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2 tbsp vegetable oil
View the complete recipe
great recipe, I always have leftover chicken breast and 90% of the time have the remainder of the ingredients!
pineapple goes well in this one.
pineapple goes well in this one.
I'm one of those Asian foodie friends...and this looks delicious!
I nearly always make leftover chicken into Indian food and use a bought source. The other alternative is Thai as I have so much of that green paste. May try this as chicken is so tasteless without an exotic sauce.
This is such a great way to use leftover grilled chicken, especially now that barbecue season is upon us! I love using leftovers to create new meals!
Any time you use garlic, ginger, and soy sauce in a dish, that's "authentic Asian" to me!
Hey Chef
How integral would you say the ketchup component is to the non complexity of this sauce? ......if I didn't know it was in there it probably wouldnt have been an issue but since i'll be the one making it and I have a mild ketchup phobia I'm just wondering if I can make an altered version or just leave this recipe alone altogether. I do like cashew chicken though....
-A Very Strange Fan.
Just suck it up, and put it in! It's only a tablespoon. You'll never taste ketchup. #toughlove
What a brilliant way to use cooked chicken breast
for a quick weeknight meal .. .
I plan on trying this recipe using rotisserie chicken
from the supermarket.
This will definitely be on the menu this weekend!
Ketchup...so plebeian.
Ok, ok, I'll trust you!
Nice and simple, my way of recycling... but may I do this with pistachios instead of cashews?
This turned out INCREDIBLY!!!!! I didn't have leftover grilled chicken (and sadly I don't have a grill) so I fired up the George Foreman and went to town. I don't recommend it though, it leaves a tough caramelizedish skin on the chicken which makes cubing it a bear! Thanks Chef! I will make this again and again!
I really enjoyed this quick meal. I made one for the kids with less heat and one for the adults following the recipe and it turned out very close to what I could expect from a Chinese restaurant!
The recipe version really wasn't very hot and would probably be fine for most kids but ours seem to have an aversion to even the slightest amount of heat.
Can I make this with my leftover hot dogs?
looks good :) will try it
Chef John,
This recipe is so delicious. But I wonder, what part does the ketchup play in the grand scheme of things? I'm definitely not complaining about...just curious about its role in the sauce. :)
I wonder about those ginger pieces, do you just leave those in and not eat them or do you eat them regardless?
for flavor, but you can eat if you want!


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An Alaska village has voted to banish two sovereign citizens after one of the men's son was charged with fatally shooting two state troopers. Nathanial Kangas is accused of shooting to death Trooper Sgt. Patrick "Scott" Johnson and Trooper Gabriel Rich as they attempted to arrest his father May 1…
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By Katie Halper
By TBogg
By Roy Greenslade, The Guardian
By The Conversation
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subset: commoncrawl


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William Stafford was born in Hutchinson, Kansas, in 1914, and died at his home in Lake Oswego, in 1993, at the age of 79. Between 1960 and 1993, William Stafford wrote more than 60 published collections of poetry and prose, including 12 full-length books of poems. Stafford's first book of poetry, West of Your City, was published in 1960 when he was 46 years old. His second, Traveling Through the Dark, won the National Book Award in 1963. All but one of his books was written in Oregon.
William Stafford was also an influential and beloved teacher of writing. He served as Poetry Consultant to the Library of Congress (the post now known as United States Poet Laureate) during 1970-71 and as Poet Laureate of Oregon from 1975 through 1989. In 1948, Stafford joined the faculty of Lewis & Clark College, where he taught until his retirement in 1980.
Stafford grew up during the Great Depression in central and southwest Kansas, with an appreciation for nature, the Great Plains, and books. As a pacifist and conscientious objector during World War II, Stafford did alternative service in civilian work camps in Arkansas, California and Illinois. After the war, Stafford worked for the Church World Service relief organization, taught high school and finished his master's degree in English at the University of Kansas. His master's thesis, a memoir of his wartime experience in the civilian work camps, was published as Down in My Heart in 1947 and is still in print from Oregon State University Press. In 1948, Stafford joined the faculty of Lewis & Clark College, where he taught until his retirement in 1980.
Stafford's poems tend to be short and deceptively simple. His plain-spoken style invites readers into the poems, which often take unexpected turns toward discovery. His poems are at once quiet and tough-minded, clear and mysterious, open-hearted and sly, serious and funny, witty and down-to-earth. While grounded in day-to-day life and local experience, they also touch on universal concerns, from war and peace to the tension between individual freedom and social responsibility.


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This group is open to all undergraduate and graduate women interested in exploring readings in Christian spirituality and theology and sharing questions, reflections, and experiences of faith. An information session for the Womens Wisdom spirituality group will be held in January 2014. WOmen's Wisdom meets during the spring semester.
Contact Emily Schumacher-Novak in Campus Ministry for more information.


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In 1953 the Denver Police Department began to gather information on individuals and groups regarding activities that might pose a threat to public safety. The files came to be known as the Spy Files during the publicity surrounding an American Civil Liberties Union class action lawsuit in 2002. According to the lawsuit, as many as 3,200 individuals and 208 organizations had been targeted for intelligence gathering operations. These groups and individuals included not only criminal elements but also peace activists and education and human rights organizations. The lawsuit was settled in 2003 with the city revising its policies governing the gathering of this type of information.
Mayor John Hickenlooper ordered the records be archived at the Denver Public Library and preserved for study. Part of the archive is currently available to the public and part is a restricted collection, accessible only by those individuals and organizations specifically named in the documents. The complete collection will open to the public in the year 2055.
Police officers sit at desks at the information office in the Denver Police Building, Denver, Colorado [1966].
Denver Public Library Online ©
Updated: June 25, 2013


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Rush County Heritage is issuing an invitation to one and all for an old-fashioned picnic to be held at noon Saturday, July 27 at the Offutt covered bridge.
The group wants to highlight the work they do with a celebration held at a covered bridge they successfully worked to save.
The Offutt bridge is in a lovely spot with a beautiful covered bridge set in a well-kept area. Jim Irvine, the owner of the land surrounding the bridge, is extending a hearty invitation to everyone who would like to come, park, eat, and spend some happy hours there.
Outdoor games for children and adults will be available and there is a small river to enjoy.
Heritage is furnishing hamburgers, hot dogs, drinks and table service. Guests will need to bring a covered dish for the pitch-in meal and lawn chairs for their seating.
The people cooking the burgers and hotdogs would appreciate knowing how many are coming, so please let Eleanor Arnold (at 932-5204) know your plans.
The Offutt bridge is northwest of Arlington on Offutt Bridge Road (formerly 475 W) just north of 300 N. Cars coming from Rushville might want to go north on SR 3, turn left on CR 300 N and continue for a few miles. The road to the bridge will be marked with a sign and balloons. Parking will be available at the site of the picnic.
The Rush County Heritage group is an historic preservation group which works to save the historic buildings and areas which are such an important part of Rush County's past.
Over the years they have been in existence they can point to many successes, including the covered bridges and the Booker T. Washington Community Center. The recent restoration of the Moscow Covered Bridge shows how much Rush County values its heritage.
The group is currently engaged in several projects and continues to be a voice for preserving our past.
Tagline (right aligned):— Rushville Republican


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Learn more about the five boroughs that make up New York City with our complete guide.
Discover what to do, where to stay and what to see in New York City with our planning tool.
Any visit to New York City offers a multitude of highlights for children and their families.
Enjoy The Nutcracker, the Times Square New Year's Eve Ball Drop, the Orchid Show and more.
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Chicago News
Local news for Chicago, IL continually updated from thousands of sources on the web.
25 min ago | Lincoln Daily News
Special to Watchdog.org S PRINGFIELD - Awhile back I took a cab to Chicago's Navy Pier and attempted to pay for my ride with a credit card.
4 hrs ago | WLS-AM Chicago
1 killed, 10 wounded in overnight shootings
One man was killed and at least 10 other people were wounded in shootings across the city since early Friday night.
Cops: Woman dies following Tri-State crash
A 50-year old woman died after her car hit a truck and then crashed into a light pole on Interstate 294 near Schiller Park early this morning, officials said.
Frequently overlooked treasure trove on Chicago's lake shore
Originally created as part of the Columbian Exposition of 1893 , Chicago's Field Museum not only has a great history, but its collection of 25 million artifacts - including anthropology , botany , geology , culture, zoology and the environment -- offers a treasure trove of valuable information, insights and discoveries.
The North Shore Channel is a manmade canal and part of the Illinois Waterway System.
Most of what I know about close, lifelong female friendships-the all-consuming kind, that start in the sandbox, continue through confidences about first periods and first gropings with boys, and survive marriage and children -comes from books.
Reader's Agenda Sat 8/30: Artopia, Northwestern Wildcats, and...
The Chicago Urban Art Society hosts local artists and performers to create an art utopia at Artopia.
Pour it on: Rivers of fickle concrete run through Chicago
If you answered, "c," fresh concrete, then you probably already know a little about the rivers of beige-gray flowing around Chicago this summer.
Allston Accused by HFT Rival of Manipulating Prices on CME
High-frequency trading firm Allston Trading LLC was accused by a competitor of manipulating prices on CME Group Inc.'s exchange, three people with knowledge of the proceeding said.
Second person denied bail in July slaying in South Chicago
David Radford, 21, a second person charged in a July 6 shooting that killed a man and injured two others.
Chicago Theater AA: Announcements & Auditions
Announcements The theater management firm KMP Artists and Chicago Children's Theatre will send Red Kite, Brown Box on a national tour in 2015-2016.
C.S. Lewis on Stage returns to Provision Theater in Chicago this fall
Provision Theater Company launches its 2014-2015 Season with the return of C.S. LEWIS ON STAGE, written by C.S. Lewis and adapted by Tom Key.
Chicago man delivers his baby girl oon Edens expressway
Lincolnwood officials say an off-duty paramedic delivered his baby girl after making an emergecy stop on the Edens Expressway near Touhy Ave. Daniel Lynch of the Evanston Fire Department and his wife, Elizabeth, were on their way to a local hospital early Friday morning when they pulled over to deliver the baby.
Neglected pup surrendered to busy animal control in Chicago
On August 7, an eight-month-old pup named "Prince" was surrendered to the Chicago Animal Care and Control facility in Illinois.
Chicago: Kempf Plaza Has All the Right Ingredients for a Great Public Space
Giddings Plaza is used in all types of weather. This photo was taken in early April.
River North Dance Chicago's 25th Anniversary Season to Open with ...
Celebrating a milestone 25th Anniversary Season, River North Dance Chicago forges into the fall with "Silver: 25th Anniversary Fall Engagement," October 8 - 11, 2014 at the Harris Theater .
Reader's Agenda Fri 8/29: Noir City, North Coast Music Festival, and Taste of Polonia
It's day one of Noir City: Chicago 6, a week-long film festival devoted to international noirs from France, Spain, Italy, Japan, Argentina, and the UK.
Big Hurt takes swing at restaurant business in Berwyn
Frank Thomas, former White Sox first baseman and Hall of Famer, at a ceremonial groundbreaking today for the Big Hurt Brewhouse in Berwyn.
Saint Xavier Opens New Student Veteran Resource Center on Chicago Campus
Vice President of Student Affairs John Pelrine; Dr. Paul DeVito, SXU Provost; SXU Pres.
Chicago police Cmdr. Evans dedicated, has detractors
When Chicago police rolled up last summer on a Woodlawn block in response to complaints of a loud outdoor party, leading the charge was Glenn Evans, then the top commander of that South Side police district.
Chicago News, Events & Info
Updated: Sun Aug 31, 2014 03:59 am
Copyright © 2014 Topix LLC


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Article Last Updated: Friday, February 22, 2013 3:23pm
Courtesy Photo
Amanda Ward, daughter of Eunice and Stephen Ward of Cedaredge, Colo. and Micah Conrads, son of Debbie and Larry Conrads of Cortez, were joined in marriage on Oct. 27, 2012, in Cedaredge. Micah and Amanda are students at Colorado Mesa University in Grand Junction. Amanda is completing her BBA of Business Administration while Micah's degree is in Criminal Justice. Micah is goalkeeper for the university's soccer team and a member of the Army Reserves. Amanda is employed on campus.
By By Sarah Elizabeth Walker Moore
Email announcements to firstname.lastname@example.com and include "Community Calendar" in the subject field. Items submitted less than two weeks in advance will be less likely to be published. Entries may be edited for length and content.Friday, Saturday Aug. 22 & 23Biennial Dolores Mountain Quilters Quilt Show Friday from 9 a.m. to 6 p.m. and Saturday from 9 a.m. to 4 p.m. at the Dolores Community Center.


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In our view, dashboards have the following characteristics:
We took at stab at delineating five distinct types of dashboards:
1) Business Intelligence Dashboards
These display detailed information about a particular area of an organization's operations. Many customer relationship management systems, for example, like Salesforce and Raiser's Edge, include dashboards to make it easier for the development staff to track fundraising activities, donations, and other performance measures. Fundraising and advocacy management tools like Convio use dashboards to display campaign status. Google Analytics, with its robust dashboard system displaying key web site metrics, is another example. Technical dashboards help specialized staff keep a close watch on what's happening within their organizational purview. Technical dashboards are typically inward facing, so that only staff and perhaps board members can view them, but they can be outward facing as well. The Indianapolis Museum of Art's dashboard is an oft-cited example.
2) Status Dashboards
Organizational status dashboards, like the one the software company Panic described on their blog, are another variant. In contrast to technical dashboards, which tend to focus on a single functional area within an organization, status dashboards display less information from a wider range of functional areas across an organization. A status dashboard is the answer to the question: what is the critical information everyone in the organization should be able to view all the time? Rather than probing deeply into any one area of an organization's operations, they offer a broader overview of value to everyone.
3) Accountability Dashboards
Increasingly, we are seeing dashboards used in external accountability contexts: a nonprofit or local government that wants to share its real-time performance data with its donors and its community. The Town of Oro Valley in Arizona maintains a financial dashboard displaying the town's financial performance compared to past trends. It's not a great example in that it is only updated monthly, and not in real-time, but it's at least in the ballpark. Over at PlaceMatters (where I spend part of my week), we've been doing a lot of work on sustainability dashboards, web-based tools that openly share a community's performance against its sustainability goals. Incidentally, we described the Indianapolis Museum of Art dashboard as a Technical Dashboard because of its depth, but it really serves as an Accountability Dashboard as well.
4) Tracking Dashboards
These can be inward or outward facing, and typically show visualizations of unfolding data streams in real-time. These aren't organizational in nature but, rather, are tracking events that are taking place outside the organization. The data stream may have implications for an organization, but it isn't specific to that organization. Al Jazeera's "Region in Turmoil" dashboard shows the volume of Twitter traffic by country in the Middle East as a proxy for the level of political activity.
5) Scenario Comparison Dashboards
These are typically designed to compare likely outcomes of a range of future scenarios across a range of key metrics. For instance, MetroQuest uses dashboards to compare multiple regional development scenarios across factors. CommunityViz, a GIS-based data visualization and decision support tool, allows user to analyze the environmental and other community outcomes from a range of land use scenarios, and it uses dashboards to display those outcomes across a range of factors.
We shouldn't entirely neglect the category of "Displays That Are Called Dashboards But Aren't." It probably isn't useful to use 'dashboard' to refer to web pages full of relatively static narrative information, for example. One example is the recycling portion of the Emory University Sustainability Dashboard.
We would welcome your thoughts. Does this seem like the right breakdown? Are we missing anything? What are the terrific examples of each category?


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|Medical Foods for Celiac Patients
Excerpted from materials developed by Robert Moore, Ph.D. Section on Nutrition, Food and Drug Administration (FDA)
Introduction: The question is: Should there be a category of medical foods for patients with the conditions of nontropical sprue and dermatitis herpetiformis? The Food and Drug Administration (FDA) is soliciting comments to initiate a reevaluation of its approach to the regulation of the broad group of heterogeneous products that are marketed as medical foods. FDA's goal is to arrive at a regulatory regime that will ensure the following goals:
The agency believes that there is a need to reevaluate its policy for regulating medical foods because of a number of developments, including enactment of a statutory definition of "medical food". The rapid increase in the variety and number of products that are marketed as medical foods, safety problems associated with the manufacture and quality control of these products, and the potential for fraud as claims that are not supported by sound science proliferate for these products.
Background. One of the first medical foods to be developed was the infant formula. Lofenalac, product that was designed for use in the dietary management of a rare genetic condition known as Phenylketonuria (PKU). This product contains only a very limited amount of the essential amino acid phenylalanine because the individuals with this condition have an impaired ability to metabolize this amino acid. If infants with PKU consume foods that contain phenylalanine, harmful end products of phenylalanine metabolism accumulate in the body and can cause severe, irreversible mental retardation. Dietary management to carefully limit phenylalanine intake (for example, by using a formula that provides only a limited, minimal amount of this essential amino acid) can result in normal growth and development and avoid mental retardation.
Before 1972, FDA regulated products like the infant formula Lofenalac as drugs under section 201(g)(1)(B) of the Federal Food, Drug and Cosmetic Act (the act) (21U.S.C. 321(g)(1)(B) because of their role in mitigating serious adverse effects of the underlying diseases. In 1972, FDA reassessed its position. At that time, such products were very limited in number and were being produced by a small number of reputable manufacturers with high standards of quality control. Additionally, the nutritional formulation requirements for this type of product were straightforward and well-established by the medical community. FDA believed that the usefulness of these products in patient populations was widely accepted by health care professionals, and that close physician supervision ensured safe use in the patient population. The agency was interested in fostering innovation in the development of these products, most of which had been developed for the dietary management of diseases and conditions that are not widespread, to ensure that such products would be available at reasonable cost.
For all these reasons, the agency concluded that a revision of its regulatory approach to these products was appropriate. At the same time, the agency recognized that use of these products for feeding healthy individuals could be hazardous. For example, an infant formula that was purposely formulated to be suitable for an infant with PKU would be nutritionally inadequate for a normal infant. Thus the agency saw that it was important to differentiate these products from foods for general use. As a result, in 1972, FDA stated that the PKU product described above would no longer be regulated as a drug but rather as a "food for special dietary use". (37 FR 18229 at 18230, Sep 8 1972). In addition, the agency began to follow a policy of regulating similar types of products as foods for special dietary use.
Since 1972, the legislative and regulatory history of medical foods has reflected the agency's efforts to develop a regulatory framework to ensure the safety and nutritional adequacy of foods that are designed to meet distinctive nutritional requirements resulting form diseases or health conditions. Medical foods are used under the supervision of a physician when such distinctive nutritional requirements cannot be met with a conventional diet. These characteristics have led the agency to exempt medical foods from many of the requirements that apply to conventional foods.
When FDA made nutrition labeling mandatory for certain foods in 1973, the agency exempted certain types of foods for special dietary use from this requirement. In the preamble to the 1973 final rule on nutrition labeling (38 FR 2124 at 2126, Jan 19 973), FDA noted that nutrition labeling developed for foods intended for consumption by the general population was not well-suited for some food products, including two types of foods for special dietary use: 1) Any food represented for use as the sole item of the diet; and 2) foods represented for use solely under medical supervision in the dietary management of specific diseases and disorders. Therefore, this final rule provided that these two types of foods for special dietary use would be exempt from the general requirements for nutrition labeling and were to be labeled in compliance with regulations that the agency intended to include in 21 CFR part 125 (later redesignated as 21 CFR part 105).
The Orphan Drug Amendments of 1988 enacted, for the first time, a statutory definition of "medical food:"
The term "medical food" means a food that is formulated to be consumed or administered entirely under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. (21 U.S.C.360ee(b)(3)
In the Nutrition Labeling and Education Act of 1990 (the 1990 amendments), Congress incorporated the definition of medical foods contained in the Orphan Drug Amendments of 1988 into section 403(q)(5)(A)(iv) of the act (21 U.S.C. 343(q)(5)(A)(iv) and exempted medical foods from the nutrition labeling, health claim, and nutrient claim requirements applicable to most other foods. The Federal Register of Nov 27 1991 (56 FR 60366 at 60377), FDA published a proposal to implement the mandatory nutrition labeling provisions of the 1990 amendments. This proposal discussed the statutory exemption for medical foods and advised that the agency considered the statutory definition of medical foods to "narrowly constrain the types of products that can be considered to fall within this exemption."
In the Federal Register of January 6, 1993, FDA published several final rules implementing the 1990 amendments. The final rule on mandatory nutrition labeling (58 FR 2079 at 2151, January 6, 1993) exempted medical foods from the nutrition labeling requirements and incorporated the statutory definition of a medical food into the agency's regulations at 101.9(j)(8)(21 CFR 101.9(j)(8). In this regulation, FDA enumerated criteria that were intended to clarify the characteristics of medical foods. The regulation provides that a food may claim the exemption from nutrition labeling requirements only if it meets the following criteria in 101.9(j)(8):
In the preamble to the final rule on mandatory nutrition labeling, FDA noted that it had received a number of comments asking for further clarification of the types of products that the agency considers to be medical foods. The agency acknowledged that such clarification would be helpful and announced that it intended to address the issue in the future (58 FR 2079 at 2151). In the same document, the agency also noted the need for labeling regulations for medical foods and reiterated its intention to propose such regulations.
In 1990, the Life Sciences Research Office of the Federation of American Societies for Experimental Biology (LSRO/FASEB) published "Guidelines for the Scientific Review of Enteral Food Products for Special Medical Purposes" (Ref 1). This report defined medical foods as products that are distinct from foods for special dietary use in that they "demonstrate greater suitability for nutritional management of a specific disease than standard enteral formulas" and are intended for patients with special medically determined nutrient requirements, the dietary management of whom cannot be achieved by the modification of the normal diet alone, by other foods for special dietary uses, or by a combination thereof. The report proposed criteria that would establish a strict standard that a food would have to meet to be considered a medical food. LSRO/FASEB's proposed definition of a medical food did not include all foods that might be useful for persons with a disease or medical condition.
Reasons for Re-evaluating Regulation of Medical Foods
Introduction. The agency is re-evaluating its policy for regulating medical foods in light of several developments, including the enactment of a statutory definition of "medical food," the impact of the 1990 amendments, the rapid increase in the variety and number of products that are marketed as medical foods and in the uses for which these products are marketed, safety problems associated with the manufacture and quality control of these products, and the resulting potential for injury to consumers and fraud as claims that are not supported by sound science proliferate for these products.
The Definition of "Medical Food" and the Impact of the 1990 Amendments: The Medical Food Paradox. The statutory definitions of "medical food" (21 U.S.C. 360ee(b)(3) and food for special dietary use (see section 411(c)(3) of the act), and the differing treatment of these two categories of products under the 1990 amendments to the act (i.e., medical foods are exempted under section 403(q)(5)(A)(iv) and (r)(5)(A) of the act, while there is no special treatment of foods for special dietary use), establish that Congress intended that medical foods and foods for special dietary use be viewed and regulated as separate and distinct categories of products. Foods for special dietary use are subject to the same nutrition labeling requirements and requirements for health claims and nutrient content claims established for most other foods by the 1990 amendments. Thus, foods for special dietary use, like ordinary foods, must be labeled with certain nutrition information in a prescribed format to ensure that such information is presented in an informative and understandable fashion. Moreover, any nutrient content claims or health claims on the label or in the labeling of a food for special dietary use must have been authorized by FDA to ensure that the claim is scientifically valid and is presented in such a way that it is truthful and not misleading.
In contrast, under the 1990 amendments, medical foods are specifically exempted from the requirements for nutrition labeling, nutrient content claims, and health claims. Thus, a medical food that is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements have been established may be sold without any nutrition information on its label or labeling, and it may bear claims that have not been evaluated under the 1990 amendments to ensure that they are scientifically valid. Moreover, there is no assurance that the formulation of a medical food has been evaluated prior to sale to ensure that it is suitable for the intended patient population. The exemption from the requirements of the 1990 amendments, therefore, creates a troubling paradox: medical foods intended for use by sick people are subject to much less scrutiny than virtually all other foods, which are intended for the healthy general population. This lack of scrutiny creates a situation that could have averse public health consequences if these products bear claims that are not scientifically valid, or if their labeling does not disclose nutrition or other information that is necessary for the safe and effective use of the food.
Universe of Products. The number and variety of products marketed as medical foods, the number and types of claims made for such products, the types of ingredients included in these products and the number of manufacturers of these products have increased significantly since the mid-1970s. In 1974, a limited survey of pharmaceutical and food manufacturers revealed that fewer than three dozen products were being sold as medical foods (Ref 2). As of 1989, however, well over 200 products were being sold as medical foods (Ref 2).
However, many products marketed as medical foods may not qualify as such under the statutory definition of medical foods. Many of these products, for example, complete liquid nutrition products, are not formulated or promoted for the dietary management of a particular disease or condition but rather are formulated and marketed for use by the general population as supplements to a normal diet or as meal replacements.
Enteral nutrition is nutrition provided through the gastrointestinal tract, taken by mouth or provided through a tube or catheter that delivers nutrients beyond the oral cavity (i.e., directly to the stomach or small intestine). This document uses the term "enteral nutrition products" to refer to products that have been marketed as medical foods; "statutory medical foods" to refer to enteral nutrition products that meet the statutory definition of a medical food in section 5(b)(3) or the Orphan Drug Amendments (21 U.S.C. 360ee(b)(3); and "nonstatutory enteral nutrition products" to refer to enteral nutrition products that have been marketed as medical foods but that do not meet the statutory definition of a medical food.
Enteral nutrition products labeled and marketed as medical foods are generally liquid or powdered products formulated to meet specific needs. They include nutritionally complete formulations (such as modular products that contain only one nutrient or a small number of nutrients and that are intended for use with other formulations), formulations for metabolic disorders (including inborn errors of metabolism) in patients over 12 months of age, and oral rehydration products. While many such products are intended to provide a complete source of nutrition and are consumed orally or administered by feeding tube for this use, the labeling of such products frequently bears claims related to an intended use of the product in the management of a disease or condition, e.g., in alleviating specific symptoms and clinical manifestations of a particular disease.
Safety Problems. As discussed above, there has been a dramatic increase over the past 20 years in the number and types of products that purport to be medical foods. The number of manufacturers producing these products has also increased. As the number of manufacturers has grown, the level of industry experience in the current food manufacturing practice (CGMP) and quality control procedures necessary to produce products that contain nutrients within a narrow range of declared label values has become quite variable. Medical foods are complex formulated products, generally requiring sophisticated and exacting technology comparable to that used in the manufacture of infant formulas and drugs. Moreover, the populations that consume these products, often as the sole or a major source of nutrition, are extremely vulnerable, e.g., pediatric patients in periods of growth and development, the elderly, patients who have serious illnesses, and patients in intensive care units. Although excessive or, conversely, insufficient amounts of particular nutrients may not be a health hazard when consumed by healthy persons, serious adverse consequences (even death) may result when these vulnerable populations consume these products for long, or even short periods of time.
Significantly, in recent years, FDA has become aware of some serious problems with foods that purport to be medical foods. In 1986, four infants died as a result of being fed an oral rehydration solution that contained lethal concentrations of potassium. FDA identified the oral rehydration solution as the cause of these deaths (Ref 4), inspected the site where the product was manufactured, and analyzed the product's nutrient content. FDA determined that elevated amounts of potassium occurred in the product because CGMP had not been followed. Notably, weighing scales were used improperly, and persons responsible for the formulation of product lacked adequate training.
Results of a compliance program that FDA initiated for medical foods in 1988, and follow-up on adverse reactions reported to the agency, have identified examples of deviations from CGMP that have caused the actual nutrient content of the product to deviate significantly from the declared label value. Some deviations have been significant enough to create acute, life-threatening health hazards and have led to product recalls. For example, in 1989, problems with a nutritionally complete product containing excessive amounts of potassium and sodium were brought to the FDA's attention as a result of complaint from the Veterans Administration Medical Center in Nashville, TN. Administration of this product to a patient resulted in hyperkalemia, or elevated blood potassium levels, which can have life-threatening consequences, including fatal cardiac arrhythmia. This patient required intensive medical treatment to reduce blood potassium levels and to prevent the serious side effects of hyperkalemia. FDA inspection of the facility that had manufactured this product revealed serious flaws in CGMP. These flaws resulted in extreme variability in product composition between lots or individual packets of product, which became evident when the product was analyzed by FDA for nutrient composition. This product was recalled. (Ref 5).
In 1993, in response to a complaint to FDA from a medical center in Seattle, WA, FDA analysis of a complete nutritional product being administered internally to patients contained levels of potassium that were approximately twice the amount declared on the label. The agency concluded that this product represented an acute, potentially life-threatening hazard to persons with impaired kidney function, particularly those who were not being closely monitored for serum potassium levels. As a result, a number of products were recalled. (Ref 6).
FDA is also aware of problems involving potential microbiological contamination of products that purport to be medical foods. For example, in 1993, a modular product containing protein and a modular product containing carbohydrate were recalled because they had been manufactured under conditions in which they may have been contaminated with Salmonella (Ref 7).
Claims and the Potential for Economic Fraud. FDA has not, to date, undertaken a comprehensive review of the claims being made for products that purport to be medical foods but rather has evaluated claims for a small number of these products on a case-by-case basis, applying the following general principles:
A product marketed for use as a medical food in the dietary management of a disease or condition should have characteristics that are based on scientifically validated distinctive nutritional requirements of the disease or condition.
There should be a scientific basis for the formulation of the product and the claims made for the product.
There should be sound, scientifically defensible evidence that the product does what it claims to do.
The agency is concerned that some of the claims made for products that purport to be medical foods are not based on sound science, and that consumers that use products that bear such claims, and health professionals that recommend the use of such products, are being misled regarding the value of these products. In addition to the health risks created by unsafe or ineffective medical foods, consumers and third-party payers, such as insurance companies and government health care agencies, suffer significant economic losses when products marketed as medical foods do not do what they claim to do.
A number of publications by and for health care professionals express concern about unsupported claims for foods that purport to be medical foods. For example, a recent edition of a book published by the United States Pharmacopeial Convention, Inc. USP DI Vol I, Drug Information for Health Care Professional (Ref 8), lists enteral nutrition products that are formulated to meet nutrient requirements for individuals with specific diseases but states: "In general, scientific evidence for efficacy of these products is weak and requires further study." The 1990 LSR)/FASEB report "Guidelines for the Special Medical Purposes" (Ref 1) noted that products containing substances such as essential amino acids, peptides, and medium-chain triglycerides were available, and that such products were represented as being useful for the dietary management of diseases and disorders. However, the report also stated that clinical trials of these preparations were limited, and that "none has fully confirmed or refuted the putative advantage of these products over ordinary nutritionally adequate preparations."
Clarification of the Medical Food Definition
In the preamble to one of the proposed rules implementing the 1990 amendments. FDA advised that it considered the statutory medical food definition to narrowly constrain the types of products that can be considered to be medical foods (56 FR 60366 at 60377). As noted previously in this document, however, the agency recognizes that the universe of products that purport to be medical food to include foods that are more appropriately foods for special dietary use. In part, this expansion has occurred because many have difficulty distinguishing between medical foods and foods for special dietary use. While the agency recognizes that some ambiguity exists in the distinction between these two types of foods, the statutory language provides several bases on which to distinguish medical foods from foods for special dietary use.
"Distinctive Nutritional Requirements"
A fundamental element of the medical food definition that distinguishes this type of product from a food for special dietary use is the statutory requirement that a medical food be intended to meet distinctive nutritional requirements of a disease or condition. Under 21 U.S.C. 360ee (b) (3), distinctive nutritional requirements must be based on recognized scientific principles and established by medical evaluation. The law does not define what constitutes a "distinctive nutritional requirement" will best protect and promote the public health. The agency is suggesting two possible interpretations of this phrase.
"Physiological Interpretation of "Distinctive Nutritional Requirement"
"Distinctive nutritional requirement" may be interpreted to refer to the body's requirement for specific amounts of nutrients to maintain homeostasis (the state of equilibrium in the body with respect to various functions and the chemical compositions of the fluids and tissues) and sustain life; that is, the amount of each nutrient that must be available for use in the metabolic and physiological processes necessary to sustain life.
The nutritional requirements of healthy people for specific nutrients reflect their quantitative and qualitative requirements for absorbed nutrients (i.e., the physiological requirements for the nutrient), with adjustments for common inefficiencies associated with absorption, metabolism and retention. However, the dietary management of patients with specific diseases requires, in some instances, the ability to meet nutritional requirements that differ substantially from the needs of healthy persons. For example, in establishing the recommended dietary allowances for general, healthy population, the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences recognized that different or distinctive physiologic requirements may exist for certain persons with "special nutritional needs arising from metabolic disorders, chronic diseases, injuries, premature birth, other medical conditions and drug therapies (Ref 9). Thus, the distinctive nutritional needs associated with a disease reflect the total amount needed by a healthy person to support life or maintain homeostasis, adjusted for the distinctive changes in the nutritional needs of the patient as a result of the effects of the disease process on absorption, metabolism and excretion. These distinctive nutritional requirements may be greater than, less than, or in a narrower range of tolerance that for an otherwise healthy individual.
Under this physiological interpretation of "distinctive nutritional requirements, "medical foods" are foods that are formulated to aid in the dietary management of a specific disease or health-related condition that causes distinctive nutritional requirements that are different from the nutritional requirements of healthy people. Foods for special dietary use, on the other hand, are foods that are specially formulated to meet a special dietary need, such as a food allergy or difficulty in swallowing, but that provide nutrients intended to meet ordinary nutritional requirements. The special dietary needs addressed by these foods do not reflect a nutritional problem per se; that is, the physiological requirements for nutrients necessary to maintain life or homeostasis addressed by foods for special dietary use are the same as those formulated in such a way that only the ingredients or physical form of the diet is different. For example, a person who has difficulty swallowing solid food may have a special dietary need for a food that is in liquid form, but this special dietary need does not change his or her physiologic nutrient requirements. Similarly, a person who is allergic to specific food proteins (e.g., gluten) may need foods specially-formulated food not to contain these proteins. However, the specially-formulated food still would provide the same amount of protein (i.e., amino acids) as needed by the general population because the quantitative and qualitative amount of protein required by the body is similar in both healthy and protein-sensitive patients. Thus, foods for special dietary use are foods that are intended to meet ordinary nutritional requirements through special dietary means.
Alternative Interpretation of "Distinctive Nutritional Requirements"
"Distinctive nutritional requirement" may also be interpreted to encompass physical or physiological limitations in a person's ability to ingest or digest conventional foods, as well as distinctive physiological nutrient requirements. The FASEB report on medical foods stated that medical foods are for "patients with limited or impaired capacity to ingest, digest, absorb or metabolize ordinary food-stuffs or certain nutrients contained therein, or (who) have other specially medically determined nutrient requirements" (Ref 1). This definition would include uses that a purely physiological definition of "distinctive nutritional requirements" would exclude, such as foods intended for persons not able to ingest foods in certain physical forms (e.g., solid food), foods intended for persons who need a concentrated form of nutrition because of reduced appetite as a result of disease or convalescence), or foods intended for persons who may have other physical limitations on the amount or composition of food that they can consume. Although these types of conditions do not necessarily result in nutrient needs different from those of healthy persons, they represent a situation where it may be necessary that the food be formulated and manufactured within very narrow tolerances to ensure that the food provides most or all of the essential nutrients, as the persons for whom the food is intended may not be able to eat a variety of foods to ensure that they meet their nutrient requirements.
Therefore, it may be appropriate to define "distinctive nutritional requirements" to include those requirements that result from a disease or condition that cause a physical or physiological limitation in the ability of a person to ingest or digest conventional nutrient sources and result in that person needing specially formulated foods to meet part or all of their daily nutrient needs. Defining this term in this way may be appropriate because these circumstances create nutritional needs that are more narrowly defined than those of healthy persons, because the patient is relying on only a limited number of foods or a single food for sustenance. The agency asks for comments on whether persons with an impaired ability to ingest or digest specific foods because of a disease or condition, or who have physical or physiological limitations that cause them to rely on an enteral nutrition product for a significant part or all of their nutrient needs, have "distinctive nutritional requirements" within the meaning of the medical food definition.
"Under the Supervision of a Physician"
The second element of the medical food definition that distinguishes a medical food from a food for special dietary use is the statutory requirement that a medical food be "formulated to be consumed or administered internally under the supervision of a physician." As stated in the preamble to the proposed rule implementing the nutrition labeling requirements of the 1990 amendments (56 FR 60366 at 60377). "under the supervision of a physician means that the intended use of a medical food is for the dietary management of a patient receiving active and ongoing medical supervision (e.g., in a health care facility or as an outpatient). The physician determines that the medical food is necessary to the patient's overall medical care, and the patient consults the physician on a recurring basis.
Medical foods are intended for the dietary management of patients who have a short-term or long-term medical need for a particular nutrient or combination of nutrients to meet distinctive nutritional requirements. The use of a medical food requires ongoing physician oversight to ensure that the food effectively meets the distinctive nutritional requirements of the patient's disease or condition, and that the use of an enteral medical food is the appropriate means (i.e., as opposed to a patient requiring a parenteral nutrition product) to meet the patient's distinctive nutritional requirements. Therefore, medical foods are foods that are an integral component of the clinical management of a patient. Medical foods are not foods simply recommended by a physician as apart of an overall diet designed to reduce the risk of a disease or medical condition to lose or maintain weight, or to ensure the consumption of a healthy diet. Foods recommended by a physician for these purposes may be foods for special dietary use, but they are not medical foods.
"Specific Dietary Management"
The third fundamental element of the definition of a medical food that distinguishes a medical food from a food for special dietary use if the statutory requirement that a medical food be intended for the specific dietary management of a disease or condition. The term "specific dietary management" in the statutory definition of medical foods evidences that Congress intended these foods to be an integral part of the clinical treatment of patients. Consistent with this interpretation of this term, the LSRO/FASEB Panel concluded that the objectives on incorporating the use of medical foods into patient management were, in no part, to "ameliorate clinical manifestations of the disease process," and "positively influence morbidity and morality (patient outcomes)" (Ref 1). There is no language corresponding to specific dietary management" in the statutory definition applicable to foods for special dietary use. Thus, although they may be useful in supplying the special dietary needs of patients who have a disease or other condition that prevents them from eating normally, foods for special dietary use, unlike medical foods, are not specifically tailored for use as the nutritional component of the patient's treatment.
The statutory definitions of medical foods and foods for special dietary use overlap to the extent that both categories encompass foods that are intended for use by sick people. The differences in the statutory definitions evidence, however, that Congress intended foods for special dietary use under section 411(c)(3)(A) of the act to be a broader category of foods for use by people with special dietary needs or desires, while it intended medical foods to be a narrower category of foods for use by people with particular diseases or conditions that have distinctive nutritional requirements. Since medical food must address the "distinctive nutritional requirements" of a disease or condition, a medical food is suitable only for use by patients with that disease or condition. Of course, it is possible for more than one disease or condition to create the same distinctive nutritional requirements. A product that is intended to address the distinctive nutritional requirements of a particular disease is a medical food, even though some of those requirements may also be created by other diseases. A product that is designed to address a problem that is common to several diseases, but not the full-range of requirements of any specific disease, would be a food for a special dietary use. For example, the distinctive nutritional requirements of burn patients include a greater energy requirement due to hypermetabolism and a requirement for dietary glutamine because endogenous synthesis of this amino acid does not meet the metabolic requirement. Thus, a product formulated to meet the higher energy requirement due to the hypermetabolic state, but which does not meet the requirement for glutamine, would be a food for special dietary use and not a medical food because it does not meet the full range of distinctive nutritional requirements in patients with burn injuries.
Need for Substantiation of Nutritional Efficacy and Claims Made in Product Labeling
Because of their intended use in supplying the distinctive nutritional needs of patients who are ill or otherwise medically vulnerable, it is essential that medical foods be appropriately formulated for the particular disease or condition for which they are labeled. Moreover, because the statutory definition of a medical food provides that these foods are part of the clinical management of a disease or condition, the definition necessarily incorporates a requirement that the product actually meet the distinctive nutritional requirements for the disease or condition. It is not enough that a manufacturer merely declare or subjectively intend that the product be used for the dietary management of patients with certain disease or conditions. If the product, as formulated and consumed, does not actually meet those requirements, it would violate the act. Under any other view, the medical foods category would merely create a safe harbor for fraudulent claims targeted at those who are most vulnerable.
Other elements of the statutory definition support this view. In defining the term "medical food" in the Orphan Drug Amendments, Congress included the requirements that distinctive nutritional requirements of a disease or condition exist, and that they be based on recognized scientific principles and established by medical evaluation. Thus, Congress established a strict standard for when a food qualifies as a medical food. The establishment of this strict standard for distinctive nutritional requirements necessarily implies an exception that this standard will in fact be net.
Acceptance of the manufacturer's intent that the product meets the special needs of the disease, without objective information to support the manufacturer's intent, would establish a subjective standard that would provide no assurance that the statutory has been met. Moreover, such a standard would ignore the fundamental differences between a medical food and other types of food. As stated above, a medical food is intended for use as the source of nutrients that are necessary in the medical management of a particular disease or condition. Thus, it is crucial to the health of the patient. No other type of food, including food for special dietary use, has such a direct relationship to the health of an individual. It is therefore necessary that the physician be able to rely on the medical food to effectively meet the distinctive nutritional requirements of the patient.
Finally, the statutory scheme for regulation of claims relating to health and disease confirms the appropriateness of a strong standard for substantiation of the nutritional efficacy of medical foods. The act establishes a range or circumstances under which claims relating to health and disease may be made. At one end of the spectrum are conventional foods which under section 403(r) of the act bear a health claim only if FDA determines:
At the other end of the spectrum are drugs, whose effectiveness in diagnosing, curing, mitigating, reting or preventing disease must be established by substantial evidence defined as:
Evidence consisting of adequate and well-controlled investigations, including analytical investigations by experts qualified with scientific training and experience of the drug involved on the basis of which it could fairly and responsibly be concluded by such experts that the drug will have the effect it purports or it is represented to have under the conditions of use prescribed, recommended or suggested in the labeling or proposed labeling thereof. (Section 505 (d)(7) of the act (2FAS.C.355(d)(7).)
Clearly, medical foods fall somewhere between these two points, and the statutory scheme thereof requires some level of substantiation for medical food's claimed usefulness in the dietary management of disease.
When Congress enacted authorization for health claims on conventional foods, it provided that such claims would be permitted only if FDA determined that the substance-disease relationship that is the subject of the claim is supported by significant scientific agreement among experts. The House Report for the 1990 Amendments states "The standard is intended to be a strong one. The bill requires that the Secretary have a high level of confidence that the claim is valid" (Ref 10). The establishment of a "strong" scientific standard was necessary to ensure that claims were supported by adequate scientific evidence so that they would not be misleading, and so that consumers could have confidence in the scientific validity of the claimed substance-disease relationship. Thus, even a health claim for a food intended to used by healthy individuals must meet a high standard.
The reasons for requiring a strong standard of substantiation apply with even more force to medical foods. The statutory definition of a medical food states that such a food must be intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. As discussed earlier, this aspect of the definition makes it clear that Congress intended that claims made for medical foods be supported by scientific evidence, and it also constitutes a scientific standard that must be met for a food to be a medical food. The nature of these products (i.e., from health claim requirements applicable to conventional foods) provided for them by virtue of their status as medical foods necessitates at least as much substantiation to support claims made for medical foods as for health claims on conventional foods. It would make no sense to establish a standard for claims on medical foods that was lower than the standard for health claims that are made for foods sold to healthy people.
The agency is concerned that many claims made for products marketed as medical foods are not supported by adequate scientific evidence, and that these unsupported claims result in the inappropriate use of some products by patients and physicians when effective alternative nutritional strategies for managing the disease are available. One medical expert on enteral nutrition formulas voiced this concern by stating that since the:
A physician relies on the claims made for medical foods on their labels and in their labeling as a significant factor in deciding whether to use a particular medical food in the clinical management of a patient. Thus, it is essential that the claims made for such a product present an accurate interpretation of the scientific evidence concerning the usefulness of that product or specific formulation. Is it critical for the safe and appropriate use of the medical food that the claims made for it are accurate and unbiased, and that they are based on a critical evaluation of the science available to the manufacturer. The need for physicians and patients to have confidence that any claim that a product is a medical food formulated for the specific dietary management of a disease or condition requires that a strong standard of substantiation be in place. A strong standard of substantiation would be one that requires that all pertinent data be considered in the formulation of any claims about its use.
Further, the misbranding provisions of the act do not permit a food, including a medical food, to bear misleading labeling claims (section 403(a) of the act). Claims may be misleading not only because of affirmative representations made in the labeling, but also because the labeling fails to reveal facts material in the light of such representations with respect to consequences which may result from the use of the food under the conditions of use prescribed in the labeling or under usual or customary conditions of use (section 201(n) of the act). Thus, a medical food that bears claims that are not based on all the information available, and that do not permit the consumer or physician to make an informed choice, may be misbranded.
In summary, the intended uses of medical foods, the statutory definition of a medical food, and the statutory scheme for regulating health and disease claims all point to the need for a strong standard of scientific evidence for the composition and effectiveness of medical foods to provide assurance to health care providers and patients of the nutritional utility of these products. The standard should be no less demanding than for health claims for foods intended for the healthy general population. Moreover, because medical foods are intended for use in the clinical management of seriously ill and injured patients, it may be appropriate and necessary to apply a more stringent standard to the scientific evidence used to support claims made for medical foods. The agency's preliminary view is that the scientific standard contained in the statutory medical food definition may require some of the same types of data for medical foods as are needed to support drug claims (e.g., date from clinical investigations). The agency asks for comments regarding how stringent a scientific standard is necessary to ensure the safe and appropriate use of a medical food for a particular disease or condition.
Agency Plans for FDA
The agency is soliciting comments to initiate a reevaluation of its approach to the regulation of the board group of heterogeneous products marketed as medical foods and whether this approach serves the best interests of the consumers of such products. If the current regulatory approach is not adequate, the agency is interested in how it can improve the regulatory regime for medical foods to best serve those interested. FDA will review and consider all comments received. While this reevaluation is ongoing, however, the agency advises that it intends to continue to take regulatory action when necessary to protect consumers from unsafe or fraudulent products marketed as medical foods.
Economic Issues
Under Executive Order 12866, FDA will be required to consider the costs and benefits of any proposed regulations pertaining to medical foods when regulations are proposed. In addition, under the Regulatory Flexibility Act and the Small Business Regulatory Enforcement and Fairness Act, FDA will be required to consider the impacts on small entities of such regulations.
The primary benefit of any proposed change in the requirements applicable to medical foods will be a reduction in the health risks posed by medical foods that specify the level of scientific support required to make claims concerning the product will mean that consumers will have assurance that the claims are valid, and that the claims that are made provide reliable information. Other benefits will derive from the elimination of fraudulent and unsupported claims which will save consumers and third-party payers money and will improve patient health because people will use products that are appropriate for their conditions instead of relying on those bearing unsupported claims that do not have a positive impact on their conditions.
FDA asks for comments and information of the current health risks posed by medical foods meeting existing CCMP, labeling and other applicable regulations. FDA also asks for comments on the degree to which these health risks may be reduced by additional regulation of medical foods, such as quality control requirements and additional CGMP and labeling regulations.
The primary cost of any proposed change will be the difference between the current cost of producing and marketing medical foods and the anticipated cost of producing and marketing medical foods under the proposed change. For example, relevant costs may include the cost of changing labels, generating particular types of information for labels, changing production methods or facilities to accommodate new CGMP requirements, the generation of additional information to establish product safety and effectiveness, and the cost of any uncertainty or delays associated with a potential premarket notification process.
FDA asks for comments on the costs that would be generated if medical foods were subject to additional regulatory requirements, such as quality control requirements, specific CGMP requirements and labeling regulations. FDA also asks for comments on the impacts on small entities that would result if medical foods were subject to additional regulatory requirements of the type discussed in this document.
Summary and Questions for Reaction
Patients rely on medical foods to meet the distinctive nutritional needs resulting from their disease or condition, and, therefore, medical foods are often a significant part of the clinical management of these patients. Despite the importance of medical foods, however, existing regulations do not provide clear guidelines on what products should be considered to be medical foods or on requirements to ensure that these foods do what they purport to do and are safe for their intended use. There is no regulatory framework that establishes specific quality assurance requirements, ensures the safety of medical foods under their intended conditions of use, ensures that they provide the nutrients that they claim to provide with safe ranges, or ensures that the benefits claimed for their purported use are supported by adequate scientific evidence. Therefore, the agency asks for comments on the following questions:
Miscellaneous. Should the present definition of medical foods include a specialty diet [i.e., the gluten-free diet] as needed by celiacs? Consider whether having 20 to 30 prescription medical foods for the gluten-free diet would be helpful for celiac and DH patients. Consider how such a unit of foods would be helpful to celiacs while in hospitals or care centers and those incarcerated in jails. Or, would a prescription group of foods for celiacs really not be necessary? What alternatives would you suggest? What monitoring and what regulations do you see as being helpful to persons on the clinical gluten-free diet and their related health care providers?
CSA Library Series
CSA Library Series is a collection of articles that pertain to celiac disease and dermatitis herpetiformis. Most of these articles have appeared in CSA's quarterly newsletter, Lifeline, which all CSA members receive. Historic articles included in these resources may or may not include updated notes. Updated information indicated in red type. Articles represent the work of the author.


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Encourage organised play and packing away! Kids love colour so why not create fun toy storage with a Blue Modular Kids Cube. A great addition to any toy room or childs room these cubes are perfect for storing toys and books; they're stackable, come with connector pins, they are easy to clean and they look great!
For older children, consider using these cubes to store clothing; or stack two on top of one another and use as a bed side table.


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Effingham Daily News
---- — Roland Smith, 75, of Shelbyville, died at 6:45 p.m. Tuesday, Oct. 29, 2013, in St. Mary's Hospital, Decatur.
Funeral services will be at 2:30 p.m. Saturday at Howe and Yockey Funeral Home, Shelbyville, with the Rev. Don Wallace officiating. Burial will be in Windsor Cemetery. Visitation will be from 1 to 2:30 p.m. Saturday at the funeral home. Memorials may be given to Effingham Assembly or Compassion International. Online condolences may be left at www.howeandyockey.com.
Roland was born on Jan. 17, 1938, in Schenectady, N.Y. He served in the U.S. Army. Roland was retired from United Parcel Service (UPS) in New York, where he was a tractor-trailer driver for 33 years. He was a member of Effingham Assembly. He married Shirley D. Maxey on June 7, 1965, in New York. She died on Aug. 2, 1996.
Roland is survived by his dear friend, Audrey Lucas of Findlay; sons, Anthony Dahm and wife, Kymberli of Chantilly, Va., and Douglas Dahm and wife, Melissa of Ashburn, Va.; brother, Hal; sister, Janice; and four grandchildren, Andrew and Teresa Dahm and Brian and Tyler Dahm.
He was preceded in death by his parents; and wife, Shirley.
Sign the guestbook at www.effinghamdailynews.com.


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|Men's Basketball » News
|» News » Schedule » Roster » Coaches » Stats (PDF) » Stats (HTML) » Big Cypress Basketball Clinic » Records » Archive
Men's Basketball Faces Mercer
Story by Casey Wohlleb
FORT MYERS, Fla. - The Florida Gulf Coast Men's Basketball team looks to even their record in conference play and win their first home conference game as they face the Mercer Bears. The Eagles are 5-11 after a tough loss to the Stetson Hatters. This was their first televised and home conference game in the schools history. The Eagles are currently 1-2 in conference play with a chance to grab a win from Mercer who was picked 3rd in the preseason polls.
Mercer is now 7-9 overall and 2-1 in the league as they suffered a buzzer beater loss (72-70) to the Jacksonville Dolphins who are atop the league currently. The Bears are second in scoring offense and first in field goal percentage in the Atlantic Sun. The Bears explosive offense is lead by sophomore James Florence at 18.1 points per game and senior Shaddean Aaron at 16.1 points per game while both are averaging about four and a half rebounds a game. Mercer is 3-5 on the road and got their single conference road victory at Kennesaw State who FGCU faces Saturday night at Alico Arena as well.
The Eagles are 1st the league in scoring defense and steals per game. Senior point guard Rob Quaintance (Glendale, Az.) leads the Eagles on the defensive end. The 6-4 guard is second in the conference in steals at 2.63 per game. Quaintance is coming off of a career-high 17 points in the Eagles' last game and also ranks among the A-Sun leaders in assists (2nd) and three-point field goal percentage (6th).
It should be a fast paced, quick game that will lead right into the highly dynamic half time show. The Team Flight Brothers are returning to Alico Arena again this time with seven high-flying explosive dunkers including both members who were here for the home opener against Drexel.
The game can heard live on Sportsradio 770 am as Dave Moulton calls the action. The game can also be seen live on ASun.TV. Tickets are still available and can be purchased by calling (239) 590-7145 or by visiting www.fgcuathletics.com/tickets.


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The Islanders will, for once, be moving from the outhouse to the penthouse, but not before some final drama.
The New York Islanders have decided to pack up their stuff and move back in with their parents rather than spend another day dealing with a miserable landlord. (parody)
Part Four of the series. Riding in following the criminal Spano Affair, Steven Gluckstern & the Milstein brothers, Howard & Edward, painted themselves as the Islanders' heroes. Instead, they turned...
Because this is Nassau Coliseum of course the man who helped lure the New York Islanders away will help the arena they left behind.
photo by Bruce Bennett via cdn2.sbnation.com Hope grows in Brooklyn for the once, and perhaps future, model franchise of the NHL. As I've mentioned so many times and in so many places, the...
The Islanders were the NHL's last true dynasty. Now, with the team moving to Brooklyn in 2015, its crystal clear that Nassau County itself did more damage to the dynasty than any other team ever...
Getting arena resolution is a reward for all of the New York Islanders fans who suffered through uncertainty and the leanest of lean years.
As another call is put out to developers for plans for a new Nassau Coliseum, this satire looks at the form interested developers must submit to County offices.
Constantly bickering Nassau County leaders decide to take in "The Dark Knight Rises." What could possibly go wrong?
Nassau County is set to issue an RFQ for developers who would build a new Nassau Coliseum, develop the land around it, and charge rent from the New York Islanders.
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User Reviews & Ratings - Proventil HFA Inhl
Read user comments about the side effects, benefits, and effectiveness of Proventil HFA Inhl.
Overall User Ratings43 Total User Reviews
User Reviews
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Reviewer: Brugor, 75 or over Male on Treatment for 6 months to less than 1 year (Patient)
Ease of Use
I have used it for about six months. I may be getting resistant to it. It used to last 6 hours, now only lasts about 4 hours. I tried Qvar inhaler and Singulair pills, which have no effect on me at all. Proventil is effective, although slower to act than the old albuterol.
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Reviewer: 65-74 Male on Treatment for 1 to 6 months (Patient)
Ease of Use
Reviewer: Gerbil89, 19-24 Female on Treatment for 1 to 6 months (Patient)
Ease of Use
When I feel an asthma attack coming, it helps within about 10 minutes, but the after effects drive me nuts. Sometimes I'd rather deal with the asthma attack. My hands shake, I get a headache, my heart starts racing and sometimes it makes it hard to BREATH. It works when I absolutely need it but I think I might try ProAir instead.
Reviewer: mmartin, 25-34 Female on Treatment for 10 years or more (Patient)
Ease of Use
I have had asthma for 22 years. In the past, I have only had to use my inhaler if I was ill or sometimes following exercise. I'm not sure if my asthma has gotten worse, or if it's a casualty of this replacement inhaler. The new Proventil HFA is NO WHERE CLOSE to being as effective as the old Albuterol inhalers. I am all for decreasing the amount of CFC's we release into the ozone, ... Show Full Comment
Reviewer: betty, 45-54 Female on Treatment for less than 1 month (Patient)
Ease of Use
I have been using this medicine for two weeks now and find that I have to use it more to relieve my breathing. Also now I have muscle cramps in my lower leg. This is one of the side affects, I am going to ask the Dr. if there is anything else I can take to relieve my asthma.
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Family Vacation in Lake Havasu in Lake Havasu
- bedrooms 3
- baths 2
- sleeps 8
- pool no
- hot tub no
- pets allowed yes
- type House
- community
rates (USD)
/ night
$ 700 - $ 900 / week
vacation rental description
Built in 2003, this great 3 bedroom 2 bath, fully furnished home is located in South Lake Havasu on a large corner lot located on a quiet cul-de-sac. Grocery store, restaurants, gas stations, launch ramps & golf courses all within minutes of this exceptional rental.
This house offers Boat & RV parking with 50 AMP hookup. Nice covered patio for nice evenings at home.
This house offers activities for adults & children which includes video games, IPod Docking station, variety of DVD's & games for your enjoyment.
Note: Outside Smoking Only Please!
vacation rental location
property availability
- dates with deals
- unavailable dates
Last modified on 06-6-2014 at 3:31 PM.
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Tim 7608152195
house rental amenities
Master Bedroom:
- Queen size bed
- TV w/ satellite
- Walk-in closet & shower
- Dual vanity (blow dryer included)
Other Bedrooms include:
- Queen size beds
- (1) w/ TV & satellite
- All linens & towels
Fully equipped kitchen w/breakfast bar
Living Room Includes:
- 32" TV w/DVD/CD/VHS & Surround Sound Stereo
- Satellite TV (Channels include but not limited to SPEED, ESPN, HGTV, Animal Planet & music channels)
Laundry Room w/ washer/dryer & water cooler
All rooms include ceiling fans & central A/C & Heating
Stainless BBQ (Propane)
No Garage Access at this time for short time rentals only. One month or more partial garage access. (Sorry)
activities and attractions in Lake Havasu Arizona
Local activities include:
- Boating - Go-Karting - PGA Style Golfing
- Fishing - Desert Exploring - Winter Swamp Meets
- Water skiing - Movie Theater - Casino Gaming across the river
- Jet skiing - In-door water park - National Jetski & Boat Races
"The Shops at Lake Havasu", (Dillards, JC Penny, Walmart Supercenter, PetSmart & Other Shops & Resturants)
Day/Overnight Trips to:
Laughlin (within 1 hour)
Las Vegas (within 2 1/2 hours)
Phoenix (within 3 1/2 hours)
San Diego (within 5 1/2 hours)
Grand Canyon (within 4 hours)
vacation rental rates
Daily Rates:
$189.00 per night (Oct. - Apr.)
Weekly Rates:
$700 per week (Oct. - Apr.)
Monthly Rates:
$1,475 1st month (Oct. - Apr.)
Utilities: Min. $50 charge for less than a month stay. Max $100 for one month.
10% off for all additional months rented
Refundable Security Deposit (Amount depended on length of stay)
Cleaning Fees have been included in published rates.
*Special Discounts available (Fire, Police, Military)
Pets considered with additional deposit
Tim 7608152195
accepted payment methods
Prior to paying a reservation deposit, always verify payment instructions by calling the phone number displayed on this listing page. By contacting the owner directly and paying by an approved method - credit card, paypal, check or bank transfer - your reservation payment will be protected up to $1,000.Learn more in our Security Center


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Ricky Rubio has reportedly agreed to join the Minnesota Timberwolves just two years after David Kahn and the Minnesota Timberwolves made him the No. 5 pick in the loaded 2009 NBA Draft. Back then, it was Kahn's second move at the helm of the Wolves; he had first traded for the pick that became Rubio, sending Mike Miller and change to the Washington Wizards for the selection and some gnarly but not debilitating contracts.
Kahn has made many more decisions since then, most of them bad. He picked Jonny Flynn (another point guard) at No. 6 in 2009, over Stephen Curry, Brandon Jennings, Jrue Holiday and Jeff Teague. (Bad.) He traded the No. 19 pick in 2009 to Denver for a 2010 pick; the 2009 pick became Ty Lawson, the 2010 was flipped to Portland for Martell Webster. (Bad.) He hired Kurt Rambis as head coach in August 2009. (Bad.) He signed Ryan Hollins. (Bad.) He signed Ramon Sessions to block Flynn in the rotation. (Not good.) He traded Brian Cardinal for Darko Milicic. (Hilarious.) He picked Wesley Johnson No. 4 in 2010. (Bad.) He re-signed Darko Milicic. (Hilariously bad.) He traded two second-round picks for Michael Beasley. (Rather good, actually.) He signed Luke Ridnour. (Bad.) To justify Ridnour, he traded Sessions for basically nothing. (Not good.) He traded Al Jefferson for cap space when he already had cap space. (Bad.) He used part of said cap space to trade Corey Brewer for Anthony Randolph. (Good.)
That's a lot of moves in two years ... and those are only the most notable. But it's a stunning record: two wins, nine losses, two draws. That's a .181 winning percentage, stunningly similar to the Wolves' .195 winning percentage (32-132) since Kahn took over. His Losses Over Replacement GM is incredibly impressive.
But none of that matters if those first two decisions -- the decision to grab the No. 5 pick in 2009, and the decision to use it on Rubio -- work out. If Rubio now succeeds, and take the Wolves where Kahn thinks they can go, all the Flynns and Wesleys and even the Darkos will be forgotten and forgiven. If Ricky is the Ricky that David Kahn believes he is, that so many domestic fans believed he was, that so many Spaniards know he is ... then Kahn is golden.
Now what are the odds of that happening?
Time will tell. Our friends at Canis Hoopus are already pleading for Rambis to be fired before he can taint Ricky. Flynn is reportedly on the trading block so that Rubio won't have any challengers in the rotation; Ridnour is the other point guard on the roster, and a willing bench contributor who played behind Brandon Jennings two seasons ago. (Some in the Kings' front office used to compare Ricky to Luke back around the 2009 draft as a way of denigrating the Spaniard; they are no doubt amused by the latest news out of Minneapolis.)
Rubio will be given every chance to succeed by the Minnesota Timberwolves, and little chance to succeed by reality. Minnesota has no shooters; Johnson and Webster are the best bets, and Kevin Love on the pick-and-pop. That's about it. If the Wolves use the No. 2 pick on Derrick Williams, he'll help there and as a finisher at the rim ... but displace Beasley in the process. It's complicated, and there's no easy fix unless Kahn swings a major trade.
But with Rubio in place, those major trades don't look like desperate flails of a failing man. They look like attempts to build a team. Without Ricky? Nothing Kahn did had any semblance of organization. None. The jokes about Kahn's Year of the Point Guard and Year of the Small Forward -- Kahn acquired Beasley and Webster around and picked Johnson, Lazar Hayward and Nemanja Bjelica in 'the 10 draft; every last one is a natural small forward -- are well-worn, but are absolutely telling of the chaos in Minnesota. We make fun of Kahn because he has been terrible at his job. Go read the second paragraph if you don't believe me.
But Rubio can fix it. If Ricky is great, you have two stars. You have an identity that isn't maniacal laughter. If Ricky and Love can mesh around a new coach, and the other parts can sort themselves out, this is a team. Maybe not a great team, maybe not even a good team. But it's something you can actually understand, which is a lot more than be said about the last two incarnations of the Wolves under Kahn.
That's why today's news is so important and so welcome in Minneapolis. That's why Kahn has been busting his ass for two years to convince Ricky to jump the pond. For better or worse, the kid is the new face of the Wolves, and he's the only person on Earth who can vindicate Kahn. Let the task begin.


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Blog Archives
Guild Reputation
Guild reputation was a brand new feature that came out with Cataclysm and combined with the guild perks, rewards, achievements, and other stuff like that. Your guild levels and gets perks, and the more reputation that you have with the guild (by killing bosses in a guild group or doing daily quests), you get access to more of the rewards.
I'm not talking about any of this.
As I had mentioned before, I recently joined the AIE guild with my Death Knight on the Earthen Ring server. I was looking for an alternative place to hang out and find somewhere that had a better raiding schedule. After being in the guild for about a month, I've found that I'm rarely ever spending any time on my Druid anymore and mainly hanging out on my DK.
Many times I'm doing random dungeons for the Valour and Justice points, daily quests, a Baradin Hold run, or whatever the case may be. Yet, I could easily be doing these things on my Druid as he also needs some upgrades as well. At this point, I've all but decided that I will be moving him over to AIE soon-ish.
Getting used to a new guild is tough, and even more tough when there's so many people in it. At any point in time, there's at least over one hundred people online, and it's hard to see familiar faces when there's over 7000 to pick from. That being said, AIE is fortunate in the fact that the guild as a whole is very well run and has a great culture by itself that people seem to embrace easily.
For an example of the guild culture, twice a year they have craft fairs. People give up a ton of materials from each profession to help others level up theirs. I've heard stories of people maxing whatever profession they are (even the annoying ones like Leatherworking and Blacksmithing) within the short period of time that the craft fair is on. This is a guild culture that I can support without a problem.
The Instance podcast has definitely made AIE popular, and is the reason why I decided to join. Yet, even though it was the podcast that got me there, it's the people who keep me there. During BlizzCon, there were a bunch of volunteers who made a guild hall in one of the nearby hotels, which was basically a place for guildies to hang out when they weren't at the convention. Some people flew down there just to go to the hall, rather than the convention itself. Goodie bags were made specifically for this, and it was a whole event contained within that hall.
Just by these few examples, it's obvious why I've decided to try out this guild. The reputation that it has gained from the amazing people who are members is truly awesome.
As a whole, I've had enough experience with AIE that I want to continue my association with them. The reputation that a guild has outside of the reputation panel is extremely important. If you don't enjoy being in a guild, why bother getting Exalted with them?
Does Guild Size Matter?
Guilds have always been a key factor to World of Warcraft and most MMOs. When Cataclysm launched and the guild system was reworked, they became even more integral to the gameplay. While not required to do anything, they make life a whole lot easier with the perks that they provide.
I had mentioned before that I created a new character on a different server to try and get a new play experience. Since then, I have successfully joined the guild Alea Iacta Est (AIE) on the Earthen Ring server. This guild might ring a bell for some people as being one of the biggest in all of WoW. As far as I'm aware, there are over 7000 players spread out across a number of "co-guilds", since there is a cap on how many characters can be in an guild. At one point, everyone was all in one guild, but the guild panel would stop showing people past a certain number.
My Death Knight that I was leveling just recently hit level 84, and is now a member of AIE Libertas. This is just a slight change from where my Druid is, back on the Thrall server. Band of Thorns is a very small guild, and might have about 10-15 people on at most at any point in time – usually during raids. Both guilds are level 25 and have all perks available.
So, does the size of the guild matter? It certainly does… to an extent.
One of the first things I noticed was just the fact that there's always somebody on. Even if not in the specific co-guild that I'm in, but through one of the addons that makes guild chat go between all guilds, someone will be there. Even so, even in my co-guild I have yet to be on at a time where there's less than 10 people on.
Along with that, with more people comes more help that can be available. Something simple as having some lockboxes to open, I asked in guild chat and I had five people who were willing to help out. I would normally have to wait for a while for a rogue to appear to help out, but now I have a number of people ready right away.
Raiding is a very different situation. There are a great number of raid teams in AIE, and a new team can easily be formed by starting a signup for a regular time. Rather than just having one chance to make the raids per week, I'll now have many teams to choose from or be able to start a new one if needed.
The only downside that I have had so far is the fact that the guild is so big. I want to get to know people, but with so many people out there it's hard to find the same people to talk to time after time. I know everyone in Band of Thorns, so far in AIE I don't know anyone. At the same time, I've only been in the guild for about two weeks so far, so there's definitely time to make it work.
There are plenty more options available in AIE than I currently have in Band of Thorns. More than once, I've thought about transferring my Druid over to Earthen Ring and joining in with him as well. The problem that I have is that I've been with Band of Thorns (in one way or another) since the game's launch, and have never not been in the guild. There are people who I've known through the guild since the very beginning, and it's very hard to let go. I wouldn't sever all ties, but at the same time I want to keep my main character active.
Lots of things to consider. All I know is that I've been playing my DK a lot more than my Druid, for the main reason that I have stuff to do again, and I'm enjoying the people I play with.


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Salem — Lucy "Lou" (LaBrie) Clark, 95, of Salem, passed away at her home, Friday, June 14, with her family by her side. She was the devoted wife of the late Freeman Jack Clark.
Born in Peabody and raised in Salem, she was the daughter of the late Felix and Delima (Chouinard) LaBrie. A loving wife, mother, grandmother, great-grandmother, and sister, she took special pride in creating a wonderful home for her family. She especially loved her garden and during the 1960s and 1970s, enjoyed her time at the family's second home in Maine, where she won an award for snowmobiling. Lou was also a faithful member of Ste. Anne Parish, where over the years, she did crafts and volunteered for the parish Holiday Church Fair. She was a member of the League of Catholic Women.
She is survived by her daughters, Carol L. Clark of Salem, Sally A. Cooke and her husband, Richard of Denmark, Maine; a son, Maurice G. Clark and his wife, M. Susan of Randolph Center, Vt.;, her two sisters, Ida Landry of Canada and Lorraine Belanger of Salem; five grandchildren, Karen Reardon and her husband, Sean, Adrian Clark and his wife Jo-An, Brian Clark and his close companion Maria, Kevin Clark and companion, Heather, Steven Cooke and his wife, Cheryl; as well as ten great-grandchildren, nieces and nephews. She was predeceased by her brother, Archie LaBrie and sister, Antoinette Ann Ouellette.
ARRANGEMENTS: Relatives and friends are invited to her visiting hours on Tuesday, June 18, at the Levesque Funeral Home, 163 Lafayette St., Route 114/1-A, Salem, from 8 to 9:30 a.m., to be followed by her Funeral Mass in Ste. Anne Church, Jefferson Ave., Salem at 10 a.m. Burial will follow in St. Mary's Cemetery, Salem. In lieu of flowers, memorial contributions may be made to Hospice of the North Shore, 75 Sylvan St., Suite B-102, Danvers, MA 01923. For additional information and guest book please visit www.LevesqueFunerals.com.


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The Health Center of Plant City specializes in providing the best quality of life for our patients. Established in Plant City, FL, we offer rehabilitation programs that assist patients through physical, occupational and speech therapy. Our mission is to provide the highest quality of rehabilitation and long-term care. Those who visit our facility appreciate the genuine care and knowledge of our staff. We desire to help you live the best life possible by achieving your personal and physical goals.
Our facility was built in 1985 and our rehabilitation wing was expanded in 1995. We've recently received a five star rating from the Florida Agency for Healthcare Administration.


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In addition to that individual honor, Bailey and two more Golden Eagles were named to the all-conference team, while Marquette was picked to finish second in the Big East behind Creighton.
MU gets started TONIGHT down in the Valley when they host Loyola-Chicago, plus we preview Sunday's match against Northwestern.
Marquette men's soccer finished in a tie with Georgetown for first place in the preseason coaches poll, while Axel Sjoberg was named the Defensive Player of the Year. Plus: two more Golden Eagles...
It was just an innocent picture of a view from the Al McGuire Center, but it's become so much more....
The season starts on Friday, so let's identify three questions about the 2014 season for the five time champs.
Our preview of the 50th season of men's soccer at Marquette continues with a look at the new guys on the roster this season.
Wojo's two commits for the Class of 2015 are both in the top 100. Heck, they're both in the top 90. There's also seven more players with Marquette interests.
The NBA announced their schedule yesterday, so let's take a look at what the Bradley Center's availability looks like for the upcoming season.
The results of the preseason coaches' poll are in, and the Golden Eagles are the unanimous choice to take the Big East title this season. Plus: Two MU players were named to the all-conference team!
There's been a slight change to how the Al McGuire Center looks for volleyball matches.
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