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POLL: What's the longest you've stayed with one carrier?
Todd Dills | March 25, 2014
If you've ever leased to or driven for another carrier, how long was your longest consecutive tenure with one. Tell us in this poll.
Imagine running for the same fleet for 50 years…
Todd Dills | May 25, 2012
Can you? We've heard no shortage of stories of independents who've stayed active that long leased to different carriers or on their own, but never with the same company. (If you have, I'm all ears!) I ...
Feature Article: Siping Strides
John Baxter | December 01, 2009
Tire makers take tread to new levels through advanced siping, improving traction and longevity.
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The Grand Jury and Special Award winners of the 2013 SXSW Film Festival were revealed Tuesday in Austin. Destin Cretton's "Short Term 12," starring Brie Larson and John Gallagher Jr. as foster care workers dealing with their own troubled pasts, has taken the Narrative Feature prize, while Ben Nabors...Read More »
It's Nate's (Rami Malek) first day at the adolescent foster care facility Short Term 12, and his new coworker Mason (John Gallagher Jr., scruffy and soulful) is regaling the staff with a silly monologue about an unfortunate sharting incident he suffered in the line of duty. It's a funny tale, but it...Read More »


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So Yeon Ryu's Louise Suggs Rolex Rookie of the Year Award Speech
Topics: Ryu, So Yeon
Watch and get to know Natalie Gulbis off the course. This video is part of a series, produced by the U.S. Women's Open, that will allow you to get to know the LPGA players "Beyond the Ropes" before you see them compete at Blackwolf Run in Kohler, Wisconsin for the 2012 U.S. Women's Open. For more information visit www.2012uswomensopen.com.


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Reviewed Sausage Brioche Dressing
Nov 22, 2010 in Food Network Community Toolbox on Food Network
"I would like to make this but I'm unable to find brioche. I'm worried that the brioche was going to aid in calming the sage flavor and I don't know what kind of bread to substitute. If I use white bread or regular french bread, should I add egg or butter to the mixture?"


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List all websites via ISPConfig remote API
I'm assuming that when I access sites web_domain_list.php is executed?
How can I use that from ISPConfig remote API?
Anyway I'd like to list all website domain using ISPConfig remote API...
Please see remote API documnetation for a list of api functions, you find that in the remote_client/ API-docs/ folder of the ISPConfig tar.gz. All functions are described there incl. script examples.
I've found the example, but that only allows retrieving one website at a time by providing the id
Found a simple solution: =)
PHP Code:
Kinda late... but...
Till showed me this one:
$domain_record = $client->sites_web_domain_get($session_id, array('system_group' => 'client'.$client_id));
I just so happen to store the client_id in the interfacing system so I pull client_id from my local database, concat with 'client' and search the web_domains using 'system_group' which equals clientX.
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*Cathy McDowell*Doing Great
I plan to keep depositing too. Maybe by the time I retire, I can actually retire. 6 years ago
10 years after introducing 43 Things to the world, we have decided we have met our last goal: completing the incredible experience that has been 43 Things. Please join us in giving one last cheer to all the folks who have shared their goals with the world, as well as all the people who have worked at The Robot Co-op to build this incredible website. We won a Webby Award, published a book, and brought happiness to a lot of people.
Starting today, 43 Things users can export their goals and entries from the site. Starting August 15, we will make the site "read only". 43 Things users will still be able to view the site and export their content, but we won't be taking any new content from users. We hope to leave the site up for folks to see and download their content until the end of the year. Ending on New Year's Eve takes us full circle.
It has been a long ride (one of our original goals was to "build a company that lasts at least 2 years" - we beat that one!) While we wish the site could live on, it has suffered from a number of challenges - changes in how people use the site, the advertising industry, and how search engines view the site. We wish the outcome was different – but we've always been realistic about when our goals are met and when they aren't.
As of today, you will be able to download your goals and entries. See more about that on the FAQ page. Thanks for 10 great years of goal-setting and achieving.
- The Robots.
I plan to keep depositing too. Maybe by the time I retire, I can actually retire. 6 years ago
I have the opposite problem. Right now, while I can still live at home, I've been saving up for college and a car to get me there. But, even with these reasons for motivation, I hate to spend money! Rarely do I go out somewhere and really see something I can't walk away without. My Grandpa says I have a sensitive pocketbook. Good luck with this, it's worth doing! 7 years ago
I have been doing this and then I try to forget it's there.
I need to save money. I spend enough!! 7 years ago
I just logged onto 43things and saw this goal about depositing money into savings so I went and logged into my savings and deposited. I probably wouldn't have if I hadn't seen it in front of me. 7 years ago
This time I need to leave it alone.
Just as soon as it increases to a rather large amount, I find something to spend that money on so I always withdraw it.
I'll try harder this time to leave it alone. 7 years ago
...since completely depleting my entire savings over the past 2 1/2 years (
$22,000) and going into some serious debt, ( $15,000),,,,and with finally getting some paying jobs in the past 3 months,,,,I set up an auto-transfer from my checking into my Roth IRA at the beginning of the month…
It's not much, just $17, but its a start, and an amount i wont miss. Any bonuses or Xmas $$ will go into that account as well. As the olde cliche goes: pay yourself first. Even with all my debt, i know i also have to start first with building up the Nest Egg. the Rainy Day / slush fund…..
A small start, but a start….!8 years ago
That will rise substantially (like, by a factor of 8) when I finish clearing my debt.
About $194.79 at current exchange rates, in case you were wondering.8 years ago
For my kids. $50 a week. 8 years ago


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Find commute times to your work, school, gym and more.
Hunter'S Chase
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Prices, specials, features and availability subject to change.
Property Features
- Leisure
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- 2 Swimming Pools
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- Close to Shopping, Dining
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- Courteous and Energetic Staff
- Credit Cards Accepted
- Minutes from Lake Travis
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Units may feature
- Amenities
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Property Details
It's Where You Belong
Conveniently nestled in the heart of Northwest Hills, Hunter's Chase is everything a perfect home should be! From our 2 sparkling pools and volleyball courts, to our carefully manicured lawns perfect for barbecues or picnics, playscape and a 24-hour fitness center, Hunter's Chase is where you???ll find everything you???re looking for. Our updated homes feature walk-in closets, in-unit washer and dryer, wood-burning fireplaces, balconies, as well as great laminate wood floors for a clean and contemporary look. Adjacent to major highways and a short drive to downtown Austin, our location makes commuting a breeze. Outdoor enthusiasts will welcome the proximity to Lake Travis while young families will appreciate the nearby Round Rock schools.Did we mention all the shopping amenities you???ll ever need are just a few minutes away? Add the flawless and dedicated service from our on-site management and you???ll know why Hunter's Chase truly is where you belong! Please call for an appointment today.
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If you want an unbelievable selection of the high quality Mercedes C230 Control Arm parts at discounted prices, AutohausAZ is your Mercedes C230 Control Arm parts source. As soon as your order ships, we will send you all the tracking information through your email so you can track your package. Every Mercedes C230 Control Arm parts order over $75 ships free via UPS Ground. Our prices are quite a bit lower than retail and dealer pricing. It is always fun to save tons of money on Mercedes C230 Control Arm parts. When you order Mercedes C230 Control Arm parts from us, we will ship it from the closest warehouse we have it in stock. We always display our lowest prices.
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The 20 enjoyable, interactive classroom activities that are included will help your students understand the text in amusing ways. Fun Classroom Activities include group projects, games, critical thinking activities, brainstorming sessions, writing poems, drawing or sketching, and more that will allow your students to interact with each other, be creative, and ultimately grasp key concepts from the text by "doing" rather than simply studying.
1. Charades
Split the class into two teams. A player from each team will act out an event or a person from the book without making any sounds. The player that is acting must write down what they are acting out and fold the paper where no one can see it. Both teams get to guess, and the first team to guess correctly wins a point. Have the teams take turns sending someone up.
2. Painting
Paint a picture of the USS Mobile Bay, based on O'Rourke's...
This section contains 867 words
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Facebook - page 5
I just wondered... Has anyone out there been in trouble due to anything on facebook? On my old unit we took care of VAD (ventricular assist device) pts, and they are in and out all the time so you really get to know them in and... Read More
- 0Dec 21, '10 by Belle EpoqueBut it's not just employers, it's anybody. Anybody with accessible internet and good computer knowledge, which is probably about 80% of the population. People think just because they have privacy settings, they have control over who sees what. Think about it for a second. You are putting information out there on the internet - the most widely available venue for information distribution and exchange on the entire planet. And you are putting it out there willingly. If gov't agencies can get scammed or banks can be hacked into or IDs can be stolen, what the heck are you thinking if you believe anything is private or protected?
Seriously people need to get their head out of the sand. Wake up and smell the information technology.


text: Strict Standards: Redefining already defined constructor for class XML_Parser in /home/sites/www.americanpoems.com/web/store/aom/includes/os.php on line 1188 Strict Standards: Declaration of XML_Parser::raiseError() should be compatible with PEAR::raiseError($message = NULL, $code = NULL, $mode = NULL, $options = NULL, $userinfo = NULL, $error_class = NULL, $skipmsg = false) in /home/sites/www.americanpoems.com/web/store/aom/includes/os.php on line 1604 Strict Standards: Declaration of XML_Unserializer::startHandler() should be compatible with XML_Parser::startHandler($xp, $elem, &$attribs) in /home/sites/www.americanpoems.com/web/store/aom/includes/os.php on line 3503 Strict Standards: Declaration of Cache_Lite_File::get() should be compatible with Cache_Lite::get($id, $group = 'default', $doNotTestCacheValidity = false) in /home/sites/www.americanpoems.com/web/store/aom/includes/cache.php on line 1020 American Poems: Books: Worth the Risk (Worth It) Home Apparel Appliances Books DVD Electronics Home & Garden Kindle eBooks Magazines Music Outdoor Living Software Tools & Hardware PC & Video Games Search All Products Apparel Appliances Arts & Crafts Automotive Baby Beauty Books Computers DVD Electronics Gourmet Food Grocery Health Home & Garden Industrial & Science Jewelry Kindle eBooks Kitchen Magazines Miscellaneous Mobile Apps MP3 Downloads Music Musical Instruments Office Products Outdoor Living Pet Supplies Photo & Camera Shoes Software Sporting Goods Tools & Hardware Toys VHS Video On Demand PC & Video Games Watches Wireless Wireless Accessories Advanced Search Sitemap View Cart Checkout Location: Home » Books » Worth the Risk (Worth It) Worth the Risk (Worth It) enlarge Other Views: Author:Karen Erickson Brand:Brand: Samhain Publishing Category:Book List Price: $14.00 Buy New: $7.66 as of 12/27/2014 02:44 EST details You Save: $6.34 (45%) In Stock New (20) Used (14) from $0.49 Seller:Omega Books and More Inc. Sales Rank:2,760,071 Languages:English (Unknown), English (Original Language), English (Published) Media:Paperback Number Of Items:1 Pages:232 Shipping Weight (lbs):0.7 Dimensions (in):5.5 x 0.5 x 8.5 Publication Date:June 4, 2013 ISBN:1619212390 EAN:9781619212398 ASIN:1619212390 Availability:Usually ships in 1-2 business days Features: Used Book in Good Condition Also Available In: Kindle Edition - Worth the Risk (Worth It Book 2) Similar Items: Worth the Scandal Worth the Challenge (Worth It) Worth Everything (Worth It) Come Away With Me: Book One in the With Me In Seattle Series (Volume 1) Play With Me (With Me In Seattle) Editorial Reviews: SynopsisHow to make a strong man fall hard? Refuse him.Worth It, Book 2Hunter Worth lives life to the absolute fullest. As vice president and head of brand marketing for Worth Luxury Goods, he's brought his family's business firmly into the twenty-first century. Ruthless yet charming, he's now set his sights on the sexiest member of the marketing team. First thing on his agenda? Seduction.Gracie Hayes needs her job at Worth—and she's not about to let the gorgeous owner and her direct boss distract her—again. Orphaned, and with a rough childhood behind her, she's worked too hard to compromise everything for a fling, no matter how tempting. Independent, strong and resourceful, she will fight off Hunter. She has to.Flirting, stolen kisses, a few nights of scorching hot sex…Hunter has all that in mind and more with the delicious Gracie. He never figures he'd fall in love or that she'd deny him. How will Hunter convince Gracie he's the one for her?Warning: Contains yet another one of those sexy, bossy Worth brothers, though this one is too full of charm for his own good. Watch as he falls hard—and watch as she tries her hardest to dodge his every attempt at seduction. CERTAIN CONTENT THAT APPEARS ON THIS SITE COMES FROM AMAZON SERVICES LLC. THIS CONTENT IS PROVIDED 'AS IS' AND IS SUBJECT TO CHANGE OR REMOVAL AT ANY TIME. Brought to you by American Poems Categories •Apparel •Appliances •Arts & Crafts •Automotive •Baby •Beauty •Books •Computers •DVD •Electronics •Gourmet Food •Grocery •Health •Home & Garden •Industrial & Science •Jewelry •Kindle eBooks •Kitchen •Magazines •Miscellaneous •Mobile Apps •MP3 Downloads •Music •Musical Instruments •Office Products •Outdoor Living •Pet Supplies •Photo & Camera •Shoes •Software •Sporting Goods •Tools & Hardware •Toys •VHS •Video On Demand •PC & Video Games •Watches •Wireless •Wireless Accessories Subcategories United States •African American •Asian American •Classics •Anthologies •Drama •Hispanic •Humor •Native American •Poetry Related Categories •United States Literature & Fiction Subjects Books •Literary Literature & Fiction Subjects Books •Contemporary Romance Subjects Books


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Pemandangan & Atraksi
- Alam & Margasatwa
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- Perkebunan Anggur & Tempat Pembuatan Bir
- Proyek Kerajaan, Penelitian dan Pengembangan
- Rekreasi & Hiburan
- Seni, Budaya & Warisan
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Thai markets may simply be the places that local Thais go to shop, but the traditional Thai marketplace is so unlike those in the west that visitors are drawn to these colorful and vibrant venues. Whether a wet market selling fresh local produce, a flower market filled with floral bouquets, or a uniquely Thai floating market, these attractions make an outstanding addition to any Thailand trip.
Tha Sadet is the port for local people to cross Mekong River to Tha Duea in Laos. There's a market for Indo-Chinese and European products, as well as the local goods....
In the past, daily commerce in Thailand was conducted mostly along rivers and canals (or khlongs in Thai). Bangkok's water network was busy and served as the principal means of communication causing Bangkok to be c...
This Chinese community and old-fashioned market, complete with wooden shop houses, has retained its authentic Thai style, dating from a century ago. Visitors can explore the traditional shops, including a photography sto...
This afternoon-only floating market is located near a temple, Wat Amphawan Chetiyaram, where parking is provided. On Fridays and on weekends, the Amphawa Canal brims with boats loaded with drinks like O-Liang (Thai iced ...
The charming of this market is that it sits along the canal in the Thai and Mon community. There are many interesting local product and delicious food including the homegrown fruits, boat noodles and hand-wo...


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OmniGroup overhauls OmniOutliner, OmniFocus and OmniPlan for iOS 7
The OmniGroup has overhauled its iOS apps for the iOS 7 release, including creating a completely revamped OmniFocus on the iPhone that is just a joy to use. OmniOutliner 2 adds a number of keyboard shortcuts and a redesigned Doc Picker, as well as new templates. The Doc Picker makes its way over to OmniPlan 2 as well and adds an in-app purchase for importing Microsoft Project files.
For those who have had their OmniGroup apps from day one of their original release -- for me, that would be going all the way back to 2008 -- you will have to make a new purchase in order to upgrade. OmniFocus 2 for the iPhone is US$19.99; OmniOutliner 2 for iPad is $29.99; and OmniPlan for iPad is $59.99. The older versions of these programs have been removed from the App Store.
I've been testing all three of these apps for the past week and will be presenting reviews on each within the next week.
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Software Updatesmore updates
- Dropbox adds file/folder renaming and Office document editing to iOS app
- Vizzywig 8xHD price tag now a very affordable $49.99
- Automatic targets teen drivers with License+ service
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- YouTube for iOS gets updated with full support for iPhone 6 and 6 Plus
- iOS 8.0.1 update now available (Updated -- Don't update!)


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Zombie Apocalypse: Woman trades sex with 13-year-old for groceriesSubmitted by carpavel on Fri, 05/03/2013 - 08:37
Call it Mad Max or call it the Zombie Apocalypse but if you can't see it coming then more then likely you are just an actor in the film.
HARTFORD, Conn. (WTNH)-- A very disturbing case of sexual abuse in Hartford. Police say a woman used sex with a teenage girl as payment for groceries.
The bodega is closed, yet not for the reason most would expect. Police say the owner of the small store on Hartford's Zion Street, 55-year-old Ruffino Fernandez, sexually assaulted a 13-year-old girl.
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Transactional sex due to climate change?
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oh it's so wrong but..
Well played sir. Lol.
Homeland security statement: patriotism is now considered terrorism.
I love www.isidewith.com shared it with everyone I know. If anything they realize its not just a red and blue idiot running for reelection.
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|I just discovered this forum. I am chuckling over the unabashed lists of symptoms that are proudly included in people's posts - and realizing that it is time to stop brooding over my own increasingly long list. I enjoy the freedom folks feel to share their aches with non-judgmental listeners. I also admire the list members' bravery in dealing with multiple frustrations.
My question - the forum seems to focus on ways to persist in gardening even though it is hard on our bodies. Is there any gardening activity that actually is helpful exercise? Is there something that you do in the garden that leaves you feeling better in your joints than when you started? I can't think of one. Thanks!
Follow-Up Postings:
- Posted by Debbie_SW_OK z7 OK (My Page) on Wed, Mar 2, 05 at 1:12
|Weeding usually makes my joints feel better, as long as I don't overdo it.
There is no lifting involved & I do it sitting down so there is no strain on my back or knees. The stretching motion helps keep my joints limbered up. The trick is to listen to my body when it tells me the reach is too much of a stretch and then I move closer to the target.
- Posted by Plant_Manager z7SC (My Page) on Thu, Mar 3, 05 at 2:15
|Greetings! I have found that most gardening activities are good for your joints, but here is my however list.
However 1. It is a good thing to do some stretching prior to any gardening activity. A sudden movement when the weather is cold or your muscles are not loosened up can keep you out of the garden for a week easy.
However 2. Know your limits. There may be some things that you should just not do anymore. I have multiple ruptured disks and auto immune disorders affecting the joints. So I must limit the amount of weight that I lift. If it is over my limit I find a friend to help. It is not worth another, or first time ruptured disk.
However 3. Do everything that you can in moderation. You may see that a large bed needs to be weeded, but it may not be good for you to maintain that possition or activity for that long a period of time. Do some weeding then switch to another project.
However 4. Take regular breaks. Rome was not built in a day and neither will your garden. Work for 15 to 30 minutes and then take a break and watch the birds or take notes on what you have done and what you would like to do in the future.
However 5. Reduce your territory. You will need to scale back on some of what you have done in the past. Try to decide what the most important garden projects that you have are and make them your priority. It doesn't mean that you have to let everything go. Let some of your garden areas become self sustaining by the use of shrubs and low maintenace perenials and ground covers that will be attractive and yet require less out of you.
However 6. Discover the joy of container gardening. Start small. If you are like most of us and you see your abilities decreasing; begin to make a move to container gardening as that may one day be the only real gardening activity that you will be able to do.
However 7. Find tools that make gardening easier on you and also find ways to move things without the use of your brute force. Pay the neighbor kid to put out your mulch. Better yet train your grandchildren to help you with those things and pass on to another generation the joy and practicallity of gardening.
Does anyone else have any other gardening howevers? Have a great week and a great garden! Jon. Plant_Manager. South Carolina.
- Posted by lynne_melb z9b Melb FL (My Page) on Thu, Mar 3, 05 at 11:13
|Walking through garden center to buy more plants (ha-ha).
What I call puttering:
- planting seed (in pots, or inside), where it is higher
A lot of garden activities may make me temporarily sore, but with moderation, I will feel better overall getting more exercise. Going for a walk or a swim may be "better" for me, and I do those, but I will spend far more time gardening because it's fun, and I feel better getting more exercise.
|Hoeing and raking and sweeping, with tools that are the right height for me. Gentle and rhymical. Unhurried.
And, oddly enough, shifting a heap of grit with a long-handled shovel - for the same reasons.
However (!) if you haven't already got the knack of using your whole body for this task - don't try it. Many people haven't a clue how to use a shovel with comfort.
Actively work out ways to do tasks with least impact on at-risk body parts. Watch yourself working so you become aware of where you're over-working, tensing up - and find ways around it.
|Okay, so this post is probably dead useless, but...the more my joints hurt, the more I feel driven to do heavy yard/garden work. I dig, I haul, I carry, I drag, I climb, I crawl, and about the only concession to pain I make is to wear knee pads. And yes, I moan, groan, say "OUCH" and carry on the whole time, muttering about how I must be crazy, stupid or both. Then, after I've made myself even sorer, I go for a walk to loosen up all the kinks, and that DOES help. Seems not only the kinks from the gardening work out as I walk, but I get rid of a little of the joint pain as well (at least for a day or two).
My conclusion: when it comes to gardening, it's ALL good, even if it hurts like hell!
|Vetivert8 wrote: "...Many people haven't a clue how to use a shovel with comfort..." So - how do you do it, Vetivert?
Thanks, Merry
- Posted by UpstateNYgardener z5NY (My Page) on Tue, Jul 5, 05 at 14:35
|Whenever I work in the yard and whatever I do, I do a few stretching exercises. There are some great tai chi moves that are perfect (no stake in the $ but David Carradine has a great tai chi video I use). Is great for joints. And, yogic breathing taught by Andrew Weil is excellent for keeping stamina and energy while I garden.
- Posted by compost_hugger_nancy z4/5 NES MI (My Page) on Tue, Jan 17, 06 at 14:53
|As long as one doesn't over do any one position too long and rotates jobs the reaching across beds stretch the joints and keeps range of motion from further limitation.
On my buttom I fill a small bucket with weeds by reaching in my 4 x 4 beds two feet (stretching my arms and lower back.) Follow that by pushing up off bucket to stand, walk down to compost pile, dump bucket and either take a bathroom break or return to weeding.
Picking berries by planting feet widely and rocking back and forth into briars and back out to bucket. That helps the hips and ankles retain movement. On days I can sit between rows I weed/pick from row on left then right and scoot myself backward with my
|As the saying goes, "Use it or lose it." My gardening activity does cause a lot of sore muscles and sore joints, so I take aspirin, Aleve, and some of those "horse pills" that contain Glucosamine, Chondroitin, and MSM. Mine also say on the bottle, "with Hyaluronic Acid". They're hard to swallow, but they do seem to help.
Our garden and the adjoining woods keep me active all year long. Today I have been dragging limbs to a pile near my shredder-chipper. I have been grinding up brush piles to make compost piles. I have four compost piles so far and plan to make another three before spring. The muscles and joints will be sore, but that's sort of the price I pay for remaining active.
And I enjoy the freedom of movement, even with a little pain. I remember my Mother used to say, "A little pain never hurt anyone." I'm not quite sure what she meant by that.
|well infonose it looks like a lot of gardeners are anxious to help. I have found that any gardener you ask will and I will agree with what they have said and I to wish you a lot of good gardening with less pain.
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Advanced Air Defence is an integrated set of Thales, ThalesraytheonSystems
and third party system solutions that ensures timely decision making and
effective responses for the protection of military forces, key assets,
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Thales Advanced Air Defence leverages all of the technologies, innovations,
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the sector. More importantly, it is a step-change that has been shaped
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» Proliferation of new airborne threats such as missiles and UAVs
and the increasing complexity of the airspace
» Protecting Air Defence assets against evolving cyber threats
» Integration and interoperability of Air Defence Systems and operation
in real time within force structures
» Helping customers apply the right solutions within demanding schedules
and budgets.
The key components of Thales's Advanced Air Defence capability
SHIELD – Air and Missile defence Solutions
SKYVIEW – Command and control Systems
CONTROL – Weapon co-ordination
GROUND – Air Surveillance radars
RAPID – Mobile integrated Weapon Systems
STAR – Missiles
At IndoDefence 2012, Thales presents the following systems on its booth
Ground Master (GM) 400:
The Ground
Master (GM) 400 is a 3-D long-range air defence radar able
to detect threats from both high and low altitudes; from 5 to 470 km.
Its specific design (S Band, 6s rotation, Full Digital, Stacked Beam,
Adaptive Doppler modes) brings a unique capability to track highly manoeuvrable
low flying targets with a small Radar Cross Section whilst providing an
excellent global air picture.
The GM
400 weighs 10 tons, fits inside a single 20ft ISO container
and can be rapidly deployed (single truck, single C130). The GM 400 requires
simplified maintenance and has a reduced life cycle cost. Manufactured
by Thales for ThalesRaytheonSystems (TRS), the GM 400 was launched in
2008. Over the past three years, TRS has bolstered its leading position
in the air defence radar field, winning a number of contracts encompassing
32 radars for 9 countries. These include Slovenia, Malaysia, France, Finland,
Estonia, Germany, Canada and other undisclosed customers.
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Orphan is a new and already controversial horror film scheduled to be released on July 24th by Warner Brothers. One of its producers recently interviewed me on camera here in Los Angeles for the film's forthcoming DVD and bonus documentary (Mama's Little Devils: Bad Seeds, Evil Kids and Orphan) regarding one of the film's central themes: the enigmatic nature of human evil.
First, let me make something very clear: I haven't seen the movie. So this isn't any sort of review, critique or endorsement. Nor was my interview. Rather, we discussed in broad terms the early psychological development and evolution of evil or destructive, cruel, violent behavior. Orphan is in the genre of previous cinematic tales like The Bad Seed, The Exorcist, The Omen, Village of the Damned, Children of the Corn, Lord of the Flies, The Good Son, Firestarter, The Brood, The Ring, The Innocents and other fictional dramatizations of seemingly innocent children gone haywire, wreaking havoc, mayhem and sometimes even murder in their wake. The common thread in such stories is not so much about being an orphan or adoptee or not, but rather whether children in general are capable of evil desires and deeds. And, if they engage in evil deeds, what possesses them to do so? Are they born evil, or do they become evil because of their experiences? Is it nature or nurture? Some combination of both? Or are supernatural, metaphysical, demonic or satanic forces to blame, as some movies suggest. How can evil be explained?


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I hate traffic
April 9, 2009 Around the Globe, cool pictures 3 Comments
How many of you thought you had a bad commute into work this morning? Just remember that it could always be worse and you could be on of these poor bastards sitting in a never ending road of gridlock. Good thing I just sleep on he train every morning.
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Disclosures: Coburn H Allen, MD Nothing to disclose. Gary R Fleisher, MD Nothing to disclose. Sheldon L Kaplan, MD Grant/Research/Clinical Trial Support: Pfizer [Pneumococcal surveillance studies (PCV13)]; Cubist [S. aureus skin and soft tissue infections (daptomycin pediatric studies)]; Optimer [fidaxomicin pediatric studies]; Cerexa [ceftaroline pediatric studies]. Consultant/Advisory Boards: Pfizer [Pneumococcal surveillance studies (PCV13)]. James F Wiley, II, MD, MPH 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 — Fever is a common symptom among children seeking medical care. Most children undergo evaluation for a febrile illness before their third birthday, and nearly one-third of pediatric outpatient visits are for fever [1-3].
When the history and physical examination cannot identify a specific source of fever in an acutely ill, nontoxic-appearing child less than three years of age, the illness is often called fever without a source (FWS). Alternative terms are fever without localizing signs (FWLS) or fever without a focus.
This topic will review the etiology, evaluation, and management of the child 3 to 36 months of age with fever of less than seven days duration. Fever in newborns, infants younger than three months, and fever of unknown origin (≥7 days) are reviewed separately. (See "Evaluation and management of fever in the neonate and young infant (younger than three months of age)" and "Fever of unknown origin in children: Evaluation" and "Etiologies of fever of unknown origin in children".)
Fever of concern — In children 3 to 36 months of age, the diagnosis of fever is based upon core temperature, which is measured most accurately rectally. The history of an elevated temperature recorded at home should be considered equivalent to that taken in a medical facility. Fever 39ºC (102.2ºF) or higher is the threshold above which evaluation for a source of occult infection, including urinary tract infection (UTI), may be warranted [4]. (See 'Occult sources of infection' below.)
The majority of children with fever have either a self-limited viral infection or a recognizable source of bacterial infection. However, research in the 1970s identified a population of well-appearing febrile young children who had occult bacteremia [5,6]. Subsequent studies demonstrated that some of these children went on to develop serious focal bacterial infections, such as pneumonia and meningitis [7,8]. Although laboratory testing identified a group of children at an increased risk for occult bacteremia, many who were not bacteremic received presumptive treatment with broad spectrum antibiotics while awaiting definitive blood culture results.
The introduction of vaccines to prevent Haemophilus influenzae type b (Hib) and pneumococcal disease has dramatically lowered the incidence of occult bacteremia and, as a result, changed the issues facing the clinician who is evaluating a young child with fever. (See 'Impact of vaccines' below.)
Population of interest — This topic will focus on the evaluation and management of well-appearing, immunocompetent children 3 to 36 months of age with fever ≥39ºC (102.2ºF) of less than seven days duration and no focus of infection identified by a complete physical examination. The evaluation of the febrile infant younger than three months is discussed separately. (See "Evaluation and management of fever in the neonate and young infant (younger than three months of age)".)
Immunization status — The approach to the child who has fever without a source is greatly determined by immunization status.
Complete immunization — In the discussion that follows, a completely immunized child has received the primary booster series of three immunizations with conjugate vaccines Streptococcus pneumoniae (PCV7 or PCV13), at least two doses of Haemophilus influenzae, type b (Hib), and remains on schedule. However, some experts consider two doses of PCV7 or PCV13 sufficient to prevent invasive Streptococcus pneumoniae infection. Patients who have not received the booster 12 to 15 months after the third Hib and either PCV7 or PCV13 are also considered to be at much lower risk of bacteremia. (See "Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in children", section on 'Alternative or abbreviated schedule'.)
Incomplete immunization — In the discussion that follows, an incompletely immunized child has not received the primary booster series of three vaccinations with both Hib and either PCV7 or PCV13. Based on these criteria, any child under six months of age is incompletely immunized.
CAUSES OF FEVER — Fever can be caused by infectious and noninfectious processes. The vast majority of young children with fever have an infectious etiology. Noninfectious etiologies include drug fever, immunization reactions, central nervous system dysfunction, malignancy (eg, leukemia), and chronic inflammatory conditions (ie, inflammatory bowel disease and juvenile idiopathic arthritis).
Although caretakers may sometimes attribute fever to teething, fever >38.5ºC is unlikely to be caused by teething [9]. (See "Anatomy and development of the teeth", section on 'Primary teeth eruption'.)
The source of fever may be a recognizable bacterial or viral illness. In a study of a large cohort of children 3 to 36 months of age presenting to a primary care provider with a febrile illness, a readily identifiable presumed bacterial illness was diagnosed at the initial encounter in 56 percent of children, almost 90 percent of whom had otitis media [1]. A specific viral infection (eg, croup, bronchiolitis, varicella, roseola) was identified in an additional 4 percent of children [1]. Similarly, 6 percent of 21,216 children 3 to 36 months of age with fever ≥39ºC seen in the emergency department of an urban tertiary care children's hospital had a recognizable viral syndrome, 47 percent had fever without a source (FWS), and 47 percent had a specific bacterial infection requiring antibiotics or chronic illness (eg, immunocompromised state, central line) that affected the fever evaluation [10].
Serious bacterial infectious syndromes that occur in children 3 to 36 months of age include meningitis, pneumonia, and cellulitis. In one series (prior to the introduction of Hib and pneumococcal conjugate vaccines) of 996 febrile children less than 36 months of age, <1 percent had meningitis, 10 percent had focal soft tissue infections, and 30 percent had pneumonia [11]. These diagnoses are discussed in detail elsewhere. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis" and "Cellulitis and erysipelas" and "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Clinical presentation'.)
OCCULT SOURCES OF INFECTION — The goal of the evaluation of a young child with fever is to identify sources of infection that require further evaluation and definitive treatment. Such infections are usually bacterial, although the majority of children who are well-appearing and have no identifiable source of infection have a nonspecific self-limited viral illness [1,12]. The remainder of this discussion will focus on occult bacterial infections.
Pneumonia — Most children with fever and pneumonia have some abnormality on physical examination: usually tachypnea, abnormal auscultation, low pulse oximetry, retractions, or nasal flaring, suggesting respiratory tract disease [13-16]. However, a reliable physical examination in a young child can be a challenge. In an observational study, radiographic pneumonia was found in 20 to 30 percent of highly febrile young children (<5 years) without clinical evidence of pneumonia, but with a white blood cell count (WBC) ≥20,000/mm3 [17]. Similarly, another observational study demonstrated that 41 percent of children between 3 and 36 months of age with a WBC >25,000/mm3 had lobar or segmental pneumonia on chest radiograph [18]. This association between leukocytosis and pneumonia remains strong, even in the post-conjugate pneumococcal vaccine era [19]. (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Clinical presentation'.)
Urinary tract infection — The urinary tract is the most common site of bacterial infection among febrile infants and young children. This finding was demonstrated in two large prospective studies [20,21]. The prevalence of urinary tract infection (UTI) in these reports was significantly influenced by demographic factors, such as sex, age, race, and circumcision status (table 1). (See "Urinary tract infections in children: Epidemiology and risk factors", section on 'Host factors'.)
●The prevalence of UTI is highest among girls and warrants urinalysis and urine culture in all females age 3 to 24 months with fever ≥39ºC (102.2ºF) and no source (table 1).
●Among boys, UTI is increased in uncircumcised compared with circumcised male infants with fever, with the greatest incidence in infants younger than three months of age (table 1). The low incidence of UTI among circumcised boys supports the practice of not routinely obtaining a catheterized urine specimen for culture in febrile, circumcised boys over six months of age.
●Among highly febrile boys (ie, temperature ≥39ºC or 102.2ºF) who are 3 to 24 months with no source of infection, the probability of UTI is 10 to 25 percent in uncircumcised and 2 to 4 percent in circumcised [21]. The highest prevalence is found in younger boys. Furthermore, bladder catheterization is a painful, invasive procedure that many parents might prefer to avoid if their child's probability of disease is less than 5 percent. Thus, our practice is to evaluate for UTI in uncircumcised males ≤12 months and circumcised males ≤6 months. Some investigators suggest that high fever (ie, ≥39ºC or 102.2ºF) without a source is sufficient justification for urine studies on the first visit in all highly febrile boys between the age of 3 and 24 months [22]. (See 'Initial approach' below and "Urinary tract infections in children: Epidemiology and risk factors".)
Bacteremia — Bacteremia that occurs in a seriously ill patient with a focal infection, such as meningitis, septic arthritis, or cellulitis, is usually readily identified. The risk of sepsis in a child who is ill-appearing, febrile, and without an obvious source of infection is also apparent. This discussion will focus on the young febrile child who looks well and may have unsuspected, or occult, bacteremia.
Before routine immunization with Hib and either PCV7 or PCV13, the prevalence of occult bacteremia was 5 percent in well-appearing febrile children [5,6]. The predominant pathogens were S. pneumoniae (80 percent) and Hib (20 percent). Neisseria meningitidis represented a small number of cases.
Predictors — Factors associated with an increased the risk of occult bacteremia in unimmunized children to over 10 percent included [23-25]:
●Age 3 to 36 months
●Fever ≥39ºC
●WBC ≥15,000/microL
Neither response to antipyretics nor clinical appearance predicted bacteremia [26-28].
Some children with bacteremia went on to have serious bacterial infections (SBI), including meningitis [7,29]. When children at risk for bacteremia were treated empirically with antibiotics until the results of blood cultures were known, they were less likely to develop these complications [23,24,30].
Impact of vaccines — The initiation of routine immunization of infants with the conjugate vaccines for Hib and S. pneumoniae has dramatically altered the prevalence of invasive disease due to these organisms. The incidence of occult bacteremia in well-appearing febrile children has fallen from 5 to below 1 percent, while the rate of isolation of a contaminant from blood cultures has remained constant at 1.8 to 3.0 percent [15,31-38]. (See "Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in children", section on 'Invasive disease' and "Prevention of Haemophilus influenzae infection", section on 'Efficacy/effectiveness'.)
Since the routine immunization of children with PCV7 or PCV13 vaccine, pathogens other than S. pneumoniae are the cause of the majority of cases of unsuspected bacteremia [33]. E. coli and Staphylococcus aureus are frequently isolated organisms. Most reports of occult bacteremia also include cases caused by N. meningitidis, Group A streptococcus, and Salmonella species [33,39]. Laboratory parameters (ie, WBC >15,000/microL) may be less reliable predictors of bacteremia with these pathogens. (See 'WBC and ANC counts' below.)
In addition, the impact of PCV7 or PCV13 on variables, such as the role of nonvaccine serotypes in invasive pneumococcal disease and the duration and durability of protection after vaccination, continues to evolve. (See "Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in children", section on 'Invasive disease' and "Impact of universal infant immunization with pneumococcal (Streptococcus pneumoniae) conjugate vaccines in the United States", section on 'Invasive disease caused by nonvaccine serotypes'.)
Given the decreased prevalence of occult bacteremia in the post-conjugate vaccine era, a less aggressive approach to the management of completely immunized, well-appearing, febrile (≥39ºC) children 3 to 36 months of age who do not have a focal source of infection appears reasonable [35,40,41]. (See 'Initial approach' below.)
A cost-effectiveness decision analysis of evaluation and management strategies for fever without a source (FWS) in the post-conjugate vaccine era considered negative aspects of diagnostic testing and treatment and used cases of meningitis and lives saved as outcome measures [42]. The management strategies evaluated were no work-up, clinical judgment, blood culture, blood culture plus antibiotics, WBC plus blood culture and antibiotics, and WBC plus selective blood culture and antibiotics. The following observations were noted:
●Assuming a rate of pneumococcal bacteremia of >1.5 percent, WBC plus selective blood culture and antibiotics was the most cost-effective approach.
●With a rate of pneumococcal bacteremia <0.5 percent, strategies that utilized empiric testing and treatment were no longer cost-effective.
●At low rates of bacteremia, clinical judgment became more useful in selecting a high-risk population that might benefit from selective testing and treatment.
EVALUATION — The goal of the evaluation of the young, well-appearing, febrile child without an apparent source of infection is to identify a subtle bacterial infection and/or the risk of a more serious occult bacterial infection, both of which require further investigation and antibiotic therapy.
History — Historical features of a febrile illness that suggest an occult source of infection may be subtle and not immediately obvious to the caretakers. Therefore, a thorough history must include information about the child's functional status, including oral intake, presence of irritability or lethargy, and associated symptoms. The duration of fever appears to be a poor predictor of unsuspected bacteremia [43].
Specific questions regarding cough, vomiting, or change in activity should be included. As an example, children with pneumonia may have cough or tachypnea noted by a caretaker. Signs or symptoms of UTI (eg, dysuria, frequency, abdominal pain, back pain, new onset incontinence), should be specifically sought. Likewise, vomiting, with or without diarrhea, can occur in young children with UTI, and caretakers occasionally note that the urine is foul-smelling, although these symptoms are nonspecific. Finally, a young child with a deep soft tissue or bone infection may protect the affected area.
A careful history must identify any known underlying medical condition that increases the child's risk for serious infection, such as sickle cell disease or urinary tract reflux. In addition, the immunization history will greatly influence the subsequent evaluation, since the child who is incompletely immunized is at greater risk for occult bacteremia than the one who is completely immunized. (See 'Immunization status' above and 'Incomplete immunization' above.)
Physical examination — The child who is being evaluated for a subtle infection or fever without a source should be well-appearing. Febrile children who are acutely ill with symptoms, such as lethargy, poor perfusion, hypoventilation or hyperventilation, and cyanosis are said to appear toxic or septic. They are considered to have a significant bacterial infection until proven otherwise. Cultures of blood, urine, and CSF, when meningitis is suspected, should be obtained, intravenous fluid provided, antibiotic therapy initiated, and admission to the hospital arranged. (See 'Ill-appearing' below.)
Attention to abnormal vital signs and a thorough physical examination may identify a source of infection. Specific features to note include the following:
●Tachycardia, tachypnea, or pulse oximetry ≤95 percent
●Lesions in the oropharynx that may identify a recognizable viral illness, such as herpes gingivostomatitis (anterior ulcers) or Coxsackie virus (pharyngeal vesicles) (see "Soft tissue lesions of the oral cavity in children", section on 'Infections' and "Clinical manifestations and diagnosis of enterovirus and parechovirus infections" and "Herpetic gingivostomatitis in young children", section on 'Clinical features')
●Increased work of breathing indicated by nasal flaring, retractions or use of accessory muscle, or focal lung findings, such as rales or decreased breath sounds
●Abdominal tenderness
●Pain with bone palpation or passive joint range of motion
●Skin findings, such as petechiae, cellulitis, or viral exanthem
Laboratory testing — Testing in febrile children 3 to 36 months of age has been used to screen for the risk of bacterial infection as well as to diagnose specific infections. The decision to perform laboratory tests depends upon a variety of factors including age, immunization status, and obvious findings of infection (eg, otitis media, bronchiolitis, croup).
Recommendations regarding when to obtain specific tests are provided below. (See 'Initial approach' below.)
WBC and ANC counts — Several studies have identified an increased risk of occult pneumococcal bacteremia among unimmunized children with WBC ≥15,000/microL and absolute neutrophil count (ANC) ≥10,000/microL [33,44-46]:
●A single center, prospective observational study of 1911 children, 3 to 36 months of age, who had fever without a source ≥39ºC (102.2ºF) and performed after introduction of Hib found that a WBC ≥15,000/microL had a sensitivity of 86 percent and a specificity of 77 percent for occult bacteremia [44]. The frequency of bacteremia in these patients was 1.5 percent (149/1911).
●A multicenter, prospective observational study of 6579 children, 3 to 36 months of age, who had fever without a source ≥39ºC (102.2ºF) and performed after introduction of Hib found that a WBC ≥15,000/microL had a sensitivity of 80 percent and a specificity of 69 percent for occult bacteremia, and an ANC ≥10,000/microL had a sensitivity of 76 percent with a specificity of 78 percent [45]. In multivariate logistic regression analysis, ANC was an independent predictor of bacteremia with adjusted OR 1.15 (95% CI 1.06-1.25) for each 1000 cells/mm3 increase in the ANC. The frequency of bacteremia in this sample was 2.5 percent.
●A multicenter retrospective observational study of 41,948 children, age 3 to 36 months, who had blood cultures performed after introduction of Hib and PCV7, found that a WBC ≤15,000/microL had a negative predictive value of 99.5 percent [33]. In this study, the frequency of bacteremia (1.6 percent) was less than blood culture contamination (1.8 percent).
Taken together, these studies suggest that a WBC >15,000/microL, while not ideal in screening for occult bacteremia, is helpful in determining which incompletely immunized children deserve blood culture and treatment in the post-conjugate vaccine era. However, these reports and others also have demonstrated that an elevated WBC, by itself, has both limited sensitivity and specificity as an indicator of SBI, particularly as other pathogens, such as S. aureus become more prominent isolates in children with bacteremia [33,47].
Urine tests — Multiple studies and two meta-analyses have evaluated screening tests for UTI [48,49]. In general, urine screening tests markedly improve the ability to detect UTI, but a urine culture should be sent in all young children in whom catheterized urine is obtained. The usefulness of dipstick, Gram stain, and microscopy is summarized in the table and discussed elsewhere (table 2). (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Rapidly available tests'.)
Preliminary evidence also suggests that automated urine white blood cell (WBC) and bacteria counts can have high sensitivity and specificity for urinary tract infection in young children depending upon the thresholds used. As an example, in 342 febrile young children (median eight months of age) who had catheterized urine tested (12 percent with positive urine cultures), an automated bacterial count ≥250 cells/microL and an automated urine WBC count ≥100 cells/microL had sensitivities of 98 and 86 percent, respectively [50]. Point of care urine dipstick also had a high sensitivity (95 percent) suggesting that it is an acceptable alternative to automated urinalysis when rapid decision-making is necessary.
Cultures — The diagnosis of a SBI is often made with cultures, although the inherent delay between the initial evaluation of the patient and the availability of culture results complicates decisions regarding empiric antibiotic therapy.
●Blood – Continuously monitored blood culture systems have decreased the length of time for a blood culture to turn positive. The mean time to positive blood cultures for pathogens is approximately 15 hours, compared with 31 hours for contaminants [51].
●Urine – For the diapered child, urine for culture should be collected by catheterization, or in exceptional cases (eg, tight phimosis), suprapubic aspiration. Bag specimens should not be sent for culture because they are frequently contaminated. A clean catch is the preferred method of urine collection for culture in the child who is toilet-trained. The culture definition of UTI is discussed elsewhere. (See "Urine collection techniques in infants and children with suspected urinary tract infection" and "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Diagnosis of UTI'.)
●CSF – Children who are being evaluated for fever without a source should be well-appearing and therefore, not require lumbar puncture. That being said, CSF should be obtained from any patient with suspected meningitis. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Course'.)
Chest radiograph — A chest radiograph should be obtained in patients with tachypnea, respiratory distress, or oxygen saturation ≤95 percent. In addition, chest radiograph is suggested in children with WBC >20,000/microL even in the absence of these findings. (See 'Pneumonia' above.)
Inflammatory mediators — Preliminary evidence suggests that elevations in levels of inflammatory mediators (ie, C-reactive protein and procalcitonin) may be better markers of SBI than WBC and ANC in children at significant risk for bacterial infection, although the usefulness of these tests in practice is uncertain [52].
●C-reactive protein (CRP) is an acute phase reactant released by the liver following inflammation or tissue damage. Observational studies that have evaluated CRP as a screening tool for occult bacterial infection report a wide range of sensitivity and specificity that vary by cutoff levels used to identify infants and children with SBI [53-57]. In addition, CRP concentrations generally do not increase until 12 hours after the onset of fever and can rise in both viral and bacterial infections [55].
●Procalcitonin (PCT) levels rise in response to bacterial infections more rapidly than those of CRP. Limited preliminary data suggest that PCT levels may be more sensitive and specific markers for severe invasive bacterial infection in infants and children than WBC, ANC, and CRP [57-62]. However, in most clinical settings, PCT has limited availability.
●A meta-analysis of five studies (1379 febrile children up to 36 months of age, including infants younger than three months) found that the diagnostic accuracy of C-reactive protein and procalcitonin were comparable for serious infection [63]. The optimal values for identifying a high risk of serious infection were ≥80 mg/L for C-reactive protein and ≥2 ng/mL for procalcitonin (sensitivity 40 to 50 percent, specificity 90 percent for each). Alternatively, the best values suggesting a low risk for serious infection were <20 mg/L for C-reactive protein and <0.5 ng/mL for procalcitonin (sensitivity >80 percent, specificity 70 percent for both).
Taken together, the evidence suggests that CRP and PCT are equivalent with respect to diagnostic accuracy. However, CRP is much more widely available than PCT and is thus more useful in clinical practice.
Molecular assays — Molecular assays based upon polymerase chain reaction, detection of bacterial 16S ribosomal RNA genes, or identification of host RNA signatures have shown potential in the rapid diagnosis of neonatal sepsis. However, these tests are not routinely available and require further validation before broad clinical implementation. (See "Evaluation and management of fever in the neonate and young infant (younger than three months of age)", section on 'Molecular assays'.)
The use of polymerase chain reaction for the detection of meningococcal disease is discussed in greater detail separately. (See "Diagnosis of meningococcal infection", section on 'Polymerase chain reaction'.)
INITIAL APPROACH — The evaluation and management of the febrile child 3 to 36 months of age without a source of infection must balance the consequences of not diagnosing a SBI with the decreasing prevalence of occult infection and the potential adverse effects of excessive testing and treatment [41]. Burdens of testing and expectant antibiotic therapy include false-positive results, adverse reactions to antibiotics, and, possibly, the effect of widespread antibiotic use on patterns of antibiotic resistance. The likelihood of SBI varies significantly by clinical appearance, age, and immunization status. (See 'Occult sources of infection' above.)
Well-appearing children 3 to 36 months of age, with fever ≥39ºC (102.2ºF), who have no underlying medical condition that would alter susceptibility to infection, and no focus of infection identified by a complete physical examination, are hereafter referred to as children with fever without a source (FWS).
Ill-appearing — Children who are ill-appearing or have unstable vital signs should be fully evaluated for serious infection with cultures of blood, urine, and, when meningitis is suspected, CSF. Those with tachypnea or leukocytosis (>20,000/microL) should have a chest radiograph. These patients should receive parenteral antibiotic therapy targeting the likely pathogens in this age group (S. pneumoniae, S. aureus, N. meningitidis, H. influenzae type b) and be admitted to the hospital.
Immunization incomplete — The risk of occult bacteremia in incompletely immunized children is estimated to be as high as 5 percent (ie, what it was during the preconjugate vaccine era); the actual risk is probably somewhat lower because of "herd immunity." (See 'Immunization status' above and 'Impact of vaccines' above.)
Strategies for the evaluation and management of these children reflect the increased risk of bacteremia compared with completely immunized children and are drawn from experience and guidelines developed during the preconjugate vaccine era [4,30,31,33,44,51,64,65].
We suggest the following approach to evaluation of these children:
●CBC with differential.
●Blood culture should be obtained if the WBC is ≥15,000/microL. As a practical matter, the blood culture may be drawn with the CBC and sent if the WBC is ≥15,000/microL. Recognizing that WBC is not an ideal screening tool, some clinicians may prefer to always send a blood culture in these patients [33,39,42].
●Urinalysis, and urine culture by bladder catheterization or in exceptional cases (eg, tight phimosis), suprapubic aspiration.
●Chest radiograph in children with WBC ≥20,000/microL.
Children with an abnormal urinalysis should be treated for a urinary tract infection, although in questionable cases awaiting results of urine culture represents a reasonable alternative. (See "Urinary tract infections in infants and children older than one month: Acute management, imaging, and prognosis", section on 'Overview'.)
We recommend that children with FWS who are incompletely immunized who have a WBC ≥15,000/microL receive parenteral antibiotic therapy pending blood and urine cultures [4,42]. Ceftriaxone (50 mg/kg, intramuscularly) is preferred because of its antimicrobial spectrum and prolonged duration of action. Clindamycin (10 mg/kg, intravenously followed by oral clindamycin eight hours later) is one alternative for patients allergic to cephalosporins. Outpatient follow-up should occur within 24 hours. Patients in whom outpatient follow-up is uncertain should be admitted.
This strategy of selective treatment of high-risk children with FWS and WBC ≥15,000/microL is in agreement with the practice guidelines of the American Academy of Pediatrics and the American College of Emergency Physicians for children with FWS [4,66,67].
Support for treating patients 3 to 36 months of age with FWS and significant risk of bacteremia with empiric parenteral antibiotics is derived from meta-analyses and randomized trials performed before the routine availability of Hib, PCV7, and PCV13 conjugate vaccines [23,24,30].
●A meta-analysis of four randomized controlled trials of 7899 children, age 3 to 36 months, who had a fever ≥39°C (102.2ºF), found that treatment of occult bacteremia with IM ceftriaxone reduced the chance of serious bacterial infections by approximately 75 percent (Number needed to treat (NNT) 17; OR 0.25; 95% CI 0.07-0.89) and that oral antibiotics were not effective [68].
●A meta-analysis of prospective and retrospective studies of children age 3 to 36 months with fever without a source and bacteremia found that the mean probability of subsequent meningitis was 8.2 percent (all H. influenzae, type b) in patients treated with oral antibiotics and 0.3 percent in patients treated with parenteral antibiotics versus 9.8 percent in untreated children. No child treated with ceftriaxone developed culture-positive meningitis (0.3 percent; 95% CI 0.0-1.5 percent). The authors concluded that antibiotic therapy is effective in preventing meningitis [8].
●A randomized, double blind, placebo controlled trial of 955 children between the ages of 3 to 36 months with fever ≥39ºC (102.2ºF) demonstrated no difference in major infectious morbidity between bacteremic children receiving oral amoxicillin (2 of 19) or placebo (1 of 8). The incidence of diarrhea was 15 percent in children receiving amoxicillin versus 11 percent in the placebo group (p = 0.10) [24]. The overall rate of bacteremia was 2.8 percent in this study.
●An unblinded, randomized controlled trial of 6733 children between the ages of 3 to 36 months with fever ≥39ºC (102.2°F) also described an overall rate of bacteremia of 2.8 percent (195 of 6733) [30]. Five definitive focal infections (three meningitis, one pneumonia, and one sepsis) developed in the 3347 children receiving amoxicillin versus none in those treated with IM ceftriaxone (OR 0.0, 95% CI 0.0-0.5).
●An unblinded, randomized trial of 96 children, between 6 and 24 months of age with a temperature >40ºC (104ºF), found that 4.3 percent of untreated patients (2 of 46) developed pneumococcal meningitis versus none of the 50 children treated with intramuscular aqueous penicillin G at the initial visit followed by oral penicillin for 10 days. Bacteremia was identified in 10.4 percent of all children [23].
Possible dermatologic adverse reactions were more commonly seen in the ceftriaxone group (8.7 versus 4.9 percent), but gastrointestinal complaints, such as diarrhea, were not different (14.5 versus 15.0 percent). No anaphylaxis was seen in either group.
Taken together, these studies indicate that unimmunized children with FWS avoid progression of bacteremia to focal infections, especially meningitis, when treated with parenteral antibiotics. Given the increasing prevalence of penicillin resistant S. pneumoniae, intramuscular ceftriaxone remains a preferred parenteral agent.
Immunization complete — A child with FWS who is completely immunized has a risk of bacteremia that is <1 percent. Decision analysis suggests that at this low risk, laboratory evaluation and empiric antibiotic therapy do not significantly alter the likelihood of progression to focal bacterial infection and are not indicated [42,69]. (See 'Immunization status' above and 'Impact of vaccines' above.)
However, the risk of UTI as an occult source of infection remains substantial in fully immunized children, depending on age, gender, and circumcision status [41]. This risk guides recommendations for evaluation and treatment in these patients [68].
●For children over six months of age with FWS who are completely immunized, we suggest that girls less than 24 months of age and uncircumcised boys less than 12 months receive a urinalysis and urine culture. Urine for culture should be collected by catheterization or, in exceptional cases (eg, tight phimosis or severe labial adhesions), suprapubic aspiration. Bag specimens should not be sent for culture because they are frequently contaminated. (See "Urine collection techniques in infants and children with suspected urinary tract infection" and 'Urinary tract infection' above.)
●For girls >24 months of age, uncircumcised boys >12 months of age and circumcised boys >6 months of age, all of whom have been completely immunized, we do not suggest routine laboratory evaluation or presumptive treatment with antibiotics. However, urinalysis and urine culture should be obtained in those with signs or symptoms of UTI, which must be specifically sought (eg, dysuria, frequency, abdominal pain, back pain, new onset incontinence). In addition, children with a prior history of UTI, urogenital anomalies, or prolonged fever (>48 hours) warrant urinalysis and urine culture. (See 'Urinary tract infection' above.)
Some experts suggest that a high fever without a source (>39°C [102.2°F]) is sufficient justification for urine culture on the first visit in uncircumcised boys 12 to 24 months of age (algorithm 1). (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Decision to obtain'.)
●Children with FWS who are completely immunized against Hib and either PCV7 or PCV13, meet criteria for urine testing, and have an abnormal urinalysis should be treated for UTI. Appropriate follow-up should be arranged. (See "Urinary tract infections in infants and children older than one month: Acute management, imaging, and prognosis", section on 'Overview'.)
Despite the high risk for UTI and low risk for bacteremia among fully immunized children, evidence suggests that some emergency department (ED) clinicians may not utilize laboratory testing and antibiotic therapy appropriately when caring for these patients. As an example, between 2006 and 2008, estimates regarding laboratory testing and antibiotic treatment extrapolated from 1600 ED visits by fully immunized febrile children 6 to 36 months of age in the United States were as follows [70]:
●No testing was performed in 59 percent
●Complete blood counts were obtained in 21 percent
●Urine testing was not performed in an estimated 60 percent of girls with high fever
●Antibiotics were prescribed in an estimated 20 percent of patients in whom no testing was performed
These estimates suggest that urine testing may be underutilized while measurement of complete blood count and antibiotic treatment may be overutilized in these patients.
FOLLOW-UP — Follow-up should be arranged within 24 hours for those children with fever without a source (FWS) who have received parenteral antibiotics. Patients who are not treated with antibiotics should be instructed to seek medical attention within 48 hours if they have persistent fever.
Careful instructions should be given to caretakers to return immediately if fever becomes higher, the patient looks sicker, or local symptoms or signs develop (eg, cough, diarrhea, cellulitis).
Positive blood cultures — An organism may not be identified definitively for 24 to 48 hours after the blood culture becomes positive, making management decisions difficult. The clinical appearance of the child and the Gram stain of the organism can be useful in deciding whether or not the child should be admitted to the hospital. Consultation with the microbiology laboratory personnel and/or an infectious disease consultant may be helpful in narrowing the list of potential organisms and the likelihood that the findings represent a pathogen. Patients with a positive culture that is felt to be a pathogen should be reevaluated and managed according to appearance, persistence of fever, and specific isolate (algorithm 2).
The main goal is to identify and avoid progression to serious bacterial infection, especially meningitis:
S. pneumoniae
●Febrile – In a retrospective observational study prior to PCV7 availability, 548 children with a blood culture positive for S. pneumoniae had outcomes examined. Children who were well, but persistently febrile at the revisit and did not receive antibiotics at the initial visit had a 33 to 42 percent chance of infection (primarily persistent bacteremia) and a 4.4 percent chance of meningitis [65]. Meningitis developed despite initial oral antibiotic therapy in 2 of 49 children (4 percent). Because of this high risk of SBI, patients with a blood culture positive for S. pneumoniae who are febrile on revisit should undergo a full sepsis evaluation (including lumbar puncture). They should also receive parenteral antibiotics tailored to the isolate's susceptibility or to the community susceptibility pattern for S. pneumoniae if the culture susceptibility is not yet available.
These children may receive continued antibiotic therapy as an outpatient for 7 to 10 days with close follow-up if CSF findings show no evidence of meningitis. Antibiotic regimens should provide coverage for resistant S. pneumoniae. Possibilities include high dose oral amoxicillin (30 mg/kg per dose, three times daily; maximum dose: 3 g daily), oral amoxicillin-clavulanate 45 mg/kg per dose twice daily (maximum dose of amoxicillin: 3 g daily), or clindamycin 10 mg/kg per dose three times daily in penicillin allergic patients.
●Afebrile – Well-appearing, afebrile children who did not receive antibiotics at the initial visit and who have a blood culture positive for S. pneumoniae have an approximately 9 percent risk of persistent bacteremia [65]. These patients can be managed with antibiotics as an outpatient with close follow-up. Another blood culture should be drawn before further antibiotic therapy is initiated. Antibiotic regimens should provide coverage for resistant S. pneumoniae. Possibilities include high dose oral amoxicillin (30 mg/kg per dose, three times daily; maximum dose: 2 to 3 g daily), oral amoxicillin-clavulanate (45 mg/kg per dose, twice daily; maximum dose: 3 g total daily dose of amoxicillin), or clindamycin (10 mg/kg per dose, three times daily) in penicillin allergic patients.
Other pathogens — The limited data for bacteremia caused by organisms other than S. pneumoniae suggests that outpatient therapy with oral antibiotics does not prevent serious bacterial infection, even in well-appearing, afebrile children. In addition, the risk of meningitis is presumed to be high for patients with N. meningitidis bacteremia.
For these reasons, hospital admission and parenteral antibiotic therapy is suggested for children with a blood culture that is positive for N. meningitidis, H. influenzae type b, S. aureus, gram-negative rods, or other pathogens. A lumbar puncture should be performed if meningitis is clinically suspected. CSF evaluation is also recommended for patients with blood culture positive for N. meningitidis and for young infants (three to six months of age) with Group B Streptococcus bacteremia. Well children over three months of age with a blood culture positive for E. coli or S. aureus do not need a lumbar puncture.
Probable blood culture contaminant — With the decline in the prevalence of occult bacteremia, it is now more likely that a blood culture will be positive for a contaminant than for a pathogen [31-33,51]. Certain microbiologic features, such as slow growth or Gram stain, showing either gram-positive rods or gram-positive cocci that are coagulase negative, suggest a contaminant. Consultation with the microbiology laboratory and/or an infectious disease specialist may be useful when preliminary results are unclear.
Molecular assays can help rapidly detect Staphylococcus aureus, including methicillin-resistant strains in blood cultures positive for gram-positive cocci in clusters. (See "Rapid detection of methicillin-resistant Staphylococcus aureus", section on 'Blood cultures'.)
The child who is well on follow-up, afebrile, and has an isolate from blood culture that is a likely contaminant can be followed without antibiotic treatment, pending the final identification of the organism.
Children who are not well on follow-up or continue to have fever should be reevaluated and the assumption that the positive blood culture represents a contaminant should be reevaluated (algorithm 2). (See 'Positive blood cultures' above.)
Positive urine culture — Children with a positive urine culture should be treated for UTI. (See "Urinary tract infections in infants and children older than one month: Acute management, imaging, and prognosis", section on 'Overview'.)
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 topic (see "Patient information: Fever in children (The Basics)")
●Beyond the Basics topic (see "Patient information: Fever in children (Beyond the Basics)")
General issues
●The following recommendations apply to well-appearing children 3 to 36 months of age, with fever ≥39ºC (102.2ºF), who have no underlying medical condition that would alter susceptibility to infection, and no focus of infection identified by a complete physical examination, hereafter referred to as children with fever without a source (FWS). (See 'Background' above.)
●The majority of children with fever have either a self-limited viral infection or a recognizable source of bacterial infection. (See 'Occult sources of infection' above.)
•Serious bacterial infections that occur in children 3 to 36 months of age include meningitis, pneumonia, and focal skin infections.
•Subtle sources of infection, such as pneumonia or osteomyelitis, can sometimes be identified with a careful history and physical examination.
•Relatively common occult sources of infection include pneumonia and urinary tract infections (UTIs), with occasional cases of bacteremia.
●A thorough history, including immunization status and complete physical examination, should be performed in all febrile children to identify obvious and subtle focuses of infection. (See 'History' above and 'Physical examination' above.)
Ill-appearing child
●Children who are ill-appearing or have unstable vital signs require full evaluation for serious infection with cultures of blood, urine, and when meningitis is suspected, CSF. A chest radiograph should be obtained in patients who have tachypnea or respiratory distress and is warranted for those with WBC ≥20,000/microL, even in the absence of physical findings of pneumonia. (See 'Ill-appearing' above.)
●Children who are ill-appearing or have unstable vital signs should receive parenteral antibiotic therapy targeting the likely pathogens in this age group (S. pneumoniae, S. aureus, N. meningitidis, H. influenzae type b) and be admitted to the hospital. (See 'Ill-appearing' above.)
Well-appearing child
Incompletely immunized
●For children with FWS who have not been completely immunized, we suggest the following tests:
•CBC with differential: A blood culture should be sent for those with WBC ≥15,000/microL. Some clinicians may choose to send a blood culture for all patients. (See 'Immunization incomplete' above.)
•Urinalysis and urine culture by bladder catheterization or, in exceptional cases (eg, tight phimosis or severe labial adhesions), suprapubic aspiration. (See 'Urine tests' above and 'Immunization incomplete' above.)
•Chest radiograph when WBC ≥20,000/microL. (See 'Immunization incomplete' above.)
●We recommend that incompletely immunized children with FWS and WBC ≥15,000/microL receive parenteral antibiotic therapy pending culture results (Grade 1B). A single dose of intramuscular ceftriaxone (50 mg/kg) is preferred because of its antimicrobial spectrum and duration of action. (See 'Immunization incomplete' above.)
●These patients should be seen for follow-up by their primary care provider within 24 hours. An alternative is to follow-up in the emergency department if a regular source of primary care is unavailable. (See 'Follow-up' above.)
Completely immunized
●For children >6 months of age with FWS who are completely immunized, we suggest that girls <24 months of age and uncircumcised boys <12 months receive a urinalysis and urine culture. Urine for culture should be collected by catheterization or, in exceptional cases (eg, tight phimosis or severe labial adhesions), suprapubic aspiration. Bag specimens should not be sent for culture because they are frequently contaminated. (See 'Urinary tract infection' above and "Urine collection techniques in infants and children with suspected urinary tract infection".)
●For girls >24 months of age, uncircumcised boys >12 months of age and circumcised boys >6 months of age with FWS, all of whom have been completely immunized, we do not suggest routine laboratory evaluation. In addition, these children should not receive presumptive treatment with antibiotics (Grade 1B). However, urinalysis and urine culture should be obtained in those at high risk for UTI. (See 'Urine tests' above and 'Immunization complete' above.)
●Completely immunized children with fever ≥39°C (102.2°F) and an abnormal urinalysis should be treated for a urinary tract infection. (See 'Immunization complete' above and "Urinary tract infections in infants and children older than one month: Acute management, imaging, and prognosis", section on 'Antibiotic therapy'.)
Clinical follow-up
●We recommend that children with fever that persists for more than 48 hours or with a deterioration in clinical condition undergo repeat medical evaluation.
Culture follow-up
Urine cultures
●Patients with a positive urine culture require treatment tailored to the identified organism and their clinical status. (See "Urinary tract infections in infants and children older than one month: Acute management, imaging, and prognosis", section on 'Overview'.)
Blood cultures
●Children of 3 to 36 months of age with a positive blood culture for a presumed pathogen require reevaluation and management based on their appearance, persistence of fever, and specific isolate (algorithm 2). (See 'Positive blood cultures' above.)
●We suggest that the child who is well on follow-up, afebrile, and has an isolate from a preliminary report of a blood culture that is a likely contaminant, be followed on a daily basis as an outpatient without antibiotic treatment, pending the final identification of the organism (Grade 2C). (See 'Probable blood culture contaminant' 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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Christmas Comes To Storm-Damaged New York Coast
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Ornaments hangs on a burned tree December 25 2012 in the Breezy Point... News Photo 158713075Breezy Point - Queens,Burnt,Decorative,Emergencies and Disasters,Fire,Hanging,Horizontal,Human Interest,Natural Disaster,New York City,People,Queens - New York City,Residential District,Tree,USAPhotographer Andrew BurtonCollection: Getty Images News 2012 Getty ImagesNEW YORK, NY - DECEMBER 25: Ornaments hangs on a burned tree December 25, 2012 in the Breezy Point neighborhood of the Queens borough of New York City. Residents are still struggling to recover from a massive fire that destroyed over 100 homes during Superstorm Sandy. (Photo by Andrew Burton/Getty Images)


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Gear Question
i wear a size 14 boot will it fit in these...
Member since
i wear a size 14 boot will it fit in these bindings L/XL size?
Kris McGregor
Member since
Yes they will. I have these in the L/XL and have a size 12 foot and I have no overhang and it is not tweaked to the biggest setting. You will def have to play around with it to fit just perfect, but it is definately do-able. And these bindings are absolutely sick btw
Cameron Stinger
Member since
in video stating L/XL will fit up to 14 with ease! shred
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Sel G가 작성 2008년 08월 26일 (화)
Bitch who is a a cunt
look over there, Thats Rachel, Shes a proper Cuntbitch
charlieeeeeeeeeeeeeeeeeeeeee가 작성 2008년 12월 25일 (목)
An extreme bitch who is also an extreme cunt.
You need to stop being so cuntish, you fucking cuntbitch
. Z's가 작성 2014년 12월 04일 (목)
A word used to describe what you will do to someones face later. Usually consists in yelling or physically abusing. One may only use this word if you really want to fuck someones day up.
I will cunt-bitch you gurl, oh yes I will gurl, yes I will.
Skysten가 작성 2011년 11월 26일 (토)
A woman from Pensacola who is very promiscuous.
Also known as "CB" which is short for Cunt Bitch
Also known as "CB" which is short for Cunt Bitch
Damn that Alice, she is a cunt bitch!
JJeremy가 작성 2006년 12월 21일 (목)
a word that comes out at random when you're random and really weird and/or making a funny youtube video and it slips out lmao. aka my best friend when he hit me when we were making a random video.
cunt bitch is someone you really hate.....or a friend thats cool enough to mess around with like that and call names =]. Example: making a random YouTube video and your best friend hits you and you say "ouch you cunt bitch!" lmao
xXBeckyxThexRIOTXx가 작성 2009년 04월 24일 (금)


text:
We Like Linkin Park, and We Will Not Apologize
By Ashley Zimmerman
Better Than Ezra "Know a Lot of Fans by Name"
By Dana Krangel
T-Pain Says, "I May Get Into Some Gypsy Shit" Next
By John Hood
Review & Photos: Sara Bareilles at Hard Rock Live
By Ashley Zimmerman
Psych-Metal Outfit Orbweaver Releases Vinyl EP
By David Von Bader
Photos: John Legend in Boca Raton
By Sayre Berman
Five Things Weird Al Critiques in Mandatory Fun
By Steve Brennan
By Ashley Zimmerman
1 Panther Parkway
Sunrise, FL 33323
Category: Music Venues
Region: Sunrise/Plantation
Aerosmith,"Global Warming Tour" with Cheap Trick. 7:30 p.m. Sunday, December 9, at BB&T Center, 1 Panther Parkway, Sunrise. Tickets cost $49.50 to 149.50, plus fees. Call 800-745-3000, or visit livenation.com.
As time marches on, fans of the (now) classic rock 'n' roll animal have fewer and fewer groups to enjoy in their original, or even mostly original, configurations. The years can be pretty unkind to bands: Members quit, members die, and "the magic" can so easily disappear. Aerosmith has almost lost "the magic" on several occasions. Despite major challenges, though, the band has managed to come through to "the other side" with the original '70s lineup intact. And whether you love, hate, or simply tolerate the boys from Boston, they breathe some extremely rare air as a truly classic group that still functions in an unaltered state. Steven Tyler's star has risen even higher than his role as frontman, but of the reunion, conflicts, and a new recording, the singer told New Times and other media outlets of his primary role: "I felt the power of something I never got from anywhere else, and it was from being in this band. And the shit that we go through and the stuff that we come up with outweighs any anger." The band returned with its first album of new material in more than ten years, Music From Another Dimension, and the second leg of a world tour that promises something akin to the Aerosmith of yore.
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Embarkation We arrived about half an hour after the allotted time and found no queues. Staff were friendly and ... Read more
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this was the 1st & proberbly the last cruise we have taken, i have to say not a great experience After a very ... Read more
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First impression: The ship is huge. Even walking from one end to the other takes time, and this creates a 'village' ... Read more
First time cruising with 2 teenagers 17 and 18. Staff were excellent and courteous at all times. We all enjoyed the ... Read more
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In a set of remarks that has some observers wondering whether the Bush Administration is continuing to change its rhetoric to emphasize that the transfer - - but not the possession - - of nuclear weapons on the part of North Korea is seen as a "grave threat," President Bush warned at the National University of Singapore that "America's position is clear: the transfer of nuclear weapons and material by North Korea to states or non-state entities would be considered a grave threat to the US and we would hold NK fully accountable for the consequences of such action."
"For the sake of peace," President Bush continued, "it is vital that the nations of this region send a message to NK - -that the proliferation of nuclear technology to hostile regimes or terrorist networks will not be tolerated."
The Washington Post on Rep. Tom Lantos (D-CA), the incoming chairman of the House International Relations Committee, faulting the Bush Administration for its exclusive reliance on the six-nation negotiating framework. LINK
In the forthcoming New York Times Magazine, Matt Bai writes his opinionated opinions that two formerly top-tier candidates - - George Allen and Bill Frist - - "now seem irreparably damaged. The party's presumed frontrunner, John McCain, also faces a more troublesome environment, given his strong support for a war that many of his moderate supporters clearly oppose. On the Democratic side, the election dealt a blow to John Kerry … while perhaps opening the door further for Al Gore, whose defiant, antiwar fervor would seem well suited to the moment." Bai adds that the elections' results "may also boost the prospects for some younger candidate who can "credibly claim distance from the establishment of both parties - - a candidate much like Barack Obama."
The Senate Armed Service Committee provides an opportunity to see where front-running Sens. McCain and Clinton are on the critical issue of Iraq, reports the New York Times. LINK
Gen. Abizaid resisted calls for troop withdrawals from Democratic Senators and additional troops from Sen. McCain, per the Los Angeles Times. LINK
Critics see McCain's position on Iraq problematic in his quest to attract independent voters to his potential presidential campaign, while supporters see McCain's near-lonely call for more troops as that classic "straight talk" independents find so attractive. The Los Angeles Times takes a closer look. LINK
Gov. Mitt Romney (R-MA) signs top Republican ad maker Alex Castellanos, who has already cut the anti-McCain attack spots on his head. LINK
USA Today has McCain adviser Rick Davis talking about Sen. McCain's new exploremccain.com web site while saying: "We are not under the radar." LINK
The New York Daily News includes McCain adviser Craig Goldman's explanation of the difference between the Giuliani and McCain filings McCain's filing "provides full disclosure," claims Goldman. LINK
Be sure to Note Rep. Peter King's (R-NY) support for Giuliani's bid.
Thompson jumps into the fray:
Former Wisconsin Governor and HHS Secretary Tommy Thompson (R) joined the growing list of politicians taking--or preparing to take--formal steps to run for president, saying yesterday in Iowa that he intends to file a presidential campaign committee after the first of the year.
As Robert Pear can tell you, a brat and a brew in moderation is perfectly healthy.