Writing is fun for the writer when the flow just pours – you think of a topic and simply run with it. You are confident that your audience or readers would love your piece so you throw everything into it. After reading it over and being impressed with yourself (your work), you feel It is ready for others to read it too. Next step is pushing the publish button and just as you had hoped, everyone loved it. You get likes, comments and even new follows. So you do it again – write some more.
There are those moments as I’ve described above and there are those moments when nothing seems to be flowing. You have a theme or topic and you are ready to go but you can’t go past the first paragraph. Sometimes you have the closing in mind and you lead with that, composing the topic as you progress with the body of the post. Oh, and there are the countless drafts with topics and no content or content and no topic or the ones we have finished but keep editing because we are unsure it’s good enough to be published!
Dealing with Writer’s Block.
As writers, we put in a lot to publish that daily, weekly, or monthly post but we often have writer’s block too. Not to be swayed by the dictionary definition but having writer’s block is no indication that your skills are non-existent. It’s simply an interlude to the bigger picture you are hoping to paint. Embrace it by pushing through it.
Writing became an hobby for me at a very young age and I would often write only when I was inspired because I thought that was when my best came out. Then I realized that was not exactly true. Now, I am always writing something at all (and odd) times. Yes, at all times! I cannot count the number of times I have woken up at 2:00 am because that was when the inspiration came to me. Or stopping mid-sentence in my conversation with someone to write something in my notebook (I try not to be rude about it). I am always ready to write about every idea that comes to me at all times and it’s helped me overcome my writer’s block.
2. Leading With the End.
Most times, I have the end goal in mind. If I am writing about my experience with time management, it’s already clear that I intend to help my readers see how they can overcome it. Interesting, I always have the closing statement ready to go and I lead with that. Starting with the ending helps me fill up the “nonexistent” paragraphs.
3. Reading my Previous Posts
I like to believe that most writers go back and read their previous work. I have found that reading my old posts have become an inspiration and motivation to keep writing; it tends to help me see how my writing has improved over the years and appreciate my progress.
4. Reading Other Writer’s Posts
I am frequently looking for writers whose niches are both similar and different from mine. I have found that Inspiration comes when I read what others have written.
And that’s it! For now at least. I hope to discover new ways of learning and improving my writing.
I wrote this post to write about my experience with writing but most importantly to learn about how other writers are coping with writer’s block. If you are a writer, I would love to read and learn from you. Let’s connect!


|Home > Samantha Young > On Dublin Street Series > Moonlight on Nightingale Way (Page 24)|
|Moonlight on Nightingale Way(On Dublin Street #6)(24) by Samantha Young|
“Love you, too, Grace,” he said gruffly, squeezing me back. Reluctantly, I let him go, and he slipped quietly out of the flat.
“He an ex?”
I spun around, startled by Logan’s appearance in the hallway.
I shook my head, because technically he wasn’t really. One time didn’t count. “No. Aidan’s like family. And he’s engaged to a woman he’s madly in love with.”
Logan processed this and then shrugged. “Nice guy. Glad to know there’s someone looking out for you.”
“Thank you,” I said, surprised by his comment.
He cleared his throat. “Aye, anyway… I wanted your opinion on something.”
“Shannon wants to meet Maia tonight, but I’m not sure it’s a good idea yet.”
I loved that he was so concerned for her feelings. I walked toward him and patted his arm reassuringly. “Trust your instincts, Logan.”
“I’m thinking we should wait until the paternity results come in.”
“I would agree.”
He nodded. “I’ll call her.” I walked away, but he said my name, stopping me in my tracks. I glanced over my shoulder in question. “Thanks for everything.”
Once more the gratitude in his eyes affected me. In fact, I was hit with a wave of attraction so big I could only mumble “you’re welcome” before I had to walk away from him. I closed my eyes and prayed to God Aidan’s concerns were unfounded.
This thing with Logan and Maia… Would I end up getting hurt?
What on earth had I let myself in for?
Logan stood on my doorstep the next morning holding a padded envelope. His features were tight with anxiety. “The paternity kit arrived.”
I stepped aside to let him past. “It will all be okay,” I promised.
He didn’t respond. He was too focused on getting to Maia. I followed him into the kitchen, where we both stopped at the sight of Maia sitting in her new pajamas, scooping up spoonfuls of cereal with one hand while she held a book from my collection with the other. Her nose was practically pressed to the pages.
I’d discovered that Maia was like me in more ways than one. If I got engrossed in a book, the world around me ceased to exist. This morning, as Maia wandered into the kitchen with a young-adult novel in her hand, she’d barely grunted a “good morning” to me while I poured her a bowl of cereal and a glass of fresh orange juice.
“Maia,” Logan said. When Maia didn’t respond, he looked at me, his eyebrows raised.
“She’s reading,” I said, as if that explained everything. Logan stared blankly at me. I sighed and wandered over to Maia and gently plucked the book out of her hand.
She gazed up at me in confusion.
“Logan’s here,” I said.
“Oh.” She whipped around on the stool and smiled at him. “Mornin’.”
Logan gave her a bemused smile in return. “Good book, is it?”
“Hmm?” She frowned before understanding cleared her expression. “Oh, yeah. I borrowed it from Grace. It’s cool.”
“Well, I’m sorry to disturb your reading, sweetheart.” Logan slid onto the stool next to her, and I set about making him a coffee to help bolster him through this huge moment. “But the paternity kit arrived. I need you to take a swab of the inside of your cheek so I can send it off for the test.”
Maia’s spoon fell into her bowl with a clatter. “Okay. So… how long will it take? You know, for the results?”
“I’ll send it off today. The company I’m using has a forty-eight-hour turnaround, so we’ll know really soon.”
I watched her closely as I slid Logan his coffee. She had paled considerably.
“Maia, it’s going to be okay,” I said.
She looked up at me with tears in her eyes. “I should probably brush my teeth first.” She took the plastic packet Logan was holding out to her with the swab inside it. As soon as she disappeared out of the room, Logan took a deep gulp of coffee.
“Thanks,” he murmured, setting the mug down. “This is…” He glanced back at the door. “She looked terrified. She was practically crying. I… What’s going on? I thought she wanted this.”
“Exactly.” I slid onto the stool Maia had just vacated. “Logan, she’s not scared that you’re her dad. She’s scared you’re not.”
He thought about this, and slowly the muscles in his clenched jaw relaxed.
“What about you?” I said. “How are you feeling?”
“Whatever happens happens.” He shrugged.
“Logan,” I warned. “Macho bullshit does not fly in this flat.”
He raised an eyebrow at me. “Macho bullshit?”
“Yes, macho bullshit. I can smell it a mile away.”
He looked into his mug of coffee like it had all the answers. “There have been a lot of ups and downs for me these last few years. I’ve learned to deal with those. I can learn to deal with this. It’s a lifestyle change.” He shot me a wry look. “I had to break things off with the American.”
Ignoring the weird sense of satisfaction I felt at his announcement, I tried to be nonchalant. “Why?”
“It wasn’t serious between us, and right now it’s a distraction. I have to focus on Maia.” The violet in his eyes darkened. “C’mon, Grace. We both know this paternity test is going to tell us this kid is mine. My life as it was is over. I make this commitment to that wee girl in there, then I better mean business. What kind of arsehole would subject their kid to the fucking carousel of women I’ve had in and out of my life these past few months?”


Author: Erin McCarthy
Series: True Believers #1
Publisher: Penguin Group USA
Release Date: May 7, 2013
Genre: New Adult
More Info: Goodreads
Purchase: Amazon US
Purchase: Barnes & Noble
When Rory Macintosh’s roommates find out that their studious and shy friend has never been with a guy, they decide that, as an act of kindness they’ll help her lose her virginity by hiring confident, tattooed bad boy Tyler Mann to do the job…unbeknownst to Rory.
Tyler knows he’s not good enough for Rory. She’s smart, doctor smart, while he’s barely scraping by at his EMT program, hoping to pull his younger brothers out of the hell their druggy mother has left them in. But he can’t resist taking up her roommates on an opportunity to get to know her better. There’s something about her honesty that keeps him coming back when he knows he shouldn’t…
Torn between common sense and desire, the two find themselves caught up in a passionate relationship. But when Tyler’s broken family threatens to destroy his future, and hers, Rory will need to decide whether to cut her ties to his risky world or follow her heart, no matter what the cost…
That pathetic, hopeless wanting. The desire for what you want but can’t have. The need for someone to like you. I recognized it because I saw it in my own face every day.
And with that, we begin the journey into the world of Rory and Tyler, a road filled with self discovery, insecurity, friendship, and finding a family in the most unconventional of circumstances. This road wasn’t paved lightly, there were stumbles along the way, and many tears were shed. But when you are learning who you are, becoming the person you were meant to be, finding the people who will be by your side through thick and thin, tears are nothing but a drop in the bucket.
We begin with your typical virgin, full of self doubt, but under the surface, once you peel back all the layers, you discover that this story is so much more than that. A pretty package is just that. Appearances can be deceiving, and just because you think someone has it all figured out, quite often they are just as lost as you. Let me tell you, if you think women are the only ones full of insecurities, don’t kid yourself. Men are just as, if not more, culpable.
As we walked into the grocery store, my small cold hand wrapped in his big callused one. I marveled at the strange places and people we could draw comfort from, when we didn’t even know we needed it.
Tyler is a protector. Tyler is a friend. Tyler is a brother. When you come to find out the ‘true’ meaning behind the title of the book as well as his tattoo, your heart will melt. As I read the words, I knew I was lost to these characters and this author. I was hooked from the words, harpooned by the depth of feeling flowing from them like waves.
It was then that I realized it would be very easy to fall in love with Tyler Mann. And that if I didn’t want to get my heart broken into a million pieces, I needed to be very, very careful not to do that.
This is one of those stories that literally grabs you from page one. You are sucked in and never want to leave. These four brothers become your family and you just want to protect them and take all their worries away. I have never read a family that sticks together as this one does. Against all odds, against everything working together to pull them apart and dissuade them, they stay strong. Yes, you will experience rage and heartbreak, but don’t fret, around the corner is love. And throughout it all is hope.
I lay in the dark and listened to the sound of his breath as it slowed and evened out, and I marveled at where I was and who I was with. It didn’t make sense. It wasn’t logical. Yet there was no place I’d rather be.
The most perfect things in life never do make sense. But isn’t that the point? You don’t always have to understand the why’s and how’s for it to work. You just KNOW, deep in your heart, no matter what outside sources say. Fight for what/who you want, your faith unwavering. Prove that in the end, you aren’t going anywhere.
Ironic, wasn’t it, that the physical heart was so hard to reach, yet my emotional heart seemed to have been found with very little effort on Tyler’s part.
Heartbreaking and heartwarming story! 5 star read from me!


Laura KasischkePoetry, Fiction
Interviewed by: Angela Elam
Catalog Number: 20190322
National Book Critics Circle Award-winning poet Laura Kasischke muses on topics ranging from motherhood to beauty queens, as she reads from several of her books now published under one cover by Copper Canyon, the 2017 book, Where Now: New and Selected Poems. Also an author of novels and short stories, she then sits down onstage at the Kansas City Public Library for a short conversation with host Angela Elam, as a prelude to their upcoming studio conversation, when she reads from her fiction. To find out about her early career, a 2006 program with Laura Kasischke is also available in our audio archives.
Arab-American writer Naomi Shihab Nye was born in St. Louis and is now a long-time resident of Texas with her husband, photographer Michael Nye. She discusses how her late father has impacte...
Kansas City Literary Events


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commandment, in these words, “ Thou shalt not bow down thyself to them, nor serve them, nor worship them," Exod. xx. 5. And the worshipping of the true God is implied and expressed in these words, Matth. iv. 10, “ Thou shalt worship the Lord thy God, and him only shalt thou serve."
Non. But sir, how do you prove that these duties which you have named are parts of God's worship?
Evan. For answer hereunto, I pray you consider, that to worship God, is to render up that homage and respect that is due from a creature to a Creator; now, in prayer we are said to render up this homage unto him, and to manifest our profession of dependence upon him for all the good we have, and acknowledge him to be the Author of all good; and indeed prayer is such a great part of God's worship, that sometimes in Scripture it is put for the whole worship of God. “He that calls upon the name of the Lord shall be saved,” Rom. x. 13; that is, be that worships God aright; Jer. X. 25, “Pour out thy wrath upon the heathen that know thee not, and on the families that call not upon thy name,” that do not pray, that do not worship God.
And that hearing the word is a part of God's worship is manifest; because that in hearing ve do manifest our dependence upon him, for knowing his mind, and the way to eternal life, every time we come to hear the word of God, if we know what we do, we do thus much, we profess that we depend upon the Lord God for the knowing of his mind, and the way and rule to eternal life; and besides, herein we also come to wait upon God in the way of an ordinance, to have that good conveyed unto us by way of an ordinance, beyond what the thing itself is able to do, and therefore this is worship. And that the receiving the sacrament is a part of God's worship, is manifest, in that when we come to receive these holy sigus and seals, we come to present ourselves before God, and come to God for a blessing in communicating unto us some higher good than possibly those creatures that we have to deal with are able of themselves to convey to us; we come to God to have communion with bim, and that we might have the blessing of the covenant of grace conveyed unto us through these things; and therefore when we come to be exercised in them, we come to worship God. The like we might say of the rest of the duties before mentioned, but I hope this may suffice to satisfy you that they are parts of God's worship.
Nom. But, sir, you know that in this commandment there is nothing expressly forbidden but the making and worshipping of ima ges, and therefore I question whether all those other sins that you have named be likewise forbidden.
Evan. But you must know, that when the Lord condemneth the chief, or greatest and most evident kind of false worship, namely, the worship of God at, or by images, it is manifest that he forbids also the other kinds of false worship, seeing this is the head and fountain of all the rest; wherefore, whatsoever worships are instituted by meu, or do any way binder God's true worship, they are contrary to this commandment.
Nom. Well, sir, though that these things be so, yet for all that I am persuaded I go very near the keeping of this commandment; for I do constantly perform the most of these duties, and am not guilty of doing the contrary.
Evan. But thou must know, that for the worshipping of God aright, it is not only required that we do the good which he commands, and avoid the evil which he forbids, but also, that we do it in obedience to God, to show that we acknowledge him alone to be the true God, who has willed this worship to be thus done unto him; so that, as I told you before, the word of God must not only be the rule of our actions, but also the reason of them: we must do all things which are delivered and prescribed in the ten commandments, even for the love we bear to God, and for the desire we have to worship him; for except we so do them, we do them not according to the sentence and prescript of the law, neither do we please God therein. Wherefore, though you have prayed and heard the word of God and received the sacrament, and done all the rest of the forenamed duties, yea, and though you have not done the contrary, yet if all this has been either because the laws of the kingdom require it, or in mere obedience to any superior, or to gain the praise and esteem of men, or if you have any way made yourself your highest end, you have not obeyed nor worshipped God therein; for, says a judicious writer, “If any man shall observe these things in mere obedience to the king's laws, or thereby to please holy men, and not through an immediate reverence of that heavenly Majesty who has commanded them, that man's obedience is non-obedience; his keeping of these laws is no keeping them ;” because the main thing here intended is neglected, which is the setting np God in his heart; and that which is most of all abhorred is practised, viz. the “fear of God taught by the precepts of men,” Isa. xxix. 13. And to this purpose that worthy man of God has this saying, “ Take heed, (says he) that the praises of men be not the highest end that thou aimest at; for if it be, thou worshippest men, thou dost make the praise of inen to be thy god; for whatsoever thou dost lift up in the highest place, that is thy god, wbatsoever it be; wherefore, if thou liftest up the praise of men, and makest that thy end, thou makest that thy god, and so thou art a worshipper of men, but not a worshipper of God.”
Again, says he, “ Take heed of making self thy end. That is, take heed of aiming at thine own peace, and satisfying thine own conscience in the performance of duties." It is true, says he, when we perform duties of God's worship we may be encouraged thereunto by the expectations of good to ourselves, yet we must looķ higher, we must look at the honour and praise of God; it is not enough to do it, merely to satisfy conscience; thy main end must be, that thou mayst, by the performance of the duty be fitted to honour the name of God, otherwise we do them not for God but for ourselves, which the Lord condemns, Zech. vii, 5, 6. And now, neighbour Nomologista, I pray you, let me ask you once again, whether you think you keep this commandment perfectly or no?
Nom. No, believe me, sir, I do now begin to fear I do not.
Evan. If you make any question of it, I would intreat you to consider with yourself, whether you have not gone to the church on the Lord's day to hear the word of God, and to receive the sacrament, and do other duties, because the laws of the kingdom require it, or because your parents and masters have required it, or because it is a custom to do so, or because you conceive it to be a credit for you to do so.
And I pray you also consider, whether you have not abstained from worshipping images, and other such idolatrous and superstitious actions which the Papists use, merely because the laws of the land wherein you live do condemn such things. And I pray you also consider whether you have not been sometimes zealous in prayer in the presence and company of others, to gain their praise and approbation ; have you not desired that they should think you to be a man of good gifts and parts? And have you not in that regard endeavoured to enlarge yourself? And have you not sometimes performed duties merely because otherwise conscience would not let you be quiet? And have you not sometimes fasted and prayed, merely or chiefly in hopes that the Lord would, for your so doing, prevent or remove some judgment from you, or grant you some good thing which you desire. Now, I beseech you, answer me truly and plainly, whether you do not think you have done so ?
Nom. Yea, believe me, sir, I think I have.
Evan Then have you in all these things honoured and worshipped your parents, your masters, your magistrates, your neighbours, your friends, and yourself, as so many false gods, instead of the true God; and therein have been guilty of a breach of the second commandment.
Neo. I pray you, sir, proceed to speak of the third commandment, as you have done of the first and second ; and first, tell us how the second and third commandment differ.
COMMANDMENT III. Evan. Why, as the Lord in the second commandment doth require that we worship him alone by true means, so does he in the third commandment require that we use the means of his worship after a right manner, that so they may not be used in vain, Matt. xv. 9. And in this commandment likewise, there is a negative part expressed in these words, “ Thou shalt not take the name of the Lord thy God in vain.” And that is, Thou shalt not profane it, by using my titles, attributes, ordinances, or works, ignorantly, irrevently, or after a formal, superstitious manner. And an affirmative part, included in these words, “ But thou shalt sanctify my name, Isa. viii. 13;—by using my titles, attributes, ordinances, works, and religion, with knowledge, reverence, and after a spiritual manner, John iv. 24.
Neo. I pray you, sir, begin with the affirmative part, and first tell us what the Lord requires in this commandment.
Evan. The Lord in his commandment doth require, that we sanctify his name in our hearts, with our tongues, and in our lives, by thinking, conceiving, speaking, writing, and walking, so as becomes the excellency of his titles, attributes, ordinances, works, and religion.
Neo. And how are we to sanctify the name of the Lord in regard of his titles ?
Evan. By thinking, conceiving, speaking, and writing holily, reverently, and spiritually of his titles, Lord and God, Deut. xxviii. 58. And this we do when we meditate on them, and use them in our speeches and writings with an inward spiritual fear and trembling, to the glory of God and good of men, Jer. v.
Neo. And how are we to sanctify the name of the Lord, in regard of his attributes ?
Evan. By thinking, conceiving, speaking, and writing holily, reverently, and spiritually of his power, wisdom, justice, mercy, and patience, Psalm civ. 1, and ciii. 6, 8. And this we do when we think, speak, and write of them after a careful, reverent, and spiritual manner, and apply them to such good uses for which the Lord has made them known, Psalm xxxvii. 30.
Neo. And in which of God's ordinances are we to sanctify his name?
Evan. In every one of his ordinances, and especially in the three great ordinances, prayer, preaching, and hearing the word, and administering and receiving the sacraments.
Neo. And how are we to sanctify the name of the Lord in prayer ?
Evan. In prayer we are to sanctify the name of the Lord in our hearts, and with our tongues, in calling upon his name after a holy, reverent, and spiritual manner; and this we do when our prayers are the speech of our souls, and not of our mouths only; and that is, when in prayer we lift up our hearts unto God, Psalm xxv. 1; and pour them out unto him, Psalm lxii. 8; and when we pray with spirit, and with understanding also, 1 Cor. viv. 15; and with humility, Gen. xviii. 27; and xxxii. 10; Luke xviii. 13; and with fervency of spirit, James v. 16; and out of a sense of our own wants, James i. 5; and with a special faith in the promises of God, Matt. sxi. 22.
Neo. And how are your ministers to sanctify the name of the Lord in preaching his word ?
Evan. We are to sanctify the name of the Lord in our hearts, and with our tongues, in preaching after a holy, reverent, and spitual manner; and this we do when the word is preached, not only outwardly, by the body, but also inwardly with the heart and soul; and when the heart and soul preaches, then is the ministry of the word, on the minister's part, used after an holy and spiritual manner, and that is, when we preach in demonstration of the Spirit, 1 Cor. iii. 27; and in sincerity, 2 Cor. ii. 17; and faithfully without respect of persons, Deut. xxxiii. 9; and with judgment and discretion, Matt. xxiv. 49; and with authority and power, Matt. vii. 29 ; and with zeal to God's glory, John vii. 18; and with a desire of the people's salvation, 2 Cor. xi. 2.
Neo. And how are we hearers to sanctify the name of the Lord in hearing his word ?
Eran. In hearing it after an holy, reverent, and spiritual manDer; and this you do when your heart and soul hears the word of God; and that is when you set yourself in the presence of God, Acts x. 33; and when you look upon the minister as God's messenger or ambassador, 2 Cor. v. 20, and so hear the word as the word of God, and not as the word of man, 1 Thess. ii. 13; with reverence and fear, Isa. Ixvi. 2; and with a ready desire to learn, Acts xvii. 11 ; and with attention, Acts viii. 6; and with alacrity without wearisomeness or sleepiness, Acts xx. 9.
Neo. And how are you ministers to sanctify the name of the Lord in administering the sacraments ?
Evan. By administering them after an holy, reverent, and spiritaal manner; and that is, when we administer them with our hearts or souls, according to Christ's institution, Matt. xxvi. 26; to the faithful in profession at least, 1 Cor. x. 16; and with a hearty desire that may become profitable to the receivers.


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Head here for craft beer, fresh air, and a few good books.


The Talmud, by Joseph Barclay, , at sacred-texts.com
Preparations of the High PriestCleansing the AltarCasting LotsDaybreakOfferingsDressPrayerThe GoatsMonobazusHelenaAzazelthe Golden Censerthe VailHoly of Holies"Foundation"Sprinkling the BloodSending forth the Goat into the WildernessHigh Priest burning the Bullock and GoatReadingCeremonialRules and ExceptionsRepentance and Atonement.
1. Seven days before the Day of Atonement the High Priest was removed from his house to the chamber 1 Parhedrin, and the council prepared for him another priest, 2 lest there happen to him any defilement. R. Judah said, "they prepared also another wife, lest his wife die;" as is said, 3 "And he shall atone for himself and for his house;" for his house, i.e. for his wife. The Sages said to him, "if so, there is no end to the matter."
2. All these seven days, he (the high priest) sprinkled the blood, burned the incense, and trimmed the lamps, and offered the head and the foot. On the remainder of all the days, if he wished to offer, he offered; since the high priest first offered part, and first took part (in the sacrifices).
3. The elders from the elders of the great Sanhedrin delivered to him, and read before him, the ceremonial of the day; and they said to him, "My Lord High Priest, read with thy mouth, perchance thou hast forgotten, or perchance thou hast not learned." 4 On the eve of the day of atonement, towards dawn, they placed him in the eastern gate (of the Temple), and they caused to pass before him bullocks,
rams, and lambs, that he might be skilled and expert in his ministry.
4. All the seven days they did not withhold from him food and drink; the eve of the day of atonement, with the beginning of darkness, they did not permit him to eat much, since food induces sleep.
5. The elders of the great Sanhedrin delivered him to the elders of the priesthood, who brought him to the upper chamber of the house Abtinas. And they administered to him the oath, 1 and they left him and departed. And they. said to him, "My Lord High Priest, we are ambassadors of the great Sanhedrin, and thou art our ambassador, and the ambassador of the great Sanhedrin. We adjure thee by Him, whose Name dwells in this house, that thou wilt not change aught of all which we have said to thee." He went apart and wept. They went apart and wept. 2
6. If he were a learned man, he expounded; but if not, the disciples of the learned expounded before him. If he were skilled in reading, he read; but if not, they read before him. "And in what did they read before him?" "In Job, and in Ezra, and in Chronicles." Zachariah, the son of Kebutal, said, "I often read before him in Daniel."
7. If he desired to sleep, the young priests filliped with the first finger 3 before him, and said to him, "My Lord High Priest, stand up and refresh thyself 4 once on the pavement," and they kept him occupied 5 until the time approached for slaying (the victims).
8. Every day they cleansed the altar at cockcrow, or at its approach, intermediate before or after it; and on the day of atonement 6 at midnight; and in the three great feasts, at the first watch. And before cockcrow the court was crowded with Israel.
119:1 Where the counsellors sat.
119:2 Called Sagan (suffragan) (2 Kings xxv. 18; Jer. lii. 24).
119:3 Lev. xvi. 6.
119:4 As might occur from the frequent changes during the second Temple.
120:1 That he would incense "within" the vail (Lev. xvi. 12, 13), in opposition to the Sadducees, who maintained that the incense should be burned "without."
120:2 That such an oath was necessary.
120:3 Or the "index" finger; other trans. the "middle" finger.
120:4 Or change thyself.
120:5 Singing to him "Unless the Lord build the house, they labour but in vain that build it, etc." (Psalm cxxvii.)
120:6 The Jews think that the day of atonement was the day on which Adam sinned, on which Abraham was circumcised, and on which Moses offered atonement for the sin of the golden calf.


Good ending. I just got confused in the one part about the father. I could not follow the time line in the paragraph.This is the fifth and the last part of my short story "Departure," please would you proofread it.
Only six months after his arrival, he received the news that his home had been destroyed and his parents had become refugees in a foreign country. Everything which they had patiently built and created, all the decades of sacrifices and hard work had disappeared in flames only because a soldier was drunk and bored and wanted to have some fun watching the house burning to the ground.
Or maybe his colleague was envious and sat it on fire out of sheer malice. His parents ended as refugees in a neighbouring country together with thousands of others who had lost everything, and still were lucky to come out alive.
Some months later his father died, officially from heart attack, but he knew that the real cause was sorrow. He had hoped to enjoy his coming retirement in his garden surrounded with beautiful flowers and plants which he was looking after as if they had been his own children, but instead, he ended up in the smelly, cold barracks without much privacy. [I am confused about who is in the barracks, that father or the son.]
Then two years later his mother had become ill and asked him to come and visit her. She was still living in the same barracks and did not know what was going to happen
withto her in the future. She had a brain tumour which was diagnosed too late and probablyshe probably knew she was going to die soon. She wanted to see her only son before she died and pleaded with him to come. But he never came.
She must have felt ashamed of him. In their culture, the family was more important than anything. One was taught
alreadyas a child that when it was about the family, one should sacrifice everything, even one’s own life. He had always loved his mother more than his father, but he could not climb over the invisible walls of this city and set off on a journey to the south. When the news of her death reached him, he began to cry and the tears ran down his face as if they had been pouring from a deep well.
He had promised himself that one day he would return to his parents’ graves, at least to ask them for forgiveness and say prayers.
All these misfortunes had made him strong, callous, self-centred, and sly. Sometimes he would walk the streets thinking [wondering?], if he was still a human being or maybe had transformed into something other, a creature about which there was no description in study books.
He glanced at his watch. He had to go. He slowly rose from the bench, gripped the handle of the suitcase and started to walk, pulling the suitcase behind him, its tiny wheels making a buzzing noise on the concrete. After about a hundred metres, he reached the bridge and joined the surging crowds. At the moment he became one of them, a man with the goal and direction.
When he reached the middle of the bridge, he stopped and looked down at the river, dazzling under the sunlight. He walked on towards the train station. Close to the entrance, a young Gypsy girl was standing and playing an accordion, an empty shoebox under her feet. People were so busy that almost nobody gave her a glace. He stopped, fumbled in his pocket for the coins he would not have any use
offor in the south and threw them into the shoebox before entering the black rectangular building which reminded him of a large crypt. Before the automatic doors closed behind him, he turned towards the city for the last time and inhaled deeply.
Student or Learner


my friend elizabeth "zee" whitlock wrote this cool story its better than anything AARRON ever puts on this thing enjoy
Once upon a time about two weeks ago, a boy named Sammy was all alone and bored at a mall. So since he was bored, he decided to pop into Hot Topic.
There he saw magical emo kid clothes that made him feel deep and sensitive to other’s feelings. On the labels they called the clothes “emo.” Sammy decided to call himself emo.
“I’m totally emo!” he proclaimed to everyone.
Just then a group of emo kids came by, hoping to find new meat to train in their whiney, retarded ways. Instead, they said, “Hey! He’s not emo! We’re leaving!” So they did.
Sammy was annoyed. So he went out and bought tight jeans and band t-shirts. The next day he came back to Hot Topic and proclaimed: “I am very emo!” The same group of emo kids came back. They were not impressed.
“No you’re not, you’re a poser! You’re not emo!” they said. They warned him not to cry “emo” again or they wouldn’t come back.
So the next week all he did was do that hair-flippy thing and listen to nothing but the Get-Up Kids and the sound of his own tears.
Sammy mustered up the strength to go back to the mall again to be emo one last time. He yelled, “Look, guys, I’m emo!”
To that they replied, “You’re emo, huh? Well then, go kill yourself.”
And he did.


I wish I had this book when rearing my kids. It's not geared to parenting per se, but it is geared towards hardship and suffering, of which there can be plenty in family life. There's not a day when I pick it up that I am not blessed and strengthened.
"The Way Home" by Mary Pride radically changed my views on wife and motherhood. Now maybe it is theologically not reformed enough I don't know; I was a newish Christian, raised feminist/atheist, so, I was not as discerning as perhaps I am now. But man I loved that book. I have often thought to re read with my thoroughly reformed eyes but I loaned it out so long ago and did not get it back. . .
This isn't about motherhood per se but the "Give me Jesus" journals by Well-Watered Women has been immensely helpful for my wife daily in keeping her nourished on Jesus as a mother of five. It's gives helpful structure for her for prayer/Scripture reading. She also greatly appreciates Jen Wilken bible studies.


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Discussion questions – To Kill a Mockingbird: Analyze the relationship between Boo Radley and the children
- Analyze the relationship between Boo Radley and the children. How does this relationship change throughout the book? What are the causes of the developments in this relationship?
- Discuss the concept of fear as presented in the novel. Compare the children’s early fear of Boo Radley to their fear or lack thereof when Bob Ewell attacks them. Is Scout correct in stating that real fear can only be found in books?
Asked on 24.04.2017 in English Literature.


Jeffrey Munroe. Reading Buechner: Exploring the Work of a Master Memoirist, Novelist, Theologian, and Preacher. IVP, 2019. See here to purchase the book.
I first learned about Frederick Buechner from Philip Yancey’s book Soul Survivor. I was on a Philip Yancey kick in those days because I thrived on Yancey’s honesty about religion and his emphasis on God’s grace. Soul Survivor appealed to me because it was about the Christian anchors to whom Yancey clung when he was disillusioned with the Christians and the Christianity around him. I do not remember anything Yancey said about Buechner, but I think that the chapter made a positive impression on me. Buechner’s name stuck with me over the years, enough that I thought I would be edified in reading Jeffrey Munroe’s book.
Reading Buechner is a guide to Buechner’s life, fiction, non-fiction, and sermons. In Munroe’s telling, Buecher is a Christian thinker who grapples honestly with the suffering in life and the doubts that people have about the Christian faith. Yet, he sees importance in Christian orthodoxy, which is why he felt somewhat alienated when he taught at Harvard Divinity School. Buechner has drawn from different sources. A Pentecostal faith healer, for example, inspired his thinking about prayer.
Many evangelicals who love Buechner’s non-fiction, particularly his memoirs, do not quite know what to make of his fiction. Munroe acknowledges this common sentiment, and he speculates as to why this is the case while exploring the theological themes in Buechner’s novels.
There was a lot in this book that I appreciated and with which I identified. I did not identify much with what Buechner said about the usefulness of pain and suffering in the Christian life, since I would prefer a pleasant mood to the continual rage that I felt before taking Zoloft. Yet, suffering is a problem with which everyone copes, and this included Buechner, who for years struggled with the suicide of his father. Other topics that Buechner engaged includes the usefulness and non-usefulness of Christian apologetics and the mixture of joy, apprehension, and disappointment he had when seeing his grandchildren. His disappointment was not in them but in his realization that he would not live long enough to see how they turn out.
In terms of whether I would like to read Buechner sometime in the future, maybe some things. I would probably appreciate his memoirs and his sermons, since I prefer how non-fiction lays out theological principles in a straightforward manner rather than leaving it to the reader to discern them. At the same time, I did enjoy Munroe’s summaries of Buechner’s fiction, particularly his biblical fiction. Buechner’s placing of some biblical characters in a modern setting, with modern problems, was intriguing.
Munroe’s telling of Buechner’s own story adds a dimension of humanity to the book, but so does Munroe’s description of his own encounters with Buechner’s work and with Buechner himself. Munroe also engages the criticisms that people have had of Buechner’s work and Buechner’s response to those criticisms, as well as offers his own criticism: that Buechner presents a weak ecclesiology. Munroe’s book is honest, as is Buechner’s work.
I received a complimentary copy of this book from the publisher. My review is honest.


Title: Take a chance on me
Author: Jill Mansell
Publisher: Headline Review
Cleo lives in a village where everyone knows everyone. A village where you can’t hide your secrets.
Cleo thinks she has THE perfect boyfriend, Will, but then she discovers who he really is and they break up. Another problem is Johnny, who came back to the village. She hates him because he always teased her. But why can’t she stop thinking of him?
Abbie, Cleo’s sister finds that Tom, her husband, is acting strange. Then she discovers that he has a long-lost daughter and she feels abandoned by her husband, who only thinks about Georgia, his daughter. Her boss falls in love with her and because she feels lonely she kisses him. How can she make sure no one will ever know about this?
Ash, the neighbour of Cleo falls in love with Fia. With his friends and as radio presenter, he is really talkative, but when it comes to Fia, he can’t say a word. She has a negative impression of him and she thinks Ash doesn’t like her. Will they ever become a couple?
This is a book full of love stories and I enjoyed reading it. I haven’t ever read a book by Jill Mansell before, but I read a lot of positive comments, so I started reading. Actually, I expected more. It was a nice read, but there were too much predictable things and clichés in it. Maybe it’s because it’s almost the 20th novel by Mansell and she has no inspiration anymore? I think I should read a novel she wrote earlier and make a comparison.
Even tough the story wasn’t that original, there where a few nice situations in it and I liked the characters. For people who like reading about love, this is THE perfect read!
Rating: 3/5 stars, too predictable, but very relaxing!


Allostery is a physico-chemical phenomenon that regulates protein structure, flexibility and functions by signal transmission across nanometer distances within (or between) proteins. Allosteric signal transduction is ubiquitous in biological systems and regulates essential biochemical pathways. Understanding allostery at the atomistic level is crucial for controlling protein functions, providing roadmaps for the new developments in drug discovery and enzyme engineering. In this seminar, synergistic computational and experimental biophysical investigations [1-8] are illustrated, showing how important insights into allosteric mechanisms can be achieved for relevant biological systems, including a V-type allosteric enzyme [1-4, 7], a DNA-nuclear receptor complex  and the genoma-editing CRISPR-Cas9  and spliceosome  systems. In particular, community analysis of dynamical protein networks , see Figure 1, based on mutual information of correlated protein motions determined from classical molecular dynamics simulations will be described.
 I. Rivalta, M. M. Sultan, N.-S. Lee, G. A. Manley, J. P. Loria, and V. S. Batista, Proc. Natl. Acad. Sci. U.S.A. 2012, 109, E1428.
 G. A. Manley, I. Rivalta and J. P. Loria, J. Phys. Chem. B. 2013, 117, 3063.
 G. P. Lisi, G. A. Manley, H. Hendrickson, I. Rivalta, V. S. Batista, and J. P. Loria, Structure 2016, 24, 1155.
 I. Rivalta, G. P. Lisi, N.-S. Snoeberger, G. A. Manley, J. P. Loria, and V. S. Batista, Biochemistry 2016, 55, 6484.
 C. G. Ricci, R. L. Silveira, I. Rivalta, V. S. Batista and M. S. Skaf, Sci Rep. 2016, 6,19940.
 G. Palermo, C. G. Ricci, A. Fernando, R. Basak, M. Jinek, I. Rivalta, V. S. Batista and J. A. McCammon, J. Am. Chem. Soc. 2017, 139 ,16028
 A. Gheeraert, L. Pacini, V. S. Batista, L. Vuillon, C. Lesieur and I. Rivalta J. Phys. Chem. B 2019, 123, 16, 3452
 A. Saltalamacchia, L. Casalino, J. Borišek, V. S. Batista, I. Rivalta and A. Magistrato J. Am. Chem. Soc. 2020, just accepted DOI: 10.1021/jacs.0c02036


Weight-bearing imaging to assess pathology has become the standard of care in foot and ankle orthopaedics.1,2 Weight bearing better represents and reveals underlying pathologies such as malalignment, impingement, joint space narrowing, and instability that may not be fully appreciated when the foot is offloaded.1 Until recently, radiographs were the only readily accessible imaging modality that could be done with the patient fully bearing weight.1,3 The advent of cone-beam CT technology rather than conventional multidetector CT configurations allowed the detector to move around the patient without the patient moving through the scanner and made the development of the weight-bearing CT (WBCT) scanner possible.3
Standard weight-bearing radiographs are limited by projection, foot orientation, and difficulty in assessing the three-dimensional relationship of structures because of the bones being superimposed.2 In addition, measurements on radiographs require calibration. CT scans overcome these deficits by producing three-dimensional images that do not require calibration. Measurements of joint alignment and angles on cone-beam WBCT scans have been shown to be more accurate than on conventional radiographs and nonweight-bearing CT scans, and this may have clinical implications for surgeons planning deformity correction before surgery.2 As an example, Hirschmann et al4 reported notable differences when comparing measurements of impingement (eg, fibulocalcaneal distance) and joint space width (eg, lateral talocalcaneal joint space width) between weight-bearing and nonweight-bearing CT scans in 22 patients (Figure 1, A and B).
WBCT scans have several other advantages over conventional imaging modalities. Radiation exposure in cone-beam WBCT scans has been estimated to be approximately 10% to 66% less than conventional multidetector CT scanners.1,3,5 Less ionizing radiation exposure is a notable advantage of cone-beam WBCT scans over conventional CT scans and may be advantageous for those patients who require frequent imaging or have complex deformities. One recent study also demonstrated the cost effectiveness and decreased image acquisition time of WBCT scanners over conventional radiographic and CT imaging modalities.5 For centers that do not have access to WBCT scans at this time, a traditional CT scanner with an axial loading device that is able to produce greater than 70% of the patient's body weight has been shown to accurately represent full weight-bearing and can be used as a substitute for newer three-dimensional standing WBCT scanners.6 However, such devices still do not achieve full weight-bearing and do not truthfully represent the foot in a standing (“stance”) position.
These advantages of WBCT scans, however, must be weighed against their higher cost and increased ionizing radiation exposure to patients over standard weight-bearing radiographs. Weight-bearing radiographs remain sufficient to adequately diagnose and treat most foot and ankle pathologies, and many of the studies included in this review do not directly compare WBCT scans with weight-bearing radiographs. Therefore, the superiority of WBCT scans over traditional weight-bearing radiographs in many foot and ankle diagnoses has not been established.
The purpose of this review article on WBCT scans in foot and ankle orthopaedics is to summarize the current literature, describe how WBCT scans have been used for research purposes to help better understand foot and ankle pathologies, and demonstrate how this technology may be applied to clinical practice.
Normal Anatomy on Weight-bearing CT Scans
WBCT scans have been used to investigate normal foot and ankle anatomy in patients without notable pathology.7-11 In healthy control patients, WBCT has been most frequently used to study hindfoot alignment, which has important implications for load-bearing through the lower extremity.8,11,12 A recent study that reviewed the WBCT scans of 48 patients without hindfoot pathology described a neutral hindfoot alignment in this control subject cohort rather than the presence of innate valgus of the hindfoot, which had been previously suggested based on weight-bearing radiographs.9 Others have taken advantage of a newer measurement called the foot and ankle offset (FAO), which is a three-dimensional measurement that defines a relationship between three points on the sole of the foot and one in the center of the ankle joint, to describe the overall hindfoot alignment.8,11 In these studies, they found that the hindfoot alignment in normal patients lies slightly valgus to the midline.8,11 These studies describing hindfoot alignment in normal control patients may provide surgeons with a reference when planning for deformity correction.
Another study used a WBCT scanner with a custom pedography sensor to compare the morphologic center of the foot with the center of force during weight-bearing.10 They found that the morphologic center of the foot was distal to the center of gravity or force of the foot in 97% of feet at a mean distance of 27.5 mm distal.10 In 62% of feet, the foot center was lateral to the center of gravity but only by a mean of 2.0 mm.10
In addition to investigating alignment and force distribution through the foot and ankle, WBCT scans have been used in normal patients to describe subtalar joint position and rotational dynamics of the talus because these are difficult to visualize well on plain radiographs.13 A study by Colin et al13 in 59 patients without hindfoot pathology demonstrated that the most posterior aspect of the posterior facet of the subtalar joint is consistently oriented in valgus, whereas the most anterior aspect of the posterior facet of the subtalar joint is typically oriented in varus. This study suggests that the measurements of the varus-valgus orientation of the posterior facet of the subtalar joint are dependent on where the CT image is taken in the AP direction. Lepojärvi et al14, using 32 healthy control subjects, showed that the talus rotates a total of 10° internally-externally about the tibia when the ankle is taken from maximal internal to maximal external rotation without substantial widening of the medial clear space.
Weight-bearing CT Scans in Adult-Acquired Flatfoot Deformity
Adult-acquired flatfoot deformity (AAFD) encompasses a number of pathologies including medial longitudinal arch collapse, hindfoot valgus, midfoot abduction, and compensatory forefoot varus. These concomitant deformities can be difficult to evaluate individually on two-dimensional weight-bearing radiographs, and visualization of the subtalar joint and impingement between the calcaneus and fibula are better assessed on WBCT scans. Ferri et al15 found that CT scan measurements of forefoot arch angle, which is the angle between the horizontal and a line connecting the inferior aspect of the medial cuneiform to the inferior aspect of the fifth metatarsal, and subtalar joint subluxation were markedly changed when applying 50% weight-bearing compared with a nonweight-bearing state in a simulated weight-bearing study. Another study by Kido et al16 also reported the differences in the talar, navicular, and calcaneal positions on WBCT scans compared with nonweight-bearing CT scans. Consequently, WBCT scans have been used to quantify the severity of deformities in AAFD with good intraobserver and interobserver reliability.17 In one study comparing 10 control patients with 23 patients with stage II to IV AAFD, WBCT scans demonstrated more notable differences in radiographic parameters between control subjects and patients with AAFD than plain weight-bearing radiographs alone, although the clinical implications of these findings have not been established.18
Subtalar Joint Alignment
An early study using simulated WBCT scans demonstrated frequent subluxation of the talocalcaneal joint with an average of only 68% of the posterior facet of the calcaneus in contact with the talus in eight patients with AAFD compared with 92% in control patients.19 In a retrospective study of 22 feet in 20 patients with symptomatic AAFD who had undergone simulated WBCT scans, the anterior aspect of the posterior facet was typically oriented in valgus in contrast to a comparison cohort of normal control patients who had a varus orientation of the anterior aspect of the posterior facet (Figure 2, A and B).20 This varus orientation at the anterior part of the posterior facet of the subtalar joint in normal control patients was consistent to the results reported by Colin et al,13 who used upright, full WBCT scans, previously discussed. Similarly, the posterior aspect of the posterior facet of the subtalar joint in patients with AAFD was found to be in statistically significantly more valgus in patients with flatfoot than in normal control subjects.20 More recent studies have used standing, full WBCT scans, in contrast to simulated WBCT scans, to investigate the orientation of the subtalar joint in patients with stage II AAFD compared with control patients.21 Cody et al,21 using full WBCT scans, measured the subtalar joint alignment at 50% of the anterior-to-posterior dimension of the posterior facet in 45 patients with stage II AAFD and in 17 control patients. They found that stage II patients with AAFD had an additional 10° of subtalar valgus compared with the control subjects.21 A similar study examining subtalar joint valgus in stage II patients with AAFD found that nonweight-bearing CTs underestimated the true subtalar joint deformity compared with WBCT scans and could not be used as a substitute for full WBCT scans.22
Subtalar and Subfibular Impingement
Patients with AAFD may present with pain laterally at the anterior fibula and sinus tarsi due to calcaneofibular (subfibular) and/or talocalcaneal (subtalar) impingement (Figure 3, A and B).23,24 Malicky et al23 used simulated WBCT scans in 19 patients with AAFD who were indicated for surgery to study these impingement deformities. They found evidence of subtalar impingement in 92% of the WBCT scans and observed subfibular impingement in 66% of the CT scans, which differed markedly from control patients who had rates of 5% and 0%, respectively.23 MRI, although nonweight-bearing, may also be used to evaluate the subtalar joint for evidence of subtalar impingement and to measure the calcaneofibular distance for evidence of subfibular impingement.
More recently, Jeng et al24 used WBCT scans in 25 patients with AAFD to evaluate subtalar and subfibular impingement. Thirteen patients had stage II AAFD, 17 had stage III, one had stage IV, and three patients were not able to be staged based on chart notes.24 In contrast to Malicky et al, only 38% of patients had subtalar impingement and only 35% of patients had subfibular impingement on WBCT scans.24 Patients with subfibular impingement had a mean coronal calcaneofibular distance of 2.7 mm compared with those patients without subfibular impingement who had an average coronal calcaneofibular distance of 5.7 mm.24 In addition, they found that patients with AAFD with either talocalcaneal or calcaneofibular impingement had, on average, approximately 10° more of talonavicular abduction than patients with AAFD without bony impingement. These findings may have important implications for predicting which patients may fail a flatfoot reconstruction.
WBCT has also been shown to aid in the assessment of hindfoot deformity in patients with AAFD, although no direct comparisons have been made between WBCT scans and weight-bearing radiographs. In a study of 20 patients with stage II AAFD, de Cesar Netto et al25 reported that clinical examination of the hindfoot alignment angle underestimated the hindfoot alignment angle as measured on WBCT scans by a mean of 7.6°. They reported that the mean hindfoot moment arm measured on WBCT scans was 15.1 mm in valgus, which correlated markedly with the clinical hindfoot alignment angle.25 They advocated for the use of WBCT scans in patients with AAFD because they found the measurements of hindfoot alignment to be repeatable and reliable.25 Burssens et al were the first to describe the hindfoot alignment angle on WBCT scans, which was similar to the technique used by de Cesar Netto et al mentioned above, and found that patients with AAFD had an average hindfoot alignment angle of 20.1°.12 Such measurements have the potential to help surgeons titrate the amount of correction of various osteotomies.
Medial Longitudinal Arch Alignment and Forefoot Varus
To investigate the alignment of the bones along the medial longitudinal arch in AAFD, Kido et al16 used simulated WBCT scans to study 24 patients with flatfoot deformity and compared them with 20 healthy control subject feet. When the foot was loaded, patients with AAFD had more dorsiflexion at the first tarsometatarsal joint and more eversion at the talonavicular and talocalcaneal joints than the healthy control subjects.16 Their findings were supported by those of Zhang et al26 who compared similar WBCT measurements in patients with stage II AAFD to healthy control patients. Greisberg et al27 also used simulated WBCT scans in 37 patients with AAFD to study the medial longitudinal arch. Deformity along the medial longitudinal arch was found to be at either the navicular-cuneiform joint (65%) or talonavicular joint (20%) but rarely at both, with only one foot having more than 10° of collapse at both joints.27 They also noted severe degenerative changes in 38% of patients at the talonavicular joint, but none of the tarsometatarsal joints showed notable arthritic changes on the CT scans.27
Yoshioka et al28 used simulated WBCT scans to study forefoot alignment in patients with stage II AAFD. They reported that the fifth metatarsal bone was more plantarflexed in patients with AAFD than in healthy control patients, and the authors described this finding as the compensatory forefoot varus deformity.28 However, it should be noted that the difference in plantar flexion of the fifth metatarsal bone between flatfoot patients and normal control subjects was only 1.3°.28 This could have important implications in the surgical management of the compensatory forefoot varus pathology and may suggest that the deformity is prone to overcorrection.
Weight-bearing CT Scans in Hallux Valgus
Pronation of the First Metatarsal
Although hallux valgus (HV) has been understood to be a triplanar deformity of the first metatarsal, WBCT has recently helped to quantify the pathology at the first tarsometatarsal joint as well as the rotational deformity of the first ray. Collan et al29 used WBCT scans to compare 10 patients with HV with five asymptomatic normal control patients. They found no difference in the sagittal first metatarsal-ground angle between the HV and normal control subject groups. To study rotational deformities, they used a two-dimensional coronal view and measured the angle between the ground and either the sesamoid articulation of the first metatarsal or base of the proximal phalanx. The authors reported no notable difference in pronation of the first metatarsal in patients with HV (mean, 8°) and normal (mean, 2°) patients; however, they did note a statistically significant difference in the pronation of the proximal phalanx between the HV (mean, 33°) and control subject (mean, 4°) groups.29 The lack of statistical significance in pronation of the first metatarsal between HV and control patients may be due to the small number of patients included in the study and the authors' technique used to measure pronation based on the plantar aspect of the first metatarsal head, which may be deformed due to subluxation of the sesamoids and erosion of the crista.
In contrast, more recent studies have found increased pronation of the first metatarsal in patients with HV compared with normal control subjects.30,31 Kim et al30 demonstrated an increase of 8.1° in pronation of the first ray in patients with HV compared with control patients. Campbell et al31 used a computer-aided design to create a three-dimensional model of the first metatarsal and then measured the pronation of the first ray with the second metatarsal as a reference because the second ray forms a central, structural element of the foot (Figure 4). Using simulated WBCT scans, the authors reported that patients with HV had 9.9° of increased pronation of the first metatarsal compared with normal control subjects.31 In addition, they did not find any correlation between pronation of the first ray and IMA or HVA in HV.31 A subsequent study using the technique developed by Campbell et al found that the average preoperative pronation of the first metatarsal in patients with HV was 29.0° and decreased to 20.2° postoperatively, which was statistically significant.32 Pronation of the first ray was not associated with sesamoid position, suggesting that the position of the sesamoids is likely not a good proxy for first metatarsal pronation.32 Consequently, the rotational deformity is likely independent of the other deformities in patients with HV. Proper recognition and correction of the pronation deformity of the first ray may be important in the surgical management of patients HV.
Two studies using simulated WBCT scans have demonstrated increased mobility at the midfoot in patients with HV when compared with normal patients.33,34 Kimura et al33 performed simulated WBCT scans in 10 patients with HV and 10 patients without HV to investigate motion at the midfoot. In the HV group, they demonstrated statistically significantly greater dorsiflexion, inversion (pronation), and adduction of the first metatarsal in relation to the medial cuneiform compared with the control patients, which suggested increased motion of the first ray in patients with HV.33 In a separate study using simulated WBCT scans, the same group found greater mobility of the first-second intercuneiform joint in patients with HV.34 Another study compared simulated weight-bearing and nonweight-bearing CT scans in 10 healthy control patients and 10 patients with HV.35 A three-dimensional model of each bone was created so that widening and translation of the first metatarsal-cuneiform joint could be measured.35 In patients with HV, the first metatarsal-cuneiform joint significantly widened and translated more in the dorsal-plantar direction when compared with the normal control patients, which supports the finding of hypermobility of the first tarsometatarsal joint in patients with HV.35
Position of the sesamoids may also be more accurately measured on WBCT scans.30 Kim et al30 used simulated WBCT scans to demonstrate that no correlation was found between sesamoid position and pronation of the first metatarsal, which suggests that the degree of subluxation of the sesamoids is independent of first ray pronation. In approximately 25% of cases, they found that patients had “pseudosesamoid subluxation” on simulated WBCT scans in which there was first metatarsal pronation without true sesamoid subluxation; however, when viewed on an AP weight-bearing radiograph, the sesamoids in these cases would appear subluxated.30 Another simulated WBCT study demonstrated that tibial sesamoid position was correlated with HV severity as measured by the HV and intermetatarsal angles.36 They also found that the degree of degenerative change in the sesamoid metatarsal joint was associated with increasing lateral shift of the tibial sesamoid (Figure 5).36
Weight-bearing CT Scans to Evaluate the Syndesmosis
WBCT scans have also been used to examine motion and investigate biomechanics at the distal tibiofibular syndesmosis in both injured and uninjured patients.7,37-40 Motion at the syndesmosis under weight-bearing conditions was quantified in one study on 32 healthy control patients.7 Using WBCT scans, they found that the fibula is located anterior in the tibial incisura in 88% of patients.7 Physiologic motion of the incisura also occurs as the fibula moves, on average, 1.5 mm in the anterior-posterior direction and 3° in external rotation as the foot is moved from maximal internal to external rotation.7 Another retrospective study found similar results in a group of 26 patients who had undergone both nonweight-bearing and weight-bearing CT scans with foot and ankle diagnoses that were not believed to affect the syndesmosis.37 They found that the fibula externally rotates and translates posteriorly and laterally during weight-bearing (Figure 6).37
In patients with syndesmotic injuries, there is high interobserver and intraobserver reliability of distal tibiofibular WBCT scan measurements.40 However, the utility of WBCT scans in the diagnosis of syndesmotic injury is unclear. Burssens et al38 compared WBCT scan measurements in 12 patients with syndesmotic injuries and seven normal control patients. In the patients with syndesmotic injuries, they found increased movement of 1.4 mm in mediolateral direction of the lateral malleolus in the incisura.38 They also reported increased external rotation by 4.5° in the injured cohort.38 In contrast, Hamard et al39 found that WBCT scans were less effective at distinguishing pathologic syndesmotic injury than conventional nonweight-bearing multiplanar CT scans. They used nonweight-bearing multiplanar CT scans to analyze 11 ankles with suspected syndesmotic injury and used WBCT scans to investigate an additional of eight ankles with suspected syndesmotic injury.39 True syndesmotic instability in all ankles was determined using ankle arthroscopy.39 The results of this study suggested that conventional nonweight-bearing multiplanar CT scans were more accurate in determining syndesmotic injury.39 The authors hypothesized that physiologic widening of the distal tibiofibular syndesmosis during weight-bearing in the upright position may account for these results.39 Consequently, at this time, WBCT scans have been more important in advancing the understanding of physiologic motion at the syndesmosis than in the diagnosis of syndesmotic instability. Future work could help to identify appropriate reduction of the syndesmosis after injury.
Weight-bearing CT Scans to Evaluate Lateral Ankle Instability
Ankle sprains are commonly encountered in foot and ankle orthopaedic practices and are typically managed nonoperatively. However, a subset of patients develop chronic lateral ankle instability, which, if left untreated, can cause recurrent osteochondral injury and ultimately tibiotalar arthritis. WBCT scans have been used to study the alignment of the foot and ankle in patients with chronic lateral ankle instability to determine if certain risk factors can be elucidated.
In an early study, van Bergeyk et al41 used simulated WBCT scans to study hindfoot alignment in 12 patients with three or more episodes of lateral ankle sprains or instability with ongoing symptoms for at least 6 months. They compared this cohort of patients with 12 control patients.41 The study demonstrated that patients with chronic lateral ankle instability had measurements of hindfoot alignment including calcaneal metatarsal angle and medial calcaneal varus angle that were, on average, in approximately 3° to 4° more varus than the control patients.41 The authors concluded that hindfoot varus was an important factor correlated with recurrent ankle instability.41
More recently, Lintz et al42 used measurements on WBCT scans to examine hindfoot alignment in patients with chronic lateral ankle instability. They compared FAO, calcaneal offset, and the hindfoot angle in 34 patients with chronic lateral ankle instability with 155 patients without ankle instability.42 Calcaneal offset represents the difference (in millimeters) between a neutral position of the calcaneus and the actual position of the calcaneus.42 The hindfoot angle is formed between the weight-bearing axis of the tibia at the apex of the center of the talar dome and a line draw through the long axis of the calcaneus.42 Patients with chronic lateral ankle instability had approximately 4% more varus in their FAO, 9 mm more of varus in their calcaneal offset, and 16° more of varus in their hindfoot angle.42 For every 1% change in the FAO toward a varus alignment, there was a 35% increased odds ratio of developing chronic lateral ankle instability.42
Weight-bearing CT Scans in Clinical Practice
In addition to helping surgeons understand foot and ankle biomechanics and pathologies, WBCT scans are increasingly changing clinical practice by allowing surgeons to better assess deformities and preoperatively plan for surgical intervention. At this time, WBCT scans may be especially valuable to the clinician in assessing deformities such as subtalar and subfibular impingement in AAFD, hindfoot alignment, and pronation of the first metatarsal in HV.
In AAFD, surgeons may use WBCT scans to look for subtalar impingement at the angle of Gissane on sagittal views or subfibular impingement on coronal views. Patients with severe subtalar or subfibular impingement may require a subtalar arthrodesis to properly align the foot and prevent future impingement or recurrence because current techniques such as a medializing calcaneal osteotomy and lateral column lengthening may not address these deformities. Future work may identify patients who are likely to fail reconstructive procedures.
WBCT scans could also be used clinically to better evaluate hindfoot alignment. This may be particularly helpful in AAFD and in cases of chronic lateral ankle instability. Subtle varus and valgus deformities may be difficult to quantify on physical examination and on radiographs. WBCT scans may be an important tool to assist surgeons in titrating correction based on an individual patient's specific deformity.
WBCT scans can also be used in practice to determine pronation and instability of the first metatarsal in patients with HV. Because sesamoid position and first ray pronation are distinct deformities, the rotational deformity of the first metatarsal cannot be determined using sesamoid position on weight-bearing radiographs as a proxy for metatarsal pronation. Using WBCT scans to preoperatively understand the amount of pronation of first ray may help surgeons calibrate the appropriate surgical correction of the rotational deformity. In addition, surgeons may choose to use WBCT scans in patients with HV to evaluate for instability at the first tarsometatarsal (TMT) joint, which could assist in identifying which patients require a first TMT arthrodesis.
Finally, there may be a role for WBCT scans in the creation of patient-specific instrumentation, although there is no evidence at this time that demonstrates an advantage of WBCT scans for this use. WBCT scans may be used to more accurately model a patient's anatomy and create three-dimensional implants or cutting guides to help surgeons better treat complex deformities.
The advent of cone-beam CT technology in place of conventional multidetector CT scanner configurations has made the development of WBCT scans possible. Cone-beam CT technology also has the advantage of reducing ionizing radiation exposure to the patient. It has two-thirds the effective radiation dose of a conventional CT scan but approximately 2.5 times as much radiation as a standard, three-view weight-bearing radiograph of the foot.18 Compared with conventional nonweight-bearing CT scans, WBCT scans better demonstrate the true orientation of the bones and joints during loading conditions and help to identify underlying pathologies such as malalignment, impingement, and instability. They have provided new insight into common foot and ankle disorders such as AAFD, HV, ankle fractures, and lateral ankle instability. WBCT scans, however, have not replaced lower cost weight-bearing radiographs, which are often sufficient to adequately diagnose and manage most foot and ankle pathologies. At this time, WBCT scans may be better used as an adjunct. In clinical practice, WBCT scans may help surgeons assess subtalar and subfibular impingement and hindfoot alignment in AAFD. This technology may also help evaluate rotational deformities such as pronation of the first metatarsal in patients with HV. As WBCT scanners become more frequently used to evaluate foot and ankle pathologies, additional indications will soon emerge. Understanding the application of WBCT scans to clinical practice is becoming increasingly important for surgeons as they strive for better outcomes in the management of complex foot and ankle disorders.
References printed in bold type are those published within the past 5 years.
1. Barg A, Bailey T, Richter M, et al.: Weightbearing computed tomography of the foot and ankle : Emerging technology topical review. Foot Ankle Int 2018;39:376-386.
2. Richter M, Seidl B, Zech S, Hahn S: PedCAT for 3D-imaging in standing position allows for more accurate bone position (angle) measurement than radiographs or CT. Foot Ankle Surg 2014;20:201-207.
3. Carrino JA, Al Muhit A, Zbijewski W, et al.: Dedicated cone-beam CT system for extremity imaging. Radiology 2014;270:816-824.
4. Hirschmann A, Pfirrmann CWA, Klammer G, Espinosa N, Buck FM: Upright cone CT of the hindfoot: Comparison of the non-weight-bearing with the upright weight-bearing position. Eur Radiol 2014;24:553-558.
5. Richter M, Lintz F, de Cesar Netto C, Barg A, Burssens A: Results of more than 11,000 scans with weightbearing CT—impact on costs, radiation exposure, and procedure time [published online ahead of print June 18, 2019]. Foot Ankle Surg. doi: 10.1016/j.fas.2019.05.019.
6. Kang DH, Kang C, Hwang DS, Song JH, Song SH: The value of axial loading three dimensional (3D) CT as a substitute for full weightbearing (standing) 3D CT: Comparison of reproducibility according to degree of load. Foot Ankle Surg 2019;25:215-220.
7. Lepojärvi S, Niinimäki J, Pakarinen H, Leskelä HV: Rotational dynamics of the normal distal tibiofibular joint with weight-bearing computed tomography. Foot Ankle Int 2016;37:627-635.
8. Lintz F, Welck M, Bernasconi A, et al.: 3D biometrics for hindfoot alignment using weightbearing CT. Foot Ankle Int 2017;38:684-689.
9. Burssens A, Van Herzele E, Leenders T, et al.: Weightbearing CT in normal hindfoot alignment—presence of a constitutional valgus? Foot Ankle Surg 2018;24:213-218.
10. Richter M, Lintz F, Zech S, Meissner SA: Combination of PedCAT weightbearing CT with pedography assessment of the relationship between anatomy-based foot center and force/pressure-based center of gravity. Foot Ankle Int 2018;39:361-368.
11. Zhang JZ, Lintz F, Bernasconi A, Zhang S: 3D biometrics for hindfoot alignment using weightbearing computed tomography. Foot Ankle Int 2019;40:720-726.
12. Burssens A, Peeters J, Buedts K, Victor J, Vandeputte G: Measuring hindfoot alignment in weight bearing CT: A novel clinical relevant measurement method. Foot Ankle Surg 2016;22:233-238.
13. Colin F, Horn Lang T, Zwicky L, Hintermann B, Knupp M: Subtalar joint configuration on weightbearing CT scan. Foot Ankle Int 2014;35:1057-1062.
14. Lepojärvi S, Niinim J, Pakarinen H, Koskela L, Leskel HV: Rotational dynamics of the talus in a normal. J Bone Joint Surg Am 2016;98-A:568-575.
15. Ferri M, Scharfenberger AV, Goplen G, Daniels TR, Pearce D: Weightbearing CT scan of severe flexible pes planus deformities. Foot Ankle Int 2008;29:199-204.
16. Kido M, Ikoma K, Imai K, et al.: Load response of the tarsal bones in patients with flatfoot deformity: In vivo 3D study. Foot Ankle Int 2011;32:1017-1022.
17. de Cesar Netto C, Shakoor D, Dein EJ, et al.: Influence of investigator experience on reliability of adult acquired flatfoot deformity measurements using weightbearing computed tomography. Foot Ankle Surg 2018;25:495-502.
18. Haleem AM, Pavlov H, Bogner E, Sofka C, Deland JT, Ellis SJ: Comparison of deformity with respect to the talus in patients with posterior tibial tendon dysfunction and controls using multiplanar weight-bearing imaging or conventional radiography. J Bone Joint Surg Am 2014;96:e63.
19. Ananthakrisnan D, Ching R, Tencer A, Hansen ST, Sangeorzan BJ: Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot. J Bone Joint Surg Am 1999;81:1147-1154.
20. Apostle KL, Coleman NW, Sangeorzan BJ: Subtalar joint axis in patients with symptomatic peritalar subluxation compared to normal controls. Foot Ankle Int 2014;35:1153-1158.
21. Cody EA, Williamson ER, Burket JC, Deland JT, Ellis SJ: Correlation of talar anatomy and subtalar joint alignment on weightbearing computed tomography with radiographic flatfoot parameters. Foot Ankle Int 2016;37:874-881.
22. Kunas GC, Probasco W, Haleem AM, Burket JC, Williamson ERC, Ellis SJ: Evaluation of peritalar subluxation in adult acquired flatfoot deformity using computed tomography and weightbearing multiplanar imaging. Foot Ankle Surg 2018;24:495-500.
23. Malicky ES, Crary JL, Houghton MJ, Agel J, Hansen ST, Sangeorzan BJ: Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. J Bone Joint Surg Am 2002;84:2005-2009.
24. Jeng CL, Rutherford T, Hull MG, Cerrato RA, Campbell JT: Assessment of bony subfibular impingement in flatfoot patients using weight-bearing CT scans. Foot Ankle Int 2019;40:152-158.
25. de Cesar Netto C, Shakoor D, Roberts L, et al.; Weight Bearing CT International Study Group: Hindfoot alignment of adult acquired flatfoot deformity: A comparison of clinical assessment and weightbearing cone beam CT examinations. Foot Ankle Surg 2019;25:790-797.
26. Zhang Y, Xu J, Wang X, et al.: An in vivo study of hindfoot 3D kinetics in stage II posterior tibial tendon dysfunction (PTTD) flatfoot based on weight-bearing CT scan. Bone Joint Res 2013;2:255-263.
27. Greisberg J, Hansen ST, Sangeorzan B: Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int 2003;24:530-534.
28. Yoshioka N, Ikoma K, Kido M, et al.: Weight-bearing three-dimensional computed tomography analysis of the forefoot in patients with flatfoot deformity. J Orthop Sci 2016;21:154-158.
29. Collan L, Kankare JA, Mattila K: The biomechanics of the first metatarsal bone in hallux valgus: A preliminary study utilizing a weight bearing extremity CT. Foot Ankle Surg 2013;19:155-161.
30. Kim Y, Kim JS, Young KW, Naraghi R, Cho HK, Lee SY: A new measure of tibial sesamoid position in hallux valgus in relation to the coronal rotation of the first metatarsal in CT scans. Foot Ankle Int 2015;36:944-952.
31. Campbell B, Miller MC, Williams L, Conti SF: Pilot study of a 3-dimensional method for analysis of pronation of the first metatarsal of hallux valgus patients. Foot Ankle Int 2018;39:1449-1456.
32. Conti MS, Willett JF, Garfinkel JH, et al.: Effect of the modified lapidus procedure on pronation of the first ray in hallux valgus. Foot Ankle Int 2020;41:125-132.
33. Kimura T, Kubota M, Taguchi T, Suzuki N, Hattori A, Marumo K: Evaluation of first-ray mobility in patients with hallux valgus using weight-bearing CT and a 3-D analysis system a comparison with normal feet. J Bone Joint Surg Am 2017;99:247-255.
34. Kimura T, Kubota M, Suzuki N, Hattori A, Marumo K: Comparison of intercuneiform 1-2 joint mobility between hallux valgus and normal feet using weightbearing computed tomography and 3-dimensional analysis. Foot Ankle Int 2018;39:355-360.
35. Geng X, Wang C, Ma X, et al.: Mobility of the first metatarsal-cuneiform joint in patients with and without hallux valgus : In vivo three-dimensional analysis using computerized tomography scan. J Orthop Surg Res 2015;10:140.
36. Katsui R, Samoto N, Taniguchi A, et al.: Relationship between displacement and degenerative changes of the sesamoids in hallux valgus. Foot Ankle Int 2016;37:1303-1309.
37. Malhotra K, Welck M, Cullen N, Singh D, Goldberg AJ: The effects of weight bearing on the distal tibiofibular syndesmosis: A study comparing weight bearing-CT with conventional CT. Foot Ankle Surg 2019;25:511-516.
38. Burssens A, Vermue H, Barg A, Krähenbühl N, Victor J, Buedts K: Templating of syndesmotic ankle lesions by use of 3D analysis in weightbearing and nonweightbearing CT. Foot Ankle Int 2018;39:1487-1496.
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42. Lintz F, Bernasconi A, Baschet L, Fernando C, Mehdi N, de Cesar Netto C: Relationship between chronic lateral ankle instability and hindfoot varus using weight-bearing cone beam computed tomography. Foot Ankle Int 2019;40:1175-1181.


20 Mar 2010
I enjoy rain when it dances on the flowers on a hot summer afternoon invigorating the day and making everything smell fresh and clean. That is what rain is supposed to do. I believe it is found in section three, paragraph 17 of the rain contract. But lately, I think Madame Rain has outdone herself and I wish she would relax and take a well deserved vacation. I recommend the Sahara desert.
Rev. James L. Snyder
I was looking out the window watching the rain come down like a flood when the Gracious Mistress of the Parsonage came in and saw me.
“What are you doing?” she asked. “Trying to stare the rain away?”
“If only I could,” I sighed. I had gawked at the rain so much my eyes were beginning to flood. A person can only take so much rain before his soul begins to feel soggy and I had reached that place. I even sloshed when I walked. I hate sloshing.
I do not mind when raindrops keep falling on my head, it is when it floods my soul that I must draw the line. Of course, it is too wet to draw a line in the sand right now, so I will make a mental note to do that later.
My wife noticed I was a little gloomy about the weather and so trying to cheer me as best she could, said, “Well, you know, into every life a little rain must fall.”
I suppose this was something Mrs. Noah told her husband to cheer him up. If my wife thought that would do it for me, she was still wet behind the ears.
“I don’t mind a little rain,” I retorted, “it’s this ceaseless flooding that has more than dampened my spirits.”
One of the basic components of my philosophy of life is moderation. I really believe in moderation in everything. Well, almost everything. It is hard to be moderate when it comes to apple fritters. If God wanted me to be moderate about apple fritters why did He make them so heavenly delicious?
I do compensate for this extravagance by staying clear of broccoli as much as possible. I think it is a fair trade.
In everything else, however, I like to practice the discipline of moderation. A little bit here and a little bit there, is the motto of my life.
This brings me back to the rain situation.
While I was musing on this, my wife came in humming a hymn that, up until now, had been a favorite of mine: “There Shall be Showers of Blessing.” Under normal circumstances, I would have joined in, but this was not normal circumstances.
I know I should be thankful for everything, and I try, but some things try even the patience of Job, and right now, I feel more like Noah. I appreciate the little things in life. I want to emphasize that word, "little." It is the little things in life that truly make life worth living. Not all this deluge of rain we have been having. A little bit of rain goes a long way with me.
My wife was singing one hymn and I was singing another, "Rain, rain go away, come again some other day." I must confess I was a little weak with the "come again," but the "go away," was sung with great volume.
The matter how I sung that little chorus the rain kept coming down.
I know there is a purpose for everything under the sun. And I am often quite thankful that I am not in charge of this universe of ours. If I was in charge it would rain only when I wanted it to rain, which, may not be enough to keep the flowers blooming in my backyard. I would have it rain at my convenience.
Because of the rainy weather outside, I had plenty of time to think through some of these thoughts. What if I could control my world? What kind of world would it be? Then I began to think of good old Noah in the Ark. In reality, he had no control over the Ark inside or the weather outside. I suppose he could have complained about the rain. Much like I am doing right now.
Thinking this through, I begin to realize that it was the rain outside that Noah could not control that took Noah where God wanted him to be. Had Noah control of the rain he and his family never would have arrived where God wanted them to be when God wanted them to be there.
Even though my brain was a little soggy at the time, I began to understand certain things, particularly about God and His control over my world. When I allow God to control my circumstances, he brings me to a place that he wants me to be – a place of Blessing.
Slowly, but surely, I was beginning to have a new appreciation for the uncontrollable rain on the outside. It reminded me of one of my favorite passages in the Bible.
"Trust in the LORD with all thine heart; and lean not unto thine own understanding. In all thy ways acknowledge him, and he shall direct thy paths" (Proverbs 3:5-6 KJV).
I can try to either control all of the circumstances in my life, or, like Noah, allow God to guide me and even drive me to the place of His blessing.