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Disclosures: Michael E Pichichero, MD Nothing to disclose. Daniel J Sexton, MD Grant/Research/Clinical Trail Support: Cubist [C difficile infection (Fidaxomycin)]. Consultant/Advisory Boards: Johnson & Johnson [Vaginal mesh-related infection (Synthetic vaginal slings)]. Other Financial Interest: National Football League [Infection prevention in athletes]. Morven S Edwards, MD Grant/Research/Clinical Trial Support: Novartis Vaccines [Group B Streptococcus]. Consultant/Advisory Boards: Novartis Vaccines [Group B streptococcal vaccine development]. Elinor L Baron, MD, DTMH Employee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
INTRODUCTION — Group A streptococcal (GAS) tonsillopharyngitis presents with abrupt onset of sore throat, tonsillar exudate, tender cervical adenopathy, and fever, followed by spontaneous resolution within two to five days. Patients with sore throat lasting longer than one week usually do not have GAS tonsillopharyngitis.
Issues related to treatment and prevention of group A streptococcal tonsillopharyngitis will be reviewed here [1]. A general approach to patients with pharyngitis and the factors responsible for antibiotic failure are discussed separately. (See "Evaluation of acute pharyngitis in adults" and "Approach to diagnosis of acute infectious pharyngitis in children and adolescents" and "Antibiotic failure in the treatment of streptococcal tonsillopharyngitis".)
GOALS OF THERAPY — Goals of antimicrobial therapy for eradication of group A Streptococcus (GAS) from the pharynx in the setting of acute streptococcal pharyngitis include:
●Reducing duration and severity of clinical signs and symptoms, including suppurative complications
●Reducing incidence of nonsuppurative complications (eg, acute rheumatic fever)
●Reducing transmission to close contacts by reducing infectivity
Considerations of treatment include ease of antibiotic administration and limited expense with as few adverse effects as possible [2-4].
Reducing clinical symptoms — Antibiotic therapy is most beneficial for hastening resolution of symptoms if instituted within the first two days of illness [5-9]. Antibiotic therapy is also beneficial for reducing suppurative complications such as peritonsillar abscess, cervical lymphadenitis, and mastoiditis. Additional issues related to antibiotic therapy for reducing clinical symptoms are discussed further below. (See 'Timing of therapy' below.)
Reducing nonsuppurative complications — Antibiotic therapy is primarily helpful for reducing the incidence of acute rheumatic fever as a nonsuppurative complication of GAS pharyngitis. The role of antibiotic therapy in decreasing the nonsuppurative complications of glomerulonephritis and pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS) syndrome is not clear [10].
Acute rheumatic fever — Although symptoms of GAS pharyngitis resolve without antibiotic therapy, persistence of the organism in the upper respiratory tract elicits an immune response that can set the stage for subsequent risk of acute rheumatic fever (ARF) if the strain is rheumatogenic and the host is genetically predisposed. In some populations, group G and group C streptococci may also play a role in ARF pathogenesis [11,12]. (See "Epidemiology and pathogenesis of acute rheumatic fever" and "Clinical manifestations and diagnosis of acute rheumatic fever", section on 'Predisposing factors'.)
The efficacy of penicillin for primary prevention of ARF was established in the early 1950s when military recruits with GAS tonsillopharyngitis received injectable penicillin G mixed in peanut oil or sesame oil with 2 percent aluminum monostearate [13,14]. GAS eradication and ARF primary prevention were optimized with injection schedules that provided at least 9 to 11 days of penicillin.
Subsequently, evaluation of GAS tonsillopharyngitis therapies has been based upon GAS eradication from the upper respiratory tract; it is assumed that such eradication is an adequate surrogate marker for efficacy in primary prevention of rheumatic fever. Antibiotic therapy can be helpful for prevention of rheumatic fever if initiated up to nine days following onset of symptoms [13].
Glomerulonephritis — Children younger than seven years of age appear to be at greatest risk of poststreptococcal glomerulonephritis. Although antibiotic therapy has efficacy for primary prevention of acute rheumatic fever, the role of antibiotics in the setting of GAS tonsillopharyngitis for prevention of poststreptococcal glomerulonephritis is not certain. (See "Differential diagnosis and evaluation of glomerular disease", section on 'Hematuria following upper respiratory infection'.)
PANDAS syndrome — Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci is discussed separately. It is not clear whether antibiotic therapy for GAS pharyngitis reduces the incidence of this syndrome. (See "Complications of streptococcal tonsillopharyngitis", section on 'PANDAS syndrome'.)
Reducing transmission — The rate of GAS transmission from an infectious case to close contacts (such as a family or school setting) is approximately 35 percent. Antibiotic treatment does have a role for preventing transmission of GAS; after 24 hours of treatment with penicillin, subsequent cultures are negative in about 80 percent of cases [15]. Data on the duration of contagion for alternative antibiotics are not available. In untreated patients, GAS is eliminated from the upper respiratory tract by host immune factors in 50 percent of cases at one month following acute infection [16].
Additional issues related to antibiotic therapy for reducing transmission are discussed further below. (See 'Follow-up' below.)
TREATMENT — Antimicrobial therapy is warranted for patients with symptomatic pharyngitis if the presence of group A streptococci (GAS) in the pharynx is confirmed by culture or rapid antigen detection testing (RADT). The approach to establishing the diagnosis of acute streptococcal pharyngitis is discussed in detail separately. (See "Evaluation of acute pharyngitis in adults", section on 'Identifying patients with GAS'.)
Antimicrobial therapy may also be administered to mitigate the clinical course of pharyngitis due to group C and group G streptococci. The approach to antibiotic selection is as outlined in the following sections. However, treatment need not continue for 10 days since acute rheumatic fever is not a complication of infection due to these organisms; five days of treatment is sufficient [2,17,18]. (See "Group C and group G streptococcal infection".)
In general, antimicrobial therapy is of no proven benefit for treatment of pharyngitis due to bacteria other than Streptococcus (with the exception of relatively rare infections caused by other bacterial pathogens such as Corynebacterium diphtheriae and Neisseria gonorrhoeae). Such therapy unnecessarily exposes patients to the expense and potential hazards of antimicrobial drugs and contributes to the emergence of antibiotic resistant bacteria.
Timing of therapy — If clinical and/or epidemiologic factors point to a high index of suspicion for GAS pharyngitis while laboratory results are pending, it is appropriate to initiate empiric antimicrobial therapy. However, if laboratory testing does not confirm the diagnosis of GAS pharyngitis, antimicrobial therapy should be discontinued.
In the natural history of GAS pharyngitis, the incubation period is two to four days. Fever and constitutional symptoms usually resolve within three to four days, even in the absence of antimicrobial therapy [16]. Clinical improvement has been observed up to 48 hours sooner in patients receiving penicillin versus placebo within the first two days of illness [5-9].
There is some concern that early therapy may suppress host antibody response and thereby increase risk for recurrent pharyngitis. In a study of 142 children with presumed GAS pharyngitis, those treated with penicillin at the initial office visit had a higher incidence of recurrent infection than those for whom treatment was delayed at least 48 hours (recurrent infection occurred eight times more frequently) [6].
Nonetheless, delaying treatment is not warranted in most cases of GAS tonsillopharyngitis. It may be a useful strategy for patients who have frequent, recurrent, mild to moderate infections to allow development of immunity to the infecting strain without increasing the risk of acute rheumatic fever. Antibiotic therapy delayed for up to nine days following onset of symptoms is still helpful for prevention of rheumatic fever (although may be less effective for prevention of suppurative complications) [13]. However, this approach should not be considered if the patient is severely ill or if highly virulent or rheumatogenic strains are actively circulating within a community. Patients are considered no longer contagious after 24 hours of antibiotic therapy [15].
Antibiotics for group A Streptococcus — Antibiotic options for treatment of GAS pharyngitis include penicillin (and other related agents including ampicillin and amoxicillin), cephalosporins, macrolides, and clindamycin [19]. Sulfonamides, fluoroquinolones, and tetracyclines should NOT be used for treatment of GAS pharyngitis because of high rates of resistance to these agents and their frequent failure to eradicate even susceptible organisms from the pharynx.
Intramuscular penicillin is the only therapy that has been shown to prevent initial attacks of rheumatic fever in controlled studies [14,20]. These studies were performed with penicillin G procaine in oil containing aluminum monostearate; this preparation has since been supplanted by penicillin G benzathine. There are data suggesting that penicillin G benzathine is effective for primary prevention of rheumatic fever, although they are not definitive [21]. Other antimicrobials have been shown to effectively eradicate GAS from the upper respiratory tract, and it is assumed that such eradication is a surrogate for efficacy in primary prevention of rheumatic fever.
Resistance — Antimicrobial resistance has not been a significant issue in the treatment of GAS. No clinical isolate of GAS has demonstrated penicillin resistance, likely due to the organism's lack of altered penicillin-binding proteins and/or inefficient gene transfer mechanisms for resistance [22,23]. However, streptococcal strains tolerant to penicillin (eg, strains inhibited but not killed by penicillin in vitro, with ratio of minimum bactericidal concentration to minimum inhibitory concentration [MIC] of ≥32) have been described [24-27]. The clinical significance of such strains is not clear; they have been isolated in the setting of outbreaks in which penicillin treatment failure was observed, but there was no difference in failure rates among tolerant and susceptible strains. (See "Antibiotic failure in the treatment of streptococcal tonsillopharyngitis".)
There have been reports of relatively high levels of resistance to macrolide antibiotics in some regions of the United States and Asia; given the increasing use of macrolides for treatment of upper and lower respiratory tract infections, clinicians should be cognizant of local patterns of antimicrobial resistance [28-37].
Selection — Oral penicillin V is the agent of choice for treatment of GAS pharyngitis given its proven efficacy, safety, narrow spectrum, and low cost [2,38-42]. The appropriate duration is 10 days of therapy; dosing is outlined in the Table (table 1). This approach is extrapolated from studies performed in the 1950s demonstrating that treatment of streptococcal pharyngitis with intramuscular penicillin prevents acute rheumatic fever [14,20]. (See "Treatment and prevention of acute rheumatic fever".)
Amoxicillin is often used in place of oral penicillin in children, since the taste of the amoxicillin suspension is more palatable than that of penicillin. Some data suggest that oral amoxicillin may be marginally superior to penicillin, most likely due to better gastrointestinal (GI) absorption [43,44]. In addition, amoxicillin has activity against one-third of the common pathogens that cause otitis media (which presents concurrently with GAS tonsillopharyngitis in up to 15 percent of children, particularly those under four years of age). Dosing is outlined in the Table (table 1). (See "Acute otitis media in children: Treatment", section on 'Initial antimicrobial therapy'.)
Intramuscular penicillin G benzathine (single dose) may be administered to patients who cannot complete a 10-day course of oral therapy or to patients at enhanced risk for rheumatic fever (eg, those with history of previous rheumatic heart disease and/or living in crowded conditions). Injections of benzathine penicillin provide bactericidal levels against GAS for 21 to 28 days. The addition of procaine penicillin alleviates some of the discomfort associated with benzathine injections and may favorably influence the initial clinical response. The preferred product in children is the combination of 900,000 units of benzathine penicillin G plus 300,000 units of procaine penicillin (Bicillin C-R 900/300). (See Penicillin G benzathine-penicillin G procaine: Drug information). Dosing is outlined in the Table (table 1).
Cephalosporins are acceptable alternatives in patients with recurrent GAS infection but are not recommended as first-line therapy in national guidelines [45-52]. Cephalosporins have demonstrated better microbiologic and clinical cure rates than penicillin; these differences appear to be greater among children than adults, and some favor use of first-generation cephalosporins as first-line therapy in this group [53-55]. However, second- and third-generation cephalosporins may facilitate development of antibiotic resistance and are not favored as first-line therapy [46,47]. (See 'Recurrent infection' below.)
Antibiotic therapy directed against beta-lactamase-producing upper respiratory tract flora (such as amoxicillin-clavulanate) remains controversial and is not indicated in patients with acute pharyngitis, although it would be effective [2,56,57].
For patients with beta-lactam hypersensitivity, cephalosporins (cefuroxime, cefpodoxime, cefdinir, and ceftriaxone) may be used [38,44-50], in the absence of history of life-threatening allergic reaction to penicillin; cross reactivity with penicillin is not likely for later-generation cephalosporins than first-generation cephalosporins [45,58-60]. Macrolides (clarithromycin, azithromycin, or erythromycin) are an acceptable alternative for penicillin-allergic patients, depending on local resistance patterns [28,31-36]. For the rare patient with an erythromycin-resistant strain of GAS who is unable to tolerate beta-lactam agents, clindamycin is an appropriate choice [61].
Duration — In general, the conventional duration of oral antibiotic therapy to achieve maximal pharyngeal GAS eradication rates is 10 days, even though patients usually improve clinically within the first few days of treatment [62,63]. If penicillin is discontinued after three days of therapy, the probability of relapse is higher than if penicillin is discontinued after seven days of treatment (50 versus 34 percent, respectively) [14,16,20].
Five days of therapy with cefpodoxime, cefdinir, or azithromycin is an acceptable alternative approach, with rates of bacteriologic and clinical cure of streptococcal pharyngitis comparable with that of the conventional 10-day course of penicillin [33-36,41,64-76]. Three injections of ceftriaxone on sequential days (or every other day) are needed for optimal eradication.
Attempts to treat GAS pharyngitis with a single daily dose of penicillin have been unsuccessful. Although some data suggest that once-daily amoxicillin may be sufficient for treatment of GAS pharyngitis, others have shown that this approach is not adequate for effective eradication; further investigation is needed [77-80]. Among the alternative agents, azithromycin and some cephalosporins (including cefixime, cefpodoxime, cefadroxil, and cefdinir) are effective for eradication of pharyngeal streptococci with once-daily dosing [69,81-84].
Antibiotics for other organisms — The differential diagnosis of acute pharyngitis is outlined separately (table 2). (See "Evaluation of acute pharyngitis in adults".)
The approach to treatment of infection due to Streptococcus other than group A, influenza, infectious mononucleosis, primary HIV infection, N. gonorrhoeae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Corynebacterium diphtheriae is discussed separately. (See related topics.)
The approach to treatment of infection due to Fusobacterium necrophorum is uncertain; further study is needed to better define the role of F. necrophorum in the epidemiology of pharyngitis and the associated risk between F. necrophorum pharyngitis and Lemierre's syndrome. Some favor empiric treatment with penicillins or cephalosporins in the setting of negative diagnostic test results but at least three Centor criteria (fever, tonsillar exudate, swollen tender cervical adenopathy, or lack of cough) among patients 15 to 30 years of age, although it is uncertain whether this approach is effective for prevention of Lemierre's syndrome [85,86]. Therefore, we favor antibiotic therapy for pharyngitis only in the setting of a positive diagnostic test [41]. (See "Suppurative (septic) thrombophlebitis", section on 'Jugular vein' and "Evaluation of acute pharyngitis in adults", section on 'Evaluation'.)
The antibiotics of choice for treatment of infection due to Arcanobacterium haemolyticum are erythromycin or azithromycin; data are limited to case reports and in vitro studies [87,88]. In vitro studies show most strains to be susceptible to beta-lactam agents, although treatment failure may occur because of poor penetration into the intracellular space [88]. Clindamycin, doxycycline, ciprofloxacin, and vancomycin are also effective agents.
Follow-up — Patients with GAS pharyngitis should have improvement in clinical symptoms within three to four days of initiating antibiotic therapy. Failure to observe a clinical response to antibiotics should prompt diagnostic reconsideration or the possibility of a suppurative complication. If acute streptococcal pharyngitis was diagnosed by rapid testing, the result may represent a false-positive finding; if the diagnosis was made by culture, the patient may be a pharyngeal carrier whose symptoms are likely attributable to an alternate process. (See 'Carriers' below.)
In general, test of cure is not necessary for asymptomatic patients or their close contacts following completion of a course of antimicrobial therapy. The majority of patients with GAS remaining in their upper respiratory tracts after completing a course of antimicrobial therapy are Streptococcus carriers [89,90].
However, follow-up test of cure is appropriate testing for asymptomatic index patients and their asymptomatic household contacts in the following circumstances:
●Individuals with history of rheumatic fever
●Individuals who develop acute pharyngitis during an outbreak of acute rheumatic fever or acute poststreptococcal glomerulonephritis [90]
●Spread of GAS among several family members
Asymptomatic patients and asymptomatic household contacts in the above circumstances with positive laboratory results should receive a standard course of antimicrobial therapy with one of the agents outlined above [91]. Repeat treatment should be administered with an agent with greater beta-lactamase stability than the previous agent [56]. If a penicillin was used for initial therapy, repeat treatment with amoxicillin-clavulanate or a first-generation cephalosporin may be used; if initial treatment was with a first-generation cephalosporin, a second- or third-generation cephalosporin may be used. (See "Evaluation of acute pharyngitis in adults" and 'Antibiotics for group A Streptococcus' above.)
Recurrent infection — In the setting of recurrent acute pharyngitis with positive repeat diagnostic testing, there are several possible explanations [89,91,92]:
●Persistence of Streptococcus carriage in the setting of viral infection
●Nonadherence with the prescribed antimicrobial regimen
●New infection with GAS acquired from household or community contacts
●Treatment failure (eg, repeat episode of pharyngitis caused by the original infecting strain); treatment failure is rare.
In the setting of a second episode of acute pharyngitis with positive repeat diagnostic testing, a repeat course of treatment is appropriate (table 1). Repeat treatment should be administered with an agent with greater beta-lactamase stability than the previous agent [56].
If adherence is uncertain, intramuscular penicillin G benzathine may be chosen as the second course of therapy. If a full course of penicillin was completed as initial therapy, a first-generation cephalosporin (such as cephalexin, cefadroxil) may be used; if a first-generation cephalosporin was used for initial therapy, a second- or third-generation cephalosporin (such as cefpodoxime, cefdinir) may be used. Alternative agents include amoxicillin-clavulanate or clindamycin.
It is not necessary to perform follow-up testing after the second course of therapy unless the patient remains or becomes symptomatic or unless special circumstances as outlined above are present. (See 'Antibiotics for group A Streptococcus' above and 'Follow-up' above.)
In the setting of multiple recurrent episodes, it may be difficult to distinguish true GAS pharyngitis from viral pharyngitis in the setting of streptococcal carriage. It is likely that most of these patients are carriers experiencing nonstreptococcal infections. This may be discernible by evaluating for the presence of GAS during asymptomatic intervals and/or by typing streptococcal isolates obtained during distinct episodes (with the expertise of a specialized laboratory). In these circumstances, treatment with clindamycin or amoxicillin-clavulanate may be beneficial since these agents have demonstrated high eradication rates for pharyngeal streptococci carriage (table 1) [56,61,93]. (See 'Carriers' below.)
For patients with as many as six GAS infections in a single year or three to four episodes in two consecutive years, tonsillectomy may be an appropriate therapeutic consideration [94,95]. This was illustrated in a randomized trial including 187 children with recurrent pharyngitis, of whom 95 were managed with tonsillectomy [94]. The incidence of pharyngitis during the first two years of follow-up was significantly lower among the tonsillectomy group. (See "Tonsillectomy and adenoidectomy in children: Indications and contraindications", section on 'Recurrent infection'.)
Antibiotic failure in the treatment of streptococcal tonsillopharyngitis is discussed separately. (See "Antibiotic failure in the treatment of streptococcal tonsillopharyngitis".)
Carriers — In general, group A Streptococcus (GAS) resides in the oropharynx of Streptococcus carriers in the absence of host immunologic response to the organism [96]. In temperate climates during the winter and spring, up to 20 percent of asymptomatic school-aged children may be carriers. About 25 percent of asymptomatic individuals in the households of index patients harbor GAS in their upper respiratory tracts [91]. Streptococcal carriage may persist for many months. (See "Antibiotic failure in the treatment of streptococcal tonsillopharyngitis", section on 'Streptococcal carriage'.)
Carriers may demonstrate evidence of GAS in the upper respiratory tract during an episode of viral pharyngitis, suggesting acute streptococcal pharyngitis. In these circumstances, clinically distinguishing viral from streptococcal pharyngitis can be difficult. Useful clues may include patient age, season, local epidemiology, and the nature of presenting signs and symptoms. In addition, pharyngeal strep carriers tend to have low antistreptolysin O (ASO) titers; they may be just above detectable. (See "Evaluation of acute pharyngitis in adults".)
Streptococcus carriers are unlikely to spread the organism to close contacts and are at very low risk for developing suppurative complications or acute rheumatic fever [96]. Moreover, eradication of GAS from the upper respiratory tract of carriers is much more difficult than eradication of GAS from patients with acute infection [50,89,97]. In general, except for the circumstances described above, Streptococcus carriers do not require antimicrobial therapy. (See 'Follow-up' above.)
Foodborne illness — Streptococcal contamination of food has been implicated in foodborne outbreaks of pharyngitis [98-102], and foodborne transmission of GAS pharyngitis by asymptomatic food service workers with nasopharyngeal carriage has been reported [101,103,104]. Factors that can reduce foodborne transmission of GAS pharyngitis include thorough cooking, complete reheating, and use of gloves while handling food [98,105].
Prophylaxis — Continuous antimicrobial prophylaxis is only appropriate for prevention of recurrent rheumatic fever in patients who have experienced a previous episode of rheumatic fever. (See "Treatment and prevention of acute rheumatic fever", section on 'Secondary prevention'.)
Vaccination — There is no vaccine against GAS available for clinical use, although development of this preventive measure is under investigation [106,107]. An important area of uncertainty is whether vaccine-induced antibodies may cross-react with host tissue to produce nonsuppurative sequelae in the absence of clinical infection.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient information: Sore throat in adults (The Basics)" and "Patient information: Strep throat in children (The Basics)" and "Patient information: Scarlet fever (The Basics)")
●Beyond the Basics topics (see "Patient information: Sore throat in children (Beyond the Basics)" and "Patient information: Sore throat in adults (Beyond the Basics)")
●Goals of antimicrobial therapy for eradication of group A Streptococcus (GAS) from the pharynx in the setting of acute streptococcal pharyngitis include:
•Reducing duration and severity of clinical signs and symptoms, including suppurative complications
•Reducing incidence of nonsuppurative complications (eg, acute rheumatic fever)
•Reducing transmission to close contacts by reducing infectivity (see 'Goals of therapy' above)
●We recommend initiating treatment with antimicrobial therapy for patients with symptomatic pharyngitis if the presence of group A streptococci in the pharynx is confirmed by culture or rapid antigen detection testing (RADT) (Grade 1A). (See 'Treatment' above.)
●We suggest initiating treatment with antimicrobial therapy for patients whose clinical and/or epidemiologic factors point to a high index of suspicion for GAS pharyngitis while laboratory results are pending (Grade 2B). (See 'Treatment' above.)
●Oral penicillin V is the agent of choice for treatment of GAS pharyngitis in many clinical settings given its proven efficacy, safety, narrow spectrum, and low cost. Amoxicillin is often used in place of oral penicillin in children, since the taste of the amoxicillin suspension is more palatable than that of penicillin (table 1). First-generation cephalosporins are an acceptable alternative to penicillin and amoxicillin, especially in the setting of treatment failure or beta-lactam hypersensitivity. (See 'Selection' above.)
●Although most patients improve clinically within the first few days of treatment, the conventional duration of oral antibiotic therapy is 10 days to achieve maximal pharyngeal GAS eradication rates. Intramuscular penicillin G benzathine may be administered to patients who cannot complete a 10-day course of oral therapy. (See 'Duration' above.)
●We suggest NOT treating with antibiotics for pharyngitis in the absence of positive diagnostic culture data (Grade 2C). We suggest erythromycin or azithromycin for treatment of pharyngitis due to Arcanobacterium haemolyticum (Grade 2C). (See 'Antibiotics for other organisms' above.)
●In general, test of cure is not necessary for asymptomatic patients or their close contacts following completion of a course of antimicrobial therapy, except in unique circumstances. (See 'Follow-up' above.)
●We suggest a repeat course of treatment for patients with a repeat episode of acute pharyngitis and positive repeat diagnostic testing (Grade 2C). Patients warranting a repeat course of treatment may receive an agent with greater beta-lactamase stability than the previous agent. (See 'Recurrent infection' above.)
●Patients who are long-term streptococcal carriers may develop multiple episodes of pharyngitis due to viral infection. In such cases, repeatedly positive cultures or rapid antigen tests for GAS may be misleading, and further treatment for streptococcal pharyngitis may not be warranted. Carriers are unlikely to spread the organism to close contacts and are at very low risk for developing suppurative complications or acute rheumatic fever. Moreover, eradication of GAS from the upper respiratory tract of carriers can be difficult and is not necessary. (See 'Carriers' above.)
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.


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Bio: Scott Wallace is an internationally recognized expert on health information technology, privacy, and the transformation of health delivery. As the first president and CEO of the National Alliance for Health Information Technology, he played a major role in formulating the nation's health transformation policies and advised the White House staff, the HHS Secretary, and Congressional leaders. In addition, he worked closely with state and federal leaders to redesign the health care delivery system in Hurricane Katrina-ravaged Louisiana and implement the nation's first wide-scale medical home model of community-based care.
Mr. Wallace advises multiple constituencies of physicians, providers, payers, supply chain organizations, policy makers, and employers to integrate approaches and advance the effective use of clinical IT. He speaks and publishes internationally on health information technology, policy, chronic care models, outcomes measurement, innovation and financing issues in health care.
He received a Presidential appointment to chair the Commission on Systemic Interoperability, a Federal Commission created to advise the White House and the Congress on health transformation through information technology. In addition, he has appeared repeatedly on the Modern Healthcare magazine's list of the 100 Most Powerful People in Healthcare. He is a director of Blue Cross Blue Shield of Tennessee and actively advises venture capital funds and their portfolio companies.
Mr. Wallace holds an AB degree in Economics from Duke University, an MBA from the University of Chicago Graduate School of Business, and a JD from the University of Chicago Law School.
Expertise: Employer Initiatives in Redefining Health Care
Fellowship Focus: As a Batten Fellow, Scott Wallace will collaborate with Darden Faculty Host Elizabeth Teisberg on a journal article of employers' roles in transforming health care. Their collaboration will involve field research with leading employers, health care providers, and health plans to study innovations.
Poor health of employees is a major challenge to American competitiveness. The costs of health benefits continue to rise far faster than the rate of inflation despite repeated efforts to reform the care delivery system. At the same time, the costs of poor health borne by employers – including absenteeism and lost productivity – are as much as three times the cost of health benefits. Employers globally have launched initiatives to reduce the cost of poor health, not simply the cost of treatment. Many of these initiatives involve partnerships between employers and the care providers, and are supported by new business arrangements and by benefit designs administered by health plans.
But despite a growing awareness that focusing exclusively on health benefit costs has failed to control the cost of care, successful new approaches to promoting health, measuring the health outcomes of care, and restructuring the delivery of care have not been widely shared. The article will describe successful innovations of employers and provide CEOs and senior managers with examples that can lead to improved employee health and lower the overall health costs for employers.
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I ordered the Champagne color but it is very dark. My guess is that I was sent the gold ones, even though the packing slip said Champagne, so I'm using them in another room. They are very (very) shiny and are a bit too overstuffed to be comfortable in a chair or on a sofa, but they work as purely decorative toss pillows on a bed.
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Candidate Interview ReviewsSort: Popular Date Difficulty
- Interview Details
I had a phone interview that was terrible. The lady who gave me the interview was just so unwelcoming and unexcited. You could literally tell she was reading every question off a sheet of paper and would keep saying, "good, ok. great" after every answer. She doesn't make me want to work for them. Bad first impression.Interview Questions
No Offer
- Why sales? Answer Question
- Application Details
I applied online. The process took 3+ weeks – interviewed at Echo Global Logistics in October 2013.Interview Details
I was contacted by a Recruiter a couple days after applying to the website and we set up a phone interview for a couple weeks later. The interview was very conversational. Went into the office and sat with a rep to get a better understanding of the position. The "final" phone interview with a senior manager in Chicago seemed like it was more of an informational call and they already knew they were extending me an offer by that point.Interview Questions
Negotiation DetailsNoneAccepted OfferPositive ExperienceAverage Interview
- Tell me about yourself. Answer Question
- Application Details
I applied through a recruiter. The process took a day – interviewed at Echo Global Logistics in October 2013.Interview Details
Telephone Interview with contract recruiter representing the company. The person was not prepared and first ignored a previously scheduled interview and then re-scheduled after I sent an email about the originally scheduled interview. The interview was the most offensive I have encountered in my 30+ years work experience. I was told I may not be "modern" enough so beware if you are over 40 years of age. If you take a look at their website you will find most employees are much younger.Interview Questions
No OfferNegative ExperienceDifficult Interview
- Explain something you have architectected and what did it look like? View Answer
- Application Details
I applied online. The process took 1+ week – interviewed at Echo Global Logistics.Interview Details
four rounds interview, two phone calls and two face-to-face. Fairly easy. The only one I did not prepare at all.Interview Questions
Negotiation Detailsnot as high as I expected.Accepted OfferPositive ExperienceEasy Interview
- none. at least 90% of my answers were correct. Answer Question
1 person found this helpfulApplication Details
I applied through an employee referral. The process took 3 weeks – interviewed at Echo Global Logistics in September 2013.Interview Details
You meet with the branch manager initially, and he ask about your life, experience, what you expect from Echo. You then sit with one of the tenured reps to get a feel for the job. After that you sit with the rest of the managers in the office, and they ask for formal interview questionsInterview Questions
Negotiation DetailsStandard base, and there's a little wiggle room to negotiate.Accepted OfferPositive ExperienceAverage Interview
- This job is a grind with many sales calls and late nights/early mornings needed to truly succeed. View Answer
- Application Details
I applied through a recruiter. The process took 4+ weeks – interviewed at Echo Global Logistics in September 2013.Interview Details
Contacted by in-house recruiter on Linked-In regarding a Senior .Net Developer Position, and had a screen interview. Called back and spoke to head of recruiting department. After a few days, I was told I didn't have enough experience for the position, as I expected, and they would keep in touch. A month later I get contacted again to see if I was interested in a "mid-range position" since they had a hard time filling the Senior role. I agree and the next week, I had a in-person meeting with a Senior Developer, a Applications Manager, and 2nd level managers.
1st part was technical, with a guy asking things like "What kinds of joins are there?" and "What is the difference between an abstract and an interface?", basic .Net questions. This went fine, since it was easy and he seemed pretty relaxed about it.
2nd part was "culture" I am guessing, because the person I spoke too had a BA background. I was just asked basic questions about my previous jobs, favorite project, issues I have had, and so forth.
3rd was the only part I was iffy on, as it was just a discussion, which involved me having to explain my thought process on projects I had worked on, and to point out why I should have gone other routes, possible issues with that implementation, and so forth. Only thing I noticed is that he kept looking at his watch the whole interview, but he could have had a meeting. Other than that, I thought it went well.
4th part was just odd, as it was another second level manager who didn't make eye contact with me, only reading things off my resume and taking notes. It was awkward, but I saw no issue with anything I said during the process. At the end, he shook my hand, and made eye contact, for what seemed like a good 5-7 seconds, which I have to admit, through me off.
That was the onsite process, I get called the next week letting me know they didn't want to move forward and make me an offer, because I didn't go into enough detail and didn't seem to be strong enough technically for the position. Conversation finished with they would be in touch if anything else came up, because they thought "I was a great guy!"
Thinking about it now, I think what did me in was a mix of the technical and 3rd part of the interview. I could have gone into deeper details with the technical questions instead of giving stock answers, maybe talking about effect of idea or what have you, more or less I should have relayed my knowledge better.
I still think they were looking for a Senior type person (I have about 4 years of experience), but couldn't find one cheap enough, so they were hoping to get lucky with a senior level developer making less money somewhere else.Interview Questions
No OfferNeutral ExperienceAverage Interview
- Tell me about what you have done with WCF View Answer
1 person found this helpfulApplication Details
I applied through an employee referral. The process took 1+ week – interviewed at Echo Global Logistics in August 2013.Interview Details
Hiring team calls with a phone interview first and then sets up a face to face interviewInterview Questions
Negotiation DetailsNo room to budge. Hiring team does not have ability to negotiate itAccepted OfferPositive ExperienceEasy Interview
- Standard View Answer
1 person found this helpfulApplication Details
I applied through a recruiter. The process took 3 weeks – interviewed at Echo Global Logistics in August 2013.Interview Details
Phone interview with recruiter at another one of the branches, met with Branch Manager in Hendersonville at a temporary office, final phone interview with HR Director, second final phone interview with VP Sales. Tone of all interviews were casual but still sort of difficult becasue they put you on the spot and you were not always sure what they were looking for in questions.Interview Questions
Negotiation Detailsnone really. you have a base/draw until you do well enough to get commission. good enough incentive for me!Accepted OfferPositive ExperienceDifficult Interview
- Demonstrate your sales ability. What past experience proves you will be successful in this job? How do you deal with failure? What do you know about the industry? Answer Question
3 people found this helpfulInterview Details
1st Phone interview. 2nd brought into interview with a recruiter. 3rd Brought in again to interview with manager and then will have you shadow a rep for 30 mins. Lastly they will reach out to you if you qualify for the positionInterview Questions
Accepted Offer
- Very basic interview questions with nothing out of the ordinary just be yourself Answer Question
1 person found this helpfulApplication Details
I applied through college or university – interviewed at Echo Global Logistics.Interview Details
Pretty easy interview process. 2 phone interviews than a final on-site interview.Interview Questions
Declined OfferPositive ExperienceAverage Interview
- Why should we choose you over other more experienced canidates? Answer Question
Is this helpful? The community relies on everyone sharing – Add Anonymous Interview Review
See What Echo Global Logistics Employees Are Saying
" Not Great"
Pros: "Great people, office culture is very outgoing and fun. Beer on fridays, you are basically left alone after training to do what you need to do" "Great people, office culture is very outgoing and fun. Beer on fridays, you are basically left alone after training to do what you need to do" – Full Review


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Hey, is there anyone interested in the game in the SE GA / Jax, FL area?
Southeast Georgia and Jacksonville, Florida
Started by Eruletho , Oct 09 2012 12:40 AM
1 reply to this topic
Posted 09 October 2012 - 12:40 AM
Posted 15 November 2012 - 08:01 PM
We have three or four players here in Jacksonville. I was talking to borderlands today and they said they had applied for a Kessel Run tournament and were just waiting to hear back.


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The Cooley Peninsula is a hilly peninsula in County Louth, which includes towns such as Omeath, Carlingford and Greenore. It is 20 minutes drive from Dundalk Town.
In Irish mythology Cooley (Old Irish Cúalnge) was the home of the bull Donn Cúailnge, and the site of the Táin Bó Cúailnge or Cattle Raid of Cooley. Ancient monuments in Cooley include the Proleek Dolmen, whose capstone weighs an estimated 46 tons (46.7 tonnes), and a Bronze Age gallery grave, both near Ballymascanlon.
Travellers can visit neolithic tombs such as the Proleek dolmen and Clontygora court grave, walk in the footsteps of the legendary Cúchulainn, discover the Viking settlement and the Norman fortification – all of which add to the charm of this magical island.
Carlingford was originally a Viking settlement and even its name originates from its Viking history – Carlin Fjord' (Fjord simply meant a bay to the Vikings). It is also listed as a Medieval Heritage Town – having more historical buildings than any town of the same size in the whole of Ireland. Extensive town walls have survived, together with the ruins of monasteries and, most important of all, of civic buildings – an extremely rare happening in Ireland. Carlingford offers various adventure activities to tourists like sailing, angling, painting workshops, golf, beauty treatments, horse riding, designer shopping, bird watching, cycling and guided walking tours. Carlingford even offers a pottery workshop, Irish traditional music workshops and a range of cookery courses taught using local produce and traditional recipes.
There is also a high level of innovation within the tourism industry in the area – the adventure centre is constantly evolving and diversifying its product range, using the natural environment and sustainable materials as much as possible.
There is a full range of visitor services available on the Cooley Peninsula, ranging from banks, churches, medical, shopping, taxis and boat hire to guides and the heritage centre. In addition, there is an abundance of activities on land and sea including archery, kayaking, raft building, zip wires, horse riding, fishing, sailing, trekking and golfing. Two equestrian centres offer full- day treks, including lunch on the Cooley mountains.
The Nearby towns of Omeath, Greenore and Ravensdale are also worth visiting. Ravensdale along the southern slopes of Clermont mountain is a quiet, pretty village with its main tourist attractions one kilometre outside it: a forest park and, an equestrian and trekking centre. Greenore village offers fine views of Carlingford Lough, Slieve Foye and the Mourne mountains.
Key tourist activities in the area include an extensive exhibition on the history of Greenore port and the railway village, fishing from the seashore and golf at the beautifully situated Greenore golf club. Greenore is also the location of an angling festival in July.
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LeAnn Rimes Sports A Skinny New 'Do'
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LeAnn Rimes is thanking Chris McMillan for helping her take inches off. That's inches off her hair!
Kate Gosselin's New Hairdo: Love it or Hate it?
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Gone was the flat ironed, reverse mullet th… READ MORE
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Lindsay Lohan is sporting a head-turning new do with platinum blonde flowing locks – and the transformation took more than eleven hours!
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The younger sister of Beyonce has done a "Britney Spears' by shaving her head so that people stop comparing her to her superstar sibling.
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Atlanta Start-up, seeking a computer programmer to develop a two-sided web-based platform to request/receive/process specialty logistics orders. This is an opportunity to be a part of a an exciting Start-up that will resegment the logistics industry and become an industry-wide renowned brand. This role requires an autonomous and self-directed individual who would determine project schedule and duration.
The ideal candidate will have:
- Strong programming skills
- Web development experience
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To apply send email or resume to: firstname.lastname@example.com
How to Apply: Send email or resume to: email@example.com


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Title: Don't buy!
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I ordered this costume for Halloween and when I received the purchase I was very disappointed.
The material was very poor, the hat looked nothing like the picture, it rips very easily, very verryyy see though, the colour is completely different than on the picture and it is very uncomfortable.
I am very displeased with this purchase, if I could refund it, I would.
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Omari Hardwick
He's caught our eye over and over and over again in many movies. One of the stars of our favorite independent film this year I Will Follow we want to see Omari Hardwick win and win big in 2012. Hopefully the makers of Bolden! and Sparkle will make that a reality.
More On Bossip!
Not This Isht Again: Are Rihanna And Breezy Sending Each Other Subliminal Love Tweets?!
More Divorce Drama: Deion Sanders' Daughter Says Pilar Is A Liar, Divorce Has Been Going On For Months And She's Been Getting Chopped Down By Young Boys
On The Come Up: Famous People We Didn't Know Or Care About This Time Last Year
Let's Mix It Up! 2011′s Hottest Swirly Hook Ups Of The Year


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You know what, I miss this song. It used to be a bit of a sardonic bit of cheer before a flight. I'm from England, I never want to take the weather with me when I'm going on holiday, I go to avoid the perpetual drizzle. When not avoiding it on holidays or in work, I'm avoiding it by playing video games. Some of those video games are strategy games. A strategy game has been revealed today that allows you to control the weather and that game is called Etherium.
Etherium isn't the first game to use weather as a key part of war. Well, every game uses it with fog, but I mean direct control of the weather and using it as a sort of weapon for either defensive of offensive purposes. Elements of War is what I'm thinking of, released about two years ago and pretty much flew under every radar. It poorly received due to it lacking some basic features we're all used to and that it simply wasn't polished for release.
That's quite irrelevant because this game is neither developed nor published by the same teams. Indeed, the only link is weather and I'm just harping on about it because I'm listening to Crowded House.
Etherium is actually developed by Tindalos Interactive, the guys behind the space strategy game Stellar Impact. They've decided to be a little more grounded here, but no less futuristic. The press release states how it's got your usual army building to control resources and land. We all know that's part and parcel for most real-time strategy games now. What interests me is what is said next:
Etherium has a unique and dynamic weather control system that has a direct impact on the player's gameplay and strategy. You can use a sandstorm to approach the enemy base unseen, or mount a rearguard attack crossing a freezing river with your tanks. This weather control system will also work through synergy with the special skills of the factions. For example, one of the empires may create localized weather conditions, to help its army, or hamper the opponent's forces. Another faction will have the ability to see into the future to predict where and when the next climatic events will occur, and devise a strategy based on future events.
The solo campaign in Etherium is non-linear, so you are free to decide how your conquests progress: you can choose which of the planet's continents or moons will provide the setting for your next mission. It may be more advantageous to conquer particular territories, but these may also be better defended. You will also have to stop the enemy from recapturing territories you have gained! Every continent and moon has very diverse environments, and varied terrain that will force you to adapt your strategy and employ different tactics: arid desert, jungles and swamps that impede the advance of the tanks, icy worlds, island archipelagos… you must consider the terrain very carefully before implementing your strategy! You will also encounter six secondary factions during the campaign (raiders, alien beings, etc). You could of course fight them, but alternatively you could also rally them to your cause, to exploit their units and special skills!
A non linear campaign sounds terribly interesting to me, not that I know how it'll work. Possibly like Romance of the Three Kingdoms or Battle for Middle Earth II. It also mentions how there will be up to four player multiplayer as well, but I'm never that big on MP anyway.
Oh, and the images look pretty. Will they be actual gameplay footage on this upcoming 2014 PC exclusive title? I would say not, but they still look pretty.


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Chapman's Orthopaedic Surgery
|© 2001 Lippincott Williams & Wilkins
Figure 148.1. Evaluation algorithm for patients with failed cervical spine surgery
Figure 148.2. Evaluation algorithm for radiculopathy and myelopathy.
Figure 148.3. Evaluation algorithm for postsurgical deformity.
Figure 148.4. Algorithm for treatment of patients with failed anterior surgery.
Figure 148.5. Treatment algorithm for failed anterior surgery.
Figure 148.6. Posterior stabilization for failed anterior cervical discectomy and fusion. A: Graft collapse and pseudarthrosis result in focal kyphosis, fragmentation, and instability. B: Posterior instrumentation and fusion are carried out without disturbing the anterior graft. The simplest approach is a triple wire technique using autograft bone. Approximate the spinous processes using an 18-gauge interspinous wire applied in a modified Rodger's technique. Apply the split autograft to either side of the intact spinous processes and compress the "sandwich" with a pair of 22-gauge wires. C: Posterior wiring will most often cause the anterior graft to consolidate at the same time the posterior fusion is healing.
Figure 148.7. Treatment of residual cord compression after inadequate decompression. A: In patients who have undergone previous but inadequate surgical treatment, the original compressive lesion is densely consolidated, and access may be hindered by surgical scarring, old hardware, and, often, a well-integrated strut graft. B: Remove the strut graft with rongeurs and a high-speed burr, back to the posterior vertebral cortex. Study the preoperative CT scan to determine whether there is a distinct interval between the back of the graft and the residual vertebral body. C: Use a burr and microcurets to thin the posterior cortex in the lateral recess of the side with least compression. D: Enter the canal with a small curet or elevator directed toward the neural foramen and away from the cord. Thin the compressive mass with the burr, and use a diamond tip burr to thin the lateral recess to eggshell thickness. E: Use a small elevator or curet to reflect the residual bone fragments directly away from the canal and spinal cord. Dural adhesions may be divided with a fine Penfield elevator or microcuret.
Figure 148.8. Algorithm for treatment of failed posterior cervical spine surgery.
Figure 148.9. Postlaminectomy kyphosis. A: This patient presented with progressive pain and deformity 3 months after multilevel cervical laminectomy. The deformity was passively correctable, to a degree, and the patient was neurologically intact. B: After 48 hours in halo traction, significant correction was obtained and surgical treatment was initiated. C: A staged anteroposterior reconstruction was planned. A five-level anterior vertebrectomy was performed initially, reconstructed with an autograft fibular strut. D,E: Five days later, we performed a posterior instrumentation and fusion using lateral mass plates. The slight increase in cervical lordosis produced by the plates caused the anterior strut to loosen and shift. During the same surgical procedure, the graft was repositioned and a short anterior plate placed to buttress the distal pole of the graft. Fusion was successful and the excellent sagittal correction was fully maintained. Figures D & E show anteroposterior and lateral views 1 year after surgery.
Figure 148.10. Trap-door laminoplasty for extensive stenosis or adjacent-level degeneration. A: Cut longitudinal troughs through the involved laminae using a high-speed burr. Troughs should be centered over the medial edge of the facet so that penetration exposes the lateral recess and not the cord. Complete the defect on the side of most compression using a small Kerrison. B: Thin the opposite lamina down to the volar cortex, then gradually elevate the opened side up and away from the facet, allowing time for the intact hinge to deform plastically. If the hinge is too stiff, thin it further. C: Use the spinous processes or an allograft bone strut to hold the laminoplasty open. Groove both ends of the graft to capture the cut edges of the lamina and the lateral mass. Use a small drill to make holes at the margins of both, and pass a heavy suture through the drill holes and lengthwise through the graft. D: Position the strut and allow the lamina to close down slightly to capture the strut. Tie the heavy suture over the outside of the graft to prevent it from migrating into the canal or dislodging and allowing the laminaplasty to close.
Table 148.1. Complications of Revision Anterior Surgery


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Crime and Punishment
From Wikisource
|Crime and Punishment (1866)
by , translated by Constance Garnett
|Crime and Punishment (Russian: Преступление и наказание) is a novel written by Russian author Fyodor Dostoevsky. First published in a journal named The Russian Messenger, it appeared in twelve monthly installments in 1866, and was later published as a novel. Along with Leo Tolstoy's War and Peace, the novel is considered one of the best-known and most influential Russian novels of all time.
Table of Contents[edit]
|This is a translation and has a separate copyright status from the original text. The license for the translation applies to this edition only.


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Churchangel.com makes it easy to add your Church or Christian counseling service to our comprehensive directory
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Map And Directions To Jeters Chapel Church Of The Brethren BUCHANAN Virginia VA 24066
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Map And Directions To Jeters Chapel Church Of The Brethren BUCHANAN Virginia VA 24066
The Church of the Brethren, also known as Brethren churches, has existed as a group for over three hundred years. The goal of this Christian church is to simply do what Jesus did while he was here on earth. Members of the Church of the Brethren have the goal in mind to practice peaceful living by listening conscientiously, seeking guidance in the scriptures, and working toward reconciliation. Whether worshiping, serving, learning, or celebrating, Brethren act in community. Together, we study the Bible to discern God's will; we make decisions as a group, and each person's voice matters. If you are interested in more Brethren churches, please browse our site to find a Christian church.More


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Welcome to episode 54 of The Thrilling Adventures of Superman. The show's mission is to explore the history and development of the Superman in his formative years by chronicling the Man of Steel's Golden Age adventures in comics, radio and film.
Michael is joined for the first time in 2012 by Charlie Niemeyer as the guys return to the thrilling days of yesteryear for another adventure from the Superman radio serial. And what an episode it is as this, the the sixth storyline from the show, features the debut of everyone's favorite cub reporter and future Giant Turtle Man, Jimmy Olsen!
And be sure to check out Charlie's podcast, Superman in the Bronze Age! A huge thanks once more to Mr. Niemeyer for coming on the show.
Click here to see the post at GreatKrypton.com, the site's home base, for images related to the episode, additional notes and links.
Download the episode directly. Or, you can subscribe to the show via iTunes or the RSS feed! Questions or comments? Additions or corrections? Drop a line! Share your thoughts on the episode and the issue. You can connect with show on Facebook and Twitter, as well, to get updates!
The Thrilling Adventures of Superman is also a proud member of the Superman Podcast Network. And don't forget to check out the Superman Homepage!


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About Us
Prime Building Construction (PBC) Inc. is a full service general
construction firm offering design build construction services,
construction management services, with an emphasis on commercial and
industrial construction. We emphasize pre-construction disciplines
including scheduling, value engineering and cost control, whether a
project be design/build, cost plus negotiated or lump sum bid
The company employs a team approach to its project development, bringing
together an innovative, flexible and professional staff supported by
extensive technical resources to assist clients in meeting their
needs from initial planning through design and construction. Our
approach assures a continuity of progress, attention to detail,
timely and cost effective procedures and close client contact. Every
result is a coordinated, quality project provided at a competitive
PBC is headquartered in Corona, California to serve the needs of
California, Nevada and Arizona and in 2004 was incorporated. Upper
management is comprised by Phil Axtell, Ray Ortega, Jose Briseno and
Kevin Griffin. The collective construction experience of these
individuals constitutes over 100 years experience in the
construction industry, as a single unit. A streamlined
administrative staff and hand selected field organization allows
this organization to provide a wealth of talent to it's clients,
while providing streamlined efficiency of an organization, formerly
known as Prime Building Maintenance & Consulting Services Inc. which
operated primarily in Southern California. Our talent,
responsiveness and value that our organization provides it's clients
is unmatched by it's competitors in its work area.
Services We Offer
Copyright © 2008 Prime Building, Inc. All Rights Reserved


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Bungalow Bay Koala Village YHA Reviews
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I peaceful and quite hostel, with good helpful staff. The room I was in was next to the wildlife place so was woken up every morning at 6am when the cockatoo's woke up. The room had no lockers or space to leave bags so everyones bag were in the middle of the room, only 2 power sockets in the en suite between 8 people (there is power sockets in the common area) and no aircon, only a fan that reached people on the top bunk. Wifi was $4 for 2hrs
- Avid Traveller
- Jacko9
- England
- Male, 25-30
- (18 reviews)
Overall it was a nice stay. They booked me in the wrong room, so I had to move with all my stuff. That was anoying. The other room was lucky far more better (6 dorm), so I was glad to move to AC. cleanliness can be better! And don't expect to much of the kitchen. take you groceries with you, because there isn't a supermarket nearby. There is a koale sanctuary, but the price is expensive! Entree :25 dollars and hugging a koala 16 dollars.
- Novice Nomad
- Anonymous
- Netherlands
- Female, 18-24
- (9 reviews)
Excellent hostel. Was a bit of a walk to the beach and main shops but its definitely worth it for the great bush atmosphere. Stayed in one of the bungalows and it was very clean. The bus stop that goes around the island is right out the front as well which makes getting around the island a breeze.
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The bungalows were cold and had one plug in, making it hard for 8 of us to charge our devices. The wifi was expensive and it was unfortunate how you could only access it by the bar. It was a pretty decent place but I didn't feel like it was a place to go if you're a solo backpacker trying to meet people.
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Excellent stay...great to have good food at your door step and the JUNGLE FEVER is definitely worth it.
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Loved the environment,set amongst trees
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- Female, 25-30
- (11 reviews)


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What is the best way to remove labels from old beer bottles?
Oxyclean Free in hot water.
Epic thread on the subject: http://www.homebrewtalk.com/f46/labe...-thread-91726/
I just stick my own labels over the top of whatever is already there :-)
I boil a 6 pack at a time for about 10 mintues. If the label doesn't fall off in the water I use a semi rigid piece of plastic like a gift card and scrape off the rest. But then you still need to remove the glue from the bottle. For that use a copper pan scrubbie. After a few good shakes with the scrubbie wipe it clean with a towel and it is ready.
BTW- The bottles will be hot-hot-hot when you take them from the water so use tongs to remove them and a thick towel to hold them. Try not to get the towel to wet or the heat will transfer quickly to your hands.
I soaked 60 bottles in HOT water + Oxyclean for ~2 hours and
all but a couple only needed a rinse. No glue, no labels, nothing
stuck to them.
It also depends what brand it is.Hoegaarden bottles get naked like a 5 dollar whore.5 mins in hotwater.
I just de-labeled a bunch of Mexican beer bottles I got from my favorite Mexican restaurant/cantina. They were a bitch. Tecate, Carte Blanca, DosXX and Negra Modelo were the worst. They use a foil label and superglue. The Modelo also has gold foil up around the neck that is glued on.
I soaked them for about 2 hours in hot water and oxyclean. Then all I could peal off was the outer foil layer which left a paper layer still glued on hard. Another hour soak and vigorous scrubbing with a scouring pad finally got them clean. Then I had to get the old lime wedges out of some of them. Not sure it was worth the effort. But I am a cheap bastard.
Anyone have a better technique for these bottles?
I did a bunch of Sam Adams bottles a while back and the labels just floated off after an hour or so soaking. But in my area, the Mexican cervesas rule.
Does the name Pavlov ring a bell?
My Theme Song: "I Like Beer"
I'll tell you, the variation in ease of label removal is remarkable. Around here, I've found the easiest labels are Amber Bock (though the bottles have a raised 'Michelob' on the glass, which isn't removable and makes them ineligible for competition), and the gosh-darndest are Saranac, with not a single clean removal out of a sampler pack.
When we were getting ready to bottle our first batch, I invited a bunch of folks over who had expressed interest in consuming the final product, telling them the ticket price for homebrew was a six-pack of pop-top bottles. No one understood my surprise at their Coronas.
That'll teach me, have to be more specific next time.
Well I just did 24 Sam Adams bottles and soaked them in very hot water and most just pulled off. Some I had to scrap with little plastic scraper and washed them with a rag under water. Clean as could be.


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Weekend Plans..Jan. 18 - 20
Find a Conversation
|Sat, 01-19-2013 - 12:46am
So, what's going on this weekend everyone??
Let us know for you know for you know how nosey we are..LOL!!
Hope it's a good one for all!! :)
|Sat, 01-19-2013 - 12:57am
Happy Weekend!!
Today we just hung out taking it easy. My oldest dgd (age 15) came over after school. Then we picked up my dd1 (dgd's aunt) and took her on an errand. It was nice to visit with both of them. Today's 31 Day Organization assignment was to clean out under the kitchen sink. We did that recently when our new garbage disposal was installed. So glad to have those projects finished!! Tonight we went to our pro-soccer game. They lost..badly..we left early.
Saturday...Getting my nails done and fine tuning my lesson I'll be giving Tuesday night at TOPS. Will also be working on whatever the 31 Day Organization assignment is for that day and for Sunday, too, and for every day after that through the 31st! My house should be in really good shape by then!
Sunday...Sunday school & church. Probably won't go out for Chinese dinner this time though. Have to get back into my leeway by Tuesday night's weigh in. I'd better prepare dh now for not eating Chinese this Sunday. Poor guy!
Have a good weekend everyone!!
|Sat, 01-19-2013 - 4:36pm
|Sat, 01-19-2013 - 5:15pm
Thanks for starting this Donna,
have been gone most of today,
Youngest came home today & bought a new car ::gasp::
Most likely he will go back tomorrow if I can convince him to stay here tonight <g>
Other than that . .errands, chores & the same ole stuff :)
|Sat, 01-19-2013 - 5:25pm
Hugs...Oh, good, glad your ds found a car and bought it! I asked you that in another thread somewhere. Now I know! :) Hope he stays the night so you can have a longer visit.
Todays 31 Day Organization assignment was getting rid of old magazines. I don't keep mine, so this assignment is finished!! Looking forward to seeing what tomorrow's is.
Hope your day is still going well. I'm going to take a nap now and do some reading. See ya later! :)
|Sat, 01-19-2013 - 5:27pm
Aileen..sounds like a nice weekend for you. I've been thinking of learning how to crochet, but knowing procrastinator me, I probably won't ever get started on it. ::sigh:: It would be nice to do evenings, while watching movies with dh, to keep my hands busy and not think about wanting to snack.
|Sat, 01-19-2013 - 7:16pm
HI Donna,
DS left a bit ago ::sigh::
Oh well .. he loves his car, LOL
Good job on being done with today's assignment .. onto tomorrow's :)
|Sat, 01-19-2013 - 7:21pm
I don't know if I replied to your plans or not Donna,
In fact was just coming here to ask where they were, LOL
Now I finally see them <wink>
Poor DH on missing his Chinese food Sunday <g>
Am sure he'll get over it, LOL
Sounds like so far your weekend has been great Donna!
Nice on your visits too.
Love how often you get yoru nails done ..
Have a great rest of the weekend & keep up that Organization challenge .. you're doing great :)
|Sun, 01-20-2013 - 12:28am
Hugs...Oh, darn, sorry your son decided to leave tonight. Glad he loves his car though.
DH was really sweet as always about not going for Chinese food. I told him we can go out to eat Wednesday after I weigh in Tuesday night. That will make him a happy boy..lol!!
Oh, yes, must have my nails looking good all the time. Love being a girlie girl, so fun..lol!
Thanks, you enjoy the rest of your weekend too. I'm really enjoying the 31 day challenge, so far I am anyway..lol! He hasn't assigned anything yet that was too much for me to handle and actually most of the assignments I have already done or keep up on a regular basis anyway.
|Sun, 01-20-2013 - 1:23am
He kind of regretted going but it was to late,
How sweet of DH to be so understand & Wedneday is around the corner for that <g>
I too have beeb delcuttering in my own way so getting some things done as well.
Told DH I want to stove top look next weekend & get to Kohls.
Thinking I might be able to find some jeans better there then at Macy's .. we'll see
Glad you're doing so well with your challnge, muxt be nice :)
|Sun, 01-20-2013 - 5:08pm

He kind of regretted going but it was to late,
How sweet of DH to be so understand & Wedneday is around the corner for that <g>
I too have beeb delcuttering in my own way so getting some things done as well.
Told DH I want to stove top look next weekend & get to Kohls.
Thinking I might be able to find some jeans better there then at Macy's .. we'll see
Glad you're doing so well with your challnge, muxt be nice :)

Hugs...Awww..kind of nice that your son regretted leaving when he did.
Good you're decluttering too. Today's challenge was to clear off a flat surfact that needs it done and to committ to keeping it that way. I had to look hard to find a flat surfact in my house that had clutter on it. Found it on the side table beside my desk. Took all of about two minutes to tidy up that really not so cluttered space. :) So, another easy assignment finished! Thanks, I'm glad I'm doing well with my assignments too. I can't stand messes. Now if he assigns us a closet assignment, I'm in trouble though!! LOL!! He did assign tee shirts one day and all of the top shelves of all of our closets another day and I already had them done, so that was another easy assignment for me. The rest of the closet still needs more done to it though, not as much as before, but a little more. I'll be getting back into doing it soon for I already told my dh I want him to hang more hooks on my closet walls and I want to tidy up more in there first before he does that for me.
Ouuu..how fun for you looking for a new stove top and new jeans!! I wish you good success in a great find!! Do you currently have a flat top stove top? Will you be getting one? I love mine, so easy to keep clean. I haven't shopped in Kohls in a few years, just never think about going there. I might look around there this spring when I'll be shopping for new tee shirts that fit properly. I'm still wearing my old big ones around the house. I only wear tee shirts around the house and for taking exercise walks, prefer "tops" for when I leave the house for something. Wish we still had a Macys here. They left many years ago. :(


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With CHAN Stars On Hand Kotoko Will Emerge Victorious Against BYC
Jordan Opoku (white jersey)
By Patrick Akoto
Kotoko midfielder Jordan Opoku believes the return of the eight experienced players from the CHAN tournament will hand them a massive win against Barrack Young Controllers on Sunday.
The Porcupine Warriors have welcomed their stars back into the team as they prepare to face the Liberian champions in the preliminary qualifier of the CAF Champions League.
Opoku, who was among the players who featured for the home-based players at the continental tournament in South Africa, is counting on his colleagues to put the Liberian to the sword.
"We had a good (CHAN) tournament and majority of the payers are from Kotoko so through this exposure in this competition, I think we have had the confidence and know the game," Opoku told Accra-based Power FM
"I think for sure Kotoko is going to win (against BYC. We just have to keep our eyes on the ball.
"The fans should troop to the stadium in their numbers to support us because we're going to give them a good game."
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There's a little bit of magic in every box.™
Scottish Play Doe—aka Scott—is used to being a little different. Sometimes he hallucinates things no one else can see. Mermaids. Unicorns. A talking rabbit-man in tweed pants.
But then one of these hallucinations tries to steal Scott's backpack, and he comes face-to-face with an honest-to-goodness leprechaun named Mick who's on the run from, of all things, the Goodco Cereal Company.
With the help of their friends Erno and Emily, Scott and Mick uncover Goodco's sinister plans—and take the first steps in saving the world from the evil cereal company.
About the Author
Adam Rex is the author of many children's books, including the second book in the Cold Cereal Saga, Unlucky Charms; the New York Times bestselling picture book Frankenstein Makes a Sandwich; the middle-grade novel The True Meaning of Smekday; and the teen novel Fat Vampire. He lives in Arizona with his wife.


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Preen & Mark Fast Do Aldo
While we wait patiently for H&M to release their hugely anticipated Marni collaboration, the Brits are scooping up shoes by our favorite young Britsat Aldo.
That Julian Louie collaboration we begged Aldo to produce nearly two years ago clearly inspired the high street brand to tuck a few other fresh names under their wing. Last night, in London, the fashion pack toasted those designersJ.W. Anderson, Preen and Mark Fastand their new shoes at Selfridges. They hover just under the $200 mark and are available at Selfridges starting today.
Preen's, by the way, are the same styles that walked down the brand's spring runwaycheck them out here!


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A Sumptuous Start to Your Day on Cape Cod.
Makes 4 servings.
- 2 Cups cranberry juice
- Fresh squeezed orange juice
Select freezer safe glasses. Stemmed glassware with a rounded bottom inside the glass creates the best effect. Fill the bottom quarter of the glass with cranberry juice. Freeze the glasses over night.
When you are ready to serve. Pour orange juice into the glasses and serve immediately. As the glass warms up the cranberry will float to the top, creating your Cape Cod sunrise.
Enjoy the dining experience at this Cape Cod Bed and Breakfast.
At The Palmer House Inn our two to four course Cape Cod Gourmet breakfasts are always an event. Sit in the sun dappled breakfast room, as the aroma of fresh brewed coffee fills the room and enjoy a delightful meal. We use the finest ingredients and local Cape Cod grown and produced foods. Meals frequently consist of a fruit starter, followed by a sweet or savory main dish.
The Inn's organic herb garden, we affectionately refer to as The Humble Innkeeper's Garden, is one of the secluded nooks where you can spend time relaxing. Many of the garnishes for the breakfasts are picked each day from this garden to ensure top quality ingredients are used.
Palmer House favorites include:
Baked pears in brown sugar and spice followed by gingerbread pancakes with lemon sauce and crispy bacon, or Palmer House cranberry sorbet followed by Atlantic salmon quiche with cream cheese and a bagel.
Sumptuous Sweet & Savory Breakfasts and Tasty Treats for Your Afternoon Tea
You can find this recipe and many more in the Inn's recipe book, Favorite Recipes of The Palmer House Inn. Order a copy for yourself (at blurb.com, http://www.blurb.com/bookstore/detail/1373050 ). This 120 page (7×7 inches or 18×18 cm, printed four-color) book is a collection of traditional New England recipes and modern variations is beautifully illustrated with color photographs by L. V. O'Connell. With over 50 recipes and images of the Inn, this makes for a lovely memento of your visit to the Palmer House and the Cape.


text:
The Magazine That Brings Kids to Christ
Thanks to the efforts of prison ministry workers, Real magazine is going to hundreds of children of … [Read More...]
Real Magazine is printed by the Review and Herald Publishing Association. The primary purpose of the magazine is to bring the gospel into the homes of unchurched children.
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Submit your question below about any cosmetic procedure to be considered for posting with an answer from one of our board-certified plastic surgeons.
If your question is about the cost of a procedure, click here. For referral to a qualified surgeon in your area, see find a surgeon.
Note: ASAPS cannot give advice about specific medical problems nor should answers provided by responding surgeons be substituted for a complete medical history, work-up and an in-personal medical/surgical consultation. Sorry we can't answer all questions. We try to select questions that have the widest general interest.
What is your opinion about Snap-8 peptide, a milder alternative to Botox?
Snap-8 peptide is a skin care ingredient that is available without a prescription, but I would not characterize it as a Botox alternative. Botox is FDA approved, has a clinical history of more than 20 years of use, and there are dozens of peer-reviewed clinical studies attesting to its safety and effectiveness. I cannot find any published clinical trials on the use of Snap-8 peptide for treatment of wrinkles. So while it may be helpful, it doesn't seem realistic to compare it to Botox.
R.A. Baxter, MD


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One of the best features about our newly designed Web site, CharlotteObserver.com, is that you get a chance to comment on virtually every story and column we post.
Dozens of you took that opportunity Thursday in reaction to the new site, which debuted at 7 a.m. The first reader comment to arrive, at 7:01, was short and sweet.
"The new site looks awesome!"
Sure did to us, especially in comparison to that blank screen at 6:59 a.m.
The new CharlotteObserver.com is a total remake of our former site, Charlotte.com. That made Thursday morning's switch from old to new a very tricky maneuver that had been months in the making.
Not all the pieces immediately fell into place. Our staff worked hard to repair glitches throughout the day, and we expect to find still more as the site gets more use.
But a majority of you who left comments at the bottom of my introductory column said the change was worth it.
"Kudos on a fantastic makeover," said one. "I don't care what anyone says, the site looks fresh, crisp, and dazzling."
Some were disappointed for obvious reasons. For a time, people using Internet Explorer browsers couldn't open photo slideshows (that's fixed now). The site sometimes loaded sluggishly (a temporary ailment, attributable to the switch of platforms). Check the box to the right for frequently asked questions that may explain a problem you experienced.
One reader, disappointed with the overall appearance, speculated colorfully on how we created it.
"Looks like someone crammed content in a shot-gun and blasted it across the front page," said one. "Awful and cluttered design."
Another somehow smelled politics at work.
"All this change in the paper is driving me batty," the reader wrote. "The paper was liberal before it sold out to McClatchy. Now it's ultra-liberal."
Others who liked what they saw said they would not miss the old look at all.
"I've been waiting a long time for you guys to shake up that site," said one. "It looks great."
If you haven't already, we hope you'll go have a look for yourself. And do talk back.
To alert us to technical problems, e-mail us at firstname.lastname@example.com. If you'd like to offer your opinion, or read the opinions of others, try out the online comments feature attached to this column.
Reach Rick Thames at firstname.lastname@example.com or 704-358-5001.
Subscribe to The Charlotte Observer.
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And finally, as Mark Twain said: "Always do right. This will gratify some people and astonish the rest."
Enjoy the discussion.


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Humidity 90%
Winds 9.2mph
Humidity 90%
Winds 9.2mph
Apr 21, 2014 5:28 AM
BOSTON (AP) - State and local officials are hoping for a safe but still enjoyable day for the 36,000 runners planning to participate in the Boston Marathon and the hundreds of thousands of spectators.
One year after a pair of homemade bombs killed three people and wounded more than 260 others, the Boston Marathon returns to the streets for its 118th edition on Monday.
Bags will be restricted and searched near the finish line this year. More than 100 cameras have been installed along the route in Boston, and 50 or so "observation points" will be set up around the finish line.
Massachusetts Gov. Deval Patrick said on CBS' "Face the Nation" on Sunday that authorities didn't want to turn the 26.2-mile course from Hopkinton to Boston into a militarized zone.
(Copyright 2014 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.)
1 day ago
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i am sure that what you have said will definitely pierce the ears of your readers and make them think more deeply about it
city palace
Take A Photo Safari To Texas
For many wildlife photographers,
nothing beats an African photo safari. It's the adventure of being
"one with nature" on wide-open plains; the excitement of
framing a lion, cheetah, zebra, giraffe, or other magnificent animal
in the camera's viewfinder; and the feeling of being far away
from home in an exotic location. Ah, all of that, not to mention the
time needed to make such a trip, plus the fairly high cost of the adventure!
The place is Fossil Rim Wildlife
Center in Glen Rose, Texas (about 90 minutes south of Fort Worth). However,
when you enter the 1400 acre Center, you feel as though you have stepped
into South or East Africa. Zebra, giraffe, wildebeest, and other exotic
animals roam freely on the rolling hills and open plains. One difference
at Fossil Rim is that you can drive along a paved path--in your own
car or tour in a safari truck driven by an expert guide. During the drives,
which usually last about two hours, you can actually hand feed (with "feed"
you buy before your adventure) some of the animals, including the giraffes.
After the
sun sets at Fossil Rim, you can stay in the Center's Safari Lodge
or stay in a tent in the Center's camp. The tents are air-conditioned
and have hot and cold running water. Still, the tent does add to the way-cool,
"safari" experience.
Okay, let's see some
Zebras. When
the background is distracting, shoot tight headshots for pictures that
look as though they could have been taken in Africa. (Canon EOS-1Ds,
Canon EF 100-400mm IS zoom at 400mm, ISO 400, Canon
Travel Info
i am sure that what you have said will definitely pierce the ears of your readers and make them think more deeply about it
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I like going on safari trips. I've recently participated to a donate car USA event and I gave my old car as I want to buy a Jeep instead. I already imagine myself driving a nice Jeep in the middle of the safari.
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I like going on safari trips. I've recently participated to a donate car USA event and I gave my old car as I want to buy a Jeep instead. I already imagine myself driving a nice Jeep in the middle of the safari.
These photos are great! I like animals a lot and traveled a lot around the world in order to take picture with animals.Now I am living in Australia and here are some nice animals very different of those from U.S.Kangaroos are the Australias endangered animals and I took a lot of photos with these animals.
Last year I've spent my vacation in Texas and I borrowed a car from a trucking company Tucson in order to take a safari trip. It was a good idea as we had a great time there and took a lot of photos with animals.
I like animals a lot and this is why I've studied hard in order to become a veterinary. I work at the local zoo and in my spare time I use to travel a lot in order to take photos with the most amazing animals. Recently I made an Australia whale watching tour and I had a great time there. It is great to see whales so close and I took a lot of photos.