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The Newborn final THE PREMATURE INFANT Premature Birth
FOETAL PHYSIOLOGY Placental Function: Foetal Function: Transport: Liver – produces albumin, coagulation factors and red o Transport of nutrients from mother to foetus blood cells as well as waste products in other direction o Also acts as "lung" – responsible for gaseous Kidney – excretes urine (contributes to amniotic fluid) exchange of oxygen and carbon dioxide as well as maintenance of acid-base status Endocrine organs – produce thyroid hormones, corticosteroids, mineralocorticoids, parathormone and Metabolism: insulin from 12 weeks' gestation o Produces hormones, including human chorionic gonadotrophin (HCG), human Immunoglobulins – some produced from end of first placental lactogen (HPL) and human trimester chorionic thyrotropin (HCT) o Detoxifies drugs and metabolites Foetus breathes from about 11 weeks' gestation, but o Has very high energy demands and this is irregular until ~20 weeks; at 36 weeks foetus consumes over 50% of the total oxygen and breathes regularly glucose transported across it Foetal Circulation: Consists of 2 umbilical arteries bringing deoxygenated blood to the placenta and a single umbilical vein carrying oxygenated blood back to the heart Aorta divides into the common iliac arteries and then the internal and external iliac arteries – the umbilical arteries are branches of the internal iliacs The umbilical vein drains into the portal sinus and thence bypasses the liver via the ductus venosus to reach the IVC Deoxygenated blood is carried by the 2 UAs to the placenta where it is oxygenated as it comes into close apposition with maternal blood in intervillous spaces Oxygenated foetal blood is carried in the UV, where it bypasses the liver via ductus venosus IVC and right atrium Much of the blood here is shunted across the foramen ovale from the RA to left atrium Oxygenated blood is pumped by the RV into the pulmonary artery, but the majority bypasses the lungs via the ductus arteriosus to flow into the aorta Summary of shunts in foetal circulation: 1. Ductus venosus bypasses blood away from the liver 2. Foramen ovale shunts blood from RA to LA, bypassing lungs 3. Ductus arteriosus shunts blood from pulmonary artery to the aorta ADAPTATION TO EXTRAUTERINE LIFE Respiratory Adaptation: Cardiovascular Adaptation: While the foetus is breathing in utero, the lungs are With the first few breaths, arterial oxygen tension filled with fluid increases At the time of birth, the baby generates enormous This relative hyperoxia results in closure of the ductus negative pressures and fills the lungs with air arteriosus – functionally closed by 10 – 15 hours, but not anatomically closed until 4 – 7 days With the first 2 – 3 breaths, much of the foetal lung fluid is expelled; the remainder is absorbed into pulmonary Marked fall in pulmonary vascular resistance shortly lymphatics and capillaries over first 6 – 12 hours after birth pulmonary blood flow increases Stimulus for first breath is not known with certainty, but Drop in pulmonary blood pressure drop in pressure it's probably due to the bombardment of physical on right side of heart no longer shunting from RA to stimuli e.g. cutaneous and thermal changes; and LA across FO; takes some time to close and remains emptying of the lungs of fluid patent in 10% After birth there is a marked decrease in blood flow in the IVC and the ductus venosus closes in response to this remains as a vestigial remnant (ligamentum teres) throughout life Umbilical vessels take longer to obliterate and may still be cannulated for up to 10 days after birth Assessment of Infant at Birth: The APGAR score – performed at 1 minute, 5 minutes and 10 minutes: Sign 0 1 2 Heart rate Absent < 100 / min > 100 / min Respiratory effort Absent Weak cry Strong cry Muscle tone Limp Some flexion Good flexion Reflex irritability (suction) No response Some motion Cry Colour Pale; Centrally pink; Pink overall cyanosis peripherally blue o Score at one minute: - 7 – 10 normal - 4 – 6 moderately depressed - 0 – 3 severely depressed Routine Resuscitation of Non-Asphyxiated Infant: Resuscitation in Infant with Depression: Pharyngeal suction as head delivers Bag and mask ventilation: o Jaw should be held forward as operator Placing baby with head lower than baby squeezes the bag at rate of 35 / min o Watch chest for adequate inflation and Keep baby warm by radiant heater or wrapped in auscultate for air entry warm blankets o Continuously assess heart rate and colour Gently suction pharynx and nares Intubation and positive-pressure ventilation: Auscultate heart and calculate APGAR o Babies with Apgar score 0 – 3 at 1 min o If baby still blue following bag and mask Administer oxygen by face mask at rate of 1 – 2 o If Apgar < 6 at 5 mins L/min if baby still blue o Intubation may be orotracheal or nasotracheal Vitamin K (1mg) given IM or orally EXAMINATION OF THE NEWBORN 1. General Appearance: 6. Neck: Facies: Full range of movement o Chromosomal disorders e.g. 21, 18, 13 Redundant skin at back = Turners' or Down syndrome o Foetal alcohol syndrome Goitre o Other syndromes Colour: 7. Chest: o Should be uniformly pink o Generalised cyanosis, pallor, jaundice, plethora, Shape and size bruises, petechial haemorrhages Signs of respiratory distress – recession Posture: Stridor – upper airways obstruction o Normal position = hips abducted and partially flexed; Breath sounds – symmetry, air entry and adventitial sounds knees flexed; arms adducted and flexed at elbow o Limited movements, exaggerated or asymmetrical 8. Cardiovascular system: movements, hypotonia, stiffness Cry: Pulses – radial and femoral o Should be vigorous and sustained after stimulation Apex beat o Weak, high-pitched or hoarse is abnormal Auscultation Skin appearance: o Mild peeling on mature babies is not abnormal 9. Abdomen: o Abnormal appearances, pigmentation and naevi Head shape: Distension o Moulding and caput succedaneum (oedematous Soft, non-tender thickening of scalp due to passage through vagina) is Liver – normally palpable up to 1cm below right CM normal in newly born infants and disappears within 2 – Spleen – tip can be palpated in 25% of normal infants 3 days Kidney – may be palpable normally o Plagiocephaly = flattening of occipital region on one Anus – should be patent and normally situated side; no pathological significance o Scaphocephaly = long head with flattened 10. Umbilicus: temporoparietal regions = common in premature infants Vessels – normally 2 thick-walled arteries and a thin-walled vein o Head size should be measured Colour – normally translucent o Fontanelles – normally soft and flat; bulging may be Stump – cord usually separates by day 10 leaving a yellowish or due to raised ICP and is always abnormal greenish eschar o Craniosynostosis = premature fusion of one or more Umbilical hernia common in premmies skull bones; sagittal suture most common 11. Genitalia: 2. Eyes: Testes Site: Penis and urethra o Distance apart; too far = hypertelorism; too close = Scrotum hypotelorism Inguinal hernia Conjunctiva: Hymen – skin tags common o Usually clear; but subconjunctival haemorrhages are Vagina and vulva not uncommon o Conjunctivitis 12. Extremities: o Excessive lacrimation Cornea and iris: Feet – talipes equinovarus o Cornea should be clear and red reflex elicited Hips – dislocation o Pupils should constrict to light directly and Arms – range of normal movements consensually Simian crease – may be present in Down syndrome 3. Ears: 13. Neurological screening: Preauricular skin tags or sinuses common Primitive Reflexes: Position = top of pinna should be above a horizontal line from o Moro inner and outer canthi; low set ears seen in a variety of o Sucking conditions o Rooting o Grasping 4. Nose: o Tonic neck reflex Spontaneous movements Exclude choanal atresia by passing catheter through Posture Tone 5. Mouth: Deep tendon reflexes Lips – cleft lip Palate – cleft palate, bifid uvula, high arched palate Tongue – size and positioning THE NORMAL NEONATE Features of the Normal Neonate: Term baby > 37 weeks At birth, average = 3.5kg, 50cm long, head circumference 35cm HR 100 – 160; RR 40 – 60; Systolic BP 50 – 75 Acrocyanosis normal (hands persistently cold and blue) 2 fontanelles – anterior (1 – 4cm) and posterior (< 1cm) Freely mobile sutures (metopic, sagittal, coronal, lambdoid) Primitive reflexes – rooting, Moro, grasping, stepping, Babinski Suck reflex develops at ~ 34 weeks Obligate nose breathers until 5 months of age Liver palpable 2cm below costal margin Splenic tip palpable Bladder palpable just prior to voiding Innocent murmur normal Lose up to 5 – 10% weight in first 5 days; regained at 10 days Urinate soon after birth, then every 3 – 4 hours 95% pass meconium by 24 hours 40 – 50% have physiological jaundice Small occasional vomits Sleep for 18 hours / day Cry for 4 hours / day JAUNDICE OF THE NEONATE Physiology of Bilirubin Metabolism: Foetus: o Placenta and maternal liver metabolise the bilirubin from worn-out RBCs o If excessive foetal haemolysis e.g. in rhesus haemolytic disease placenta and maternal liver may not be able to deal with excessive bilirubin load and umbilical cord and amniotic fluid with be stained yellow o Foetus will become anaemic as bone marrow and extramedullary organs fail to keep up erythropoiesis o Foetus is capable of conjugating bilirubin in small amounts and when haemolysis occurs in utero this increases Newborn: o Bilirubin production: - Most comes from senescent RBCs - RBCs are destroyed in RE system and haem is converted to unconjugated bilirubin o Transport and liver uptake: - Most unconjugated bilirubin in blood is bound to serum albumin and transported as a bound complex to the liver (renders it non-toxic) - Free, unbound bilirubin is fat soluble and can cross the BBB and be deposited in neurons kernicterus - Unconjugated bilirubin is extracted from blood by hepatocytes o Conjugation and excretion: - Unconjugated bilirubin is conjugated in the liver with glucuronic acid - Conjugated bilirubin is then excreted into the bile then into the duodenum and small intestine - In the newborn (relatively sterile bowel and poor peristalsis) much of conjugated bilirubin is hydrolysed to unconjugated bilirubin enters enterohepatic circulation for further liver metabolism Clinical Assessment of the Jaundiced Infant: Kramer's Rule: Can be detected in the newborn when serum level is ~ 100 µmol / L Zone 1 SBR = 100 Kramer's rule = blanching of infant's skin with finger at standard zones and observe colour in blanched areas; Zone 2 = 150 zones of jaundice reflect the downward progression of dermal icterus Zone 3 = 200 Indications for investigations of jaundice: Zone 4 = 250 st o Any infant visibly jaundiced in 1 24 hours of life o Any infant whose mother has rhesus Abs Zone 5 = > 250 o A preterm infant w serum bilirubin > 150µmol / L o Term infant w serum bilirubin > 200 µmol / L o Any infant w signs of obstructive jaundice o Prolonged hyperbilirubinaemia > 1 week in term infants and > 2 weeks in preterms JAUNDICE OF THE NEONATE (CONTINUED) Unconjugated Hyperbilirubinaemia: Physiological Jaundice: Causes: Describes jaundice which is not severe enough to o Rhesus and ABO incompatibility warrant treatment o Hereditary spherocytosis o G6PD deficiency Presumed to be due to a temporary immaturity of o Septicaemia and TORCH infection glucuronyl transferase and other factors in o Extravasated blood and excessive bruising bilirubin metabolism o Twin-to-twin transfusion o Prematurity Should not fulfil any of the following criteria: o Dehydration st o Hypothyroidism o Clinical jaundice in 1 24 hours of life o Breast milk jaundice o Total serum bilirubin > 300µmol / L in o Delayed passage of meconium term infant or 255 µmol / L in preterm o Clinical jaundice persisting for > 10 days Investigations: in term infant or > 2 weeks in preterm o Prolonged jaundice requires investigation when infant present for > 10 days in a term infant and > 14 days in o An "ill" infant a premature one o Haemoglobin o Blood film for RBC morphology Others Causes of Unconjugated HB: o Maternal and infant blood grouping o Direct Coombs' test Infection: o Maternal haemolysis if ABO mismatch o Bacterial infections, esp. septicaemia o Infection screen and UTIs may unconjugated o Serum T4 and TSH hyperbilirubinaemia Management: Breastfeeding associated jaundice: o Prevention: o Increased bilirubin levels seen in first 2 - Early feeding reduces incidence of jaundice weeks of life in 60% of infants who are by preventing dehydration and elevation of breastfed free fatty acids o Can be reduced by increased frequency - Maintenance of adequate fluid intake = of breastfeeding in first few days of life essential part of management o May rarely cause kernicterus if untreated - Breast-feeding associated jaundice is minimised by frequent, early breastfeeding in Breast milk jaundice: first 3 days of life o Prolonged jaundice that extends up until the first 3 months of life o Phototherapy: o Diagnosed by exclusion of other - Resulted in a decline in number of exchange aetiologies in a thriving infant transfusions required - Phototherapy units of wavelength 450nm Delayed passage of meconium: used to degrade and isomerise o Jaundice due to increased enterohepatic unconjugated bilirubin in the skin to non-toxic absorption of bilirubin bilirubin products - Complications of phototherapy: Gilbert's syndrome: Temperature instability o Autosomal dominant condition Fluid disturbance associated with a mild unconjugated Retinal damage hyperbilirubinaemia (< 85µmol / L) Diarrhoea Bronze baby Complications of Jaundice: o Exchange transfusion: - May be required in conjunction with Kernicterus and bilirubin encephalopathy: phototherapy for infants with severe jaundice - Allows: o Classic presentation = progressive Removal of unconjugated bilirubin development of lethargy, rigidity, Removal of immune antibody if opisthotonos, high-pitched cry, fever and present convulsions over a period of 24 hours Replacement of sensitised RBCs o Followed by death in 50% of infants with cells that cannot be o Autopsy shows bilirubin staining and haemolysed as easily necrosis of neurons, especially in basal Restoration of blood vol and ganglia and hippocampus correction of anaemia o Levels at which unconjugated bilirubin Provision of free albumin for causes brain damage are unknown, and bilirubin binding it's probably only free (non-protein - bound) bilirubin that is dangerous o JAUNDICE OF THE NEONATE (CONTINUED Conjugated Hyperbilirubinaemia: Much less common than unconjugated HB but much more serious prognosis Due to intra or extrahepatic obstruction / cholestasis Clinical features: nd o Usually presents in 2 week of life or later o Greenish skin discolouration o Dark bile-stained urine o Pale acholuric stools o Hepatosplenomegaly common o Failure to thrive Occasionally present at birth as a result of TORCH infection or rhesus isoimmunisation Causes: o Neonatal hepatitis: - TORCH infection - Metabolic causes - α-1 antitrypsin deficiency o Biliary atresia (intra or extrahepatic) o Inspissated bile o Choledochal cyst o Hepatic necrosis o CF o Complication of parenteral nutrition Classification of Jaundice According to Onset: Early (days 1 – 2) – uncommon: o Haemolytic jaundice (Rhesus, ABO) Normal (days 3 – 10) – very common: o Uncomplicated o Complicated Late (days 14+) : o Breast milk – common o Conjugated jaundice – uncommon o Inherited deficiency of glucuronyl transferase – very rare BIRTH TRAUMA Introduction: Soft Tissue Injury: Definition = injuries to the infant resulting from Erythema, abrasions and lacerations: mechanical forces (e.g. compression, traction) during the process of birth o Seen following forceps and vacuum delivery, episiotomy, uterine incision at C-section Accounts for fewer than 2% of neonatal deaths Traumatic cyanosis / petechiae: Larger infants are more susceptible o Occur over head, neck and upper chest Most are self-limiting and have a favourable outcome following a difficult delivery o Usually fade within 2 – 3 days Risk factors: o Large-for-date infants Ecchymoses: o Instrumental deliveries esp. forceps or vacuum o Seen with traumatic deliveries, precipitate o Vaginal breech delivery labour, preterm infants, poorly controlled o Abnormal / excessive traction during delivery deliveries or abnormal presentations Injuries to the Head: Cephalohaematoma: o Subperiosteal collection of blood secondary to rupture of blood vessels between the skull and periosteum o Never crosses sutures o Linear skull fractures may underlie o Resolution occurs over a few weeks o Management = observation only Caput succedaneum: o A serosanguineous, subcutaneous, extraperiosteal fluid collection with poorly defined margins o Caused by pressure of the presenting part against the dilating cervix Peripheral Nerve Injury: o Extends across the midline and over suture lines Brachial plexus injury: o Does not usually cause complications and o Occurs most commonly in large babies, usually resolves over first few days frequently with shoulder dystocia or breech o Management = observation only delivery o Most are Erb palsy (C5-C6 paralysis of Skull fractures: muscles of upper arm and shoulder girdle) o Generally linear fractures require no specific o Associated traumatic lesions = fractured treatment clavicle, fractured humerus, cervical cord injury, facial palsy o Most cases will resolve in first 4 months o Management = prevention of contractures Bone Injury: Cranial nerve and spinal cord injury: Fractures: o Result from hyperextension, traction, and o Most often observed following breech delivery overstretching with simultaneous rotation +/- shoulder dystopia o Facial nerve palsy most common o Clavicle = most frequently fractured bone; o Usually resolves or improves healing usually within 7 – 10 days Intra-Abdominal Injury: Relatively uncommon Most serious acute complication = haemorrhage Liver = most commonly damaged internal organ Management = rapid identification and stabilisation with blood transfusion THE PREMATURE INFANT Definitions: Gestation: o Term ≥ 37 weeks o Preterm < 37 wks o Post-term > 42 wks Birth weight: o Low birth weight < 2500g o Very low birth weight < 1500g o Extremely low birth weight < 1000g Weight for gestational age: o Appropriate for gestation (AGA) = th th birth weight between 10 and 90 centiles o Small for gestational age (SGA) = th birth weight < 10 centile o Large for gestational age (LGA) = th birth weight > 90 centile Risk Factors for Prematurity: Short-Term Complications of Prematurity: Maternal: Respiratory: o Extremes of age o Respiratory distress syndrome o High gravidity o Periodic breathing, apnoea of newborn: o Low weight o Acute abdomen Cardiac: o Pyelonephritis o Patent ductus arteriosus (PDA) o Uterine anomalies o Pre-eclampsia Neurological: o Prior termination o Periventricular / intraventricular haemorrhage: o History of infertility o Genital infection Hepatic: o Hypoglycaemia Foetal: o Hyperglycaemia o Multiple gestation o Hyperbilirubinaemia o Foetal anomalies o Polyhydramnios Renal: o Foetal demise o Dehydration, hyper/hyponatraemia, hyperkalaemia, metabolic acidosis Placenta & membranes: o Placenta previa GIT: o Abruptio placentae o Necrotising enterocolitis o Premature rupture o Feeding problems Social: Haematological: o Low SES o Anaemia o Smoking o Alcohol abuse Immunological: o Illicit drug abuse o Infection o Fatigue and stress Thermoregulation problems Idiopathic: o Previous preterm Late Onset Complications of Prematurity: Retinopathy of prematurity (ROP) Chronic lung disease Growth failure Neurodevelopmental impairments e.g. cerebral palsy, deafness SUPPORTIVE CARE OF THE PRETERM INFANT Oxygen Therapy: Thermoregulation: Oxygen is a toxic substance in the preterm infant and Body temperature must be maintained in the normal may cause ROP range (36.5 – 37) Arterial oxygen tension should be maintained between Achieved by nursing preterm infant under an open 50 and 80 mmHg radiant heat source or in a closed incubator Methods of administration: o Directly into incubator Feeding: o Nasal prongs o CPAP o Endotracheal tube Premature infants require frequent feeding via NG tube Should be warmed to 35 – 37ºC and humidified Should be started on 1 – 2 ml/kg increasing as Monitor via pulse oximetry tolerated Gastric aspirates must be checked before the next feed Parenteral Fluids: Sick babies and infants < 1750g may need parenteral feeding with 10% dextrose infusion into umbilical or Other Considerations: peripheral vein Exogenous surfactant should be administered via ET Electrolyte requirements of preterm infants is tube prior to 2 hours of age increased due to poor conservation by immature kidneys Single IM dose of vitamin K should be administered at birth Close monitoring of serum electrolytes is necessary INFANT FEEDING AND NUTRITION Specific Nutritional Requirements: Breastfeeding: Water: Advantages to the baby: o A healthy breastfed infant will consume as o Nutritional – provides baby with a source of much fluid as is required; and healthy bottle- nutrition that changes with the baby's fed infants will know how much they need and changing metabolic needs should be allowed to consume milk when they o Confers an advantage in intellectual want it attainment o Infants who have suffered IUGR should be o Anti-infective fed to an expected weight as if they had o Antiallergic – reduces risk of asthma and grown normally in utero eczema in prone infants o Ill premature infants will tolerate less than o Protection against various illnesses e.g. their recommended volume gastroenteritis; apparent protection against SIDS Energy: o Requirements depend on baby's birthweight, Advantages to the mother: gestational age and state of health o Sense of pride and achievement o Carbohydrate – lactose is sole carb in human o Promotion of close mother-baby relationship milk; provides 40% of infant's total energy o Weight loss requirement in milk o Convenience o Fat in milk provides approx. half infant's o Contraception – delays return to ovulation energy requirements o Contraction of uterus involution o Protein – 10% of infants requirements o Financial benefit o Health advantages – protection against ovarian and premenopausal breast cancer and osteoporosis Feeding the VLBW Infant: Anti-infective properties: Some ill VLBW infants will not tolerate milk feeds and o Breastfed infants are less likely to develop require total parenteral nutrition gastroenteritis, NEC, OM and other serious infections e.g. septicaemia, meningitis For those in whom milk may be safely given, there is a o Immunoglobulins – IgA = most important Ig choice between breast milk or formula feed secreted in breast milk; in very high concentrations in colostrum Breast milk: o Cells – macrophages, polymorphs and both T o Human milk is not nutritionally adequate for and B lymphocytes very immature infants o Lysozyme – acts to lyse the E. coli cell o But has some advantages e.g. reduced risk of membrane infection, reduced risk of NEC, growth factors, o Lactoferrin – binds iron (inhibits multiplication cognitive development of some bacteria) o Antiviral properties – secretory IgA or Low birth weight formula: interferon production by lymphocytes o Often contain more sodium, potassium, protein and carbohydrate than breast milk and Contraindications to breastfeeding: regular artificial feeds o In the mother: o Continue until infant is 35 weeks - Acute illness (relative) postconceptual age and then change to - Chronic illness – neoplasms, mental regular formula feed illness, TB - Breast infection / abscess Enteral vs. parenteral feeds: - HIV infection o Early exposure of baby's gut to enteral feeds o In the infant: has been shown to mature gut function - Acute illness o Low-volume hypocaloric feeds (20ml/kg) - Mechanical problems e.g. cleft lip reduce the time to reach full feeding - Metabolic problems e.g. galactosemia, lactose intolerance Principles of management: - Breast milk jaundice o Early introduction of breast milk is beneficial, even if given in small volumes Supplements to breastfeeding: o Avoid milk feeding in the first 5 – 7 days in o Full term infant: babies at high risk of NEC - Babies receive sufficient iron in o Nasogastric route is preferred breast milk alone at least until 6/12 o No advantage of continuous feeding over - At ~6/12 some iron containing foods bolus feeding should be slowly introduced o TPN should only be used when milk feeding is o Preterm infant: contraindication; use for the shortest - Needs supplemental iron whether acceptable period of time breastfed or not COMMON FEEDING DISORDERS IN THE NEONATE Infant Colic: Some apparently healthy infants cry at certain Vomiting: times during the day, especially in evening around 6pm Common problem in the newborn Tends to disappear spontaneously at around 3 Non-organic causes: months o Overfeeding o Incorrect preparation of feeds Often no obvious cause o Overstimulation or excessive handling o Crying Treatment: o Air swallowing o Attention to feeding techniques o Posture feeding Organic causes: o Warmth to abdomen e.g. baths o Infection (UTI, GE, meningitis, OM) o Removal of milk from maternal diet o GOR o Gastritis (meconium, blood) o Hiatus hernia o Organic bowel obstruction Constipation: o Pyloric stenosis o Small bowel obstruction Aetiological factors: o Large bowel obstruction o Inadequate / improper feeding e.g. too o Food allergy concentrated milk formula o Anatomical abnormalities e.g. anal stenosis, Hirschsprung's, fissure in ano Gastro-Oesophageal Reflux: Treatment: o Local anaesthetics for fissure in ano Common cause of vomiting o Alteration of feeds may be indicated Caused by incompetent LOS e.g. giving prune juice, extra water Prevalent in preterm infants Clinical features: o Vomiting at end of feed o Gradual improvement with growth Diarrhoea: st o Cessation usually by end of 1 year Complications: Stools initially change from dark green-black o Persistent vomiting FTT (meconium), through a greenish-yellow o Oesophagitis, hiatus hernia, stricture transitional stage, and attain typical yellow o Obstructive apnoea, SIDS colour by 4 – 5 days o Recurrent aspiration of milk Investigations: May be very frequent initially, especially in o Barium swallow breastfed babies o Technetium milk scan o pH probe Causes of diarrhoea: Treatment: o Maternal diet in a breastfed infant e.g. o Prone position with 30 - 40º head-up excessive chocolate, coca-cola etc tilt o Incorrect formula preparation, over- o Nurse infant in more upright position feeding o Thickening of feeds o Infection (bacterial, viral, protozoal) o Drugs e.g. infant Gaviscon o Sugar intolerance – transient or permanent o Steatorrhoea e.g. CF Pyloric Stenosis: Management: o Attention to fluid balance Usually presents after first month of life o Anti-diarrhoeal drugs NOT used Clinical features: o Projectile vomiting o More common in boys Failure to Thrive: o Visible peristalsis o Palpable "tumour" Babies at least double birth-weight by 5/12 and o Often family history treble it by 1 year Manifests as fall-off in wt gain & linear growth Treatment: A fall in growth curve when gluten is introduced o Surgical – muscle-splitting operation of is suspicious of coeliac disease the pylorus Normal head growth may continue despite poor weight gain, as brain growth is last to fail RESPIRATORY DISORDERS IN THE NEWBORN Respiratory Distress: Following signs for > 4 hours: o Tachypnoea > 60 / min o Chest recession o Cyanosis o Nasal flaring o Expiratory grunt o Tracheal tug Investigations: o CXR o Bacteriology – blood, urine, CSF o Virology – NPA, blood o Haematocrit & FBC Transient Tachypnoea of Newborn: Respiratory Distress Syndrome: Other Causes of Respiratory Distress Benign disorder of 2 – 3% of Introduction: Pneumonia: newborns o AKA Hyaline membrane o Presents with early or late disease onset respiratory distress Predisposing factors – retained o Specific entity in preterm o Non-specific with lethargy, lung fluid: infants apnoea, bradycardia o Term / near term infant o Caused by lack of surfactant o Ex = ↓ air entry, o Heavy maternal analgesia crepitations, consolidation, o Birth asphyxia Epidemiology: effusions o Caesarian section o Common condition – 1% o CXR = lobar pneumonia o Breech delivery o Predisposing factors: rarely occurs; widespread o Male sex - Maternal DM diffuse / patchy coarse - Antepartum haem changes Clinical features: - Second twin o Organisms: o Tachypnoea - Hypoxia at birth - Gram –ve e.g. E. o Cyanosis - Male Coli, Klebsiella, o Grunt - Caesarian pseudomonas o Onset in first 1 – 3 hours - Family history - Group B o Usually lasts < 24 hours haemolytic strep Clinical features: - Staph aureus Chest x-ray: o Diagnosed at birth or first hrs - Candida o Hyperinflation o Signs of respiratory distress - Viral (rare) o Cardiomegaly o Oedema o ↑ perihilar markings o Apnoea Meconium aspiration syndrome: o Perihilar cuffing o Course = ↑ for 24 – 72 hours o Meconium staining of o Fluid in fissures then diuresis and recovery 48 liquor occurs in 10 – 15% o Coarse streaking in lungs – 96 hours of births, esp. breech, post-term, foetal distress Management: Radiological signs: o Aspiration into lungs o 30 – 40% oxygen o Hypoinflation occurs within a few o IV fluids o Diffuse granuloreticular breaths of birth o No oral feeds pattern ("ground glass") o CXR hyperinflated o Air bronchograms lungs; widespread course o Severe – diffuse white-out pulmonary infiltrate and collapse Management: o Assisted ventilation Pulmonary hypoplasia: o Exogenous surfactant o Bilateral hypoplasia occurs secondary to: Prognosis: - Oligohydramnios o Relates to severity and - ↓ intrathoracic gestational age space e.g. o Complications include hydrops neurosensory disabilities e.g. - Chest wall spasticity, deafness deformities MAINTENANCE OF BODY TEMPERATURE IN THE NEWBORN Introduction: Why is the newborn prone to heat loss? Central / core temperature should be maintained Large surface area to body weight ratio between 36.7 and 37.3ºC Limited ability to shiver Mechanisms of heat loss: Deficiency of subcutaneous fat tissue o Evaporation – when a moist baby is exposed to room temp there is conversion Relative deficiency of brown fat and glycogen of liquid to vapour with subsequent loss of heat Often born covered in liquor, vernix, meconium or blood moisture predisposes to loss of heat and o Radiation – heat is dissipated down a fluid by evaporation concentration gradient via the surrounding air o Conduction – direct heat loss from the skin to cooler objects e.g. wet nappies o Convection – heat loss occurs via a current of moving air Mechanisms to conserve heat: Prevention of Excessive Heat Loss: o Peripheral vasoconstriction Labour ward: o Increased heat production: o Provision of warmth is first essential in - Increased basal metabolism with resuscitation of newborn increased oxygen consumption o Overhead radiant heat warmer may be - Increased voluntary muscular useful activity - Involuntary muscular activity – Nursery: shivering (non-existent in preterm o VLBW infants – no superficial layer of infant) keratin ambient humidity in incubator will prevent losses o Non-shivering thermogenesis – full-term o Reduce radiant and convective heat loss infants are born with layer of brown fat by dressing infant whenever possible around the neck, between scapula and o Avoid positioning infant near cold window along aorta can be rapidly metabolised o Avoid placing infants in draughts to generate heat (under control of o Never place infant on cold surface or in sympathetic nervous system) cold cot THE FITTING NEONATE Introduction: Clinical Assessment: Causes: Most neonatal seizures occur History: Hypoxic-ischaemic encephalopathy over only a few days o Family history of neonatal convulsions Intracranial haemorrhage < 50% develops seizures later o Detailed pregnancy in life history - ? TORCH Metabolic: o Delivery history – o Hypoglycaemia Most frequent during first 10 type and APGAR o Hypocalcaemia days of life o Postnatal history o Hypomagnesemia Examination: Intracranial infections: o Lethargy between o Meningitis seizures o Encephalitis o Neurological exam o Toxoplasmosis o CMV o Bacterial – E. coli, strep Cerebral malformations: o Lissencephaly Investigations: o Polymicrogyria o Pachygyria Lab studies: o Serum glucose and electrolytes Benign neonatal seizure syndromes: o CSF analysis o Occur in first 48 – 72 hours o TORCH studies o Disappear by 2 – 6 months o Urine acids o Family history of seizures o Renal function o Development normal Imaging: o Cranial ultrasound o Cranial CT o MRI Others: o EEG o Echocardiography Management: Follow-Up: Should be treated aggressively Discontinue seizure medications between 3 and 6 months if further seizures have Correction of electrolyte abnormalities not occurred through central venous site General recommendation is to use AEDs Obtain EEG to differentiate whether for 3 months then taper gradually events are epileptic or non-epileptic Devlopmental evaluation for identification If inborn error of metabolism suspected, of physical / cognitive deficits discontinue feeding and institute IV solutions Complications: o Cerebral palsy Consider antiepileptic drug therapy: o Hydrocephalus o Epilepsy o Phenobarbitol = initial drug of o Spasticity choice o Feeding difficulties o If seizures continue, consider phenytoin Prognosis: o If EEG normal, prognosis excellent seizures resolve and normal development likely HYPOGLYCAEMIA Introduction: Symptoms: Term infants = blood glucose concentration of Major = apnoea, convulsions and coma 2.2 – 2.5 mmol / L and in preterm infants = < 1.1 mmol/L after the first 24 hours of life Minor = jitteriness, irritability, tremors, apathy, cyanotic spells and temperature instability Normoglycaemia in newborn = blood sugar levels of 2.6 mmol / L and above Symptoms are non-specific and similar to those of infection Therefore recommendations = maintain preterm and term infants at risk of hypoglycamemia above May be asymptomatic 2.5 mmol / L Causes: Management: Decreased substrate availability: Prevention: o SGA infants o Frequent heel-stick examination tests in o Premature infants at-risk infants e.g. IDM, SGA and o Second twin preterm infants o Early feeding at risk infants should be Increased glucose utilisation: fed within 2 hours of birth with high o Hyperinsulinaemia: glucose containing solutions - IDM - Rhesus isoimmunisation Treatment of established hypoglycaemia: - Islet cell tumour o If asymptomatic hypoglycaemia fails to o Polycythaemia be corrected by early, frequent feeds, an infusion with 10% dextrose will be Inability to utilise glucose: necessary o Glycogen storage disease type I o Symptomatic will require a dextrose o Galactosemia infusion o Fructose intolerance o Where possible, oral feeding should be o Inborn errors of amino acid metabolism continued Iatrogenic: Resistant hypoglycaemia: o Inappropriate infusion of glucose o Hydrocortisone o Glucagon Miscellaneous: o Diazoxide o Birth asphyxia o Investigation for insulinoma o Endocrine deficiencies o Hypopituitarism Prognosis: Severe symptomatic hypoglycaemia very poor prognosis – 50% will die and 50% of survivors will have severe neurodevelopmental abnormalities e.g. mental retardation, convulsions, spasticity, microcephaly Asymptomatic infants are not at risk of abnormal neurodevelopmental outcome? Repeated low blood sugar levels may have a cumulative adverse effect on neural function INFANTS OF DIABETIC MOTHERS (IDM) Classification of Maternal Diabetes: Effect on Foetus and Baby: Pregestational The 2 main factors determining whether maternal diabetes will have an effect on the Type 1 = due to beta cell destruction foetus and baby are the vascular complications that the diabetes causes the Type 2 = due to insulin resistance mother, and the blood glucose control during pregnancy Gestational diabetes Vascular disease: o Mothers with vascular complications are much more likely to develop hypertension in pregnancy may affect foetal growth and well-being Clinical Features of IDM: Glucose control: Congenital malformations: o Blood sugar should be maintained o Congenital heart disease, especially below 8mmol / L and hypoglycaemia VSD, transposition of great vessels avoided and coarctation of aorta o Renal vein thrombosis o Sacral / coccygeal agenesis o Left microcolon o Hypertrophic cardiomyopathy Management: Stillbirth: o Increased risk of intrauterine foetal Careful control of diabetes during pregnancy death during pregnancy decreased many of the complications Small for gestational age (SGA) Management involves: o Obsessional diabetic control Macrosomia: o Planned delivery in a suitably o Insulin = major trophic growth factor equipped hospital influencing foetal growth o Examination for congenital o Infants are plethoric, obese, and abnormalities Cushingoid in appearance o Screening for expected o Enlarged liver, heart and spleen complications, especially o Increased body length and birth hypoglycaemia weight o Head circumference and brain weight are appropriate for gestational age o Excessive fat stores and inhibition of lipolysis Prognosis for IDM: o Larger size predisposes to other problems, e.g: - Birth trauma Perinatal mortality rates = 30 / - Birth asphyxia 1000 Neonatal hypoglycaemia: 1% incidence of overt DM in o Due to hyperplasia of islet B-cells in childhood foetal pancreas with foetal 10% have abnormal glucose hyperinsulinism from chronically elevated maternal glucose levels tolerance when tested in childhood o Lasts for several days Respiratory distress: o Insulin has antagonistic effect on surfactant development o Even at full term HAEMOLYTIC DISEASE OF THE NEWBORN Introduction: Rhesus antibody is the most common cause of severe HDN Rh antigens are expressed on RBCs only After initial exposure to foreign antigen, maternal immune system produces antibodies Clinical Assessment: (IgM) that do not cross placenta History: Later produces IgG that traverses placental o Women at risk for alloimmunisation barrier = primary response should undergo Coomb's test at first prenatal visit After sensitisation, maternal anti-D antibodies cross the placenta and attach to Rh antigen on Examination: foetal RBCs lysed by lysosomal enzymes o Jaundice (at birth or < 24 hours) o Pallor (anaemia) Prolonged haemolysis severe anaemia o Hepatosplenomegaly extramedullary haematopoiesis in liver, spleen, o Hydrops foetalis (severe) skin, placenta Unconjugated hyperbilirubinaemia after delivery only as placenta effectively metabolises bilirubin HDN associated with ABO incompatibility is limited to type O mothers with foetuses who have type A or B blood Comparison of Rh and ABO Incompatibility: Characteristics Rh ABO First born 5% 50% Later pregnancies More severe No increased severity Clinical aspects Stillborn / hydrops Frequent Rare Severe anaemia Frequent Rare Jaundice Moderate – severe, freq Mild Late anaemia Frequent Rare DAT Positive Weakly positive Lab findings Indirect Coombs test Positive Usually positive Spherocytosis Rare Frequent Management: Prevention: Monitor serial maternal antibody titres Rh immunoglobulin prevents Rh alloimmunisation when administered to mother In severely affected foetus perform in-utero within 72 hours of delivery intravenous transfusion until 35 weeks gestation Administer RhIG to all unsensitised Rh-negative Phototherapy for hyperbilirubinaemia post- women at 28 weeks gestation natally Exchange transfusion to remove circulating bilirubin and antibody-coated RBCs Complications: Bilirubin encephalopathy (kernicterus) Late anaemia of infancy INFECTION IN THE NEONATE The Immature Immune System: Susceptibility of the Neonate to Infection: Immune system is not functionally fully integrated Endogenous factors: until ~1 year of age o Low levels of Igs, especially IgM and IgA o Premature infants fail to receive normal Specific immunity: passive IgG transfer during last trimester o Phagocytic action is less effective in the o Mediated through lymphocytes (T and B newborn cells) o Opsonic activity is impaired, and complement levels are low o B cells: o IUGR infants appear more susceptible - IgM is first immunoglobulin to be produced at 15 weeks gestation Exogenous factors: - IgG first produced at 20 weeks o Baby is born bacteriologically sterile, with - The 3 major Ig types are at little competition from existing bacterial minimal levels in the foetus and flora when exposed to potential pathogens remain very low at birth babies exposed to very early antibiotic - Adult levels of IgM by 1 year and use may be predisposed to colonisation of IgG by 5 years with pathogens - IgG is the only Ig that crosses the o Drugs may further impair immune function, placenta gives foetus effective especially corticosteroids passive immunity but levels fall in o Fat emulsions – e.g. Intralipid impairs months after birth phagocytic function of WBCs o Hyperbilirubinaemia reduces immune o T cells: function in several ways - Produced in the foetal bone marrow and migrate to the thymus Non-specific immunity: o White blood cells especially granulocyte – phagocytic function of engulfing bacteria o Attracted to sites of inflammation by chemotactic chemicals e.g. complement o Impaired opsonic activity in the neonate (complement and fibronectin) Origins of Infection Intrauterine: Intrapartum: Acquired: Transplacental: Colonisation of infant during Nosocomial: o First trimester = TORCH passage through birth canal (only o Bacteria: infections cause infection in small proportion) - Staph. Aureus o 2nd trimester = syphilis Risk factor = prolonged rupture of - GBHS o 3rd trimester and labour: membranes - Coliforms - Viral = varicella, HBV, Pathogens: - Salmonella Coxsackie, HIV o Herpes simplex 2 - Shigella - Bacterial = group B o Neisseria gonorrhoeae - Pseudomonas haemolytic strep, o HBV o Viruses: listeria, H. influenzae, o GBHS - Coxsackie pneumococcus o Chlamydia trachomatis - Rotavirus - Protozoan = malaria o Candida albicans - RSV o ? HIV - Adenovirus Ascending infections: - Echovirus o Occur after rupture of o Fungal: membranes - Candida o Most common pathogens = bowel albicans organisms e.g. E. coli, klebsiella, proteus, pseudomonas; GBHS, staph. aureus (rare) INFECTIONS IN THE FOETUS AND NEONATE Pathogenesis of Intrauterine Infection: Pathogenesis of Ascending Bacterial Infection: Results from clinical or subclinical maternal infection In most cases, foetus is not exposed to bacteria until with a variety of agents and haematogenous the membranes rupture and the infant passes through transplacental transmission the birth canal and enters the extrauterine environment E.g. CMV, treponema, rubella, varicella Human birth canal is colonised with aerobic and anaerobic organisms that may ascending amniotic Transplacental infection may occur at any time during infection and colonisation of neonate at birth gestation, and signs and symptoms may be present at birth or delayed for months or years Vertical transmission may occur in utero or more commonly during labour and / or delivery Consequences of infection: o Spontaneous abortion In most cases, bacterial colonisation does not result in o Congenital malformation disease o Intrauterine growth retardation o Premature birth Factors influencing which infant develops disease: o Stillbirth o Prematurity o Acute disease in neonatal period o Underlying illness o Asymptomatic persistent infection o Invasive procedures o Inoculum size Timing of infection is important: o Virulence of infecting organism st o 1 trimester alter embryogenesis o Transplacental maternal antibodies congenital malformations e.g. rubella rd o 3 trimester active infection at delivery e.g. syphilis Pathways of Ascending / Intrapartum Infection: For some etiologic agents, maternal immunity is effective and antibody is protective for foetus (e.g. rubella); for others, maternal antibody may ameliorate the outcome of infection or have no effect (CMV) Pathogenesis of Late Onset Post-Partum Infection: Post-natal infections may be transmitted by: o Direct contact with hospital staff, the mother or other family members o Breast milk (HIV, CMV) o Inanimate sources e.g. contaminated equipment Most common source = hand contamination of health care personnel Most cases of meningitis from haematogenous dissemination Aetiology of Foetal and Neonatal Infection: Intrauterine transplacental Vertical transmission: Nosocomial infection: infections: o HIV o Coag-neg staph o Syphilis o HSV o Gram neg bacilli e.g. o Rubella o CMV E. coli, Klebsiella o CMV o Group B haemolytic o Enterococci o Toxoplasmosis streptococcus o S. aureus o Parvovirus B19 o Enteric organisms o Candida o Varicella o Gonococci and o Enteroviruses Chlamydiae o CMV, RSV, HSV INFECTIONS IN THE FOETUS AND NEONATE (CONTINUED) Initial Signs and Symptoms of Infection in Newborn Infants: General: Clinical Manifestations of Transplacental o Fever, temperature instability Intrauterine Infections: o "Not doing well" o Poor feeding Present from birth: o Oedema o Intrauterine growth restriction o Microcephaly / hydrocephalus Gastrointestinal system: o Intracranial calcifications o Abdominal distension o Chorioretinitis o Vomiting o Cataracts o Diarrhoea o Myocarditis o Hepatomegaly o Pneumonia o Hepatosplenomegaly Respiratory system: o Anaemia o Apnoea, dyspnoea o Hydrops foetalis o Tachypnoea, retractions o Skin manifestations including o Flaring, grunting petechiae, purpura, vesicles o Cyanosis Late sequelae: Renal system: o Sensorineural hearing loss o Oliguria o Visual disturbances o Seizures CVS: o Neurodevelopmental o Pallor, mottling, cold, clammy abnormalities o Tachycardia o Hypotension o Bradycardia CNS: o Irritability, lethargy Evaluation of a Newborn for Infection or Sepsis: o Tremors, seizures o Hyporeflexia, hypotonia History (specific risk factors): o Abnormal Moro reflex o Maternal infection during gestation or at o Irregular respirations parturition (type and duration of Ab therapy) o Full fontanel - UTI o High-pitched cry - Chorioamnionitis o Maternal colonisation with GBS, gonorrhoea, Haematologic system: HSV o Jaundice o Gestational age / birthweight o Splenomegaly o Multiple birth o Pallor o Duration of membrane rupture o Petechiae, purpura o Complication delivery o Bleeding o Foetal tachycardia (distress) o Age at onset o Location at onset (hospital, community) o Medical intervention: Suspected Intrauterine Infection: - Vascular access - Endotracheal intubation TORCH: - Parenteral nutrition o Toxoplasmosis - Surgery o Other agents (syphilis etc) o Rubella Evidence of other diseases: o CMV o Congenital malformations (heart disease, NTD) o HSV o Respiratory tract disease (RDS, aspiration) o Necrotising enterocolitis Features supporting diagnosis: o Metabolic disease e.g. galactosemia o IUGR o Hematologic involvement Evidence of focal / systemic disease: o Ocular signs o General appearance, neurological status o CNS signs o Organ system diseases o Other organ system involvement o Feeding, stools, urine output, extremity o Nonimmune hydrops movement CONGENITAL DISLOCATION OF THE HIP Introduction: Aetiology: Should be detectable during routine screening 19 in 1000 births examination at birth Left > right due to foetal positioning causing left hip Examination of the hip should start with observation to be more adducted than the right for signs of established dislocation e.g. unequal leg length and asymmetry of thighs Following associations with CDH: Examination should be conducted in 2 parts: o Polygenic / multifactorial condition – recurs in families at rate of 1 / 30 o Ortolani's (reduction) test: - Assesses whether hip is already o Presentation – breech / vertex ratio of 10:1 dislocated - Flex hip and knees to 90º o Females > males 6 : 1 - Grasp baby's thigh with middle finger over greater trochanter and o Race – increased incidence in some lift it to bring the femoral head countries e.g. Italy from its dislocated position posterior to opposite the o Abnormalities producing muscular acetabulum imbalance around the joint e.g. spina bifida, - Simultaneously the thigh is gently hypertonia abducted, reducing the femoral head over the posterior lip of the o Syndromes e.g. trisomy 13, trisomy 18 acetabulum - Positive finding = reduction o Multiple congenital abnormalities sensed by feeling a clunk, and movement forward of the head of the femur o Barlow's (dislocation) test: - With one hand fixing the pelvis Management: with the thumb anteriorly over symphysis pubis and the other Keep hip immobilised in an abducted fingers posteriorly over coccygeal position for 2 – 3 months to allow region acetabular rim to develop and hip - Other hand grasps baby's thigh ligaments to strengthen and adducts it gently downwards - Dislocation is palpable as the After 3 months, splint can be removed femoral head slips over the and check x-rays are taken at 6 and 23 posterior lip of the acetabulum months of age Infants may have normal hips at birth which may Fixed dislocations of the hip, failure to subsequently dislocate examine hips at 6-week respond to treatment and late assessment diagnosed dislocated hips will require individual orthopaedic consideration Failure to abduct a hip is a very significant sign
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Author has written 8 stories for Romance, and Young Adult.
Hello, everyone!
Haven't been on here for a while, been away, shirking my duties as a writer. But I hope to write out my imagination, something that will hopefully amuse one and all.
Manet's Olympia
She reclines, more or less.
There's someone else in this room.
I, the head, am the only subject
- The Unexpected -
Unsafe External Link

subset: commoncrawl


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(390 ratings)
February 22, 2012
By: Lesbea
This video is part of the following collections:
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Haha February 23, 2012
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- Daisy is back in her bedroom, but this time she's with Lisa who absolutely insisted she get to do a scene with the amateur model. Wow. You just have to watch it to feel it, the kissing, the motions, the feeling, it's incredible to watch it all unfold. There is something so naturally beautiful about this it's hard to put into words. It's just a sheer joy to watch two people enjoy each other so intimately and lasciviously. Lisa is so eager she humps Daisy, she is all over her from beginning to end! Even after the girls have given each other orgasms they just continue to lay there hugging and kissing and we were lucky enough to have the camera rolling, quietly and unobtrusively shooting the them in this private after-sex moment.


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Book reviews : Brunson's 'Online Poker' and Shoten's 'No-Limit Life' - Both Invigorating BooksSeptember 27, 2005 - 2:53am
World Series of Poker Champion Doyle Brunson's Online Poker and Charlie Shoten's No- Limit Life are new arrivals in poker literature and both have value for those who are serious about improving their game.
United States of Poker: IllinoisSeptember 27, 2005 - 2:53am
Gambling in Illinois has a long and infamous history.
Havana, Illinois was known as Little Reno because of Al Capone's development of floating casinos on the Illinois River. In the mid- 1930s, the Nitti gang ran casino games in Calumet City and Cicero, and this continued under Accardo and Ricca in the 1950s. In 1953, state troopers raided 14 casinos and taverns in Mason County, ending gambling in that area. Eventually the Mafia influence on gambling in the Chicago area decreased and legal lotteries and riverboat gambling sprung up.
Falling in LoveSeptember 26, 2005 - 2:53am
I fell in love recently. The world's incredibly beautiful. The colors all around are brighter. I appreciate what I take for granted at times. Such as, how much I love my family and friends, how fortunate I am to be living in this day and age. The awesome possibilities the future may hold, that I may achieve with commitment and Faith. I've realized how precious and short life is, whether one lives a hundred years or even a fraction of that number. This enables me to slow down and experience each day, hour, minute and most importantly, moment.
Ego & StrategySeptember 26, 2005 - 2:53am
Continuing on our quest to examine all elements of our game in order to find possible weaknesses to improve upon, let's discuss egos today. Egos are a curious part of our makeup. They may be inflated, bruised, overactive or any number of other things but we all have them. Do you keep yours in check when playing poker? You really should check it at the door or leave it in the car! Have you ever witnessed someone win a big pot with ugly hole cards and then hear that individual explain to the table that he was in the big blind. Why is this explanation necessary?
Poker Cop: 'L' is for LimpSeptember 26, 2005 - 2:53am
Detective Sweeny has told the newspapers: "The people of this city can rest easy. A 'Mad Dog Killer' has been put down."
I, "The Mad Dog Killer," put down the paper and quote Mark Twain, "The reports of my death have been greatly exaggerated." Reading the story of my own exaggerated death leaves me uneasy. Again I get the feeling Something's wrong. Something's. . . ."
"Something's wrong," I say to Jake, "Listen!"
"I don't hear anything." "That's what's wrong! No cards being shuffled. No chips being riffled. No. . . ."
Jake grabs for his shotgun as the door is kicked in.
Superstitious ForcesSeptember 26, 2005 - 2:53am
Mike teaches that superstition can influence your outcome at poker. When he was giving me this lesson about not acting superstitiously, I remarked, "There are many people who are very superstitious. What you're saying is that superstition doesn't affect your outcome at poker?"
He said, "Wrong! Superstition does affect outcomes at poker in dramatic ways."
Pumped on SteroidsSeptember 26, 2005 - 2:53am
We have become a win at all cost society, so that the shortterm results have yielded a mix bag of consequences. Namely, for all the heralded accomplishments of this era there is an equal amount of failures and embarrassments. According to any number of sources, the increased steroid usage can be directly attributed to the overwhelming success of today's athlete. In addition, to what degree has the influx of new era poker player's success attributable to steroid usage? Many celebrated athletes in sports are linked with the illegal practice of steroid usage, either directly or indirectly.
Hot TipSeptember 26, 2005 - 2:53am
Hobby was driving his Silver Cloud Rolls to Hollywood Park since valets there were likely to conviently leave it out front as a showpiece. It's a short drive from Marina Del Rey to the racetrack, hardly time for me to study the Daily Racing Form for the nags in the first race. Not fair to disparage them however, they were just unproven 3 year-old maidens. My late uncle Victor was good at selecting winners of all stripes, especially those who never made it into the money. For many years he sold his cards of Vic's Picks at southern California racetracks.
Today's word is... FlopSeptember 26, 2005 - 2:53am
What can you say about the flop in hold 'em? There are few things in poker as suspenseful. The whole fate of your hand usually hinges on what those three cards will look like when the dealer turns them face up.
It's fun watching flops. Indeed.
That's why I'm asking you not to get mad at me when I ask you not to do it. You see, looking at the flop at the moment it hits the felt is the last thing you want to do if you expect to maximize your hold 'em profit. I'm going explain this concept the same way I did years ago in a lecture. Here it is...
The Cadillac of poker?!?September 26, 2005 - 2:53am
Have you spent any time watching the Travel Channel's World Poker Tour or the World Series of Poker? If you have I am sure you've heard Mike Sexton refer to No Limit Hold-Em as the "Cadillac of Poker". Will someone, anyone, including Mr. Sexton, explain just how that moniker was attached to No Limit Hold-Em.


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Double chocolate peanut butter honey cookiesPosted by Bake Club on Wednesday, March 18, 2015 In : cookies
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Soooo, I rooted my phone a while ago (galaxy s4 i337 build mk2 4.3) to erase all the bloatware and stuff.
I decided to unroot it using titanium backup because my phone was starting to slow down, even after moving off all pictures/music (what was taking up the most storage).
When i unrooted it, it was still slow and the update wouldn't go past 27%, so i was stuck on 4.3.
A few days ago I tried to flash the stock firmware using Odin and lost 4g data/any type of network data but still can connect to wifi and call/text.
ps I used a post from androidrootz, and since I am a new member, I am unable to post that link in this post.
Does anyone have any idea what could have caused that/what i could do to fix it?
Last edited by christina18249; 5th September 2014 at 03:43 AM.


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Comment: Re:Then ID would be required (Score 1) 1089
There are times when you do have to have ID, such as during curfews. People usually don't get hassled for it, but if a cop finds you out after curfew you can be in violation of the law.
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There are times when you do have to have ID, such as during curfews. People usually don't get hassled for it, but if a cop finds you out after curfew you can be in violation of the law.
As a constitutional matter, municipalities do not have any independent existence; they are organs of the state governments. Municipal governments only have whatever powers states choose to give them, and the federal government may not commandeer a state government. So if a state chooses to deny its municipalities the authority to sell Internet access (or sell it below a certain price), then no declaration from the FCC can give the municipality that power, nor require the state to give a municipality that power.
So, all this vote means is the FCC majority has decided to waste a bunch of taxpayer dollars losing a lawsuit.
Just like states are only part of the country? States were abusing their authority to disbar municipalities due to business buying their votes. A very monopolistic action. They should actually go all RICO on them and throw their boards of directors in jail.
These companies follow the tax code as written/enforced. If you don't like the revenues the current tax code generates, rewrite the tax code - but don't be surprised if they seek out a new location with lower taxes.
That's when you make sure you add a rule that even if you leave (ie. headquarter in another country) that you still have to pay an equal tax here or that foreign country.
I believe this is the current thought and idea to implement.
There are several MMOs that no longer have servers at all, ie. being essentially abandoned. Do those worlds not deserve to be preserved for posterity or for game enthusiasts?
Exempting MMOs across the board from this process seems short-sighted.
This 14% to 19% is closer to the USA's 'real' tax rate, which has so many loopholes that it's actually lower than most of the developed world.
People love to harp on the fact that the USA's corporate tax rate is so high, but it truth with all the political rewriting of the corporate tax rate its fairly low.
And then you have companies like Apple doing their all out best to not pay taxes at all.
The last is what Obama is trying to remove. And Republicans/Fox News and it's handlers are going to try their level best to sell the American People that this is a bad thing to fairly tax the poor super-corporations that get away with bloody murder.
1/ MPAA / RIAA lie - news at 10
2/ PR statements are bullshit - news at 10
Where's the surprise here?
Actually, if they report this as part of their stockholder's meeting/information about the state of their company, I think it's quite illegal. As in the Feds can come in and start checking your books for other 'hundred million dollars lies'.
(Sorry, did not mean to post anonymously).
It doesn't matter how many new features they add if their account recovery is so broken that the owners can't get control of their own account. Most people don't want to make a replacement account as a solution.
I mean, you really expect someone to remember what year you made a skype account? And (not or) the first five contacts on your contact list?
an antitrust lawsuit accusing the drug company of forcing patients to switch to the newer version of the widely used medicine to hinder competition from generic manufacturers.
Were the drug company sending hit squads round to take out the doctors that were prescribing generics? Did they launch a tactical air strike on the generics factories? Hijack the lorries carrying the generics?
I'm sorry but, so far as I can tell, manufacturers are free to manufacture the generic, doctors are free to prescribe it and patients are free to take it. I don't see why Actavis should be forced to produce a drug they no longer want to produce and I don't see what this can possibly achieve because once the drug leaves patent protection the generics manufactures will be able to manufacture it regardless and, before then, patients will have to buy the pricier brand-name drug anyway.
I don't think the patent had actually expired yet on the older medicine. It was just getting close to expiring. Drug companies have figured out the 'new' way to keep you off of generics is to 'improve' the formula so that your doctor wants to keep you on the new one. I'm on Tribenzor, which is literally just a mix of three regular and cheap blood pressure medicines, but it's 'not generic' so I have to pay a much more expensive rate.
So yeah, this is just scum sucker scam way of maximizing profits at the cost of the patient and his insurance.
We somehow need a ton of 5.62 rifles and 7.62 rifles, bayonets, a blowdart, a grenade launcher and a Hellfire High Intensity (something?).
And considering the SLC Metro area isn't _that_ rough and tumble, I'm wondering who they are planning to go to war against?
But this was just for iOS7? Or is it for Android devices too?
I'm pretty sure I saw that in Captain America: Winter Soldier last night. Now they just need to get it flying!
Not that anyone has been warning about DRM linked to servers being a failure. I wonder how much they are going to be sued for?
Did I miss where the USA added a new territory or state recently? I'm sorry, while the US does like to keep airbases in other countries, we don't invade them and force the area the airbase or navel base is in to join our country as a full territory..
The best sign that Russia is BSing about this expansion is that it only took them a week to get a 'referendum' through their proxies, while it usually takes years or decades for it to happen civilly.
They were over-reaching and taking too much power. They proved that they were corrupt and were not doing much other than infringing on American (and our Allies)'s rights.
They need to be pruned back and learn that we do no live in a fascist state.
Really, some of those leaders who lied under oath should be facing prison time.
Because they should be being asked this. And wondering about this. And even at times saying 'no, this is too far'.
Aren't you glad you're not getting all the government you pay for now?


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Undergraduate Business Programs
What kind of life are you looking for? The Gustavson Bachelor of Commerce program can take you anywhere you want to go.
Sardul S. Gill Graduate School
We offer three distinct programs, MBA, Master of Global Business and a PhD in International Management.
Executive Programs
We excel in open enrolment programs, custom programs, corporate retreats and international training.
We are turning 25 years old in 2015 and want to celebrate our birthday with our greatest achievement - our alumni!
We're organizing a global gathering on June 11, 2015, to get our Gustavson groove on. Find out more
See more recent stories on our News page.
- RBC Royal Bank Case Competition Finalists 2015
- Global marketing leader, advertising influencer, and author of Lovemarks: the Future Beyond Brands, Kevin Roberts is the first to receive honourary professorship in leadership and innovation by Peter B. Gustavson School of Business
- 2015 BCom KPMG Simulation
- Expansion of cross-cultural program for UVic global business grads
- Gustavson will honour Victoria-born musician and businessman, David Foster at DEYA 2015
Follow us
At the Gustavson School of Business we see things differently.
This video is a short trip, through the students eyes, of the unique experiences they have with us in class, on exchange overseas, on internship and most importantly having fun together.
Want to see your photos here? Tag your photos with #gustavson! Follow @GustavsonUVic on Instagram.
Our MBA students are about to present their management consulting projects to their client @mediacore #yyj #uvic http://t.co/sxlu1Vdmac
Beautiful indeed RT"@SandyH_CA: Beautiful morning ... #yyj #VictoriaBC #uvic http://t.co/ej6ptoxzps��� #gustavson
RT @ELO_BUS: Did you grad in 11/2014 from BCom? I want to know how you're doing! Check your email for a REALLY short survey :)
Congrats to BCom teams headed by Ryan Rich and Bo Macy for the wins in #PitchIt tonight!
RT @ICEUVic: And the #PitchIt winners are announced! https://t.co/GXhkz2I8UY @uvic has incredible student #entrepreneurs. Congrats to all w…
For more news, events, updates, and timely information follow @GustavsonUVic on Twitter.
Become a fan of Gustavson School of Business to receive news and events on campus.


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November 25, 2013
Comments Off
New technology gives malls same-day delivery capability
by Joel Groover Malls around the world are making it easier for customers to get merchandise delivered. U.S. mall owners are working with a Silicon Valley startup to offer a service that would have been unthinkable a few years ago: same-day delivery of items bought from tenants' stores and websites. Before mobile devices, such…


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Severe Weather
PHOTOS: Major storm causes flooding, mudslides in California
Up to 5 inches of desperately needed rain fell in some areas of Southern California, where several areas were hit by landslides, some areas saw minor flooding and fire officials rescued two people and pulled two bodies from rivers.
PHOTOS: Lake-effect snow buries Western New York
Lake-effect snow pummeled areas around Buffalo for a second straight day, leaving residents stuck in their homes as officials tried to clear massive snow mounds with another storm looming.
PHOTOS: Mount Ontake Volcano Erupts in Japan – 47 killed
Mount Ontake Volcano erupted in central Japan on Saturday, catching mountain climbers by surprise and trapping more than 250 people.
PHOTOS: Hurricane Hugo struck 25 years ago September 21-22, 1989
Hugo made landfall just north of Charleston, SC at Sullivan's Island around midnight September 22, 1989 as a Category 4 storm with estimated maximum sustained winds of 135-140 mph.
PHOTOS: Hurricane Odile slams Mexico's Baja California Peninsula
Hurricane Odile hammered Mexico's Baja California Peninsula overnight, tearing away the facades of luxury resorts, shattering countless car and hotel windows and leaving lobbies swamped and full of debris on Monday.
PHOTOS: Hurricane Norbert causes dangerous flooding in Arizona
More than 3 inches of rain closed parts of Interstates 10 and 17 and flooded numerous streets in the Phoenix aria.
PHOTOS: Then and now, the devastating Colorado floods of 2013
Hundreds of miles of roads were obliterated as rivers rechanneled themselves. Nine people died. At least 1,852 homes were washed away and many thousands more were damaged, leaving more than 18,000 people homeless.
PHOTOS: Hurricane Marie causing big waves, flooding in California
Big waves turned into floodwaters Wednesday along the Southern California shore as Hurricane Marie stirred up the surf from far asea.


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Mark English eases heat at European Indoors
- Other Sports
- March 6, 2015, 13:01
With a clear signal of both his medal ambitions and tactical cuteness Mark English comfortably qualified for the semi-final of the men's 800 metres - (...)
Mark English feels he is on right track for medal at European Indoors
- Other Sports
- February 24, 2015, 20:18
Not many Irish athletes can talk up their medal prospects in such realistic terms as Mark English. At 21, he may still be a student of 800 metre runn(...)
Funeral of boy (3) killed in lift shaft takes place in Galway
- Irish News
- January 20, 2014, 01:00
A grieving mother is to travel home to her family in Nigeria to mourn her three-year-old son who died in Galway last week. Omolara Alibi is making pla(...)
Mother too distaught to attend son's funeral in Galway
- Irish News
- January 19, 2014, 11:22
The mother of the three-year-old boy who was killed in a lift shaft in Galway last week was too distraught to attend his funeral.Omolara Alibi grieved(...)
Mother of child who died in Galway office lift calls for investigation to be made public
- Irish News
- January 18, 2014, 01:00
The mother of the three-year- old boy who died after he became trapped in a lift in Galway city has called for the investigation to be made public whe(...)
Anniversary vigils as Praveen receives Reilly invitation
- Politics
- October 27, 2013, 22:16
Minister for Health James Reilly has extended an invitation to Praveen Halappananvar, widower of Savita Halappanavar (31), to meet him.Mr Halappanavar(...)
Husband criticises Savita care staff review
- Health
- October 19, 2013, 01:00
Savita Halappanavar's husband, Praveen, has criticised the lack of outside independent involvement in the disciplinary process announced for staff inv(...)
Maternity care concerns raised in Savita report
- Health
- October 10, 2013, 01:00
Significant deficiencies in the care of critically ill women in the State's 19 maternity hospitals have been identified in a report on the death of Sa(...)
Praveen Halappanavar 'satisfied' Hiqa report vindicates his account of events
- Health
- October 10, 2013, 01:00
The husband of the late Savita Halappanavar is satisfied the Hiqa report into her death again vindicates his account of what happened his wife at Galw(...)
A year since the death of Savita Halappanavar
- Social Affairs
- October 9, 2013, 15:22
Sunday 21st October 2012: Savita Halappanavar (31), who is 17 weeks' pregnant, has been experiencing severe back-pain overnight at home in Roscam, (...)


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Indoor Plant
I got this pretty indoor plant little over a year ago. The plant was doing well till a few weeks back when I noticed some white powdery substance on the leaves and the stem. I bought the Garden Safe Fungicide which I have sprayed once every week during the last 3 weeks. I also left the plant out in the sun for a few days to see if that helps. I now find that the leaves have started to brown a lot. Please see the attached image.
Would love some help on what I can do to save the plant. I don't know a lot but would hate to lose this lovely plant.
Thank you so much!
Image link:
The leaves are badly sunburned. Plants cannot tolerate direct sunlight unless they are completely used to it. Even a very short time in the sunlight can do the damage, let alone 'a few days'.
Is this 'white powdery substance' still on the plant? If so, is there any way you could take a good (close-up) picture of the problem? In other words, are you certain that it is a fungus?
Thank you for replying. It was actually raining (not sunny or very little sun) when I left the plant out. Can that also cause burns?
Yes, the white substance is still on the plant. It is like specks of chalk powder. There isn't a lot but I would see 7-8 specks on every leaf. The stem has these specks as well. The top branch actually became really brittle and broke off yesterday while I was plucking out a leaf.
I can't add any more snaps to this thread I think but the white specks have caused yellow spots on some of the leaves. If you can share our email id, I will mail the snaps to you.
I am not sure it is fungus because powdery mildew is supposed to look quite different (as per some sites that I read). I have applied some fungicide but I don't think that is the right one.
Please do let me know what you think I should do.
Thanks again!
bitmeh send personal info via email from GW member page (My Page). It's not good to post email addys here because a spammer may get a hold of it.
Yes plants can get sunburned even on overcast days if not acclimated.
I'm also wondering if these spots could be mealybug or scale. Pics sure would help. If you would like to get or have a photobucket account upload pics there then just copy the HTML code from under your picture and paste it in your follow-up message here.
Thank you, taz6122. The white comma (,) like specks are neither attached to the plant nor do they move. So, I am not sure that they are bugs but you would know better. I had no clue that sunburn can be so bad. Lesson learnt!
Here are the photos:
Please let me know if you need any other information.
Thank you for your help!
My plant is a Dracaena Lemon Lime. (Visible here http://www.fantasticgardensaruba.com/index.php?option=com_content&view=article&id=8&Itemid=16)


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Safe Sounds for podcasting – Canada, 2014
Learning by Playing Around
I'm typing on Notability on my iPad Mini in the landscape view and using the correct fingering and I'm astounded at the speed I can type with. I'm enjoying this light tapping of a virtual keyboard, a set of letters laid out qwerty-like.The only thing I miss is a single apostrophe on the top keyboard. I find it slowing to have to tap for the number keyboard and then tap the apostrophe and then tap back to the alphabetical one. But it's interesting, with my iPad resting on my knee and slightly wobbly, just tapping away.
I'm hungry and I'm playing a little. I just found out that I can type a small "i" and it will automatically turn into uppercase. If I type "im" it will automatically become I'm. I wonder what will happen when I type "its". Yup, it converts; it's given an added apostrophe automatically. I had to use a semi-colon to need to get at the numerical keyboard. Good to know.
Hearing Winter
I'm hearing this a lot lately –
Wild Sound 1
I'm playing with recognizing sounds – guess what this one is:
The biggest predictor of career success? Not skills or education — but emotional intelligence
Originally posted on Financial Post | Business:
What determines the probable future career success of individuals? Is it intelligence, technical knowledge and skills, their socio-economic background or educational success? Are the forces that make success the same for Generations X and Y as they are for the Baby Boomers? These questions have been researched extensively by recruiters, talent management experts and human behaviour researchers in the past decade. The answers now point to emotional competencies.
First, it's important to note that a distinct North American and particularly American myth has been perpetuated that colours our perspective on career success: The "self-made man" or "anyone can make it to the top" myth. While it may have been true in the last century and the early part of this one, evidence doesn't support its veracity now.
Researchers for the past century have investigated the determinants of career success. While intelligence has been the most consistent factor in determining job…
View original 641 more words
Student Presentations Videoed
When my students make group presentations, I like to offer them a video of their performance to supplement and strengthen my feedback to them on what they did well and what they need to improve. Today, with the help of a student videographer and the iPad app Capture, I found an easier way to give them access to their video.
First, because their presentation was longer than 15 minutes, I had to prepare my YouTube account to accept that. On the advice of a student, I went to https://support.google.com/youtube/answer/71673?hl=en to find out how to do that. Once I had verified myself with my phone number, I was allowed to upload longer videos to YouTube. So then it was time to video their presentation. I handed my iPad with the Capture app to a student and she used it to video the presentation.
I have used videos before, but I always found porting the video to my computer and then uploading it to YouTube or Vimeo took many times longer than the video itself. I found it onerous. This time, I received my iPad back from my student videographer, and clicked "Upload". This is the screen I saw:
I chose the "Unlisted" posting, to give students their privacy. Only those with the link will be able to see the video. I use Wikispaces for my course container, and simply posted the link to the YouTube video of their presentation in their Project page, which only members of the group can access. I could have simply emailed the link out to them. Either way, they have control of the privacy level of their video. They can share the link, or not.
This process, using an iPad with the Capture app which is linked to YouTube, is so much easier than my previous process of uploading videos of student work, and I can give them privacy.
I've just read a very interesting post on a version of dyslexia that deals with numbers – http://www.bdadyslexia.org.uk/about-dyslexia/schools-colleges-and-universities/dyscalculia.html and now I understand a lot more about how my mind works, and doesn't work.
I have trouble with left and right, and trying to read maps is painful and embarrassing. I also switch numbers (1,2,4,3,5 etc.) if I try to read them quickly. I have to be VERY careful with large numbers as I can confuse 1000 with 10,000, etc. Plus it's very hard for me to remember telephone and other numbers, even dates in history. So I think I have dyscalculia. I am also mildly dyslexic, and have some trouble with spelling, but I love words and writing. Despite those limitations, or maybe because of them, I've been told repeatedly that I'm a good teacher, good at helping people learn.
I am deeply grateful that I was able to learn and develop tactics that allowed me to survive and thrive as a student and as a teacher. Both as a teacher and as a learner I have observed that people often don't remember how they learned something; we just own and use what we've learned and move on. So I can't remember how and from whom I learned my tactics for surviving my weaknesses by adapting my strengths to cover for them. The only way I can express my gratitude is to show others alternate learning and performing routes that might work for them. And share with everybody what I learn about how our human minds work, and how differences in how they work can be dealt with compassionately.
Giving people the space and opportunity to learn how they learn, and how they can deal with their weakness as well as their strengths is not only wise and kind, it creates a better world for all of us.
If you are reading this and think you might be dyscalculic, check out your sense of self-worth and see if you have learned to focus on adaptations to help you survive, or if you dwell too much on what you struggle with. Perhaps you need to acknowledge how hard you work, as much as what you can't do easily. To boast and inspire, I eventually got my Ph.D. and posted my thesis on line – http://www.scribd.com/mobile/doc/2063617 and here's my not quite up-to-date e-portfolio – https://joanvinallcox.wordpress.com/my-e-portfolio/


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Latest Proterozoic Stories
The appearance of oxygen in the Earth's atmosphere probably did not occur as a single event, but as a long series of starts and stops.
Global glaciation likely put a chill on life on Earth hundreds of millions of years ago, but new research indicates that simple life in the form of photosynthetic algae could have survived in a narrow body of water with characteristics similar to today's Red Sea.
Researchers are discovering strong evidence that parts of what are now Texas and Antarctica were connected.
CALGARY, Aug. 4, 2011 /PRNewswire/ - (TSX-V: ROZ) - Rodinia Oil Corp.
Latest Proterozoic Reference Libraries
The Neoproterozoic is the third of three subdivisions of the Proterozoic Eon (occurring from 1 billion years ago to 542 million years ago). This terminal era of the Proterozoic is itself divided into three sub-periods called the Tonian, Cryogenian, and Ediacaran Periods. The most severe glaciation known in the geologic record occurred during the Cryogenian Period, when ice sheets reached the equator and formed a possible "Snowball Earth." And the earliest fossils of multi-cellular life...
The Paleoproterozoic is the first of three subdivisions of the Proterozoic Eon (occurring from 2.5 billion to 1.6 billion years ago (Ga). This period is marked by the first stabilization of the continents, and also when cyanobacteria--a type of bacteria that uses biochemical processes of photosynthesis to produce oxygen--evolved. Experts have found paleontological evidence that during at least part of the Paleoproterozoic era, about 1.8 Ga, the earth year was about 450 days long, with days...
The Archean (formerly Archaeozoic) is a geologic eon between the Hadean and Proterozoic eons. The Archean Eon begins at roughly 3.8 billion years ago (Ga) and ends at about 2.5 Ga. But unlike all other geological ages, which are based on stratigraphy, The Archean eon is defined chronometrically. The lower boundary of 3.8 Ga has also not been officially recognized by the International Commission on Stratigraphy. The name Archean is derived from the ancient Greek (Arkhe), meaning...
- The practice of two or more parties jointly purchasing all or part of a butchered cow and dividing the meat between them.


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Computer courses in 2D and 3D Animation, Flash, Maya, DTP, Web designing and MS office will be conducted by Literacy House, Andhra Mahila Sabha from July 10. The courses are open to all. Also specially designed courses for senior citizens will be conducted. For details contact 040-27096464.
More In: ANDHRA PRADESH | NATIONAL


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Game & Lil Wayne "Red Nation" (VIDEO)
Click below to check out Game's new video which has already been banned by Viacom.
Go to xxlmag.com to get more info on this story, and please leave a comment below.
Click below to check out Game's new video which has already been banned by Viacom.
Go to xxlmag.com to get more info on this story, and please leave a comment below.
It's been reported that 12-year-old Reginae Carter, daughter of rap superstar Lil Wayne, just landed a spot on her mother's reality show. Carter is reportedly going to make $2,000 per episode, plus expenses, for frequent appearances on the series TOYA: A Family Affair. BE
I was truly impressed when we started playing Jennifer's new song "I'm Into You," on 93.7 WBLK, but the video really has me locked in. Check it out for yourself.
Every Thursday 93.7 WBLK plays your favorite artist back to back. So here are 2 video's from "Chris Breezy"
According to sources, rapper Lil Wayne is addressing false rumors that he and his older stylist are having a relationship after pictures surfaced of the rapper with his arm around the woman in an Atlanta club over the weekend.
Lil Wayne is the latest rapper dealing with the IRS, Sources say on March 2 the Miami-Dade County Clerk filed a $5.6 million tax lien against rapper. According to documents, Weezy owes the back taxes from 2008 and 2009.
According to reports from the IRS, Lil' Wayne (aka Dwayne Michael Carter, Jr) owes a few Dollars to the IRS.
Check out cha girl Nicki Minaj showing some special attention to her boss Lil Wayne during their most recent tour stop. Click below to view.
Go to xxlmag.com to read more about this story.
According to reports, A female catering assistant claimed she was sexually assaulted at a pre-Grammy party that took place at the house of producer Noel "Detail" Fisher in Canyon Country, CA. The assistant was hired to provide food for the party, later claimed she was held inside the house against her will and sexually assaulted
As the kickoff to his "I'm Still Music Tour" Lil Wayne and Nicki, paired with some 'surprise' guests, rocked HSBC Arena and gave an amazing show! Read more for my review and leave us comments! We want to know, what was your favorite part Buffalo? Who was the best performer? And what did you think?!
Well tonight is the night for the much anticipated "I'm Still Music " concert. and opening for Lil' wayne tonight will be Shanell. She will be in studio this afternoon with me, plus don't forget your last chance to win tickets to the concert. So listen and win. here's some background on Shanell.


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Forbidden Worlds Archives Volume 1
By Richard E. Hughes; Ogden Whitney (Illustrator)
(Dark Horse Books, Hardcover, 9781616550004, 216pp.)
Publication Date: December 11, 2012
Other Editions of This Title: Hardcover, Hardcover
Shop Local
Enter your zip code below to find indies closest to you.
Microscopic Roman centurions? Elderly ghosts clobbering gangsters? A haunted vintage of French wine? No conceit is too strange for Forbidden Worlds, the playfully bizarre anthology series that hit newsstands in 1951 and continued for 145 outlandish issues! Comic-book giants Al Williamson, Wally Wood, Frank Frazetta, and Ogden Whitney helped to illustrate these pre-Comics Code gems!
Issues #1 to #4 of the rare and fascinating Forbidden Worlds are now gathered into an archival hardcover, featuring the first in a series of introductory essays by comic-book historian and connoisseur of the obscure, Dan Nadel (Art Out of Time: Unknown Comics Visionaries, 1900-1969)!


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Offer - San Miguel Fresca 4 x 330ml
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You will be asked at checkout to verify that you are over the age of 18
- Buy any 2 for £7. Order by 14/4/2015, offer subject to availability. Maximum 20 promotional items per customer.
Product Description
Fresca is the new refreshing lager from San Miguel. It is brewed to the high level of quality that has become synonymous with the San Miguel name. Using a unique brewing formula, the flavours combine to produce an extremely well balanced and crisp lager. San Miguel Fresca is golden in colour, best served with a slice of lime to fully appreciate the refreshing, fruity taste. Fresca takes inspiration from the vibrant Spanish social scene, which epitomises living life to the full and enjoying all the moments along the way.
Alc. 4.4% Vol.
4 x 1.5 UK Units
Alc. 4.4% Vol.
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Product Information
Beer, Wine & Spirits/
Beer, Wine & Spirits/
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- Brands: San Miguel
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Tasting Notes
San Miguel Fresca is a pale blonde Spanish lager with a malty aroma and soft fruit flavours that provide a cleansing and refreshing hoppy finish. Fresca is well suited to most foods, going well with meats, snacks and salads.
Serving Suggestions
Best served well chilled with a slice of lime.
Taste Category
Bitter/zesty hoppy with well balanced sweet fruity flavours
Country of Origin
Produce of the EU
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Produce of the EU
Brewed and bottled for:
Carlsberg UK Ltd,
Package Type
Allergy Advice: For allergens see highlighted ingredients
Water, Malted Barley, Hops
Dietary Information
Contains Barley
Customer Reviews
16 December 2014
nice refreshing taste
I bought these for my husband when they were on offer, and he liked them a lot. They are refreshing and have a light taste, would recommend.
28 July 2014
great beer
So refreshing and as others have said incredibly light and easy to down.
23 May 2014
hits the spot
I liked this a lot. Tend to buy when on special offer, but would recommend as it's very refreshing and not heavy.
16 April 2012
1 of 1 found this review helpful.
exceeded expectations
Lovely clean, smooth flavour and very much enjoyed on those hot days we had in March! Does exactly what it says on the bottle.
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By: makbes
Soul calibur 4(ps3 xbox360) following the worthy soul calibur 3, but this time on next gen console. I leave you to enjoy this little trailer.
Views: 402 | Posted: 05/25/2011
By: shadowlordX8
All three of Kilik's endings from the game Soul Calibur 3
Views: 469 | Posted: 05/25/2011
By: shadowlordX8
Both of Yoshimitsu's endings from the game Soul Calibur 3
Views: 313 | Posted: 05/25/2011
By: panzerjedi
Coutesy: GameVideos.com
Views: 8,408 | Posted: 05/25/2011
By: Malunis
This is a set of battles on Soulcalibur III, using custom character models the game lets you create. Due to its limit of 3 characters, I had to delete some to make more, but I have what I need written down so I can recreate them. Sorry for the crap-quality, I have a pretty lame camera. Now, you may wonder who these guys are, right? They're from an RPG/story of mine called Hiro's Quest. Let me give a quick description of them. Hiro - Main character. He's from a rich family but dresses like a normal person for the most part. He likes adventure. Arib - A thief Hiro meets on his journey, who is not very friendly to begin with, but later becomes his ally. Amy - A female mage who normally uses magic in a difficult battle. She relies on fire the most. She is a love interest for Hiro. Kugi - A pirate/mage the group meet later on. He normally wears a heavy coat/robe, but he removes it during battle like in the video. Jinkun - Main villain. He wants to take over the world, so Hiro...
Views: 51 | Posted: 05/25/2011
By: Ken
captured this of and old VHS when me and my boy use to go at it .. this particular day I was just untouchable and he gave up after 71 times... he just couldn't take no more ..
Views: 3,383 | Posted: 05/25/2011
By: Stranger202
Another short vid.
Views: 3,615 | Posted: 05/25/2011
By: carotton
I can better do...
Views: 7,397 | Posted: 05/25/2011
By: carotton
Final Fantasy VIIAC, X, X-2, Dead or Alive, Virtua Fighter, Soul Calibur, Tekken... on French music (because I'm French !)
Views: 2,916 | Posted: 05/25/2011
By: Kalyth
MY Soul Calibur III intro - remix with metal music... Enjoy!
Views: 2,678 | Posted: 05/25/2011
Week of
Mar. 29
Week of
Apr. 05
Week of
Apr. 12
Release Date: 03/30/2015
Release Date: 03/31/2015
Xbox One
Release Date: 04/03/2015
Release Date: 04/06/2015
Xbox 360, Xbox One, PS4, PC, PS3
Release Date: 04/07/2015
This complete Dark Souls II experience will include all 3 Dark Souls II DLC, new NPCs to offer an even deeper...
Release Date: 04/07/2015
PS4, Vita
Release Date: 04/07/2015
Xeodrifter is the story of an interstellar drifter traveling the stars on a simple mission of exploration.
Release Date: 04/08/2015
A bloodthirsty Gladiator-style arena five-player co-op game set in a post-apocalyptic, third millenium.
Ouya, PC
Release Date: 04/10/2015
Vita, PS4
Release Date: 04/14/2015


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NEW Impact Investing: Balancing the Best of Responsibility and Opportunity A Commonfund RoundtableInvestors contemplating a commitment to impact investing have a wide range of investment styles and strategies from which to choose, affording them the ability to assemble a diversified portfolio. Download and read this article...
NEW 2015 Commonfund Forum Investor Survey We are pleased to present the findings of our 5th annual Commonfund Forum Investor Outlook Survey™. The survey captured responses from 208 foundations, endowments and pension funds with aggregate assets totaling $273 billion. Download and read this survey...
Weekly Economic and Financial Market Commentary
by Michael Strauss, Chief Economist, Chief Investment Strategist
Commonfund Economic Worldview
The Fed's Labor Limbo | by Michael Strauss
Responsible Investing Monthly Round-Up | February 2015 by Lauren Caplan, Assistant General Counsel and ESG Policy Officer
View Economic Worldview Archives...
Commonfund in the News
Press Release | Commonfund names Jack Foster as Managing Director, Private Equity Specialist
John Griswold receives Sarah Daignault Award | Awarded for his outstanding support of independent schools
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Article ICommonfund Institute releases the 2014 Higher Education Price Index (HEPI) Report
Article IIICommonfund Institute whitepaper | Alternatives Reality: What to expect from future allocations
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