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Do What I Say, Not What I Do! (Or maybe not....)May 13, 2010
Do composers really care about whether their tempo markings should be followed? I guess it depends….
I am thinking this a lot this week, as I'm doing two very familiar pieces with the National Symphony in Washington that are both frequent victims of tempo abuse. One is the Elgar "Enigma Variations" about which I've already written a little. The centerpiece of the Elgar is the inimitable "Nimrod" variation, a slow, stately hymnlike anthem in 3/4 that has been dragooned into any number of ceremonial uses and abuses in its hundred-plus years of life.
The other is the almost too familiar "Adagio for Strings" by Samuel Barber. Like "Nimrod," the Barber has been victim of more than just tempo abuse—you can find it on albums with titles like "Bedtime Classics," "The Most Relaxing Classical Music in the Universe," and in "Hollywood Goes to War," where it's only identified as "Platoon." Film directors love the Adagio for Strings because, when mixed with violent imagery, it shows how incredibly sensitive they are about the human predicament.
And it's not just Hollywood directors, but also big time conductors who can't resist "selling" the piece. They do so by pushing and pulling its carefully balanced emotional architecture and ignoring it for what it really is, a work of great simplicity and quiet dignity. The fact that the piece was originally the slow movement to a string quartet is all too often forgotten.
Barber doesn't give a metronome marking for the piece—he says only "molto adagio," which could be just about anything from slow to virtually motionless. But ah-hah! Up on the left hand corner of the score is a tiny little box that says "Playing time: 7-8 minutes." Bela Bartòk gave durations in minutes and seconds for his movements also, although he was much more precise in his timings. Giving a performer the liberty to do two different performances as much as 12.5% in tempo is very very, well, permissive. If I hear a conductor doing something of mine at quarter=100 when I've asked for quarter=88 (a seemingly miniscule difference) I utterly freak out and can barely sit still.
iTunes has several dozen Barber Adagio recordings, and you can go nuts, if you like, listening to the same piece played much too fast (Ormandy) or absurdly, murderously drawn out (Bernstein). You can even treat yourself, for purposes of true edification, to techno version by an all girl band named BOND. That one clocks in at a breakneck 4:23, but we'll forgive them because someone unplugged their drum machine during the studio session.
Elgar's own recording of the "Enigma Variations," done in the 1920's when electric sound recording was a very new thing, is much at odds with the tempo markings in his score. He virtually flies through some of the faster numbers, in some cases leaving his struggling players in the dust. It's possible that he had no choice—he may well have had to squeeze some movements into short time spans to accommodate the demands of the nascent recording technology. Nonetheless, I get the feeling that he knew the piece so well by the time he recorded it he may have been even a bit bored with it. Rachmaninoff's own recordings of his piano concertos can often seem strangely abrupt—as if he had a train to catch right after the session.
Or maybe these were genuinely modest composers who were embarrassed by the emotionalism of their own music and in performing it actually downplayed its expressive potential.
The justifiably famous and intensely moving "Nimrod" variation is marked at quarter=52. No one does it that fast. (Well, OK, I haven't had the Norrington Xperience on this yet, but it seems almost impossible not to take it at least a little slower, if only to savor the perfect way in which the music builds to its climax.) Elgar himself does it slower.
There is a small cottage industry of Stravinksy scholars out there who have parsed the variables between Stravinsky's recordings and his score markings. Later Stravinksy recordings become even more an area for speculation because not only was he very old and physically frail while making them, but there was always a question about the influence of Robert Craft, who seems to have done his best to respect the master's intentions, even when they contradicted the printed score.
In some cases, great composers were not very good conductors. Stravinsky, at least when younger, seems to have been good enough to get the tempo he wanted, as was Copland and most certainly Britten, who was a very skilled conductor. Should conductors consult a recording if the composer conducts that recording? Yes, absolutely.
But if what the composer-conductor does is at odds with the printed tempo marking, which version do you follow? Ultimately, one has to respect the metronome marking in the score, and then use the recording as a proposal to experience the music differently.
The bottom line comes down to taste and discretion. Most music, once you start playing, usually suggests its right tempo. I can't explain why this is, but something having to do with weights and balances and the mimesis of human gestures and even human speech inevitably arises, providing a very strong clue to the composer's intentions. I have on rare occasions had a great performer, or perhaps even not a performer but rather a very deep listener, suggest to me a different tempo that over time I ultimately grew to prefer. But that is rare. My feelings about tempi in my pieces change very little over the years, and I suspect that's pretty much the case with most composers.
When Leonard Bernstein, a great but in his later years an aggravatingly willful conductor, does the Barber Adagio and drags it out to just shy of ten minutes he's trying to make it into something it emphatically is not. That is indeed abuse, a disfiguring of the composer's intent that is no better than Bond's four-minute techno version. Unfortunately extreme tempi, either VERY slow or VERY fast, are often how conductors (and pianists and other performers) think they can say something special about the music. But more often than not they are only saying something uncomfortably revealing about themselves.
Comments (19)
May 14, 2010
Yes, yes, yes! Thank you for this insight - brilliantly put. Couldn't agree more that the inherent simplicity of Barber's Adagio is all-too-easily obscured by errant tempi
May 14, 2010
Very interesting John - I'm not a conductor myself, but as a composer I generally like the music to stick to the tempo I had in mind originally.
But sometimes I've had the experience where a different tempo has suggested itself through circumstances. A couple of times I've had a situation where a performer was 'working up' to the tempo I had in mind, just playing it for me, but at a slightly slower tempo because he/she hadn't got it to the tempo I wanted yet. And a couple of times I heard a more spacious aspect to the music at the slower tempo that I felt was worth preserving and told the performer to keep it at that tempo. These are not huge divergences - maybe 10bpm at most (though probably bigger than your allowable limit!), and sometimes I've had a situation where the piece can be played at two slightly different tempos and
I've enjoyed both of them for different reasons. Other times of course a divergence in the tempo can just awful............
Great blog
May 14, 2010
Great coment. I do remember Schostakovich being asked about his metronome marks to which he said, "oh just ignore that my metronome is broken." He also stated that composers play their own music too fast. I am waiting for Norrinton et al to have hip concerts of Adams. I wonder how they will obtain the correct instruments.
May 14, 2010
I find that I usually prefer the tempo of a piece as it was on the recording from which I first listened to the piece, which suggests to me that it's not as much about the inherent nature of the piece as the composer thinks. Of course there are surely reasonable limits to this. I can understand the composer's (or playwright's, etc) impulse to want to control the variables of performance, but I think it's usually a mistake to take such a proprietary attitude. Once it's on the page, I say let it go! It's not yours in some sense. It also shows confidence in the piece. Philip Glass seems to have a pretty hands-off approach to his compositions, which I've always respected. On the other hand, Boulez seems to place the composer's authority above all else, with sometimes absurd results, to my mind. For example, he has said he would never perform the Mahler 10th as completed by Cooke or anyone else—it's not what Mahler composed. But for most anyone who has heard a completed version of the Mahler 10th, that surely is patently ridiculous. It's gorgeous music whether the composer sanctioned it or not, and that's all that matters.
May 15, 2010
When it comes to the Adagios of Beethoven's late quartets, the music can always be longer, and so the tempo always slower...
May 15, 2010
We all know that music notation is an imperfect and imprecise system. Each composer can only strive to represent something unrepresentable, and each performer can only strive to learn something unlearnable, on the printed page.
I once heard a clinic by Nexus in which Bill (or was it Robin?) talked about performing Reich's Music for Pieces of Wood, and about how the piece worked at different tempi in different venues, based on the reverb in the room. The first woodblock entrance would take about a measure to settle in, and the members were always happy with the sound of the piece in each room despite the difference from night to night.
How many J.S. Bach works even have a tempo marking?
May 15, 2010
We have all heard Nimrod done a number of ways, and I am certain that we can all reasonably be at odds as to which parts should flow which way. I remember a conductor at an honor ensemble I was lucky enough to have placed into claiming something much more, that indeed different phrases or even individual measures deserved their own distinct treatment as tempo is concerned. It was the first time my eyes were glued to the conductor's whims of expression more than the suggestions of the score. Learning her idiosyncrasies as a conductor, in that place and time and of that specific piece, expanded my understanding of reading beyond the chart in those precious few rehearsals as much as years of jazz instruction did. While I, in bittersweet compromise, left my days of performance years ago, I must say there was something I recognized in your treatment of Nimrod with the NSO when I had the pleasure of being there on May 14th.
Copland was a fantastic choice as an introduction to The Wound-Dresser, of course and set the mood perfectly. That I had the opportunity to hear you lead that piece in person, as a lover of Whitman, will remain a well relaid highlight of the evening.
But it was your treatment of Nimrod that really took me someplace special. A third of the way through, my eyes were sealed shut and I sat up in my seat. Simply put, I was no longer where I thought I was.
Though I have left performance in past years, and as such willfully admit that my commentary is suspect, your performance brought a visceral reminder to me of the necessity of discretion. Simply put, that stuff on the page isn't music. It is at best blueprint, more realistically mere guideline. The creators of ideas, because of the tragedy of the fact that the ideas are their own, can only take them so far.
May 16, 2010
"I have on rare occasions had a great performer, or perhaps even not a performer but rather a very deep listener, suggest to me a different tempo that over time I ultimately grew to prefer."
I grew up with Reinbert de Leeuw's Satie interpretations. These are slow, very slow, possibly not as the composer meant them to be? But everytime I hear them played faster I cannot stand the tempo.
May 16, 2010
I agree with Dan's comment about how one's first exposure to a piece can lock a feeling of the "right" tempo into place. In my case there has to be some strong impression made by the music - it has to "click". It's as though a different part of my brain associates the tempo with those strong emotional feelings.
I became hooked on Nielsen's 2nd and 3rd symphonies from Herbert Blomstedt's recordings with the SFSO in the 1980s. About ten years later, i heard Salonen program the 3rd in Los Angeles. He introduced a brief pause at one point in the first movement - my favorite point in the whole symphony - and hearing that pause ruined it for me. I have no idea whether the pause is marked in the score or not, but I don't care. Blomstedt didn't do the pause, and so for me, no pause sounds "right".
I was lucky enough to sing in Mahler's 8th with Klaus Tennstedt in London when I was a grad student. Although he was pretty consistent with the general tempo from performance to performance, he was almost completely unpredictable with rallentandos and accelerandos - we had to watch him like a hawk. I think the dramatic tension this created was what made Tennstedt so appealing to his admirers and so appalling to his critics......
May 16, 2010
This is bringing to my mind a controversial performance a few years ago under Leonard Slatkin's direction (still dearly missed) in which a visiting soloist decided with the conductor to perform Rachmaninov's Second Piano Concerto at roughly half its "acceptable" tempo. No matter what you think of Slatkin's from-the-podium pedagogical style (and I won't care anyway, in defense of this sadly slighted maestro whom we lost to...Detroit!), he introduced the performance with the NSO with full disclosure that the approach was deliberately experimental and probably controversial. He honestly framed the experience as an opportunity to digest and assess the work (which is already over-the-top) in a fresh and distinctive light.
This seems to me a wholly different matter than the problematic tinkerings with tempi that are so eloquently impeached in John Adams' opinion piece here. In other words, I'm OK with experimental tempi as long as we all have the chance to "get on the same page."
May 18, 2010
I agree that most music does usually suggest its correct tempo, though it's finding the agreement between phrase, section, movement, and piece that is the difficult bit.
May 18, 2010
If you think Lenny's version of Barber's Adagio is long, wait until you hear his Enigma Variations with the BBC Symphony (who apparently didn't take very well to him, although their performance is splendid.)
However, although I wouldn't want to hear it often, and would never use it to introduce the Engima Variations to someone, I actually think the recording is quite beautiful in its way, and (as Paul suggests above in his Slatkin reference) can provide insights into the work that might be missed in a more "regular tempo" version. So I'm glad he took this approach to the piece (I feel the same way about L.B's 1986 N.Y. Phil recording of Tchaikovsky's Sixth). On the other hand, we can perhaps be grateful he's not still around to deliver the same treatment to, say, "The Chairman Dances" ("Long Ride in a Slow Machine," anyone?).
In general, I tend to agree that dragging something out doesn't necessarily make it any more expressive, and indeed it is the way the music is treated along and in between the beats that delivers the emotional variety (I have several recordings of E.V. played at a similar pace, but they're still all different in the feelings they elicit.)
I'm sorry I missed Mr. Adams conducting E.V. the other night -- but I was fortunate enough to be there yesterday for Shaker Loops and Chamber Symphony -- a rare and delightful treat.
May 19, 2010
I think most listeners form "how it's supposed to sound" expectations from initial exposure (sometimes not liking a piece based on an unfortunate performance/recording--for me it took years to overcome bad introductions to the Sibelius violin concerto and the third movement of the Barber violin concerto).
I don't recall any late Bernstein that seems too fast. Almost all strike me as lugubriously slow, and arbitrary rather than based on any fresh perspective.
May 20, 2010
hey, don't forget about the tiesto version of "adagio for strings"
I wonder why house DJ's love Barber...
August 17, 2010
A few years ago I found a score of Shostakovich's 2nd Piano Sonata in a
remainder rack, took it home, soon fell in love with the piece. But its "allegretto"
vs. its metronome markings was a problem, one of many tempo issues in trying to play this difficult work where introspection seems to be at loggerheads with lock step pedal to the metal social realism.. I was thinking of it as I opened this article, and then I saw Eric Broomfield's reassuring post. It would be more reassuring were a recording by Shostakovich which takes the first movement at warp speed didn't exist.
The late pianist Julian White said something pragmatic about tempi. If you are bored, it is too slow, but if you are missing information, it is too fast.
August 17, 2010
were...didn't yes, I know...geezers
write funny
August 22, 2010
where you can buy the best watch at lowest price?
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November 27, 2012
What i do not understood is if truth be told how you are now not actually a lot more neatly-liked than you may be right now. You're very intelligent. You know therefore considerably when it comes to this matter, produced me personally believe it from a lot of various angles. Its like women and men are not fascinated except it is something to accomplish with Girl gaga!
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Les Orchidees Hotel, Leysin
Rooms: 14
Hotel Website | | 41 (0)24 4941421
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Reviews - Les Orchidees Hotel
Surperb place to staySubmitted by: Jan in 28/10/05
- Age Group: 26 - 30
- From: United Kingdom
- Traveller type: Young Couple
After finding reviews for some places I want to venture, I think it's good idea to leave my own review for others to benefit from. This hotel although is 2 star, it was such a good hotel, we stayed there for 7 nights in April 2004 and we were made so welcome. The staff were all very nice and helpful, upon arrival, we asked to have a room looking onto the pool and they granted it, there're only 3 rooms overlooking the pool and we got 2 rooms. The breakfast selection is limited but it's nice. The room's cleaned everyday and we felt very safe and well looked after. There's no tea making facilites in the room but the staff let us borrow use their kitchen at the breakfast area. I highly recommend this hotel, it's very cheap and very brilliant!
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Spring, Texas
- Woodland Pond Resident to Publish Book on Healthcare Dilemma
- The Legacy Senior Communities' Corporate Canine Keeps Stress Levels Down and Encourages the Benefits of a Pet-Friendly Atmosphere for Seniors
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LSS Appoints Eric Vandigriff as Executive Chef at The Village at Gleannloch Farms
"We are pleased to have a chef with such an extensive range of cooking specialties," said Johanns. "Being able to provide a wide variety of healthy and delicious meals to our residents is something that brings us great joy, and Chef Eric does this seamlessly."
Vandigriff trained with the ACF/TCA Apprenticeship Program for four years and then interned with the Fairmont Hotel in downtown Dallas. With thirty plus years of experience in country clubs and high-end dining, Vandigriff has created everything from home cooked regional dishes to high-end modern European and Asian cuisines. His true passion lies in pastries and desserts and is considered an expert gingerbread house builder.
"I have always had the mentality of 'treat your clients as if you brought them into your own home,'" said Vandigriff. "I am very excited to be considered a part of this family."
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VIP Amenities
Sometimes it's the little things that make the greatest difference. The Grand America's VIP Amenities are a gracious, thoughtful way to let someone special know you appreciate them.
Give your special guest the VIP treatment with exquisite handmade artisan chocolates or a personalized gift basket. For a romantic occasion, let us prepare a rose petal turndown. And what better way to say 'Sleep tight' with love than with a bedtime snack of milk and homemade cookies?
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In this delightfully sinful treat, we combine Belgian white and dark chocolate to dress our decadent strawberries in formal tuxedo attire.
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Specialty French inspired delicacies: French Macaroons, Chocolate Bonbon Cornets, Creme Filled Chocolate Tulips.
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Create new fond family memories while enjoying the classic games of Parcheesi, Tic Tac Toe, and Skip Rope from our JouJou toy boutique. This amenity offers fun for all ages.
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Meaning and name origin
Lanny \l(an)-ny\ as a boy's name (also used as girl's name Lanny), is pronounced LAN-ee. It is of English origin. Short form and nickname of names like Roland (Old French) "famous land" and Lanzo (Old German) "land".
Lanny has 1 variant form: Lannie.
For more information, see also the related boy name Orlando.
Lanny is also pronounced similarly to Lenny and Lonny. Other suggested similar baby names are Danny, Laine, Lane, Layne, Lenn, Linn, Lonn, Lonne, Lunn, Lynn and Manny.
Lanny is a somewhat popular first name for males (#857 out of 1220) but an uncommon surname or last name for all people (2000 U.S. Census).
Displayed below is the baby names popularity of Lanny name for boys (2012 statistics). Compare Lanny with its variant form and related boy baby names.
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Cartwright Ridge Campground
Cartwright Ridge Campground is located on the shores of the scenic Sage Hen Reservoir in the Boise National Forest, perched at an elevation of 4,800 feet. Visitors enjoy boating, fishing and exploring...[more]
Cartwright Ridge is located 45 miles north of Emmett, Idaho. Take State Highway 52 north to the Sweet/Ola Road (12.3 miles). Turn left towards Sweet, drive north to Ola (17 miles), pavement ends at Ola. Take National Forest Road 618 (NF-618) to the junction of NF-626 (10 miles). Take NF-626 to NF-614 (7 miles). Take NF-614 to NF-614B. The campground is located on the right. The majority of this route is a gravel surface and can be successfully driven with a passenger car during drier weather.
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Wednesday, January 5, 2011
For some who are relatively new to social nudity, this situation is the cause of discomfort and embarrassment. It doesn't need to be that way. The remedy is simple. All it takes is awareness, some forethought and mental preparation beforehand to reduce the level of anxiety and tension. Like most new experiences, some awkwardness may remain. However, this is only natural and doesn't need to be a major source of stress.
Arriving at a clothing-optional beach or at a public nudist event, many same gender loving naturists are shocked to discover that there are naked women present. This is particularly true when prior exposure (no pun intended) has been exclusively limited to the gay male environment. Then reality hits like a speeding locomotive as we view our surroundings.
For some, the basic reaction is to cover their genitalia with their hands. Where this may calm your fears for the moment, it isn't a viable solution. It isn't possible to cup your balls and cock in your hands all day and have fun. Plus, you are attracting unwanted attention to yourself.
I have witnessed this scenario many times. We have become so complacent in our queer naturist network that we just forget that the opposite gender also enjoys nudism. I know of several otherwise-nude brothers who actually refused to remove their shorts/swimsuits upon facing this situation. Once, an aquaintance was so horrorfied that he left the beach immediately.
We all have our individual comfort zone that is to be respected. Mixed gender nudity isn't necessarily pleasant for everyone. We make that determination for ourselves. However, with a little thinking and planning ahead, integrated social nudity doesn't have to create trauma and ruin our outing with friends. Initially, we might be nervous; but, like everything else, practice makes perfect. After a while, we may not even notice. Relax and be yourself. Breathe. Remember, most of us are naked here, right?
Peace! Get naked. Enjoy!
3 comments:
I enjoy reading your comments. Being naked with naked females took me a while to handle it.... Now everything is great... I embarrassed because my limp penis grew erect....
- January 17, 2011 at 9:53 AM
- thegayte-keeper said...
Amazing how so many gay men forget that women exist.
- February 13, 2011 at 3:08 PM
- darkgoti said...
true just because you are gay does not mean you get 24/7 of nude men or gay life ,the world has beautiful women,they too need men.
- August 22, 2011 at 4:29 PM
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Fly to Moron. Transfer by 4WD to the remote ger camp at Lake Khovsgol. Overnight Alagstar Ger Camp.
Explore the rich eco-system of the lake, home to reindeer, yaks, horses, bears, moose and ibex. Kayaking on the lake. Overnight Alagstar Ger Camp.
Fly Moron to Ulaanbaatar. Stroll the city streets, which are quite cosmopolitan and interesting. Overnight Chinggis Khan Hotel.
Travel by 4WD to Khustai National Park. See Neolithic graves, elk, wolf, and Mongolian gazelle. Tonight feast near the banks of Tuul River, followed by an evening game drive to see wild takhi horses. Overnight Khustai Ger Camp.
Travel by 4WD to Karakorum, the ancient capital of the Mongolia Empire under Genghis Khan, and a UNESCO World Heritage site. See the walls of the massive Erdenezuu Monastery, built in the 1586. Overnight Dreamland Karakorum Ger Camp.
Today continue to explore the historically significant Karakorum and Erdenezuu area. Overnight Dreamland Karakorum Ger Camp.
Drive to Ulaanbaatar. Picnic lunch en route. Attend the biggest festival in Mongolia, the Naadam, which honors the nomads of the Mongol armies and features parades, wrestling, archery and horse racing. Overnight Chinggis Khan Hotel.
View the famous attractions of the Nadaam as well as some lesser-known events with your local guide. Watch the finals of the wrestling championship. Dinner at a local restaurant with traditional dance performance. Overnight Chinggis Khan Hotel.
Fly to the Gobi Desert. Visit Altai Mountains. Look for wild sheep and eagles. Visit the Natural History Museum. Overnight Gobi Mirage Ger Camp.
4WD to the Khongoryn Els, Mongolia's largest sand dunes. Ride through the desert on a two-humped Bactrian camel. Overnight Gobi Discovery Ger Camp.
Drive to Bayanzag, known as the Flaming Cliffs, where evidence of a flourishing Late Cretaceous Age may be experienced first hand. Dig at an archaeological site for dinosaur remains. Overnight Three Camels Lodge.
Fly to Ulaanbaatar. Visit the Fine Arts Museum and the Bogd Khan Palace. Dinner at a favourite local restaurant. Overnight Chinggis Khan Hotel.
Fly Ulaanbataar to U.S. or extend.
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New Arrivals
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- Metal.
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We're so sorry: this item sold out sooner than expected. For an equally chic substitute, please call our Personal Service Associates at 1.888.855.4986. Or click on Chico's Chat below for immediate assistance.


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General Health
Cane Corsos are probably about average
when it comes to the number of hereditary health problems that they are prone to in
comparison to other large breeds. As any
other large breed, they are very prone to joint problems due to their size. For more information on genetic problems, please
check out each individual link for specific information on certain health problems
affecting the Cane Corso.
Potentially life threatening or Serious Problems in the Cane Corso:
with a * in front of them are inherited)
¨ Joint problems: *hip dysplasia; *elbow dysplasia, degenerative joint disease, osteochondritis dissecans (OCD) of the shoulders, knees, elbows, or hocks.
¨ Heart Problems: *cardiomyopathy, *mitral valve defect, *heart murmurs or any other cardiac problems known to be hereditary.
¨ Other:
bloat, *
Less serious and/or less common:
¨ Eye problems: entropia, ectropian dry eye, and cherry eye.
¨ Skin: * demodectic mange, any type of skin allergy due to food, environment, and weak immune system.
¨ Reproductive: *monorchid, *cryptorchid
¨ Other:
Willebrands Disease, *Thyroid
Some common non-genetic health
problems in the Cane Corso and many other large breeds are:
¨ Cruciate ligament rupture, panosteitis,
hot spots, cysts, tumors, cancer ( some forms of cancer are inherited, but most are not)
Copyright © 2001 Cane Corso Coalition. All rights reserved.


text:
(based on 18 reviews)
Ratings Distribution
5 Stars
4 Stars
3 Stars
2 Stars
1 Stars
of respondents would recommend this to a friend.
Best Uses
Feels too small
Feels true to size
83% (15 reviews)
(15 reviews)
Feels too large
Feels too short
Feels true to length
82% (14 reviews)
(14 reviews)
Feels too long
Most Liked Positive Review
Models Coats are the best
My mother wears any of the Models Coat snap front dusters or housecoats from National every day at the nursing home. The Models Coat brand is the best and fits truest to size. They...Read complete review
My mother wears any of the Models Coat snap front dusters or housecoats from National every day at the nursing home. The Models Coat brand is the best and fits truest to size. They are easy for her to get on and off and look dressy--not like she is wearing her housecoat. The length is great for in the bed or in a wheelchair. I just wish the grippers were a little closer together. I also usually add an extra gripper at the bottom so they stay closed when she is sitting.
Most Liked Negative Review
Feel like a flower garden
Its ok, just seems "floaty" and the sleeves. I actually think they run large and mine is too large and I haven't bothered to exchange, just got the old one...Read complete review
Its ok, just seems "floaty" and the sleeves. I actually think they run large and mine is too large and I haven't bothered to exchange, just got the old one out and using it.
Reviewed by 18 customers
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Displaying reviews 1-18
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By Eileen
from Green Bay WI
About Me Comfort-oriented, Practical, Stylish
Comments about Pansy Models Coat® by Swirl®:
I needed a zippered house coat. This one looked like it would fit. It has a little bit more room but I still need one more size up. I compromised.
Bottom Line Yes, I would recommend this to a friend
Was this review helpful? Yes / No
- You may also flag this review
Spring is in the Air
By Izzi
from Hillsborough,NJ
I purchased thid for my mother-in-law at a nursing home. It looks so cheerful & happy. She saves it for going to activities in the home.
Beautiful Housecoat
By CAGirl
from Gardena, CA
About Me Conservative, Practical
This was a gift to my mother and she loves it. Colors are very pretty, coat fits well and looks good on.
By Jean the loving daughter
from Eustis, FL
About Me Practical
Just Perfect
By Fussy Old Gal
from Johnstown, NY
About Me Comfort-oriented
My 89 year old hard to please mother loves it. she won't wear any other kind or style, so please be sure to always offer this item.
Life Saver!!!
By tsy
from Laconia, NH
About Me Comfort-oriented, Conservative, Practical
This duster/housecoat provides attractive coverage if I'm caught by the doorbell! I wear it in the morning when I get up, and again in the evening when watching TV. Attractive, nice colors, and well-made.
Pretty and comforttable
By Bo's wife
from KY
Love this - stays crsip, launders well!!
Perfect Transition into Fall
By Senior Savvy Lady
from Bayside, NY
About Me Comfort-oriented, Practical
This robe is very comfortable and a great in-between Summer into Fall garment. I like the length and the peter pan collar. I'm very happy with this purchase.
Good Deal on Sale
By Over the Hill
from Boston MA
The one I ordered was too large, but I kept it. It was on sale when I purchased it and then went back to the regular price. At the regular price it is too expensive. On sale, it's great!!!
(1 of 1 customers found this review helpful)
Just love it
By Fulvietta
from Goshen, NY
About Me Comfort-oriented, Conservative, Practical, Stylish
I just like snap front closure house coats. You have quite a few pull over loungers with beautiful colors and patterns. Please make some with same patterns and colors that snap in the front.
Pretty & light weight
By livncool
from Portland, OR
holds its shape & color
By Sharon
from Pacific NW
nicely made and comfortable enough,and must say it does launder well. I just don't like the colors as much as I had hoped.
By Honey
from Missouri Ctiy, TX
About Me Stylish
Pretty as a garden
By The professor
from Thousand Oaks, CA
About Me Frugal, Practical
I am comfortable wearing this model's coat out in front of my house while watering the lawn and garden in the morning. It is cool, comfortable and pretty enough for my neighbor's to see me in it.
I would buy this again
By Barb
from Hilliard, OH
Pansy Model Coat
By Susie
from Tx
I wear Model coats or patio dresses at home daily for comfort and love that the Model coats have snaps down the front. Love the colors also.
just what we wanted
By Schnauzermom
from New Mexico
Very pleased
Finally I find Models Coats. Love it.
By Sunshine
from South Texas
Very comfortable. Wear around the house. Perfect for our South Texas weather.


text:
Photo #: NH 101797
Katrina Luckenbach (U.S. freighter, 1918)
Photographed upon completion, circa spring 1918, still wearing her builder's hull number (# 265). Constructed by Bethlehem Steel Company's Fore River shipyard, Quincy, Massachusetts, she was chartered by the Navy and commissioned on 18 May 1918 as USS Katrina Luckenbach (ID # 3020).
The original print is in National Archives' Record Group 19-LCM.
U.S. Naval Historical Center Photograph.
Online Image: 58KB; 740 x 455 pixels
Click on the small photograph to prompt a larger view of the same image.
If you want higher resolution reproductions than this digital image, see: "How to Obtain Photographic Reproductions."
2 April 2001


text:
Thu 2 Apr 2009
{ Chocolate passionfruit macarons }
Posted by Julia Tuomainen under Baking, Cookies, Macarons
[5] Comments
Living in sub-tropical Queensland certainly comes with its advantages; it is the perfect climate for a range of home-grown produce. One of my colleagues at work is the proud owner of a yellow passionfruit plant. I often only see the purple variety available in stores (I rarely come across the yellow…), so I was pretty happy when I was able to snaffle myself a handful of these tarty fruits. I endeavoured to somehow combine this flavour into a macaron.
Gifted macaron-maker, Duncan, of Syrup and Tang, recently posted his version of the famous PH passionfruit macaron. This little gem comprises a macaron shell lightly flavoured with coffee essence, dusted with cocoa and sandwiched together with a passionfruit infused ganache.
I could not ever remember eating passionfruit and chocolate together, so I instantly knew this would be macaron flavour / version #6 for the month.
I was keen for a fairly strong passionfruit flavour, so skipped the infusing part of the ganache and simply added whole passionfruit pulp. The result? The flavour was still delicate (thanks to the yellow passionfruit variety), but it was unmistakably passionfruit in taste without being too overbearing.
As a ganache is relatively quick to make, these macarons were produced almost in record time. The same base recipe was used but again seems like the shells were thicker than preferred after letting the sugar syrup reach too high a temperature. But despite that, they were still delicious!
Next weekend I am attending a baby shower and have been requested to bring some baked treats. Macarons, of course. There was no direction in terms of flavour, only colour. Colour = mint. Flavour = ? Stay tuned…
{ Passionfruit macarons }
* Ingredients *
100g egg whites
3g egg white powder
125g almond meal
125g icing sugar
Dash coffee essence
Cocoa for dusting
For the syrup:
150g sugar and 50ml water
* Directions *
Process the almond meal and icing sugar together. In a mixer, whip half the egg whites to soft peaks. Meanwhile, in a saucepan bring the water and sugar for the syrup to 117C (or 242F) on a candy thermometer. Once ready, slowly add the boiling syrup to the egg whites and continue to whip on medium speed until they thick and shiny and are completely cooled (about 10 minutes). At the final changes of whipping the meringue, add the flavouring / colouring. Mix the remaining egg whites to the sifted almond mixture and fold into the meringue in four parts.
Pipe macarons on lined baking sheets. Dust lightly with cocoa. Double up your baking sheets if you do not have professional grade quality. Let your macarons sit at room temperature for 30-60 minutes. Bake at 140C or 280F for 15-18 minutes. Fill with ganache or filling of your choice. Refrigerate to set.
{ Passionfruit ganache }
* Ingredients *
120g dark chocolate, chopped
1/2 cup heavy cream
Pulp of one passionfruit
* Directions *
Heat cream until bubbles form around the edge of the pan. Pour cream over the chocolate. Let sit for 2-3 minutes and then stir. Cool slightly and add the passionfruit pulp. Transfer to the refrigerator to thicken.
5 Responses to " { Chocolate passionfruit macarons } "
They look yummy, and great photo! I notice you bake yours for longer at a lower temperature. I did my last batch at 180′C for 8-9 minutes. Also, regarding the thick shells, you might want to let them sit for a shorter period of time..?
They do look great! Congratulations are in order for producing such pretty ones at such a low temp. You're much more likely to get thick shells from both such slow cooking and from resting them so long. In my experiments, there was no identifiable advantage in resting piped shells beyond about 5 mins (which serves to smooth out some bumps and lets some air bubbles become visible and quickly poppable).
Y – good suggestions, thanks! I will try a higher temperature and less resting time with my next batch!
Duncan – thank you. Sounds like you also have similar suggestions as Y. Will definitely give it a go.
I just got my hands on French passion fruit pulp at a specialty store here. It's not a fruit familiar to me at all! The last time I bought some from the supermarket were local ones and they were dead sour and tart *bleugh* I am crossing my fingers on this one with the pulp; it's really watery rather than pulpy in that tub i just defrosted. Is that normal?? Will the macarons be as nice?
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[...] macarons, Champagne macarons, Liquorice macarons Middle row: Blueberry macarons, Lemon macarons, Passionfruit macarons Bottom row: Pistachio macarons, Rose macarons with raspberry cream, Caramel [...]


text:
The third annual Love Sterling event will take place on Saturday, April 28, starting at 9:00 a.m. Love Sterling was started as a way for the students, faculty, and staff of Sterling College to give back to the community that has supported them for so long.
Sterling College is a Christ-centered, four-year college located in Sterling, Kansas. Learn more.
125 W. Cooper
Sterling, KS 67579
800-346-1017 | 620-278-2173
Email Sterling College
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Valid Nov. 7, 2013 - April 1, 2014. Cruise are held daily at noon and 3 p.m. Reservations are required; subject to availability and weather conditions. Park by the boats in Public Parking Lot #12 (just before the apartment building at 14069 Marquesas Way) and call 424-217-9295 once you have arrived. A 24-hour cancellation policy applies. Not valid on major holidays or holiday weekends. Group cruises include up to six guests per sailing.See all terms
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Advanced Search
Common Core | In Print
Students at Eastway Middle School in Charlotte, NC, use graphing calculators to send data to their teacher as part of a Texas Instruments algebra-readiness program known as MathForward.
The impending switch to Common Core State Standards will require a transformation of teaching and learning in K-12 classrooms across the United States. Many current teaching practices simply will not provide students with the necessary skills to be productive 21st century citizens, and most educators recognize that fact. However, changing a teacher's practice and a school's culture are daunting tasks.
At Charlotte-Mecklenburg Schools (NC), where I work, a number of students and teachers are bringing in sweeping change as they move toward full implementation of the Common Core's Standards for Mathematical Practice. They are reimagining the way math teachers are trained and students are taught, using an approach that makes use of technology and focuses on professional development.
Specifically, more than two years ago the district began employing a Texas Instruments initiative called MathForward that combines the use of technologies like graphing calculators and a navigator system (which allows teachers to collect instant feedback from students), a heavy focus on professional development, and differentiated learning. The program can be used in conjunction with any textbook, because it's not a curriculum--it's a way to change the teacher's pedagogy and work in the classroom. Today, the district's Title I middle schools (150 classrooms) and high school Algebra 1 classes (100 classrooms) are enrolled in the program.
As part of its overall Common Core implementation strategy, the Charlotte-Mecklenburg district's principal focus now is on the core's W-1 standards, which, while not math-specific, focus on evidence-supported argumentative writing, a skill that applies to all content standards. W-1 is about using data to form opinions and to back up those opinions. A central part of the MathForward program incorporates using math-based data to support a student's hypotheses.
Teaching Teachers First
The program consists of multiple parts, but it all starts with the teachers, who begin with five days of face-to-face training on using the technology and research-based pedagogy for math instruction. Then, four days each month a program coach observes teachers' classrooms and works with them to create lessons that take advantage of the data teachers collected from students (i.e., test scores and homework answers). Then, four to five times a year, all participating teachers are pulled out to learn more content and work as a professional learning community.
The program is in use every day in the classroom. When students come in, teachers ask randomly selected homework questions, and students answer them using buttons on their graphing calculators. The questions could be multiple choice, fill in the blank, or even open response. The data is then transmitted to the teacher's navigator system, where teachers can display the answers for the entire class without identifying which student offered which response, and also privately identify which student gave which response. . Teachers then can say, for instance, "We need to go over No. 7, a lot of you missed that." The great thing is that it gives the teacher immediate buy-in. They see instantly that this is something that can make their lives easier.
The students have taken to it too. If they have 15 homework problems and everyone in the class got 14 of them right, they know they won't have to spend 30 minutes in class going over it. The teachers can focus instruction on the areas in which the students need the most help.
In these MathForward classes, students also spend about 20 minutes of each class solving what we call "real-world problems." Texas Instruments has a team that scours the news and develops topical situations that students can think critically about.
For instance, last year, when oil was spilling into the Gulf of Mexico, students spent about eight weeks looking at data coming in from the region and solving problems based on it. They used Google Earth, their math skills, and various technologies to digest the just-in-time data the experts were generating. Kids then learned to ask questions to try and solve these problems. Each day, after they spent some time on the Gulf oil spill problem, they moved on to a regular math lesson, and then returned to their real-world problem with teachers asking if what they just learned would help them solve--or think differently--about the problem.
Obviously, we did not expect students to solve many of the complex, theoretical questions that were posed--the experts do that--but students learned that you need to use math to solve these types of problems and, in doing so, they used every one of the eight Standards for Mathematical Practice in the Common Core, from reasoning abstractly to attending to precision.
In addition to making sure students employed the standards, we also felt it was important to make them aware of what they were doing. Each math classroom has posters on the walls demonstrating the eight math-related standards with an aligned graphic. Students are expected to write a "ticket out the door" each day explaining what they learned in class, and which mathematical practice they employed. The practice also reinforces our focus on W-1 argumentation--using data to form an opinion and then being able to back up that opinion--since what we are really asking kids to do is to take information, analyze it, and communicate about it.
Differentiating Data
For the teachers, the professional development part of the program is the real hook, because the ultimate goal is to change their practice so they can be better teachers for all kids. But they couldn't do it without the technology to take care of a lot of the grading and differentiating.
In MathForward classrooms, teachers typically collect 15 to 20 points of data about students every day. Instead of teachers having to spend time grading these problems, they now spend time reflecting on who is struggling with what and how they can best meet their needs. The technology, coupled with the face-to-face coaching, is enabling them to differentiate. The teacher, who in the past could only provide two to three different assignments to differentiate, can now provide as many as 30 different assignments.
From the first implementation of MathForward more than two years ago, we have seen significant improvements. In particular, 23 eighth-grade classrooms produced two years' worth of growth in student achievement in one school year, and several schools are moving student mastery on state tests from 40 percent to nearly 90 percent. Special education and limited English-proficiency students have shown four to five years of growth in these classes because of the engaging technology and teachers' instructional practices.
In the schools that have been using MathForward for more than two years, the culture of math has been transformed to one where all students know they can master difficult math concepts. Teacher retention in high poverty schools has always been low, but the success teachers experience with the support and technology provided by MathForward has improved the retention rate in our Title I middle school math departments to more than 90 percent. The rigor of the Common Core standards requires students to begin using graphing calculators in the sixth grade and, with MathForward, our teachers feel empowered to do that successfully.
Creating a Common Core Toolkit
The overall move to the Common Core State Standards presented Charlotte-Mecklenburg Schools (NC) with a number of challenges. Among them was the dearth of collected resources freely available that teachers could turn to in making sense of the new standards.
To counter this deficiency and help teachers and administrators prepare for their new roles, district leaders created a comprehensive internal resource that compiles webinars, video clips, and samples of student work, all revolving around the new concepts and standards. Called the Common Core toolkit, the resource serves as a compendium of everything schools need to begin preparing themselves for the shift. For teachers, multimedia is paired with recommended websites, like insidemathematics.org, and whole lesson plans. For principals, there are video demonstrations of administrators observing lessons and discussing them with staff.
"It's the district place where we put high-quality resources," explains Cindy Moss, the district's director of PreK-12 STEM education. "We've already juried what's out there, so you can trust that it's high quality."
Ultimately, teachers will be able to take as much as 80 percent of their lesson plans directly from the toolkit, enabling them to train their focus on changing their practice, not creating lessons.
"We have almost 10,000 teachers," Moss says. "You can have a really great teacher that's not great at writing lessons, so we have always provided alignment guides and pacing guides. We provide lessons that focus on the appropriate content to the appropriate level of rigor."To develop the toolkit, the district created a Common Core steering team with curriculum and assessment specialists, special education experts, ELL teachers, and other stakeholders who will be affected by the switch, including parents, who were represented by leaders of the district's Parent University, which offers free skill-building courses. The team then wrote grade-level-specific lessons in subjects like language arts, math, and science. Afterward, stakeholders were allowed to examine it with their specific populations in mind.
As Moss explains, "The ELL rep might take it and make some modifications that might be needed for a kid who is an English language learner, the special ed might make some recommendations for some modifications a kid with a certain IEP, and the Parent University representative would look at it and say, 'Here's a paragraph we need to send home to parents when students are learning these units.'"
The best part is that Charlotte-Mecklenburg is sharing its toolkit with other districts. Currently, Moss says, the toolkit is not accessible online; however, she hopes that will change next year. For now, interested districts can gain access to the toolkit upon request. For more information, contact Cindy Moss using this form. --Stephen Noonoo
About the Author
Cindy H. Moss is director of PreK-12 STEM education at Charlotte-Mecklenburg Schools in North Carolina.
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text: I love nylons! I love sniffing stinky and wet nylon feet! This girls shares my fetish! She is sniffing feet and getting horny! Do you like the smell of old, two days worn nylons? Gosh, I love the nasty smell of that stuff! Nylon feet having a great scent, really arousing.


text:
DC*TV: From Bad to 'Verse — How Do They Come Up With That Stuff?
Coming up with ideas for Dragon*conTV video plots involves a lot less alcohol than you might think.
[pullquote quote="So it's turning into an organization despite the fact that it's just a bunch of nuts shooting Stormtrooper videos in my basement." credit="Brian Richardson, DCTV Exec. Producer"]The creative minds, many of whom live outside of Georgia, keep in touch via a message board where they post notes up to eight or nine months before the convention.
About three months after that, they have a face-to-face meeting where they pitch further and talk about what can be practically created, what can be done on a green screen, what can be shot outside. Can they get someone to lend them needed props? Will this idea still be funny when it's produced or is it only funny to them?
After that, they discuss who they can cast in these parts, can they pull someone from their existing network of people, or grab someone from The Renaissance Festival, the Shakespeare Tavern, etc.
[photogallerylink id=56987 align=right]Now it's time to break down into production teams – Stephen Grenade will produce the bumpers, Brian Richardson will do the videos, others do the editing, Sketch MacQuinor, a local animator, actor, voice-over artist and writer, does writing, or he may cast and produce videos on his own. "So we are sort of [doing it the way] a TV network would do, where some stuff they shoot in house and some stuff they farm [out]. It's turning into an organization despite the fact that it's just a bunch of nuts shooting Stormtrooper videos in my basement."
Re Your Brains (2007)
The Basement with a Green Screen
[photogallerylink id=57068 align=right]Most of the DCTV videos are produced at "Geek Farm," which is a nickname for the country home where Brian lives with his wife, Suzan, four cats, two horses and five chickens. His basement is set up with a green screen that he built himself, a camera and old props lying here and there from past shoots. Other scenes are set in his living room, kitchen, or the woods and fields surrounding his property.
Tigh's Fried Chicken (2009)
[photogallerylink id=57006 align=right]I followed Brian and a couple of actors one early summer day on his property as they were filming clips for a video. A rooster followed us from spot to spot, apparently eager to get in the shot. This isn't "low-budget," it's "no-budget."
But that doesn't seem to matter. Labors of love are always better, anyway.
MORE Dragon*conTV Stories


text:
Spiriva Respimat 2.5 micrograms solution for inhalation
Last Updated on eMC 19-Sep-2014 View changes | Boehringer Ingelheim Limited Contact details
- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
COPDTiotropium is indicated as a maintenance bronchodilator treatment to relieve symptoms of patients with chronic obstructive pulmonary disease (COPD).
AsthmaSpiriva Respimat is indicated as an add-on maintenance bronchodilator treatment in adult patients with asthma who are currently treated with the maintenance combination of inhaled corticosteroids (≥800 µg budesonide/day or equivalent) and long-acting β2 agonists and who experienced one or more severe exacerbations in the previous year.
PosologyThe medicinal product is intended for inhalation use only. The cartridge can only be inserted and used in the Respimat inhaler (see 4.2).Two puffs from the Respimat inhaler comprise one medicinal dose.The recommended dose for adults is 5 microgram tiotropium given as two puffs from the Respimat inhaler once daily, at the same time of the day.The recommended dose should not be exceeded.In the treatment of asthma the full benefit will be apparent after several doses of the medicinal product.
Special populationsGeriatric patients can use tiotropium bromide at the recommended dose. Renally impaired patients can use tiotropium bromide at the recommended dose. For patients with moderate to severe impairment (creatinine clearance ≤ 50 ml/min, see 4.4 and 5.2).Hepatically impaired patients can use tiotropium bromide at the recommended dose (see 5.2).Paediatric population
COPDThere is no relevant use of Spiriva Respimat in children and adolescents below 18 years
Cystic fibrosisThe efficacy and safety of Spiriva Respimat has not been established (see sections 4.4 and 5.1).
AsthmaThe efficacy and safety of Spiriva Respimat in children and adolescents has not yet been established.
Method of administrationTo ensure proper administration of the medicinal product, the patient should be shown how to use the inhaler by a physician or other health professionals.
Patient's instructions for use and handling
Spiriva Respimat inhaler and Spiriva Respimat cartridge
1 ) Inserting the cartridgeThe following steps 1-6 are necessary before first use:
|1 With the green cap (A) closed, press the safety catch (E) while pulling off the clear base (G).
|2 Take the cartridge (H) out of the box. Push the narrow end of the cartridge into the inhaler until it clicks into place. The cartridge should be pushed firmly against a firm surface to ensure that it has gone all the way in (2b). The cartridge will not be flush with the inhaler, you will still see the silver ring of the lower end of the cartridge. Do not remove the cartridge once it has been inserted into the inhaler.
|3 Replace the clear base (G). Do not remove the clear base again.
2) To prepare the Spiriva Respimat inhaler for first-time use
|4 Hold the Spiriva Respimat inhaler upright, with the green cap (A) closed. Turn the base (G) in the direction of the red arrows on the label until it clicks (half a turn).
|5 Open the green cap (A) until it snaps fully open.
|6 Point the Spiriva Respimat inhaler towards the ground. Press the dose release button (D). Close the green cap (A). Repeat steps 4, 5 and 6 until a cloud is visible. Then repeat steps 4, 5 and 6 three more times to ensure the inhaler is prepared for use. Your Spiriva Respimat inhaler is now ready to use.These steps will not affect the number of doses available. After preparation your Spiriva Respimat inhaler will be able to deliver your 60 puffs (30 medicinal doses).
Daily use of your Spiriva Respimat inhaler
You will need to use this inhaler ONLY ONCE A DAY.
Each time you use it take TWO PUFFS.
|I Hold the Spiriva Respimat inhaler upright, with the green cap (A) closed, to avoid accidental release of dose. Turn the base (G) in the direction of the red arrows on the label until it clicks (half a turn).
|II Open the green cap (A) until it snaps fully open. Breathe out slowly and fully, and then close your lips around the end of the mouthpiece without covering the air vents (C). Point your Spiriva Respimat inhaler to the back of your throat. While taking in a slow, deep breath through your mouth, press the dose release button (D) and continue to breathe in slowly for as long as you can. Hold your breath for 10 seconds or for as long as comfortable. III Repeat steps I and II so that you get the full dose.You will need to use this inhaler only ONCE A DAY.Close the green cap until you use your Spiriva Respimat inhaler again.If Spiriva Respimat inhaler has not been used for more than 7 days release one puff towards the ground. If Spiriva Respimat inhaler has not been used for more than 21 days repeat steps 4 to 6 until a cloud is visible. Then repeat steps 4 to 6 three more times.
When to get a new Spiriva Respimat inhaler
|The Spiriva Respimat inhaler contains 60 puffs (30 medicinal doses). The dose indicator shows approximately how much medication is left. When the pointer enters the red area of the scale, there is, approximately, medication for 7 days left (14 puffs). This is when you need to get a new Spiriva Respimat inhaler prescription. Once the dose indicator has reached the end of the red scale (i.e. all 30 doses have been used), the Spiriva Respimat inhaler is empty and locks automatically. At this point, the base cannot be turned any further. At the latest, three months after use the Spiriva Respimat inhaler should be discarded even if not all medication has been used.
How to care for your inhalerClean the mouthpiece including the metal part inside the mouthpiece with a damp cloth or tissue only, at least once a week.Any minor discoloration in the mouthpiece does not affect your Spiriva Respimat inhaler performance.If necessary, wipe the outside of your Spiriva Respimat inhaler with a damp cloth.
PregnancyThere is a very limited amount of data from the use of tiotropium in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity at clinically relevant doses (see 5.3). As a precautionary measure, it is preferable to avoid the use of Spiriva Respimat during pregnancy.
Breast-feedingIt is unknown whether tiotropium bromide is excreted in human breast milk. Despite studies in rodents which have demonstrated that excretion of tiotropium bromide in breast milk occurs only in small amounts, use of Spiriva Respimat is not recommended during breast-feeding. Tiotropium bromide is a long-acting compound. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Spiriva Respimat should be made taking into account the benefit of breast-feeding to the child and the benefit of Spiriva Respimat therapy to the woman.
FertilityClinical data on fertility are not available for tiotropium. A non-clinical study performed with tiotropium showed no indication of any adverse effect on fertility (see 5.3).
Summary of the safety profileMany of the listed undesirable effects can be assigned to the anticholinergic properties of tiotropium bromide.
Tabulated summary of adverse reactionsThe frequencies assigned to the undesirable effects listed below are based on crude incidence rates of adverse drug reactions (i.e. events attributed to tiotropium) observed in the tiotropium group pooled from 5 placebo-controlled clinical trials in COPD (2,802 patients) and 6 placebo-controlled clinical trials in asthma (1,256 patients) with treatment periods ranging from twelve weeks to one year. Frequency is defined using the following convention: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data)
|System Organ Class / MedDRA Preferred Term
|Metabolism and nutrition disorders
|Not known
|Not known
|Nervous system disorders
|Not known
|Eye disorders
|Not known
|Intraocular pressure increased
|Not known
|Vision blurred
|Not known
|Cardiac disorders
|Atrial fibrillation
|Not known
|Supraventricular tachycardia
|Not known
|Not known
|Respiratory, thoracic and mediastinal disorders
|Not known
|Not known
|Not known
|Not known
|Gastrointestinal disorders
|Dry Mouth
|Oropharyngeal candidiasis
|Not known
|Gastrooesophageal reflux disease
|Not known
|Dental caries
|Not known
|Not known
|Intestinal obstruction, including ileus paralytic
|Not known
|Not known
|Not known
|Not known
|Skin and subcutaneous tissue disorders, immune system disorders
|Angioneurotic oedema
|Skin infection/skin ulcer
|Not known
|Dry skin
|Not known
|Hypersensitivity (including immediate reactions)
|Not known
|Anaphylactic reaction
|Not known
|Not known
|Musculoskeletal and connective tissue disorders
|Joint swelling
|Not known
|Not known
|Renal and urinary disorders
|Urinary retention
|Not known
|Not known
|Urinary tract infection
|Not known
Description of selected adverse reactionsIn controlled clinical studies in COPD, the commonly observed undesirable effects were anticholinergic undesirable effects such as dry mouth which occurred in approximately 3.2% of patients. In asthma the incidence of dry mouth was 1.2%.In 5 clinical trials in COPD, dry mouth led to discontinuation in 3 of 2,802 tiotropium treated patients (0.1 %). No discontinuations due to dry mouth were reported in 6 clinical trials in asthma (1,256 patients).Serious undesirable effects consistent with anticholinergic effects include glaucoma, constipation, intestinal obstruction including ileus paralytic and urinary retention.
Other special populationAn increase in anticholinergic effects may occur with increasing age.
Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard
Mechanism of actionTiotropium bromide is a long-acting, specific antagonist at muscarinic receptors. It has similar affinity to the subtypes, M1 to M5. In the airways, tiotropium bromide competitively and reversibly binds to the M3 receptors in the bronchial smooth musculature, antagonising the cholinergic (bronchoconstrictive) effects of acetylcholine, resulting in bronchial smooth muscle relaxation. The effect was dose dependent and lasted longer than 24h. As an N-quaternary anticholinergic, tiotropium bromide is topically (broncho-) selective when administered by inhalation, demonstrating an acceptable therapeutic range before systemic anticholinergic effects may occur. Pharmacodynamic effectsThe dissociation of tiotropium from especially M3-receptors is very slow, exhibiting a significantly longer dissociation half-life than ipratropium. Dissociation from M2-receptors is faster than from M3, which in functional in vitro studies, elicited (kinetically controlled) receptor subtype selectivity of M3 over M2. The high potency, very slow receptor dissociation and topical inhaled selectivity found its clinical correlate in significant and long-acting bronchodilation in patients with COPD and asthma.
Clinical efficacy and safety in COPDThe clinical Phase III development programme included two 1-year, two 12-weeks and two 4-weeks randomised, double-blind studies in 2901 COPD patients (1038 receiving the 5 µg tiotropium dose). The 1-year programme consisted of two placebo-controlled trials. The two 12-week trials were both active (ipratropium) - and placebo-controlled. All six studies included lung function measurements. In addition, the two 1-year studies included health outcome measures of dyspnoea, health-related quality of life and effect on exacerbations.In the aforementioned studies, tiotropium solution for inhalation, administered once daily, provided significant improvement in lung function (forced expiratory volume in one second and forced vital capacity) within 30 minutes following the first dose, compared to placebo (FEV1 mean improvement at 30 minutes: 0.113 litres; 95% confidence interval (CI): 0.102 to 0.125 litres, p< 0.0001). Improvement of lung function was maintained for 24 hours at steady state compared to placebo (FEV1 mean improvement: 0.122 litres; 95% CI: 0.106 to 0.138 litres, p< 0.0001).Pharmacodynamic steady state was reached within one week.Spiriva Respimat significantly improved morning and evening PEFR (peak expiratory flow rate) as measured by patient's daily recordings compared to placebo (PEFR mean improvement: mean improvement in the morning 22 L/min; 95% CI: 18 to 55 L/min, p< 0.0001; evening 26 L/min; 95% CI: 23 to 30 L/min, p<0.0001). The use of Spiriva Respimat resulted in a reduction of rescue bronchodilator use compared to placebo (mean reduction in rescue use 0.66 occasions per day, 95% CI: 0.51 to 0.81 occasions per day, p<0.0001). The bronchodilator effects of Spiriva Respimat were maintained throughout the 1-year period of administration with no evidence of tolerance.The following health outcome effects were demonstrated in the long term 1-year studies:(a) Spiriva Respimat significantly improved dyspnoea (as evaluated using the Transition Dyspnoea Index) compared to placebo (mean improvement 1.05 units; 95% CI: 0.73 to 1.38 units, p<0.0001). An improvement was maintained throughout the treatment period.(b) The improvement in mean total score of patient's evaluation of their Quality of Life (as measured using the St. George's Respiratory Questionnaire) between Spiriva Respimat versus placebo at the end of the two 1-year studies was 3.5 units (95% CI: 2.1 to 4.9, p<0.0001). A 4-unit decrease is considered clinically relevant.(c) COPD Exacerbations In three one-year, randomised, double-blind, placebo-controlled clinical trials Spiriva Respimat treatment resulted in a significantly reduced risk of a COPD exacerbation in comparison to placebo. Exacerbations of COPD were defined as a complex of at least two respiratory events/symptoms with a duration of three days or more requiring a change in treatment (prescription of antibiotics and/or systemic corticosteroids and/or a significant change of the prescribed respiratory medication). Spiriva Respimat treatment resulted in a reduced risk of a hospitalisation due to a COPD exacerbation (significant in the appropriately powered large exacerbation trial). The pooled analysis of two Phase III trials and separate analysis of an additional exacerbation trial is displayed in Table 1. All respiratory medications except anticholinergics and long-acting beta-agonists were allowed as concomitant treatment, i.e. rapidly acting beta-agonists, inhaled corticosteroids and xanthines. Long-acting beta-agonists were allowed in addition in the exacerbation trial.Table 1: Statistical Analysis of Exacerbations of COPD and Hospitalized COPD Exacerbations in Patients with Moderate to Very Severe COPD
|Study (NSpiriva, Nplacebo)
|Spiriva Respimat
|% Risk Reduction (95% CI)a
|1-year Ph III studies, pooled analysisd (670, 653)
|Days to first COPD exacerbation
|29 (16 to 40)b
|Mean exacerbation incidence rate per patient year
|22 (8 to 33)c
|Time to first hospitalised COPD exacerbation
|25 (-16 to 51)b
|Mean hospitalised exacerbation incidence rate per patient year
|0.09 c
|0.11 c
|20 (-4 to 38) c
|0.096 c
|1-year Ph IIIb exacerbation study (1939, 1953)
|Days to first COPD exacerbation
|31 (23 to 37)b
|Mean exacerbation incidence rate per patient year
|21 (13 to 28)c
|Time to first hospitalised COPD exacerbation
|27 (10 to 41)b
|Mean hospitalised exacerbation incidence rate per patient year
|19 (7 to 30)c
Clinical efficacy and safety in asthmaThe clinical Phase III programme for persistent asthma included two 1-year randomised, double-blind, placebo-controlled studies in a total of 907 asthma patients (453 receiving Spiriva Respimat) on a combination of ICS (≥800 µg budesonide/day or equivalent) with a LABA. The studies included lung function measurements and severe exacerbations as primary endpoints.PrimoTinA-asthma studiesIn the two 1-year studies in patients who were symptomatic on maintenance treatment of at least ICS (≥800 µg budesonide/day or equivalent) plus LABA, Spiriva Respimat showed clinically relevant improvements in lung function over placebo when used as add-on to background treatment. At week 24, mean improvements in peak and trough FEV1 were 0.110 litres (95% CI: 0.063 to 0.158 litres, p<0.0001) and 0.093 litres (95% CI: 0.050 to 0.137 litres, p<0.0001), respectively. The improvement of lung function compared to placebo was maintained for 24 hours. In the PrimoTinA-asthma studies, treatment of symptomatic patients (N=453) with ICS plus LABA plus tiotropium reduced the risk of severe asthma exacerbations by 21% as compared to treatment of symptomatic patients (N=454) with ICS plus LABA plus placebo. The risk reduction in the mean number of severe asthma exacerbations/patient year was 20%.This was supported by a reduction of 31% in risk for asthma worsening and 24% risk reduction in the mean number of asthma worsenings/patient year (see Table 2).Table 2: Exacerbations in Patients Symptomatic on ICS (≥800 µg budesonide/day or equivalent) plus LABA (PrimoTinA-asthma studies)
|Spiriva Respimat, added-on to at least ICSa/LABA (N=453)
|Placebo, added-on to at least ICSa/LABA (N=454)
|% Risk Reduction (95% CI)
|two 1-year Phase III studies, pooled analysis
|Days to 1st severe asthma exacerbation
|21b (0, 38)
|Mean number of severe asthma exacerbations / patient year
|20d (0, 36)
|Days to 1st worsening of asthma
|31b (18, 42)
|Mean number of asthma worsenings / patient year
|24d (9, 37)
Paediatric population
COPDThe European Medicines Agency has waived the obligation to submit the results of studies with Spiriva Respimat in all subsets of the paediatric population in COPD (see section 4.2 for information on paediatric use).AsthmaThe European Medicines Agency has deferred the obligation to submit the results of studies with Spiriva Respimat in one or more subsets of the paediatric population in the treatment of asthma (see section 4.2 for information on paediatric use).
Clinical efficacy and safety in cystic fibrosis (CF):The clinical development programme in CF included 3 multicentre studies in 959 patients aged 5 months and above. Patients below 5 years used a spacer (AeroChamber Plus®) with face mask and were included for safety assessment only. The two pivotal studies (a dose finding Phase II study and a confirmatory Phase III study) compared lung function effects (percent predicted FEV1 AUC 0-4h and trough FEV1) of Spiriva Respimat (tiotropium 5 µg: 469 patients) versus placebo (315 patients) in 12-weeks randomised, double-blind periods; the Phase III study also included a long term open label extension, up to 12 months. In these studies, all respiratory medications, except anticholinergics, were allowed as concomitant treatment, e.g. long acting beta agonists, mucolytics and antibiotics.Effects on lung function are displayed in Table 3. No significant improvement in symptoms and health status (exacerbations by Respiratory and Systemic Symptoms Questionnaire and quality of life by Cystic Fibrosis Questionnaire) have been observed. Table 3: Adjusted mean difference from placebo for absolute changes from baseline after 12 weeks
|Phase II
|Phase III
|All patients (NSpiriva = 176, Nplacebo = 168)
|All patients (NSpiriva = 293, Nplacebo = 147)
|≤11 years(NSpiriva = 95, Nplacebo = 47)
|≥12 years(NSpiriva = 198, Nplacebo = 100)
|mean(95% CI)
|mean(95% CI)
|mean(95% CI)
|mean(95% CI)
|FEV1AUC0-4h (% predicted) aabsolute changes
|3.39(1.67, 5.12)
|1.64(-0.27, 3.55)
|-0.63(-4.58, 3.32)
|2.58(0.50, 4.65)
|FEV1AUC0-4h (litres) absolute changes
|0.09(0.05, 0.14)
|0.07(0.02, 0.12)
|0.01(-0.07, 0.08)
|0.10(0.03, 0.17)
|Trough FEV1 (% predicted) aabsolute changes
|2.22(0.38, 4.06)
|1.40-0.50, 3.30
|-1.24(-5.20, - 271)
|2.56(0.49, 4.62)
|Trough FEV1 (litres) absolute changes
|0.06(0.01, 0.11)
|0.07(0.02, 0.12)
|-0.01(-0.08, 0.06)
|0.10(0.03, 0.17)
|≤11 years
|≥12 years
|Nplacebo = 96
|NSpiriva = 158
|Nplacebo = 215
|NSpiriva = 307
|Abdominal pain
|Distal intestinal obstruction syndrome
|Respiratory tract infections
|Sputum increased
a) General IntroductionTiotropium bromide is a non-chiral quaternary ammonium compound and is sparingly soluble in water. Tiotropium bromide is available as solution for inhalation administered by the Respimat inhaler. Approximately 40% of the inhaled dose is deposited in the lungs, the target organ, the remaining amount being deposited in the gastrointestinal tract. Some of the pharmacokinetic data described below were obtained with higher doses than recommended for therapy.
b) General Characteristics of the Active Substance after Administration of the Medicinal ProductAbsorption: Following inhalation of the solution by young healthy volunteers, urinary excretion data suggest that approximately 33% of the inhaled dose reach the systemic circulation. It is expected from the chemical structure of the compound (quaternary ammonium compound) and from in-vitro experiments that tiotropium bromide is poorly absorbed from the gastrointestinal tract (10-15%). Oral solutions of tiotropium bromide have an absolute bioavailability of 2-3%. Food is not expected to influence the absorption of this quaternary ammonium compound.At steady state, tiotropium bromide plasma levels in COPD patients at peak were 10.5-11.7 pg/ml when measured 10 minutes after administration of a 5 microgram dose delivered by the Respimat inhaler and decreased rapidly in a multi-compartmental manner. Steady state trough plasma concentrations were 1.49-1.68 pg/ml. A steady state tiotropium peak plasma concentration of 5.15 pg/ml was attained 5 minutes after the administration of the same dose to patients with asthma. Distribution: The drug is bound by 72% to plasma proteins and shows a volume of distribution of 32 l/kg. Local concentrations in the lung are not known, but the mode of administration suggests substantially higher concentrations in the lung. Studies in rats have shown that tiotropium bromide does not penetrate the blood-brain barrier to any relevant extent.Biotransformation: The extent of biotransformation is small. This is evident from a urinary excretion of 74% of unchanged substance after an intravenous dose to young healthy volunteers. The ester tiotropium bromide is nonenzymatically cleaved to the alcohol (N-methylscopine) and acid compound (dithienylglycolic acid) that are inactive on muscarinic receptors. In-vitro experiments with human liver microsomes and human hepatocytes suggest that some further drug (< 20% of dose after intravenous administration) is metabolised by cytochrome P450 (CYP) dependent oxidation and subsequent glutathion conjugation to a variety of Phase II-metabolites.In vitro studies in liver microsomes reveal that the enzymatic pathway can be inhibited by the CYP 2D6 (and 3A4) inhibitors, quinidine, ketoconazole and gestodene. Thus CYP 2D6 and 3A4 are involved in metabolic pathway that is responsible for the elimination of a smaller part of the dose.Tiotropium bromide even in supra-therapeutic concentrations does not inhibit CYP 1A1, 1A2, 2B6, 2C9, 2C19, 2D6, 2E1 or 3A in human liver microsomes.Elimination: The terminal elimination half-life of tiotropium bromide is between 5 and 6 days following inhalation by healthy volunteers and COPD patients. The effective half-life was 34 hours in patients with asthma. Total clearance was 880 ml/min after an intravenous dose in young healthy volunteers with an interindividual variability of 22%. Intravenously administered tiotropium bromide is mainly excreted unchanged in urine (74%). After inhalation of the solution by healthy volunteers urinary excretion is 20.1-29.4 % of the dose, the remainder being mainly non-absorbed drug in gut that is eliminated via the faeces. In patients with asthma, 11.9% (0.595 µg) of the dose is excreted unchanged in the urine over 24 hours post dose at steady state. The renal clearance of tiotropium bromide exceeds the creatinine clearance, indicating secretion into the urine. Linearity / Nonlinearity: Tiotropium bromide demonstrates linear pharmacokinetics in the therapeutic range after intravenous administration, dry powder inhalation and inhalation of the solution.
c) Characteristics in PatientsGeriatric Patients: As expected for all predominantly renally excreted drugs, advanced age was associated with a decrease of tiotropium bromide renal clearance (326 ml/min in COPD patients < 58 years to 163 ml/min in COPD patients > 70years) which may be explained by decreased renal function. Tiotropium bromide excretion in urine after inhalation decreased from 14 % (young healthy volunteers) to about 7 % (COPD patients); however plasma concentrations did not change significantly with advancing age within COPD patients if compared to inter- and intraindividual variability (43 % increase in AUC0-4h after dry powder inhalation). Exposure to tiotropium was not found to differ with age in patients with asthma.Renally Impaired Patients: In common with all other drugs that undergo predominantly renal excretion, renal impairment was associated with increased plasma drug concentrations and reduced renal drug clearance after both intravenous infusion and dry powder inhalation. Mild renal impairment (CLCR 50-80 ml/min) which is often seen in elderly patients increased tiotropium bromide plasma concentrations slightly (39% increase in AUC0-4h after intravenous infusion). In COPD patients with moderate to severe renal impairment (CLCR < 50 ml/min) the intravenous administration of tiotropium bromide resulted in doubling of the plasma concentrations (82% increase in AUC0-4h), which was confirmed by plasma concentrations after dry powder inhalation and also by inhalation of the solution via the Respimat inhaler. In asthma patients with mild renal impairment (CLCR 50-80 ml/min) inhaled tiotropium did not result in relevant increases in exposure compared to patients with normal renal function.Hepatically Impaired Patients: Liver insufficiency is not expected to have any relevant influence on tiotropium bromide pharmacokinetics. Tiotropium bromide is predominantly cleared by renal elimination (74% in young healthy volunteers) and simple non-enzymatic ester cleavage to pharmacologically inactive products.Paediatric Patients: There were no paediatric patients in the COPD programme (see 4.2). Paediatric patients were studied as part of the CF clinical programme also covering adults. Following inhalation of 5 µg tiotropium, the tiotropium plasma level in CF patients ≥5 years was 10.1 pg/ml 5 minutes post-dosing at steady-state and decreased rapidly thereafter. The fraction of the dose available in CF patients <5 years old who used the spacer and mask was approximately 3- to 4-fold lower than that observed in CF patients 5 years and older. Tiotropium exposure was related to body-weight in CF patients <5 years.
d) Pharmacokinetic / Pharmacodynamic Relationship(s)There is no direct relationship between pharmacokinetics and pharmacodynamics.
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gamabello:At appointment yesterday (I am 40 weeks today) I learned that I am 0 dilated and 75% effaced and a -1. I don't know what is "normal" or not. But I have an induction scheduled for Wednesday morning if this baby girl doesn't come first!
that's basically exactly what they told me... idk what the -1 means, but doc said it's good