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Fermilab's Lederman Science Center
The Leon M. Lederman Science Education Center houses hands-on exhibits for ages 10+, technology and science labs, a store and the K-12 Teacher Resource Center. Science Adventures classes for all ages take place at the Lederman Science Center. The Center also has a unique collection of indoor and outdoor exhibits introducing students to the world of particle physics. Open to the public Monday–Friday 8:30 AM–4:30 PM and on Saturdays from 9:00 AM–3:00 PM. The Center can accommodate groups of five or fewer on a walk-in basis. Larger groups must book a visit. Call 630-840-8258 for more information. A guided tour for families is available the first Saturday of the month from 10:00 am to noon.
Great brewery tours, great beers, Taco Thursdays - you must see 5 Rabbit! The name 5 Rabbit was inspired by the Aztec culture of Latin heritage. 5 Rabbit beers are mysterious and captivating, and every taste reveals a new detail. Great for those seeking fresh, unique and delicious beers.
CITY:Bedford Park
Kuma's started in 2005 with its flagship location at the corner of Belmont and Francisco avenues in Chicago's Avondale neighborhood. From their origins as a corner bar with solid American bistro fare, they've grown to two locations that offer the finest burgers available on this planet or any other. Our ethos is simple. Support your community. Eat beef. Bang your head.
Fountain Square Art Festival is the largest and oldest fine arts fair on Chicago's majestic North Shore. Featuring the eclectic works of more than 150 juried artists, a popular children's art tent with fun activities overseen by the acclaimed Evanston Art Center, food and a soothing jazz-centric music lineup. Location: Church & Sherman in Downtown Evanston.
Cooper's Hawk Winery & Restaurant - Oak Lawn
After four years of planning and construction, Cooper's Hawk Winery & Restaurant opened in 2005 in Orland Park, a south suburb of Chicago. The concept was unique. We would create a signature menu with a selection of dishes designed to pair perfectly with our own Cooper's Hawk wines, made in our own private winery. With sophisticated food and exceptional wines, our concept was born. The Cooper's Hawk concept includes four distinct components: an upscale casual dining restaurant, full-service bar, private barrel-aging room, and Napa-style tasting room and retail gift store…all under one roof. Each Cooper's Hawk location is distinctive in layout and décor, but carries the same warmth and elegance that guests have come to expect.
CITY:Oak Lawn
Serving the classic griddle burger alongside a modern soda program, beers that run the gamut from cult favorite to craft, and a carefully curated spirit selection, Parts and Labor brings a taste of a Southside legacy to Logan Square.
The Legacy Walk is a dynamic outdoor LGBT history exhibit in the "Lakeview" neighborhood of Chicago. Presently, along the half mile of the North Halsted Street Corridor, between Belmont Avenue and Grace Street, ten (10) pairs of 25'-tall decorative "Rainbow Pylons" define the nexus of Chicago's LGBT community. Affixed to the pylons are a series of bronze memorial plaques commemorating the life and work of notable lesbian, gay, bisexual, or transgender individuals whose achievements have helped shape the world
Bangers & Lace stands as a tribute to craft beer and great sausage. The Midwestern lodge-styled restaurant offers 32 draft beers as well as an extensive bottle selection. Enjoy your sausage on a plate with sides or on a sandwich, and if you're not in the mood for sausage, there are other options available as well. The Wicker Park location also offers a special brunch menu on Sunday. Patio seating is available.
Classic fun food, cruise nights, neon lights and service with a smile. Situated on the historic Illinois Lincoln Highway, Route 30 next to Phillips Park Golf Course & Mastodon Visitors Center and the Illinois Lincoln Highway gazebo.
Seven Lions is a modern interpretation of the classic clubhouse restaurant. Whether the occasion calls for getting together over a beer and a burger, negotiating over a power lunch, snacking after sightseeing or celebrating a special night out, Seven Lions offers the perfect ambiance, social energy and everyday fare for a variety of dining experiences. For ten seasons, Alpana Singh served as the host of the Emmy Award-winning restaurant review television show, Check, Please!, which airs weekly in Chicago on the PBS station WTTW Channel 11. She is now Seven Lions' Proprietor / Master Sommelier.
Open Range Grill is a family owned restaurant in Sugar Grove, IL on Bliss Creek Golf Course. We're open every day and are nearby with nightly dinner specials including our weekly Friday Fish Fry and Saturday Prime Rib, live entertainment every weekend, and an amazing patio overlooking the beautiful Bliss Creek Golf Course. Our food, drinks, and events are close by - stop in and check them out!
CITY:Sugar Grove
Chicago Blackhawks 2016-2017 Season
Don't miss a minute of the Chicago Blackhawks hockey season, as the team pursues its dream of another Stanley Cup win. Home games at the United Center will thrill hockey fans of all ages.
The Chicago Bandits are a women's professional softball team based in Rosemont, Illinois. Since the 2005 season, they have played as a member of National Pro Fastpitch (NPF). The Bandits won the 2008 NPF championship, defeating the Washington Glory in the final game of the championship series. The team won their second NPF championship following the 2011 season when they won the championship series two games to none over the USSSA Pride. Following the 2015 season the team won its third NPF championship defeating the USSSA Pride two games to none. They play their home games at Rosemont Stadium in Rosemont, Illinois.
Open, airy dining room, farm to table, freshest alternative to dining, local growers, comfort foods, gluten-free/vegan options, full-service bar, handcrafted cocktails, and fine wines.
CITY:Palos Heights
Dine at La Quinta de los Reyes for the best in authentic Mexican cuisine, drinks and live entertainment. Located on the corner of Broadway (Rt. 25) and New York Street in downtown Aurora between the Aurora Transportation Center and Paramount Theatre.
The Onion Pub is a perfect place to relax with friends and family. Enjoy fresh handcrafted beers from our own Wild Onion Brewery and hearty comfort food. The timber framed bar and dining room, anchored by a massive stone fireplace, create a comfortable atmosphere that has made the Onion a local favorite since 2003. The Great Hall banquet facility can accommodate 200 people and is anchored by a large timber frame cathedral ceiling that overlooks a beautiful 11 acre lake. Guests can enjoy a champagne toast under a canopy of bistro string lights with the sweet sound of flowing water. Also enjoy brewery tours and live entertainment.
Golfers will enjoy all that Bliss Creek has to offer, from the casual atmosphere of the bar and grill, to cocktails on the deck overlooking the first hole. With the addition of the Pine Room, a dedicated building designed specifically for golf outings, it is the perfect course for any size outing or fundraiser. Open to the public daily, it offers beautiful, tree-lined fairways, well-placed water hazards and a challenging 18 holes of golf that can most often be played in less than four hours. Truly one of the best golf values in the Chicagoland area.
CITY:Sugar Grove
Interesting variety of vintage books, postcards, jewelry, glass, porcelain, military, coins and deco lighting.
CITY:St. Charles
BuckleDown Brewing is a small craft brewery and taproom just outside of Chicago. They create bold, flavorful beers, and take diligent care to craft the finest small-batch beers with premium ingredients. Taproom open Wed-Sun.
Morkes Chocolates provides high quality and diverse tastes at affordable prices. With a history of candy making going all the way back to 1920, we at Morkes Chocolates continue to make our chocolate confections from scratch, with all natural chocolate, pure butter, fresh roasted nuts, and a lot of fun.
Featured on The Golf Scene with Steve Kashul and Heralded as one of Chicagoland's best buys for 18 holes, Settler's Hill is a favorite in Kane County and beyond. Here links, parkland and water holes combine to create a truly varied and memorable golf experience. Quirky greens, deep bunkers and colorful seasonal wildflower displays add to the course's charm. Superb conditioning and a casual atmosphere make Settler's Hill welcoming and enjoyable for all levels of golfers. The course's west-central location in Batavia near the Fox River makes Settler's Hill a natural choice for meeting friends for a round or planning an outing.
A Taste of Heaven Bakery and cafe
This Andersonville cafe and bakery sells an array of rich treats: raspberry crumble bars, orange poppy seed cake, giant sugar cookies, and heavenly mini apple pies, not to mention scones tagged the best in town. Breakfast items include French toast, quiche, and a breakfast burrito; lunch and dinner entrees are homey--spinach lasagna, chicken potpie, soups, salads, and sandwiches with meat piled high on homemade bread. The room is cozy, with natural light streaming in through the windows.
Pal Joey's has prided itself with a pizza that has remained consistent throughout its 32 year history. The pizza was given 4 stars by Chicago Tribune food critics and named as one of the best pan pizzas in the Chicago area. Fine Italian food and award-winning pizza. Outdoor dining by the Fox River is a special treat!
Established in 1974 and located on Historic Lincoln Highway (Rt. 30) O'Malleys Pub & Eatery is the place to go for great beer, food and a happy atmosphere. Celebrate where great times and great food come together!
Frank Lloyd Wright, Emil Bach House, Chicago's impressive "one of a kind" vacation rental home. Whether you are in town for business or pleasure, you will look forward to staying at this wonderfully restored home, again and again. The two guest bedrooms are located on the 2nd floor, each with a hallway bathroom for your comfort. The Emil Bach House is not your typical meeting space. It is great for private outside events in our large garden areas and smaller indoor events. Tailor the event to use the house and gardens to your own personal needs.
ZaZa's Tavola Italiana offers an intimate, comfortable seating to relax and savor authentic and fresh Italian foods like visiting a Trattoria in the Italian countryside. The pastas are rich and flavorful reproductions of "Old World" standards, such as our Rigatoni Abbruzzese or Paccheri Tartuffi. There are plenty of entrees for our guests to enjoy, like the Filet Barolo and the Pesce Bianco Spinaci, as well as insalates, antipastas and rustic brick-oven pizzas.
Fireside Grille offers a ski-lodge feel, with two fireplaces and a warm, wooden cathedral ceiling. The cozy yet classy atmosphere lends itself to dinner events of all kinds. At first glance the menu reveals a classic American dining experience, but digging a little deeper you'll find a lively helping of creativity that is sure to satisfy.
CITY:Sugar Grove
Nevin's Brewing Company opened in December of 2012. Nevin's delivers their spent grain to local farmers to use as feed for livestock and compost to enrich the soil for vegetables. Experience freshly brewed beer - Nevin's own recipe. Their goal is to bring you the freshest, most flavorful food and beer possible.
Chief O'Neill's Pub & Restaurant
Since 1999, Chief O'Neill's has had the privilege of serving Chicagoland as well as many people from around the world. A Pub, Restaurant and Banquet facility with a majestic garden area and private rooms for you to choose from when hosting your next event.
Iconic Michael's opened in 1977 as a hot dog stand in downtown Highland Park. At the infamous counter the food is made-to-order before the customer's eyes. Order the fare that made Michael's famous such as Chicago-style hot dogs, hamburgers, teriyaki chicken sandwiches, Italian beef, Polish sausage and cheddar fries. Alternatively, opt for healthier selections such as wraps, bison burgers, pockets, baked potatoes, veggie or turkey burgers, signature greens or create-your-own salad from our 60+ salad ingredient choices. Talk with our professional Events by Michael's staff about a corporate event, milestone celebration, reunion or fundraiser. Catering at the restaurant or your place. Let us bring our popular Char Bar to your backyard BBQ or if you desire a more upscale menu, we have you covered. In early 2016 Michael's will undergo a full renovation including private event space with sophisticated AV, a fully-equipped bar and a built-in DJ booth.
CITY:Highland Park
Cooper's Hawk Winery & Restaurant - Naperville
Cooper's Hawk Winery & Restaurant opened in 2005 in Orland Park, a south suburb of Chicago. The concept was unique. We would create a signature menu with a selection of dishes designed to pair perfectly with our own Cooper's Hawk wines, made in our own private winery. With sophisticated food and exceptional wines, our concept was born. The Cooper's Hawk concept includes four distinct components: an upscale casual dining restaurant, full-service bar, private barrel-aging room, and Napa-style tasting room and retail gift store…all under one roof. Each Cooper's Hawk location is distinctive in layout and décor, but carries the same warmth and elegance that guests have come to expect.
Aurora's Zagster Bike-Share Program
The City of Aurora and Zagster, Inc. launched a new bike-share program that will provide Aurora visitors with a convenient, affordable and healthy way to get around town. 18 cruiser bikes are available at three downtown stations for riders to use for on-demand, local trips. Stations are located at RiverEdge Park - 360 Broadway Ave., Aurora City Hall - 44 E. Downer Place and Santori Public Library of Aurora - 101 S. River Street. This initiative creates new opportunities for visitors to experience the Aurora Area from a different vantage point and see it in a whole new light.
Sweet Pete's Candy is the sweetest destination on Earth. We offer handmade chocolates and confections, ice cream, frozen yogurt, cupcakes and more. Join us for a party, class or field trip for a sweet candy-making experience you will be sure to love.
CITY:Lake Forest
Lemont Area Historical Society
Historic museum located inside of a national registered church built during the Civil War. We offer exhibits, tours and the "old stone church" chapel is available for rental of weddings and special occasion ceremonies.
Enjoy your meals with family and friends in our cozy country dining room with a warming fire during the winter months. The atmosphere at the Olde North Pancake House is warm, friendly and filled with items created by local craftsmen for that at home feeling!
CITY:West Chicago
An ode to the American table with its diversity and global influence. We set out to be an expressive regional American kitchen, all while remaining approachable, affordable, and welcoming.
CITY:St. Charles
Wood-roasted chicken, ribs. Free s'mores in outdoor fire pit. Seven flat screen TV's to watch sports.
CITY:St. Charles
Aurora University's Crimi Auditorium
This much-lauded and beautiful auditorium hosts classical and popular musical events as well as popular lectures and recitals. It is located in Aurora University's Institute for Collaboration building.
Juicebox - Chicago Cultural Center
With engaging music and dance in a kid-friendly setting, the free admission Juicebox programs are geared toward the stroller set and enjoyable for the whole family. Children will experience a diverse range of artistic and educational presentations, with hosts regularly inviting youngsters to move, dance and interact with performers. Presented by the Chicago Department of Cultural Affairs and Special Events, the Juicebox series runs on alternating Fridays at the Chicago Cultural Center and Saturdays at the Garfield Park Conservatory, with occasional special events at other venues. Except where noted, performances are 11-11:45am.
Nestled on the eastern edge of Highland Park's bustling Central Avenue among other trendy boutiques is Ooh-La-La, a small shop that's big on style and service. Located in the historic Highland Park Movie Theatre Building, in a space previously dedicated to a millinery shop during the 30's and 40's, proprietor and designer Lisa Farrell interprets the art of millinery with a modern eye. This tres chic boutique feels like a Parisian millinery salon complete with draped velvet curtains, an elegant chaise lounge and an ornate vintage mirror. By far the most dramatic element of the salon is the wall lined with old hat blocks – a true mark of craftsmanship seldom seen in department stores. Beautifully handcrafted women's hats are displayed in small vignettes throughout the intimate salon. These one-of-a-kind couture creations are wonderfully detailed with frothy feathers, sumptuous fabrics, vintage beading or another well-crafted trim.
CITY:Highland Park
Welcome warmer weather and shake off cabin fever during Naper Settlement's annual tribute to the changing of the seasons. Learn the time-honored method of collecting sap the old-fashioned way and see a maple tree tapping demonstration. Enjoy hands-on activities and presentations that recount Illinois' Native American heritage and pioneer past and try a tasty maple treat. Each of the historic buildings will have a different theme and special activities for families to enjoy.
Located above "Hamburger Mary's" Dining Room, Mary's Attic plays host to a variety of weekly and special events including our famous MaryOke, theatre performances and musical acts. Mary's Attic is also available for private events. From corporate outings to weddings, let Mary's take care of all of your special event needs.
Clucker's serves only the highest quality organic, natural, golden plump chickens. As each bird is carefully roasted, the irresistible aromas of open air charcoal are infused into the chickens giving them a rich, earthy flavor that's sure to ignite every appetite. From Cajun to Latin the chickens cater to a wide range of taste buds. Menu also includes turkey burgers, salads, Chicken Enchiladas, BBQ Brisket and more along with an array of sides.
Today the old tavern has taken on a new life, yet still with the same spirit. Emmit's owners, Kevin Doherty and Ron Halvorsen (both firemen) re-opened the bar in July of 1996. With hard work, both renovating and becoming established, these gentlemen have brought back the nostalgia, creating a new Irish Pub with great spirit, great food and more wild times to come.
Basement of the Dead Haunted House
Features Shattered the 3D nightmare, ranked Top 13 3D Haunt in the World by Haunted Attraction Magazine. Terrifying...not for the faint of heart. Enter at your own risk. Open year-round. Recommended for ages 13 and older.
Holiday Inn William Tell Hotel Chicago SW Countryside Banquets and Conference Center
Located just minutes from downtown Chicago and both Midway and O'Hare airports, the Holiday Inn & William Tell Chicago SW Countryside Banquets and Conference Center is the premier destination for business and leisure travel. We feature 176 comfortable Countryside, IL hotel rooms appointed with modern amenities, over 25,000 square feet of flexible meeting space, onsite dining and easy access to area businesses and sightseeing. While here, guests can enjoy a 25-yard lap pool, sauna, steam room and jacuzzi tub, making us a top choice for families. Our Countryside, Illinois hotel is also pleased to offer complimentary Wi-Fi and a free shuttle within a 5-mile radius upon request. When it's time to explore, venture out to a plethora of nearby attractions and activities, including the Brookfield Zoo, Max McCook, Toyota Park and much more.
Fun Inc. is a manufacturer and wholsale distributor of magic tricks and gag novelties. Our knowledgeable and experienced factory staff, most of whom have been with the company for over 20 years, take pride in paying attention to the smallest details. This makes accurate fulfillment of orders and timely shipments a top priority.
Mr. Jackson's acclaimed works of art can be found throughout the state of Illinois. Check his website for details. One of a family of ten children growing up in the small city of Decatur, Illinois, Preston Jackson became a storyteller and an artist at an early age. In his artwork he intends to deliver information about who we are, where we came from, and where we are headed. His training is in the field of metal fabrication, both steel and foundry cast metals, as well as in painting. The materials used most often in his pieces are cast bronze, steel, and stainless steel. His work tends to be narrative in nature, with emphasis on relating the details and personalities of our past.
Chicago Northwest Restaurant Week
Let the foodie in you enjoy something new! From all-you-can eat soup and salad to soy ginger salmon, you'll find menus from the area's most popular steakhouses and international cuisine from over 35 unique restaurants in Chicago Northwest. This 10-day event only happens once a year so don't miss out!
At Bow Truss, their goal is to make specialty coffee more approachable, bringing fantastic single origins, naturals, and delicious direct trade to you through partnerships and collaborations around the world. Visit one of their shops, see what's new, or pick up a subscription for your home or office.
North Aurora Hotel Inn and Suites
North Aurora Hotel has 120 comfortable, convenient guest rooms including King, Queen, Double and King Suites. Complimentary continental breakfast from 7 - 10 am every day. 24-hour front desk welcome center. Kitchenettes, free WiFi access and cable TV. Spacious free parking for up to 250 cars. Conveniently located right off I-88, Exit 117 at Rt. 31. Minutes from Chicago Premium Outlets, Hollywood Casino Aurora and the Aurora Transportation Center.
CITY:North Aurora
Known as Chicago's liveliest Irish bar, located in the heart of downtown Chicago's River North Neighborhood, The Kerryman is a little piece of Ireland. The 3 owners all hail from Co. Kerry Ireland and the Head Chef Damo Moloney from Co. Limerick, Ireland who creates an upscale authentic Irish menu.
Courtyard by Marriott St. Charles
121 guest rooms. Amenities: Business center, exercise room, extended stay, indoor pool, restaurant, lounge. Pet friendly-charges apply. Guest rooms renovated 2014
CITY:St. Charles
Best Western PLUS Chicagoland - Countryside
The Best Western hotel offers the best in amenities, customer service, and accommodations at an affordable rate. Located about 20 miles from Chicago and located on Old Route 66. Convenient access to I-55 brings them to the favorite Chicago area attractions. Hot breakfast buffet is complimentary along with High-Speed WiFi.
41st Annual Kane County Railroad Collectibles & Model Train Show
Railroad Collectibles include items used by railroads such as: lanterns, china, silverware, keys, locks, timetables, train parts, maps, books, photographs, DVD's on railroad topics. Show is 80% railroad collectibles, 20% model trains..
CITY:St. Charles
During the early 1900's, George Filbert, his wife and their young son, Charlie, could be seen on a horse-drawn wagon in Chicago's Bridgeport neighborhood delivering bottles of milk to stores and homes. It wasn't until the height of prohibition that Filbert's began making Root Beer. Now 85 years later, Ron Filbert, the fourth generation Filbert, continues to make his families famous Root Beer in the same Bridgeport neighborhood where his Great-Grandfather started it all back in 1926.
A classic neighborhood diner serving a variety of delicious breakfast, lunch, dinner and late night dishes. Founded in 1961, Melrose Diner has been a local staple in the neighborhood. Since then, the menu has evolved to include vegetarian and gluten free options. Come join us on our lush outdoor patio on the corner of Melrose and Broadway in the heart of Lakeview East and bring your friends.
Bridget McNeill's is not your average Irish Pub. They are serving up affordable, craveable American comfort food in a laid back, local environment. You can find items for every palate and every pocket, and with their rotating beer and drink lists and great wine selections, they've got something for everyone!
Fresh and Friendly since 1973, Nookies is committed to serving the highest quality and most delicious of comfort foods to Chicago. From our family to yours, Eat, Live and Enjoy.
Situated in the picturesque Wicker Park neighborhood in Chicago, Alliance Bakery features fine European pastries and desserts, custom-designed cakes to suit any occasion, and a full espresso bar. Come visit us and enjoy our free wifi lounge and outdoor café. And discover Alliance Patisserie, a modern day pastry boutique rooted in French style and tradition. Here we pair European technique with an artistic eye and an unmatched flavor profile, specializing in macarons, petits gateaux, and viennoiseries. Nestled in the River North neighborhood of Chicago's bustling downtown, we provide a sweet stopping place for neighbors and visitors alike.
Chef Alain Roby, a three-time Guinness World Record holder, prepares exquisite desserts and truffles from the finest grand cru-quality Belgian and Swiss chocolate, as well as authentic Italian Gelato, just like in Rome! The Devil's Food cake he prepared as a guest star on The Martha Stewart Show also can be enjoyed while admiring the life-sized chocolate sculptures that are seen on many Food Network specials.
Take a kayaking class or a kayaking trip with an ACA certified instructor on the beautiful Fox River, Batavia. It's fun and informative. Check out some videos on what you will learn in the different classes. Several group and private kayaking classes - first time kayakers to intermediate. See the calendar for dates and times. So grab your friends and let's go paddling!
Double Yolk Pancake House and Restaurant
Finding a brunch spot as delicious as Double Yolk is about as rare as finding a double yolk in an egg. With homemade corned beef hash, the shamrock benedict is great! The hollandaise is perfect, especially when paired with the corned beef hash. Their chipotle chicken sandwich is seasoned to perfection. *This restaurant recently ranked one of TOP 25 in the USA by Restaurant.com.*
Hang with the Beverly crowd at this Far South Side institution, where Irish brogues are the norm and the staff is among the friendliest in town. The fenced-in, wooden deck has a homey, antique decor along with two bars that are great places to root on the White Sox.
67 guest rooms. Amenities: Complimentary Continental Breakfast, Pet friendly-charges apply.
CITY:St. Charles
Windmill City Spinners & More Decor
Our shop specializes in artisan garden spinners, crafted by Bill Saloga. These beautiful pieces are as efficient as they are artistic, using an aerodynamic and bearing technology Bill and his dad developed, allowing the spinner to perform with as little as two m.p.h wind speed. As Windmill City Spinners changes from season to season our artistic presentation of home and garden décor makes this little shop a worthy destination.
The SoFo Tap is your neighborhood bar South of Foster, located at the corner of Clark and Argyle. Enjoy a game of darts, hang out in our spacious outdoor patio, play your favorite song on the jukebox or check out the videos on our flat panel TVs. Our friendly staff is here, ready to pour your favorite drink.
122 guest rooms, Amenities: Business Center, Exercise Room, Outdooe Pool, Complimentary Hot Breakfast. Pet friendly - charges apply.
CITY:St. Charles
Replay is the premier entertainment establishment. An extensive collection of the finest bourbons and a huge selection of craft beers (over 20 on tap alone!), Replay also boasts the largest collection of vintage arcade games in the East Lakeview!
Tighthead Brewing Company is a craft brewery located in Mundelein, a suburb of Chicago. Our brewpub is a neighborhood institution where friends and families can meet up and enjoy great music, wonderful company, and the best beer in town. Since we opened our doors in 2011, we have poured our heart and soul into every glass. Stop in and taste what we're talking about!
Da Baffone Cucina Italiana, in downtown Crystal Lake, is a culinary gem and everything you want a family-owned restaurant to be. Sample old-world recipes made with fresh ingredients while you sip wines from around the world. With a knowledgeable and friendly wait staff, this restaurant is the best of Italiana without renewing your passport. Reservations highly recommended.
CITY:Crystal Lake
1042 guest rooms, IACC-Certified Space to 2000. Amenities: Business Center, Exercise Room, Lounge, Spa. No leisure guests-corporate and association meetings only.
CITY:St. Charles
When it comes to steaks, Chicago has much more than the sizzle, it's got the meat. Guests on this tour will get the sizzle, the smells and the tastes as they learn about the grand history of steaks in Chicago and go to the great steakhouses that serve them. Chicago Steakhouse Tours is the first excursion of its kind that takes visitors and locals through some of the most historic neighborhoods and to the most iconic steakhouses of Chicago's rich history. Our guests will take a tour through the River North, Gold Coast and Streeterville neighborhoods via luxury bus and stop at three different Chicago steakhouses to sample a prime cut of meat or a signature dish at each establishment. You will get an exclusive look at what makes each individual steakhouse so special while learning not only the secrets of their steak preparation, but stories of some of the world's most famous celebrities that have dined and partied there. Each steakhouse has a unique story of its own with it's own savory flavor.
Opened in October of 2014 and headquartered in Geneva, Fox River Distilling Company produces premium handcrafted artisan spirits using traditional distilling methods. Free tours are given to the general public on Friday, Saturday, and Sunday afternoons and at other scheduled times for private parties and events. Join us for "First Friday" – A monthly open house where the distillery and tasting room will be open to the public for extended hours.
Our Tap Room is a place where everyone can feel comfortable to enjoy our beer at its freshest. Temperance Beer Company is not a brewpub, but we offer freshly-made sandwiches from our neighbors at Curt's Cafe South. Come meet us, have a tour and a taste. We are excited to offer tours each month on the 2nd Saturday at 1 PM.
The feel is casual, comfortable yet energetic and an inviting, exciting and sophisticated atmosphere. The menu features artesian hand tossed Pizza made in a wood fired oven with a very thin crust and exceptional flavor profiles, house made chips, Dutch oven steamed mussels, truffle deviled eggs, proprietary ground beef blend hand patty burgers, Braised Beef of the Day and baked pasta dishes. The Brew-House will produce up to 12 different brews to be served, from Lagers to IPA's, to Stout's and seasonal, and even some small batch wood barrel aged specialty beers. The Brew Master will also create craft sodas, do brewery tours and walk throughout the facility and let guests sample our craft brews, and be educated on the Half Day Brewing experience.
The Richard H. Driehaus Museum
The Richard H. Driehaus Museum immerses visitors in one of the grandest residential buildings of 19th-century Chicago, the Gilded Age home of banker Samuel Mayo Nickerson. Philanthropist Richard H. Driehaus founded the museum on April 1, 2003 with a vision to influence today's built environment by preserving and promoting architecture and design of the past.
Clucker's serves only the highest quality organic, natural, golden plump chickens. As each bird is carefully roasted, the irresistible aromas of open air charcoal are infused into the chickens giving them a rich, earthy flavor that's sure to ignite every appetite. From Cajun to Latin the chickens cater to a wide range of taste buds. Menu also includes turkey burgers, salads, Chicken Enchiladas, BBQ Brisket and more along with an array of sides.
The Aurora Elks Lodge No. 705 is a Mayan style building on Stolp Island in Aurora, Illinois. It is included in the Stolp Island Historic District. The building was built in 1926 and was listed on the National Register of Historic Places in 1980. (Re-development planning in process.)
Operation Finale: The Capture and Trial of Adolf Eichmann
The dramatic story behind one of the world's most notorious escaped Nazi war criminals being brought to justice is told using recently declassified artifacts from the Mossad, Israel's Secret Intelligence Service. This is the first time this exhibition has ever left the State of Israel and the first exhibition in the United States to fully document the pursuit, capture, extradition and 1961 trial of a principal perpetrator of The Final Solution.
It's time to kick back and relax. They have great food and drinks, plus Lake Michigan on their doorstep. How could it get any better? Oh yeah, live music acts and festivals constantly throughout the summer, so you are never bored and always satisfied!
Ellen King is the co-owner and head baker at Hewn. She is a classically trained chef and has worked in various restaurants in Seattle with a specialty in French, Mediterranean and Vegetarian foods. Each day our bakers mix the dough by hand, turning it every 30 minutes over a four hour period. The dough is then shaped and placed into bannetons, where it rests overnight to rise naturally. The results are delicious.
Begyle Brewery is a community supported brewing company on Chicago's north side. The taproom is filled with unique as tasty beers and tours of the facilities are available.
With seasonal freshness reflected in both food and drink, the rooftop dons the relaxed ambience of a Great Lakes beach house with a view. Executive Chef Christian Ragano, creator of Glencoe's much loved Guildhall, and former Chef de Cuisine at NoMi, joins forces with renowned Spirit Guide and alumni of The Violet Hour, Nandini Khaund, to bring classic comfort and culinary invention via large format style dining over cocktails and apothecaries. Open for lunch, dinner, cocktails and weekend brunch.
Think of The Kimpton Gray Hotel like a perfectly bespoke suit from London's Savile Row — beautiful, bold, and with no detail out of place. Clad in marble and terra-cotta, The Kimpton Gray has been a tastemaker for more than a century, first as an office building and now as an elevated-experience hotel. When the 9-to-5 day is done in the Financial District, those in the know flock to the on-site restaurants - Volume 39, a law library-themed bar, and Boleo, an Argentinean-inspired rooftop lounge.
Sidetrack® has been welcoming the community and the world for more than 30 years with a unique video mix of pop, rock, comedy, show tunes and retro favorites.
Delicious pickings and treats are available at the marking on Wednesdays at Berwyn between Clark and Ashland from May 11th to August 31st 3pm-8pm and September 7th- October 19th 3pm-7pm.
Roscoe's is a fun and entertaining gay nightclub for the most adventuresome customer. Whether you come to drink, dance, sing, watch videos, dine at our sidewalk patio or hang out by the fireplace or in the garden, there's something for everyone.
Style Room 326 is Chicago's 1st members only wholesale/retail showroom & creative space offering discounted exclusive shopping workshops private events and more. Offers beauty, fashion and entrepreneurial workshops as well as hosting facilities for style and product launch parties.
Craft cocktail lounge located on the upstairs of 3208 N Halsted St. Great vibes, even better drinks. A 1920s style bar with prohibition era craft cocktails.
Evanston's Stone Terrace. An original Queen Anne Victorian mansion built in 1883, re-imagined in 1910 as a Tudor-revival style house, has found new life as a luxury bed and breakfast only steps away from Lake Michigan. Those looking for a piece of history can explore this property's two century-old architectural and design components, including original fireplaces, beautiful crown moldings and luxurious details for the modern-day guest. A real gem, Stone Terrace sits near Northwestern University and downtown Evanston's world-class restaurants and shops. Stone Terrace's world-class accommodations and amenities include 5 guest bedrooms with ensuite baths, an executive library, a spa, sunroom, and gym. The innkeepers offer a first-class experience and can help meet any guest need. The grounds include two perennial gardens steps away from the beach and lakefront paths. Come enjoy a stay in this meticulously restored and historic Evanston mansion.
Leland Tower is a twenty-two story tall building located on Stolp Island in Aurora, Illinois. Leland Tower was at one point the tallest building in Illinois outside of Chicago. Stolp Island is recognized as a Historical District by the National Register of Historical Places. Leland Tower was at one time the tallest building in the world, and dominates the downtown of Aurora, dwarfing all the other buildings located there. The tower was built initially as a hotel. The Leland Hotel project was conceived in 1926 and was one of the most ambitious projects in the city's history. The project was announced by an organization known as the Aurora Building Corporation through Herbert P. Heiss of the First Illinois Company. Mr. Heiss had located and purchased the site for the proposed hotel. The building contract was awarded to the H.G. Chtistman Company, general contractors of South Bend, Indiana and Detroit, Michigan. Anker Sveere Graven and Arthur Guy Mayger were chosen to design the hotel which was planned to be one of the grandest buildings outside of Chicago.
Located in Boystown, Cell Block is long known as one of Chicago's premiere gay clubs. The front bar has a dance floor, DJ and live entertainment.
Brewery & Restaurant located Downtown Weaton near the Metra Train Station. Upscale Casual Fare & Award Winning Handcrafted Beer.
At Fulton Market Kitchen our hope is to create an entertainment experience that provides guests with the opportunity to simultaneously indulge their passions for dining, drinking and art. To that end, every week a different artist transforms our lounge space into their personal studio, allowing guests to observe, engage, and draw inspiration from their creative process; all while enjoying dinner and cocktails.
Evanston's first luxury B&B! An exquisitely restored Tudor mansion built in 1889, this historic boutique property is home base for anyone visiting Northwestern University; looking to escape for a magnificent weekend; or wanting to explore the world-class entertainment and shopping options found in Evanston. Stone Porch by the Lake provides the ultimate luxury experience by embracing the past while integrating 21st century innovation. The lodging features; flat screen TVs; en suite spa bathrooms with heated marble floors and towel racks; wifi, bedside phone docks; plush robes and H20 Plus shower amenities. A hot gourmet breakfast is served daily in the private dining room. Walk, run or bike along the lakefront path across the street, or kick back and watch the world go by from the front porch. Please come and enjoy our backyard patio, which features a 10-foot tall brick fireplace, couches and chairs, and cozy blankets on cool nights. Life is great by the lake!


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Psalm 43
The righteous praise God and cry, Send out Thy light and Thy truth.
2 For thou art the God of my strength: why dost thou cast me off? why go I
3 O send out thy
4 Then will I go unto the altar of God, unto God my exceeding joy: yea, upon the harp will I praise thee, O God my God.
5 Why art thou cast down, O my soul? and why art thou disquieted within me? hope in God: for I shall yet praise him, who is the health of my countenance, and my God.

subset: commoncrawl


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Leafs to buy out Mike Komisarek
Ryan Fancey
June 23 2013 03:37PM
It's been a pretty crazy day for Leafs fans. We've had the Bernier trade, the talks of Phaneuf being on the block, and now it looks like Mike Komisarek will be bought out by the club.
I don't believe the player or agent have been told directly, but expect Mike Komisarek to be bought out by the Leafs.— Darren Dreger (@DarrenDreger) June 23, 2013
This isn't a big surprise by any means, but it does use one of the Leafs' compliance buyouts that could have been used on a salary dump from another team, or potentially John-Michael Liles.
Either way, Nonis is really going to work right now and it's creating a lot of discussion around the team. Looks like a wild couple of weeks coming up.
June 23 2013, 04:15PM
Similar to the Bernier trade in that it's not a bad move but it's less than optimal. Both leave me rather unexcited and a little nervous.
Mike Komi-who?
June 23 2013, 11:27PM
Unrelated question: What do people think of Chad LaRose as a buy low opportunity to fill a bottom six winger role?


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Kachelhoffer Clement/adoc-photos/Corbis via Getty Images
The original Grimm fairy tales are a far cry from the happily-ever-after versions you grew up with. Test your knowledge of the downright disturbing tales from the brothers Grimm.
Start Quiz »
You scored
0 out of 30
Question 1 of 30
Who were the Grimm brothers?
Lars and Johan
Jacob and Wilhelm
Jacob and Wilhelm Grimm published fairy tales throughout the 19th century.
Friedrich and Anton
Question 2 of 30
Where were they from?
The Grimms were born in Hanau, Germany.
Question 3 of 30
What was a formative turning point in the brothers' lives?
Their home burned down.
Their father died.
The boys' father died when they were 10 and 11 years old, and the family fell into poverty.
Their sister was kidnapped.
Question 4 of 30
What was the name of the Grimms' first collection of fairy tales?
"Tales for Children and Parents"
"Folklore for the Nursery"
"Nursery and Household Tales"
It was titled "Kinder- und Hausmarchen," or "Nursery and Household Tales."
Question 5 of 30
When was "Nursery and Household Tales" published?
The first edition was published in 1812.
Question 6 of 30
How many fairy tales were in the collection?
It contained 86 tales.
Question 7 of 30
How many stories were in the second collection, which was published in 1815?
The second volume contained 70 tales.
Question 8 of 30
Which edition of "Grimm's Fairy Tales" is best known today?
The 1857 seventh edition contains the fairy tale versions that are most familiar today.
Question 9 of 30
About how many of the tales were deleted or almost completely changed between the first and seventh editions?
An estimated 45 to 50 of them were deleted or drastically altered.
Question 10 of 30
When was the first English translation of the first edition published?
Jack Zipes, a professor at the University of Minnesota, was the first to translate 156 of the original tales in 2014.
Question 11 of 30
In which deleted tale does a mother say to her children, "I've got to kill you so I can have something to eat"?
"The Children of Famine"
"The Children of Famine" is a very short, very disturbing tale of a starving mother and her two daughters.
"The Burial Shirt"
"Lean Lisa"
Question 12 of 30
In which tale does a stepmother chop off the head of her stepson?
"Faithful John"
"Mary's Child"
"The Juniper Tree"
And then she chops him into pieces and serves him in a stew to his father.
Question 13 of 30
And then what happens?
The father throws up when he realizes what he's eaten, and the boy is resurrected.
The boy's sister finds out and hangs the stepmother from a tree.
The boy reappears as a bird and kills the stepmother by dropping a stone on her head.
The boy's sister buries his bones, and a bird flies out of the tree that grows there.
Question 14 of 30
In which tale does a father make tiny coffins with pillows for his sons?
"The Twelve Brothers"
The king wants to kill his 12 sons so that if his 13th child is a girl, she can inherit the kingdom. So he preps by having 12 tiny coffins made.
"The Seven Ravens"
"The Singing Bone"
Question 15 of 30
What's the modern name of the Grimm tale "Aschenputtel"?
"Aschenputtel" is better known as "Cinderella."
Question 16 of 30
Which group used the Grimm tales as propaganda in the 20th century?
the suffrage movement
the Communist Party
the Nazis
The Nazis held up Cinderella, for one, as a symbol of Aryan purity.
Question 17 of 30
In "Rumpelstiltskin," the titular character turns a poor girl into a queen in exchange for what?
her hand in marriage
her firstborn son
Creepy old Rumpelstiltskin wants her firstborn son.
a lock of her hair
Question 18 of 30
In which tale is a naked servant rolled down the street in a barrel lined with nails?
"Death and the Goose Keeper"
"The Fox and the Geese"
"The Goose Girl"
In "The Goose Girl," a devious servant posing as a princess receives this cruel and unusual punishment.
Question 19 of 30
In the original "The Frog Prince," what does the princess do to the frog instead of kissing him?
throws him against a wall
The frog's spell is broken when the princess throws him against a wall.
steps on him
drowns him
Question 20 of 30
In which tale does a gang of men abduct a woman and chop "her beautiful body into pieces and sprinkle them with salt"?
"The Girl Without Hands"
"The Robber Bridegroom"
The robber bridegroom and his gang are appropriately put to death at the end of the tale.
"Sweetheart Roland"
Question 21 of 30
In the original version of "Rapunzel," what do Rapunzel and the prince do during their "merry time" in the tower?
have sex
It isn't explicitly stated, but after said "merry time," Rapunzel wonders why her clothes are getting tight.
chop up small children
Question 22 of 30
And then what happens to the prince when Mother Gothel confronts him about it?
She cuts off his head.
He is blinded.
He does fall out of the tower, but it isn't fatal. He lands in some bushes … and the thorns scratch out his eyes.
He falls to his death from the tower.
Question 23 of 30
Does he ever encounter Rapunzel again?
The blind prince becomes homeless and eventually runs into Rapunzel and his twin children.
Question 24 of 30
Does he ever see Rapunzel again?
Rapunzel's magical tears restore the prince's sight.
Question 25 of 30
In the original Grimm "Cinderella," how do the stepsisters try to make the glass slipper fit?
They bind their feet in bandages.
They dip their feet in poison that makes them shrivel.
They slice off pieces of their feet.
The stepmother instructs the girls to chop off their toes and slice off their heels.
Question 26 of 30
What creatures notify the prince about the stepsister's bloody feet?
The prince actually thinks the slipper fits the stepsister, but then the pigeons direct his attention to the blood. And then the pigeons peck out the sisters' eyes at Cinderella's wedding.
Question 27 of 30
In the original "Snow White," which parts of Snow White does the evil queen express a desire to eat?
kidneys and spleen
brain and heart
lungs and liver
The queen — who is actually Snow White's mother, not her stepmother — wants to consume her lungs and liver.
Question 28 of 30
How does the evil queen die?
She's tricked into wearing a pair of burning-hot iron shoes.
The queen survives to attend Snow White's wedding, where the guests have her put on the iron shoes.
The dwarves lure her into the mine and bury her alive.
Snow White chases her off a cliff.
Question 29 of 30
In the original "Little Red Riding Hood," whom does the wolf eat?
Little Red Riding Hood
the grandmother
both of them
But fear not — the hunter cuts open the wolf's belly and rescues them.
Question 30 of 30
In the original "Rumpelstiltskin," how does Rumpelstiltskin die?
He's eaten by a dragon.
He turns into a ball of fire.
He's torn in two.
When the queen correctly guesses his name, an angry Rumpelstiltskin stomps his foot deep into the ground and then rips himself apart when he tries to get it out.


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Puma Voltaic III Athletic Sneaker - Mens
Sorry, this item is sold out!
Looks like you've got more shoe shopping to do - have fun!
Looks like you've got more shoe shopping to do - have fun!
Item # 248058
Send waves of shock through the street when you hit the pavement in these Voltaic 3's by PUMA®. Run, cross train, walk or play in these athletic sneakers and experience their versatility.
- Air mesh and single layer mesh upper with synthetic leather overlays and reflective TPU
- Bootie construction for easy on/off
- Eco-Ortholite™ footbed to maintain shape and consistent fit
- TPU toe cap for additional protection and durability
- Midsole features a TPU shank and 10CELL heel technology
- Carbon rubber sole
- Imported
By: Sandybythebeach
Location: Corona ca
December 11, 2012
Love these shoes
"These shoes are awesome. I've bought several pairs in different colors. My husband loves them"
Click anywhere to close this.


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YALSA's Virtual Mentoring Program
YALSA's virtual mentoring program pairs an experienced librarian (an individual with 5 or more years of experience) with a new librarian (an individual with 4 or less years of experience), graduate student in a Library Science program, or library staff member whose primary responsibilities focus on teen services.
This is a virtual mentoring program, so there is no requirement to meet face to face. All participants are required to devote 4 hours per month for a continuous 12 month period to the program. This year's program runs from August 2016 - July 2017.
Participants are strongly encouraged to design a project to work on throughout the mentoring year with their mentoring partner that relates to YALSA's recent report, "The Future of Library Services for and with Teens: a Call to Action." Mentors are required to have 5 or more years of professional library experience.
Program Application Materials
At this time our application period has closed. Check back in the spring of 2017 for our next round.
Frequently Asked Questions (FAQs)
Questions about the program? Please read our FAQ or contact Linda W Braun, firstname.lastname@example.com or 917-847-7804.
Q: May non-members apply for YALSA's Virtual Mentoring Program?
A: At this time, the Virtual Mentoring Program is only open to YALSA members.
Q: What is the time commitment for the YALSA mentoring program?
A: All mentors and protégés are asked to participate in online training sessions during the month of August and additional training sessions throughout the mentoring year. All participants are expected to give at least four hours per month to the program.
Q: How long is the program?
A: The mentoring program runs for 12 months, from August 2016 through July 2017.
Q: Is there a fee for applying to the mentoring program?
A: There is no fee for applying to the mentoring program, nor is there a fee should you be accepted as a mentor or protege into the program.
Q: When does the program begin?
A: Applicants will be notified of their status in August 2016; accepted mentors and protégés will be matched and notified in August 2016.
Q: How do I communicate with my mentor/protégé?
A: Once you are matched with your mentor/protégé the two of you will decide how best to communicate with one another.
Q: How does the program work?
A: This is a virtual mentoring program. Participants communicate with each other primarily through phone/email/skype/chat. After being matched with his or her mentor, the protégé will contact the mentor and determine when and how they will communicate. Mentors and protégés should establish short-term and long-term goals for the year, which meet the learning needs of both the mentor and protégé. YALSA encourages mentors and protégés to identify and collaborate on specific activities to support the learning goals of the mentoring relationship.
YALSA will provide participants with a handbook that includes monthly discussion topics as well as a suggested list of resources that mentors and protégés can use to develop their mentoring goals or jump start their mentoring conversations and activities. In addition, YALSA will provide a space on ALA Connect for mentors and another for protégés. The space can be used for sharing resources, networking, exchanging ideas and more. YALSA will also host quarterly training sessions for mentors and protégés. At the conclusion of the program, mentors and protégés will be asked to complete a program evaluation.
Q: Why does YALSA strongly encourage protégés to have a project to work on throughout the mentoring year?
A: YALSA has found that protégés who apply to the program with firm goals and a project in mind have greater success and get more out of their mentoring partnership. YALSA does not assign projects to protégés because everyone's needs are different. Having a project or goal in mind when entering the program helps give shape and structure to your mentoring relationship.
Q: How will I be matched up with my partner?
A: A Task Force, appointed by the YALSA President-Elect, will review the submitted applications. The task force will match accepted mentor and protégé applicants based on type of library, geographic location, and areas of interest.


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Mix No. 6 Often Lace-Up Wedge Bootie
Sorry, this item is sold out!
Looks like you've got more shoe shopping to do - have fun!
Looks like you've got more shoe shopping to do - have fun!
Item # dsw12prod4060026
Put some edge in your wedge with the Mix No. 6 Often. This lace-up wedge bootie is sure to be your favorite go-to style this season.
- Faux leather upper
- Foldover cuff
- Adjustable laces
- 3½" covered wedge
- Synthetic sole
- Imported
By: DesireeB
Location: Oakbrook, IL
December 01, 2012
Great Shoes!
"When i first tried these on they were very comfortable. Then after wearing them in the club for a few hours the balls of my feet did begin to hurt. It was because i was dancing, but just wearing them on a regular day to day, i love them."
By: missdanyybabyy
December 01, 2012
By: ShoesInChi
Location: Chicago, IL
October 30, 2012
So disappointed!
"I was so excited about these booties - they have all of the right elements! I received them and couldn't wait to put them on. I usually wear an 8, but went for an 8.5 since my feet are a bit wide.The first day I wore them, they were extremely uncomfortable, but I attributed that to them not being "broken in" yet. For most of the day, I was sitting (I work in an office), so I didn't judge just yet.The second day, I did a bit of walking (I do live in Chicago, after all). While the leather did stretch, I discovered the arch support is horrible! By the end of the day, my feet were throbbing. And as an added bonus: the toe area scuffed. I understand shoes don't last forever, but I did not do any strenuous activities, and I couldn't believe they scuffed that quickly. Now I have a white spot on the toe!I really wanted to like these booties, but they have no support and are very cheaply made."
By: Jerez
Location: New York
October 22, 2012
Cute with everything
"I have been looking for a cute wedge bootie for a while now, and when I saw these I fell in love. I love that its not too high (my boyfriend is not the tallest of men :-) ) so it fits comfortable and can be used as an everyday kind of shoe. It also looks great with everything, as black goes with everything and so do wedges."
Click anywhere to close this.


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Matty's Lacie Wedge Pump
Sorry, this item is sold out!
Looks like you've got more shoe shopping to do - have fun!
Looks like you've got more shoe shopping to do - have fun!
Item # 240700
Only the boldest of fashionistas can make an entrance in this wedge platform. The Lacie from Matty's is sure to pump up your look and take your style to new heights.
- Fabric upper with lace overlay
- Faux leather trimming
- Adjustable ankle straps
- 2¼" platform, 5" covered wedge heel
- Synthetic sole
- Imported
- Online Exclusive!
By: Jstarks
Location: Minneapolis
August 15, 2012
"I thought these shoes were going to be super cute, but they ended up looking a little trashy instead. The straps hold well on your feet"
By: Khelena
Location: California
August 01, 2012
they're ok
"They're comfortable but they don't look as pretty as I thought."
By: klc141
Location: Sydney
July 31, 2012
"I just love these shoes. They are beautiful to look at, let alone wear! The color is darker than pictured and the lace has more of a shine than I was expecting, but I only mention that FYI - I actually like them better in reality than in the picture.My only issue is that these are VERY roomy - even though lengthwise my size selection was right, there is a lot of room to move in the toes and the whole shoe is quite wide - definitely not recommended for someone with slender feet (which, by the way, I DON'T have!). I'll still be able to wear them, but will just have to be a little careful while I'm getting used to them.These are quite high, but it doesn't feel like it due to the platform.But can't get over how attractive these shoes are - the color and style will go with many outfits."
By: statejailgirl
Location: tx
June 30, 2012
So adorably cute!
"These shoes are fantastically awesome!"
Click anywhere to close this.


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KISS star partners with Henrico organization
A&E show to highlight Simmons' trip to Zambia with ChildFund International
Gene Simmons, legendary lead singer of the band KISS, was on television June 25, but not in his usual rock-star role. His show, Gene Simmons Family Jewels, featured his recent trip to Zambia, where he met up with several children he sponsors through Henrico-based ChildFund International.
The experience was originally a surprise to Simmons, planned by his new wife, Shannon Tweed, for the couple's honeymoon.
"[Shannon] decided she wanted to go to Africa, and that's where this brainchild of hers started," said Cynthia Price, ChildFund's director of communications. Price worked with the show's production company to coordinate the trip and accompanied the couple to Zambia.
Simmons sponsors more than 140 children, Price said.
"Gene came to ChildFund the way so many people do," she said. "He was watching TV, saw the commercial, and he was moved by it, so he sponsored his first child, and then many more."
Price hasn't seen the episode but hopes it will portray the trip well. The trip began with Simmons being introduced to one of his sponsored children named Edward. Edward then walked Simmons around the area, showing Simmons the long distances from his water source to the road going to his school.
"Gene was overwhelmed by it," Price said, "moved to tears actually."
During the trip, the couple visited three different schools, where he met several of his other sponsor children. Simmons and Tweed were both impacted significantly by the poverty they saw.
"I will waste less, spend less and appreciate more," Tweed said.
The episode aired on A&E.
"It's a great way for people who might be considering sponsorship to see how real it is and the impact that a person can have overseas," Price said. "And obviously, we hope it moves more people to sponsor."
ChildFund International is headquartered in Henrico's Near West End. The organization was founded in 1938 by a former minister in Richmond to help children in China who were orphaned by the war, Price said.
Sponsoring a child costs $28 a month, and ChildFund works with local partners within the affected areas because "they understand the culture and environment and issues and opportunities," Price said.
"You as a potential sponsor can pick which country you want, and we have 31 countries," she said. "You can pick the age of the child, the sex of the child and then the money that you give each month goes to the child's family and to the community."
For details, visit http://www.childfund.org.
Villa's Flagler Housing wins national NAEH award
St. Joseph's Villa's Flagler Housing & Homeless Services was one of three entities to earn the National Alliance to End Homelessness' Champion of Change Award. The awards were presented Nov. 17 during a ceremony at the Newseum in Washington, D.C.
NAEH annually recognizes proven programs and significant achievements in ending child and family homelessness.
Flagler completed its transition from an on-campus shelter to the community-based model of rapid rehousing in 2013, and it was one of the nation's first rapid re-housing service providers to be certified by NAEH. > Read more.
RIR's Christmas tree lighting rescheduled for Dec. 12
Richmond International Raceway's 13th annual Community Christmas tree lighting has been rescheduled from Dec. 6 to Monday, Dec. 12, at 6:30 p.m., due to inclement weather expected on the original date.
Entertainment Dec. 12 will be provided by the Laburnum Elementary School choir and the Henrico High School Mighty Marching Warriors band. Tree decorations crafted by students from Laburnum Elementary School and L. Douglas Wilder Middle School will be on display. Hot chocolate and cookies will be supplied by the Henrico High School football boosters. > Read more.
Weekend Top 10
Given the warm weather lately, Saturday's RVA Polar Plunge Winter Fest, benefiting Special Olympics Virginia, might actually be enjoyable! Other weekend events you're sure to enjoy include the 14th annual Richmond Kids Expo at the Richmond Raceway Complex, the Richmond Symphony and The Taters in concert at The Cultural Arts Center at Glen Allen, and the Richmond Ballet Minds in Motion Team XXL performing at the Henrico Theatre. This is also the last weekend to check out HATTheatre's production of "Bill W. and Dr. Bob." For all our top picks this weekend, click here! > Read more.
ACLU urges McAuliffe to veto anti-immigration bills
Business in brief
Henrico to offer free workshop March 4 on outdoor improvements
Governor signs bills to fight Virginia's opioid crisis
New law lets concession stands sell cans of beer
- More News
Print Edition
Feb. 16, 2017Click here to read the print edition.
Weekend Top 10
Restaurant Watch
Weekend Top 10
American Tap Room at Willow Lawn closes
Weekend Top 10
- More Entertainment
Obituary – Anne Faudree Barker
Obituary – Jonathan "Bryan" Lawler
Obituary – Jean Harless
- More Obituaries
Villa's Flagler Housing wins national NAEH award
RIR's Christmas tree lighting rescheduled for Dec. 12
project:HOMES' 'Renew Crew' helps Henrico citizen
- More Community
Thanksgiving, Part II
Storm woes for e-junkies
'Good old days' were good – for some
- More Opinions
RIR to admit children 12 and younger free next year
Henrico teams win district, state championships
Varina HS to host Basketball Skill Development Academy June 20-23
- More Sports
|February 2017
Place an Ad | More Classifieds
CalendarBen Sollee and Jordan Ellis will perform at 8 p.m. at The Tin Pan, 8982 Quioccasin Rd. Doors open at 6 p.m. Tickets are $20 in advance and $25 at the door. For details, call 447-8189 or visit http://www.tinpanrva.com. Full text


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The 15-year old boy poem.
The end is near
The end of the year
Time for lists
Time to listen to the tunes you've missed
What could will be happen to be number one?
If Animal Collective is, there would be no fun
So go and check what I've made
Before the fun of lists is going to fade...
fade fade fade.
Anyways, I've made a list on my blog. You should check it out and say what you have to say, there is a lot missing, so it'll change and it will be made into a 50 if I have the time.
Also; post your own top <enter random number> in here


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- Sale
- New Arrivals
- Statues
- Home
- Zen Garden
- Jewelry
- Apparel
- Meditation
- Rituals
- Books & Gifts
Sorry but this item is currently unavailable.
Please check back at a later stage.
This Tibetan mantra bracelet is a modern connection to ancient spiritual tradition. Made of copper by Nepalese artists, bracelet measures 0.375 inches wide, adjusts to fit most wrist sizes. Handmade item, each bracelet is individually created and minor organic imperfections add to artistic character.


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* This is the Professional Version. *
- Etiology
- Pathophysiology
- Symptoms and Signs
- Diagnosis
- Prognosis
- Treatment
- Drugs for RA
- Key Points
- More Information
- Resources In This Article
- Drugs Mentioned In This Article
Rheumatoid Arthritis (RA)
Patient Education
- Joint Disorders
- Introduction to Joint Disorders
- Rheumatoid Arthritis (RA)
- Osteoarthritis (OA)
- Neurogenic Arthropathy
- Overview of Seronegative Spondyloarthropathies
- Anklyosing Spondylitis
- Reactive Arthritis
- Psoriatic Arthritis
Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that primarily involves the joints. RA causes damage mediated by cytokines, chemokines, and metalloproteases. Characteristically, peripheral joints (eg, wrists, metacarpophalangeal joints) are symmetrically inflamed, leading to progressive destruction of articular structures, usually accompanied by systemic symptoms. Diagnosis is based on specific clinical, laboratory, and imaging features. Treatment involves drugs, physical measures, and sometimes surgery. Disease-modifying antirheumatic drugs help control symptoms and slow disease progression.
RA affects about 1% of the population. Women are affected 2 to 3 times more often than men. Onset may be at any age, most often between 35 yr and 50 yr, but can be during childhood (see Juvenile Idiopathic Arthritis) or old age.
Although RA involves autoimmune reactions, the precise cause is unknown; many factors may contribute. A genetic predisposition has been identified and, in white populations, localized to a shared epitope in the HLA-DR β1 locus of class II histocompatibility antigens. Unknown or unconfirmed environmental factors (eg, viral infections, cigarette smoking) are thought to play a role in triggering and maintaining joint inflammation.
Prominent immunologic abnormalities include immune complexes produced by synovial lining cells and in inflamed blood vessels. Plasma cells produce antibodies (eg, rheumatoid factor [RF], anticyclic citrullinated peptide antibody [anti-CCP]) that contribute to these complexes, but destructive arthritis can occur in their absence. Macrophages also migrate to diseased synovium in early disease; increased macrophage-derived lining cells are prominent along with vessel inflammation. Lymphocytes that infiltrate the synovial tissue are primarily CD4+ T cells. Macrophages and lymphocytes produce pro-inflammatory cytokines and chemokines (eg, TNF-α, granulocyte-macrophage colony-stimulating factor [GM-CSF], various ILs, interferon-γ) in the synovium. Release of inflammatory mediators probably contributes to the systemic and joint manifestations of RA.
In chronically affected joints, the normally thin synovium proliferates, thickens, and develops many villous folds. The synovial lining cells produce various materials, including collagenase and stromelysin, which contribute to cartilage destruction, and IL-1 and TNF-α, which stimulate cartilage destruction, osteoclast-mediated bone absorption, synovial inflammation, and prostaglandins (which potentiate inflammation). Fibrin deposition, fibrosis, and necrosis are also present. Hyperplastic synovial tissue (pannus) releases these inflammatory mediators, which erode cartilage, subchondral bone, articular capsule, and ligaments. Polymorphonuclear leukocytes (PMNs) on average make up about 60% of WBCs in the synovial fluid.
Rheumatoid nodules develop in about 30% of patients with RA. They are granulomas consisting of a central necrotic area surrounded by palisaded histiocytic macrophages, all enveloped by lymphocytes, plasma cells, and fibroblasts. Nodules and vasculitis can also develop in visceral organs.
Symptoms and Signs
Onset is usually insidious, often beginning with systemic and joint symptoms. Systemic symptoms include early morning stiffness of affected joints, generalized afternoon fatigue and malaise, anorexia, generalized weakness, and occasionally low-grade fever. Joint symptoms include pain, swelling, and stiffness.
The disease progresses most rapidly during the first 6 yr, particularly the first year; 80% of patients develop some permanent joint abnormalities within 10 yr. The course is unpredictable in individual patients.
Joint symptoms are characteristically symmetric. Typically, stiffness lasts > 60 min after rising in the morning but may occur after any prolonged inactivity (called gelling). Involved joints become tender, with erythema, warmth, swelling, and limitation of motion. The joints primarily involved include the following:
However, virtually any joint, except uncommonly the distal interphalangeal (DIP) joints, may be involved. The axial skeleton is rarely involved except for the upper cervical spine. Synovial thickening is detectable. Joints are often held in flexion to minimize pain, which results from joint capsular distention.
Fixed deformities, particularly flexion contractures, may develop rapidly; ulnar deviation of the fingers with an ulnar slippage of the extensor tendons off the metacarpophalangeal joints is typical, as are swan-neck and boutonnière deformities (see Figure: Boutonnière and swan-neck deformities.). Joint instability due to stretching of the joint capsule can also occur. Carpal tunnel syndrome can result from wrist synovitis compressing the median nerve. Popliteal (Baker) cysts can develop, causing calf swelling and tenderness suggestive of deep venous thrombosis.
Extra-articular manifestations
Subcutaneous rheumatoid nodules are not usually an early sign but eventually develop in up to 30% of patients, usually at sites of pressure and chronic irritation (eg, the extensor surface of the forearm, metacarpophalangeal joints, occiput). Visceral nodules (eg, pulmonary nodules), usually asymptomatic, are common in severe RA.
Other extra-articular signs include vasculitis causing leg ulcers or mononeuritis multiplex, pleural or pericardial effusions, pulmonary infiltrates or fibrosis, pericarditis, myocarditis, lymphadenopathy, Felty syndrome, Sjögren syndrome, scleromalacia, and episcleritis. Involvement of the cervical spine can cause atlantoaxial subluxation and spinal cord compression; subluxation may worsen with extension of the neck (eg, during endotracheal intubation). Importantly, cervical spine instability is frequently asymptomatic.
RA should be suspected in patients with polyarticular, symmetric arthritis, particularly if the wrists and 2nd and 3rd metacarpophalangeal joints are involved. Criteria for the diagnosis of RA are listed in Diagnosing Rheumatoid Arthritis*. Criteria include laboratory test results for RF, anti-CCP, and ESR or CRP. Other causes of symmetric polyarthritis, particularly hepatitis C, must be excluded. Patients should have a serum RF test, hand and wrist x-rays, and baseline x-rays of affected joints to document future erosive changes. In patients who have prominent lumbar symptoms, alternative diagnoses should be investigated.
Diagnosing Rheumatoid Arthritis*
RFs, antibodies to human γ-globulin, are present in about 70% of patients with RA. However, RF, often in low titers (levels can vary between laboratories), occurs in patients with other diseases, including other connective tissue diseases (eg, SLE), granulomatous diseases, chronic infections (eg, viral hepatitis, subacute bacterial endocarditis, TB), and cancers. Low RF titers can also occur in 3% of the general population and 20% of the elderly. An RF titer measured by latex agglutination of > 1:80 or a positive anti-CCP test supports the diagnosis of RA.
Anti-CCP antibodies have high specificity (90%) and sensitivity (about 77 to 86%) for RA and, like RF, predict a worse prognosis. RF and anti-CCP values do not fluctuate with disease activity.
X-rays show only soft-tissue swelling during the first months of disease. Subsequently, periarticular osteoporosis, joint space (articular cartilage) narrowing, and marginal erosions may become visible. Erosions often develop within the first year but may occur any time. MRI seems to be more sensitive and detects earlier articular inflammation and erosions. In addition, abnormal subchondral bone signals (eg, bone marrow lesions, bone marrow edema) around the knee suggest progressive disease.
If RA is diagnosed, additional tests help detect complications and unexpected abnormalities. CBC with differential should be obtained. A normochromic (or slightly hypochromic)-normocytic anemia occurs in 80%; Hb is usually > 10 g/dL. If Hb is ≤ 10 g/dL, superimposed iron deficiency or other causes of anemia should be considered. Neutropenia occurs in 1 to 2% of cases, often with splenomegaly (Felty syndrome). Acute-phase reactants (eg, thrombocytosis, elevated ESR, elevated CRP) reflect disease activity. A mild polyclonal hypergammaglobulinemia often occurs. ESR is elevated in 90% of patients with active disease.
Synovial fluid examination is necessary with any new-onset effusion to rule out other disorders and differentiate RA from other inflammatory arthritides (eg, septic and crystal-induced arthritis). In RA, during active joint inflammation, synovial fluid is turbid, yellow, and sterile, and usually has 10,000 to 50,000 WBCs/μL; PMNs typically predominate, but >50% may be lymphocytes and other mononuclear cells. Crystals are absent.
Differential diagnosis
Many disorders can simulate RA:
RF can be nonspecific and is often present in several autoimmune diseases; the presence of anti-CCP antibodies is more specific for RA. For example, hepatitis C can be associated with an arthritis similar to RA clinically and that is RF-positive; however, anti-CCP is negative.
Some patients with crystal-induced arthritis may meet criteria for RA; however, synovial fluid examination should clarify the diagnosis. The presence of crystals makes RA unlikely. Joint involvement and subcutaneous nodules can result from gout, cholesterol, and amyloidosis as well as RA; aspiration or biopsy of the nodules may occasionally be needed.
SLE usually can be distinguished if there are skin lesions on light-exposed areas, hair loss, oral and nasal mucosal lesions, absence of joint erosions in even long-standing arthritis, joint fluid that often has < 2000 WBCs/μL (predominantly mononuclear cells), antibodies to double-stranded DNA, renal disease, and low serum complement levels. In contrast to RA, deformities in SLE are usually reducible because of the lack of erosions and bone or cartilage damage.
Arthritis similar to RA can also occur in other rheumatic disorders (eg, polyarteritis, systemic sclerosis, dermatomyositis, or polymyositis) or there can be features of more than one disease, which suggests an overlap syndrome or mixed connective tissue disease.
Sarcoidosis, Whipple disease, multicentric reticulohistiocytosis, and other systemic diseases may involve joints; other clinical features and tissue biopsy sometimes help differentiate these conditions. Acute rheumatic fever has a migratory pattern of joint involvement and evidence of antecedent streptococcal infection (culture or changing antistreptolysin O titer); in contrast, RA has an additive arthritis.
Reactive arthritis can be differentiated by antecedent GI or GU symptoms; asymmetric involvement and pain at the Achilles insertion of the heel, sacroiliac joints, and large joints of the leg; conjunctivitis; iritis; painless buccal ulcers; balanitis circinata; or keratoderma blennorrhagicum on the soles and elsewhere.
Psoriatic arthritis tends to be asymmetric and is not usually associated with RF, but differentiation may be difficult in the absence of nail or skin lesions. DIP joint involvement and severely mutilating arthritis (arthritis mutilans) is strongly suggestive, as is the presence of a diffusely swollen (sausage) digit.
Ankylosing spondylitis may be differentiated by spinal and axial joint involvement, absence of subcutaneous nodules, and a negative RF test.
Osteoarthritis can be differentiated by the joints involved; the absence of rheumatoid nodules, systemic manifestations, or significant amounts of RF; and by synovial fluid WBC counts <2000/μL. Osteoarthritis of the hands most typically involves the DIP joints, bases of the thumbs, and proximal interphalangeal joints and may involve the metacarpophalangeal joints but typically spares the wrist. RA does not affect the DIP joints.
RA decreases life expectancy by 3 to 7 yr, with heart disease, infection, and GI bleeding accounting for most excess mortality; drug treatment, cancer, as well as the underlying disease may be responsible.
At least 10% of patients are eventually severely disabled despite full treatment. Whites and women have a poorer prognosis, as do patients with subcutaneous nodules, advanced age at disease onset, inflammation in ≥ 20 joints, early erosions, cigarette smoking, high ESR, and high levels of RF or anti-CCP.
Treatment of RA involves a balance of rest and exercise, adequate nutrition, physical measures, drugs, and sometimes surgery. (See also the European League Against Rheumatism's 2013 update EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-Modifying Antirheumatic Drugs.)
Lifestyle measures
Complete bed rest is rarely indicated, even for a short time; however, a program including judicious rest should be encouraged.
An ordinary nutritious diet is appropriate. Rarely, patients have food-associated exacerbations; no specific foods have reproducibly been shown to exacerbate RA. Food and diet quackery is common and should be discouraged. Substituting ω-3 fatty acids (in fish oils) for dietary ω-6 fatty acids (in meats) partially relieves symptoms in some patients by transiently decreasing production of inflammatory prostaglandins. Smoking cessation can increase life expectancy.
Physical measures
Joint splinting reduces local inflammation and may relieve severe symptoms of pain or compressive neuropathies. Cold may be applied to reduce pain from temporary worsening in one joint. Orthopedic or athletic shoes with good heel and arch support are frequently helpful; metatarsal supports placed posteriorly (proximal) to painful metatarsophalangeal joints decrease the pain of weight bearing. Molded shoes may be needed for severe deformities. Occupational therapy and self-help devices enable many patients with debilitating RA to perform activities of daily living.
Exercise should proceed as tolerated. During acute inflammation, passive range-of-motion exercise helps prevent flexion contractures. Heat therapy can be helpful. Range-of-motion exercises done in warm water are helpful because heat improves muscle function by reducing stiffness and muscle spasm. However, contractures can be prevented and muscle strength can be restored more successfully after inflammation begins to subside; active exercise (including walking and specific exercises for involved joints) to restore muscle mass and preserve range of joint motion should not be fatiguing. Flexion contractures may require intensive exercise, casting, or immobilization (eg, splinting) in progressively more stretched-open positions. Paraffin baths can warm digits and facilitate finger exercise.
Massage by trained therapists, traction, and deep heat treatment with diathermy or ultrasonography may be useful adjunctive therapies to anti-inflammatory drugs.
Surgery must always be considered in terms of the total disease and patient expectations. For example, deformed hands and arms limit crutch use during rehabilitation; seriously affected knees and feet limit benefit from hip surgery. Reasonable objectives for each patient must be determined, and function must be considered; straightening ulnar-deviated fingers may not improve hand function. Surgery may be done while the disease is active.
Arthroplasty with prosthetic joint replacement is indicated if damage severely limits function; total hip and knee replacements are most consistently successful. Prosthetic hips and knees cannot tolerate vigorous activity (eg, competitive athletics). Excision of subluxed painful metatarsophalangeal joints may greatly aid walking. Thumb fusions may provide stability for pinch. Neck fusion may be needed for C1-2 subluxation with severe pain or potential for spinal cord compression. Arthroscopic or open synovectomy can relieve joint inflammation but only temporarily unless disease activity can be controlled.
Drugs for RA
The goal is to reduce inflammation as a means of preventing erosions, progressive deformity, and loss of joint function. Disease-modifying antirheumatic drugs (DMARDs) are used early, often in combination. Other drug classes, including biologic agents, TNF-α antagonists, and IL-1 receptor antagonists, seem to slow the progression of RA. NSAIDs are of some help for the pain of RA but do not prevent erosions or disease progression and thus should be used only as adjunctive therapy. Low-dose systemic corticosteroids (prednisone < 10 mg once/day) may be added to control severe polyarticular symptoms, usually with the objective of replacement with a DMARD. Intra-articular depot corticosteroids can control severe monarticular or even oligoarticular symptoms.
The optimal combinations of drugs are not yet clear. However, some data suggest that certain combinations of drugs from different classes (eg, methotrexate plus other DMARDs, a rapidly tapered corticosteroid plus a DMARD, methotrexate plus a TNF-α antagonist or an IL-1 receptor antagonist, a TNF-α antagonist or an IL-1 receptor antagonist plus a DMARD) are more effective than using DMARDs alone sequentially or in combination. In general, biologic agents (eg, TNF-α and IL-1 receptor antagonists) are not given in combination with each other due to increased frequency of infections. An example of initial therapy is
Aspirin is no longer used for RA, as effective doses are often toxic. Only one NSAID should be given at a time (see Table: NSAID Treatment of Rheumatoid Arthritis), although patients may also take aspirin at ≤ 325 mg/day for its antiplatelet cardioprotective effect. Because the maximal response for NSAIDs can take up to 2 wk, doses should be increased no more frequently than this. Doses of drugs with flexible dosing can be increased until response is maximal or maximum dosage is reached. All NSAIDs treat the symptoms of RA and decrease inflammation but do not alter the course of the disease; thus, they are only used adjunctively.
NSAIDs inhibit cyclooxygenase (COX) enzymes and thus decrease production of prostaglandins. Some prostaglandins under COX-1 control have important effects in many parts of the body (ie, they protect gastric mucosa and inhibit platelet adhesiveness). Other prostaglandins are induced by inflammation and are produced by COX-2. Selective COX-2 inhibitors, also called coxibs (eg, celecoxib), seem to have efficacy comparable to nonselective NSAIDs and are slightly less likely to cause GI toxicity; however, they are not less likely to cause renal toxicity.
NSAIDs other than perhaps coxibs should be avoided in patients with previous peptic ulcer disease or dyspepsia. Other possible adverse effects of all NSAIDs include headache, confusion and other CNS symptoms, increased BP, worsening of hypertension, edema, and decreased platelet function. NSAIDs increase cardiovascular risk (see Nonopioid Analgesics). Creatinine levels can rise reversibly because of inhibited renal prostaglandins; less frequently, interstitial nephritis can occur. Patients with urticaria, rhinitis, or asthma caused by aspirin can have the same problems with these other NSAIDs.
NSAID Treatment of Rheumatoid Arthritis
Traditional disease-modifying antirheumatic drugs (DMARDs)
(See table: Other Drugs Used to Treat Rheumatoid Arthritis for specific dosage information and adverse effects of other drugs used to treat RA.)
DMARDs seem to slow the progression of RA and are indicated for nearly all patients with RA. They differ from each other chemically and pharmacologically. Many take weeks or months to have an effect. About two thirds of patients improve overall, and complete remissions are becoming more common. Many DMARDs result in evidence of decreased damage on imaging studies, presumably reflecting decreased disease activity. Patients should be fully apprised of the risks of DMARDs and monitored closely for evidence of toxicity.
Other Drugs Used to Treat Rheumatoid Arthritis
When choosing DMARDs, the following principles should be considered:
Combinations of DMARDs may be more effective than single drugs. For example, hydroxychloroquine, sulfasalazine, and methotrexate together are more effective than methotrexate alone or the other two together.
Combining a DMARD with another drug, such as methotrexate plus a TNF-α antagonist or an IL-1 receptor antagonist or a rapidly tapered corticosteroid, may be more effective than using DMARDs alone.
Methotrexateis a folate antagonist with immunosuppressive effects at high dose. It is anti-inflammatory at doses used in RA. It is very effective and has a relatively rapid onset (clinical benefit often within 3 to 4 wk). Methotrexate should be used with caution, if at all, in patients with hepatic dysfunction or renal failure. Alcohol should be avoided. Supplemental folate, 1 mg po once/day, reduces the likelihood of adverse effects. CBC, AST, ALT, and albumin and creatinine level should be determined about every 8 wk. When used early in the course of RA, efficacy may equal the biologic agents. Rarely, a liver biopsy is needed if liver function test findings are persistently twice the upper limit of normal or more and the patient needs to continue to use methotrexate. Severe relapses of arthritis can occur after withdrawal of methotrexate. Paradoxically, rheumatoid nodules may enlarge with methotrexate therapy.
Hydroxychloroquinecan also control symptoms of mild RA. Funduscopic examination should be done and visual fields should be assessed before and every 12 mo during treatment. The drug should be stopped if no improvement occurs after 9 mo.
Sulfasalazinecan alleviate symptoms and slow development of joint damage. It is usually given as enteric-coated tablets. Benefit should occur within 3 mo. Enteric coating or dose reduction may increase tolerability. Because neutropenia may occur early, CBCs should be obtained after 1 to 2 wk and then about every 12 wk during therapy. AST and ALT should be obtained at about 6-mo intervals and whenever the dose is increased.
Leflunomideinterferes with an enzyme involved with pyrimidine metabolism. It is about as effective as methotrexate but is less likely to suppress bone marrow, cause abnormal liver function, or cause pneumonitis. Alopecia and diarrhea are fairly common at the onset of therapy but may resolve with continuation of therapy.
Parenteral gold compoundsare not commonly used anymore.
Systemic corticosteroids decrease inflammation and other symptoms more rapidly and to a greater degree than other drugs. They also seem to slow bone erosion. However, they may not prevent joint destruction, and their clinical benefit often diminishes with time. Furthermore, rebound often follows the withdrawal of corticosteroids in active disease. Because of their long-term adverse effects, some doctors recommend that corticosteroids are given to maintain function only until another DMARD has taken effect.
Corticosteroids may be used for severe joint or systemic manifestations of RA (eg, vasculitis, pleurisy, pericarditis). Relative contraindications include peptic ulcer disease, hypertension, untreated infections, diabetes mellitus, and glaucoma. The risk of latent TB should be considered before corticosteroid therapy is begun.
Intra-articular injections of depot corticosteroids may temporarily help control pain and swelling in particularly painful joints. Triamcinolone hexacetonide may suppress inflammation for the longest time. Triamcinolone acetonide and methylprednisolone acetate are also effective. No single joint should be injected with a corticosteroid more than 3 to 4 times a year, as too-frequent injections may accelerate joint destruction (although there are no specific data from humans to support this effect). Because injectable corticosteroid esters are crystalline, local inflammation transiently increases within a few hours in < 2% of patients receiving injections. Although infection occurs in only < 1:40,000 patients, it must be considered if pain occurs > 24 h after injection.
Immunomodulatory, cytotoxic, and immunosuppressive drugs
Treatment with azathioprine or cyclosporine (an immunomodulatory drug) provides efficacy similar to DMARDs. However, these drugs are more toxic. Thus, they are used only for patients in whom treatment with DMARDs has failed or to decrease the need for corticosteroids. They are used infrequently unless there are extra-articular complications. For maintenance therapy with azathioprine, the lowest effective dose should be used. Low-dose cyclosporine may be effective alone or when combined with methotrexate. It may be less toxic than azathioprine. Cyclophosphamide is no longer recommended due to its toxicity.
Biologic agents
Biologic response modifiers other than TNF-α antagonists can be used to target B cells or T cells. These agents are typically not combined with each other.
Rituximab is an anti-CD 20 antibody that depletes B cells. It can be used in refractory patients. Response is often delayed but may last 6 mo. The course can be repeated after 6 mo. Mild adverse effects are common, and analgesia, corticosteroids, diphenhydramine, or a combination may need to be given concomitantly. Rituximab is usually restricted to patients who have not improved after using a TNF-α inhibitor and methotrexate. Rituximab therapy has been associated with progressive multifocal leukoencephalopathy, mucocutaneous reactions, delayed leukopenia, and hepatitis B reactivation.
Abatacept, a soluble fusion cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) Ig, is indicated for patients with RA with an inadequate response to other DMARDs.
Other agents
Anakinrais a recombinant IL-1 receptor antagonist. IL-1 is heavily involved in the pathogenesis of RA. Infection and leukopenia can be problems.
TNF-α antagonists (eg, adalimumab, etanercept, golimumab, certolizumab pegol, and infliximab) reduce the progression of erosions and reduce the number of new erosions. Although not all patients respond, many have a prompt, dramatic feeling of well being, sometimes with the first injection. Inflammation is often dramatically reduced. These drugs are often added to methotrexate therapy to increase the effect and possibly prevent the development of drug-neutralizing antibodies.
Tocilizumab blocks the effect of IL-6 and has clinical efficacy in patients who have responded incompletely to other biologic agents.
Tofacitinib is a Janus kinase (JAK) inhibitor that is given orally with or without concomitant methotrexate to patients who do not respond to methotrexate alone or other biologic agents.
Although there are some differences among agents, the most serious problem is infection, particularly with reactivated TB. Patients should be screened for TB with PPD or an interferon-gamma release assay. Other serious infections can occur, including sepsis, invasive fungal infections, and infections due to other opportunistic organisms. It is not clear whether risk of lymphomas or other cancers is increased. Recent information suggests safety during pregnancy. TNF-α antagonists should probably be stopped before major surgery. Etanercept, infliximab, and adalimumab can and probably should be used with methotrexate. High-dose infliximab should not be used in patients with severe heart failure.
Key Points
RA is a systemic inflammatory disorder.
The most characteristic manifestation is a symmetric polyarthritis involving peripheral joints such as wrists and metacarpophalangeal and metatarsophalangeal joints, often with constitutional symptoms.
Extra-articular findings can include rheumatoid nodules, vasculitis causing leg ulcers or mononeuritis multiplex, pleural or pericardial effusions, pulmonary nodules, pulmonary infiltrates or fibrosis, pericarditis, myocarditis, lymphadenopathy, Felty syndrome, Sjögren syndrome, scleromalacia, and episcleritis.
Take x-rays but diagnose primarily by specific clinical criteria and laboratory test results, including autoantibodies (serum rheumatoid factor and anti-cyclic citrullinated peptide antibody) and acute-phase reactants (ESR or C-reactive protein).
RA decreases life expectancy by 3 to 7 yr (eg, due to GI bleeding, infection, or heart disease) and causes severe disability in 10% of patients.
Treat almost all patients early and primarily with drugs that modify disease activity.
Drugs that modify disease activity include traditional DMARDs, methotrexate, biologic agents such as TNF-α antagonists, an IL-1 antagonist, and other drugs that are immunomodulatory, cytotoxic, or immunosuppressive.
More Information
EULAR Recommendations for the Management of Rheumatoid Arthritis with Synthetic and Biological Disease-Modifying Antirheumatic Drugs(European League Against Rheumatism 2013 Update)
Resources In This Article
Drugs Mentioned In This Article
Drug NameSelect Trade
IbuprofenADVIL, MOTRIN IB
MeclofenamateNo US brand name
cyclosporineNEORAL, SANDIMMUNE
NaproxenALEVE, NAPROSYN
DiclofenacCATAFLAM, VOLTAREN
diphenhydramineNo US trade name
FlurbiprofenANSAID, OCUFEN
CyclophosphamideCYTOXAN (LYOPHILIZED)
- Joint Disorders
- Introduction to Joint Disorders
- Rheumatoid Arthritis (RA)
- Osteoarthritis (OA)
- Neurogenic Arthropathy
- Overview of Seronegative Spondyloarthropathies
- Anklyosing Spondylitis
- Reactive Arthritis
- Psoriatic Arthritis
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AH KEE, Vernon
not an animal or a plant is a declaration. I am declaring on my own behalf and that of my family and my people that 'I am not an animal or a plant'.
In 1901 when Australia ceased being a collection of British colonies simply sharing a land mass and became a federated country, the Aborigine – the native people of the land – was excluded from the
new nation's constitution and the many arbitrary rights of citizenship that accompanied all its new citizens. Which is not to say that the Aborigine had escaped consideration altogether, rather, the Aborigine, ever the least considered was, as a people, relegated to a status less than human, ergo, an 'animal' or a 'plant'. Subsequently, the Aborigine's life became government property and one of rigid control. This truly degrading and derogatory action is not surprising given the prevailing beliefs and attitudes towards the Aborigine at the time.
What is surprising, or shocking, is that it wasn't until May 1967, facing substantial international attention and mounting criticism that Australia, by virtue of a national referendum, removed the Aborigine from under the heel of quasi-slavery and possession and placed this 'othered thing' within the constitution proper, albeit as a confined ward of the state. Nevertheless, the Aborigine was transformed from an Aboriginal thing of scientific curiosity and public derision, into an Aboriginal people of romanticised curiosity and political derision.