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Cardiovascular, Lymphatic and Systemic Diseases Cardiovascular & Lymphatic » Septic shock » Rheumatic fever » Schistosomiasis » Elephantiasis/Filariasis Systemic » Anthrax » Plague » Lyme disease » Dengue fever » Malaria SEPTIC SHOCK Sepsis or septic shock is a systemic inflammatory response secondary to a documented infection. Consequently, sepsis is a continuum of detrimental host responses to infection that ranges from sepsis to septic shock and Multiple Organ Dysfunction Syndrome(MODS). Shock refers to a state of inability to maintain adequate tissue perfusion and oxygenation, ultimately causing cellular, and then organ system dysfunction. Pathophysiology » Inflammatory mediators are the key players in the pathogenesis. » The gram-positive and gram-negative bacteria induce a variety of proinflammatory mediators, including cytokines. Such cytokines play a pivotal role in initiating sepsis and shock. The bacterial cell wall components are known to release the cytokines; these include lipopolysaccharide (gram-negative bacteria), peptidoglycan (gram-positive and gramnegative bacteria), and lipoteichoic acid (grampositive bacteria). » An imbalance of homeostatic mechanisms leads to disseminated intravascular coagulopathy (DIC) and microvascular thrombosis causing organ dysfunction and death. The predominant hemodynamic feature of septic shock is arterial vasodilation. Diminished peripheral arterial vascular tone may result in dependency of blood pressure on cardiac output, causing vasodilation to result in hypotension and shock if insufficiently compensated by a rise in cardiac output. Vasoactive mediators cause vasodilatation and increase the microvascular permeability at the site of infection. Nitric oxide plays a central role in the vasodilatation of septic shock. Impaired secretion of vasopressin also may occur, which may permit the persistence of vasodilatation. Etiology » Most patients who develop sepsis and septic shock have underlying circumstances that interfere with the local or systemic host defense mechanisms. The most common disease states predisposing to sepsis are malignancies, diabetes mellitus, chronic liver disease, chronic renal failure, and the use of immunosuppressive agents. In addition, sepsis also is a common complication after major surgery, trauma, and extensive burns. » Respiratory tract infection and urinary tract infection are the most frequent causes of sepsis, followed by abdominal and soft tissue infections. » The use of intravascular devices is a notorious cause of nosocomially-acquired sepsis. » Multiple sites of infection may occur in 6-15% of patients. » Lower respiratory tract infections are the cause of septic shock in 25% of patients. The following are common pathogens: ♪ Streptococcus pneumoniae ♪ Klebsiella pneumoniae ♪ Staphylococcus aureus ♪ Escherichia coli ♪ Legionella species ♪ Haemophilus species ♪ Anaerobes ♪ Gram-negative bacteria ♪ Fungi » Urinary tract infections are the cause of septic shock in 25% of patients, and the following are the common pathogens: ♪ E. coli ♪ Proteus species ♪ Klebsiella species ♪ Pseudomonas species ♪ Enterobacter species ♪ Serratia » Soft tissue infections are the cause of septic shock in 15% of patients, and the following are the common pathogens: ♪ S. aureus ♪ Staphylococcus epidermidis ♪ Streptococci ♪ Clostridia » GI tract infections are the cause of septic shock in 15% all patients, and the following are the common pathogens: ♪ E. coli ♪ Streptococcus faecalis ♪ Bacteroides fragilis ♪ Acinetobacter species ♪ Pseudomonas species ♪ Enterobacter species ♪ Salmonella species Risk factors » Extremes of age ( <10 y and >70 y) » Primary diseases ♪ Liver cirrhosis ♪ Alcoholism ♪ Diabetes mellitus ♪ Cardiopulmonary diseases ♪ Solid malignancy ♪ Hematologic malignancy » Immunosuppression ♪ Neutropenia ♪ Immunosuppressive therapy ♪ Corticosteroid therapy ♪ Intravenous drug abuse ♪ Compliment deficiencies ♪ Asplenia » Major surgery, trauma, burns » Invasive procedures ♪ Catheters ♪ Intravascular devices ♪ Prosthetic devices ♪ Hemodialysis and peritoneal dialysis catheters ♪ Endotracheal tubes » Prior antibiotic treatment » Prolonged hospitalization » Other factors - Childbirth, abortion, and malnutrition Signs and Symptoms » Temperature greater than 38°C or less than 36°C. » Heart rate greater than 90. » Respiratory rate greater than 20 per minute. » WBC count more than 12,000/µL. » Chills are a secondary symptom associated with fever, which is a consequence of increased muscular activity that produces heat and raises the body temperature. » Sweating occurs when the hypothalamus returns to its normal set point and senses the higher body temperature, stimulating perspiration to evaporate excess body heat. » Alteration in mental function often occurs: apprehension, anxiety, agitation, and, eventually, coma are manifestations of severe sepsis. » Hyperventilation with respiratory alkalosis is a common feature of patients with sepsis secondary to stimulation of the medullary respiratory center by endotoxins and other inflammatory mediators. Diagnosis » PE, v/s » Observe patients for systemic signs of inadequate tissue perfusion. In the early stages of sepsis, cardiac output is well maintained or even increased. The vasodilation may result in warm skin, warm extremities, and normal capillary refill (warm shock). As sepsis progresses, stroke volume and cardiac output fall, the aeg start to manifest signs of hypoperfusion(cool skin, cool extremities, and delayed capillary refill or cold shock). » CBC with dif count (Hgb, WBC, plt). » Assess renal and hepatic functions (serum creatinine, BUN, ALT, AST, albumin). Treatment » The principles in the management of septic shock, based on current literature, include the following components: ♪ Early recognition ♪ Early and adequate antibiotic therapy ♪ Source control ♪ Early hemodynamic resuscitation and continued support ♪ Corticosteroids (refractory vasopressordependent shock) ♪ Proper ventilator management with low tidal volume in patients with ARDS ♪ Vasopressor drugs: Dopamine, Epinephrine, Norepinephrine Nursing Interventions » Assist doctor in management » Medications as ordered » Administer oxygen as ordered » Assist in intubation » Aseptic technique » » » » pericardial involvement usually resolves without serious sequelae. However, rheumatic endocarditis results in permanent and often crippling adverse effects. Rheumatic endocarditis first manifests anatomically as tiny, translucent vegetations or growths along the margins of the valve leaflets. These become the starting point of a process that gradually thickens the leaflets, causing them to shorten and thicken, preventing them from closing completely. As a result, blood flows backward through the valve (valvular regurgitation). The most common site of valvular regurgitation is the mitral valve. In some patients, the margins of the valve leaflets become adherent or the chordate tendineae fuse resulting in valvular stenosis. Occurs most often in school-age children. ARF presents 2-6 wks following an untreated or partially treated GABHS infection of the URT Prompt tx of strep throat with antibiotics can prevent the development of ARF. Epidemiology » As a sequel of beta-streptococcal exposure, ARF occurs during school years when streptococcal pharyngitis is most prevalent. Similarly, prevalence is higher in the colder months of the year when streptococcal pharyngitis is most likely to occur. Signs and Symptoms » Guidelines of diagnosis used by the American Heart Association include major and minor criteria (i.e., modified Jones criteria). In addition to evidence of a previous streptococcal infection, the diagnosis requires 2 major Jones criteria or 1 major plus 2 minor Jones criteria. RHEUMATIC FEVER Rheumatic fever causes chronic progressive damage to the heart and its valves. The association between sore throat and rheumatic fever was not made until 1880. The dramatic decline in the incidence of rheumatic fever is thought to be largely owing to antibiotic treatment of streptococcal infection Pathophysiology » Acute Rheumatic Fever (ARF) is a sequel of a previous group A streptococcal infection, usually of the upper respiratory tract. » This condition is non-infectious in the sense that tissues are not invaded and directly damaged by the streptococci. Injury is caused by an inflammatory or sensitivity reaction to streptococci. Leukocytes accumulate in the affected tissues and form nodules, which eventually are replaced by scar tissue. The myocardium is involved in the inflammatory process. Rheumatic myocarditis develops which temporarily weakens the contractile power of the heart. The pericardium is affected, and rheumatic pericarditis occurs during the acute illness. Myocardial and Major criteria » Carditis: This occurs in as many as 40% of patients and may include cardiomegaly, murmur, congestive heart failure, and pericarditis, with or without valvular disease. » Migratory polyarthritis: This condition occurs in 75% of cases and involves large joints; may last up to 4 wks. » Subcutaneous nodules (ie, Aschoff bodies): These nodules occur in 10% of patients and are edematous, fragmented collagen fibers. They are round, firm, painless, free-moving nodules on the extensor surfaces of the wrists, elbows, and knees; usually disappear after 1-2 wks » Erythema marginatum: This condition occurs in about 5% of cases; characterized by macular or popular, non-itchy rash on the trunk and proximal extremities. » Chorea (also known as Sydenham chorea and "St Vitus dance"): This characteristic movement disorder occurs in 5-10% of cases. Sydenham chorea consists of rapid, purposeless, erratic, jerky, uncoordinated, involuntary movements of the face and upper extremities. Onset may be delayed for several months and may cease when the patient is asleep; usually resolves completely within 6 mos. Minor criteria » Clinical findings include arthralgia, fever and previous history of ARF » Laboratory findings include elevated acute phase reactants (e.g., erythrocyte sedimentation rate, C reactive protein), a prolonged PR interval, and supporting evidence of antecedent group A streptococcal infections (i.e., positive throat culture or rapid streptococcal screen and an elevated or rising streptococcal antibody titer). Other Assessment Finding » Elevated antistreptolysin O (ASO) titer » Weight loss, HA, malaise, diaphoresis and pallor Diagnosis » Jones criteria » Streptococcal antibody tests disclose preceding streptococcal infection. » Isolate group A streptococci via throat culture Complications » Rheumatic Heart Disease: affectation of cardiac valves, particularly the mitral valve, as evidenced by heart murmur » Mitral stenosis; pericarditis; cardiomegaly; CHF Treatment » Penicillin G benzathine IM » Prednisone (glucocorticoid) » Naproxen (NSAID) » Haloperidol may be helpful in controlling chorea Nursing Interventions » Antibiotics as ordered; completing the course of antibiotics minimizes the risk of developing ARF (and subsequently rheumatic heart disease) » Salicylates and anti-inflammatory agents » Emphasize importance of long-term cardiac reevaluation and regular prophylactic antibiotics » Maintain hydration » Control joint pain and inflammation with massage » Limit physical exercise in child with carditis » Monitor symptoms of complications (pulmonary HPN), CHF, thromboemboli, valvular disease, arrhythmias individuals with new schistosomal infections. It may correspond to the first cycle of egg deposition and is associated with marked peripheral eosinophilia and circulating immune complexes. It is most common with S japonicum and S mansoni infections and is most likely to occur in heavily infected individuals after primary infection. Symptoms usually resolve over several weeks, but the syndrome can be fatal. Early treatment with cidal drugs may exacerbate this syndrome and necessitate concomitant glucocorticoid therapy. » Mild maculopapular skin lesions may develop in acute infection within hours after exposure to cercariae. Significant dermatitis is rare with the major human schistosomal pathogens, probably because the invading and developing cercariae are minimally immunogenic. However, abortive human infection with schistosomal species that rely on other primary hosts may cause marked dermatitis or swimmer's itch. This self-limited process may recur more intensely with subsequent exposures to the same species. Epidemiology » Highly endemic in Regions VIII, X, XI and XII Incubation Period » 2-6weeks Mode of Transmission » Skin penetration of infective cercariae through wading, swimming in infested waters » Not transmissible from person to person Signs and Symptoms » Swimmer's itch: itchiness within 24hours; redness; and pustule formation at the point of entry of cercariae lasting 2-3days. » Diarrhea; abdominal pain. » Katayama fever: fever; generalized lymphadenopathy; hepatosplenomegaly 2-3weeks after initial infection and last for 1-2months. Diagnosis » S/E: ID of eggs » Liver & rectal biopsy Complications » Portal cirrhosis; cor pulmonale (hypertrophy of LV resulting from lung disease); myocardial damage. Treatment » Praziquantel PO Nursing Interventions » Proper disposal of excreta » Avoid wading in infested waters » Elimination of intermediate host » Maintain nutrition ELEPHANTIASIS Or Lymphatic Filariasis, is a rare disorder of the lymphatic system caused by parasitic worms such as Wuchereria bancrofti and Brugia malayi, all of which are transmitted by mosquitos(Aedes poicilus, Culex fatigans, Anopheles flavirostris). Inflammation of the lymphatic vessels causes extreme enlargement of the affected area, most SCHISTOSOMIASIS Also Bilharziasis or snail fever is a human disease syndrome caused by infection from one of several species of parasitic trematodes of the genus Schistosoma. This is a major source of morbidity and mortality for developing countries in Africa, South America, the Caribbean, the Middle East, and Asia. Most human schistosomiasis is caused by Schistosoma haematobium, Schistosoma mansoni, or Schistosoma japonicum. Pathophysiology » Acute schistosomiasis (i.e., Katayama fever) is a serum sickness–like illness that develops after several weeks in some, but not most, commonly a limb or parts of the head and torso. It occurs most commonly in tropical regions. Pathophysiology » Larvae from the mosquito migrate to the lymphatics, where they develop into threadlike adult worms within 6 to 12 months. Gravid adult females produce microfilariae that circulate in blood. Epidemiology » Phil stat: 2.5/100,000 population » Distribution: Camarines Norte/Sur, Sorsogon, Quezon, Albay, Mindoro, Bohol, Samar, Palawan, Sulu, Tawi-Tawi, Basilan Mode of Transmission » Bite of mosquito Diagnosis » Fresh blood smear » Bentonite Flocculation Test Signs and Symptoms » Acute: fever, malaise, chills » Chronic: lymphadenitis, swelling of scrotum, lymphatic channel affected; eosinophilia a protective antigen, a lethal factor, and an edema factor. The protective antigen is an 83-kd protein that binds to cell receptors within a target tissue. Once bound, a fragment is cleaved free to expose an additional binding site. This site can combine with edema factor to form edema toxin or with lethal factor to form lethal toxin. Edema toxin acts by converting adenosine triphosphate (ATP) to cyclic adenosine monophosphate (cAMP). Cellular cAMP levels are increased, leading to cellular edema within the target tissue. Lethal factor is not well understood, but recent work suggests that it may inhibit neutrophil phagocytosis, lyse macrophages, and cause release of tumor necrosis factor and interleukin 1. Epidemiology » A zoonotic disease; spores can remain viable in soil for years. » Livestock can become infected and can transmit infection to humans on contact with infected animals or animal products (hides, hair, wool, meat). Incubation Period » 2-60 days Mode of Transmission » Ingestion, inhalation or ingestion Signs and Symptoms » Cutaneous: pruritic papule or vesicle which enlarges and ulcerates in 1-2days; a central black aschar forms (malignant pustule); lesion is painless but with surrounding edema » Inhalational: fever; chills; non-productive cough; chest pain; headache; myalgia; malaise; pleural effusion; septic shock » GI: N&V; anorexia; abdominal pain; ascites; hematemesis; bloody diarrhea Diagnosis » CXR » G/S and culture of blood, pleural fluid, CSF, skin discharges, tissue biopsy specimen Treatment » Penicillin » Ciprofloxacin Nursing Interventions/Considerations » Standard precaution » Meds as ordered » Post-exposure prophylaxis » Anthrax vaccine Prognosis » high mortality for inhalational and GI anthrax Treatment » Diethylcarbamazine citrate (Beltrazan) » AH or corticosteroid » Surgical Nursing Interventions » Meds as ordered » Vector control » Health education in endemic areas ANTHRAX The term anthrax means coal in Greek, and the disease is named after the appearance of its cutaneous form. Anthrax is described in the Old Testament, by the poet Virgil, and by the Egyptians. At the end of the 19th century, Robert Koch's experiments with anthrax led to the original theory of bacteria and disease. Anthrax is caused by inhalation, skin exposure, or gastrointestinal (GI) absorption. Disease caused by inhalation is usually fatal, and symptoms usually begin days after exposure. This delay makes the initial exposure to Bacillus anthracis difficult to track Can be grown in laboratories and is a potential biowarfare agent. Pathophysiology » Virulence depends on the bacterial capsule and the toxin complex. The capsule is a poly-D-glutamic acid that protects against leukocytic phagocytosis and lysis. Anthrax toxins are composed of 3 entities: PLAGUE The plague has caused more fear and terror than perhaps any other infectious disease in the history of humankind. It has laid claim to nearly 200 million lives and has brought about monumental changes, such as the end of the Dark Ages and the advancement of clinical research in medicine. Alexandre Yersin isolated the plague bacillus, developed an antiserum to combat the disease, and postulated its connection with fleas and rats during the epidemic of 1894. The plague bacillus was named Yersinia pestis in his memory. Although, the plague has been considered a disease of the Middle Ages, recent interest has been spurred by concerns over its use as a potential biological weapon. Aerosolized Y. pestis, causing primary pneumonic plague, has been recognized by bioterrorism experts as having one of the highest potentials for adverse public health impacts. In addition to the concern over its use in acts of terrorism, there are further reasons that may cause a dramatic increase in the number of plague cases worldwide in the years to come. One reason may be the climatic change brought about by global warming. This change is ideal for increasing the prevalence of Y. pestis in the host population. A recent study has estimated a more than 50% increase in the plague host prevalence with an increase of 1degree centigrade of the temperature in spring. Another reason may be the increasing population explosion worldwide, which is bringing humans into ever-increasing contact with wildlife. Lastly, the dramatic population increase will contribute to conditions of overcrowding and poor sanitation—conditions ripe for plague hosts and vectors to flourish in. Pathophysiology » Three forms of the plague exist: bubonic plague, pneumonic plague, and septicemic plague. The bubonic form of the plague involves the pathognomonic "bubo" and is caused by deposition of the bacillus in the skin by the bite of an infected vector. If the vector is a flea, bacillus proliferates in the flea's esophagus, preventing food entry into the stomach. To overcome starvation, the flea begins a blood-sucking rampage. Between its attempts to swallow, the distended bacillus-packed esophagus recoils, depositing the bacillus into the victim's skin. » The bacillus invades nearby lymphoid tissue, producing the famous bubo, an inflamed, necrotic, and hemorrhagic lymph node. Spread occurs along the lymphatic channels toward the thoracic duct, with eventual seeding of the vasculature. Bacteremia and septicemia ensue. The bacillus potentially seeds every organ, including the lungs, liver, spleen, kidneys, and rarely even the meninges. » The most virulent form, pneumonic plague, results from direct inhalation of the bacillus, which occurs from close contact of infected hosts or from aerosolized bacteria such as may occur if used as a biological weapon. A severe and rapidly progressive multilobar bronchopneumonia ensues with subsequent bacteremia and septicemia. Secondary pneumonic plague is caused when an infected patient seeds his or her lungs and airways. » The third type of plague is a primary septicemic plague. This is hypothesized to occur when the bacillus is deposited in the vasculature, bypassing the lymphatics. Early dissemination with sepsis occurs but without the formation of a bubo. This usually is observed in bites to the oral, tonsillar, and pharyngeal area and is believed to occur because of the vascularity of the tissue and short lymphatic distance to the thoracic duct. Epidemiology » From 1967-1993, the World Health Organization has reported an annual average of 1666 cases of the plague. Mode of Transmission » Bite of vector, rat flea Xenopsylla cheopis » Contact with infected tissue or body fluid » Inhalation Signs and Symptoms » Fever ; chills; myalgias; sore throat; malaise » Enlarged, painful, swollen lymph node (bubo) » Abdominal pain » Nausea, vomiting (bloody at times) » Constipation, diarrhea, and black or tarry stools » Cough, which may be productive of bloody sputum » Shortness of breath » Stiff neck Diagnosis » CBC: elevated WBC » U/A: hematuria, proteinuria » ABG: hypoxia and/or acidosis » G/S, culture of blood, sputum or bubo aspirate Treatment » Gentamicin IV/IM » Supportive Nursing Considerations » Medications as ordered » Universal precaution (goggles, gloves, gown; mask if pneumonic) LYME DISEASE Is a multi-system infection commonly affecting the skin, CNS, heart and joints caused by the spirochete Borrelia burgdorferi. The bacterium is inoculated into the skin by a tick bite. The tick is almost always of the genus Ixodes. (ticks live in wooded areas and survive by attaching to a host) Pathophysiology » Once in the skin, the spirochete can (1) be overwhelmed and eliminated by host defense mechanisms; (2) remain viable and localized in the skin where it produces the pathognomonic skin lesion, or erythema migrans (EM); or (3) disseminate through the lymphatics or blood. Hematogenous dissemination can occur within days to weeks of initial infection; the organism can travel to the skin, heart, joints, CNS, and other parts of the body. Epidemiology » In 2001, the CDC reported 17,029 cases and, in 2002, that number rose to 23,763—a 40% increase. Year-to-year variation can be significant. More than 95% of cases come from 12 states (Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Wisconsin). Even within these states, incidence can be quite variable from county to county and even neighborhood to neighborhood. Incubation Period » 14-23 days Mode of Transmission » Vector-borne Signs and Symptoms » Bull's eye rash or Erythema Migrans (a small red pimple develops at the site of bite that spreads into a ring-shaped rash) usually found in most parts of the body (1-33 days later; average, 7-10 days). The size varies enormously (as large as 70 cm; average, 16 cm) and depends on disease duration. EM usually is flat, round, or oval and monocyclic but nonpruritic » Flu-like symptoms (HA, stiff neck, myalgia, fatigue) » Arthralgia » Neurological and cardiac complications » Progression of arthritis Diagnosis » Aeg history » Dermatologic findings: Classic EM is an erythematous papule or macule that occurs at the site of the tick. » Elevated IgM Treatment » Amoxicillin » Doxycycline » Cefuroxime » Erythromycin Nursing Interventions » Ascertain if the aeg was exposed to deer ticks » Gently remove the tick with tweezers, wash the skin with antiseptic, and dispose of the tick by flushing it down the toilet; the tick may also be placed in a sealed jar for inspection by the health care provider. » Obtain a blood test 4-6 wks after a bite to detect the presence of the disease (testing before this time is not reliable) » Instruct the client to avoid wooded, grassy areas, esp in summer months » Instruct aeg to wear light colored, long-sleeved tops, long pants. Closed shoes and hats while outside » Instruct client to use tick repellent DENGUE Dengue has been called the most important mosquito-transmitted viral disease in terms of morbidity and mortality. Dengue fever is a benign acute febrile syndrome occurring in tropical regions. In a small proportion of cases, the virus causes increased vascular permeability that leads to a bleeding diathesis or disseminated intravascular coagulation (DIC) known as dengue hemorrhagic fever (DHF). In 20-30% of DHF cases, the patient develops shock, known as the dengue shock syndrome (DSS). Worldwide, children younger than 15 years comprise 90% of DHF subjects; however, in the Americas, DHF occurs in both adults and children Dengue is a homonym for the African ki denga pepo, which appeared in English literature during an 1827-28 Caribbean outbreak. The first definite clinical report of dengue is attributed to Benjamin Rush in 1789, but the viral etiology and its mode of transmission via mosquitoes were not established until the early 20th century. EA: DEN-1, DEN-2, DEN-3, DEN-4, Chikungunya virus Also called breakbone fever Pathophysiology » Dengue viral infections frequently are not apparent. Classic dengue primarily occurs in nonimmune, nonindigenous adults and children. Symptoms begin after a 5 to 10 days incubation period. DHF/DSS usually occurs during a second dengue infection in persons with preexisting actively or passively (maternally) acquired immunity to a heterologous dengue virus serotype. Illness begins abruptly with a minor stage of 2-4 days duration followed by rapid deterioration. Increased vascular permeability, bleeding, and possible DIC may be mediated by circulating dengue antigen-antibody complexes, activation of complement, and release of vasoactive amines. In the process of immune elimination of infected cells, proteases and lymphokines may be released and activate complement coagulation cascades and vascular permeability factors. Epidemiology » Phil stat: 29.8/100,000 population » Source: infected persons » Common during rainy season » Infants and children mostly affected generally 0-9years old Incubation Period » 4-6days (min 3days, max 10days) Mode of Transmission » Day biting female mosquitoes (Aedes aegypti, Aedes albopictus) Signs and Symptoms » Grade I ♪ Fever; (+) tourniquet test; non-specific symptoms; abdominal sign; Herman's sign (petechiae) » Grade II ♪ Grade I + bleeding (epistaxis, melena, gingival bleeding, coffee ground vomitus) » Grade III ♪ Grade II + circulatory collapse (hypotension, rapid & weak pulse, cold clammy skin » Grade IV ♪ Grade III + shock with undetectable BP & P Delayed capillary refill may be the first sign of intravascular volume depletion. Hypotension usually is a late sign in children. This child's capillary refill at 6 seconds was delayed well beyond a normal duration of 2 seconds. Diagnosis » Tourniquet test: assesses capillary fragility » CBC: leukopenia, thrombocytopenia, low hct » Dengue blot test Treatment » Symptomatic and supportive » No specific antiviral treatment » Avoid aspirin Nursing Interventions » Monitor for signs of bleeding and fall in BP » Epistaxis: lean forward » Gingival bleeding: ice chips » Hematemesis: NPO Prognosis » Grade I & II: good » Grade III: guarded » Grade IV: serious, high mortality rate Treatment » Chloroquine + Sulfadoxine/Pyrimethamine (CQ+SP) – 1st line drug in the treatment of probable malaria and confirmed Pf. » Artemether-Lumefantrine (Co-Artem TM) – 2nd line drug; given only to microscopically confirmed Pf which did not respond to CQ+SP. » Quinine + Tetracycline/Doxycycline – 3rd line drug; should be given to those who did not respond to CoArtem or if CQ+SP is not available. » N.B.: Tetracycline and Doxycycline are conrtaindicated for pregnant women and children under 8years old; instead give Quinine with Clindamycin. MALARIA » Term malaria is derived from Latin words mal (bad) and aria (air). » Infection transmitted by female Anopheles mosquito, caused by Plasmodium falciparum(most fatal), P. vivax, P. ovale, P. malariae. » at high risk are pregnant women and children » Sexual cycle in mosquito; asexual cycle in human rbc » Pf: malignant tertian malaria » Pv: benign tertian malaria » Po: benign tertian malaria » Pm: quartan malaria Pathophysiology » The degree of damage to the tissue depends mainly on the parasitic concentration » Red cell changes: » Low deformability » High adhesion » High fragility » Low oxygen transport » Hemolysis leading to anemia » Rupture of infected and non-infected RBC (blackwater fever) » Organ damage: spleen, liver, brain, kidneys Epidemiology » Phil stat: 52/100,000 population Incubation Period » Pf: 10-13days » Pm: 27-37days or up to years » Po: 11-26days » Pv: 12-21days Mode of Transmission » Bite of female Anopheles Signs and Symptoms » Stages ♪ Cold: chilling: 10-15minutes (hot water bath on soles) ♪ Hot: 41degrees fever (TSB, antipyretics) ♪ Diaphoretic (increase fluids, rest) Diagnosis » Symptomatic » Malarial smear (peak of fever) » IFA
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The Playoff Prediction Project
Jonathan Willis
April 12 2011 02:19PM
The regular season is ended. Now cometh upon us the time of the playoff.
Not coincidentally, the time of playoff prediction is here.
Jay Day
Pat Steinberg
April 12 2011 12:24PM
Acting Flames General Manager Jay Feaster held his after season news conference with the Calgary media on Tuesday morning, and a few interesting things came from it. Feaster spoke for almost 40 minutes, answering questions on the future and a second straight season out of the playoffs. You can listen to the entire thing below, courtesy of our friends at Sportsnet Radio FAN 960.
Blogging for Charity
April 12 2011 11:06AM
Ryan Lambert and I like to stir the pot in the hockey blogosphere. From his work at Puck Daddy to my tribute to the Washington Capitals we've won our fair share of critics (mostly in the "they hate us" sense and not the "objective analysis of humor").
Cleaning Up
Pat Steinberg
April 11 2011 06:02PM
The 2010/2011 edition of the Calgary Flames went their seperate ways on Monday afternoon after a second straight season out of the postseason. The team fulfilled their final media obligations, met with the coaching staff for the final time and, of course, cleaned out their lockers. Here are some observations from a day the that came too early for the Flames.
April 10 News and Notes
Robert Cleave
April 10 2011 09:50PM
The regular season reached its conclusion this evening, with the playoff matchups now set for next week's hostilities. Before that gets underway, it's a good time to have one last look at the news from Calgary and around the league. This time around, the Flames play out the string, the Ducks get home ice, and the 'Canes fall at the last hurdle.

subset: commoncrawl


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Whip your mind into shape with these easy tips.
more slideshows
5 Post-Sun Beauty Picks We Swear ByYou've had some fun—now it's time to refresh your hair
6 Healthy and Satisfying Summer Cocktails You'll Want To Make TonightWhip up a batch and enjoy all weekend long.
Girl Power! Life Lessons from the Littlest AthletesWe asked some of our favorite young sports stars what
Boost Your Brain Power
N-back exercises are proven to increase both fluid intelligence and dopamine receptors. (And maybe if you do enough of them, you'll understand that sentence.) These memory games challenge you to track visual or sound cues—e.g., noting when a certain letter repeats and recalling how many pages back you first saw it. The BetterBrain app (iOS; $2.99) lets you do them on your lunch hour.


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Pineapple And Rice Salad
10 Jun 2009
Rice makes a best deal for salads and this Pineapple And Rice Salad proves just the same. This Pineapple And Rice Salad is rich with the flavors of fruits, heavy cream and cooked rice. Give this yummy Pineapple And Rice Salad a try.
|1 Cup (16 tbs), crushed
|Lemon gelatin
|3 Ounce
|Cold water
|1⁄2 Cup (8 tbs)
|Cooked rice
|1 Cup (16 tbs)
|1 Cup (16 tbs), chopped
|1⁄2 Cup (8 tbs)
|Powdered sugar
|1⁄4 Cup (4 tbs)
|Heavy cream
|1 Cup (16 tbs), whipped
Drain pineapple, reserving 1 cup juice.
Dissolve gelatin in hot pineapple juice; add water.
Chill until thickened.
Add rice, pineapple, marshmallows and nuts.
Add sugar to cream; fold into gelatin mixture.
Chill until firm.
Recipe Summary
Difficulty Level:Easy
Course:Side Dish, Fruit Dessert
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Pineapple And Rice Salad Recipe


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43 year old woman | Miami, FL, USA | Seeking men 38-48 within 50 miles
Searching for my soul mate
Thank you for looking at my profile. Just a few things about me, I'm Latina and come from a traditional Latino family, which I love. There's lots of family, love and support. I'm passionate about many things but music, a good book and spend time traveling is by far my biggest one. I also enjoy being at home. Whether it's watching a movie, dinner parties or decorating, Home Is where the heart is. Friends and family are also very important to me. I enjoy working out and being healthy. My friends describe me a bright, caring, and very supportive and loyal. I'm looking for a man that is also goal-oriented, family-oriented and confident. My ideal man understands the importance of giving each other love, I will be the person that always be there for him. He must also be intelligent, value family, be honest, I believe in taking it slow and being friends first. I would love to hear from you...
Camping , Coffee and conversation , Cooking , Dining out , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Nightclubs/Dancing , Playing sports , Travel/Sightseeing , Watching sports
Aerobics, Dancing
I exercise 1-2 times per week.
I have Dogs
I adopted a very friendly poodle, she's very funny, sweet, adorable and smart! Though I'm discovering she's also mischievous!
Middle of the Road
All the places where I found peace & fun
I love seafood but i'm open to try the world culinary food, My favorite color is White. When it rains outside I like to get romantic with my partner and watch a movie at home or walk in the beach
(In no particular order) The beach. Live music. Great red wine. Morning lattes. My dog. Yoga. Romantic comedies. Live theater, especially musicals. Casual biking. Home cooking. Snuggling. Spa days for massages. Laughing with friends.
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What she is looking for
|5'1" (154cms)
|5'5" (165cms) to 6'4" (193cms)
|Body type:
|About average
|Slender, About average, Athletic and toned, A few extra pounds
|Black, Blue, Brown, Grey, Green, Hazel
|Light brown
|No preference
|No Way
|No Way
|Social Drinker
|Never, Social Drinker, Regularly
|I'll tell you later
|No preference
|I'll tell you later
|$50,001 to $75,000, $75,001 to $100,000, $100,001 to $150,000, $150,001+
|Never Married
|Never Married, Widow / Widower, Currently Separated, Divorced
|Have kids:
|Yes, and they sometimes live at home, Yes, and they live at home
|Wants kids:
|Not sure
|Definitely, Someday
|Latino / Hispanic, White / Caucasian
|Latino / Hispanic, White / Caucasian
|Christian / Catholic
|Christian / Catholic, Christian / Protestant, Jewish, Spiritual but not religious, Christian / Other
My faith is important and I consider myself to be a very spiritual person. My belief in God is strong, without being burdened by legalism
|English, Spanish
|English, Spanish
|Some college
|Some college, Associates degree, Bachelors degree, Graduate degree, PhD / Post Doctoral


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Release Date:
May 8, 2007
Oliver Stone's breakthrough as a director, Platoon is a brutally realistic look at a young soldier's tour of duty in Vietnam. Chris Taylor (Charlie Sheen) is a college student who quits school to volunteer for the Army in the late '60s. He's shipped off to Vietnam, where he serves with a culturally diverse group of fellow soldiers under two men who lead the platoon: Sgt. Barnes (Tom Berenger), whose facial scars are a mirror of the violence and corruption of his soul, and Sgt. Elias (Willem Dafoe), who maintains a Zen-like calm in the jungle and fights with both personal and moral courage even though he no longer believes in the war. After a few weeks "in country," Taylor begins to see the naïveté of his views of the war, especially after a quick search for enemy troops devolves into a round of murder and ******. Unlike Hollywood's first wave of Vietnam movies (including The Deer Hunter, Apocalypse Now, and Coming Home), Platoon is a grunt's-eye view of the war, touching on moral issues but focusing on the men who fought the battles and suffered the wounds. In this sense, it resembles older war movies more than its Vietnam peers, as it mixes familiar elements of onscreen battle with small realistic details: bugs, jungle rot, exhaustion, C-rations, ******, and counting the days before you go home. This mix of traditional war movie elements with a contemporary sensibility won Platoon four Oscars including Best Picture and Best Director, and a reputation as one of the definitive modern war films. Mark Deming, All Movie Guide
Loosely based on a real-life operation during World War II, this action-adventure from director John Woo stars Nicolas Cage as Joe Enders, a Marine traumatized by the loss of his entire platoon in the Solomon Islands during an ambush he believes was deadlier than necessary due to his indecision. Suffering from eardrum damage in Hawaii, Joe manages to be declared fit for duty once again thanks to a sympathetic nurse (Frances O'Connor), but his new assignment isn't what he expects. Joe is ordered to safeguard a Navajo soldier named Ben Yahzee (Adam Beach) because the military has developed a new secret code based on the near-dead Navajo language that is proving unbreakable to the Japanese. Any soldier that speaks Navajo is an immediate asset, including Ben and his pal, Charlie Whitehorse (Roger Willie). Joe's orders are to "baby sit" Ben during the invasion of Saipan, protecting him if possible, but -- if the code-talker's capture becomes imminent -- to kill him before he falls into enemy hands. Meanwhile, Charlie is to be guarded by affable harmonica player Ox Henderson (Christian Slater). Joe reluctantly accepts this new duty as a way to get back into the war, and in the ensuing carnage, his nearly suicidal acts of bravery make him a hero while Ben becomes paralyzed by fear. Determined to live up to Joe's example, Ben musters up his courage, even in the face of racism from a fellow soldier (Noah Emmerich), and ends up rescuing his own protector behind enemy lines by briefly posing as a Japanese soldier. Despite their growing mutual respect, Joe is eventually forced to take an action that threatens to shatter his bond with Ben, as the war's tragic losses strike closer to home for both men. Windtalkers co-stars Peter Stormare, Jason Isaacs, and Mark Ruffalo. Karl Williams, All Movie Guide
- Genre: Military & War
- Category War Drama, Anti-War Film, Combat Films
- Theme: Innocence Lost, Dropping Out, Unlikely Friendships, Military Life
- Run Time: 04 hr 14 min
- Language: Spanish , French , English
- Subtitle Language: English , French , Spanish
- Picture Format: widescreen
- Lead Actor: Willem Dafoe , Adam Beach , Nicolas Cage , Tom Berenger , Charlie Sheen
- Supporting Actor: Martin Henderson , Richard Edson , Kevin Dillon , Brian Van Holt , Mark Ruffalo , Francesco Quinn , Noah Emmerich , Forest Whitaker , Peter Stormare , Chris Castillejo , Bernardo Manalili , Li Mai Thao , Li Thi Van , James Terry McIlvain , Ivan Kane , Basile Achara , Corey Glover , Corkey Ford , Bob Orwig , Ron Barracks , Than Rogers , Nick Nicholson , Oliver Stone , Paul Sanchez , Chris Pederson , Andrew B. Clark , Dale Dye , Kevin Eshelman , Mark Moses , Romy Sevilla , Tony Todd , Warren McLean , Willem Dafoe , Matthew Westfall , Peter Hicks , Steve Barredo , Adam J. Glover , Roger Willie , John C. McGinley , Frances O'Connor , Reggie Johnson , Christian Slater , Keith David , Jason Isaacs , Johnny Depp , David Neidorf , Clarisa Ortacio
- Director: John Woo , Oliver Stone
other Info.
- Online Item #: 11362935
- Store Item Number (DPCI): 058-24-0183
- Made in the USA or Imported


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Sweetwater County Republicans Elect New Officers
The Sweetwater County Republican Party elected new officers Wednesday night during their March meeting in Green River. Bill Hooley was elected to serve as the new chairman. Bill takes the reins of the party from outgoing chairman Jon Aimone. Speaking about his election, Bill said, "I am honored to be elected as chairman of the Sweetwater County … Continue Reading ››
Get to Know Doug Hecox – Our Special Guest and Speaker at the 2015 Lincoln Day Dinner
Our special guest and speaker at this year's Lincoln Day Dinner is writer and comedian, Doug Hecox. Doug Hecox's life is a study in comedy, beginning with his debut in school plays and cracking jokes on the air as a radio DJ to … Continue Reading ››
Get Your Tickets To The 2015 Lincoln Day Dinner
The SweetwaterGOP 2015 Lincoln Day Dinner is the primary annual fundraiser of the Sweetwater County Republican Party. Over the last couple years, this event has become one of the premier political social events in Wyoming, and draws guests from all over Wyoming and beyond. Past guests have included Liz Cheney, … Continue Reading ››
Sign Up To Volunteer At The SweetwaterGOP Booth At The Sweetwater County Fair!
The SweetwaterGOP is once again hosting a booth at the Sweetwater County Fair! Help us promote the Republican Party, and to educate and enable voters, by volunteering to help out this year. Just follow the link, and sign up to spend a few hours at the booth. We will be giving … Continue Reading ››
Volunteer for our Flaming Gorge Days booth and parade float!
Sign up here to volunteer to help us setup and staff the Flaming Gorge Days booth and parade float! We will be selling freeze pops at the booth and playing bean bag toss. We need people to walk with the float at the parade giving out candy, and others to ride on the float and wave. CANDIDATES: All … Continue Reading ››


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organic and vegan skincare in Atlanta at Authentic Beauty Salon & Studio
Authentic Beauty's new healthy, restorative and organic facial treatments from licensed esthetician Stephanie Simmons.
Authentic Beauty is here to get you gorgeous and looking your absolute best for summer. Join us on Tuesday, July 21st from 11am-7pm and be our guest for cocktails, light bites, makeup applications, services and sizzling summer deals at our Summer Soiree and One Day Sale. Our Summer Soiree party is an all day open [...]
Stephanie Simmons is a licensed esthetician and makeup artist at Authentic Beauty Salon & Studio in Atlanta who creates beautiful makeup and beautiful skin for clients.
When you keep your body, mind and soul healthy, you achieve greater beauty – and it's the real deal because it comes from within and never goes out of style. Follow these beauty commandments from Authentic Beauty guest columnist Cassie Brewer to achieve timeless beauty.
Stephanie Walent, who specializes in neuro muscular therapy, massage therapy, reflexology, and energy work as a Reiki master, is a welcome addition and incredible talent joining the Authentic Beauty team. Licensed in 2014 from Gwinnett College, she has found her calling healing people and making them feel better. "Seeing someone in pain, seeing that in their eyes [...]
In memory of a mentor.
Have they discontinued your favorite lipstick color? At Authentic Beauty's custom blended lipstick station in Atlanta, we can create the lipstick of your dreams made specifically for you at our studio.
For first time clients, get a Brazilian wax service for just $39. Get your first full set of eyelash extensions for just $125 and enjoy a manicure for just $17 at Authentic Beauty.
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Images in this gallery
Biscayne Bay View from the 30th Floor of the Marriott Hotel on Bayshore Drive. Thanks to the exceptional courtesy of Suzanne. At the center of the picture is the Venetian Causeway crossing Biscayne Bay between Miami, at N.E. 15th Street on the mainland and 17th Street on Miami Beach. This bridge built in 192...
- Manhattan, Lower Manhattan, New York City, NY in July 1013 as seen from Liberty Park in New Jersey by Robert Holmes
Lower Manhattan, New York City, NY in July 2013 as seen from Liberty Park in New Jersey (Image MG230123-0241-2_C.psb) This is a corrected version of this image with error correction and image sensor dust spots removed. This image was shot with a Nikon D800 camera with a Nikon 28-300mm lens, mounted on a Gigapan Epic...
Miami, Looking West-Northwest from the Vizcayne Condo in Downtown Miami (Image MC070008-0146A_A,psb)
- Brickell Avenue from the Miami River South at Night as seen from Area 31 of the Epic Hotel/Condo in Miami, Florida. by Robert Holmes
- Miami looking Northeast from the top of the Vizcayne Miami Condo, North Tower, Biscayne Blvd & N.E. 3rd Street by Robert Holmes
Miami looking Northeast from the top of the Vizcayne Miami Condo, North Tower, Biscayne Blvd & NE 3rd street, with color and contrast corrections. Included in this image is the Marina Blue Condo, Miami's Freedom Tower, The American Airlines Arena (Home of the Heat Basketball Team),a portion of Bayside and the causeway...
- Biscayne Bay Highrises and Venetian Causeway in Miami as seen from the Venetian Isle Condo by Robert Holmes
Biscayne Bay Highrises and Venetian Causeway in Miami as seen from the Venetian Isle Condo. (Image MD271435-1805_A.PSB) This image shot with a Nikon D800 Camera and a Nikon 300mm F4 lens with a 1.7 teleconverter giving an equivalent focal length of 510mm.
Venetian Causeway Bridge. This is my second Panorama of this Scene, taken on a slightly overcast day and therefore the lighting in this picture is not quite as good as the previous image ( www.gigapan.com/gigapans/91518 ). This Panorama, however, was shot using the new Nikon D800 camera with its 36 megapixel ...
This picture was taken from the Margaret Pace Park in Miami, looking across Biscayne Bay to Miami Beach. The tall buildings in the background are on Collins Avenue on Miami Beach which are 3 - 5 miles away. This image was exported out of the stitcher program as a TIF file. This image has not been cropped or altered ...


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First trip to Bonaire--feedback
Arrange for taxi before showing up. Search for "Bonaire Taxis" to see the licensed drivers and their contact info. Victor Ruiz, Taxi 8, was great with clean well maintained van.
Some places may take AMEX, but far away most of my experience suggest that Visa or M/C, sometimes Discover, are the only cards one can use.
Phone system works fine. Don't shy away from using your room phone.
Probably you're driving. Learn to identify the local stop sign. Not North America's version. Rest you can figure out. No traffic lights friends. Stops or circles. Courteous drivers overwhelmingly.
Snorkelers should not wait to get on the island to reserve time with Renee Leach (through Info Bonaire site). You will want to spend hours and days with Renee and her educated eyes. You can't begin to count the species you will see--common and rare. Uncommonly reasonable cost. Sorry to report that you will want to spend time snorkeling far longer than you'll be comfortable in the water here; about 45 minutes. Bring a full wet suit with you or you can sometimes buy a used suit at the larger dive outfits.
The dive/snorkel sites in the island's developed areas are not easy to find from the road. But look hard to those small yellow painted rocks with the site names on them. South of town at the airport and beyond no problem Ditto north once you're by the homes/villas. Note that once the coastal road leaves the inhabited coast behind it is ONE WAY going north until it intersects with the road to the center of the island. So you literally must make a round trip up the north coast, then island, then back to town. Not too long but it can seem that way. Why just one way up north? The foliage is up against the road on both sides. It would be very deadly to try and drive the single lane with its twists and turns in both directions.
Van den Tweets is clearly way and above all the rest of what North Americans would call a super market. Sure its all in Dutch, but you can figure it out without a problem and the cashiers and staff all speak English. Frequently you pay the same price or less than in the States for both food and other stuff. Warehouse Supermarket is indeed the most price competitive on the island but the selection and shopping experience at Tweets is way different.
Being a vegetarian means a comparative limited selection of restaurants. Capriccio, the comparative new Italian restaurant on south end of town and on the water (near the Casino) is great in that respect. For anyone, this place has got to be the best in terms of modern architecture and the place to be seen upscale dining. Reservations a must. Tuesdays of all days is the day they have been closed.
Impressive array of schools, rentals, and just plain doing it for both wind surfing and kite boarding on the island. You can get neat pictures of these too.
Plaza Resort appears to be the largest and most upscale on the island. Buddy Dives is certainly the largest dive resort, boat fleet for dives, and what seems at times like a fleet of pickups for rent that must be in the 100's.
Thought the days cruise ships were in port was going to be heck with people crawling all over the place. Not bad at all. The cruisers are clearly around but they hardly swamp the place.
Here's hoping that Bonaire continues to act to restrict development along the coasts and keeps the island as good looking as it is. This is an exceptional island for snorkeling and diving and I've been all over the Caribbean, Mediterranean, and Red Sea.
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Bonaire Tips
First trip to Bonaire--feedback
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thanks for writing your trip report. lots of helpful info. where did you stay? we like to rent villas. did you see any that looked wonderful? or is there an area that might be better than others? we like beachfront
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I never use my hotel room phone, unless local calls are free.
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Dennis Cunningham Receives Ray Trayle Prize
Dennis Cunningham, art faculty, was unanimously selected as the recipient of the 2015 Ray Trayle Print Prize, given annually to a "remarkable Northwest printmaker."
Tuesday, November 13, 2012, 7:30 pm
The Old Library, BP John Admin. Bldg.
Marylhurst University
Free and open to the public.
Fiction writer Natalie Serber reads from her recent debut story collection, Shout Her Lovely Name (Houghton Mifflin Harcourt).
Serber's work has appeared in The Bellingham Review, Fourth Genre, Third Coast, Inkwell and others. Her awards include Tobias Wolff Award, H.E. Francis Award, and the John Steinbeck Award, all for fiction. She also received a finalist mention for the Annie Dillard Creative Nonfiction Award, and a short-list mention in Best American Short Stories.
She is currently at work on a novel about the geometry of family life, the families we are born into and the families we create and sustain by choice. She also teaches fiction writing courses at Marylhurst University.
The series is sponsored by Marylhurst's English Literature and Writing program and supported by the Thomas Binford Endowment Fund for Writing.
Dennis Cunningham, art faculty, was unanimously selected as the recipient of the 2015 Ray Trayle Print Prize, given annually to a "remarkable Northwest printmaker."
Sponsored by Portland Classical Guitar.
Portland Actors Ensemble celebrates 45 years as Portland's free Shakespeare-in-the-Parks. Bring a blanket or a beach chair, pack a picnic supper,...
Week One: Ages 5-9. The Creative Arts Day Camp for children with and without special needs is a one-week, half-day program where children have acce...
Support arts and cultural events at Marylhurst University. Every gift makes a difference!
News about upcoming events at Marylhurst University can be delivered direct to your inbox.


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- ArmyHire.com
- U.S. Army Civilian Career Opportunities
Students and Recent Graduates
Entry-Level Positions for Students and Recent Graduates
The ACC's Pathways Internship Program offers challenging job opportunities in acquisition and procurement and other career fields with great career advancement potential. There are three Pathways programs:
- Internship Program: This program replaces the Student Career Experience Program (SCEP), and Temporary Employment Program (STEP). The program is designed for current students enrolled in a wide variety of educational institutions, from high school to graduate level opportunities to work in agencies and explore Federal careers while still in school.
- The Recent Graduates Program: Provides developmental experiences in the Federal Government intended to promote possible careers in the civil service to individuals who have recently graduated from qualifying educational institutions. Applicants must apply within two years of degree completion (except for veterans which have six years after degree completion. Successful applicants are placed in a dynamic, developmental program with the potential to lead to a civil service career in the Federal Government.
- The Presidential Management Fellows (PMF) Program: The Federal Government's premier leadership development program is a program at the entry-level for advanced degree candidates (e.g.; masters or professional degree). The Program attracts and selects from among the best candidates and is designed to develop a cadre of potential Federal Government leaders.
ACC vacancies will be posted on ArmyHire.com and on USAJobs. For more information on Pathways Programs, please visit the USAJobs Students and Grads page.
ACC often hires individuals for entry-level positions. Recruiting is typically done at the college/university level. Contact your local college/university placement office for future site visits.
|Close Date
|Job Title
|9 Jul 2015
Purchasing Agent (OA)
Salary: $39,570–$51,437
|Fort Leonard Wood, Missouri
|13 Jul 2015
Contract Specialist
Salary: $52,867–$83,153
|Fort Wainwright, Alaska
|13 Jul 2015
Purchasing Agent
Salary: $43,823–$56,974
|Fort Jackson, South Carolina
|17 Jul 2015
Procurement Technician
Salary: $39,570–$51,437
|Fort Jackson, South Carolina
|30 Sep 2015
Quality Assurance...
Salary: $27,982–$66,688
|Multiple Locations
|13 Jul 2015
Purchasing Agent
Salary: $39,570–$62,920
|Fort Campbell, Kentucky
|20 Jul 2015
Contract Specialist
Salary: $39,179–$75,376
|Fort Knox, Kentucky
|20 Jul 2015
Contract Specialist*
Salary: $39,179–$75,376
|Fort Knox, Kentucky


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Well met on Audiko.net! All you need is to download a free Celtic Thunder ringtones for your iPhone or mobile. Scope out your favorite tune from your favorite composition - Ireland's Call, Mull of Kintyre, Raggle Taggle Gypsy, or any other track. Then download the prepared Celtic Thunder ringtones to your mobile, and enjoy Celtic music by Celtic Thunder every time your phone rings. If you wig Celtic or maybe Folk and irish music, then you will probably like Mary Black, or The High Kings as well. On Audiko you can get your tune both in the MP3 and m4a formats, compatible with both mobile phones and iPhones. Just select a track, and choose free Celtic Thunder ringtones download option.
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Originally written on NESN.com | Last updated 8/8/12
What did the Red Sox do to anger the gods? Baseball gods, Greek gods, whichever ones you pick, the Red Sox appeared to be cursed by 'em on Wednesday. Time and time again, the team battled back to tie things up, but then couldn't get over the hump. Like the ancient Greek myth of Tantalus, the Sox were left wanting in the end. NESN Nation's Dan Duquette isn't giving up on these guys yet, though -- not when they have Will Middlebrooks in the mix day-in and day-out. That's why he's our "Tantalus" player of the game after another tantalizing...
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Sometimes, it feels as if we are eavesdropping on day-to-day conversations rather than just hearing the usual litany of platitudes and regrets.
Sometimes, it feels as if we are eavesdropping on day-to-day conversations rather than just hearing the usual litany of platitudes and regrets.
"Stray Dog" largely succeeds because Granik's technique complements her subject. Both he and the film are modest in their goals and cherish the value of…
"The Ballad of Narayama" is a Japanese film of great beauty and elegant artifice, telling a story of startling cruelty. What a space it opens…
Patrice Leconte's "Monsieur Hire" is a tragedy about loneliness and erotomania, told about two solitary people who have nothing else in common. It involves a…
Nick Allen picks one of his favorite Roger reviews.
An excerpt of Tony Fitzpatrick's column, "Dime Stories," which has its first published compilation in stores this month.
Nick Allen picks one of his favorite Roger reviews.
An excerpt of Tony Fitzpatrick's column, "Dime Stories," which has its first published compilation in stores this month.
A review of Han Gong-ju from a Far Flung Correspondent.
An FFC responds to Kyle Smith's assertion that women can't enjoy GoodFellas.
America takes on Trump; "St. Elmo's Fire" turns 30; Music in Sofia Coppola's films; Chat with "Vampire Diaries" DP Darren Ganet; R.I.P. Brian Clark.
The table of contents for RogerEbert.com's complete coverage of AFI Docs 2015.
"Youth Without Youth" proves that Francis Ford Coppola can still make a movie, but not that he still knows how to choose his projects. The film is a sharp disappointment to those who have been waiting for 10 years since the master's last film. The best that can be hoped is that, having made a film, Coppola has the taste again, and will go on to make many more, nothing like this.
His story involves Dominic (Tim Roth), a 70-year-old Romanian linguist who fears he will die alone and with his life's work unfinished, and decides to kill himself. Before he can do that, he is struck by a bolt of lightning that should have turned him into a steaming puddle, but instead lands him in a hospital, burned to a crisp. Then a peculiar process begins. He starts to grow younger. His hair thickens, and loses its gray. His rotten teeth are pushed out by new ones. His skin heals. His health returns.
It is the eve of World War II, and Dominic becomes of intense interest to the scientists of the Third Reich. Perhaps Hitler thinks his wounded soldiers can be made whole, or that he himself can turn back the march of time. Dominic, now hale and hearty, finds himself in Switzerland being seduced by a sexy German spy, when one day he sees, or thinks he sees, a woman on a mountain hike who resembles Laura, the lost love of his youth.
This is Veronica (Alexandra Maria Lara), who is, wouldn't you know, struck by lightning and starts to grow older. In the process, she regresses backward in linguistic time, and begins speaking Sanskrit, Babylonian and perhaps even the Ur-language from which all others descended.
This is exciting beyond all measure to Dominic, who has researched the origins of language, but it is also heartbreaking, because he seems to have had his lost love restored to him, only to be taken away by the implacable advance of age.
Coppola found this story in a novella by the Romanian-born Mircea Eliade, for many years a scholar of religious history at the University of Chicago. It is possible to see how the movie might have been simplified and clarified into an entertainment along the lines of "Time After Time," but Coppola seems to positively embrace the obscurity and impenetrability of the material.
There is such a thing as a complex film that rewards additional viewing and study, but "Youth Without Youth," I am afraid, is no more than it seems: a confusing slog through metaphysical murkiness. That it is so handsomely photographed and mounted, and acted with conviction, only underlines the narrative confusion.
We know from interviews that the story means a great deal to Coppola, now at the same age as his protagonist. But his job is to make it mean a great deal to us. He is a great filmmaker, and I am sure this film is only a deep, shuddering breath before he makes another masterpiece.
A rebuttal to Joni Edelman's piece on "Inside Out."
MTV's Scream and CBS's Zoo premiere tonight. One is worth your time. Which one?
Three films starring Gina Lollobrigida have been released on Blu-ray; Glenn Kenny looks at them and her entire career.
An essay on the underrated scores of late composer James Horner.


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I am a big fan of white wines-particularly sauvignon blanc from NZ but the more I read the more I find that red wine is actually a healthy part of a good diet (unless you drink too much). So I started trying various red wines but they seemed so heavy to me that I longed for something lighter with less tannins and less density (?). I tried some pinot noir from Oregon and it is great and it makes me wonder what else might be out there that is similar. I could drink it all winter and be happy but maybe there are a number of reds that are in the same ballpark as pinot noir.Any suggestions?
What types of wine are similar to Pinot Noir?
- Reply by EMark, Feb 28, 2013.
You might want to try Gamay-based wines. Here is a Wikipedia Link for you to learn a bit about Gamay. The most famous examples of Gamay are Crus Beaujolais. OK, Beaujolais Nouveau is also somewhat famous, but I might call it infamous. There are domestic versions, but they are pretty hard to find.
Another idea might be some of the lighter bodied Italian wines like Chianti (from Sangiovese) or Barbera. I don't see them as being similar to Pinot Noir other than the fact that the are not the big, tannic monsters that you do not seem to like. They are somewhat higher in acid, which, to my point of view, make them excellent accompaniments to a meal. Both Sangivese and Barbera are grown in California (I don't know about other states), and it is not to hard to find examples made from them.
I am sure that others will jump in here with their ideas.
Please keep us up to date on your discoveries.
- Reply by JonDerry, Feb 28, 2013.
There really is no substitute for Pinot Noir, though you might try its sister Chardonnay. Liquid Farm makes some great ones with fruit from Santa Barbara.
- Reply by Tom Wandeloski, Feb 28, 2013.
You also might want to try the Pinotage wines from South Africa. This cousin maybe what you are looking for. One Pinotage, I would recommend is the 2010 Pinotage from Southern Right vineyards of Walker Bay, South Africa. Cheers! and enjoy. :-)
- Reply by duncan 906, Feb 28, 2013.
If you like Pinot Noir from Oregon then you will certainly like Burgundy
- Reply by JonDerry, Feb 28, 2013.
Good call on Pinotage actually, probably as close as you can get.
And of course, red Burgundy is made from Pinot Noir so that should be on your short list.
- Reply by Natashaz, Feb 28, 2013.
Wrath make some incredible Pinot Noirs.
- Reply by JonDerry, Feb 28, 2013.
Drinking an 09' Calluna Merlot from the Chalk Hill AVA tonight.
Could definitely pass for being in the Pinot family, the CA chapter of course.
- Reply by EMark, Feb 28, 2013.
I'm finishing off a 2010 Mazzei Badiola, tonight--an 80% Sangiovese/20% Merlot blend from Tuscany. Cherry/berry flavors, not terribly big and no detectable tannin. Peggy is testing some kind of sauteed chicken in tomatoes recipe, tonight, and I think this will match well. Here's the best part--$9.99 at Costco.
- Reply by Tom Wandeloski, Mar 1, 2013.
Thanks for the kudos on the Pinotage. I've always been a fan of Pinot Noir and my first time trying Pinotage was in early 2004 after taking some R&R leave from my military duties in Iraq to Cape Town, South Africa and tasting the Pinotage at the Spier Winery. The location, view, vineyards, food and Pinotage were outstanding!
- Reply by penguinoid, Mar 5, 2013.
Gamay is a good suggestion. I haven't tried it, but I know Brick House Vineyards in Oregon make a Gamay. http://www.brickhousewines.com/gamay.html . I've only ever tried their Pinot Noir, though. In France, there are lots of good Gamay to choose from from Beaujolais, and quite a few from the Loire. I think their are even one or two NZ producers, too...
From Italy, Dolcetto and Barbera would be worth trying too. You might also like Valpolicella.
If you don't mind the wine being a bit more tannic, Cabernet Francs from the Loire (Chinon, Bourgueil, Saumur) are worth checking out. They also grow some Pinot Noir in the Loire too, but that might be harder to find.
- Reply by zufrieden, Mar 6, 2013.
Actually, there is nothing quite like Pinot Noir - and I am not trying to be logical in a silly way. However, the beast varies depending on site and clone. If you are a Burgundy fan, you may be surprised by the variety of (Pinor Noir) PN styles the world over.
If interested in a wine that might sometimes approach a PN in terms of silky, voluptuous charm, try a Beaujolais Cru; in particular, Moulin-a-Vent or Morgon. In a good vintage (say 2009), you will find that these wines (if consumed today) have many of the qualities of a decent AC Nuits PN. These qualities include more elegance, less acidity, greater depth and a move away from simple Beaujolais floral notes.
Ordinary Beaujolais won't work, so choose a meaty Cru. This comment seconds the Gamay suggestion of Penguinoid.
- Reply by penguinoid, Mar 7, 2013.
zufrieden - yes, no other wine other than, as you suggest, maybe aged cru Beaujolais is exactly like pinot.
I interpreted the query as looking for red wines that are light to medium bodied and without much in the way of tannins -- this gives a wider range of wines to chose from.
Most of them won't be exactly like pinot noir, some will be nothing like it whatsoever, except for those criteria mentioned.


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Marilyn Monroe
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|Reviews for Colors and Capes
| Rake1810 chapter 6 . 4/25
OOC - i'm still amused over that days after reading the chapter and I'm begging for RDJ to use that line in Avengers 2. Too clever.
| Disgrace101 chapter 6 . 4/17
Hahaha. Loved it.
| Guest chapter 6 . 3/30
So at what point did Xander become a preachy hipster? Because that's how he's totally coming off.
| epyon318 chapter 6 . 3/15
Supergirl is older then Superman. just so you know
| The Richmaster chapter 6 . 3/15
You mentioned that 'Flannel-man' had just stopped a robbery when Lois talked to him; it would not be unlikely that someone else on the street noticed what was happening, recorded it on their phone and uploaded it n I'd especially like to see the reactions of Bruce and Lex.
| Allexan chapter 6 . 3/6
Thank you for another chapter, I love this story, In the end of this chapter i saw this:
After accepted apology we see Huntress and Canary (who once again in off romance with Q/Green Arrow).
- Flannel Man thank God we find you here! There is emergency, we need your help! Two girls take each hand of X and drag him off the room.
Dumbfolded man only here:
- It looks like a job for Flannel Man! - from the distance in mock X voice.
P.S. Yes, girls in JL gossip too _
| anon chapter 6 . 3/5
Man so many fics with so many entertaining ideas in them lol. Hope you manage to churn out a few more updates to this one.
| Wonderbee31 chapter 6 . 3/6
Awesome section, and great to see it get turned back on Lois there in the start.
| jlnorris75 chapter 2 . 3/6
Your missing a chapter on twisting the hell mouth chapter 2 is different and helps pull the story together
| Gundum M chapter 6 . 3/5
Great chapter.
| frytrix chapter 6 . 3/5
Cheers,, please give us another chapter to read soon.
| Fibinaci chapter 6 . 3/5
Xander's rebuke of Lois falls under the "ObiWan" rule, i.e., its true from a certain point of view. She certainly was that way in the older comics, the Chris Reeves movies, and season 1 of the Dean Cain tv show, with hints in the original tv show. Lois has been totally toned down since then though. Not coincidentally since then she been less interesting and back burnered more.
| 4everfictional chapter 6 . 3/5
Beautiful. XD
| 4everfictional chapter 5 . 3/5
| 4everfictional chapter 4 . 3/5
Me too. ;)


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Posted: 04/29/2008 - A large storm spawning bolts of lightning 10,000 times more powerful than any seen on Earth is raging on Saturn.
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Posted: 04/28/2008 - Beaufort County and Hyde County each had one tornado on Monday afternoon as a line of strong thunderstorms moved through the area.
Posted: 04/28/2008 - Scientists are doing research in the Arctic to determine whether haze is increasing the rate of melting.
Posted: 04/28/2008 - Strong thunderstorms spawned several tornadoes that caused damage and injuries in southeastern Virginia.
Posted: 04/28/2008 - The area around Reno, Nevada, continues to shake as another moderate earthquake has been recorded in the region.
Posted: 04/28/2008 - Firefighting crews are working to contain a wildfire that crept to within yards of several homes in Sierra Madre.
Posted: 04/28/2008 - A moderate earthquake has rattled Mexico.
Posted: 04/27/2008 - A strong cold front will move through Eastern North Carolina on Monday likely bringing another round of strong to severe thunderstorms.
Posted: 04/27/2008 - Another round of strong thunderstorms hit Eastern North Carolina on Sunday causing gusty winds and torrential rainfall.
Posted: 04/27/2008 - Severe weather has dumped between 5 and 6 six inches of rain on parts of North Carolina.
Posted: 04/25/2008 - Eastern North Carolina should experience warm conditions on Saturday as inland temperatures reach the lower to middle 80s.
Posted: 04/25/2008 - Several major weather events occurred in North Carolina on this date in history.
Posted: 04/25/2008 - The narwhal, a whale with a tusk, is now considered more endangered by climate change than polar bears.
Posted: 04/24/2008 - Although temperatures have warmed worldwide, portions of Antarctica have actually cooled during the summer.
Posted: 04/24/2008 - New Zealand's largest glacier is shrinking at its fastest pace in recent history.
Posted: 04/24/2008 - A storm system brought severe thunderstorms and a tornado to northern Texas on Wednesday night.
Posted: 04/23/2008 - After years of dry conditions the drought across the western United States has improved.
Posted: 04/23/2008 - A new report shows a substantial increase in carbon dioxide and methane over the past few years.
Updated: 04/23/2008 - Following last week's earthquake in the Midwest, the U.S. Geological Survey has released a new set of maps and information with updated information regarding earthquake risk.
Posted: 04/22/2008 - A new study by the National Academy of Sciences suggest that expose to ozone is linked to premature deaths.
Posted: 04/22/2008 - It appears Eastern North Carolina is headed for a wet spring after enduring a year of drought.
Updated: 04/23/2008 - The showers continued across Eastern North Carolina on Tuesday bringing significant 3-day rainfall totals.