be changed or expanded to include 'imaging remission' or 'laboratory remission', there was final agreement on the term clinical remission, especially as defined by the ACR–EULAR remission criteria for clinical trials and practice,28 since the vast majority of the literature, if not the entire inflammatory rheumatology literature addressing 'hard outcomes' of RA, like radiographic changes, disability and quality of life, has been based on clinical observations, not on observations using imaging techniques. Upon fulfilment of clinical remission according to the ACR–EULAR definition, functional and structural outcomes are maximised and only minimal abnormalities can be detected by imaging such as sonography.45 ,46 ,50 Also, a first study targeting a clinical low-disease activity state compared with targeting sonographic remission revealed no major differences in clinical or functional outcomes despite the use of low-disease activity rather than ACR–EULAR defined remission as the clinical target.42 On the other hand, some data indicate that there may still be residual active synovitis by sonographic examinations in patients in clinical remission51 and, therefore, further studies on sonography and MRI, especially in relation to important long-term outcomes, need to be awaited. Given all these data,52 imaging remission was not included into the current update of the recommendations, leaving clinical remission as the therapeutic target.
Clinical remission is defined as the absence of signs and symptoms of significant inflammatory disease activity. Also, this point was not changed. There was a major discussion ongoing as to which remission criteria should be used. Whereas with few exceptions everyone agreed that composite measures, in particular Clinical Disease Activity Index (CDAI), DAS, DAS28 or Simplified Disease Activity Index (SDAI),53 should be generally used to assess disease activity (see also item 4), several participants felt that, despite the existence of the new preliminary ACR–EULAR remission definition,28 one should not dismiss DAS and DAS28 remission, while others were of the opinion that the new definition of remission (Boolean or SDAI-based) should be used, to which the 2010 Task Force had already referred to, in particular given even considerations of its sonographic correlates (see above). It was then argued that the ACR–EULAR remission criteria had been developed for clinical trials, but this view was contended by the fact that also remission definitions for clinical practice (Boolean criteria without C-reactive protein (CRP) and CDAI remission criteria) had been presented in the ACR–EULAR publication.28 Moreover, evidence that the residual disease activity in the presence of DAS28 scores <2.6 is associated with progression of joint damage and some functional impairment has accumulated since the time of formulating the 2010 recommendations. Indeed, patients in DAS28 remission not fulfilling ACR–EULAR remission criteria compared with those achieving ACR–EULAR remission (Boolean- or index-based) may have a large number of residually swollen joints,54–56 show more damage progression, worse physical function, worse quality of life and increased rates of comorbidities. DAS28 remission is thus not easily compatible with the term remission.27 ,46 ,57–59 Some fears were raised that using stringent remission criteria would allow for achievement by only few patients and might lead to overtreatment, but this view was opposed by pointing to the relatively large frequency of attaining these criteria in clinical practice and trials of patients with early RA.60 ,61 The significant residual disease activity that can be observed with DAS28<2.6 has been debated for long28 ,45 ,46 ,54 ,55 ,62 ,63 and is associated with progression of joint damage.57 ,64 Also, a recent publication evaluating several clinical trials addressed the underestimation of disease activity by the DAS28 remission criteria.65 Important in this context is further that the US Food and Drug Administration classifies DAS28<2.6 as reflection of low-disease activity,66 which is in line with all of the above notions. It was further mentioned that clinical remission was mainly a treatment goal for early disease and that there is an alternative target of low-disease activity, especially for established disease (see item 3), while in early disease one would aim for stringent remission with a minimum of residual disease activity. Moreover, since some of the discussions focused on imaging (sonographic) remission that is even more difficult to achieve, stringent clinical remission as defined by ACR–EULAR may currently be the definition best reflecting the wording of item 2, leaving other definitions reflecting low-disease activity as alternative targets (see item 3).
While remission should be a clear target, low-disease activity may be an acceptable alternative therapeutic goal, particularly in long-standing disease. The meaning of this recommendation remained unchanged, but it was shortened by deleting the insert 'based on available evidence' because that evidence had further increased over the last four years, making obsolete to specifically point it out. It was further discussed that comorbidities may be present that might preclude the intensification of therapy to target remission, especially in long-standing disease. However, this aspect was not included here since it was felt that 'long-standing' disease in itself inferred not only RA with significant damage but also the potential presence of comorbidities and that this would be dealt with in a subsequent recommendation anyway (no. 5). Moreover, the word 'particularly' implied that low-disease activity could also be a target in early disease, although—as the item is worded—low-disease activity is not a preferred state for early disease but may be so more in established RA. Importantly, defining the alternative to remission as being low-disease activity in the context of treatment targets precludes any other state, such as moderate disease activity, as a therapeutic goal, although even this viewpoint is to some extent counterbalanced for exceptional situations by recommendation 7. It was also regarded important to recommend documentation of the chosen treatment target in the files and to share this decision with the patient, in line with overarching principle A (shared decision). Importantly and to reiterate, the Task Force does not insinuate to replace the target of remission by the alternative target of low-disease activity but rather implies that if remission cannot be achieved for any reason (such as in patients with long-standing disease), low-disease activity is an alternative and valid target, but any other state than low-disease activity would usually not be acceptable. However, patient factors, such as comorbidities, have to be taken into account in the course of a shared decision with the patient when defining the treatment target and the way to arrive there.
The choice of the (composite) measure of disease activity and the target value should be influenced by comorbidities, patient factors and drug-related risks. This recommendation, previously comprised in no. 9, underwent a change in wording in two respects: first, the prior word 'may' was replaced by 'should', making a stronger point on the choice of other treatment targets than remission (or even low-disease activity) under certain circumstances (see below); second, old no. 9 stated "…influenced by consideration of co-morbidities,…" while the 'consideration' has now been removed and the recommendation calls for adaptation of treatment targets according to the presence of comorbidities, patient factors and drug-related risks. Moreover, this recommendation was shifted from its previous position as no. 9 of 10 to no. 5. Again, logic and the desire to give more prominence and thus attention to this recommendation were driving this decision. Logic, since this item now follows immediately after the recommendation on the importance to apply composite measures of disease activity and brings some respective caveats forward. Since in particular the presence of some comorbidities, such as severe cardiovascular disease, uncontrolled diabetes, or impaired renal or hepatic function, may preclude attempts to change treatment geared at reaching the main treatment target, the therapeutic goal may have to be different in such patients. Similar thoughts pertain to contraindications or safety aspects; if a patient suffers from recurrent infections, one will likely refrain from intensification of therapy to avoid risky overtreatment. Regarding the choice of the composite measure and the potential need to employ other instruments, such as comorbidities that increase or decrease acute phase reactants (which will confound scores that comprise erythrocyte sedimentation rate or CRP), some of our traditional composite measures may not be useful tools and other means may have to be the focus of disease activity assessment in such patients. On the other hand, with some particular aspects accompanying RA, such as pain hypersensitivity, patient-reported outcomes may not reflect the inflammatory events correctly but will likely be overshadowed by the comorbidity; this relates to the patient global assessment, but also to function and quality-of-life questionnaires as well as tender joint counts. Importantly, and in line with what was stated above, the instrument used to assess disease activity and the treatment target should be documented. The discussion partly focused around combining this point with the previous one, but it was felt that they address different issues and that this cautionary recommendation might be 'diluted' if it became an appendix of the previous one. Moreover, some criticism had arisen around this particular aspect29 despite its prior existence and, therefore, its presentation as a distinct recommendation was deemed important. It is now less likely to be overlooked. In the course of the discussion, another important point emerged: while comorbidities may preclude intensification of therapy due to perceived risks, some comorbid conditions (such as amyloidosis or cardiovascular disease) are a consequence of active inflammation and, therefore, they may even require to aim for a target of remission without tolerance of low-disease activity; indeed, there has been a significant survival advantage in recent years with modern treatment approaches.75–79 Also, in elderly patients with RA intensive therapy is frequently avoided out of the perception that they may not require it,80 although there is evidence against such contention.81 ,82 Another 'patient factor' to be considered is work capacity and its impairment. Moreover, it needs to be borne in mind that comorbidities and other patient factors may change in the course of the disease and its treatment, which may impact the maintenance of the treatment target as requested in recommendation 9. Thus, overall, this recommendation relates to a personalised approach of the treatment strategy, considering all factors related to the individual patient.
Measures of disease activity must be obtained and documented regularly, as frequently as monthly for patients with high/moderate disease activity or less frequently (such as every six months) for patients in sustained low-disease activity or remission. There was only a small change regarding this item, which was previously no. 5. It had stated 'such as every 3–6 months' for control examinations in patients who sustain the therapeutic target of low-disease activity or remission, maintenance of remission being an important goal. However, 3-month intervals were felt undue for this population of patients, and some rheumatologists may even consider less frequent control examinations than every six months to be appropriate. Nevertheless, assessments at different time points have not been compared and therefore most of these time-related aspects have a low level of evidence, but strong expert opinion with good agreement, as indicated by the 94% positive vote. This recommendation also explicitly calls for documentation of the measure of disease activity chosen in the patient's chart. On the other hand, since with very active disease frequent adaptation of therapy may be needed, the Task Force reiterated the potential need for monthly controls in such situations. Moreover, as will be also stated in a subsequent recommendation (no. 9), the necessity for maintenance of remission (or low-disease activity) is already mentioned at this point in time. However, even patients in sustained remission must be assessed at certain intervals to ensure maintenance of the good outcome and lack of adverse events. In the course of sharing decisions with the patient, it is also important to advise the patient to reach out for the rheumatologist earlier than at the predetermined time point if the condition changes unexpectedly. In many countries, follow-up assessments are undertaken by health professionals other than physicians in the setting of a multidisciplinary care. Irrespective of the assessing person, numerous practice trials have revealed the importance of regular disease activity assessments. Without such regular evaluations using respective instruments, patients will be undertreated and therefore may encounter worse structural and functional outcomes, but also more comorbidities. It was also discussed if longer intervals should not be suggested for patients who have reached remission. However, the majority of participants felt that a first achievement of remission may still be a vulnerable situation and longer intervals should only be considered for patients in sustained remission; also the duration to which the term 'sustained' would pertain was not clear—3 months or 6 months might be considered as the absolute minimum requirement in this respect.
Until the desired treatment target is reached, drug therapy should be adjusted at least every three months. The wording of this recommendation (originally no. 4) was not changed. Of particular importance, almost all practice trials have shown that patients under routine care that is not informed by a composite measure of disease activity have much worse outcomes than patients in whom treatment decisions are based on the disease activity assessment by such instruments.16 This is an important concept since the observations that routine care that does not apply clinical scoring and a targeted therapeutic approach suggest that patients with RA have been significantly undertreated. The shift to its new positioning, therefore, does not imply that the Task Force did not appreciate this point as sufficiently important to be among the initial items; on the contrary, the Task Force felt, just as before, that this is a key recommendation. However, appropriate adjustments of therapy have already been implied in items 4 and 6, where we advocate guidance of treatment decisions by the use of composite measures and a high frequency of taking these measures in the presence of active disease. 'Adjust' is then an expansion of the term 'guide', but it does not primarily, let alone exclusively, imply a change of a drug regimen, but also comprises aspects such as dose increases of ongoing therapy (where pertinent) or intra-articular glucocorticoid injections, for example, in the presence of residual joint swelling. The recommendation regarding the frequency of treatment adjustments (the verbalisation 'at least every three months' includes a higher frequency) is based on the results of strategic clinical trials that showed that adapting therapy every month leads to good outcomes compared with conventional care.16 ,17 ,36 ,39 Recommending adjustments in active disease 'at least' every three months, implying that this should not be later, is also based on evidence, since the treatment response at 3 months allows to predict if patients are highly likely or highly unlikely to achieve the treatment target at subsequent points in time.38 ,87–89 Therefore, adjustments, potentially also a change of the drug regimen, may have to be performed. Importantly, by recommending to see these patients every three months, this item indirectly will also serve the purpose of treatment monitoring and prevention of overtreatment, yet another important aspect in the context of treatment to target. The term adjustment also comprises reduction or even withdrawal of some therapies, when stability of the overall response allows such decision to be made (see also item 9). In any case, if medication is reduced or intervals prolonged, the patients should be carefully watched by composite measures of disease activity to be sure that they do not experience a deterioration of their clinical status.
The desired treatment target should be maintained throughout the remaining course of the disease. Unchanged compared with 2010 (then no. 8), this item refers to observations that complete halt of joint damage and further improvement of physical function depend on the maintenance of the clinical remission state.11 ,58 ,90 Moreover, loss of the targeted good outcome can reignite the process leading to joint damage.91 ,92 Maintenance of the treatment target does not in itself imply maintenance of treatment; indeed, a number of studies on tapering of therapy, especially dose reduction, interval increases and even withdrawal of biologicals, have been performed since 2010.92–101 These studies indicate that in established RA stopping biologicals leads to very frequent loss of low-disease activity or remission, while dose reduction or spacing of intervals of applications carries less risk of return of active disease. In early disease, the question of successful withdrawal is not yet resolved. Stopping conventional synthetic DMARDs102 is followed by flares more frequently compared with their continuation.103 In this context, the aspect of adherence to therapy has also to be considered since non-adherent patients flare up to four times more frequently than adherent patients,104 pointing to the significant importance of information and shared decision-making with the patients (items A and 10). Safety aspects and drug costs may also have to be taken into consideration in this respect.
The rheumatologist should involve the patient in setting the treatment target and the strategy to reach this target. The involvement of the patient in making decisions and the type of information provided should be recorded, along with the treatment target and the measures to be used during follow-up. The agreed and documented target should be visible in the patient records to every HCP involved in the monitoring of the disease evolution of the individual patient. Compared with previous no. 10, this recommendation has not only been simplified, but a proactive role is now assigned to the rheumatologist (previously: 'under the supervision of the rheumatologist'). Rheumatologists, but also all other health professionals caring for patients with RA, are reminded that the reasons to propose a particular treatment target and the means to achieve this ought to be not only properly communicated to the patient, but also agreed upon with the patient, in line with respective information on the disease and the benefits and risks of various therapies. Indeed, patients have a wide range of beliefs related to DMARD therapy105 and appropriate communication allows patients to make informed decisions.106 Moreover, adherence to treatment has been clearly shown to depend on the level of information and on a good interaction with the rheumatologist.107 In this context, it also must be reiterated that patients with RA require a multidisciplinary care and that in many countries nurse practitioners/specialists or other health professionals take a very important role in informing, following and managing patients (see also overarching principle A). Offering such care where available, or attempting to establish it, is also part of the overall role of the rheumatologist. This item inherently comprises all aspects of the present recommendations, such as the setting of the treatment target, the means of disease evaluation, the chosen drug and non-medical therapy including their risks, the focus on comorbidities and other patient factors, the follow-up process—all this has to be taken into consideration when the rheumatologist 'involves' the patient. Indeed, it may be challenging to explain to a patient whose disease activity has significantly improved that therapy should be intensified—and these recommendations and especially their patient version108 may be helpful to this end. Educational programmes supporting this process need to be expanded.
The procedures were initiated by a Steering Committee that adhered to the EULAR operating procedures.109 The Steering Committee solicited the SLRs.33 Based on this new evidence, a large Task Force was convened comprising 43 individuals, of whom 5 were patient representatives and 37 rheumatologists from around the world. Contrasting the previous Task Force, the current one also obtained input from a nurse specialist.
The Task Force revisited the overarching principles and the 10 itemised recommendations and reiterated that a pivotal aspect in the care of RA is the shared decision-making with the patient. The whole set presented is framed by this aspect, with overarching principle A introducing it and item 10 calling again for the involvement of the patient in setting the goals and the strategy. Overarching principle B has been amended to now include work participation since this is not only an important aspect related to overall quality of life,47 but an important outcome that can be increasingly achieved with modern therapeutic strategies.
Also, recommendation 3, namely that low-disease activity constitutes the alternative for remission, has not been changed and was regarded equally important as item 1 by the Task Force. This is particularly true for patients with long-standing disease who will mostly not be able to achieve clinical remission. Indeed, low-disease activity is the second best state, leading to much better functional and structural as well as work-related outcomes than moderate let alone high-disease activity.11 ,25 ,26 Indeed, most evidence for the benefit of targeting a good therapeutic outcome compared with conventional care exists for the low-disease activity state target. Having defined low-disease activity as the alternative target to remission implies that any higher disease activity state would not be an acceptable outcome. However, this conclusion is pertinent to the care of uncomplicated RA and may have to be adjusted in line with recommendation 5, when comorbidity, drug-related risks or other patient factors mandate to refrain from intensifying therapy to reach the most desired target. Likewise, while usually composite measures of disease activity that include joint counts, such as DAS, DAS28, CDAI or SDAI, should be employed to assess disease activity during follow-up (recommendation 4); other instruments may be a better choice to evaluate disease activity if one or more components of the composite measures are confounded by non-RA-related factors, especially comorbidities such as exaggerated pain sensitivity (fibromyalgia); this aspect is encompassed in item 5. On the other hand, in the course of caring for our patients we need to bear in mind that drugs are not the only therapeutic approach, and sometimes interventions, such as physiotherapy, surgical procedures to prevent tendon rupture or a particular focus on footcare,113 may be helpful and important.
Recommendation 6 addresses the need for regular assessment of disease activity and its documentation. The major change here is the deletion of a 3-month assessment if the treatment target is maintained; the Task Force felt that once the desired state is achieved for prolonged periods of time, less frequent assessments, such as every six -months (or less), is sufficient. The term 'sustained' is important in this respect since if the targeted status is achieved for the first time additional control examinations to ensure maintenance of the therapeutic success are usually needed. Recommendation 7 now refers to comorbidity in addition to structural damage progression and functional impairment. Usually, joint damage will not progress in sustained clinical remission but may increase slightly in low-disease activity. Thus, addressing destruction may be particularly pertinent to a state of low-disease activity that, should damage be rapidly progressing or functional impairment increase, may require intensification of therapy. However, comorbidity may also require adaptation of treatment, such as withdrawal or dose reduction of certain agents. On the other hand, it should be borne in mind that some comorbidities may be a consequence of inflammation and their prevention may require more intensive therapy.
As recommended in item 8, the adjustment of therapy in accordance with disease activity under the provisos discussed above is a pivotal item in the treatment strategy. It was shifted from position 4 to 8 for two reasons: first, it is only logical that before making treatment decisions disease activity has to be assessed and all factors pertaining to the treatment decision, starting with the target and ending with thoughtfulness regarding disease activity assessment, that is, recommendations 1–7, have to be accounted for; second, the need to control disease by therapeutic adaptations is implicitly included in several of the prior recommendations, namely items 4–6 (disease activity assessment), but also in items 1–3 (treatment target): how else than by treatment adaptation would one usually reach the treatment target? All the evidence currently available relates to such therapeutic adjustments at 1-to-3-month intervals—this is the foundation of treatment success, based on regular disease activity assessment and definition of a treatment target.33 The subsequent recommendation relates to the maintenance of the treatment target and implicitly includes the possibility to taper therapy by reducing dose or expanding intervals between applications, whether csDMARDs or bDMARDs.
During the 5 years since the first formulation of the recommendations, we have witnessed an increasing proportion of patients in low-disease activity or remission, both in clinical trials and observational studies, especially when the treat-to-target strategy is employed.92 ,99 ,100 ,114–117 The amended set of recommendations may allow for even further improvement as we have addressed aspects of work productivity and comorbidities more clearly and have strengthened the advice to not only evaluate disease activity but also record it in conjunction with recording the treatment target and strategy as well as the information given to the patient. This documentation is of particular importance in settings where patients are seen by different rheumatologists in the course of their disease, but are also a good prompt in all situations of interactions between patients with RA and health professionals.
The updated recommendations constitute a major advancement when compared with the 2010 version because several of the items are now based on much better evidence. In particular, the SLR has now revealed evidence for the validity and effectiveness of the T2T approach also in patients with established RA (before evidence existed only for early RA); for remission as a treatment target (rather than only low-disease activity as before); and for the effect of a T2T approach on working ability. In addition, several items were strengthened by the new evidence. Overall, this also led to a dramatic change in the level of evidence: while originally only two recommendations had an evidence level of 1 or 2, now 7 of them are based on such high levels. Moreover, four recommendations in 2010 had levels of agreement of <9.0, while now all recommendations achieved agreement levels of ≥9.0, indicating that the members of the Task Force felt much more confident with the 2014 recommendations than was the case a few years ago. Moreover, the updated recommendations focus more strongly than the original version on the individual patient level since they more clearly address aspects of daily life that patients are rooted in, such as return to work, as well as comorbidity. They continue to emphasise the importance of shared decision-making with the patient. All this is also reflected in the algorithm depicting the recommendations in a graphic way (figure 1).
Algorithm of treating rheumatoid arthritis (RA) to target based on the updated recommendations provided in the table 1 and discussed in detail in the 'Results' section. Indicated as separate threads are the main target (remission and sustained remission) and the alternative target (low-disease activity in patients with long-term disease and sustained low-disease activity), but the approaches to attain the targets and sustain them are essentially identical. Adaptation of therapy should be usually done by performing control examinations with appropriate frequency and using composite disease activity measures that comprise joint counts, but should take comorbidities and other patient factors into account. Setting the target as well start and adaptation of therapy should be done as a shared decision with the patient.
The research agenda for a potential next revision of these recommendations is inherent in the open question discussed before. To name a few: (i) Is attaining imaging remission superior to stringent clinical remission (ACR–EULAR) regarding structural and functional outcomes? (ii) If imaging remission provides statistically superior radiographic and functional outcomes compared with stringent clinical remission, is it of clinical significance that makes it worth the effort and risk of controlling patients regularly by sonography and intensifying therapy? (iii) Which measures of disease activity could be reliably used to evaluate patients with RA with particular pain sensitivity? (iv) Is monthly adaptation of therapy16 superior to adaptations done every three months?118 (v) How much improvement in outcomes do well informed patients experience compared with less informed patients? Finally, another important research item relates to (vi) adherence of T2T strategies in clinical practice.
In summary, the updated version of the treat-to-target recommendations have brought this guidance document to a new level regarding evidence and agreement and will hopefully be adopted by the community of rheumatologists, patients and the other stakeholders.
. Adherence to a Treat-to-Target (T2T) strategy in early rheumatoid arthritis. Is it feasible in daily clinical practice? Arthritis Rheum 2014;66(Suppl):S1037.
. Evidence for treating rheumatoid arthritis to target—a systematic literature research informing the treat-to-target task force. Ann Rheum Dis 2015; in press.
. Targeting ultrasound remission in early rheumatoid arthritis—results of the Taser study. Arthritis Rheum 2013;65(Suppl):S338–9.
. Time in remission is important for improvement of physical function in patients with rheumatoid arthritis (RA). Arthritis Rheum 2012;64(Suppl):S1104–5.
Food and Drug Administration. Guidance for Industry—Rheumatoid arthritis: Developing drug products for treatment. Draft Gudance May 2013. http://www.fdagov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM354468pdf (accessed 5 Oct 2013).
. Mortality in rheumatoid arthritis: the impact of disease activity, treatment with glucocorticoids, TNFalpha inhibitors and rituximab. Ann Rheum Dis 2015;74:415–21doi:10.1136/annrheumdis-2013-204021.
. Safety and efficacy of etanercept treatment in elderly subjects with rheumatoid arthritis. J Rheumatol 2006;33:234–43.
. Biologic-free remission of established rheumatoid arthritis after discontinuation of abatacept: a prospective, multicentre, observational study in Japan. Rheumatology (Oxford) 2015;54:683–91doi:10.1093/rheumatology/keu338.
. Discontinuation of adalimumab after achieving remission in patients with established rheumatoid arthritis: 1-year outcome of the HONOR study. Ann Rheum Dis 2015;74:389–95doi:10.1136/annrheumdis-2013-204016.
. Discontinuation of biologics in patients with rheumatoid arthritis. Clin Exp Rheumatol 2013;31(4 Suppl 78):S22–7.
. Compliance to drug treatment of patients with rheumatoid arthritis: a 3 year longitudinal study. J Rheumatol 1999;26:2114–22.
Contributors All authors have participated in the development of the recommendations and/or the generation of the manuscript. No company representative was present at the Task Force meetings or had any influence on the contents of the literature search, the recommendations or this manuscript.
Funding This activity was supported by an unrestricted educational grant from Abbvie to the Medical University of Vienna.
Competing interests JSS received grant support from and/or provided expert advice to Abbvie, Amgen, Astra-Zeneca, Astro, BMS, Celgene, Chugai, Glaxo, Janssen, MSD, Novartis-Sandoz, Pfizer, Roche, Samsung and UCB; GRB has provided expert advice to AbbVie, Astra-Zeneca, BMS, MSD/Merck, Novartis/Sandoz, Pfizer, Roche and UCB; VB has been Consultant or received Research Grants from Amgen, Abbvie, BMS, UCB, Roche, Genentech, Crescendo, Antares, Medexus, Janssen, Pfizer; MD has participated at symposiums and/or advisory boards organised by Pfizer, Abbvie, UCB, Novartis, BMS, Merck, Lilly, Sanofi and his department has received research grants from Pfizer, Abbvie, UCB, Novartis, BMS, Merck, Lilly, Sanofi; PE has undertaken clinical trials and provided expert advice to Abbvie, BMS, Pfizer, UCB, MSD, Roche, Novartis, Samsung, Takeda and Lilly; TKK has provided expert advice to AbbVie, BMS, Celgene, Celltrion, Eli Lilly, Hospira, Merck Serono, MSD, Novartis, Orion Pharma, Pfizer, Roche, UCB; VN-C has received speaking fees or funding for research projects and attending congresses from Abbvie, BMS, MSD, Novartis, Pfizer, Roche; SO received honorariam for work undertaken in relation to education/training and expert advice from AbbVie, Pfizer, MSD, Regeneron; TT has received grants from Astellas, BMS, Chugai, Daiichi Sankyo, Eisai, Mitsubishi Tanabe, Pfizer, Santen, Takeda, Teijin, AbbVie, Asahikasei, Taisho Toyama, and SymBio, speaking fees from AbbVie, BMS, Chugai, Eisai, Janssen, Mitsubishi Tanabe, Pfizer, Takeda, Astellas, Diaichi Sankyo ,Celtrion, and Nipponkayaku, and consultant fees from Astra Zeneca, Eli Lilly, Novartis, Mitsubishi Tanabe, Asahi Kasei, Abbivie, Daiichi Sankyo BMS, and Nipponkayaku; DA received grant support from and/or provided expert advice to Abbvie, BMS, Glaxo, Janssen, Medac, MSD, Pfizer, and UCB; JLA has received speaker fees from AbbVie, GSK, MSD, Roche, Pfizer and UCB; and honoraria as expert advisor from Abbvie, GSK, Lilly, Sanofi and UCB; MA gave expert advice on advisory boards and/or had speaking engagements for Abbvie, BMS, Chugai, MSD, Pfizer, Roche and UCB; MB has consulted for Abbvie, Amgen, Astra-Zeneca, BMS, Janssen, Pfizer, Roche/Genentech, served as speaker for Abbvie and BMS and owns stock from Pfizer and BMS; NB has received fees totalling not more than 10 000 euros from each of the following companies: Abbvie, BMS, Celltrion Healthcare, Grunenthal, Janssen and Pfizer; JB has received advisory/lecture fees from AbbVie, BMS, Eli-Lily, Janssen, Mundipharma, MSD, Pfizer, SUN, UCB and Department grants from AbbVie, BMS, Crescendo, Hemics, Janssen, MSD, Pfizer, UCB; MC Mario H Cardiel has participated as a principal investigator, speaker or advisor for: Abbvie, Amgen, Astellas, Bristol Myers Squibb, Infinity, Pfizer, Roche and Sanofi; BC has received consultancy honoraria or research funding from: AbbVie, BMS, Janssen, Lilly, Merck, Novartis, Pfizer, Roche-Chugai and UCB; JEF received Grants or acted as a speaker or served in advisory boards for Abbvie, Pfizer, UCB, MSD, Jansen, Celgene, Novartis; AG is a Stockholder of AbbVie, Amgen, GSK, J&J, Pfizer, and Regeneron, was Consultant for AbbVie, Amgen, Celgene, Genentech, Horizon, Iroko, Medac, Pfizer, Takeda, and UCB and has served as Speaker for AbbVie, Amgen, Celgene, Genentech, Horizon, Iroko, and Pfizer; JJG-R is on Advisory Boards of Abbvie, BMS, Hospira, Jansen&Jansen, MSD, Pfizer, Roche, and UCB; has received lecture fees from Abbvie, BMS, Pfizer, Roche, and MSD and research grants from Pfizer, MSD, Roche, and UCB; WG served as advisor for or received speaker's honoraria from MSD, Pfizer, Roche, GSK, Lilly, Abbott, UCB; PH served on advisory boards for MSD, Pfizer and Roche and has received honoraria as a speaker from Abbvie, Astra-Zeneca, BMS, MSD, Pfizer and Roche; BH has taken part in advisory boards, received research grants, or speaking engagements for Abbvie, Amgen, BMS, Celgene, Janssen, Pfizer, Roche, UCB; RL has consulted for AbbVie, Ablynx, Amgen, Astra-Zeneca, Bristol Myers Squibb, Janssen (formerly Centocor), Glaxo-Smith-Kline, Novartis, Novo-Nordisk, Merck, Pfizer, Rhoche, Schering-Plough, TiGenics, and UCB, has received research grants from Abbvie, Amgen, Centocor, Novartis, Pfizer, Rhoche, Schering-Plough, and UCB, speakers fees from AbbVie, Amgen, Bristol Myers Squibb, Janssen (formerly Centocor), Merck, Pfizer, Rhoche, Schering-Plough, and UCB and is Director of Rheumatology Consultancy BV, which is a registered company under Dutch law; EMM has participated in advisory board of and/or had speaking fees from MSD, Janssen, BMS, Hospira, Biogen, Abbvie, and Pfizer; PN received funding for clinical research and honoraria for advice and lectures on behalf of Abbvie, Amgen, BMS, Janssen, Novartis, Pfizer, Roche, Sanofi and UCB; MO received consultancy/speaker fees and/or research support form Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Janssen, Merck, Mundipharma, Novartis, Novo, Pfizer, Schering-Plough, Roche, Takeda, and UCB; AÖ has received consulting and expert testimony fees for expert opinion, honoraria for lectures; fees for the development of educational presentations and aids; and travel expenses to attend conferences from all or some of the following: Roche, Chugai, MSD, Abbvie, Pfizer, BMS & Lilly; TS-I has received Honoraria, consultation fees, support for travel, research grants from Abbott, Abbvie, BMS, DiaGraphIT, Eli Lilly, GSK, Hospira, Medac, MSD, Muikkusäätiö, Novo Nordisk, Orion Pharma, Pfizer, Roche, and UCB; AT's Department has received research grants from Abbvie, Pfizer, UCB, Novartis, GSK and MSD; RvV has received Research Support and Grants from AbbVie, BMS, GSK, Pfizer, Roche, and UCB and consultancy or other honoraria from AbbVie, Biotest, BMS, Crescendo, GSK, Janssen, Lilly, Merck, Pfizer, Roche, UCB, and Vertex; MdW has received Consulting and/or speaker fees from AbbVie, BMS, Eli-Lilly, and Roche; DvdH has received honoraria or grant support from AbbVie, Amgen, AstraZeneca, Augurex, BMS, Boehringer Ingelheim, Celgene, Centocor, Chugai, Covagen, Daiichi, Eli-Lilly, Galapagos, GSK, Janssen Biologics, Merck, Novartis, Novo-Nordisk, Otsuka, Pfizer, Roche, Sanofi-Aventis, UCB, and Vertex and is Director of Imaging Rheumatology bv, The Netherlands.


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redpajama_set_name: RedPajamaStackExchange


Last summer, I sprained my ankle. I hopped home, iced it, and ran a half-marathon a month later.
Two months after that., I turned my ankle again. It was the same ankle, weakened by the first twist. This time I heard it snap. I was up running on it in two weeks.
I ran another half marathon and injured my knee. It was the knee on the same leg that I had twisted my ankle. I rested for a week or so, and then signed up for a full marathon.
A month into marathon training, I injured my IT band and couldn't run for almost 8 months.
I look back – if only, if only, if only. If only I had cared for myself properly with the small injury, if only I had properly healed, if only I hadn't pooh-poohed it as a small problem and then watched the cumulative damage creep up from my ankle to my knee to my hip.
I don't always notice the way that small injuries in my soul build up, either. I don't tend to take time to care for them until they've worn me down and cracked me open and I'm stuck taking months and months to care for what would have been a small fix if only, if only, I had tended to myself more gently after that initial wound.
When I think of my ankle sprain, I think of shame.
Shame works its way into our bones, year by year, decade by decade, until all those moments of embarrassment, failure, let downs, sins, rebuke, build up around us so that all we can see of ourselves is someone that has nothing to offer, someone that doesn't deserve love, someone that isn't interesting, isn't good, isn't smart, who has to say loudly that "everyone is out to get me" because deep, deep down, you are really scared that the reason you are suffering is your own fault, because you're bad or stupid or sinful.
One of the reasons that I keeping coming back to Psalm 71 is the that his or her story is a long story. The author is old and has grey hairs, and she has been worshipping and lamenting for a long time. She hasn't known a moment without God: God was her midwife, "took her from her mother's womb," pulled her out bawling into the world and held her while she screamed about how cold it was.
It's a long story, and damn it's a bumpy story. She's blunt that she's seen pain and calamities along the way, and that's she's seeing them now, again. The struggles and the depths just keep coming. But just as she's seen shame, again and again, she's seen God's faithfulness, again and again, and in this Psalm she comes recklessly and boldly back to God, demanding that God would revive, again, comfort, again, save, again. She turns to God again and again, and God comes to save, again and again. Her soul is wounded, and she turns for healing. She is attacked, and she retreats to shelter. She is shamed, and she begs for her honor to be returned to her.
Be to me a rock of refuge, a strong fortress, to save me.
Shame has wounded our heart and wounded our souls. And we keep running, keep pushing ourselves beyond our capacity because we are scared that if we stop, our effectiveness in ministry or work or relationships will deteriorate – even while our effectiveness is already deteriorating because our cumulative shame is stopping us from loving recklessly and gently. We don't stop because it feels selfish, and we see so much need in the world that we don't have time to have our own needs tended – even while our untended shame makes us more selfish, gathering our defenses around us and making us less kind and less present.
We don't stop because we think we can keep running and the cumulative soul damage will never catch up with us.
We don't stop because what if the voices are true.
There it is – that deepest voice of shame that whispers that we can't listen to the shame because it is all real.
And of course it is. Oh my dear, of course it is. You haven't gotten this far in life without ruining things, breaking things, falling short, being wrong, being bad, being broken.
But running on that shame is not going to make it go away.
And what's a safer place to encounter the dark and dirty parts of our souls but in the safe fortress of our God, surrounded by thick walls, set high on a rock, where our deepest identity can't be shaken: the truths that Scripture tells us again and again, that in Christ we are saved, loved, valued, empowered, embraced, called, equipped.
Be to me a place that I can run and hide in, to be surrounded by your Love.
Be to me my rock, that doesn't move when it snows or storms, that isn't shifted by rising tides.
Be to me a fortress, a walled in place to rest in You, to sit and be comforted and revived.
Find me battered on the side of the road and scoop me up and carry me a ways.
Bring me to the rock of refuge, hold me there, and while I am sitting in safety, revive my heart.


Spaniards, Numidians, African, Berbers, and so on all fell in their wake.
And they celebrated with great triumphs in Rome.
Winning the battle was one thing.
celebrations, and a formal triumph was another.
the [FOREIGN], the glory of the Roman troops.
Usually these military paintings do not survive, of course.
discovery was made in a chamber of a tomb belonging to an important Roman family.
Most of the painting had degraded and disappeared but a small section survived.
featuring scenes from some great war.
We still don't know for sure which.
no doubt celebrating the famous family interred here.
And they date to the third or second centuries BCE.
Luckily the Romans often labeled there images.
And here we are given the names of two men.
Quintus Fabius and Marcos Fanius, how were the images to be read?
Presumably the viewer proceeded left to right.
that suggests further divisions were made in the work.
well we just don't know for sure.
Fanius at the left and Fabius appearing at the right seem to be negotiating.
The figure on the left wears a helmet and greaves, or shin armor and a short kilt.
He reaches out to another warrior carrying a spear that has been set on the ground.
now the two men appear to be shaking hands while warriors clash to the left.
tunics appear, stacked in tiers at the right.
Below this is an intense battle scene which is very poorly preserved.
So what is depicted here?
It could be the tomb of a famous family.
The Fabius are the better known gens, or family, of the two.
the mediocre quality of the painting, may point to the Fanius.
Unfortunately, we don't know for sure what battle or war is being depicted.
entirely Roman and not simply a recycling of Greek or Etruscan imagery.
Besides triumphal painting, painting in general in Rome was very popular.
of sophistication covered their interiors with all sorts of elaborate decoration.
which had been under Greek dynastic control since the time of the Tolimas.
The last Tolima, by the way, was Cleopatra.
The wall was divided into three parts.
A dado or socle at the base.
A large middle course, and an upper course, that imitated drafted masonry.
was bordered at each stage by a stucco molding.
fact it was simply stuccoed and painted, and almost everyone could afford it.
it can be found in abundance, particularly in Pompeii.
the Romans began to develop their own sculptural iconography.
what they are, how they are detailed.
to be depicted still using the traditional techniques inherited from the Greeks.
100 BC, now beginning to add their own Roman approach.
use them to depict things that were a particular interest to them.
One example of this is a pediment.
displayed in the Capitoline Museums in Rome.
Rome's Via San Gregorio on the Capitoline Hill in 1878.
And it took a while to put together.
They didn't finally get it all together and exhibit it until 2002.
known to have been built in 132 BCE in this part of Rome.
the central pediment was normally closed to Polemist was there.
But here in the Greek style it is open and filled with sculptures.
was done in cheaper terracotta and painted in the Etruscan tradition.
and they don't interrelate dramatically.
This style is typically Greek of the mid to later second century BC.
But the key thing to note is that the scene is uniquely Roman.
It's something called a suovetaurilia, the sacrifice of a sheep, a goat, and a pig.
Surrounding mars in the center are two goddesses.
probably represent Venus, Mars's consort, and victory.
But it is unsure which is which.
cinched below the breasts is late Hellenistic in date.
Dates vary, 150 to 100 BCE for this controversial work.
the assignation to a temple of Mars, not unreasonable.
The whole pediment was gaily painted.
Although primitive, it represents a major first step towards a genuinely Roman art.
the Greek heroes and their government center within the Roman forum.
just stylized impressions of these individuals?
When did real portraiture begin and when did the Romans begin to use it?
over the past century and half than any other.
as Lucius Junius Brutus, founder of the Roman republic.
the head sits on a base made during the Renaissance.
It is the earliest Roman portrait in bronze that exists.
found on silver dinari, those Roman coins, of 54 BCE.
place it closer in date to the denarious coin in the mid 1st century BCE.
appearance tend towards Roman portraiture of the 1st century BCE.
what is called plasticity of form, of Greek portraits.
with simple geometric treatment of the neck and even the facial structure.
was a hero of early Rome.
Did a later member of Brutus' kins or family pose for the portrait?
who was made to look like a bearded Zeus during the Augustan period?
Capitoline Brutus has not yet given up all its secrets.
Its deep set ivory eyes inlaid with dusky blue glass.
The contrast with the smooth and carefully done hair.
Some scholars are convinced that it should be dated just this side of 300 BCE.
the angle at which it is viewed.
It remains one of art history's most fascinating enigmas.
I think its time to end lecture five.


An attempt to identify diversity in the ESL classroom using a Multiple Intelligence Theory questionnaire.
Many teachers know something about the Multiple Intelligence Theory(MI) proposed by Howard Gardner in his book "Frames of Mind", published in 1983, and subsequently developed by his team at Harvard University through Project Zero. But it is not always clear as to how this theory could be used in the classroom in order to improve the learning of English as a second language.
Teachers are well aware of the fact that every classroom is full of students who are different from each other in many different ways. Each student comes from a different social, economic and cultural background, each one has different areas of interest, different ways of expressing themselves, different strengths and weaknesses, and now the teacher is being asked to be aware of the fact that each student also has their own individual intelligence profile. Obviously all of these factors can affect the student's learning process but how should the teacher face such diversity in the classroom?
Teachers are aware of the diversity in their classrooms. They know it is important to learn something about their students in order to invest more efficiently in the teaching-learning process, but it is not always clear what kind of knowledge would be most relevant and in what way this knowledge can be acquired. In this paper, I would like to propose that Gardner's MI Theory could be used as an initial step in order to investigate the diversity which exists in every classroom, to find out more about students' strengths and weaknesses as related to the learning process.
I often see clear visual images when I close my eyes.
I enjoy doing jigsaw puzzles, mazes and other visual puzzles.
An analysis of the data obtained from the questionnaire is presented in Table 1, where the highest scores obtained by each student have been marked in green and the lowest in red. From this data it is possible to identify not only individual strengths and weaknesses but also group tendencies. First of all, it is interesting to note that individual students marked a different number of statements overall. For example, student number 23 only marked a total of 16 statements, scoring a maximum of 5 points for Bodily-Kinaesthetic and a minimum of 1 for Mathematical-Logical Intelligence. Whereas student number 5 marked a total of 43 statements altogether, scoring a maximum of 9 points for Musical and a minimum of 2 points for Bodily-Kinaesthetic Intelligence, demonstrating a much wider range of scores than student 23.
Despite the different range of scores for each student, it is nevertheless possible to identify the highest and the lowest scores for each student, then compare the groupings for maximum and minimum scores within the class. The two Intelligences which seem to be most highly developed by the class as a whole are Linguistic Intelligence and Musical Intelligence. Both areas have 8 students registering their maximum scores in this area. Linguistic Intelligence totalling 123 points for the class and Musical Intelligence totalling 127 points __ the maximum score obtained by the class. This result might be considered surprising since the students are studying language, not music. But if we analyse both disciplines we discover that they have a lot in common. The study of language does involve the study of rhythm, stress, accent and melody, which are also fundamental concepts in the study of music. So perhaps language teachers should be more aware of the importance of music and the study of music as it relates to the acquisition of language.
Another extremely important point which teachers should be aware of when trying to relate MI theory to their practise in the classroom is that students should be encouraged to use their strengths in order to make the learning process more accessible. Thus, students who have one area of intelligence which is more fully developed than the others should be encouraged to approach their learning using that particular inteligence as an entry point. For example, student number 7 demonstrates strength in Musical intelligence, scoring 10 points for that area, whereas his next highest score is 7 points in Interpersonal Intelligence. This student should be encouraged to use his knowledge and interest in music to develop his knowledge of the English language. Whereas student number 19 scored 10 points for Interpersonal Intelligence, with his next highest score registered as 6 points for both Linguistic and Bodily-Kinaesthetic Intelligence. This student should therefore have opportunities to develop his knowledge of English using his Interpersonal strength.
Gardner believes that the learning process will function more effectively if several points of entry are used in order to explore specific content. Therefore, teachers must learn to be flexible in the presentation of the material which is being studied in order to create opportunities for all of the students in the class to use their different strengths. It is obviously not the case that the teacher should try to involve all of the intelligences at all times in every lesson. This would be an extremely difficult thing to do. But if the teacher is aware of the intelligence profile of the class, strategies can be developed in order to use the students' intelligence strengths to acquire knowledge more effectively. Thus, according to the preliminary data obtained from this initial questionnaire, the class teacher should be aware of the fact that the group as a whole is strong in linguistic and musical intelligence.
However, it is also extremely important to bear in mind that there is a small group of students who do not demonstrate specific strengths in linguistic or musical intelligence, and these students must be given the chance to use their individual strengths at some point during the course.
The lowest scores obtained by the majority of the students are registered in the area of mathematical-logical intelligence, with 11 students registering their minimum scores for this intelligence. However several areas present scores below five for many students. More than 16 students scored less than 5 points in mathematical-logical intelligence, visual-spatial, bodily-kinaesthetic, intrapersonal intelligence and interpersonal intelligence.
What are the implications of these low scores for the teaching-learning process in this particular classroom? Well the most important implication is that there seems to be plenty of room for development. All of the students have registered at least 2 low scores, with 17 out of 25 registering less than 5 points in at least 4 different areas of intelligence. This information can play an extremely important role in the development of the students' attitude towards the learning process. It is often the case that students will identify a small number of 'elite' students in the classroom who are considered the 'best' students. But if the data elicited by the multiple intelligence questionnaire is discussed by the whole group, it should be obvious to all of the students that each and every one of them has areas of strength and areas of weakness. Some of these strengths and weaknesses might not normally be obvious in a traditional language learning classroom, but if the teacher tries to flexibilise her approach to the learning process and uses as many different entry points as possible, then the students soon begin to appreciate that the best students have weaknesses and the apparently weak students have strengths. It should therefore be possible to build a much more cooperative approach to the learning process.
CAMBOURNE, Brian. The Whole Story: Natural Learning and the Acquisition of Literacy in the Classroom, Ashton Scholastic, Aukland, New Zealand, 1988.
GARDNER, Howard. Frames of Mind, Paladin Books, London, 1985.
__________________ The Unschooled Mind, Basic Books, New York, 1991.


Caesars Entertainment Corporation has signed a non-binding letter of intent with Meraas Holdings LLC to manage two new hotels and a beach club in Dubai. The two new properties will be Caesar Entertainment's first non-gaming resorts.
The Caesars Palace Bluewaters Dubai and Caesars Bluewaters Dubai will be located on Bluewaters Island development. The manmade island in Dubai is Meraas' latest leisure destination project in the emirate.
"Through our collaboration with Meraas, we anticipate Bluewaters Island will evolve into the region's top hospitality, dining and entertainment destination," explained Mark Frissora, the President and Chief Executive Officer of Caesars Entertainment.
The two luxury hotels will be located on the beachfront, and between them will have 479 guest rooms and suites. Guests will have access to an array of upscale facilities and services, including indoor and outdoor swimming pools, a lavish spa, meeting rooms and convention space, and the Caesars Beach Club Bluewaters Dubai. There will also be 12 gourmet restaurants and stylish bars, and appearances from celebrity chefs.
"We are creating unique experiences and leveraging strategic partnerships to showcase the best of what Dubai can offer to its visitors," added Abdulla Al Habbai, the Group Chairman of Meraas.
Caesars Entertainment is one of the world's largest entertainment promoters, and it has a world-class portfolio of global performers. The company owns the Zappos Theatre in Planet Hollywood, Las Vegas, which is the leading theatre in the world.
Meraas Holdings LLC is based in Dubai, and specialises in the development and management of real estate, tourism, hospitality, retail and leisure and entertainment. The group has numerous partnerships with hotel groups including Bulgari Hotels and Resorts, Marriott and Nikki Beach Hotels and Resorts. The company also operates the CITY WALK, THE BEACH, BOXPARK, Last Exit and The Outlet Village in Dubai.
Bluewaters Island is a new development under construction 500 metres off the coast off the Jumeirah Beach Residence near Dubai Marina. It is connected to Sheikh Zayed Road by a direct road, and is home to hotels, serviced apartments, beachfront residences, entertainment venues, more than 200 restaurants, cafes and shops, and the Ain Dubai observation wheel.


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Edward Collings Knight
Historical Images of Philadelphia Castner Scrapbook Collection
Item No: pdcc00038
Title: Edward Collings Knight
Media Type: Scrapbooks
Source: Print and Picture Collection
Engraved portrait of Edward Collings Knight, 1813 - 1892, a prominent Philadelphia businessman. A sugar refiner who pioneered the importation of molasses from Cuba. He was also a Director of various Railroad Companies in Pennsylvania and New Jersey and was at one time President of the Pennsylvania Railroad Company. He was for years a Director of the Union League and an active promoter of the Bi-Centennial Association.
Source: New York Times obituary, published July 22, 1892.
Call Number: A917.481 P536 v.1
Creator Name: Knight, Edward C. (Edward Collings), 1813-1892
Castner, Samuel, Jr., 1843-1929 - Compiler
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Knight, Edward C. (Edward Collings), 1813-1892, Castner, Samuel, Jr., 1843-1929 - Compiler. Edward Collings Knight. [Scrapbooks]. Retrieved from https://libwww.freelibrary.org/digital/item/38760
Knight, Edward C. (Edward Collings), 1813-1892, Castner, Samuel, Jr., 1843-1929 - Compiler. Edward Collings Knight. Scrapbooks. Free Library of Philadelphia: Philadelphia, PA. https://libwww.freelibrary.org/digital/item/38760. (accessed Jan 17, 2020)
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This print is a perfect addition to your Christmas decor. Noel printed in a gold foil/shimmer effect over a red background. This piece is printed on canvas using archival inks, and then sealed with a satin finish polyurethane to keep the ink from smudging. It is then glued to a wood backing, and framed in one of our hand made frame options seen in the listing pictures above. It has a picture hanger attached to the back for hanging. Please use the drop down menu to select the size and frame color for your print. If you'd like this design printed in colors other than those shown in the listing example, please use the "Request Custom Order" button on our shop page to message us. Thank you!


Nevada Volunteers, known previously as the Nevada Commission for National and Community Service, serves as the Governor's commission to administer AmeriCorps programs throughout Nevada and as the state's information and resource center for volunteer and service efforts.
Bureau of Land Management (BLM), Winnemucca Field Office, is an agency within the U.S. Department of the Interior, which administers 261 million surface acres of America's public lands, located primarily in 12 Western States. The BLM sustains the health, diversity, and productivity of the public lands for the use and enjoyment of present and future generations. NOS partners with the BLM Winnemucca Field office to bring outdoor education, interpretive programs and volunteer projects to the Black Rock Desert High Rock Canyon National Conservation Area.
Nevada State Parks plans, develops and maintains a system of parks and recreation areas for the use and enjoyment of residents and visitors. The Division also preserves areas of scenic, historic and scientific significance in Nevada.
Newmont has been pouring gold in Nevada for nearly 50 years along a 100-mile stretch of highway in the north section of the state. Our Nevada properties operate as an integrated unit, and together, they boast the widest variety of processing methods of any gold mining complex in the world. This allows us to maximize economic recovery of gold from a wide range of ore types and grades. Operations include 14 open-pit and four underground mines and 14 processing facilities. In addition to gold, our operations produce silver and copper.
The Turquoise Ridge property is located in the Potosi Mining District, about 70 kilometres northeast of Winnemucca, Nevada, on the eastern flank of the Osgood Mountains. Turquoise Ridge uses underhand cut-and-fill mining methods due to the relatively low rock quality in the ore zones. Ore is transported to Newmont's Twin Creeks mill for processing. The refractory gold ore is treated by pressure oxidation technology and gold is recovered using conventional carbon-in-leach technology.
Nevada Division of Enviromental Protection mission is to preserve and enhance the environment of the state in order to protect public health, sustain healthy ecosystems, and contribute to a vibrant economy.
NV Energy is not only the leading source of electrical energy in Nevada, but are also highly dedicated to the communities they serve and operate in. Their continuing support to NOS has helped us grow to where we are today.
To restore, improve and protect mule deer habitat resulting in self-sustaining and healthy deer population in Nevada.
To encourage and support responsible wildlife management with cooperative interactions with government agencies, private organizations and landowners in Nevada.
To promote public education and scientific research related to mule deer and wildlife management in Nevada.
To support and encourage responsible and ethical behavior and awareness of issues among those whose actions affect mule deer in Nevada.
Recognize licensed hunting as an important component of mule deer conservation in Nevada.
Educating the public about habitat conservation and the value of hunting ethics in wildlife management.
Support mule deer related conservation educational opportunities within the regional school system(s).
Allied Nevada Gold Corp's strategy is to utilize the expertise of our highly qualified Management team, technical and geologic strength to expand existing discoveries in our asset portfolio and, where feasible, develop these properties into producing mines or significant royalty streams. Allied Nevada conducts its exploration, development, and operating activities in a safe, profitable, and environmentally responsible manner. The key to success in these areas is to have a committed Management team and a shared common vision.
Southwest Gas provides service to more than 1.9 million customers in Arizona, California and Nevada as the local distributor of the environmental fuel of choice - natural gas.
Natural gas is the solution for tomorrow's energy challenge -- it's clean burning, efficient, and nationally abundant and an energy resource that allows you to be greener than you think.
Choose natural gas for your energy needs and help keep the sky blue and the planet green. For more than 80 years, Southwest Gas has been committed to building strong communities through employee volunteer efforts as well as social, economic and environmental initiatives.
HCSD's geographic location continues to make the school district highly attractive for all professional positions. HCSD is a progressive public school system located in rural north central Nevada, 170 miles east of Reno, Nevada.The District serves approximately 3,500 students in 11 schools--three K-4 schools, a 5-6 middle school, 7-8 junior high, and a 9-12 high school located in the community of Winnemucca and four K-8 schools and one K-12 school in rural areas throughout Humboldt County.
APPL (Association of Partners for Public Lands) is a not-for-profit organization working to enhance the potential of its members, who are dedicated to public understanding, appreciation, and stewardship of America's natural and cultural heritage. Through education, information, and representation, APPL promotes the vitality of its members and their programs of service and support to the agencies who oversee this nation's public lands.
NAAEE is the professional association for environmental education. Their members promote professional excellence in nonformal organizations, K-12 classrooms, universities (both instructors and students), government agencies, and corporate settings throughout North America and in over 55 other countries. Since 1971, the Association has created opportunities for its members to improve their skills in creating and delivering programs and services that teach people how to think, not what to think.
PLT uses the forest as a "window" on the world to increase students' understanding of our environment; stimulate students' critical and creative thinking; develop students' ability to make informed decisions on environmental issues; and instill in students the commitment to take responsible action on behalf of the environment.
Leave No Trace Center for Outdoor Ethics is an educational, nonprofit organization dedicated to the responsible enjoyment and active stewardship of outdoors by all people, worldwide.
City Hall is located on the corner of Melarkey and West Fourth Street in the former U.S. Post Office building. Their physical and mailing address is 90 West Fourth Street, Winnemucca, Nevada 89445.
National Public Lands Day began in 1994 with three federal agencies and 700 volunteers. On September 26, 2009, 150,000 volunteers worked at over 2,000 locations and in every state and in many U.S. territories. Now, eight federal agencies and many state and local lands participate in this annual day of caring for shared lands.
4-H is a community of young people across America learning leadership, citizenship and life skills. 4-H began a century ago as an educational program for the nation's rural youth. Today, 4-H meets the needs of and engages young people in positive youth development experiences. 4-H is the youth development education program of University of Nevada Cooperative Extension.
Sierra Nevada Journeys' mission is to empower youth through positive risk-taking and experiential leadership, science, and outdoor education.
Humboldt Development Authority is working to identify and develop economic improvement opportunities, provide recommendations concerning economic development and improvement to the governing bodies of the City of Winnemucca and Humboldt County, and to assist in the attraction, retention, expansion, and growth of business that is compatible with the interests and concerns of the residents of Winnemucca and Humboldt County.
Lander County School District is located in beautiful Battle Mountain and Austin, Nevada, two small communities nestled between several mountain ranges in northeastern Nevada. Their K-12 public school district has an enrollment of approximately 1,300 students and offers comprehensive curricular, co-curricular, and extra-curricular programs through two high schools. Their district is renowned for its hospitality and for producing outstanding academic and activity performance. All teachers continue working on curriculum, exhibiting curriculum on the Internet for parents and others to review, and planning assessment, which will measure the success of these efforts.
The Winnemucca Ministerial Association manages the Winnemucca Food Bank, Thrift Store and Soup Kitchen. The Food Bank provides emergency food to individuals and families in crisis situations, as well as, supplemental food to low income individuals and families. The Thrift Store provides clothing and household items free of charge to those in need and unable to pay. It also, provides an income source to help support the Food Bank. The Soup Kitchen provides four hot meals per week for individuals in need at no cost to them, no questions asked.
As a community garden, we provide members of the community all the resources needed to grow their own fresh, organic fruits and vegetables free of charge: land, water, seeds, compost, tools, and guidance. To cultivate a beautiful garden where the community can gather, grow, and celebrate nature.
Pershing County Senior Center - Seniors Meet and Eat.
Boys and Girls Clubs - of Elko Our mission is to enable all young people, especially those who need us most to reach their full potential as productive, caring, responsible citizens.
The Tahoe Rim Trail Association is a volunteer, non-profit 501(C)(3) organization established in 1981 to plan, construct, and maintain the Tahoe Rim Trail. This 165-mile, twenty-four inch, single-track trail is open to hiking, equestrians, and mountain biking (in most areas).
Elko County is the 4th largest county in the contiguous United States. Totaling 17,203 square miles, Elko County provides vast recreational opportunities and scenic sites including the beautiful Ruby Mountains.