text:
"Music You Know" Draws Inspiration from the Familiar
By Allison Babka
Pokey LaFarge Signs to Rounder Records
By Daniel Hill
Miami Dolphins Is Not a Football Team
By Drew Ailes
Combating a Rash of Tour Van Break-Ins
By Brian Heffernan
Grammophone to Close, Reopen As Restaurant
By Joseph Hess
Playing for the Cause Helps Out Those in Need
By Joseph Hess
Nots Works Hard to Keep Punk Weird
By Mike Appelstein
Local Bands Getting TV, Film Exposure
By Alison Babka
Ryan McNeely has produced tracks for the likes of Rockwell Knuckles, Scripts N Screwz and Tech Supreme, and his dense, layered backing tracks carry faint whiffs of psychedelia and indie rock. But his solo work as Adult Fur shows that it's less correct to think of him as a hip-hop beat maker dabbling in rock & roll, and closer to the truth to say he's a musical pantheist. At eight songs and 24 minutes, ii is a brief but fetching sampler platter of McNeely's hazy shade of pop music. Most of these songs ride on a backbone of thin, clicky drum-machine patter and thick synth bass, and the BPMs are mostly set for a languid slow grind. In this sense McNeely shares a smartly retro-minded palette with St. Louis native (and now New York-based) Phaseone, another producer who unites touches of old-school hip-hop, outmoded synth pads and lush production techniques. But throughout the EP, McNeely showcases his high, dreamy vocals alongside tracks that, in another context, could have backed up a hard-rhyming STL emcee.
McNeely proves an able, if occasionally unremarkable, singer on these tracks — in fact, he treats his voice more like another instrumental layer rather than a megaphone for any kind of lyrical message. He'd rather relish in the skitter of a treated high-hat or let moody guitar patterns set for a while against a wall of blippy arpeggios. Songs like "Blazertone" find Adult Fur at its most conventionally rock-driven, though the following track "Octangler" is lovably campy and new-wavey. McNeely's vocals take a back seat to French vocalist Sacha Bernadson, whose similarly high-reaching pipes help make "I Am Dream" the EP's Euro-trash standout. But sharing the stage is an easy move for McNeely, a natural collaborator with a thumbprint that will hopefully be found on an increasing number of local releases.
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Category: Bars and Clubs
Region: St. Louis - South City
Want your CD to be considered for a review in this space? Send music c/o Riverfront Times, Attn: Homespun, 6358 Delmar Boulevard, Suite 200, St. Louis, Missouri, 63130. E-mail email@example.com for more information.


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Dr. Pairote Jaroonwanichkul, MD
Hematology/Oncology, Loma Linda VA Healthcare Oncology/Hematology
- 11201 Benton St
Loma Linda, CA 92357
- 1 Office Location
- (909) 825-7084
Dr. Pairote Jaroonwanichkul has been practicing medicine for 32 years. Dr. Jaroonwanichkul graduated from the Chiang Mai Univ, Fac of Med, Chiang Mai, Thailand in 1982. He practices medicine in Loma Linda, CA and specializes in Hematology/Oncology. Dr. Jaroonwanichkul is affiliated with Jerry L Pettis VA Medical Center.
Gender: Male
Years in Practice: 32 Years
Languages Spoken: English
Medical School: Chiang Mai Univ, Fac of Med, Chiang Mai, Thailand
Graduation Date: 1982
Hospital Affiliations: Jerry L Pettis VA Medical Center
Specialties: Hematology/Oncology

subset: commoncrawl


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EU aims for deal on tackling failing banks next week
BRUSSELS (Reuters) – European Union governments and parliamentarians will try to reach a compromise this week on how to wind down failing banks, in marathon talks intended to settle who decides to close banks and who picks up the bill.
A deal in the negotiations, set to span three days, would be the final step in a European banking union that would mean one supervisor for all euro zone banks, one set of rules to close or restructure those in trouble and one common pot of money to pay for it.
Ukraine ready to use military to defend itself against Russia
BRUSSELS (Reuters) – Ukraine is ready to use military force to defend itself if Russia further expands its presence on Ukrainian soil, Prime Minister Arseny Yatseniuk said on Thursday, emphasizing that Ukraine would not be made subordinate to its neighbor.
Speaking at a news conference after meeting European Union leaders in Brussels, Yatseniuk said Crimea was and would remain an integral part of Ukraine and dismissed a decision by Crimea's parliament to join up with Russia.
EU warns Italy is in economic trouble, France to miss deficit targets
BRUSSELS (Reuters) – The European Commission put Italy on Wednesday on its watch list because of the country's very high public debt and weak competitiveness and warned France that will miss agreed budget deficit reduction targets unless it takes action.
The Commission, the European Union's executive arm, conducted in-depth reviews of the economies of 17 EU countries that it believes have macro economic imbalances.
Germany, Finland fear EU going soft on budget rules
BRUSSELS, Feb 28 (Reuters) – Germany and Finland say changes
in the way the European Commission assesses an EU member's
adherence to budget rules could weaken the bloc's pact on fiscal
discipline, a document showed on Friday.
The 8-page document, obtained by Reuters, also called for
independent monitoring of the EU executive's decisions.
EU team to visit Ukraine to examine financial needs
BRUSSELS (Reuters) – A small team of financial experts from the European Commission will travel to Ukraine on Monday to assess exactly how much financial assistance it needs, EU officials said on Friday.
The team from the Commission's directorate-general for economic and financial affairs is expected to meet Ukrainian finance ministry and central bank officials to determine what the country's budget shortfall and capital needs are.
Euro zone inflation stabilizes in 'danger zone'
BRUSSELS (Reuters) – Euro zone inflation stabilized in the European Central Bank's "danger zone" in February but did not fall as expected, making it less likely the ECB will loosen monetary policy further at its monthly meeting next week.
European Union statistics office Eurostat estimated on Friday that consumer prices in the 18 countries sharing the euro rose an annual 0.8 percent this month. That was the same rate as in January and December, after readings of 0.9 percent in November and 0.7 percent in October.
Euro zone inflation stabilises in "danger zone", unemployment stays high
BRUSSELS, Feb 28 (Reuters) – Euro zone inflation stabilised
in the European Central Bank's "danger zone" in February but did
not fall as expected, making it less likely the ECB will loosen
monetary policy further at its monthly meeting next week.
European Union statistics office Eurostat estimated on
Friday that consumer prices in the 18 countries sharing the euro
rose an annual 0.8 percent this month. That was the same rate as
in January and December, after readings of 0.9 percent in
November and 0.7 percent in October.
Euro zone sentiment improves, inflation expectations fall
BRUSSELS, Feb 27 (Reuters) – Euro zone economic sentiment
improved more than expected in February, data showed on
Thursday, but falling inflation expectations among consumer and
producers underlined deflation risks.
A monthly European Commission survey showed economic
sentiment in the 18 countries now sharing the euro rose to 101.2
points this month from an upwardly revised 101.0 in January,
above the long-term average of 100 for the third month in a row.
G20 aspires to faster economic growth, roadmap sketchy
SYDNEY (Reuters) – The world's top economies have embraced a goal of generating more than $2 trillion in additional output over five years while creating tens of million of new jobs, signaling optimism that the worst of crisis-era austerity was behind them.
The final communique from the two-day meeting of Group 20 finance ministers and central bankers in Sydney said they would take concrete action to increase investment and employment, among other reforms. The group accounts for around 85 percent of the global economy.
EU to back G20 growth target if accompanied by reforms
SYDNEY (Reuters) – Europe is in favor of setting an economic growth target for the world's 20 biggest developing and advanced economies (G20), but only if they agree on bold reforms, the European Union's Economic and Monetary Affairs Commissioner Olli Rehn said.
G20 finance ministers and central bank governors are meeting in Australia on Saturday and Sunday to find ways to boost global economic growth by focusing on investment, competitiveness, trade and employment.


text:
Cleocin IV
FDA Approves Impavido to Treat Tropical Disease Leishmaniasis »
"The U.S. Food and Drug Administration today approved Impavido (miltefosine) to treat a tropical disease called leishmaniasis.
Leishmaniasis is a disease caused by Leishmania, a parasite which is transmitted to humans through sand fly bites."...
Read the FDA Approves Impavido to Treat Tropical Disease Leishmaniasis article »
Cleocin I.V.
Cleocin I.V. Consumer (continued)
Some products that may interact with this drug include: erythromycin, live bacterial vaccines.
Although most antibiotics probably do not affect hormonal birth control such as pills, patch, or ring, some antibiotics may decrease their effectiveness. This could cause pregnancy. Examples include rifamycins such as rifampin or rifabutin. Be sure to ask your doctor or pharmacist if you should use additional reliable birth control methods while using this antibiotic.
OVERDOSE: If overdose is suspected, contact a poison control center or emergency room immediately. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.
NOTES: Laboratory and/or medical tests (e.g., kidney or liver function test) may be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.
MISSED DOSE: For the best possible benefit, it is important to receive each scheduled dose of this medication as directed. If you miss a dose, contact your doctor or pharmacist immediately to establish a new dosing schedule. Do not double the dose to catch up.
STORAGE: Consult the product instructions and your pharmacist for storage details. Keep all medications away from children and pets.
Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.
Information last revised March 2013. Copyright(c) 2013 First Databank, Inc.
Cleocin I.V. Consumer Overview
Additional Cleocin I.V. Information
Cleocin I.V. - User Reviews
Cleocin I.V. User Reviews
Now you can gain knowledge and insight about a drug treatment with Patient Discussions.
Here is a collection of user reviews for the medication Cleocin I.V. sorted by most helpful.
Report Problems to the Food and Drug Administration
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.
Women's Health
Find out what women really need.


text:
This RIVA Solutions vice president used social media monitoring and engagement to transform the Education Department's aid application process.
This GSA Rising Star single-handedly provided program management for the Continuous Diagnostics and Mitigation portfolio in its first year.
This IT auditor at USPS helps monitor one of the largest computing infrastructures in the federal government.
This Rising Star leads the team that is in charge of conducting risk assessments for the Navy's IT systems.
Agency leaders must proactively invest time, energy and resources to shape the future rather than reactively wait for change to happen.
Defense Secretary Chuck Hagel is stepping down, but the innovation initiative he announced Nov. 15 could live on. FCW interviewed three former high-ranking officials about what it will take for the effort to succeed.
As costs have come down and capacity has soared, the benefits extend to both budgets and performance.
Data gathered by the Sensor Fish could aid in redesigning dams' hydroturbine chambers, where abrupt changes in pressure can kill salmon.
A new Gallup Poll finds respondents happier with the oft-disparaged Postal Service than any other major federal agency.
News and notes from around the federal IT community.
Army Cyber Command Sgt. Maj. Rodney Harris says the Army is learning as it goes along in the uncharted terrain of cybersecurity.
Researchers aim for "an operational disease monitoring and forecasting system with open data and open source code."
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text:
Kemba Walker is Clutch: Forces OT, Then Hits Game-Winner
Michael Jordan was proud.
25 Sep
Jeff Taylor of the Charlotte Hornets Arrested on Domestic Assault Charge
Second pro athlete in North Carolina arrested for domestic abuse this year.
23 Sep
Lance Stephenson Releases Music Video Featuring Gratuitous Air Horn
I can't say the song's name or I'll get in trouble.
09 Jul
The Bobcats Overpaid Al Jefferson and it Worked ... Will Overpaying Gordon Hayward Work Too?
The Jazz will probably match … right?
19 Jun
Roundup: Tony Gywnn Tribute, Twitter Supports Gifs, Spell "Dwyane Wade" For $100
There is a video of Kawhi Leonard celebrating, but he doesn't show any emotion.
20 May
Roundup: Man Tries to Have Sex with ATM; Buy Notre Dame Stadium Grass for $149.95 & Police Officer Jumps Off Bridge to Avoid Drunk Driver
If you liked Garden State, you'll like the sequel, 'Wish I Was Here.'


text:
Originally Posted by HourBeforeDawn
huh Im like split, part me is like wow thats amazing and then another part of me is like umm kinda hideous for a HTPC but overall I will say that the craftsmanship is simply superb, you did an amazing job.
Originally Posted by Demolition Man
Hi all, this is my first post and this is absolutely amazingly, futuristic. i like to see someone mod a laptop like this (as close as this)
Meet the new Caseking Selective Fire systems by der8auer
20th November 2014
ASRock Z97 Pro 3 Review
19th November 2014
Corsair Hydro Series HG10 A1 Review
18th November 2014


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ACE Fit Share
Use a combination of these core back exercises to strengthen your lower, upper or middle back areas. Whether you're interested in barbell deadlifts or reverse extensions, we have back strengthening exercises for every level. These exercises are also featured in convenient workout routines that include proper warm-up and cool-down techniques, which greatly reduces the risk of injury.
Fit Life Articles
Taking the time to cool down after a great exercise session, game or other activity is important for recovery and allows time to discuss accomplishments, provide feedback, set future goals and assign homework that youth can do on their own. Here are six great stretches to...
The BOSU—which stands for both sides up—is a unique piece of fitness equipment that allows you to perform exercises on top of an unstable surface. Among its many benefits include the ability to make exercises easier or more challenging. Here are six great core exercises...
Gassers. Suicides. Sprints. Whatever you want to call them, they may not be a lot of fun, but they are an essential part of conditioning for many sports and offer a long list of benefits. ACE Certified pro Pete McCall offers some compelling reasons why you should consider...
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text:
When people talk about penis pumps and penile enlargements, they talk about an industry that has been tainted with shame of scam and broken promises. The fact is that many people don't actually believe in the several promises made by the promoters of these products, and it's for a good reason.
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So, if you're in search of a penis enlargement method that doesn't involve surgery or anything artificial, then Bathmate is ideal for you. Unlike other pumps, it uses water to function in place of air. The pump has also been shown to be very gentle and comfortable around the penis shafts.


text: CHEST Recent Advances in Chest Medicine Recent Advances in Community- Acquired Pneumonia* Inpatient and Outpatient Michael S. Niederman, MD, FCCP Community-acquired pneumonia (CAP) is a common illness, with the majority of patients treated out of the hospital, yet the greatest burden of the cost of care comes from inpatient management. In the past several years, the management of these patients has advanced, with new information about the natural history and prognosis of illness, the utility of serum markers to guide management, the use of appropriate clinical tools to guide the site-of-care decision, and the finding that guidelines can be developed in a way that improves patient outcome. The challenges to patient management include the emergence of new pathogens and the progression of antibiotic resistance in some of the common pathogens such as Streptococcus pneumoniae. Few new antimicrobial treatment options are available, and the utility of some new therapies has been limited by drug-related toxicity. Ancillary care for severe pneumonia with activated protein C and corticosteroids is being studied, but recently, inpatient care has been most affected by the development of evidence-based "core measures" for management that have been promoted by the Centers for Medicare and Medicaid Services, which form the basis for the public reporting of hospital performance in CAP care. (CHEST 2007; 131:1205–1215) Key words: community-acquired pneumonia; drug resistance; methicilllin-resistant pneumonia; severe pneumonia; severity index; Staphylococcus aureus; Streptococcus pneumoniae Abbreviations: APACHE acute physiology and chronic health evaluation; CAP community-acquired pneumonia; CMS Centers for Medicare and Medicaid Services; CRP C-reactive protein; CURB-65 confusion, elevated BUN level, elevated respiratory rate, low systolic or diastolic BP, and age 65 years of age; DRSP drug-resistant Streptococcus pneumoniae; HCAP health-care-associated pneumonia; MRSA methicillin-resistant Staphylococcus aureus; OR odds ratio; PCT procalcitonin; PSI pneumonia severity index; SARS severe acute respiratory syndrome I community-acquired years, clinical (CAP) have n the past several pneumonia advances in spectrum of etiology, including drug-resistant Strep- tococcus pneumoniae (DRSP), methicillin-resistant emerged in a number of areas that can aid in the care Staphylococcus aureus (MRSA), and emerging viral of both inpatients and outpatients. Major clinical pathogens (eg, severe acute respiratory syndrome issues for all CAP patients have been the changing [SARS] and avian influenza). In addition, there has been an interest in better understanding the natural *From the Department of Medicine, State University of New history and prognosis of CAP by trying to define the York at Stony Brook, Stony Brook, NY. role of prognostic scoring systems in guiding the Dr. Niederman has been a speaker, consultant, or researcher for decision about site of care (ie, inpatient, outpatient, Schering, Johnson and Johnson, Aventis, Pfizer, Bayer, Merck, Elan, and Wyeth. or ICU) and by applying a number of serum markers Manuscript received August 10, 2006; revision accepted October (ie, C-reactive protein [CRP] and procalcitonin 5, 2005. [PCT]) to prognosticate outcome. New antimicrobial Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. agents have become available for both outpatients org/misc/reprints.shtml). and inpatients, in several antibiotic classes, but the Correspondence to: Michael Niederman, MD, FCCP, Department of utility of some of these agents has been limited by Medicine, Winthrop-University Hospital, 222 Station Plaza N, Suite 509, Mineola, NY 11501; e-mail: firstname.lastname@example.com new findings of toxicities that were not evident in DOI: 10.1378/chest.06-1994 registration trials of these medications (ie, gatifloxa- www.chestjournal.org CHEST / 131 / 4 / APRIL, 2007 1205 cin and telithromycin) prior to their approval for clinical use. In addition to new antimicrobial agents, CAP paradigms for therapy have been advanced by a Control focus on better defining the optimal duration of therapy and on the role of adjunctive therapies for 45 those with severe illness, including corticosteroids and activated protein C. 40 One of the major factors that has dominated the inpatient care of CAP in the United States has been 35 the promulgation of "core measures," or standards of care, which have been supported by the Centers for 30 Medicare and Medicaid Services (CMS) and the 25 Joint Commission on the Accreditation of Health- care Organizations. Success in achieving these mea- 20 sures has been publicly reported for the perfor- mance of individual hospitals, and it seems possible 15 that these data could serve in the future as the basis for "pay for performance," thereby impacting the 10 financial well- being of a specific health-care institu- tion. Interest in these core measures has refocused 5 attention on assuring that all patients receive evi- 0 dence-based antibiotic choices, that they receive Hospital Mortality 1 Year Mortality timely administration of antibiotics, that there is a proper use of blood cultures prior to antibiotic ALL DIFFERENCES WITH p < 0.001 administration, and that each patient is current with pneumococcal and influenza vaccinations. Figure 1. In this case-control study of Medicare patients with CAP, with five control subjects matched for age, sex, and race with each case, the in-hospital and 1-year mortality rates for patients with CAP were significantly higher than those for control Understanding the Natural History and subjects. From Kaplan et al.1 Prognosis of CAP Most of the studies of CAP have examined the short-term outcomes of the illness, focusing on lation was generally elderly, with 85% being 65 either 30-day or inpatient mortality. Kaplan and years of age; nursing home patients were included, colleagues1 used a Medicare database to perform a and 70% had a comorbid medical illness. The find- matched case-control study to evaluate the long- ings expand on an older Scandinavian study2 that term impact (ie, 1-year mortality rate) of older reported a lower 10-year survival rate in CAP pa- patients with CAP. The authors compared 158,960 tients 60 years of age than in an age-matched CAP patients to 794,333 hospitalized control sub- population without CAP. In that study, the relative jects (5 for each patient) matching for age, sex, and risk for death in CAP patients was 1.5 compared to race. While the in-hospital mortality rate for CAP those without CAP, and the 10-year survival rate was patients exceeded that of control subjects (11% vs 39%, compared to 61% in the non-CAP population, 5.5%, respectively), the differences in the 1-year with many of the deaths related to cardiovascular mortality rate were even more dramatic (40.9% vs disease and subsequent pneumonia. All of these data 29.1%, respectively) [Fig 1]. The high mortality rate make it very clear that CAP requiring hospital was impressive, and the differences could not be admission is a disease that should be prevented, explained by the types of underlying disease; the whenever possible, in the elderly. findings persisted, even if only the hospital survivors were examined. These findings make it clear that Prognostic Scoring Systems CAP is much more than a self-limited illness for those who survive, and that the 1-year mortality rate The optimal management of CAP requires the of elderly patients with CAP is four times higher than prompt recognition of seriously ill patients to avoid the in-hospital mortality rate, with one in three such mistakes as the failure to use the hospital or survivors of CAP dying in the subsequent year, ICU for patients who could benefit from care and following hospital discharge. The exact cause of observation in such settings. On the other hand, the death was not examined in the study, but the popu- major impact on the cost of CAP care is determined 1206 Recent Advances in Chest Medicine by whether or not a patient is admitted to the was less discriminating, defining only two groups as hospital.3 In the United States, 20% of all CAP being severely ill. In another analysis,6 the CURB-65 patients are admitted to the hospital, but the dollars score also appeared to identify, most accurately, spent on these patients account for 90% of the those patients with CAP who were likely to benefit total cost of care for this disease, emphasizing the from treatment with drotrecogin alfa in the recom- impact of the hospital admission decision.3 For a binant Human Activated Protein C Worldwide Eval- number of years, prognostic scoring systems have uation in Severe Sepsis (or PROWESS) study. A been used to define not only the predicted mortality reexamination of the data from that study demon- rate of CAP, but also, by inference, the site of care, strated that a threshold CURB-65 score of 3 was reserving hospital admission for those with a high associated with a decrease in the 28-day mortality predicted mortality rate. rate in drotrecogin alfa-treated patients of 10.8% The two commonly used tools for the purpose of when compared to control subjects (p 0.018) vs a predicting outcome in CAP patients have been the decrease in mortality rate in treated patients in PSI pneumonia severity index (PSI), which was devel- classes IV and V of 9.7% compared to control oped in the United States, and the British Thoracic subjects (p 0.013).6 Society rule, which has recently been modified to the Capelastegui and colleagues7 used both the PSI CURB-65 (referring to its assessment of the follow- and the CURB-65 approach to evaluate a large ing five factors: confusion; elevated BUN level; number of both inpatients and outpatients with CAP elevated respiratory rate; low systolic or diastolic BP; in Spain. They observed that the CURB-65 (and its and age 65 years of age) rule.4 Each of these simpler CRB-65 version, which excludes the mea- approaches has limitations, and it may be best to surement of BUN, and therefore can be used in view them as complementary, ideally identifying outpatients) could accurately predict the 30-day patients at opposite ends of the disease spectrum.5 mortality rate, the need for mechanical ventilation, The PSI has been best validated as a way to identify and, to some extent, the need for hospitalization. In patients with a low risk of mortality, but the scoring addition, the CURB-65 criteria correlated with the system can occasionally underestimate severity of time to clinical stability, and thus a higher score was illness, especially in young patients without comor- predictive of a longer duration of IV therapy and a bid illness because it heavily weights age and comor- longer length of hospital stay. The PSI also worked bidity, and does not measure CAP-specific disease well to predict mortality in that study. severity.5 On the other hand, the CURB-65 ap- While both the PSI and CURB-65 are good for proach may be ideal for identifying patients with a predicting mortality, neither can be used to define high risk of mortality with severe illness due to CAP, the site of care, without considering other clinical who might otherwise be overlooked without the and social variables. A study at a public hospital in formal assessment of subtle aberrations in key vital the United States, with many indigent patients, signs.5 However, one deficiency of the CURB-65 showed that the PSI could not define the need for approach is that it does not generally account for hospital admission if patients were homeless or comorbid illness and thus may not be easily applied acutely intoxicated, or if they did not have a stable in older patients who may still have a substantial home environment that allowed them to be dis- mortality risk if even a mild form of CAP destabilizes charged from the hospital while receiving oral anti- a chronic, but compensated, disease process. biotic therapy.8 In one recent commentary,5 the In one recent study4 that compared the PSI to the suggestion was made to combine both of these CURB-65 in 3,181 patients seen in an emergency prognostic scoring tools, recognizing that neither department, both were determined to be good for approach can stand alone. Low-risk patients (ie, PSI predicting mortality and for identifying patients with classes I to III or CURB-65 score of 0 to 1) can be a low risk of mortality. However, the PSI appeared to managed at home if serious vital sign abnormalities be more discriminating in identifying patients with a (in the case of PSI) or comorbidities (in the case of low risk of mortality, with 68% being defined by PSI CURB-65) are absent, and if patients do not have to have a low risk (classes I to III), with a mortality social factors or other illnesses that are unstable and rate of 1.4%, while 61% were defined by the that necessitate hospitalization. Moderate-risk pa- CURB-65 to have a low risk (score of 0 to 1) with a tients (ie, CURB-65 score of 2 or PSI classes IV mortality rate of 1.7%. However, the CURB-65 may and V) probably should be admitted to the hospital, have been more valuable at the severe disease end of and clinical assessment should be used to separate the spectrum because it defined high-risk patients as those who need ICU care from those who are likely those with a score of 2, 3, 4, or 5, each with a to become clinically stable rapidly and who would progressively increasing risk of death, while the PSI then require only a short hospital stay. www.chestjournal.org CHEST / 131 / 4 / APRIL, 2007 1207 Serum Markers To Predict CAP Outcomes ments of levels of PCT, which were evaluated when the patient was first seen, 6 to 24 h later if antibiotics The two serum markers that have been most were withheld, and then at days 4, 6, and 8. Only 3% widely studied for this purpose are CRP and PCT. In of all patients were not admitted to the hospital, general, both measures have been used to correlate making this primarily an inpatient study. With the with outcomes, but more data have recently been use of PCT levels, 15% of patients had antibiotics collected9 with PCT, and the most exciting finding withheld, compared to 1% of those receiving stan- has been that serial measures correlate not only with dard care. The use of PCT levels to guide therapy led outcomes, but may also be useful for guiding the to a significantly shorter duration of therapy that duration of therapy. applied to all patients, regardless of PSI class. Most CRP was measured in one study of 201 patients importantly, outcomes were similar in both groups, with CAP who were compared to 84 healthy control documenting the safety of looking for strategies to subjects and 25 patients with suspected pneumonia, reduce antibiotic usage. which was not confirmed on clinical follow-up, and Serial measurements of PCT have also been used the levels were highest in those with pneumonia.10 to define prognosis in patients with severe CAP. In However, among those with proven CAP, the levels one study12 of 110 patients who had only one of CRP correlated with the clinical course, with the measurement performed within 48 h of ICU admis- median level being higher in hospitalized patients sion, levels of PCT were higher in those with positive than in outpatients (132.0 vs 76.9 mg/L, respectively; bacteriology results than in those with negative p 0.001). These findings might in part be ex- results, and in those with complications (eg, septic plained by the observation that CRP levels tended to shock and organ dysfunction) and death than in be higher in those with pneumococcal and Legio- those without. Bolstered by these findings, the same nella etiologies than in those with a viral or atypical investigative group collected serial PCT levels in 100 pathogen pneumonia; possibly those with the bacte- ICU CAP patients on day 1 and day 3.13 In the study, rial illnesses were more severely ill, and thus more in survivors had a decrease in PCT levels, while non- need of hospitalization. survivors had an increase by day 3. Numerous clin- In general, CRP, an acute-phase reactant that is ical parameters, were also measured, as well as serial synthesized in the liver, has not been as sensitive or levels of CRP, but in the multivariate predictors of specific for infection as PCT. PCT, the precursor of mortality, the relevant factors were as follows: need calcitonin, has no hormonal effects. Its value arises for mechanical ventilation (odds ratio [OR], 9.9); because serum levels are increased in severe bacte- presence of multilobar infiltrates (OR, 5.6); increas- rial infections, but not in viral illness. The release of ing PCT levels (OR, 4.5); and worsening of a multi- PCT can be stimulated by microbial toxins (including organ failure score. Among mechanically ventilated lipopolysaccharide), cytokines (eg, tumor necrosis patients, the PCT level on day 3 was highly predic- factor, interleukin-1, and interleukin-6), and by the tive of mortality if it remained elevated. Serial cell-mediated immune response. Levels can be at- measurements of CRP did not have predictive value tenuated by virus-induced cytokines (interferon- ). in this study. In a study11 of 185 patients who had PCT measured within 24 h of hospital admission for CAP, the levels correlated with PSI score (higher in classes III and V New Issues in the Pathogens Causing CAP than in classes I and II) and the development of Drug-Resistant Pneumococcus complications (higher with empyema, mechanical ventilation, and septic shock), and levels were also While the clinical relevance of DRSP continues to increased in those who died compared to those who be debated, recent data14 have suggested that the did not. Interestingly, the levels were higher in frequency of some forms of drug resistance may be patients with a low risk of mortality (ie, low PSI) with stabilizing or declining, while concerns still remain a bacterial etiology for CAP than in those without, for other classes of antibiotics. Using data from 2002 but similar findings did not apply to those with more to 2003, Doern et al14 studied 1,817 pneumococcal severe CAP. This may mean that low levels in respiratory isolates from 44 US centers and observed outpatients could indicate that it is safe to withhold that while penicillin resistance was present (34.2%), antibiotic therapy. it was not occurring with an increased frequency. Another recent study9 supports the idea of using They found that 15.7% of isolates were intermedi- serial measurements of PCT levels to guide the need ately sensitive and 18.5% were highly resistant to for antibiotic therapy and its duration. In this study, penicillin. On the other hand, macrolide resistance 302 patients were randomized to receive either was increasing (although most was low-level, efflux standard care or therapy guided by serial measure- pump-mediated), while trimethoprim-sulfa resis- 1208 Recent Advances in Chest Medicine tance was declining. Quinolone resistance rates were toxin, the Panton-Valentine leukocidin, and it con- very low ( 1%), but 21% of the isolates had a fers resistance to methicillin through the carriage of first-step mutation (par C) that still permitted the the type IV mecA gene, which is carried on the antibiotics to be active. However, if a second muta- staphylococcal chromosomal cassette (type IV SCC- tion (gyr A) were acquired, these organisms could mec element).19 The cases that have been reported become quinolone-resistant, urging caution to ob- have been severe necrotizing pneumonias, generally serve trends in this type of mutation. In terms of in previously healthy individuals following viral in- reliable choices for suspected DRSP, quinolones fection or documented influenza illness. The pneu- remain effective, but ceftriaxone remained the most monia is often rapidly progressive, bilateral, and with active -lactam agent, with a 6.9% resistance rate. In shock, cavitation of lung parenchyma, and pleural clinical studies, ceftriaxone has been a reliable effusion. The organism is sensitive to a wide range of choice, even if DRSP is present, while, among the antibiotics, including vancomycin, clindamycin, tri- cephalosporins, cefuroxime is not a reliable choice methoprim-sulfa, and gentamicin, with variable sen- since patients with bacteremia and in vitro resistance sitivity to quinolones.19 The optimal therapy is yet to to this agent had a worse outcome than when be defined, but one case series20 reported failure organisms were sensitive to this agent.15,16 with vancomycin alone, which was overcome by One of the clinical factors that is driving pneumo- coccal resistance is antibiotic use, and new data have either the addition of clindamycin or the use of shown that recent therapy, within the past 3 months, linezolid. These findings may relate to the fact that is a risk factor for pneumococcal resistance.17 In a clindamycin and linezolid can inhibit toxin produc- remarkable study,17 the Toronto Bacterial Network tion, and thus successful therapy may require both evaluated data from patients in 3,339 cases of inva- an antibacterial and an antitoxin form of treatment. sive pneumococcal infection, of whom 563 had a history of antibiotic therapy in the preceding 3 Viruses months and the identity of the therapy was known. In the study, recent therapy with penicillin, macro- Over the past several years, there has been a lides, trimethoprim-sulfa, and quinolones (but not renewed interest in epidemic viral illness with the cephalosporins) was associated with a higher fre- emergence of SARS, and recent concerns about quency of resistance to that same agent. Among all of avian influenza. These experiences have emphasized the classes of antibiotics, the one with the greatest the epidemic nature of illness and the rapidity of effect of recent therapy on subsequent resistance (ie, patient-to-patient spread. In the case of SARS, the highest OR of an effect) was quinolones. This latter risk to health-care workers was evident. Very little is finding is consistent with case reports of lack of known about the frequency of viral infection in response to quinolones in CAP patients that docu- routine CAP, and thus a Spanish study21 of this topic mented recent quinolone therapy as a major risk is of interest. The investigators evaluated 338 pa- factor.18 All of these data lend further support to the tients with paired serologies for respiratory viruses in idea of "patient-specific antibiotic rotation" in CAP, the setting of CAP, and classified patients as having making sure that among all acceptable therapeutic pure viral, mixed viral, and bacterial or pneumococ- alternatives the clinician takes a history of recent cal CAP.21 antibiotic use and chooses an agent that differs from The viruses investigated included influenza, para- what the patient had recently received. influenza, respiratory syncytial virus, and adenovirus. Viruses were detected in 18% of patients, and in half Community-Acquired MRSA of those patients viruses were the only pathogen MRSA has always been a nosocomial pathogen present. Influenza was the most common infection, and a common cause of ventilator-associated pneu- being present in 64% of patients with viral infection. monia. In the past several years, MRSA has been The only clinical correlates of pure viral pneumonia, reported as a cause of sporadic cases of severe CAP, compared to pneumococcal pneumonia, were the especially following a preceding viral infection.19 presence of heart failure and the absence of expec- This pathogen is not the same as its nosocomial toration. Only 8% of the pure viral pneumonia counterpart, having a different genetic makeup, dif- patients needed visits to the ICU, but 58% were in ferent host susceptibility, and different virulence and PSI classes IV and V. Interestingly, despite the high antibiotic sensitivity. The community-acquired strain mortality risk of these patients (defined by PSI class), generally belongs to a single pulse-field gel electro- none died. Given the importance of influenza and phoresis type, the USA 300 strain. In addition, it viral respiratory infection in general, and the role of carries the genes for the production of a necrotizing these infections in predisposing the patient to MRSA www.chestjournal.org CHEST / 131 / 4 / APRIL, 2007 1209 CAP, these data highlight the relatively common tients were evaluated with an "uncontaminated" occurrence and importance of viral pneumonia in specimen including transthoracic needle aspirate, the community. pleural fluid, blood cultures, and specimens from a surgical sample, but not bronchoscopy samples Aspiration Pneumonia alone. In this group, pure anaerobic infection was present in only 18 patients, and 10 others had mixed The bacteriology of aspiration pneumonia arising infection. However, aerobic Gram-negative patho- in the community setting has been confusing, and gens were present in 37 patients, with Klebsiella the exact role of anaerobes is uncertain. In a study22 pneumoniae recovered from 28 patients. Thus, the of 95 patients, 65 years of age, who were admitted level of involvement of enteric Gram-negative patho- to the ICU from a long-term care facility with gens in these two aspiration-related illnesses is quite presumed aspiration pneumonia, the bacteriology of high and must be considered when selecting therapy. infection was studied using a protected BAL fluid sample that had been collected within 4 h of ICU admission. Aspiration was presumed to be present New Approaches to Therapy because patients had known risk factors such as Guidelines for CAP have stressed the approach of intestinal or swallowing disorders, neurologic dis- empiric therapy, recognizing the difficulty of obtain- ease, and anatomic abnormalities that could lead to ing pathogen-specific data that allow the early focus- aspiration. The data demonstrated that Gram-nega- ing of initial therapy choices. One recent study24 tive pathogens were the dominant type of pathogen, found that when therapy was given according to and that anaerobes were present in only 11 of the 95 guidelines, it led to patients becoming clinically patients; in only 5 patients were anaerobes the only stable sooner than if other therapy had been used. pathogens present22 (Fig 2). In another study of lung However, the value of empiric therapy was evaluated abscess,23 which is a disease that is commonly attrib- directly in a study from the Netherlands25 that used uted to aspiration and anaerobic infection, 90 pa- a prospective, randomized, open study design to compare empiric therapy with pathogen-directed therapy in 262 patients with clinical and radiograph- ically proven CAP. All patients had undergone ex- Percent tensive diagnostic testing, but the empiric therapy group received therapy with a -lactam / -lactamase inhibitor combined with erythromycin when not in 50 the ICU or ceftazidime plus erythromycin when in the ICU. The pathogen-directed group had Gram 45 stains performed on sputum samples and underwent urinary antigen testing, along with a clinical evalua- 40 tion to define the suspected pathogen; then penicil- 35 lin was used for the treatment of pneumococcus, erythromycin for atypical pathogens, amoxicillin/ 30 clavulanate for mixed infection, and flucloxacillin with optional gentamicin for therapy after influenza 25 infection. There were no differences in either group 20 for length of stay, early or late clinical failure, and 30-day mortality rate (Fig 3). However, empiric 15 therapy patients did have a higher mortality if they were admitted to the ICU, and the empiric therapy 10 group had more adverse events, which may have been related to the use of IV erythromycin rather 5 than a newer macrolide with fewer IV side effects. 0 While the study established the safety of empiric Anaerobes Gram S. Aureus therapy, it did not test other benefits of diagnostic Negatives testing, such as the long-term control of antibiotic use Figure 2. Results of nonbronchoscopic BAL fluid cultures and the avoidance of resistance. collected within 4 h of ICU admission in 95 elderly nursing-home patients with aspiration pneumonia admitted to the ICU. The New Therapies and Toxicities dominant organism group was enteric Gram-negative pathogens, and anaerobes were less common and often part of a mixed In the past several years, new therapies have been infection. From El-Solh et al.22 approved and new data have been collected about 1210 Recent Advances in Chest Medicine drug-resistant pneumococcus, but it is not consid- ered to be a drug for empiric therapy of CAP, since it is being used as an agent against MRSA arising in both the hospital and the community. A concern with these new agents is to define their role in CAP management. Safety has been a major consideration with the quinolone class of antibiotics, and gatifloxacin has recently been documented30 to cause hypoglycemia and hyperglycemia, limiting its ability to be used safely in diabetic patients. Quino- lones have caused QT prolongation and cardiac arrhythmias, and this has limited the use of agents such as sparfloxacin. As mentioned before, a ran- domized, double-blinded comparative study of levo- floxacin and moxifloxacin, using clinical evaluation and Holter monitoring, found no difference in the frequency of clinically significant cardiac events be- tween the two agents.27 Telithromycin has recently been associated31 with infrequent cases of drug- induced liver necrosis, and awareness of this poten- tial complication is essential if this drug is used. Duration of Therapy Figure 3. A randomized trial of pathogen-directed therapy (PDT) compared with empiric therapy in 262 adults with CAP The optimal duration of therapy for CAP is not found no significant differences in length of stay (LOS), mortality known, but several recent developments have rate, or rate of therapeutic failure. From Van der Eerden et al.25 pushed for shorter durations, especially in outpa- tients. A new formulation of azithromycin allows for the administration of a full course of therapy with a these agents. Moxifloxacin, a fluoroquinolone, has single 2-g dose in an outpatient population.32 Te- been used to treat CAP, and an inpatient trial26,27 in lithromycin has been used for 5 days in outpatients elderly hospitalized patients has demonstrated car- with CAP, and levofloxacin, 750 mg, is as effective diac safety equivalent to levofloxacin, with a statisti- when given for 5 days to inpatients with CAP as cally significantly more rapid rate of clinical improve- when given for 10 days at a dose of 500 mg.29,33 A ment at days 3 to 5 during therapy. The high recent study34 compared 3 days of therapy with bioavailability of quinolone agents may allow oral amoxicillin to 8 days of therapy in hospitalized therapy to replace IV therapy, thus keeping some patients and showed the short-duration therapy to be patients with CAP out of the hospital. Using oral comparable to longer duration therapy in terms of levofloxacin, along with a cluster-randomized proto- clinical success. However, the study included only col design, Loeb et al28 documented the safety of this patients with mild-to-moderate illness, and patients approach in nursing home patients who had CAP, were eligible for short-duration therapy only if their but were able to eat and drink, had a pulse of 100 conditions had improved substantially with IV ther- beats/min, a respiratory rate 30 breaths/min, a apy by day 3. One correlate of these findings is that systolic BP of 90 mm Hg, and an oxygen saturation a hospitalized patient who becomes clinically stable of 92%. with IV therapy could be safely discharged from the Telithromycin, the first ketolide, is similar to a hospital without continued inpatient observation. A macrolide in terms of antimicrobial spectrum but is recent Medicare database study35 compared CAP active against macrolide-resistant pneumococci. It patients who were not observed, and were dis- has demonstrated a tendency to reduce the need for charged on the same day as the switch to oral hospitalization when it has been used as an oral therapy, to those observed for a day after the switch. outpatient therapy for CAP, compared to clarithro- There were no differences in the 14-day readmission mycin.29 However, the drug is not optimally active rate and the 30-day mortality rate between the against Haemophilus influenzae, and toxicity issues groups, emphasizing the safety of not keeping (see below) have limited its widespread use. Lin- the patient in the hospital for observation after the ezolid has also been shown to be effective against switch from IV therapy. www.chestjournal.org CHEST / 131 / 4 / APRIL, 2007 1211 Adjunctive Therapy of Severe CAP this expensive therapy, but ideally a randomized trial of patients with severe CAP, rather than a subset The care of patients with severe pneumonia has analysis alone, would be more convincing. In addi- focused on the early identification of these patients tion, the limited benefit for those who received and on prompt therapy with multiple antibiotics. adequate therapy, and the falloff in the 3-month Current guidelines for these patients recommend survival benefit detract from the cost-effectiveness of against monotherapy with any agent, including quin- this therapy. olones, and a recent randomized study36 of levofloxa- Therapy with systemic corticosteroids has been cin monotherapy, compared to combination therapy, demonstrated to be useful for patients who are in in CAP patients admitted to the ICU supports these septic shock and have relative adrenal insufficiency. recommendations (Table 1). The study evaluated However, in a new study,37 therapy with systemic 398 patients admitted to the ICU and found that corticosteroids has been tested in patients with monotherapy was not as effective as combination severe CAP, based on the idea that adverse out- therapy for those persons needing mechanical ven- comes are mediated by the inflammatory response to tilation. Since the trial also excluded those patients infection rather than by uncontrolled infection. In a who were in septic shock, the authors concluded that small (48 patients), multicenter, randomized, monotherapy could not be recommended for CAP blinded trial,37 therapy with a continuous infusion of patients who were in septic shock or for those hydrocortisone was compared to therapy with pla- receiving mechanical ventilation, which are condi- cebo. Although patients had severe CAP, not all of tions that represent the majority of individuals ad- them were treated in an ICU. Steroid therapy led to mitted to the ICU. significantly lower mortality, shorter length of ICU Two adjunctive therapies, activated protein C and stay, and shorter duration of mechanical ventilation. systemic corticosteroids, have been studied in pa- In addition, steroid therapy led to fewer late com- tients with severe CAP.6,37 A retrospective analysis6 plications. Although the data are impressive, confir- of the PROWESS study of activated protein C mation in a larger study is needed. Nonetheless, the (drotrecogin- ) identified that 35.6% of those pa- findings do suggest that steroid therapy is not dan- tients studied had CAP, and that approximately a gerous, even for patients with a severe infection such quarter of them were infected with pneumococcus. as CAP. Patients with CAP who received activated protein C had a survival benefit if they had an acute physiology and chronic health evaluation (APACHE) II score of 25, or pneumococcal infection, a PSI class of IV or Core Measures for Inpatient Care V, or a CURB-65 score of at least 3. For unclear Since 1998, the CMS, in conjunction with the reasons, patients who received adequate therapy had Joint Commission on the Accreditation of Health- a small drop in mortality rate from 37 to 33%, while care Organizations, has promoted standards of care the benefit was much greater in those who received for CAP patients that have been shown to improve inadequate therapy with the mortality rate dropping outcomes, with the expectation that hospitals will from 65.2 to 47.1%. While the mortality rate reduc- meet these standards whenever possible (Table 1). tion was 28% at 28 days, it fell to 14% at 90 days. The pressure to achieve a high compliance rate with These data are interesting and suggest a benefit for these measures has increased with the move to collect data on compliance and to publicly report the information. The evidence that supports these core Table 1—Current CAP Core Measures for Admitted measures is generally strong, but it may not be Patients correct to try to achieve these measures for all patients in all clinical situations, and a reasonable First dose of antibiotics within 4 h of arrival to hospital goal may be 80 to 85% compliance, with a variety of Oxygenation assessment within 24 h of hospital admission Correct antibiotic for admitted patients unintended adverse consequences occurring if rates Non-ICU are higher.38 ICU The current evidence-based standards (with most Includes no monotherapy being based on retrospective database analysis) are Blood cultures within 24 h for all patients admitted to ICU in first as follows: to administer the first dose of antibiotics 24 h Blood for cultures drawn prior to antibiotics administration for within 4 h of the patient's arrival at the hospital; to those drawn in ED select one of the recommended antibiotic therapies Evaluation and offering of pneumococcal and influenza vaccination for admitted patients, with different choices for Smoking cessation advice those in the ICU and those on the medical ward; to *ED emergency department. make sure that if blood cultures are performed, they 1212 Recent Advances in Chest Medicine are collected prior to antibiotic administration; to antibiotics has only been demonstrated to affect provide smoking cessation advice to appropriate mortality in patients 65 year of age, and that the patients; and to evaluate the need and to offer to findings of these studies support the idea that 100% those who meet the criteria both pneumococcal and compliance with the standard would not necessarily influenza vaccines. Several areas have been problem- mean good medical care; thus, the goal should be a atic, and new data are available to guide the clinician lower number of patients given antibiotics within about the recommendations to administer therapy 4 h.38 The standard of antibiotic administration within 4 h, the recommendation not to use mono- within 4 h is likely to change in 2007. therapy for ICU-admitted CAP, the value of blood Blood cultures have not been shown to favorably cultures, and the safety of repeat pneumococcal alter the outcomes of CAP patients, and thus some vaccinations. have argued against collecting them routinely. While One important change in the application of core all patients admitted to the hospital may not need measures is the recognition that some patients who this testing, it may be wise to still collect blood are admitted to the hospital with pneumonia have cultures in those patients with signs of severe illness, health-care-associated pneumonia (HCAP), and that and it is important to collect the cultures prior to these patients are at risk for infection with multi- antibiotic administration. Metersky et al43 studied drug-resistant Gram-negative pathogens and MRSA, 13,043 Medicare patients with CAP who had been and thus need a different approach to therapy than admitted to the hospital to define the predictors of the usual CAP patient.39 HCAP was included in the bacteremia. They found that certain populations 2005 guidelines for nosocomial pneumonia as a form (especially those who had received prior antibiotic of nosocomial infection; thus, since July 2005 pa- therapy) were unlikely to have true positive culture tients who have been identified as having HCAP findings; thus, a large percentage of positive results have been excluded from the CMS core measure of in these patients would be false-positive results and CAP antibiotic choices. This is justified by data could lead to mistakes in management. The predic- showing that HCAP has a different natural history tors of bacteremia were as follows: prior antibiotic than CAP, that the bacteriology is also different from therapy (OR, 0.5); comorbid liver disease (OR, 2.3); CAP, and that, presumably, the therapy should not systolic BP 90 mm Hg (OR, 1.7); fever 35°C or be the same.40 40°C (OR, 1.9); pulse 125 beats/min (OR, 1.9); Controversy about the administration of antibiot- BUN level of 30 mg/dL (OR, 2.0); serum Na level ics within 4 h of a patient's arrival at the hospital has of 130 mEq/L (OR, 1.6); and WBC count of been vigorous, and there is concern that even if 5,000 cells/ L or 20,000 cells/ L (OR, 1.7). large-scale databases show a reduced mortality rate The most common pathogen found in blood cultures with therapy given in this time interval, several was pneumococcus, but 643 of 886 pathogens were unintended consequences can follow.38 These in- contaminants. The authors suggested that patients clude the indiscriminate use of antibiotics in any who have received prior antibiotic therapy and have patient with respiratory symptoms in the emergency none of the severity/comorbidity risk factors listed department, even before the diagnosis is certain, and above should not have blood cultures performed, the temptation to prioritize pneumonia patients since only 3% of patients had true-positive findings ahead of other sick individuals in a busy emergency for bacteremias. Those without prior antibiotic ther- department. Two recent studies41,42 have added to apy and no predictors, or those with prior antibiotic the controversy. The first study41 confirmed that therapy and one predictor should have one blood when therapy is provided in 4 h, mortality is reduced, culture performed since the incidence of true-posi- but the predictors of increased time to antibiotic tive results was 5%. Finally, the yield is high in those administration were altered mental status, absence patients with two predictors (16% bacteremia) or in of fever, absence of hypoxia, and increasing age. those with one predictor and no prior antibiotic When these factors were controlled for, the timing of therapy (9% bacteremia); these patients should have therapy had no impact on mortality, and thus the two blood cultures performed. authors concluded that time to the administration of One concern with the core measure emphasis on antibiotics is not a good quality measure. In support pneumococcal vaccination is the possibility that pa- of these findings was another study42 that found that tients will receive repeated vaccination in less than 22% of 86 Medicare patients with CAP presented the recommended 5-year interval because of the with atypical clinical features that led to diagnostic absence of a reliable history of vaccination, especially uncertainty, which could appropriately lead to a in those patients who have been repeatedly hospital- delay in the administration of antibiotics. In an ized or in those patients who have been treated in editorial accompanying these articles, the observa- nursing homes. One way to deal with this is to tion was made that time to the administration of vaccinate all patients if there is any uncertainty about www.chestjournal.org CHEST / 131 / 4 / APRIL, 2007 1213 the history of vaccination, and that may be justified 2 Koivula I, Sten M, Makela PH. Prognosis after community- by the proven efficacy of the vaccine and the long- acquired pneumonia in the elderly: a population-based 12 year follow-up study. Am J Med 1999; 159:1550 –1555 term consequences if pneumonia does develop in a 3 Niederman MS, McCombs JI, Unger AN, et al. The cost of patient. If this approach is used, it is reassuring to treating community-acquired pneumonia. Clin Ther 1998; know that it is generally safe to administer repeat 20:820 – 837 pneumococcal vaccinations more frequently than the 4 Aujesky D, Auble TE, Yealy DM, et al. Prospective compar- recommended 5-year interval. A study44 evaluated ison of three validated prediction rules for prognosis in 179 patients who had received at least three vacci- community-acquired pneumonia. Am J Med 2005; 118:384 – 392 nations and compared their clinical courses to those 5 Niederman MS, Feldman C, Richards GA. Combining infor- of 181 patients who had received either one or two mation from prognostic scoring tools for CAP: an American doses. Even though 54.6% of those patients who view on how to get the best of all worlds. Eur Respir J 2006; were revaccinated received their repeat vaccinations 27:9 –11 in 6 years, there was only one patient with an 6 Laterre PF, Garber G, Levy H, et al. Severe community- acquired pneumonia as a cause of severe sepsis: data from the adverse reaction, which was described as tachycardia PROWESS study. Crit Care Med 2005; 33:952–961 and arm redness. Thus, it appears to be safe to 7 Capelastegui A, Espana PP, Quintana JM, et al. Validation of administer a vaccination, and although this is not to a predictive rule for the management of community-acquired be done indiscriminately, if it is done, the benefits pneumonia. Eur Respir J 2006; 27:151–157 are likely to far outweigh any associated risks. 8 Goss CH, Rubenfeld GD, Park DR, et al. Cost and incidence of social comorbidities in low-risk patients with community- In support of the recommendation to give pneu- acquired pneumonia admitted ot a public hospital. Chest mococcal vaccines more widely are the findings of 2003; 124:2148 –2155 two more recent studies.45,46 One study45 of the new 9 Christ-Crain M, Stolz D, Bingisser R, et al. Procalcitonin heptavalent conjugated pneumococcal vaccine in guidance of antibiotic therapy in community-acquired pneu- children demonstrated a benefit in reducing invasive monia: a randomized trial. Am J Respir Crit Care Med 2006; 174:84 –93 illness, not only for the population group immunized, 10 Almirall J, Bolibar I, Toran P, et al. Contribution of C-reac- but also to adults, particularly those 65 years of tive protein to the diagnosis and assessment of severity of age, who were not the target of the immunization community-acquired pneumonia. Chest 2004; 125:1335–1342 efforts. The findings imply that the vaccination of a 11 Masia M, Gutierrez F, Shum C, et al. Usefulness of procal- large segment of the at-risk population has a benefit citonin levels in community-acquired pneumonia according to the patients outcome research team pneumonia severity for nonvaccinated patients by lowering the incidence index. Chest 2005; 128:2223–2229 and spread of invasive disease.45 Another database 12 Boussekey N, Leroy O, Georges H, et al. Diagnostic and study46 evaluated the impact of prior pneumococcal prognostic values of admission procalcitonin levels in com- vaccination on patients who had been hospitalized munity-acquired pneumonia in an intensive care unit. Infec- with CAP. Only 12% of 62,918 hospitalized CAP tion 2005; 33:257–263 13 Boussekey N, Leroy O, Alfandari S, et al. Procalcitonin patients had received prior vaccinations, but this kinetics in the prognosis of severe community-acquired pneu- group was less likely to die from any cause, and had monia. Intensive Care Med 2006; 32:469 – 472 a lower risk of respiratory failure and other compli- 14 Doern GV, Richter SS, Miller A, et al. Antimicrobial resis- cations, as well as a reduced length of hospital stay, tance among Streptococcus pneumoniae in the United States: compared to patients who were not vaccinated.46 have we begun to turn the corner on resistance to certain antimicrobial classes? Clin Infect Dis 2005; 41:139 –148 15 Lujan ML, Gallego M, Fontanals D, et al. Prospective observational study of bacteremic pneumococcal pneumonia: Conclusion effect of discordant therapy on mortality. Crit Care Med 2004; 32:625– 631 While the studies of CAP in the past several years 16 Yu VL, Chiou CC, Feldman C, et al. An international have tackled a large number of important topics, the prospective study of pneumococcal bacteremia: correlation with in vitro resistance, antibiotics administered, and clinical general direction of new developments, which have outcome. 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Am J tion after antibiotic switch in pneumonia: a national evalua- Respir Crit Care Med 2003; 167:1650 –1654 tion. Am J Med 2006; 119:512:e1– e7 23 Wang JL, Chen KY, Fang CT, et al. Changing bacteriology of 36 Leroy O, Saux P, Bedos JP, et al. Comparison of levofloxacin adult community-acquired lung abscess in Taiwan: Klebsiella and cefotaxime combined with ofloxacin for ICU patients pneumoniae versus anaerobes. Clin Infect Dis 2005; 40:915– with community-acquired pneumonia who do not require 922 vasopressors. Chest 2005; 128:172–183 24 Menendez R, Torres A, Zalacain R, et al. Guidelines for the treatment of community-acquired pneumonia: predictors of 37 Confalonieri M, Urbino R, Potena A, et al. Hydrocortisone adherence and outcome. Am J Respir Crit Care Med 2005; infusion for severe community-acquired pneumonia: a pre- 172:757–762 liminary randomized study. Am J Respir Crit Care Med 2005; 25 Van der Eerden MM, Vlaspolder F, de Graaff CS, et al. 171:242–248 Comparison between pathogen directed antibiotic treatment 38 Houck PM. Antibiotics and pneumonia: is timing everything and empirical broad spectrum antibiotic treatment in patients or just a cause of more problems? Chest 2006; 130:1–3 with community acquired pneumonia: a prospective random- 39 Hiramatsu K, Niederman MS. Health-care-associated pneu- ised study. Thorax 2005; 60:672– 678 monia: a new therapeutic paradigm. Chest 2005; 128:3784 – 26 Anzueto A, Niederman MS, Pearle J, et al. Community- 3787 Acquired Pneumonia Recovery in the Elderly (CAPRIE): 40 Kollef MH, Shorr A, Tabak YP, et al. Epidemiology and efficacy and safety of moxifloxacin therapy versus that of outcomes of health-care-associated pneumonia: results from a levofloxacin therapy. Clin Infect Dis 2006; 42:73– 81 large US database of culture positive patients. Chest 2005; 27 Morganroth J, Dimarco JP, Anzueto A, et al. A randomized 128:3854 –3862 trial comparing the cardiac rhythm safety of moxifloxacin vs 41 Waterer GW, Kessler LA, Wunderink RG. Delayed admin- levofloxacin in elderly patients hospitalized with community- istration of antibiotics and atypical presentation in communi- acquired pneumonia. Chest 2005; 128:3398 –3406 ty-acquired pneumonia. Chest 2006; 130:11–15 28 Loeb M, Carusone SC, Goeree R, et al. Effect of a clinical 42 Metersky ML, Sweeney TA, Getzow MB, et al. Antibiotic pathway to reduce hospitalizations in nursing home residents timing and diagnostic uncertainty in Medicare patients with with pneumonia: a randomized controlled trial. JAMA 2006; pneumonia: is it reasonable to expect all patients to receive 295:2503–2510 antibiotics within 4 hours? Chest 2006; 130:16 –21 29 Lonks JR, Goldmann DA. Telithromycin: a ketolide antibiotic for treatment of respiratory tract infections. Clin Infect Dis 43 Metersky ML, Ma A, Bratzler DW, et al. Predicting bactere- 2005; 40:1657–1664 mia in patients with community-acquired pneumonia. Am J 30 Park-Wyllie LY, Juurlink DN, Kopp A, et al. Outpatient Respir Crit Care Med 2004; 169:342–347 gatifloxacin therapy and dysglycemia in older adults. N Engl 44 Walker FJ, Singleton RJ, Bulkow LR, et al. Reactions after 3 J Med 2006; 354:1352–1361 or more doses of pneumococcal polysaccharide vaccine in 31 Clay KD, Hanson JS, Pope SD, et al. Brief communication: adults in Alaska. Clin Infect Dis 2005; 40:1730 –1735 severe hepatotoxicity of telithromycin: three case reports and 45 Whitney CG, Farley MM, Hadler J, et al. Decline in invasive literature review. Ann Intern Med 2006; 4:415– 420 pneumococcal disease after the introduction of protein- 32 Blasi F, Tarsia P. Value of short-course antimicrobial therapy polysaccharide conjugate vaccine. N Engl J Med 2003; 348: in community-acquired pneumonia. Int J Antimicrob Agents 1737–1764 2005; 26: S148 –S155 46 Fisman DN, Abrutyn E, Spaude KA, et al. Prior pneumococ- 33 Dunbar LM, Wunderink RG, Habib MP, et al. High-dose, cal vaccination is associated with reduced death, complica- short-course levofloxacin for community-acquired pneumo- tions and length of stay among hospitalized adults with nia: a new treatment paradigm. Clin Infect Dis 2003; 37:752– community-acquired pneumonia. Clin Infect Dis 2006; 42: 760 1093–1101 www.chestjournal.org CHEST / 131 / 4 / APRIL, 2007 1215


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November 27, 2014
HOUSTON (AP) - Police say a man accused of killing his ex-girlfriend in Houston and dumping her body hundreds of miles away in a West Texas oil field taped an interview about the case for the "Dr. Phil" show two days before confessing to investigators.
Mark Augustin Castellano has been charged with murder in last month's slaying of 31-year-old Michelle Warner.
Houston police Det. Fil Waters said Monday that Castellano told investigators Sunday that he drove the couple's 3-year-old son to his parents' home in Odessa before returning to Houston to get Warner's body. Waters says Castellano left the body in a plastic container in the backseat of a car parked outside his parents' home for 1 ½ days before dumping it in a ditch in Midland.
Castellano doesn't have an attorney yet.
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Savage Arms Magazine Savage 220 20 Gauge 2-Round Polymer Black
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This replacement magazine is a factory original from Savage. Factory replacement parts are manufactured to the exact same specifications and tolerances and use the same manufacturing materials as the original parts which guarantees excellent fit and reliable operation.
Keeping a few extra factory magazines around is never a bad idea; extra magazines save loading time at the range and also serve as a backup for those days when you simply cannot remember where you put your primary magazine. Technical Information:
All side release magazines may require minor fitting
Keeping a few extra factory magazines around is never a bad idea; extra magazines save loading time at the range and also serve as a backup for those days when you simply cannot remember where you put your primary magazine. Technical Information:
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He chugged from a bottle of wine and then we had pretend sex
Lady with a stroller in a bar. Think she's out of my league?


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"He said we would bounce around. I think it's a great idea and I'm not going to have a problem with it."
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"I don't know if the puck was bouncing or not, but he played it well. I directed it on net and he kept his pad down and it hit the top of his pad."


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May 14, 2004
BAGHDAD [MENL] -- Iraq's interim government has agreed that the nation'smilitary will be based on voluntary service.
May 13, 2004
ANKARA [MENL] -- The United States has relayed a pledge that it will notestablish military bases in Cyprus as part of a solution to reunite theisland.
ANKARA [MENL] -- Turkey's powerful military has lost its budget autonomyunder a constitutional amendment ratified as part of Ankara's campaignto join the European Union.
ATHENS [MENL] -- Greece has launched another major exercise to ensuresecurity at the Olympic Games.


text:
Wilkinson handed Lions lifeline
ESPN Staff
December 13, 2012
Jonny Wilkinson was on the Lions' last tour to Australia in 2001 © Getty Images
Jonny Wilkinson has been given fresh hope of touring with the British & Irish Lions for a third time next summer.
Despite retiring from international rugby last year, the 33-year-old hopes his form for high-flying Toulon will force his way on to the plane to Australia for the three-test tour with the Wallabies. And the former England international was given cause for optimism by Rob Howley, who was named as one of Warren Gatland's three assistant coaches on Wednesday.
"He (Wilkinson) is playing in a good team at Toulon, who are going pretty well in the Heineken Cup, and Warren has said that all players who are in contention will be looked at," said Howley, who formed a Test half-back partnership with Wilkinson on the last Lions tour of Australia in 2001.
"I'm sure Toulon will be in the quarter-finals and they are the games you need to be playing - quarter-finals and semi-finals of the Heineken Cup, if you're not playing international rugby. We have to see the players under pressure in those sorts of situations."
Ireland's Jonny Sexton remains favourite to be the Lions starting No.10 against the Wallabies but who will join him on the plane is far from clear at this stage. A serious Achilles injury appears to have ended Rhys Priestland's hopes while England duo Owen Farrell and Toby Flood continue to squabble over the England No.10 shirt, with both the struggling to convince at times.
That could throw the door open to Wilkinson who toured with the Lions in 2001 and 2005 but his challenge is set to depend on his form for Toulon in the Heineken Cup.
Howley said: "I enjoyed Sexton's performances during the autumn series, and the likes of Owen (Farrell) and Toby (Flood). They are all different styles of 10 and there will be a lot of analysis on those players in the next three or four months.
"It's competition, and that's what brings the best out of them. None of them have been on a Lions tour, so it will be interesting to watch them under the microscope during a Six Nations, in a Lions year. Particularly as a No 10, a key ingredient in performances is how they react under pressure."
© ESPN Sports Media Ltd.
|Live Scores
The latest Week in Pictures takes in all the action from the weekend when rugby united behind Samoa
Style nothing without substantial pack
The Wallabies showed flair in Dublin, but they still have a way to go if they are to do more than make up the numbers at the World Cup, writes Greg Growden
Ford helps England re-find focus
England broke their losing streak, but this was not them clawing their way back among the best, writes Tom Hamilton
Wales' lessons to learn in defeat by New Zealand are almost exactly the same as those from previous near-misses, writes Huw Richards


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only will Selena be starring in the big event, but she is also executive
producing! Sel chatted with Radio Disney host Ernie D. yesterday, explaining
her reasoning for the move. "I'm not ready for it to be over, so I just kind of
want to do one more thing," she said. And as for the decision to try her hand
at the action behind the lens, she said, "It was my idea to kind of start this,
because I wanted to do it really badly. I want to make sure I promise the cast
and the fans a really, really good hour-long event that will leave them feeling
good." We're glad you brought it back, Sel!
what exactly will take place in this new special? The story's set to revolve
around the Russo family visiting Tuscany, Italy to reunite with their long-lost
family. While there, Alex (Selena Gomez) accidentally conjures a spell that
causes, well, double Alex trouble! Good Alex and Evil Alex must battle to see
who will come out on top. At the same time, she must prevent a charming wizard
from taking over the world, while saving her family and everyone else!
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text:
Maines Provokes Fresh Dixie Chicks Row
LATEST: DIXIE CHICKS lead singer NATALIE MAINES has come under fire from country music bigwigs for wearing a controversial T-shirt at last month's (MAY03) ACADEMY OF COUNTRY MUSIC AWARDS ceremony.
Maines - who faced a huge backlash when she said she was ashamed to come from the same state as President GEORGE W BUSH - sported the slogan FUTK on her top.
This was thought to be a thinly-veiled insult to country music singer TOBY KEITH, who has made vocal his opposition to the Chick's political stance.
CADILLAC JACK, music programmer of Philadelphia's WXTU said yesterday (02JUN03), "With all the patriotism in the air that night, it was a downer and completely unnecessary. I was disappointed with them yet again."
Programming director BRIAN JENNINGS of Nebraska station KZKX adds, "Just when you think it's safe to add the Chicks back into rotation... Oh, Natalie, why do you make it so hard to love you?"03/06/2003 17:08


text:
Dominion's Smith to play in U.S. Army All-American Bowl
Smith, a 6-foot-3, 215-pound Clemson University recruit, becomes the fourth player from Loudoun chosen to play in the game. He joins Stone Bridge alums Jonathan Allen (now playing for Alabama) and Ryan Burns (Stanford), along with Briar Woods alum Alex Carter (Stanford).
The U.S. Army All-American Bowl will feature 90 high school football players in an East vs. West match-up. The game will be played Jan. 3 at the Alamodome in San Antonio and will be televised live on NBC at 1 p.m.
"Chad and all of the 2015 U.S. Army All-American Bowl players were selected not only for their ability on the football field, but also because they demonstrate mental, emotional and physical toughness – similar strengths to those of our Army Soldiers," Mark S. Davis, deputy assistant secretary of the Army for marketing, said in a release.
"We are pleased to welcome these talented athletes to this year's showcase of athleticism, teamwork and excellence," Davis continued. "We congratulate each of them on their selection."
Smith was a four-year varsity starter at Dominion, playing for coach Karl Buckwalter. A stand out at both running back and linebacker, Smith helped the Titans record their first-ever playoff victory in 2013 and advance to the postseason once again in 2014.
He garnered scholarship offers from a dozen NCAA Division I schools - including Wisconsin - before deciding Clemson was his best fit. Smith was recruited by colleges to play outside linebacker, where he ranks among the top 20 players nationally by several recruiting websites.
Smith will graduate from Dominion in January and will enroll at Clemson for the spring semester. Enrolling early provides Smith a head start in preparing for his initial collegiate season.
Top / Eastern Loudoun / Sterling /
- Dominion's Smith to play in U.S. Army All-American Bowl
- Former Redskin Fred Smoot arrested for domestic violence
- Rape story jolts UVA campus; LCPS grads demand changes
- Hops, not houses: How a Lucketts transplant hopes to bring Loudoun back to its agrarian roots
- Rezoning requests would mean major changes for Brambleton


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Efficient parametric fluorescence is obtained from a pump wavelength λ=1.06 μm in low-loss, form-birefringent GaAs/AlOx waveguides. Besides showing a 1 μm wide tuning range and the onset of amplification regime for continuous-wave pump levels around 50 mW, an 8% parametric gain is determined. This is the highest figure reported to date in semiconductor waveguides, and confirms GaAs/AlOx waveguides as a candidate for an integrated parametric optical source.
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Living with Wildfire
As the drought-stricken American West struggles with worsening fires, ecologists are calling for a new strategy: coexistence.
As the drought-stricken American West struggles with worsening fires, ecologists are calling for a new strategy: coexistence.
A weekend-long gathering of engineers, designers, and parents recently sought to reinvent one of the most loathed trappings of modern motherhood.
Dying fish populations in Ghana caused children to start skipping school. Scientists should look for more connections like that.
One of the recurring arguments in favor of Keystone XL—the hard-fought "bullet pipeline" that would create a direct link between the Alberta oil sands and the Gulf of Mexico—is that its defeat won't keep oil in the ground or keep carbon out of the
In the fall of 1990, at a meeting of the American Chemical Society, C. Lowell Miller, then the associate deputy assistant secretary for clean coal at the Department of Energy, took issue with his job title. "There is no point in pretending that coal is what it is not, nor
In the nineteen-thirties, the literary theorist Kenneth Burke proposed what he called the "comic frame"—the view, he wrote, of "human antics as a comedy, albeit as a comedy ever on the verge of the most disastrous tragedy." Tragedy marches inexorably …
Gold miners in California at their sluice box, c. 1850. See Photo Booth for a slide show of more daguerreotype images. In 1843, a Dartmouth College freshman named Augustus Washington needed to earn some money for tuition. As a man of mixed-race—a black father, a South Asian …
In 1965, while on assignment for the magazine, John McPhee visited the University of Florida's venerable Citrus Experiment Station, where the staff spent much of its time counselling citrus growers suffering from bad luck, waterlogged soil, or one of a host of pests and


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Defend your castle against hordes of ankle-biting green goblins by hurling rocks from the walls and dumping boiling oil on their heads! Upgrade your capabilities by racking up the points and taking down the pests. Featuring mouse-based controls and randomized gameplay, Goblins at the Gate is simple fun.
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Publisher:Penguin Books
Saint Mark's Gospel is generally agreed to be the primary source for the life of Jesus - both Matthew and Luke drew on his account when they were writing their own. None of them, stresses the author of this book, was attempting to create a modern-style biography. But although Mark lays his own individual emphasis on the perennial struggle between the forces of good and evil, the suffering and secret Messiahship of Christ, he seems largely to be handing on, unmodified, the traditions of the early Christian Church.
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Wacoal-5-year-old 着やせ jacket ARA177
And under the armpits and back Hami 着やせ jacket -5-year-old meat to work and such,
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