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AbstractWith the aim of reviewing critical concepts and producing recommendations for the management of chronic myelomonocytic leukemia, key questions were selected according to the criterion of clinical relevance. Recommendations were produced using a Delphi process and four consensus conferences involving a panel of experts appointed by the Italian Society of Hematology and affiliated societies. This report presents the final statements and recommendations, covering patient evaluation at diagnosis, diagnostic criteria, risk classification, first-line therapy, monitoring, second-line therapy and allogeneic stem cell transplantation. For the first-line therapy, the panel recommended that patients with myelodysplastic-type chronic myelomonocytic leukemia and less than 10% blasts in bone marrow should be managed with supportive therapy aimed at correcting cytopenias. In patients with myelodysplastic-type chronic myelomonocytic leukemia with a high number of blasts in bone marrow (≥10%), supportive therapy should be integrated with the use of 5-azacytidine. Patients with myeloproliferative-type chronic myelomonocytic leukemia with a low number of blasts (<10%) should be treated with cytoreductive therapy. Hydroxyurea is the drug of choice to control cell proliferation and to reduce organomegaly. Patients with myeloproliferative-type chronic myelomonocytic leukemia, and a high number of blasts should receive polychemotherapy. Both in myelodysplastic-type and myeloproliferative-type chronic myelomonocytic leukemia, allogeneic stem cell transplantation should be offered within clinical trials in selected patients.
Chronic myelomonocytic leukemia (CMML) is classified by the WHO as a clonal hematopoietic malignancy characterized by features of both a myeloproliferative neoplasm and a myelodysplastic syndrome.1 CMML accounts for 10% of all cases of myelodysplastic syndromes;2,3 affected patients are diagnosed at a median age of 65–75 years, and there is a 2 to 1 male predominance.3 The most common symptoms of CMML are a reflection of the underlying cytopenia, hyper-catabolic syndrome, splenomegaly, or organ infiltration of monocytes. The disease presents with variable clinical phenotypes, the prognosis is generally poor, and effective therapies are limited.2 In recent years, array and sequencing technologies have provided new insights into the molecular pathogenesis of CMML.2 Molecular discoveries, however, have not yet been translated into changes in disease management. Therefore, therapy for CMML remains a challenge. For this reason, the Italian Society of Hematology (SIE) and affiliated Societies (the Italian Society of Experimental Hematology, SIES, and the Italian Group for Bone Marrow Transplantation, GITMO) decided to review recent data regarding diagnostic criteria, evaluation needs at diagnosis, assessment of prognostic risk, and determinants of therapeutic intervention, in order to produce recommendations aimed at helping to optimize and standardize CMML clinical management.
An expert panel of 8 hematologists with a long experience and scientific interest in CMML was selected. During an initial meeting on December 2011, the areas of major concern in the management of CMML were identified. Clinical key-questions were generated and rank-ordered using the criterion of clinical relevance (Table 1).
Each panelist drafted statements that addressed the key questions, and the remaining panelists scored their agreement with those statements providing suggestions for re-phrasing. To exploit this phase of the process, the Delphi questionnaire method was used.4 Finally, the panel met three times in Bologna, Italy, for consensus conferences. The nominal group technique5 was used according to which participants were first asked to comment in round-robin fashion on their preliminary votes and then to propose a new vote.
Patient evaluation at diagnosis
The diagnosis of CMML relies largely on findings of bone marrow (BM) morphological dysplasia or clonal genetic abnormalities in patients with persistent peripheral blood monocytosis. Conventional cytogenetic analysis can allow clonal abnormalities to be indentifed, even if most patients with CMML exhibit a normal karyotype.6 The most frequent abnormalities involve chromosome 7, mostly consisting of monosomy, trisomy 8, and a complex karyotype involving 3 or more abnormalities.7
Several molecular gene mutations have been found in CMML.8–10 These mutations affect different cellular targets and processes, like RUNX19,11,12 (transcription regulation), isocitrate dehydrogenases IDH1/IDH213 (metabolism), KRAS, NRAS, CBL, and JAK29,14–17 (tyrosine-signaling pathways), TET2, DNMT3A, ASXL1, UTX, EZH28,18–21 (epigenetic regulatory mechanism), and SRSF222 (splicing regulation). Mutations involving the NRAS, KRAS, TET2, CBL and SRSF2 genes, and JAK2 V617F mutations are the most frequently reported.22 A comprehensive mutation analysis revealed that 93% of all CMML patients carried at least one somatic mutation in 9 recurrently mutated genes.22
Flow cytometry immunophenotyping may detect aberrancies in the monocytic lineage, including abnormal CD11b/HLA-DR, CD36/CD14, abnormal intensity of CD13, CD14, CD16, CD33, CD36, CD64, expression of CD34 and lineage infidelity markers, and overexpression of CD56.23–25 None of these aberrancies are specific for CMML.
The diagnostic workup of a suspected CMML should include: patient’s history aimed at excluding reactive causes of monocytosis (in particular, infectious diseases and solid tumors); physical examination (in particular, assessment of spleen size and search for cutaneous lesions); complete blood count and peripheral blood smear examination with differential leukocyte count; bone marrow aspiration and biopsy; conventional cytogenetic analysis; molecular assays to exclude bcr/abl fusion gene and rearrangement of PDGFRA and PDGFRB; any investigation necessary to exclude infectious diseases with monocytosis. A sample of bone marrow cells should be stored for possible further molecular analysis in centers where a certified tissue bank is available.
Useful diagnostic information gained from peripheral blood smear examination includes: monocyte count; presence of dysgranulopoiesis; presence of promonocytes, blasts, and neutrophil precursors. Useful diagnostic information from bone marrow aspiration is: presence of dysplasia in one or more myeloid lineages; granulocytic hyperplasia; percentage of blasts, that should include myeloblasts, monoblasts and promonocytes.
Staining of bone marrow biopsy sections should include hematoxylin-eosin or equivalent, immunostaining for CD34 and monocytic cells (CD68R and CD163), and Gomori’s silver impregnation for fibrosis. Useful diagnostic information from BM biopsy is: marrow cellularity; dysplasia and hyperplasia of megakaryocyte compartment; blast count; and bone marrow fibrosis.
Conventional cytogenetic analysis should allow acquired clonal chromosomal abnormalities to be detected and t(9;22) and t(5;12) translocations excluded that are characteristic for chronic myeloid leukemia and MDS/MPN with eosinophilia, respectively.
In patients with negative t(9;22), bcr/abl fusion gene molecular assay should be performed to definitively exclude chronic myeloid leukemia. In the case of eosinophilia and negative t(5;12), the PDGFRA and PDGFRB rearrangement molecular assay should be performed in order to exclude MDS/MPN with eosinophilia.
The panel agreed that validation of potential diagnostic molecular biomarkers, like SRSF2, TET2, JAK2 or RAS mutations, and a better knowledge of their specificity is needed before they can be indicated for routine assessment in CMML patients at diagnosis.
Comprehensive diagnostic criteria
Diagnostic criteria proposed by the FAB group in the 1980s included: blood monocytes > 1×10/L; bone marrow blasts <20%, associated with dysplasia in erythroid, granulocytic, or megakaryocytic lineages; peripheral blasts < 5%; and absence of Auer rods in myeloid cells.26 Due to the variability of this presentation, in 1994 the FAB group distinguished “dysplastic” (MD-CMML) and “proliferative” (MP-CMML) variants, considering a white blood cell (WBC) count of 13×10/L as a cut-off point.27 In most of the studies investigating the prognostic significance of such a subdivision,28–34 median survival of patients with the MP-CMML turned out to be shorter than that of patients with the MD-variant, even though the observed differences were hardly ever statistically significant. On the contrary, the probability of transformation to acute myeloid leukemia (AML) was generally similar between the two subtypes of CMML.
In 2001, the WHO classification definitively separated CMML from MDS.35 A new group of diseases with both myelodysplastic and myeloproliferative features was established, named “myelodysplastic/myeloproliferative diseases” including CMML, atypical CMML, and juvenile CMML. WHO committees chose not to maintain the distinction between MD and MP CMML, but to divide CMML into two prognostic categories based on blast number: CMML-1 (blasts < 5% in blood and < 10% in BM) and CMML-2 (blasts 5–19% in blood and/or 10–19% in BM). A diagnostic sub-category of “CMML with eosinophilia” was recommended in cases where peripheral eosinophil counts resulted over 1.5×10/L.
The WHO classification was reviewed in 20081 and “myelodysplastic/myeloproliferative diseases” were renamed “myelodysplastic/myeloproliferative neoplasms”. A new subgroup, “myeloid and lymphoid neoplasm with eosinophilia and abnormalities of PDGRFA, PDGRFB and FGFR1”, was added. “CMML with eosinophilia” harboring PDGRFA or PDGRFB rearrangement was included in this new entity.
Diagnostic criteria for CMML are clearly set out in the WHO 2008 classification and their use is recommended (Table 2). We suggest that the distinction of CMML into MP- and MD-variants should be maintained in the diagnostic workup, since it retains importance due to the different therapeutic options that this may involve. For the time being, although arbitrary, a white blood cell count of 13×10/L is considered an appropriate cut-off point for this distinction.
Prognosis and risk classification
In the past, patients with CMML were usually assessed for risk using scoring systems developed for MDS.36 In 2002, a specific prognostic scoring system was developed at the University of Texas MD Anderson Cancer Center (MDACC).37 This study identified a hemoglobin level (<12 vs. ≥12 g/dL), absolute number of lymphocytes (>2.5 vs. ≤2.5×10/L), the presence of immature myeloid cells (IMC) in the peripheral blood and marrow blast percentage (≥10 vs. <10%) as the variables independently associated to prognosis that could identify four subgroups of patients (low, intermediate-1, intermediate-2, and high risk, with median survival times of 26, 14, 9, and 5 months, respectively) showing significantly different life expectations (MDAPS). The association of higher lymphocyte counts with shorter survival has been confirmed by the MDS Düsseldorf Registry.38 A few years later, a slight modification of the MDAPS was proposed (MDAPS M1) replacing BM blasts with LDH, which allowed a slightly better stratification in four risk groups to be obtained in comparison to the original MDAPS.39
The presence of cytogenetic aberrations has been associated to shorter survival in CMML,37 in particular in patients with high-risk disease.39 A recent multivariate analysis of 414 CMML patients included in the Spanish MDS Registry confirmed the independent association of an abnormal karyotype (reported in 27% of patients) with poorer overall survival and a higher risk of AML evolution.40
Independent associations of molecular abnormalities with prognosis have been recently identified.14 Indeed, the presence of RAS point mutations appears to be significantly higher in MP-CMML than in MD-CMML (40% vs. 20%).41 The presence of EZH2 implies an unfavorable prognosis8 while mutation of ASXL1 correlates with evolution to AML and a shorter overall survival.18 The impact of TET2 mutations remains controversial.9,42 No impact of SRSF2 mutation on survival was observed.22 However, in the RUNX1 mutated sub-cohort, SRSF2 Pro95His had a favorable impact on overall survival.22 Most important, a recently concluded phase II trial in which 39 CMML patients were treated with decitabine suggested that lower CJUN and CMYB gene expression levels were independently associated with an improved overall outcome and survival.43 However, the value of somatic gene mutations in the prognosis of CMML has not been validated and no scoring system including such molecular aberrations has been developed.
Because life expectancy is so heterogeneous in CMML, risk assessment is highly recommended for clinical decision making in individual patients.
The CMML-1 and CMML-2 WHO classification is recommended for prognostic implications but it should not be considered sufficient on its own to discriminate between low- and high-risk patients. Additional clinical criteria should be taken into account to decide the timing and modalities of therapeutic interventions.
At present, there is no universally used validated CMML-specific risk classification system. The use of CMML specific risk-oriented systems (i.e. MDAPS, MDAPS-M1, Düsseldorf or Spanish Registry scores) for individual patient risk assessment is recommended, in particular for patients who are candidates for allogeneic HSCT or enrolled in clinical trials.
Determinants of therapeutic intervention
Although criteria for starting therapy in CMML have not yet been fully established, the panel reasoned that clinical relevance should be considered when deciding the criteria for starting therapy. Thus empirical values were selected for the severity of anemia, thrombocytopenia, percentage of blasts and immature myeloid cells. The panel agreed on the following recommendations.
Therapy should be started when the disease is symptomatic or progressive, and, in particular, when one of these events occurs: a) severe anemia (Hb less than 10 g/dL); b) percentage of blasts in peripheral blood >5% (including myeloblasts, monoblasts and promonocytes;) c) platelet count ≤ 50×10/L; d) WBC count ≥ 30×10/L; e) immature granulocytes ≥ 10% in peripheral blood; f) extramedullary manifestations of the disease, such as cutaneous or lymphnodal; g) symptomatic splenomegaly.
Response criteria and definition of resistance
In 1996, Wattel et al. proposed five grades of response (clinical remission, good response, minor response, progression and stable disease) based on blood count, bone marrow aspirate and biopsy, and karyotype. However, these criteria were not used thereafter.44 Stressing the need for response criteria that are specific for CMML, the panel concluded that, at present, either the IWG 2006 response criteria for MDS or the IWG response criteria for myelofibrosis are appropriate for CMML in the myelodysplastic and myeloproliferative variants, respectively45,46 (Tables 3 and 4). There is no universally applied standardized definition of resistance/intolerance to first-line therapy (either hydroxyurea or 5-azacytidine) in CMML.
Response to treatment should be assessed according to the MD- and MP-disease classification at the time of treatment. For patients with MD-CMML, the IWG 2006 criteria for MDS (Table 3) should be applied. For patients with MP-CMML, the same set of IWG criteria of response used for primary myelofibrosis should be applied (IWG 2009 - Table 4). In both variants of the disease, the distinction of patients according to the WHO classification (CMML-1 vs. CMML-2) does not imply modifications of response criteria.
In MD-CMML, the absence of hematologic improvement after at least six cycles of 5-azacytidine and without progression of the disease should be defined as resistance. In MP-CMML, the same criteria used for defining resistance to hydroxyurea in myelofibrosis may be used47 (Table 5).
Monitoring patients not candidates for treatment
The frequency of clinical and laboratory monitoring in patients who are not candidates for treatment should be initially set according to the individual disease characteristics and then adjusted depending on the natural clinical course.
Patients with MD-CMML who are not candidates for treatment should be monitored with a full blood count one month after diagnosis to assess the hematologic stability. These patients should then be monitored by full blood count and clinical examination every three months.
Patients with MP-CMML at diagnosis or evolving from an MD-CMML and not candidates for treatment, should be monitored monthly by full blood count for the first three months from diagnosis to exclude a rapid rise in WBC count or significant changes in other hematologic parameters, then by complete whole blood count and clinical examination every three months. Clinical examination should aim to evaluate spleen size, and the appearance of lymphoadenomegalies or extra-hematologic involvement (e.g. skin).
In cases of disease evolution from MD- to MP-CMML, as well as in cases of a significant increase in WBC count or a considerable spleen size enlargement in patients with a previously stable MP-CMML, hematologic and cytogenetic re-evaluation is recommended. Molecular evaluation should be considered, storing marrow cell DNA for further studies.
In patients not candidates for stem cell transplantation or any other possible experimental treatment, BM examination for blast count and cytogenetics should be performed once a year and in cases of relevant hematologic changes.
Management of CMML is usually focused on supportive care and cytoreductive therapy, depending on the characteristics of individual patient’s disease (MD- vs. MP-CMML). Wattel et al. compared 1,000 mg/day of oral hydroxyurea (HU) to 150 mg/week of oral etoposide in 105 patients.44 After a median follow up of 11 months, 60% of patients in the HU arm responded compared with 36% in the etoposide arm. Median overall survival (OS) was statistically superior in the UH arm leading to the trial ending early.
Two randomized studies established the efficacy and safety of hypomethylating agents (5-azacitidine and decitabine) in a total of 361 patients with MDS.48,49 However, only 14 patients with CMML were enrolled in each of these studies. Although the responses for CMML patients were not reported separately in the trials, it was reported that there were no significant differences in response rates among patients with refractory anemia as compared to CMML. Only one out of the 7 CMML patients randomized to the decitabine arm had a response. 5-azacitidine and decitabine have been approved by the US FDA for the treatment of CMML. More restricted approval was given by the EMA who indicated 5-azacitidine for the treatment of CMML-2 in absence of myeloproliferative aspects (<13×10/L WBC) therefore allowing a treatment indication only in 10–20% of patients. Recently, Costa et al. retrospectively reviewed 38 CMML patients treated with two different schedules of 5-azacytidine and reported a 39% overall response rate (ORR) and a significantly improved survival in responders versus non-responders.50 In a retrospective study, clinical data of 31 patients with CMML consecutively treated with 5-azacitidine were collected.51 5-azacitidine was administered at 75 mg/m or 50 mg/m daily for 7 days, or at 100 mg daily for 5 or 7 days, every 4 weeks. Overall, 51% of the patients responded to the drug, with a high rate of complete remissions (CR), while hematologic improvement (HI) was obtained in 2 patients. The disease remained stable in 7 patients (SD, 23%) while 8 patients (26%) were resistant to the drug. Patients responding to 5-azacitidine had a better survival than those with SD or progression. The use of 5-azacytidine in MP-CMML is debated because at low doses the drug primarily acts as a demethylating agent, with minimal cytotoxicity that is unable to control high proliferation rates.52 In contrast to this observation, a recent study on a small group of 10 CMML patients treated with 5-azacytidine reported an ORR of 60%. Response was increased in proliferative CMML, with good control of leukocytosis and achievement of transfusion independence in 66% of the patients.53
Phase II studies using decitabine showed ORRs ranging from 38% to 70%.54,55 A recent trial of decitabine 20 mg/m/day for 5 days carried out on a median of 10 cycles in CMML patients with advanced myeloproliferative or myelodysplastic features indicated an ORR of 38% and suggested that a lower CJUN and CMYB expression could be predictive of response.43
Intensive chemotherapy with intermediate doses of Ara-C and topotecan was investigated in a phase II trial in CMML, obtaining a CR rate of 44%, with a median remission duration of 33 weeks and a median survival of 41 weeks.56 Therapy with topotecan as single agent induced CR in 28% of CMML patients, with a median survival time of 10.5 months, and a median CR duration of 7.5 months.57 In a more recent trial in 90 patients with MDS and CMML treated with oral topotecan following 2 different schedules, the response rate in CMML patients was 50%, but no CR was reached.58
As CMML, especially in its proliferative variant, has the highest frequency of N- and K-RAS mutations among hematologic malignancies, farnesyl transferase inhibitors were considered potential effective drugs. Tipifarnib and lonafarnib were the most closely studied: unfortunately, both drugs, as single agents, were effective in only a few patients, resulting in limited disease control and leading to sporadic CR.59,60
In a pilot study, bendamustine was utilized in 15 pre-treated elderly patients with AML or high-risk MDS.61
Patients who start therapy later than three months from the diagnosis should have a pre-treatment re-evaluation, including BM aspiration, BM biopsy, and cytogenetic analysis. HLA typing is recommended for patients aged under 65 years. Serum erythropoietin should be determined in all patients with severe anemia (Hb ≤ 10 g/dL).
The treatment strategy should be decided first according to the disease hematologic phenotype, in particular whether it is an MP or MD phenotype, and to the number of blasts in BM.
Patients with MD-CMML and less than 10% blasts in BM should be managed with supportive therapy aimed at correcting cytopenias. Patients with severe anemia (Hb ≤ 10g/dL and with serum erythropoietin ≤ 500 mU/dL) should be treated with erythropoietic stimulating agents. Myeloid growth factors may be considered only for patients with febrile severe neutropenia.
In patients with MD-CMML with high number of blasts (≥10% in BM, ≥5% in the blood), the supportive therapy should be integrated with the use of hypomethylating agents (5-azacytidine or decitabine). In selected patients, allo-SCT may be offered within clinical trials.
Patients with MP-CMML with a low number of blasts should be treated with cytoreductive therapy. Hydroxyurea is the drug of choice to control proliferative myelomonocytic cells and to reduce organomegaly.
Patients with MP-CMML and a high number of blasts should receive blastolytic therapy with polychemotherapy followed, when possible, by allo-SCT.
If allo-SCT is not a possible option, patients should be informed that, although not curative, chemotherapy is recommended to maintain Quality of Life.
In the absence of any scientific evidence that could address the decision on second-line therapy in patients refractory or intolerant to first-line treatment, the panel approved the following recommendations.
Patients with MD-CMML with a high number of blasts, resistant or intolerant to 5-azacitidine, and not eligible for transplant, should be treated with supportive therapy and enrolled in experimental therapeutic studies.
In patients with MP-CMML and resistant or intolerant to hydroxyurea (Table 5) without blasts (<10%), cytolytic therapy should be given to control the disease and avoid a rapid increase in WBC count. VP16, low-dose ARA-C, thioguanine as single agents are reported to be efficacious. Hypomethylating agents should be used in the context of clinical trials. Patients with MP-CMML with a high blast count resistant to conventional blastolytic therapies should be treated with new and experimental therapies. Topoisomerase I inhibitors, farnesyl-transferase inhibitors or other drugs like bendamustine seem to have little effect as single agents.
Hematopoietic stem cell transplantation
Allo-SCT is the only strategy that may lead to cure in patients with CMML. However, due to the advanced age of the vast majority of patients, this treatment option is rarely feasible. Recently,62 a literature search was performed and data from adult CMML patients undergoing allo-SCT were reviewed. In all, 197 patients from eight studies63–70 met the final inclusion criteria. All studies were retrospective, 6 out of 8 (71%) being single institution experiences. The overall results of allogeneic SCT following myeloablative conditioning in CMML patients were disappointing, indicating a manifest excess mortality. The overall survival (OS) at 2–10 years ranged from 18% to 75% for all studies: relapse-free survival (RFS) ranged from 18% to 67%. Reduced intensity conditioning (RIC) transplant improved non-relapse mortality, OS and RFS without increasing the relapse rate.
The panel agreed that allo-SCT should be considered a therapeutic option in CMML for fit patients aged under 60 years with high-risk CMML requiring treatment. Its use should be considered experimental under a controlled strategy that investigates new pre-transplant therapies and transplant protocols. In MP-CMML and a high number of blasts, allo-SCT should be preceded by polychemotherapy, whereas in MD-CMML, 5-azacytidine may be considered before enrolling patients in a program of allo-SCT.
Few recommendations in this work were grounded on strong scientific evidence, thus most of them reflect the uncertainty surrounding many issues in CMML. A critical issue in the disease assessment derives from recent comprehensive studies of somatic gene mutations. In these analyses, more than 80% of patients were found to have gene aberrations, and it has been hypothesized that such mutations, especially in the SRSF2, TET2, ASXL genes, represent disease-associated diagnostic markers. The panel concluded that these aberrancies must be validated before entering clinical practice. The hope is that integrating genetic lesions with traditional prognostic markers could lead to a better definition of risk classes, improving the indications for different therapeutic strategies.
The second issue is reflected in the recently revised WHO classification of CMML, which specifies hematologic, morphological and molecular parameters distinguishing two clinical CMML types on the basis of the number of blasts. However, the experts in this work considered that this distinction is not fully exploitable in therapeutic decision making. They believe that the previously reported distinction between myelodysplastic and myeloproliferative characteristics retains a clinical relevance in therapeutic decision making and that a validation of this distinction and correlation with genetic or molecular characteristics of the disease could improve patients’ stratification for therapy.
A difficult therapeutic decision is that of advising patients about allo-SCT. The panel recommended that allo-SCT should be performed as an experimental procedure. Nevertheless, by significantly reducing toxicities and extending the allo-SCT option to older patients, approaches based on reduced intensity conditioning transplant are definitely worth investigating in CMML.
Since submission of the paper, a new CMML-specific prognostic scoring system (CPSS) has been published by Such et al.71 The most relevant variables for overall survival and evolution to acute myeloblastic leukemia were FAB and WHO CMML subtypes, CMML-specific cytogenetic risk classification, and RBC transfusion dependency. CPSS was able to segregate patients into four clearly different risk groups for OS and risk of AML evolution.
Authorship contribution: GB and ST designed the research. FO, GL, LM, EM, VS, GS and ST formed the panel of experts who produced recommendations. FO and GB wrote the preliminary version of the paper. All authors participated in writing significant sections of the paper.
- Funding Funding of the project was provided by SIE, SIES, and GITMO societies. The SIE administered all aspects of the meetings.
- Authorship and Disclosures Information on authorship, contributions, and financial & other disclosures was provided by the authors and is available with the online version of this article at www.haematologica.org.
- Received January 17, 2013.
- Accepted May 17, 2013.
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- Tefferi A, Barosi G, Mesa RA, Cervantes F, Deeg HJ, Reilly JT. International Working Group (IWG) consensus criteria for treatment response in myelofibrosis with myeloid metaplasia, for the IWG for Myelofibrosis Research and Treatment (IWG-MRT). Blood. 2006; 108(5):1497-503. PubMedhttps://doi.org/10.1182/blood-2006-03-009746Google Scholar
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ERLANGER, KY (WAVE) - A Boone County, Kentucky man was arrested and charged with sodomy after it was reported that he sodomized a 14-year-old male juvenile.
According to police, Edward Hernandez, 21, admitted to committing the sexual act in the early morning hours of Sunday, Jan. 27. Hernandez also admitted to nine additional acts of sodomy spanning over the past year involving the same juvenile victim. Police say Hernandez had a relationship with the victim’s parents.
Hernandez is also charged with drug possession, after police a glass pipe and a grinder with marijuana residue in his backpack.
Hernandez is currently lodged at the Boone County Detention Center in lieu of a $100,000 cash bond.

domain: news


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New Kent Winery
New Kent Winery
This album has a strong Americana feel with some old school folk mixed in. All 10 tracks are original songs either written solely by Dave or with co-writers! A combination of great story telling and seasoned musicians make this album a must have!
A singer/songwriter based out of Richmond Virginia Dave has spent the last 10 years writing and recording original songs and performing them around the country. In 2013 He released his first studio album "Four Hour Lunch Break" and since then has released 2 others, "Back In Time" and most recently "Debts Of Gratitude" in November of 2018.
Dave credits his songwriting style to the influence of songwriters such as John Prine, Guy Clark, and Jimmy Buffett. Keeping things simple and telling stories are the backbone of his songs.
While he spends most of his time performing locally in Virginia and the Mid-Atlantic states, he has enjoyed many opportunities to perform at songwriter festivals around the country in states such as Texas, Florida, Louisiana, New England and the Pacific Northwest.
With a lot of road behind him and so many great memories, Dave Looks forward to whatever his musical adventures in the future will bring him.
Country/Americana music with a Tropical Twist
My musical influences come from all different directions from genres such as old school country to Americana with even a little bit of jazz thrown in! This album is best described as diverse with songs like "Let Me Drink This Beer First" that offers and old school country sound to "Lazy Summer Sunday" that has a strong jazz feel. And if you listen hard enough you can hear that Jimmy Buffett influence in the music!

domain: artistic


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Although it’s almost that time when you’ll be able to eat as much dairy as you wish again, this article is definitely gonna be useful for you. So, lent
goes hand in hand with the lack of milk, cheese and yoghurt, right? At least we hope you’re strict with yourself when it comes to Easter fasts
So, if you’re one of those people who managed to go all the way through with no dairy, congrats
! However, we’re pretty sure you’ve struggled with the idea of how to replace the favorite products, huh?
Today we’re giving you 5 useful tips
on what to use instead of milk and the other dairy:
- Use coconut milk instead of cream
OK, let’s take the morning drink for an example. When preparing your coffee, you always feel the need to put some cream on top, right? Well, you don’t have to give up on this tradition any more. Nowadays you can find coconut milk
almost everywhere and it’s totally ready-to-use
. We guarantee you won’t even notice the difference!
- Experiment with the sauces
It’s always a good idea to have a tasty sauce at hand. Unfortunately (for those of you who’re following the Easter traditions), most types of sauces are made of what? Something plus dairy products like mayo, for instance. How to replace them, though, and still have the perfect addition to your dish? The answer is simple. Experiment!
Don’t you remember our blog post about chickpeas? Check it out here
for some inspiration. Plus, there are thousands of other recipes on the internet.
- Coconut butter and avocado
The perfect combination for a vegan
! Firstly, you can use coconut butter for cooking over heat as well as for preparing sauces and even desserts. On the other side, avocado might be an amazing addition to a toasted bread. Yummy!
- Go for the nuts
Expect for nut milk (like the coconut that we mentioned) you might get creative in the kitchen. What do we mean? Try making your own nut milk using cashews, walnuts, almonds or any other nuts you like. When you strain the vegan milk version
, there will be a thick paste left. You can always use it for pesto and similar sauces. Again, the choices are countless!
- Frozen bananas instead of ice cream
How about this, huh?! Sounds like something you should definitely give a try! Plus, it’s simple to make. Peel and slice a banana and then freeze it for a couple of hours. After that you will most probably have a 100% natural
fruit ice cream, which you made yourself!
Did you like this article?
Read more about Food and Drinks on our Blog section:
7 Suggestions on When & How to Drink Coffee
Greek Easter: 5 of the Most Important Holiday Traditions in Greece
3 Appetizer Recipes with the All-Time-Favorite Mustard

domain: food


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This gallery has some embroidery I did for a local baseball team. These are their championship towels that will hold all of their championship pins.
I also embroidered the zipper pouch on the side of their baseball bags.
Towels and Stockings
This gallery has stockings and towels that I have embroidered. I only added the name on the stockings shown here and did not do the other designs that are on some of them.
I have personalized towels with monogram, shot gun shells, and other requests.

domain: design


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Lovely welcome form the staff, room just what we wanted but most of all we were happy with the price. Breakfast was excellent and I hope they keep this standard. If we are in the area again we will definitely return and will recommend the hotel to our friends.
- Reservation Options:
- TripAdvisor is proud to partner with Booking.com, Expedia, Ebookers, Hotels.com, Priceline, TripOnline SA, LateRooms, 5viajes2012 S.L., Evoline ltd, HotelQuickly, HRS and Cancelon so you can book your Highfield House Hotel reservations with confidence. We help millions of travellers each month to find the perfect hotel for both holiday and business trips, always with the best discounts and special offers.
- Also Known As:
- Highfield Hotel Southampton

domain: travel


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Veronafiere returns to foreign countries with two wine business events
Two business events in the wine world “speak Italian” thanks to Veronafiere, with the collaboration of the ICE Trade Agency. As of today and until 23 September, the Bento Goncalves Exhibition Centre (Brazil) is home to the third edition of Wine South America – followed on 24 September by at the special edition of Wine to Asia organized in Guangzhou.
Overall, 360 brands will be take part in the event organised by our subsidiary, Veronafiere do Brasil, including 120 international brands – mostly from Italy, Argentina, Chile, France, Georgia and Portugal. Matching with the South American wine system is likely to ensure an expected attendance of around 6,000 professional operators at Wine South America and Enoteca Italia, representing 14 Italian regions and 194 labels for b2b meetings, seminars and master classes. “The Brazilian market,” said the Managing Director of Veronafiere, Maurizio Danese, “is currently limited by punitive tariff barriers which will gradually ease in coming years thanks to the EU-Mercosur trade agreement. This is undoubtedly a market ensuring a strategic perspective, not the least given the significant number of people with Italian origins.”
Last year, import of Italian wine posted growth of 19.4% (to 43 million dollars) over 2020, thereby even improving on pre-pandemic levels in 2019 (+12.7%). Italy enjoys a 9% share of imported products, just like France but behind Portugal, Argentina and the market leader Chile which, thanks to discounted duties, boasts 38% of the market. In the last 3 years, demand for wine in Brazil has grown by 28% and now worth 477 million dollars. The format of the Veronafiere branded event in Rio Grande State is exclusively business-oriented, with buyers from more than 20 countries and over 300 exhibitors representing well-defined market segments embracing national and international wines, spirits, extra virgin olive oil, technologies for vineyards and wine and olive oil production, accessories for consumption and companies providing specialist services.
A special edition of Wine to Asia on 24 September in Guangzhou, once again in the Greater Bay Area – one of the most important wine consumption areas in China. It will showcase 130 wine cellars from 26 countries.Wine to Asia Guangzhou Special Edition will host four premium master classes, including one specifically for Italian wine supported by ICE and conducted by Ian D’Agata, and another focusing on Chinese wine with Grace Vineyard guided by one of the most influential producers, such as Judy Chan. 21-24 September: in conjunction with the Guangzhou Special Edition, the Greater Bay Area Wine Week Preview will also make its debut – an initiative that sees Wine to Asia collaborate with the top wine shops and wine bars in the cities of Guangzhou and Foshan.
Veronafiere has decided to maintain its presence in China even under the “zero-Covid policy”, with a b2b day based on master classes, tastings and business meetings. Maurizio Danese, Managing Director of Veronafiere, said; “Anti-Covid policies have had a major impact on Wine to Asia. All major events are currently suspended, including trade fairs, but we have decided to continue to support wine cellars and importers in China. The goal, until such times when things get back to normal, is to organise more events targeting business with an agile and professional format.” This is why Wine to Asia will be followed, together with Ice, 10-14 November by the fifth edition of Vinitaly China Roadshow travelling to the cities of Shanghai, Nanning and Shenzhen. The epidemic has severely limited Chinese wine imports, with an overall downturn in value over the last three years of 31%. In the same period (2019-2021), however, orders for Italian wine grew by almost 6% (to 165 million dollars), thanks also to the all-but zeroing of imports from Australia following the punitive super duties imposed at the end of 2020. Today, Italy is the third main supplier of wine to China behind Chile (332 million dollars) and France (753 million dollars).


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Activity Level: Easiest
Dominating the city of Jodhpur is Mehrangarh, literally meaning "Majestic Fort." It is one of Rajasthan's three great hilltop forts (the other two are Kumbhalgarh and Chittaurgarh). Mehrangarh It is located at the very center of the city, and is visible from the surrounding area. There are three gates, each built to commemorate a particular victory, as well as to reinforce the fort.
Originally built in 1806, the fort has been added to many times since. Carved panels and porches, elaborately adorned walls and windows of Moti Mahal, Phool Mahal, Sheesh Mahal, Sileh Khana and Daulat Khana seem to make the medieval splendor come alive. The palaces in this fort were built in an informal pattern over several centuries. They have their own peculiar style, with narrow staircases serving as the only means of access to the royal residences within. A collection of musical instruments, palanquins, furniture and cannons on the fort's ramparts are well-preserved. Mehrangarh appears impregnable, and with good reason. Its battlements soar four hundred feet above a hill that rises sharply from the surrounding countryside. Mehrangarh has its own architectural appeal, such as brilliant stained glass that creates vibrant mosaics on the floors with the passage of the sun through the day.Courtesy of India Tourism Board


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So true, love how you used the arrows in a couple different ways.
Project - Hello and Goodbye
by Melissa Elsner
posted 01/24/13 at 08:38 AM
Created as a design team layout using the January Kit Harmony. Used my Silhouette Cameo for many of the elements and shapes on this layout. (Except the tag.)
Copyright © 1999-2014 It's Like This LLC. Two Peas in a Bucket is a trademark of It's Like This LLC. All Rights Reserved.


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Agencies Move Fast to Help Ohioans with Housing Costs
Wednesday, December 9, 2020
COLUMBUS, Ohio -- Agencies are moving fast to get struggling Ohioans the CARES Act funding that can help them stay in their homes.
In November, Ohio's Community Action Agencies received a total of $50 million through the Home Relief Grant to help those who are behind on their mortgage, rent or other housing-related bills due to the pandemic.
At IMPACT Community Action in Columbus, Kay Wilson, director of engagement and advancement, said demand was so high that they had to cut off applications after the first week.
"We've seen a tremendous, tremendous amount of need," she said. "People who never thought that they would have needed our services."
The Mahoning-Youngstown Community Action Partnership still is taking applications in southeastern Ohio. Its chief executive, Sheila Triplett, said the funding is a crucial support in unprecedented times.
"It's been a godsend for the agency to be able to help people that are affected by COVID," she said.
The Home Relief Grant program runs through Dec. 30. To qualify, income must be at or below 200% of the federal poverty level, which is about $52,000 a year for a family of four.
At Gallia-Meigs CAA, executive director Lora Rawson said she's proud of how her staff is adapting to the pandemic's ever-changing challenges. She noted they're doing all they can to get Housing Relief Grant money to people who need it as quickly as possible.
"They have looked for ways to make it easier for residents, and working with other organizations to try to help get the assistance out to where it needs to be," she said. "They've risen to every challenge."
In Franklin County, Wilson said they're hoping more funds become available for the families now on their waitlist, as well as others who might need help in the coming weeks.
"We are still aggressively looking for additional funding," she said. "There are families who are on the verge of being homeless and are sitting at a kitchen table hopeless, mulling over bills. The last things you want are more people on the street."
Disclosure: Ohio Association of Community Action Agencies contributes to our fund for reporting on Housing/Homelessness, Hunger/Food/Nutrition, Poverty Issues, Social Justice. If you would like to help support news in the public interest, click here.
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domain: sociology


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True Religion plans to close about 30% of its stores as it works through the bankruptcy process. The company's sales were hit hard by the popularity of yoga pants and leggings, as well as lower-priced jeans from brands such as H&M.
"Competition has also increased from emerging and established fast fashion and low-priced apparel retailers," reads the True Religion bankruptcy filing.
The focus on fast-fashion capabilities has allowed e-commerce sellers to pivot quickly to take advantage of consumer whims, while mall stores work through inventory.
"Why would you spend $300 on ripped jeans, especially if you can get the same thing for $60?" asks Retail Systems Research managing partner Paula Rosenblum.
True Religion joins Forever 21, American Apparel, Wet Seal and Pacific Sunwear on the list of mall retailers ravaged by a drop in traffic and sales from younger consumers.
Towerbrook Capital acquired True Religion in 2013 for $850M.
Now read: Gap: Time to Buy »

domain: economics


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In the heart of Texas, Williamson County beckons with a delightful surprise – an authentic taste of Italy. Beyond the Texan horizon, you'll find a culinary scene that transports you directly to the heart of Italy itself. This charming county boasts a collection of Italian cafes that serve as gateways to the Mediterranean. This article invites you to embark on a culinary adventure through Williamson County's finest Italian cafes, where every sip of espresso and every bite of pasta tells a story of tradition, flavor, and the unmistakable charm of Italy.
The Allure Of Italian Cafes In The Texan Landscape
In the Texan landscape, Italian cafes offer a captivating escape from the ordinary. These charming oases, with their old-world charm and rustic aesthetics, beckon visitors and locals alike to experience a slice of Italy amidst the Lone Star State.
Upon entering these cafes, you're greeted by the irresistible aroma of freshly brewed espresso and the scent of baking bread. These fragrances promise a sensory journey that tantalizes your taste buds.
Much like their counterparts in Italy, Texan Italian cafes take immense pride in their culinary craftsmanship. From artfully crafted cappuccinos to pasta dishes prepared from cherished family recipes, each bite and sip showcases the dedication of the chefs.
Beyond the cuisine, Italian cafes serve as cultural hubs. Many cafes celebrate Italian art, music, and literature, offering an enriching cultural experience alongside their culinary offerings.
Community and Escape
These cafes foster a sense of community, where patrons gather for conversations or to enjoy a moment of tranquility. They provide an escape from the demands of daily life, allowing you to savor the present moment.
A Taste of Italy, A Taste of Texas
In a land known for its steak and barbecue, Italian cafes offer a delicious and comforting alternative. They remind us that amidst the Texan expanse, there's always room for a taste of Italy.
The Best Italian Cafes In Williamson County
Williamson County, nestled in the heart of Texas, may not be the first place that comes to mind when you think of Italian cuisine. However, this charming region offers a surprising array of Italian cafes that have captured the hearts and palates of locals and visitors alike.
Gino's Italian Restaurant
Located in Georgetown, Gino's Italian Restaurant is a local favorite known for its classic Italian dishes and welcoming ambiance. Whether you're in the mood for homemade pasta, wood-fired pizza, or a rich tiramisu, Gino's has it all.
Tony and Luigi's Italian Mediterranean Restaurant
Situated in Round Rock, Tony and Luigi's is a family-owned gem that has been serving up Italian and Mediterranean delights for years. From their delicious spaghetti Bolognese to the savory chicken marsala, the menu offers a diverse range of options to satisfy any craving.
Mamma Mia Italian Grill & Pizza
In the heart of Cedar Park, Mamma Mia Italian Grill & Pizza stands out for its extensive menu and friendly service. Whether you're in the mood for a hearty calzone, a crisp Caesar salad, or a classic Margherita pizza, Mamma Mia's offers a wide array of choices, all made with authentic Italian flavors.
Siena Ristorante Toscana
Located in Austin, just on the outskirts of Williamson County, Siena Ristorante Toscana offers a taste of Tuscany in a sophisticated setting. Known for its impeccable service and exceptional wine list, this Italian restaurant is the perfect place for a special occasion or a romantic dinner.
Salerno's Restaurant & Pizzeria
Round Rock's Salerno's Restaurant & Pizzeria is a local institution known for its New York-style pizza and hearty Italian dishes. Whether you're craving a slice of pizza or a plate of chicken parmigiana, Salerno's serves up comforting Italian classics with a smile.
Casa G's Italian Kitchen
Nestled in Cedar Park, Casa G's Italian Kitchen offers a cozy and inviting atmosphere. The menu features a variety of pasta dishes, including the beloved lasagna, as well as Italian sandwiches and tempting desserts.
Mandola's Italian Market
While technically just outside Williamson County in Austin, Mandola's Italian Market is worth the short drive. This market and cafe offer a delightful selection of Italian sandwiches, freshly baked bread, and a marketplace filled with Italian imports for you to take home.
As you embark on this culinary adventure, don't forget that the pleasure of dining goes beyond the taste of the food itself. It's about creating memories, savoring moments with loved ones, and enjoying each bite with confidence. And speaking of confidence, if you happen to be in Taylor, TX, you can also explore options like porcelain veneers to enhance your smile. With porcelain veneers in Taylor, TX, you can savor your meals with the assurance of a bright and beautiful smile.
Signature Dishes And Must-Try Items In Williamson County's Italian Cafes
Williamson County's Italian cafes are a hidden gem, offering a warm blend of Texan hospitality and authentic Italian flavors. These cafes are home to a delightful menu filled with signature dishes, delectable desserts, and delightful drinks that promise to tantalize your taste buds.
These cafes boast wood-fired ovens that create pizzas with a smoky, charred flavor. From classic Margheritas with fresh basil and mozzarella to inventive creations topped with prosciutto and arugula, the pizza selection is a true delight.
A hallmark of Italian cuisine, these cafes excel at crafting homemade pasta. Whether it's silky fettuccine in Alfredo sauce, comforting lasagna, or perfectly al dente gnocchi, these dishes exemplify Italian comfort food.
No Italian meal is complete without dessert, and tiramisu reigns supreme. Layers of coffee-soaked ladyfingers and mascarpone cheese create a perfect balance of sweet, creamy, and caffeinated flavors.
Italian cafes in Williamson County often offer exquisite risotto dishes. From creamy mushroom risotto to more elaborate options, these rice dishes showcase the culinary mastery of the region.
A refreshing and vibrant appetizer featuring fresh tomatoes, mozzarella cheese, basil leaves, and a drizzle of balsamic reduction.
A hearty and satisfying dish featuring crispy, breaded eggplant smothered in tomato sauce and melted cheese.
Prosciutto and Melon
A delightful antipasto that pairs thinly sliced prosciutto with sweet, ripe cantaloupe, creating a simple yet sophisticated combination.
During the holiday season, savor a slice of panettone—a sweet Italian bread studded with candied fruits, often enjoyed with a glass of Vin Santo.
Coffee lovers will appreciate the simplicity of an affogato—a dessert consisting of a scoop of vanilla gelato or ice cream "drowned" in a shot of hot espresso.
Besides the culinary delights, Italian cafes offer a wide range of beverages to complement your meal. Enjoy a freshly brewed espresso, a velvety cappuccino, or even a glass of Italian wine to enhance your dining experience.
Tips For Savoring Your Italian Cafe Experience In Williamson County
To make the most of your Italian cafe experience in this Texan region, here are some valuable tips that will enhance your dining adventure.
If you plan to visit during peak hours or on special occasions, it's a good idea to make a reservation. This ensures you have a table and minimizes wait times, allowing you to relax and enjoy your meal.
Take a moment to appreciate the cozy and inviting ambiance of Italian cafes. The rustic decor and soft lighting create the perfect atmosphere for a memorable dining experience.
Italian cafes typically have an excellent selection of Italian wines. Consult your server for wine pairings that complement your meal and enhance your dining experience.
Italian dining is known for its relaxed pace. Meals are meant to be enjoyed slowly, so don't rush through your food. Take your time, savor each course, and enjoy the moment.
Conversations and Relaxation
Italian cafes offer a welcoming and leisurely atmosphere. Engage in conversations with your dining companions or simply unwind and enjoy the ambiance.
If you have a wonderful dining experience, express your appreciation to the staff. A simple "Grazie" (thank you) in Italian goes a long way in conveying your gratitude.
Take a Piece of Italy Home
Many Italian cafes offer items like freshly baked bread, homemade sauces, or imported Italian products for sale. Consider bringing a taste of Italy home with you to extend the experience.
Learn More About Italian Cafes In Williamson County
In the heart of Texas, Williamson County's best Italian cafes offer a delightful surprise, seamlessly blending the warmth of Texan hospitality with the flavors and traditions of Italy. These culinary gems invite diners on a journey where every dish tells a story, from the wood-fired pizzas with their smoky allure to the comforting embrace of homemade pasta dishes. As patrons indulge in tiramisu and sip on exquisite Italian wines, they find themselves transported to the heart of Italy, all while basking in the charm of Williamson County.


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Black frangipani shaped stainless steel cremation pendant.
The pendant is designed to hold a small amount of your pet’s ashes via a small screw at the back of the pendant.
If ordered with a pet cremation we will fill and glue the pendant permanently closed for you.
- Black Frangipani pendant approx. 22 mm (w) x 22 mm (h) plus bail. 19 grams with chain.
- 18″ (45cm) long, 1.5 mm wide black stainless snake chain.
- Mini funnel, mini screwdriver and filling instructions (without a cremation booking)
- Polishing cloth
- Gift box
We recommend that you do not wear in the shower, bath or during any water activity.
Free express postage Australia wide.


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|Birth: ||Sep. 21, 1911|
|Death: ||Sep. 21, 1911|
Per Rogers Mortuary Records 1880-1979, Denver Public Library Call Number: WH1501 (Box 3-10), Denver Public Library, Denver, Colorado - Baby Bishop born and died 21 Sep 1911 in Denver, Colorado. Baby Bishop is the son of Margaret Clayton who was b. in England and Harry Bishop who was b. in Nebraska.
Note: Still Born, white, male. Interred: 23 Sep 1911. Denver Riverside Cemetery, Records of Burials 1876-1953, Church of Jesus Christ of Latter-day Saints Family History Library Film #2712, Salt Lake City, Utah.
Plot: Block 12, Walk 2, Sec 221 - No Headstone
Created by: Vickie Smejkal
Record added: Jan 07, 2009
Find A Grave Memorial# 32731988

domain: library


It is mainly for steel pipes, which are prone to corrosion reactions, and there are certain hidden dangers to equipment damage after corrosion. After removing all kinds of oil, rust, oxide scale, welding spots and other dirt, the corrosion resistance of steel can be greatly improved.
If there is dirt on the surface of the stainless steel pipe, it should be cleaned by mechanical cleaning, then degreasing and degreasing. The presence of grease on the surface will affect the quality of pickling and passivation. Therefore, degreasing and degreasing cannot be omitted, and lye, emulsifier, organic solvent, and steam can be used. and so on.
Passivation is the last process step in chemical cleaning and a key step, and its purpose is to prevent corrosion of materials. For example, after the boiler is pickled, rinsed, and rinsed, the metal surface is very clean, very activated, and easily corroded. Therefore, passivation treatment must be performed immediately to form a protective film on the cleaned metal surface to slow down corrosion.


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The use of objective tools to determine the risk of ischaemic complications in patients with non-ST-segment elevation acute coronary syndromes helps the appropriate application of evidence-based therapies but these patients are often undertreated. GPs should check that the secondary prevention strategies patients are discharged on are optimal.
- Guidelines recommend risk stratification for patients presenting with non-ST-segment elevation acute coronary syndromes (NSTEACS).
- Both clinical and objective risk stratification tools have been developed; the latter have better predictive value but are seldom applied.
- Patients at highest risk have the most to gain from evidence-based treatment. However, cardiologists tend to underestimate the risk of adverse events and overestimate the risk of harm from investigations and therapies, and undertreat these patients.
- Wider use of objective assessment tools such as predictors of the likelihood of death or myocardial infarction and bleeding risk and frailty scores may minimise unjustified risk-averse behaviour and promote use of appropriate therapies.
- Following discharge after NSTEACS, the patient’s GP should ensure optimal secondary prevention.

domain: medical


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Quinn Soular has released his official debut single ‘Bring It Back’ (available on all music streaming services). Bring It Back is a Pop, Zouk infused R&B song complemented with sultry […]
We all got enemies and Moe Dollaz really brings this fact to the forfront with his track featuring Travis Morton. The track is spit over an easy-going production, which makes […]
True Pharoah releases new single titled “Black Rose” to radio, which can be found on his album I’m Back. Be sure to head over to iTunes to pick up the […]
C.J. Nealy releases to radio the R&B/Soul single ‘HOW’ out now on iTunes here. Be sure to listen out for the single, now in rotation on All Unsigned FM.
Shaddow releases new music relating to the latest crypto craze. Listen out for ‘Bitcoin Billionaire’ that can be purchased at shaddowryderzarmy.com, the official site to find all things Shaddow Music.
Off the MTB Entertainment independent record label, Marcus Christ releases to radio the single ‘You Knew That ’ to radio. The single is a mix to a previously released single […]
Off the MTB Entertainment independent record label, Marcus Christ releases to radio the single ‘If I Knew (Single Mix)’ radio. The single is a mix to a previously released sinble […]
Accacia was born in the parish of Manchester and raised in Clarendon Jamaica, where there was never a dull moment as a child. She has been blessed with an amazing […]
Burhan Omer releases to radio the song ‘Lost in Puerto Rico,’ an easy listen for anyone who enjoys a good instrumental. You can get this release now on CDBaby here.
Ice Black delivers the reggae tune ‘Gangsta Love’ which takes you back to the era of skankin. The track can be played and enjoyed at any rubba dub party. Be […]
34 Ringz releases to the radio new single ‘Use Me’ featuring Mr. Flawless. The track is about being in a toxic relationship, recognizing it was toxic and in turn putting […]
PakMan Blaze teams up with Yanni B for the sizzling single ‘Movie.’ The single debuted on SoundCloud and is currently in rotation on All Unsigned FM. The single lives on […]


The most important characteristics of KACL’s board extend far beyond its commitment to excellence in governance and ethical conduct. KACL’s board consists of people who are enthusiastic and passionate about KACL’s history of advocacy and service delivery in the quest for social and health justice for those people who have been kept at the margins, and for whom the story of not belonging has had the most devastating consequences. This keeps the Board focused on providing compassionate and courageous leadership, both to the people of the organization and the community at large.
KACL’s board has established a culture of collaboration and listening and takes measures to ensure its voice and power in the community is authorized by those people who are impacted by KACL’s work.
KACL’s board provides the organization with purpose driven leadership that makes explicit the uniqueness of our role in our community, is open and curious to hearing the challenges confronting people and the organization in a very dynamic social sector, and has the courage to work in new ways to ensure equitable outcomes to create the conditions for a meaningful and satisfying life for those people who rely on KACL, while always remaining committed to being a respectful and responsible member of the formal and informal community.
The Signature Gift of KACL’s Board was crafted collaboratively in 2020 and summarizes how they see their board role.
Our signature gift is Advocating for change. We bring it by being progressive, empathetic, honest and transparent about the risks we take.
At the Kenora Association for Community Living, we believe in people, and in their ability to participate as citizens, to grow, heal, recover, and rise above the challenges they face as a consequence of living with an intellectual disability or serious mental health concern. The Mission of KACL is to provide opportunities for people to live a meaningful and satisfying life and to interact as equals in their community through education, training, support, advocacy and an informed public.
As an organization committed to having a rigorous approach to deepening our understanding and creating new knowledge, we have come to know the significance of examining the assumptions informing our way of engaging with the work. As we search for models and practices to better serve the people who rely on us, we have learned to consistently ask ourselves the question, “Does this activity increase our capacity to assist people with intellectual disabilities, or a serious mental illness, and their families, to expand their opportunities to participate in community life as they choose?” This approach has provided us with new understandings about our work, those we serve, and our community.
We have learned that it is through relationships and conversations with each other, those we serve, and our community, that KACL can keep our identity, purpose and history, honoured and alive.
We respect that our staff, the people we serve, and our community members, are rich in gifts and talents that they are willing to offer in the service of a common interest; namely, to create a community where everyone is welcome, secure and able to live their lives with dignity.
We have seen that the work we do today makes a difference in the lives of people, and in our community.
We have learned that our creativity and commitment to do the work is nourished in our relationships with each other, and with the people we serve.
We know that KACL is a mature organization, with both successes and failures in the pursuit of our mission, and that our shared stories of those past experiences have created the resilience we need to meet the challenges of the emerging future with our highest intentions.
We know our mission is belonging. So we continue to learn the skills of bringing people together in socially innovative ways, just as we have done with the Arts Hub, Fitness Friends, and Community Wellness. We will become social architects in pursuit of ways to bring people together in spaces that are focused on welcome and possibility.
We know our mission is social justice. So we continue to have an historic duty to make sure the ever-changing face of inequality does not confine the dreams of the people we serve. Funding the absence of a strong social network is becoming unaffordable. But we know, and we have known for some time, that the felt sense of wellbeing, the creation of a good life, does not lie in service. We know that equality is the way to create a sustainable future for all of us in community.
KACL will continue to meet the challenges of our times with grace, flexibility, adaptability and compassion. We know we will stumble at times, but we trust that we have each other to rely on. We have a leadership role to play in enlivening the community instinct, and working collaboratively with a vital community that understands its unique role in creating health for all citizens. All of us at KACL know that our work contributes to something beyond ourselves, and we know that our work contributes to helping others – the people we serve, the community, our colleagues, and each other.
I look forward to our continuing conversation.
The Board and Employees of KACL gratefully acknowledge that we live, work, enjoy the richness of and play on the traditional territory of the Anishinaabe people of Treaty 3, and on the homeland of the Metis. We pay our respect to the First Nations and Metis ancestors of this place and reaffirm that the historic and current relationship that exists between us is defined by Treaty.
We commit to work to create the conditions for belonging and social justice so that each person can live fully in the unique identity that matters to them, in a community that accepts and welcomes. We recognize that our work must be in the service of Reconciliation. Our work must be at the level of the individual and the community, so that our collective identity as a community lives up to the values we want for ourselves and our children. A community where equity, peace, and respect for cultural differences are respected and nourished; and a community that acknowledges that the early Anishinaabe people of these lands saw we were strangers, welcomed us as guests, and invited us to stay as neighbours.


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GAPYEONG, South Korea—The Rev Sun Myung Moon was a self-proclaimed messiah who built a global business empire. He called both North Korean leaders and American presidents his friends, but spent time in prisons in both countries. His followers around the world cherished him, while his detractors accused him of brainwashing recruits and extracting money from worshippers.
These contradictions did nothing to stop the founder of the Unification Church from turning his religious vision into a worldwide movement and a multibillion-dollar corporation stretching from the Korean Peninsula to the United States.
Moon died Monday at a church-owned hospital near his home in Gapyeong County, northeast of Seoul, two weeks after being hospitalized with pneumonia, Unification Church spokesman Ahn Ho-yeul told The Associated Press. Moon’s wife and children were at his side, Ahn said. He was 92.
The church will hold a 13-day mourning period beginning Monday and start accepting mourners Thursday at a multipurpose gym at its nearby religious center, the church said in a statement. The funeral will be held Sept. 15, and Moon will be buried at nearby Cheonseung Mountain, where his home is located, the statement said.
Moon founded his Bible-based religion in Seoul in 1954, a year after the Korean War ended, saying Jesus Christ personally called on him to complete his work.
The church gained fame—and notoriety—by marrying thousands of followers in mass ceremonies presided over by Moon himself. The couples often came from different countries and had never met, but were matched up by Moon in a bid to build a multicultural religious world.
Today, the Unification Church has three million followers, including 100,000 members in the US, and has sent missionaries to 194 countries, Ahn said. But ex-members and critics say the figure is actually no more than 100,000 members worldwide.
The church’s holdings include the Washington Times newspaper; the New Yorker Hotel, a midtown Manhattan art deco landmark; and a seafood distribution firm that supplies sushi to Japanese restaurants across the US. It gave the University of Bridgeport US $110 million over more than a decade to keep the Connecticut school operating.
It acquired a ski resort, a professional football team and other businesses in South Korea. It also operates a foreign-owned luxury hotel in North Korea and jointly operates a fledgling North Korean automaker.
The church has been accused of using devious recruitment tactics and duping followers out of money. Parents of followers in the United States and elsewhere have expressed worries that their children were brainwashed into joining. The church has pointed out that many new religious movements faced similar accusations in their early years. Moon’s followers were often called “Moonies,” a term many found pejorative.
Moon was born in 1920 in a rural part of what is today North Korea. He said he was 16 when Jesus Christ first appeared to him and told him to finish the work he had begun on Earth 2,000 years earlier. Moon, who tried to preach the gospel in the North, was imprisoned there in the late 1940s for alleged spying for South Korea; he disputed the charge.
When the Korean War broke out in 1950, he went to South Korea. After divorcing his first wife, he married Hak Ja Han Moon in 1960.
In South Korea, Moon quickly drew young acolytes to his conservative, family-oriented value system and unusual interpretation of the Bible. He conducted his first mass wedding in Seoul in the early 1960s, and the “blessing ceremonies” grew in scale over the years. A 1982 wedding at New York’s Madison Square Garden—the first outside South Korea—drew thousands of participants.
“International and intercultural marriages are the quickest way to bring about an ideal world of peace,” Moon said in a 2009 autobiography. “People should marry across national and cultural boundaries with people from countries they consider to be their enemies so that the world of peace can come that much more quickly.”
Moon began building a relationship with North Korea in 1991, even meeting with the country’s founder, Kim Il Sung, in the eastern North Korean port city of Hamhung. In his autobiography, Moon said he urged Kim to give up his nuclear ambitions, and that Kim responded by saying that his atomic program was for peaceful purposes and he had no intention to use it to “kill my own people.”
“The two of us were able to communicate well about our shared hobbies of hunting and fishing,” Moon wrote. “At one point, we each felt we had so much to say to the other that we just started talking like old friends meeting after a long separation.”
When Kim died in 1994, Moon sent a condolence delegation to North Korea, drawing criticism from conservatives at home. The late Kim Jong Il, who succeeded his father as North Korean leader, sent roses, prized wild ginseng, Rolex watches and other gifts to Moon on his birthday each year. Moon said Kim Il Sung had instructed Kim Jong Il that “after I die, if there are things to discuss pertaining to North-South relations, you must always seek the advice of President Moon.”
The church also sent a delegation to pay its respects after Kim Jong Il died in December and was succeeded by his son Kim Jong Un.
Moon sought and eventually developed a good relationship with conservative American leaders such as former Presidents Richard Nixon, Ronald Reagan and George H.W. Bush.
Yet he also served 13 months at a US federal prison in the mid-1980s after a New York City jury convicted him of filing false tax returns. The church says the US government persecuted Moon because of his growing influence and popularity with young Americans.
One of the more bizarre chapters in Moon’s relationship with Washington came in 2004, when more than a dozen US lawmakers attended a “coronation ceremony” for Moon and his wife in which Moon declared himself humanity’s savior and said his teachings have helped Hitler and Stalin be “reborn as new persons.” Some of the congressmen later said they had been misled and had not been aware that Moon would be at the event.
In later years, the church adopted a lower profile in the United States and focused on building up its businesses. Moon lived for more than 30 years in the United States, the church said.
As he grew older, Moon also handed over day-to-day control of his empire to his children, but in 2009 he married 45,000 people in simultaneous ceremonies worldwide in his first large-scale mass wedding in years, the church said. Some were newlyweds and others reaffirmed past vows.
Moon married an additional 7,000 couples in South Korea in February 2010. The ceremonies attracted media coverage but little of the controversy that dogged the church in earlier decades.
Moon and Hak Ja Han have 10 surviving sons and daughters, according to the church.
One of Moon’s sons reportedly sued his mother in 2011 demanding the return of more than US $22 million allegedly sent without his consent from a company he runs to his mother’s missionary group. Yonhap news agency reported that a court ruled the money was a loan but ordered it returned.
Another son committed suicide in 1999, officials said, plunging to his death from the 17th floor of Harrah’s hotel in downtown Reno, Nevada. Two other sons reportedly died in accidents, one in a car accident and another in a train wreck.
Moon’s US-born youngest son, the Rev Hyung-jin Moon, was named the church’s top religious director in April 2008. Other children run the church’s businesses and charitable activities in South Korea and abroad.
Hyung-jin Moon told The Associated Press in February 2010 that his father’s offspring do not see themselves as his successors.
“Our role is not inheriting that messianic role,” he said. “Our role is more of the apostles … where we become the bridge between understanding what kind of lives (our) two parents have lived.”


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March 04, 2021 | Andrea Cox
Community Profile: Redwood MeadowsPerched at the junction of Highways 8 and 22X with a beautiful mountain backdrop, the townsite of Redwood Meadows is attracting young families who want to get away from it all, while staying close enough to the city for a quick commute.
"It's very social and very friendly here. I know it sounds cliché, but you know your neighbours," said resident Mike Decore, who moved to the area three years ago and commutes to an office in downtown Calgary.
"When we first moved in, I jokingly asked my wife, 'have we moved into a commune?' because there were kids always around. Between our house and five doors down, there are 23 kids between the ages of two and 10."
"I know it sounds cliché, but you know your neighbours." - Mike Decore, Redwood Meadows resident
The couple, who have two young boys aged three and six, purchased a six-bedroom, 2,800-square-foot home.
Redwood Meadows is located just minutes from Bragg Creek on the Tsuut'ina First Nation. The townsite has just over 1,000 residents living in 354 single-family homes.
Owners purchase their homes, but the land is leased from the Tsuut'ina.
"We don't pay a fee to lease – we pay municipal taxes, but that's it," said Decore, who is also a town councillor.
The lease is set to expire in 2049. Without a new lease or an extension in place, that could mean challenges for homeowners and buyers.
But Decore says that won't happen. "We've been in negotiations for the better part of a year. We can see the finish line," he said.
"We hope to have the framework agreement done and everything signed by the fall of 2019."
- The charming hamlet of Bragg Creek is just minutes away, with its quaint selection of boutiques and eateries.
- Redwood Meadows is 20 minutes from Cochrane, 30 minutes from Kananaskis Country and less than 15 minutes from several beautiful landmarks, such as Elbow Falls, Bragg Creek Provincial Park and the Canyon Creek Ice Cave, a perfect place to try spelunking.
- The picturesque, 18-hole Redwood Meadows Golf and Country Club is located within the community.
- Redwood Meadows gets its name from the abundance of beautiful, red-hued poplar and spruce trees.

domain: geography


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Monday, January 5, 2015
"Hood Canal", 6 x 8 In, Oil on Museum Board
This painting is from last summer--a fast sketch from the Dosewallips State Park on the banks of Hood Canal. Hood Canal is a long arm of Puget Sound that backs up to the Olympic Mountains--a place with so many childhood memories of canoeing on the Canal and hiking in the mountains. This view is looking east to the low hills on the other side of the Canal.
Purchase this unframed painting.
Contact me if you would like to purchase a plein air frame.


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Rae Sremmurd’s Swae Lee is in work mode. The hip-hop entertainer is making the best out of his quarantine by working on new music.
This week, Swae hit up his Twitter page to alert followers about what he’s up to during this isolation period. He promised followers his focus is currently on wrapping up a new studio effort.
“I’ll be self quarantining finishing up my album.”
Recently, vixen Amber Rose went online and shared a big Swae Lee co-sign. In the clip, Amber is rocking a white hat, pink Nike top and turning up to his recently released “Someone Said” anthem.
“D*mn. Swae Lee stay with that fire tho. Someone Said.”
Wait, There’s More
A few weeks ago, the popular crooner shared his latest single’s video to the masses. In the visual, Swae Lee dons various outfits as different TV characters.
Before You Go
Recently, Swae went to Twitter to shut down Rae Sremmurd group rumors. Lee told followers he and fellow member Slim Jxmmi did not break up.
“I’m good, Slim Jxmmi good. We two different individuals more solo songs on the way and SremmLife on the way. We two different types of artists and that’s gone be respected.”