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By Rabbi Daniel Lapin
July 24, 2011
Last night Susan made one of my favorite dinners—tofu, salad, and celery sticks with peanut butter. C'mon, you know that was a joke, right? Actually, Susan made marinated steak with baked potatoes; I'm easy to keep happy. After dinner I said, "Thank you so much. That was a wonderful steak." But I wasn't happy.
Why wasn't I happy? I didn't quite know until, suddenly during the night, I awoke with the thrill I always get upon realizing that my soul has been working hard while I've been asleep. I knew what was worrying me.
It wasn't my steak that was wonderful; it was my wife who was wonderful. The dinner I enjoyed was the result of my having a wonderful wife. Saying, "That was a wonderful steak," was meaningless. Lying awake last night I realized that what I should have said was, "You are the most wonderful wife; thank you for making my favorite dinner again."
I fell back asleep bothered by my failure. Sometimes I wish my soul wouldn't work so hard.
Many of us do the same at home and work. "Thanks for such a comprehensive report," is not nearly the same as, "You are the best assistant imaginable, nobody else could have created that report."
Doug Conant, the CEO who, during the past ten years literally turned around the failing Campbell Soup Company, spends about an hour each business day writing personal notes thanking some employees and congratulating others for their achievements.
Now you already knew that people love getting praise. I utterly reject the notion that humans are merely the result of evolutionary biology, but it's true that the brain chemical, dopamine which produces enjoyable feelings, is released when we receive praise. Still, who says that just because you enjoy praise, I am obliged to pander to you and provide it? Maybe you should just grow up and learn to live your life without praise.
at the great prophet Samuel's life. It is clear that his main function
was not foreseeing the future or prophesying but instead bringing peace
by judging conflict and the normal disagreements that occur when normal
human beings live and do business together.
And Samuel judged Israel all the days of his life.
He did an annual circuit …and judged Israel in all those places.
He would return to Ramah where he lived and there he judged Israel…
(1 Samuel 7:15-17)
We see the same emphasis a few verses later when the people approach Samuel.
They (the Elders of Israel) said to him (Samuel)
'You're old and your sons do not walk in your ways,
now appoint us a king to judge us like other nations.
(I Samuel 8:5)
this was terrible in Samuel's eyes—
because they said 'give us a king to judge us...'
(I Samuel 8:6)
Ancient Jewish wisdom emphasizes that Samuel was deeply saddened because they were rejecting him in his own area of specialty, judging. Had the people said, "Give us a king to rule us" he wouldn't have been nearly as upset. Samuel felt totally unappreciated. If the great Samuel needed recognition and God comforted him when he didn't receive it, we too can freely acknowledge our own need. We must also acknowledge our obligation to recognize and praise others.
Here is the key. Giving people praise is not a nice thing; it is the moral thing. Recognition is part of a person's dignity and is his or her right.
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Yes, it is hard to praise another person, mainly because doing so implies making yourself a bit smaller. But humbling oneself is a powerful character builder and long-term success in both personal and professional life is often the reward of the strong character. There is no better character-building program than that which God built into His Message to mankind.
Many more character and relationship building tips fill my double audio CD set, Prosperity Power: Connect for Success. It is packed with practical ways to increase the number and quality of your interactions with others in lessons that spring from the Bible. For only $10 for online orders this week, it's a terrific investment in your financial future.
© 2011 Rabbi Daniel Lapin - All Rights Reserved
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Rabbi Daniel Lapin, known world-wide as America's Rabbi, is a noted rabbinic scholar, best-selling author and host of the Rabbi Daniel Lapin Show on San Francisco's KSFO. He is one of America's most eloquent speakers and his ability to extract life principles from the Bible and transmit them in an entertaining manner has brought countless numbers of Jews and Christians closer to their respective faiths. In 2007 Newsweek magazine included him in its list of America's fifty most influential rabbis.
You can contact Rabbi Daniel Lapin through his website.
Web Site: www.rabbidaniellapin.com


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April 17, 2013
A red "S" adorns a fence outside the home of Jerry Siegel in Cleveland. Superman collaborators Siegel and Joe Shuster lived several blocks apart in the Glenville neighborhood which shaped their lives, dreams for the future and their imagery of the Man of Steel.
Stories this photo appears in:
Superman's 75th puts spotlight on Cleveland roots
The tough, blue-collar roots of Superman's creators are getting a fresh look on the superhero's 75th anniversary.
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Every month we run a fun photo competition through our official Facebook page. You can enter by sending your photo to email@example.com.
Those selected will be posted on our page so their friends, family and everyone else can like their photo.
Mid way through the month, the 5/6 photos that have the most "likes" will be shortlisted in the push for the winner.
Great Outdoors will then use the winning picture as it's Featured Fan Photo on Facebook for the following month and the person who entered it wins themselves a €50.00 gift card. Not too shabby!
The theme of the entries is "Life is Great, Outdoors" and the subject matter of the photos should reflect that. Pictures entered should be of the sender or taken by the sender although we assume that is the case regardless.
This competition is open to all customers of the Great Outdoors except for staff and their families.
Get snapping, get sending, get "like"-ing!


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I'm new here and looking for some help on the purchase of a Chariot Cougar 2. I'd prefer to buy used (for obvious money reasons), and have the option to purchase from a local craigslist seller for $350, which includes the strolling kit, jogging kit, carrying bag and trailer attachment, but it's about 4 yrs old. Or we could buy new - the REI sales rep says there's a good chance they'll go on sale for Labor Day, but it would still cost around $700 for an equivalent set up.
Anyone know if there have been any major changes between the 2009 and 2013 models? Just trying to figure out if paying twice the amount is worth it.
Thanks so much!


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dwarf gouramis
would a pair of dwarf gouramis be ok to house with tiger barbs in a 29 gallon?
Dwarf gouramis can be pretty territorial/aggressive. Here in the US, you'd be extremely hard pressed to find anything other than a male dwarf gourami, so if you buy two you're likely going to end up with two males that don't really like one another. If you have a lot of plants and can break the tank into two distinct territories, you might be able to get away with it.
As for the tiger barbs...well, that'd be iffy. The gouramis don't really have long fins (other than those long, thin "feeler" type ventral fins) so I'm not sure if tiger barbs would really see them as potential targets for nipping. That, and dwarf gouramis are generally grumpy enough that they likely wouldn't put up with harassment from tiger barbs, meaning they might chase the barbs away and prevent any sort of injuries. So it could work, but it might not.
Has anyone here ever tried this combination for themselves?
I purchased a neon blue dwarf gourami today. Since adding him to the tank over an hour ago he hasn't come out of this tree I have for more than 30 seconds. Think he is just adapting?
Update, he was obviously just adapting. He is swimming about the tank and looking very content.
iv had a gourami for 2 months and she still swims off and hids as soon as theres any movement so he is probably still ajusting
I have a flame dwarf gourami in with 3 angels and 2 bolivian rams and he thinks he is in charge of the tank. That is until the big angel comes his way. Good Luck
So, my gourami is being very finicky with food and will even spit out bloodworms, thoughts on what to feed him?
maybe try fish slakes or tubifex worms...my gouramis also like the algie waffers i feed as a treat
I had one male and one female Dwarf Gourami for two years and loved them! I would recommend them for larger community tanks. They can really catch the observer's eye. They were not aggressive to any other fish in my tank, but the male would occasionally pick on the female (nothing too bad though). I encourage you to add a pair of gouramis to your tank.
Mine eat anything I put in there. They eat the flakes, they eat the bloodworms for my frog, they eat the zucchini for my pleco, they eat baby guppies, they even ate hydras off of the plants and the walls when I had a hydra bloom. Heck, they even try to eat poop when they see it, but then they spit it out, try again, spit it out again, etc...
Anyway, he's probably just nervous or something. He'll probably come around. Then you'll have trouble getting him to not eat :P
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Have you printed this coupon for BOGO Tillamook Yogurt? These are on sale for $.71 each at Winco right now, so you can get this good deal:
Buy (2) Tillamook Yogurt — $.71
Use (1) BOGO Tillamook Yogurt Coupon
Final Price: $.36 each
You may need to change your zip code to find this coupon. Click here and enter zip code 84121 then click the blue arrow. Then come back to this post and click the link above to easily find the coupon.
Head over to print two of these per computer. Also, check here for other great Winco match-ups! Also, you can find more great printable coupons at Coupons.com, Smartsource, Redplum and Coupon Network! And you should check out iBotta for another great way to save!


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May 1, 2016
April 11, 2007
AUGUSTA, Ga.---The Georgia Bank and Trust on Walton Way was robbed this morning.
Deputies say a masked man walked into the bank at around 10 o'clock demanding money. He did not have a weapon.
Investigators released a surveillance photo.
Click Here to access the online Public Inspection File
Viewers with disabilities can get assistance accessing this station's FCC Public Inspection File by contacting the station with the information listed below. Questions or concerns relating to the accessibility of the FCC's online public file system should be directed to the FCC at 888-225-5322, 888-835-5322 (TTY), or firstname.lastname@example.com.


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Dean and Sam must search for three key items in order to defeat Dick Roman and the Leviathans. Their quest takes them to Crowley and the Alpha vampire, but the Leviathans will stop at nothing to kill the Winchesters and put their plan for global domination into effect.moreless
No results found.
Jared Padalecki
Sam Winchester
Jensen Ackles
Dean Winchester
Laci J. Mailey
Guest Star
Larissa Gomes
Guest Star
Rick Worthy
Alpha Vampire (uncredited)
Guest Star
Jim Beaver
Bobby Singer
Recurring Role
Osric Chau
Kevin Tran
Recurring Role
Mark Sheppard
Recurring Role
Dick: Which is why we're diving whole hog into what keeps Americans living longer and tasting better.
Gloria: You do mean of course to say the food will be tasting better.
Dick: That's exactly what I mean.
Dick: Susan... are we still looking for a rep in mainstream media?
Susan: Yes, we are.
Dick: Wunderbar. Put a replace order on Gloria there.
Susan: And with the corpse?
Dick: Call Chief Fieri. I feel like barbecue.
Dean: Okay, man, I have read this more times than the Playboy I found in Dad's duffle.
Sam: Anna Nicole?
Dean: Anna Nicole. Ah, the good, they die young, huh?
Dean: "Roman acquires…" What's SucroCorp?
Sam: They make food additives. Namely, high-fructose corn syrup. Well, that crap is in just about everything. Soda, sauces, bread...
Dean: Don't say pie.
Sam: Definitely pie.
Dean: Bastards.
Vampire: Go to hell.
Edgar: No, my neighborhood is worse than that.
Sam: Monks get up at 4 a.m. to pray.
Dean: Ugh. Can't get laid, can't sleep in. A friggin' tragedy.
Emily: What's a Kardashian?
Dean: Oh, that's... just another bloodsucker.
Gloria: Yesterday I introduced you to this rising star in American business. In this hour we go behind the scenes and answer the question everyone's been asking for months: what makes Dick so hard to beat?
Alpha Vampire: We come from you.
Edgar: Barely.
Alpha Vampire: I am the son of Eve.
Edgar: A pathetic mutt. Hardly one of us. I knew Eve, and honestly, your mommy was a whore.
Dean: Let's never do that again. The cops thought we took that kid!
Sam: None of that matters, as long as he gets back to his parents.
Dean: We had to jump out a window, dude!
Music: Why Can't We Be Friends? (War)
Injoke: The book the vampires use to conceal the hidden button is "How to Serve Man." The book is best known for featuring in the original Twilight Zone episode "To Serve Man." Initially believed to be a book for an alien race instructing them on how to dedicate themselves to mankind, the twist at the end is that it is actually a cookbook.
International Airdates:
Australia: May 21, 2012 on Eleven
Norway: June 1, 2012 on FEM
UK: October 31, 2012 on Sky LIVING
Finland: July 7, 2014 on Sub
Referencing the 2007 movie loosely based on Upton Sinclair's 1927 novel Oil! The story revolves around the intrigue and backstabbing during the oil boom in California in the late 19th century.
Sam: Just saying that the lore doesn't have a single real-life example of Casper the Friendly Ghost.
Referencing the animated character Casper The Friendly Ghost. Casper was first developed as a series of theatrical shorts. Casper later appeared in comic books, a few television series, and finally a full length theatrical movie.
Dean: What about Paula Deen over here?
Referencing the celebrity chef who started as a bank teller but became a caterer. She has since hosted several Food Network TV series and published numerous books on cooking.
Dean: I think any way you slice it, you got Pac Man and True Blood in the same room, and that's bad news.
Referencing first the video game character Pac Man, a small yellow circle with a large mouth that runs around a maze eating pac-dots. True Blood is the HBO TV series based on The Southern Vampire Mystery series of novels by Charlaine Harris, which features vampires as members of human society after the creation of synthetic blood for them to feed on.
S 11 : Ep 19
Aired 4/27/16
S 11 : Ep 18
Aired 4/6/16
S 11 : Ep 17
Aired 3/30/16
S 11 : Ep 16
Aired 3/23/16
User Score: 10034
User Score: 653
User Score: 351
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User Score: 129
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User Score: 97
User Score: 96


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I've been cycling with my wife and 2 sons (3 & 5) for a while now. My wife and I ride a tandem and we pull the boys in a trailer. Well, they're getting older, bigger and restless and so we need a change. We think the ideal solution would be to get a trail-a-bike that can hold 2 kids. I don't think these are in production anymore, so was wondering if anyone had one they'd want to sell. Probably a long shot, but thought I'd give it a try.
I'd also appreciate any stories/pics from those who have either used such a bike or who have come up with another creative solution for bringing kids on a ride.


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Dogs were in the headlines recently at Mayo Clinic with the release of the book "Dr. Jack the Helping Dog," which features a 9-year old pincher who is Mayo's first, and only, facility-based service dog.
Also, a new friend of mine, Jean, is the owner of a beautiful English Yellow Labrador named Koda who is a therapy dog. What's the difference between a diabetes therapy dog and a diabetes service dog?
Therapy dogs are trained to provide affection and comfort to people in hospitals, retirement homes, nursing homes, mental health facilities, schools, and stressful situations such as disaster areas.
Service dogs are trained for 3 roles:
Diabetes service dogs also provide valuable help. For years, as a diabetes educator, I've heard stories from patients who have pets about how their pet alerted them to impending low blood sugar (hypoglycemia).
Diabetes service dogs are trained to:
Several programs train diabetes service dogs for individuals with type 1 diabetes, including Dogs4diabetics and Can Do Canine. Both of these service organizations have specific criteria that must be meet before a service dog is placed with someone. Also, dogs are restricted to specific regions or states. If you know of other organizations that provide diabetes service dogs, please let us know.
A person with a diabetes service dog said on the Dogs4Diabetic's Web site:
"The best part for me is that when she helps me, it's non-judgmental."
Everyone have a good week, and please share your story. Signing off for now,
Sara J. Carlson, R.N., C.D.E.
Peggy Moreland, R.N., C.D.E.
Original article: http://www.mayoclinic.org/diseases-conditions/diabetes/expert-blog/diabetes-service-dogs/bgp-20056463
Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below.
Mayo Clinic is a not-for-profit organization and proceeds from Web advertising help support our mission. Mayo Clinic does not endorse any of the third party products and services advertised.
A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.


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Swift Boaters Start Your Engines
If Obama is hit with an attack ad fusillade, this secretive GOP operative will likely be behind the onslaught.
The man behind AIP, Tony Feather, could become one of the most significant players in the election. Feather, a longtime Republican operative, is not a household name and he rarely talks to the media. But his specialtymounting stealth political advocacy campaignshas played an outsized role in the last two presidential elections. Should Obama end up confronting a Swift Boat-style fusillade in the closing weeks of this campaign, the odds are that Feather will be one of the ops responsible for the onslaught.
A former executive director of the Missouri Republican Party, Feather is known for his fierce campaign tactics on behalf of candidates like John Ashcroft and former Missouri Attorney General Bill Webster. Feather ran Websters 1992 campaign for governor; Webster not only lost but went to prison on charges related to misusing his office for campaign purposes. Feather is also a compatriot of Karl Rove, whom he first met in 1974. The two are close enough that Rove at one point endorsed Feather's consulting firm on its website.
Politics has also made Feather a rich man. He started a handful of companies that specialize in "microtargeting" voters with direct mail, phone, and grassroots lobbying for GOP campaigns and big corporate clients. One of his companies sets up fake grassroots groups to give the appearance of public support for corporate legislative efforts. In 1999, Feather founded Feather Larson Synhorst with another GOP operative, Tom Synhorst, who is sometimes referred to as the "Johnny Appleseed of Astroturf."
FLS is responsible for many of those annoying robo-calls to voters that arrive during the days leading up to elections. The firm and its related entities, including the lobbying shop DCI Group, were among the biggest recipients of Republican National Committee money in 2004 election cycle and raked in nearly $27 million from Republican Party entities and candidates, including Bushs reelection campaign.
Another one of Feather's companies, FLS-Connect, has a virtual monopoly on campaign phone work for the GOP, having worked for the state Republican parties in all 50 states, according to the company's website. In the past year, the RNC has paid FLS-Connect more than $9 million for its services. Since 2007, Feather's firms have earned more than $16 million from Republican Party entities, candidates, or affiliated interest groups like the National Rifle Association, according to CQ Moneyline. In June McCain Victory 2008, a PAC run by the RNC and a handful of state Republican committees, paid FLS-Connect $4,000 to provide "telemarketing" services.
Feather was the political director of the Bush/Cheney 2000 campaign, and was central to Republican efforts to get around new campaign finance laws banning soft money donations to the national parties. In 2001, Feather founded Progress for America, a nonprofit group that served as the de facto political arm of the Bush White House on everything from Social Security privatization to judicial nominees. In 2003, Feather stepped down from the group to work for the Bush campaign, but PFA lived on, spinning off a 527 group, the PFA Voter Fund, to spend unregulated money directly influence the 2004 election.
Mother Jones encourages readers to sign in with Facebook, Twitter, Google, Yahoo, Disqus, or OpenID to comment. Please read our comment policy before posting.


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weather in the jungle
Tropical vegetation zone of the Amazon River basin, which houses the largest nature reserves.
The vast Peruvian jungle, bisected by the mighty Amazon River can be divided into two very distinct areas: the high jungle or mountain brow (above 700 m) which has a subtropical and temperate, with abundant rainfall (about 3000 mm per year) between November and March and sunny days from April to October, and the lowland (below 700 m) where the dry season occurs between April and October and is an ideal time for tourism, with sunshine and high temperatures, often above 35 ° C.
Between the months of April and October the river levels dip and roads are easily passable. The rainy season however, between November and March, features frequent rain showers (at least one per day) that may cause damage to the terrestrial paths. The humidity in the jungle is very high throughout the year.
In the south there are occasional "cold fronts" or "surazos" cold fronts from the south end of the continent that occur between the months of May and August, when temperatures can drop to 8-12 ° C.
CuscoPeru.com recommends visiting the Peruvian jungle as the weather is hot and humid relatively constant throughout the year. The normal high temperature for the day is 31 ° C, the lowest at night is 17 ° C and humidity can be between 80-90%.
useful information
A summary of necessary information for the traveler: Exchange, schedules, reference prices and much more.
tourist packages
Choose tours where you can appreciate breathtaking landscapes and vestiges of ancient cultures.
hotels & lodgings
Find accommodation for your stay in Cusco, from facilities in rural areas to five star hotels.


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Things to see and do - Rabbah
Leaving for Jordan
Nearby hotels
Asri Hotel from19 JODBook
Sandra hotel from25 JODBook
Hawa Amman Hotel from25 JODBook
Things to do nearby
Private 4-Day Jordan Special Tour: Petra, Wadi Rum and The Dead Sea
- 412 €
- Book
Private Three Day Tour to Petra - UNESCO World Heritage Site
- 294 €
- Book
Private Half Day Jerash and Amman City Sightseeing Tour
- 130 €
- Book
Sheraton Amman Al-Nabil Hotel :
Nearby tourist sites
Sheraton Amman Al-Nabil Hotel
Sheraton Amman Al-Nabil Hotel
Address : 5th Circle, Zahran Street HKJ - Amman 11183
from : 126 JODBook
This luxurious 5-star hotel in the centre of Amman's business district is only 3.5 km from Al Mukhtar Mall Amman. It offers indoor and outdoor pools, a spa and gym. All rooms are fitted with chic and elegant furnishings. Modern facilities include a satellite TV in every room. Some rooms of Sheraton Amman Al Nabil Hotel have a seating area and a balcony. Massage treatments and a steam bath are available at Sheraton Amman spa. There is also a modern gym equipped with cardiovascular equipment and free weights. Wi-Fi access is also provided. The Sanctuary Lounge offers refreshing cocktails and various dishes in a buffet or à la carte style. Drinks, snacks and live entertainment can be enjoyed at The Green Lounge. Free private parking is possible at Sheraton Amman Al Nabil Hotel. Marka International Airport is 10.5 km away.
Useful Information
- Address : 5th Circle, Zahran Street HKJ - Amman 1118311183Amman
Main services
- Restaurant
- Air conditioning
- Disabled access
- Non-smoking rooms
- Satellite TV


text:
Just as technology ushered in an era of deceit in some ways — hence, films and television shows like "Catfish" — I have recently sensed a backlash, an insistence by consumers who demand truth in advertising. Empowered with so many new digital tools and products, along with the abundance of information available online, simply put, your customers are more powerful than they have ever been. My case in point is former CEO Andrew Mason's goodbye letter to the Groupon team upon his termination for poor performance:
"After four and a half intense and wonderful years as CEO of Groupon, I've decided that I'd like to spend more time with my family. Just kidding — I was fired today."
It gets even better, enough to prompt some analysts and business blog pundits to call this the greatest CEO departure letter of all time. Mason continued:
"If you're wondering why. . . you haven't been paying attention. From controversial metrics in our S1 to our material weakness to two quarters of missing our own expectations and a stock price that's hovering around one quarter of our listing price, the events of the last year and a half speak for themselves. As CEO, I am accountable."
I recently read another article in The Times about the success of an entrepreneur in Virginia whose company was missing consecutive payrolls and in dire straights in 2009, and who flipped his marketing strategy, went rogue and started an inbound program of honest content that — gasp! — actually answered his customers' questions.
A Revolutionary Marketing Strategy: Answer Customers' Questions
Marcus Sheridan, whose company, River Pools and Spas, was suffering in the early years of the downturn, decided to publish a list of the best pool installation companies in Virginia — including his core competitors — and not include his own company.
Sheridan had been spending about $250,000 annually on outbound programs that used broadcast and local media outlets to promote their pools. But as the recession gripped his customers and as buying, begging and other traditional methods of marketing failed, he did something radical. He began publishing answers to questions online for anyone interested in learning more about pools. Today, River Pools and Spas has rebounded to reach its pre-2007 revenues and Mr. Sheridan is considered a web marketing guru, lecturing at conferences on his unconventional tactics that were clearly successful enough to turn around an ailing company.
The Times article shared a brief Q&A:
"The question I was always asked within the first two minutes of talking to customers was, how much does a fiberglass pool cost? Pool installers are like mattress or car dealers — we hate talking about how much a pool costs until we have you in person because there are so many options and accessories we want to sell you. As a result, pool companies never mention price on their Web sites. But I said, I don't care what the question is, we're going to answer it," said Sheridan.
* * *
We're in the era of the anti-spin. It's a new demand by consumers and a response by savvy marketers who are hearing and heeding the call. Unfortunately, even as consumers become increasingly empowered with knowledge (read: reviews) through the web, there's a growing tide of frustration over this whole sequestration debacle. Watching the bandying back and forth between House Speaker Boehner and President Obama — between the doctrines and party allegiances of stubborn Republicans and Democrats — has become an exhausting, cynical experience that threatens our nationalism and loyalty. As it turns out, through the grace of our taxpayer contributions, this finite group "inside the beltway" really does live in a protected, impenetrable cocoon.
Truth in advertising works and we're seeing more of this as marketers understand the power of the modern consumer. Now if only Congress and the President could learn the same lesson.
Tags: advertising, Andrew Mason, answers, business, CEO, Groupon, honesty, knowledge, marketing, marketing strategy, modern consumer, questions, resignation letter, technology, truth
This entry was posted on Sunday, March 3rd, 2013 at 11:50 am and is filed under Advertising, Brand Identity, Brand Image, Business, Marketing, Media. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.


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if i look at the republic tech tree it says that jou can build the chancellors secret weapon but i just cant get it does any one of jou know how to build it
long live infinity ward (for making the modern warfare series:))
if i look at the republic tech tree it says that jou can build the chancellors secret weapon but i just cant get it does any one of jou know how to build it
jou are right Urban_Chaos_99
its as fake as possible
we shall destroy jou!!!
have we tried negotiating with the mandalorians? they shall be a usefull
rc-0001-nick give up the rebel allaince totaly because we are allmighty
and we shall cruch annyone who opposses us
delta is right. since i am a spartan i can take a lot of pain
i swear jou should bring out a demo
he ik kom ook bij de groep
the sith will live forever
i wanna be in the Sith academy
the mandalorians have always hated the jedi so they will join us.
they did it before
he thanks it really helped me conquer mordor and rhun
he how do jou get a huge city
he guys i cant get a huge city
i already have 50000 villagers in one city
could jou tell me what to do
sorry i forgot to thank jou for helping me out
so thanks for helping me out
the mod is great but the mod craches when i want to play a custom battle
in a villige or city. But even so its a great mod
i think it could be fun to have a demo
so what that there are bugs in the game. no pain no gain
it is on a D disk
jou want to let spider droids spawn from those factory's?!
he guys, me again. I can't start the mod. Can jou help me????
alreardy thanks for the help
change the discription
im losing faith in this mod
why the **** is it only for Alexander?!!!
i can't find it in any store
i can't start the mod
pity that the mod will take longer to develop but i understand it completely. it will be much nicer if there wore no bugs in the mod.
keep it up guys :)


text:
Sophisticated theology
this wiki
Sophisticated theology is a general term for the incredibly wide range of elegant and important advances made in the vital and lively field of theology when no one, apparently, was looking, and which the New Atheists resolutely fail to address, clearly to their detriment. All of these clearly demonstrate that belief in a deity or deities is eminently defensible logically, philosophically, etc. Really, it's a shocking scandal that they haven't addressed these arguments, this evidence. Arguments such as... umm...
Well, we'll get back to you on that. But trust us, there's, like, hundreds of 'em, we're sure. Thing is, we must have left them in our other pants.
...oh, wait. Here's one. Atheists get their panties in a wad because The One True God is invisible, and are terribly fond of saying things like: "The invisible and the nonexistent look very much alike." But from another perspective though, we actually do have proof – evidence – that The One True God is invisible: no one can in fact see Him!!!
Deny that, monkey boy.
How to tell if it's really sophisticated theology
Somewhat more seriously--or roughly as seriously as the topic probably deserves--'sophisticated theology' is a little like said invisible god. You can tell it's sophisticated because you've never actually heard it. Or, to borrow a quote from the comments section:
- I use this handy metric: if you've actually heard it or read it, it's not Sophisticated Theology™. Sophisticated Theology™ cannot be explained because in doing so it would become open to refutation. Thus, Sophisticated Theology™, like the rainbow's end or a mirage, is forever beyond your reach. Rest assured though that ST™ is indeed what every believer really believes, no matter how much they may indicate that they—like Anthony Horvath—appear to have a slow preschooler's understanding of the world.
(Brownian, on Sophisticated Theology)
See also
External links
- More sophisticated theology A large part of this is about how believers use sophisticated theological excuses for doing wrong, by PZ Myers
- Myth: Atheist Critiques are Simplistic, Don't Understand Sophisticated Theology Christians expect atheists to follow higher standards than they follow themselves.
- Theology Atheism Wiki on Theology


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text:
Donna M. Kraus, Pharm.D.
Spring 1998
Pediatrics Nutrition
Goal: To familiarize students with the differences in nutritional requirements between adults and children with respect to fluids, electrolytes, calories, carbohydrates, proteins, fats and trace elements.
1. Given the age, weight and disease state of a child, calculate the daily maintenance fluids and total daily fluid requirement.
2. List the indications and monitoring parameters (with monitoring frequency) for a child receiving TPN.
3. Given the age, weight and disease state of a child, be able to describe how to initiate and advance TPN with respect to fluids, carbohydrates, protein and fat.
4. Given the age, weight, disease states and TPN order for a pediatric patient, determine if the TPN order is adequate in terms of supplying appropriate calories, protein, fats, electrolytes, minerals, vitamins and trace elements.
5. For both central and peripheral TPN, list the maximum concentration of dextrose that can be used.
6. Explain why neonates and young infants need special amino acid formulations.
7. Discuss the important neonatal issues regarding lipid metabolism and the controversies/complications surrounding its use.
8. List and discuss the common complications of TPN.
9. List the 4 advantages of breast feeding.
10. Discuss the differences in human milk, cow milk and infant formulas with respect to protein, carbohydrates, fats, and mineral content.
11. For each of the following types of infant formulas, list 3 different brand names, how the content differs between types, the rationale of why each type would be used, and the disease state(s) that each would be used in.
a. Cow milk-based infant formulas
b. Soy based infant formulas
c. Therapeutic infant formulas
d. Preterm infant formulas
12. Given a pediatric patient case, be able to appropriately recommend an infant formula and whether or not the infant requires vitamin or mineral supplements.
Required Reading:
Chessman KH, Anderson JD. Chapter 135/ Pediatric and Geriatric Nutrition Support in Pharmacotherapy, A Pathophysiologic Approach. 3rd ed. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Appleton & Lange, Stamford, Connecticut, 1997 (pages 2787 - 2797).
Highly Suggested Readings:
Cochran EB, Phelps SJ, Helms RA. Parenteral nutrition in pediatric patients. Clinical Pharmacy Vol 7, May 1988, pp 351 - 66.
McKenzie MW, Bender KJ, Seals AJ. Infant formula products in The Handbook of Nonprescription Drugs, 9th Edition, APhA editors, Washington: APhA 1990 (pages 529 - 561).
Additional References:
Manual of Pediatric Parenteral Nutrition, Kerner JA (editor), 1983, John Wily and Sons Publishers, New York.
Total Parenteral Nutrition, Lebenthal E (editor), 1986, Raven Press, New York.
Marshall LL. Infant formula products. American Pharmacy. Vol NS33, No 10. October 1993:55-60.
ASPEN Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition 1993:17:1SA - 52SA.
I. Introduction: Adequate nutrition for the proper growth and development of a child requires individualization. The amount and type of fluid, calories, electrolytes, and trace elements are all based on age, weight, nutritional status, and disease state.
II. The total daily fluid requirement of any patient is equal to the normal daily maintenance fluids plus replacement of any fluid deficit plus replacement of any significant abnormal ongoing losses. Two methods to calculate normal maintenance fluids are described below. Normal maintenance fluids provide replacement for normal body functions and for normal losses (for example, insensible water loss, urine output and stool losses). Other factors that may increase the patient's total daily fluid requirements need to be replaced in addition to the normal daily maintenance fluids.
Total daily fluid requirement = Normal Maintenance Fluids + Deficit + Ongoing Abnormal Losses
Total daily fluid requirements may be increased by: 1) increases in insensible water losses due to such factors as fever, hyperventilation, phototherapy, radiant warming, skin breakdown, burns, etc. 2) initial deficits of fluid i.e., dehydration 3) significant ongoing abnormal losses such as diarrhea, vomiting, nasogastric tube losses, high output renal failure, etc.
A. Daily maintenance fluid requirements (i.e., normal maintenance fluids) are those required to maintain normal homeostasis for a 24 hour period. Surface area and body weight are two common methods used for the calculation of maintenance fluids in pediatric patients.
NOTE: Premature infants will have greater daily maintenance fluid requirements then those shown here due to their larger surface area to body weight ratio and thinner skin, both of which significantly increase their insensible water losses from the skin. In fact, preterm infants < 750 grams often require 200 - 250 ml/kg/day to prevent dehydration. Due to their highly specialized needs, calculation of fluid requirements for premature neonates will be considered beyond the scope of this lecture.
1. Daily maintenance fluid requirements calculated by body surface area: For pediatric patients, the amount of daily maintenance fluid required is in the range of 1500 - 1800 ml/m2/day. Usually 1500 ml/m2/day is used. The surface area method is usually used in children > 10 kilograms because a precise measurement of surface area is often difficult in smaller infants.
2. Daily maintenance fluid requirements calculated by body weight
|Daily maintenance fluid requirements
|< 2.5 kg
|120 ml/kg/day.
|2.5 - 10 kg
|100 ml/kg/day.
|11 - 20 kg
|1000 ml plus 50 ml/kg for every kg over 10 kg.
|> 20 kg
|1500 ml plus 20 ml/kg for every kg over 20 kg.
|Maintenance fluid
|8 kg :
|100 ml/kg/day = 800 ml/day
|15 kg :
|1000 ml + (50 ml/kg * 5) = 1000 + 250 = 1250 ml/day
|27 kg :
|1500 ml + (20 ml/kg * 7) = 1500 + 140 = 1640 ml/day
3. Factors which may increase insensible water loss will increase daily fluid requirements.
a. Estimates of additional insensible water loss (e.g., fever) can be calculated as a percent increase of normal maintenance fluids (e.g. for fever, increase daily fluid by 12% of normal maintenance for every degree Centigrade over 37 degrees).
b. Neonates who receive phototherapy require 20 ml/kg/day additional fluid due to increased insensible water loss.
B. Fluid deficit is calculated by clinical assessment of dehydration.
Degree of dehydration Clinical Signs Mild Moderate Severe Thirst slight moderate intense Behavior alert, restless irritable to touch, may be lethargic hyperirritable to lethargic, may be comatose Mucous membrane normal dry very dry Tears present +/- absent Eyes normal sunken grossly sunken Skin elasticity (pinch retracts) immediately slowly very slowly > 2 seconds Skin color normal pale mottled or gray Anterior fontanelle normal sunken very sunken Weight loss 3 - 5 % 8 - 10 % 12 - 15 % Fluid deficit 30-50 ml/kg 80-100 ml/kg 120-150 ml/kg
NOTE: If the pediatric patient is hemodynamically stable, 1/2 of the fluid deficit is replaced over the first 8 hours, and the second 1/2 of the fluid deficit is replaced over the next 16 hours.
C. Ongoing losses also need to be replaced. Estimates of sensible fluid losses can usually be easily measured (e.g., NG tube losses, vomiting, etc).
D. Fluid restriction: As in adults, the amount of daily fluids administered to a pediatric patient may need to be restricted. Situations which require fluid restriction include patients with cerebral edema, congestive heart failure, renal failure, SIADH, patent ductus arteriosus, and certain pulmonary disorders. Fluid restriction may be calculated 1) as a percent of maintenance fluids (e.g., 2/3 or 3/4 maintenance) or 2) as insensible loss (300 - 400 ml/m2) plus urine output.
III. Pediatric Total Parenteral Nutrition (TPN)
A. The indications for TPN in children are similar to the indications in adults, i.e., if the G.I. tract cannot be used as a route of administration for nutrition, then parenteral nutrition may be indicated. One big difference vs adults is that due to fewer body stores and a higher caloric daily requirement, children are started on hyperalimentation sooner than adults. Generally, the smaller or younger the child is, the sooner (s)he needs appropriate nutritional intake. Indications:
1. Congenital or acquired anomalies if the G.I. tract: gastroschisis, bowel fistulas, intestinal obstruction, atresias, short gut syndrome.
NOTE: "Short gut syndrome" or "short bowel syndrome" is a condition which is present after a significant amount of intestine has been surgically removed. Often these patients are dependent upon lifetime parenteral nutrition.
2. Chronic or recurrent diarrhea: malabsorption syndrome, inflammatory bowel disease.
3. Preterm infants
4. Malnutrition (i.e. TPN as a supplement in certain diseases in which adequate caloric intake is not being achieved via the oral route: cystic fibrosis, cancer, anorexia nervosa, hypermetabolic states, e.g., burns).
5. Patient who are NPO (or who will be NPO) for sufficient periods of time to cause a significant decrease in caloric intake (e.g., post-operative patients).
B. Pediatric Parenteral Nutrition Practice Guidelines (from the American Society for Parenteral and Enteral Nutrition1):
1. Patients who are candidates for parenteral nutrition support are those requiring nonvolitional feeding who are either already malnourished or are at risk of developing malnutrition.
2. Peripheral parenteral nutrition should be used to provide partial or total nutrition for up to 2 weeks in patients who cannot ingest or absorb oral or enterally delivered nutrients, or when central vein parenteral nutrition is not feasible.
3. Peripheral parenteral nutrition may be used for short-term (less than 2 weeks) maintenance, supplemental nutrition, or repletion nutrition support in some older infants and children who are not fluid restricted.
4. Central intravenous nutrition support should be used in patients who do not tolerate enteral nutrition support or in whom peripheral access is limited, parenteral support will last longer than 2 weeks, nutrient needs cannot be met by peripheral parenteral nutrition, or fluid restriction is required.
C. Monitoring: In order to assure that TPN is meeting the nutritional goals, growth parameters (i.e., weight, height, head circumference) need to be assessed periodically. Monitoring of specific laboratory parameters assures adequate intake and decreases the complications of TPN. (See required reading: Table 108.11, Suggested monitoring schedule during pediatric TPN)
D. Fluid Calculations
1. Initial: The actual volume of TPN (hyperalimentation plus intralipid) to be given is calculated by subtracting the volume of the patient's other necessary fluids (e.g., continuous dopamine infusions, arterial lines, etc.) from the total daily fluid requirement. In patients who are not fluid restricted, who do not have fluid deficits or ongoing abnormal losses, and who do not receive other fluids, TPN is usually started at normal daily maintenance fluids.
2. Advancement of TPN fluid: In order to provide an adequate amount of calories for normal growth and development, the daily total fluid volume will need to exceed the daily normal maintenance fluid requirements.
a. Precautions: Congestive heart failure can easily be produced in a pediatric patient, if fluids are advanced too rapidly or too much fluid is given per day. Daily fluids should be increased according to the following guidelines and patients need to be monitored for signs/symptoms of fluid overload, edema, and CHF.
b. For infants < 10 kg the initial daily fluid volume may be increased (if tolerated) by 10 ml/kg/day until the desired caloric intake is achieved. The maximum amount of fluid (if tolerated) is 200 ml/kg/day.
c. For infants > 10 kg, the initial daily fluid volume may be increased by 10% of the initial volume per day (if tolerated) until the desired caloric intake is achieved. The maximum amount of fluid (if tolerated) is 4000 ml/m2/day).
E. Caloric Requirements: The goal of TPN is to provide adequate calories and nutrients for proper growth and development of the child. Proper growth of the child is determined by maintenance of the child's respective growth percentile for age and gender. For example, if an infant is 75th percentile for height and weight at age 3 months, then the goal is to maintain the 75th percentile for height and weight at older ages (i.e. as the child gets older, (s)he should be following the 75th percentile growth curves).
NOTE: Although controversial, the goal of nutrition in the preterm infant is to achieve a postnatal growth rate equal to the intra-uterine growth rate of a fetus at the same postconceptional age.
1. Caloric requirements per kg are greater in infants compared to children and adults. Children also require more calories per Kg than adults. These increases in caloric requirements are due to increases in cellular growth and physical activity, as well as an increased heat loss (due to the larger surface area per body weight seen in infants and children vs adults).
TPN caloric requirements2
AGE (yrs)
Kcal/kg/day 0 - 1 90 - 120 1 - 7 75 - 90 7 - 12 60 - 75 12 - 18 30 - 60
2. Factors that increase caloric requirements: Similar to adults, certain factors will increase daily caloric requirements in children.
Fever 10 - 12 % for each degree > 37o C Cardiac failure 15 - 25 % Major surgery 20 - 30 % Burns up to 100 % Severe sepsis 40 - 50 % Long term growth failure 50 - 100 %
NOTE: Infants with protein calorie malnutrition may require 150 - 175 Kcal/kg/day for growth.
F. Carbohydrates: As in adults, pediatric patients are NOT started on TPN with the highest amount of dextrose required to give adequate calories. Carbohydrates are started at a lower amount and advanced in a stepwise fashion to allow an appropriate response of the pancreas. This stepwise advancement allows the pancreas to adjust to the higher amounts of dextrose given by secreting larger amounts of endogenous insulin. Hyperglycemia, glucosuria and osmotic diuresis are thus prevented. (NOTE: Dextrose = 3.4 Kcal/gram)
1. Carbohydrate intake must be calculated for newborns and the very low birth weight premature infant in terms of gm/kg/day or mg/kg/min.
a. Preterm infants < 1 kg
1. Initial: 3 - 5 mg/kg/minute (Homeostasis)
2. Advance by: 0.5 - 1 mg/kg/minute per day
b. Term newborns and older infants
1. Initial: 7 - 8 mg/kg/minute
2. Advance by: 2 - 4 mg/kg/minute per day
c. Infants: Usual maximum rate of infusion: 18 - 20 mg/kg/minute
d. Children: Usually require 6 - 9 mg/kg/minute
2. Practical guidelines: Recommendations according to percent dextrose: Serum and urine glucose must be monitored as some patients may not tolerate these increases. These patients (usually preterm infants) will require other percent concentrations of dextrose, e.g., 6%, 7% etc.
Patient Age Group
Initial concentration
Advance by
Premature infants
Newborn infants
5 % Dextrose
2.5 % Dextrose every
other day
Older infants
5 % Dextrose
2.5 % Dextrose per day
5 % Dextrose
5 % Dextrose per day
NOTE: Premature and newborn infants are more likely to become hypoglycemic if the dextrose solution is suddenly discontinued. Serum dextrose must be monitored if TPN discontinued. Excess carbohydrates (in comparison to protein and fats) may result in fatty infiltrates of the liver and an increase in pCO2 on blood gas.
3. Maximum dextrose concentrations for infants and children
a. Peripheral: 10%. Concentrations above 10% are associated with an increase in phlebitis and a decreased duration of use of the peripheral line. The peripheral use of 12.5% dextrose containing TPN is discouraged however, 12.5% dextrose containing TPN is sometimes used in patients who require higher calories or who are fluid restricted. Close supervision of the IV site then becomes mandatory (e.g., direct nursing care, ICU care).
b. Central: 20 - 25 %. The rapid dilution of TPN solutions with the larger quantities of blood in central veins, allows for solutions with higher final osmolalities to be used centrally (i.e., higher concentrations of dextrose). Typically, dextrose concentrations up to 20 % are used centrally. TPN with 25 % dextrose is usually reserved for severely malnourished patients. Occasionally, concentrations greater than 25% (i.e. 30 - 35 %) have been used in older infants and children who are severely fluid restricted.
G. Protein Requirements: Pediatric patients require a greater amount of protein per kilogram per day compared to adults. Again, this is due to their increased growth rates.3
Age group
Daily amount of parenteral protein to promote nitrogen retention Premature neonates and infants 2.5 - 3 grams/kg/day Greater than 1 year of age 1.5 - 2 grams/kg/day Adolescents & adults 1 - 1.5 grams/kg/day
1. Initiation and Advancement: Similar to carbohydrates, pediatric patients are NOT started at the daily amount of protein to promote nitrogen retention. Again, patients are started on lower amounts of protein and advanced in a stepwise fashion.
a. Neonates: Start with 0.5 - 1 gram/kg/day of protein and advance daily by 0.5 gm/kg/day.
b. Older infants and children: Start with 1 gram/kg/day and advance daily by 0.5 - 1 gm/kg/day.
2. Pediatric essential amino acids: In addition to the amino acids which are considered essential in adults,* cysteine, taurine, tyrosine and histidine are thought to be essential amino acids in neonates and young infants. These 4 amino acids are not synthesized in adequate quantities in neonates and young infants due to their decreased activity of enzymes. Therefore, these amino acids must be provided nutritionally.
* Isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine are considered to be the essential amino acids for all age groups.
For example: decreased activity of hepatic cystathionase results in a decreased production of cysteine with a subsequent decrease in taurine. (see figure 1)3 Hepatic cystathionase is thought to mature at approximately 6 months of age.
3. Pediatric amino acid formulations: (see Table 4)3
Neonates receiving standard adult amino acid formulations were found to have elevated plasma concentrations of methionine, phenylalanine and glycine as well as decreased concentrations of tyrosine, cysteine and taurine compared to normal breast fed infants. Two amino acid formulations have been designed to meet the special amino acid requirements in neonates and young infants. TrophamineR and Aminosyn-PFR contain less methionine, phenylalanine and glycine than adult formulations. Both also contain taurine, tyrosine, and histidine. L- Cysteine HCL must be added at the time of TPN preparation due to its instability in solution for prolonged periods.
NOTE: When using TrophamineR, 40 mg of cysteine HCL is added to the TPN for every one gram of protein. Since cysteine HCL comes as a HCL salt, one mmol of acetate or lactate is added to the TPN for every mmol (160 mg) of cysteine HCL. This acetate or lactate is added to balance the HCL load and prevent a metabolic acidosis which can be produced in premature and young infants. (Remember that bicarbonate results from acetate and lactate via the Kreb's cycle.)
Studies have shown that neonates receiving TPN utilizing TrophamineR had "normal" amino acid patterns i.e., patterns that were similar to breast fed infants. Significantly greater weight gain and nitrogen balance were seen in infants were given Trophamine compared to adult amino acid formulations. Further studies in neonates comparing Aminosyn-PFR and TrophamineR are needed.
4. Nonprotein calorie to gram nitrogen ratio: If an improper amount of nonprotein calorie to gram nitrogen ratio is given to a patient, (s)he will utilize proteins as a caloric source rather than for anabolic processes (i.e, as building blocks for cell growth). The optimal nonprotein calorie to gram nitrogen ratio in pediatric patients is not well defined. In the past, a nonprotein calorie to gram nitrogen ratio of 150 -200: 1 was suggested for adults. However, it is now realized that the ideal nonprotein calorie to gram nitrogen ratio differs with age and severity of illness. For critically ill infants and children, a nonprotein calorie to gram nitrogen ratio of 240 - 350: 1 has been suggested for proper utilization of amino acids. Remember:
Grams of protein / 6.25 = nitrogen content in grams
5. Caloric density: 4 Kcal/gram. Since it is not optimal to use protein as a caloric source, the protein caloric content of hyperalimentation fluids is generally not calculated.
H. Lipids: Lipids are administered as part of TPN to prevent or reverse an essential fatty acid deficiency and to provide a concentrated iso-osmotic source of calories.
1. Essential fatty acid deficiency:
a. Both linoleic acid and linolenic acid are thought to be essential.
b. The premature infant may develop biochemical evidence of essential fatty acid deficiency in as little as 2 days, due to limited fat stores.
c. Provision of 2 - 4 % of the required total daily calories as IV fat emulsion or approximately 0.5 - 1 gram/kg/day will prevent clinical signs and symptoms of essential fatty acid deficiency.
d. Signs of essential fatty acid deficiency include reduced growth, decreased platelets, impaired wound healing, dry scaly skin and sparse hair.
e. Biochemical evidence of essential fatty acid deficiency includes a triene:tetraene ratio greater than 0.4.
2. Lipid Metabolism:
a. Importance of Vitamin E: Lipid metabolism results in lipid peroxidation and free radical formation. Free radicals can damage cell membranes if Vitamin E is deficient. (Vitamin E acts as a free radical scavenger.) Lipid emulsions do contain a small amount of Vitamin E, however, supplementation with MVI is recommended, especially in infants. In order to prevent peroxidative injury, a vitamin E : polyunsaturated fatty acid (PUFA) ratio of > 0.6 mg/g is needed.
b. Decreased lipoprotein lipase activity: Lipoprotein lipase hydrolyzes fat particles to free fatty acids and monoglycerides. Both premature and term newborns have low lipoprotein lipase activity compared to adults. This results in a reduced lipid clearance rate. Hypertriglyceridemia / hyperlipidemia (fat intolerance) occurs when the rate of infusion of the fat emulsion exceeds the plasma lipid clearance rate. Premature infants, small for gestational age infants (regardless of gestational age) and nutritionally depleted older children are at risk for hypertriglyceridemia. Due to decreased fat clearance, lipid infusions for these patients should be administered over 24 hours.
NOTE: In infants and children, IntralipidR is typically infused over 18 - 24 hours.
c. Decreased metabolism of glycerol and free fatty acids:
Plasma lipid clearance is also decreased in neonates due to their decreased metabolism of free fatty acids and glycerol. Carnitine facilitates the transport of free fatty acids across the mitochondrial membranes to the site of fat oxidation. Premature neonates and newborns have limited carnitine stores which can decrease the proper utilization of free fatty acids.
3. Lipid emulsion dosing guidelines 2,3
Premature or SGA Full term or AGA Older children Initial dose 0.5 gm/kg/day 1 gm/kg/day 1 gm/kg/day Advance by 0.25 gm/kg/day or every other day 0.5 gm/kg/day 0.5 gm/kg/day Maximum dose 3 gm/kg/day 3 - 4 gm/kg/day 2 - 3 gm/kg/day
4. Serum triglycerides should be monitored before every (or every other) increase in lipid emulsion, especially in premature infants and routinely thereafter. If triglyceride levels are less than 200 mg/dl the patient can be maintained on her/his present dose.3
5. Caloric Content: Fats are usually considered to contain 9 kcal/gram. Due to emulsifying agents and other additives, IntralipidR 10% = 1.1 kcal/ml and IntralipidR 20% = 2 kcal/ml. Usually 25 - 40 percent of the total calories are provided by lipids but no more than 60 percent of total calories should be provided by lipids.
6. Hypersensitivity reactions including allergic reactions, fever, chills, shivering, cyanosis, flushing, nausea, vomiting, headache, dizziness, or chest and back pain have been reported due to the egg phospholipids which are used to emulsify fat emulsions. Patients should be monitored for these immediate adverse reactions.
7. Controversies
a. Hyperbilirubinemia: Free fatty acids, which displace bilirubin from albumin binding sites, may cause an increase in the concentration of unconjugated bilirubin and increase the risk of kernicterus. Decreased amounts of fat emulsion (0.5 - 1 gm/kg/day i.e., just enough to prevent essential fatty acid deficiency) are usually given to neonates with elevated bilirubin concentrations. These decreased amount of lipids are usually given when total bilirubin concentrations are greater than one-half that required for exchange transfusion.
b. Pulmonary compromise: In patients with pulmonary compromise, lipid emulsions may decrease pulmonary diffusion capacity with a resultant decrease in PO2. These effects were observed when large amounts of fat emulsion were administered over short periods of time. The risk is decreased if lipids are infused over 24 hrs.
c. Heparin stimulates the release of lipoprotein lipase and has been postulated to be effective in reducing serum triglyceride concentrations in neonates receiving lipid emulsions. Further studies are needed before routine use of heparin can be recommended.
NOTE: Heparin is routinely used in TPN at a final concentration of 1 unit/ml to decrease thrombus formation at the central catheter tip, and to increase the duration of patency of peripheral hyperalimentation lines. (see required text reading)
I. Electrolytes and minerals
1. Requirements: Unless the patient has an electrolyte abnormality, start with the recommended daily amount and adjust according to serum chemistries.
Element Daily requirement (infants and children) Sodium 2 - 4 mEq/kg Potassium 2 - 3 mEq/kg Chloride 2 - 3 mEq/kg Magnesium 0.25 - 0.5 mEq/kg Calcium Gluconate 100 - 500 mg/kg Phosphorus 1 - 2 mmol/kg
Sodium: Premature neonates may require higher daily amounts.
Magnesium: Do not routinely add magnesium in the TPN for infants whose mothers have received therapeutic dose of magnesium (i.e. for tocolysis or prophylaxis against eclampsia). Check magnesium serum concentration first. Magnesium may be added if serum magnesium is not elevated.
Calcium Gluconate: Usually, the higher amounts listed are needed in premature newborns and neonates (300 - 500 mg/kg/day), while the lower amounts are recommended for older infants (200 mg/kg/day) and toddlers (100 mg/kg/day). Older children may require only 1 - 2 grams per day of calcium gluconate.
Phosphorous: Older infants and children will require less phosphorous (0.5 mmol/kg/day) than premature infants and newborns (up to 2 mmol/kg/day).
Potassium phosphate = 0.68 mmol phosphate per mEq
Sodium phosphate = 0.75 mmol phosphate per mEq
2. Calcium and Phosphate Compatibility
Since premature newborns, neonates, and young infants require a greater amount of calcium and phosphorus compared to adults, calcium / phosphate compatibility in hyperalimentation fluid is an important issue. Many times the amount of calcium and phosphorous that these patients require is greater than the solubility and calcium-phosphate can precipitate.
Many factors effect the solubility of calcium with phosphate in hyperalimentation solutions. Specific texts (e.g., Trissel's Handbook on Injectable Drugs) and solubility curves4 are utilized to determine if the amount of calcium and phosphate ordered in a hyperalimentation will precipitate.
2. Calcium and Phosphate Compatibility (continued)
Factors which effect calcium and phosphorous solubility include:
a. Concentration of calcium and phosphorous
b. Salt form of calcium
c. Concentration of amino acids
d. Type of amino acid solution
e. Concentration od dextrose
f. Addition of cysteine (effects pH)
g. Temperature of solution
h. Final pH
J. Vitamin requirements
1. MVI PediatricR provides the American Medical Association Nutrition Advisory Group (AMA-NAG) requirements for infants greater than 10 kg until 11 yrs of age. (See table 7 below) 5
2. Unlike the adult MVIR product, the pediatric product contains Vitamin K.
3. FDA recommendations for MVI PediatricR:
Infants < 1 kg 30 % of a vial (1.5 ml) Infants 1 - 3 kg 65 % of a vial (3.25 ml) Infants > 3 kg - 11 yrs 100% of a vial (5 ml)
4. In premature infants, the above FDA recommendations may not be adequate for certain vitamins (vitamin A and E) and may result in higher serum concentrations of water soluble vitamins (e.g., ascorbic acid).
K. Trace elements requirements: 6
1. Trace elements should be given to premature infants upon initiation of TPN and to term neonates and infants who will receive TPN for > 2 weeks.
2. Copper, zinc, chromium, and manganese available as combination products: EXAMPLES: Trace element content per 1 ml:
PTE-4 Pedtrace Neotrace Zinc 1 mg 0.5 mg 1.5 mg Copper 0.1 mg 0.1 mg 0.1 mg Manganese 25 mcg 25 mcg 25 mcg Chromium 1 mcg 0.85 mcg 0.85 mcg
The usual dose of these products is 0.2 ml/kg/day. Please note the big difference in zinc concentrations in these products. Neotrace has the highest amount of zinc and (just as the name implies) is intended for use in neonates. PTE-4 and Pedtrace have less zinc than neotrace and are intended for use in infants and children whose zinc requirements are less than neonates. If PTE-4 or Pedtrace is used in neonates, additional zinc must be given in order for the neonate to receive the total daily recommended amount. Children > 40 - 50 Kg should use the adult trace element formulations (e.g., Multitrace).
3. Selenium 2 - 3 mcg/kg/day up to daily maximum of 30 - 40 mcg also needs to be added to the TPN.
4. Iodine
a. Absorbed from topical povidone iodine solution or ointment, so no need to add to TPN.
b. Thyroid profile monitoring recommended for long term TPN.
5. Iron
a. IV iron dextran is recommended for infants > 2 months of age receiving TPN for > 1 month. Preterm infants < 2 months of age may experience hemolysis after given IV iron dextran.
b. If iron is added to the hyperalimentation daily (controversial) the dose is 0.1 - 0.2 mg/kg/day.
c. For monthly IV replacements of iron: calculate iron needs by the following equation and administer the dose over 3 days. (Maximum daily dose = 25 mg).
Body weight (pounds) x (100 - % Hgb) x 0.3 = mg of elemental iron
6. Disease states which alter trace element requirements:
a. Increased losses: In diarrheal states or excess G.I. fistula losses extra zinc may be needed.
b. Decreased elimination:
1. Cholestasis (obstructive jaundice):
Eliminate copper and manganese from TPN
2. Renal failure:
Eliminate Cr and Se from TPN
NOTE: Some clinicians may eliminate Zn or decrease the daily amount.
L. Complications associated with TPN include infectious, mechanical, metabolic and other problems such as cholestasis and rickets: (see Table 9-27) 6. For further discussion of the complications of TPN see required reading text.
1. Infection: The most common organisms to cause sepsis in TPN patients are Staphylococcus epidermidis and Staph aureus. Other common bacteria include: Streptococcus, gram-negative organisms and Candida. Catheter site infections also occur.
2. Mechanical: One of the many mechanical problems with central TPN is thrombus formation. Urokinase (5,000 units/ml) may be used in children to lyse clots in catheters. When using urokinase to lyse a catheter thrombus, it is important to "treat the clot and not the patient" i.e., urokinase should NOT be injected past the catheter into the patient. The internal volume (ml) of the patient's central catheter must be known and only that same amount of urokinase used. Also, after allowing the urokinase to sit in the catheter and dissolve the clot, the urokinase should be withdrawn from the catheter. It should not be administered systemically to the patient. NOTE: The amount of urokinase that is used in adults to clear a catheter can have systemic effects in small infants if inadvertently administered through the catheter and not drawn back as required.
3. TPN cholestasis can occur in pediatric patients, usually after about 2 weeks of TPN. Premature infants and those receiving > 2.5 gm/kg/day of protein have a higher incidence of liver dysfunction. Other factors which may increase the incidence of TPN cholestasis include: sepsis, fasting (being NPO), and calorie overload. Discontinuation of TPN will usually reverse liver dysfunction. If TPN cannot be discontinued, TPN cholestasis may be managed by the following:
a. Give the appropriate type and amino acids and reduce the amino acid load.
b. Give the appropriate amount of calories (i.e. give an adequate but not an excessive amount).
c. Cyclic hyperalimentation (i.e., cycling the patient off of hyperalimentation for part of the day): Pediatric precautions: Infants more often than older children and adolescents may not be able to tolerate infusion periods less than 12 hours/day. Intolerance is usually due to inability to handle the higher ml/hr rates of fluid volume or nutrients that are given over the shorter period of time (i.e., the total daily amount of fluid and nutrients may be given over < 24 hours time, this results in a higher ml/hour rate).
d. Stimulate the gut with minimal enteral feeds.
M. Heparin: As previously mentioned, heparin 1 unit per ml (final volume) of hyperalimentation solution is often used in the pediatric population, both in central and peripheral TPN. Therapeutic doses of heparin may be approached with extremely high hyperalimentation rates or with frequent heparin flushes. (Maintenance doses of heparin are considered to be 10 - 25 units/kg per hour.) Therefore, a reduction from the usual 1 unit/ml of heparin in the hyperal to 0.5 units/ml may be needed especially in small infants requiring larger volumes of fluid.
IV. Pediatric Enteral Nutrition
A. Breast-feeding: "Breast is best": Mature human milk better meets the nutritional demands of human infants than cow's milk. Human milk is the standard against which all infant formulas are compared. Most commercially available (cow's) milk-based infant formulas are designed to closely approximate human breast milk.
1. Advantages of breast feeding and breast milk: Aside from the differences in protein, fat, carbohydrate and renal solute load (see next page) that exist between human milk and cow's milk, there are several other advantages of breast-feeding and breast milk.7
2. Disadvantages of breast-feeding:
1. Infant nutrition is dependent upon maternal nutrition
2. Possible mastitis (inflammation of the breast)
3. Transfer of drugs and/or pollutants (DDT, PDBs, etc.) to the infant
4. Transfer of viruses (Hepatitis B, CMV, HIV)
5. Transfer of allergen's from maternal diet to infant
3. Weaning
1. A gradual weaning of breast-feeding starting after 4 - 6 months of age is typical.
2. Bottle (or cup) feedings are increased over a period of several weeks as breast-feedings are decreased and finally discontinued.
B. Comparison of nutrient composition of human milk, cow's milk and milk based infant formulas.
Table 5 -12: Composition of milk (per 100 kcal)8
1. Protein: Human milk contains a lower amount of protein compared to cow's milk, but is easier to digest.
a. Protein types: There are two major types of proteins that are found in milk.
1. Whey protein contains alpha-lactalbumin, beta-lactoglobulin, lactoferrin, albumin, lysozyme and IgA, IgG and IgM. Whey protein is highly soluble and easier to digest.
2. Casein protein contains a mixture of caseins (alpha, beta, gamma and kappa). Casein is relatively insoluble and forms "tough" curds.
b. Whey: Casein ratio
1. Breast milk 60:40 to 70:30
2. Cow's milk 20:80
3. Milk-based infant formula 60:40
Human milk contains a lower casein content and therefore is more easy to digest, compared to cow's milk. Milk-based infant formulas are made with heat-treated cow's milk proteins which form smaller, softer curds than raw or pasteurized cow's milk.
c. Other protein differences: breast milk vs cow's milk
1. Lactoferrin is found in greater quantities in human milk then cow's milk. Lactoferrin is an iron binding protein found in whey (1/3 saturated with iron). Lactoferrin increases the bioavailability of iron. It also has an inhibitory effect on E. Coli and may offer some protection against enteric infection.
2. Secretory IgA is also found in greater quantities in human milk than cow's milk. As an immunoglobulin, it may offer some local G.I. protection against infection.
3. Lysozyme is found in human milk but not in cow's milk. Lysozyme has bactericidal effects.
d. Protein sources, other than cow's milk protein, may be used for infant formulas. These include vegetable protein (soy) or protein hydrolysate (enzymatic breakdown products of casein or whey which result in reduced antigenicity).
2. Fats: Human milk and cow's milk contain a similar total amount of fat but the type of fats differ.
a. Human milk contains more of the essential fatty acid, linoleic acid, compared to cow's milk. Typical commercial infant formulas contain ever more linoleic acid.
b. Human milk but not cow's milk contains human milk lipase to aid in the digestion of fat.
c. Human milk contains long chain unsaturated fatty acids as well as medium chain fatty acids. Cow's milk contains short and long (primarily saturated) fatty acids. Milk based infant formulas replace butterfat with vegetable oil and special MCT oils to provide highly digestible, unsaturated, medium-chain triglycerides (MCTs).
3. Carbohydrates: Because cow's milk contains less carbohydrates than human milk, supplementation of cow's milk with carbohydrates to make milk-based formulas is necessary.
a. Lactose is the primary carbohydrate for human milk, cow's milk and milk-based infant formulas.
b. Infants are especially prone to lactose intolerance. The activity of the intestinal enzyme lactase is not fully developed until late in fetal life. In addition, infants may have a temporary reduction in lactase with diarrhea or malnutrition. (Lactase, as you recall, is the enzyme which is found in the brush border of the small intestine. Lactase cleaves lactose into galactose and glucose which are then absorbed.) Without lactase, the increased amount of lactose in the intestine creates an osmotic gradient in the colon that results in diarrhea. Excess lactose is also fermented by bacteria in the gut to produce CO2 and lactic acid.
c. Other carbohydrates such as dextrins, maltose, corn syrup solids and sucrose are can also be used in infant formulas (i.e., lactose-free formulas).
4. Renal solute load, osmolality, and caloric content
a. Cow's milk has three times the ash (mineral residue) and protein content as that of human milk. This results in a much higher renal solute load for cow's milk as compared to human milk. As you recall, renal solute load is related to the protein (urea) and mineral content of a formula. The renal solute load represents the total amount of water-soluble substances that must be removed from the body by the kidneys. The renal solute load of human milk = 79 mOsm/l, Cow's milk = 228 mOsm/l.
b. Osmolality is directly related to the mineral and carbohydrate content of a formula. The osmolality of human milk is approximately 300 mOsm/kg. Most formulas intended for use in infants are iso-osmotic. Generally, the higher the caloric content, the higher the osmolality. Infant formulas for preterm infants (24 cal/oz) have osmolalities less than 400 mOsm/kg.
c. Caloric content: Human and cow's milk have 20 kcal/oz. Most infant formulas are either 20 or 24 kcal/oz.
5. Mineral content: Although less in content/ml, both zinc and iron in human milk is more readily absorbed (ie, more bioavailable) than zinc and iron in cow's milk. Infants fed whole cow's milk diets often have iron deficiency anemias due to the decreased bioavailability of iron. The calcium to phosphorus ratio for human milk is 2:1, while for cow's milk it is 1:1.
C. Types and uses of infant formulas
(NOTE: composition is per 100 kcal.)
1. Complete cow milk-based infant formulas9
a. Used for normal term infants
b. Lactose is carbohydrate source
2. Complete soy based infant formulas9
a. Soy protein rather than cow protein
b. Lactose free
c. Used for
1. lactose intolerance or primary lactase deficiency (e.g., galactosemia)
2. milk allergy (NOTE: Protein hydrolysate formulas rather than soy based formulas are preferred for infants with cow milk allergy. About 10% of infants with cow milk allergy will also react to soy protein)
d. For disaccharide intolerance (sucrase deficiency) use Prosobee or Isomil SF
3. Therapeutic Formulas 9 /disease states
a. For fat malabsorption states, such as cystic fibrosis, short bowel syndrome, bile acid deficiency or cholestasis use Portagen or Pregestimil.
b. For general malabsorption states, use Pregestimil.
c. For protein and disaccharide intolerance, use Pregestamil or Nutramigen.
d. For congestive heart failure or when low salt content is needed, use Lonalac (short-term use only, Na = 1 mEq/l), SMA, or Similac 60/40.
e. For chronic renal failure use PM 60/40, SMA
f. For phenylketonuria use Lofenalac
g. For galactosemia use soy based formulas, Nutramigen or meat-based formulas (older infants).
4. Preterm formulas: differences include:
a. Partial substitution of glucose polymers for lactose
b. Increased protein
c. Substitution of long-chain fatty acids with MCT
d. Increased concentrations of vitamin D, calcium and phosphorus to promote bone growth
e. Altered concentrations of iron and vitamin E to prevent hemolytic anemia.
D. Supplemental foods are introduced at 4 to 6 months of age (after the infant has established the ability to swallow non-liquid foods). Introducing foods at this time also allows the infant to develop his/her host defense mechanisms to protect the infant from foreign proteins (i.e., food allergies are less likely to develop). In addition, the continued maturation of kidneys at this time will increase the handling of renal solute loads.
1. Feedings are usually started with iron fortified cereals such as rice. (Oatmeal cereals may follow.)
2. Vegetables, fruits, and pureed meats may also be introduced with cereal.
3. It is important to add one new food at a time and continue for 3 to 4 days before adding another. This allows time to evaluate allergy or sensitivity problems and to identify the food which caused the problem.
4. Iron fortified cereals are usually continued until about 2 years of age as an iron source.
E. Vitamin and mineral supplementation: It is now recommended that all infants receive iron fortified infant formulas. (These are commercially available)
1. General recommendations for supplements in healthy infants10
2. Fluoride supplementation is dependent upon age and concentration of fluoride in the drinking water. 11
NOTE: Fluoride dose is in mg/day.
3. Recommended daily dietary allowances for vitamins and minerals change with age. (See tables 12)
Recently, higher daily calcium requirements have been recommended by the NIH panel on optimal calcium intake.13
F. General Guidelines for Infant Feeding: Remember, introduce one new food at a time and continue for 3 to 4 days before adding another. Evaluate for allergy / hypersensitivity (diarrhea, vomiting, coughing, hives or rash).
1. DO NOT give foods such as nuts, seeds, popcorn, raw vegetables, hot dogs, candy or gum that may cause choking.
2. DO NOT give honey or corn syrup, which have been associated with infant botulism.
3. DO NOT force infant to eat everything, this may lead to overeating.
4. DO NOT give whole, 2% or skim milk under 1 year of age. Only give 2 % or skim milk after 2 years of age.
5. DO NOT add salt or sugar to infant's food.
6. DO NOT feed infant any solids or semi solids before the age of 4 months. Infant is not physically ready to eat solids nor do they need them. Breast milk or iron-fortified infant formula provides all the nutrients a FT infant needs to grow on until 4 - 6 months.
7. DO NOT prop up bottle and leave infant to feed him/her self (this may increase choking, as well as tooth decay and otitis media).
8. DO NOT leave older infant unattended at mealtime.
Physical Development
3 months
|Stroking the cheek near the mouth causes the infant to turn the face to that side, open mouth and attempt to suckle (Rooting reflex).
milk or formula, 6 - 10 feedings per day (21 - 24
Do not give semi-solid foods.
Vit D, Fe & Fl Rx may be recommended for breast fed infants.
No vitamin/mineral Rx needed for FT with iron fortified infant formula.
Plain water 3 - 4 ounces/day in very hot weather OK if tolerated.
|4 - 5 months
|Infant is able to hold neck steady and sit with support. Can begin to draw in lower lip as spoon is removed.
milk or formula, 4 - 6 feedings per day (24 - 32
Vitamin/mineral Rx if indicated.
May start spoon feedings of Fe fortified dry infant cereal mixed with formula or breast milk to a thin consistency. Start with 1 Tablespoon of rice cereal at 1 feeding for 4 - 5 days. Gradually offer other single grain cereals and slowly increase to 3 - 4 Tablespoons per day.
|7 months
|Infant can reach and grasp for objects. Jaw begins to use up and down movement.
milk or formula, 4 - 5 feedings per day (24 - 32
Vitamin/mineral Rx if indicated.
Fe fortified cereal: > 4 Tablespoons/day Vegetables/fruit: Start with 1 Tablespoon strained plain vegetables such as green beans, peas or carrots. Do not feed from jar, can cause bacterial growth. Put anticipated feeding in bowl. Feed from bowl. Cover remaining food in jar and refrigerate Do not add salt. Gradually add 1 Tablespoon plain strained fruit such as applesauce, apricots, peaches or pears. Slowly increase serving size to 4 - 5 Tablespoons/day.
Teething foods: Offer toast strips, unsalted crackers, zwieback, teething biscuits.
|8 - 9 months
|Infant can sit alone without support. Baby is learning to chew. Important to offer foods that encourage chewing.
milk or formula, 3 - 4 feedings per day (24 - 32
Vitamin/mineral Rx if indicated.
Fe fortified cereal: > 4 Tablespoons/day Vegetables: > 4 Tablespoons/day
Fruit: > 4 Tablespoons/day
Chewing foods: toast strips, zwieback, unsalted crackers.
Protein Foods: Offer well cooked, strained or ground lean beef, pork, chicken, turkey, liver, cheese, cottage cheese, or egg yolk. Do not give egg whites until 12 months of age due to high chance of allergic reactions. Do not add seasoning. Remove all bones before straining. May use plain meat baby jar food (not mixed vegetables and meat dinners). Start with 1 Tablespoon and increase to 2 Tablespoons/day.
Juice: Give Vit C containing juice in a cup. Be sure to give fruit juice. Juice is more nutritious than fruit drink, fruit punch, pop or koolaid. Dilute 1 part juice with 2 parts water at first. Start with 1 - 2 ounces & increase to 2 - 6 ounces according to appetite. Do not give fruit juice by bottle especially at naptime. Fruit sugar can cause decay. Do not give citrus juices until 1 year of age due to high chance of allergic symptoms.
Finger foods: Give soft pieces of food such as toast strips, soft peeled fruit pieces, soft cooked vegetable pieces, cooked macaroni or noodles, milk cheese cubes or strips.
|10 - 12 months
|Infant is able to hold a cup with help and try to feed self. Baby likes to play with food more than eat it. Expect a smaller and more picky appetite as infant's growth rate slows at 1 year of age.
milk or formula, 3 - 4 feedings per day (24 - 32
ounces/day). Offer some from a cup.
Vitamin/mineral Rx if indicated.
Fe fortified cereal: 1/4 cup/day Vegetables:soft cooked 1/4 - 1/2 cup/day
Fruit and fruit juice: 1/2 - 3/4 cup/day
Bread or toast: 1 - 2 slices/day.
Protein Foods: 2 - 4 Tablespoons/day. The infant's meal pattern should be similar to that of the rest of the family with 3 meals and 2 snacks.
1. ASPEN Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition 1993:17:1SA - 52SA.
2. Manual of Pediatric Parenteral Nutrition, Kerner JA (editor), 1983, John Wily and Sons Publishers, New York.
3. Cochran EB, Phelps SJ, Helms RA. Parenteral nutrition in pediatric patients. Clinical Pharmacy Vol 7, May 1988, pp 351 - 66.
4. Fitgerald KA, MacKay MW. Calcium and phosphate solubility in neonatal parenteral nutrient solutions containing Trophamine. Am J Hosp Pharm 1986;43:88-93.
5. Total Parenteral Nutrition, Lebenthal E (editor), 1986, Raven Press, New York.
6. Heyman MB. "Enteral and Parenteral Nutrition" in Rudolph's Pediatrics 19th edition. Rudolph AM, ed., 1991 Appleton & Lange, East Norwalk, Conn.
7. Wilson JT. "Prevalence and Advantage of Breast Feeding" in Drugs in Breast Milk. ADIS press 1981.
8. Hambidge KM, Krebs NF. "Normal Childhood Nutrition and Its Disorders" in Current Pediatric Diagnosis and Treatment 10th edition Hathaway WE, Groothius JR, Hay WW Paisley (editors), Appleton & Lange, East Norwalk, Conn, 1991.
9. Nichols BL. "Infant Feeding Practice" in Nutrition During Infancy Tsang RC, Nichols BL (editors), Hanley & Belfus, Inc, Philadelphia 1988.
10. McKenzie MW, Bender KJ, Seals AJ. "Infant Formula Products" in The Handbook of Nonprescription Drugs, 9th Edition, APhA editors, Washington: APhA 1990.
11. Committee on Nutrition. Fluoride supplementation for children: interim policy recommendations. American Academy of Pediatric News 1995;11(2):18.
12. Johnson KB (ed). The Harriet Lane Handbook, 13th edition, Mosby Year Book, St. Louis Mo, 1993.
13. NIH Consensus Developmental Panel on Optimal Calcium Intake. Optimal Calcium Intake. JAMA 1994;272:1942-8.
|The College of Pharmacy
|The University of Illinois at Chicago
|Last modified: Dec 19, 1997


text:
TDP On Shortened Sentences
This article, Shortened sentences concern DA, police, has several problems. The least of which seems like it was fed to them by the Williamson County DA and the Taylor police chief. The offender they highlight in this article about early release is a repeat drug offender and, as best I can tell from the article, NOT a violent offender.
Antwon Sanford, 40, of Taylor was arrested by Taylor police on Dec. 15, 2003 in Robinson Park and charged with possession of cocaine. According to Williamson County District Attorney John Bradley, the arrest was part of a federal Drug Enforcement Agency Task Force investigation after several people reported the park as an "open-air†drug market. In addition to Sanford, the investigation yielded more than 10 arrests on drug dealing and possession charges.
Bradley said Sanford was on parole after being sentenced to 60 years in prison at the time of his arrest in Robinson Park.
"It makes you wonder why was he out to begin with?†Bradley said. He said he has seen the number of repeat offenders released on parole rise dramatically during the past year.
According to arrest records, Sanford had previously been arrested and convicted four times; three of those arrests occurred after he was paroled following a prior conviction.
"We have to challenge our statewide officials to focus on the importance of long-term confinement as a proper and effective method for punishing repeat criminals and thereby preventing new crimes,†Bradley said. "Taylor suffers just as much as any other city in the county when you put drug offenders back on the street.â€
Bradley said he has met with several state legislators across Texas in an effort to garner more legislative support to build new prisons in the state.
Bradley is right, it does make one wonder why he was out. But building more prisons and abetting the "prison industrial complex" – like the T. Don Hutto Residential Facility – is not the answer either. When jails fill up, non-violent offenders, mostly drug possession cases, are released and the violent offenders are kept behind bars. That's preferable. I'd much rather have the guy busted with a couple of joints back out on the streets and make sure the child predator is still behind bars.
Another thing this article also goes to show is how bad our criminal justice system does at rehabilitating people, if that's what it's supposed to do, these days. The man in this article has been in and out of prison many times and there was no mention of whether any kind of drug rehab or counseling was ever tried as a solution to help end his addiction. It would seem to me if someone keeps getting busted for a non-violent drug possession crime it would be best to try and keep that person from wanting to possess those drugs again. We all know that prison/jail is nowhere to try and stop using drugs.
At the end the Taylor Chief tries to say that in the end he will get blamed for this just like local cops did in the early 80's. There were some rough economic times in the '80's that helped cause much of that crime, maybe like the economy today, at least for those that aren't in the top 1%.
More prisons is not the answer. You can read Grits For Breakfast for much more on this topic.


text:
Every year there are films that somehow miss the moviegoer's mark, receiving less exposure than a Cathy Bates sex tape. While there is good reason for us to avoid a sensual second helping of Misery with Bates, these films deserve better than to be relegated to second-hand status. The equivalent of the wallflower you knew in high school that blossomed into a college beauty, here are eleven films that flew under the radar in 2008.
It was surprising how little fanfare Transsiberian received after the buzz of Brad Anderson's previous film, The Machinist. Maybe that's because it doesn't feature a deathly thin Christian Bale, but this train-ride thriller does bring the goods in suspense and paranoia. It also displays the talent of Ben Kingsley, Woody Harrelson (who has had some nice roles lately in films like No Country for Old Men) and Emily Mortimer, an actress that always finds a way to stand out in the films she chooses.
An upbeat story about a 30-year-old school teacher might not sound appealing, but go see this film and I promise you won't be disappointed. Sally Hawkins delivers a breakout performance, living life to the fullest without coming across as annoying. In a world that is currently beat down by pessimism, Hawkins' portrayal of Polly will make you smile in spite of yourself, and Happy-Go-Lucky has the optimism equivalency of Amelie in 2001.
Son of Rambow
A testament to the beauty in the ambition of amateur filmmaking, Son of Rambow drew critical acclaim. It never drew people to the theaters, however, and so it is worthy of making this list. Will Poulter and Bill Milner's young on-screen friendship is only rivaled by Azharruddin Mohammed Ismail and Ayush Mahesh Khedekar in Slumdog Millionaire. Plus, the film finds a way to blast the negative aspects of religion while propping up First Blood for the bad ass film it is.
The Signal
I'm a sucker for films that find fresh ways to tell stories, and The Signal falls into that category. The Signal is is a horror film written and directed in three different parts by David Bruckner, Dan Bush, and Jacob Gentry, offering a psychological study on society's downfall in its dependence on technology. You won't get to see the film adaptation of Stephen King's The Cell for a while, and in all honesty you may be disappointed when you do. See The Signal instead.
Man on Wire
No, this wasn't the alternate title for the interrogation scene in Slumdog Millionaire. This documentary tells the unbelievable story of Philippe Petit, who worked for seven years on a project that would shake the world, a high-wire walk 1,350 feet in the air between the Twin Towers in New York. James Marsh finds a way to turn this true story into one of the best heist stories in recent memory. Man on Wire reminds us both of the powerful symbol the Twin Towers once had, and the even more powerful statement a human being can make in individual artistic expression.
In Search of a Midnight Kiss
Appropriately placed on the list as we head towards New Year's Day, Alex Holdridge wrote and directed this modern day romance that exposes the desperation and hope of a single late-20s male. Holdridge's black and white cinematography helps hide the scratches many indie films are full of, and the film finds a way to offer insight into relationships today without dripping with Hollywood sap. Score one for the American independent filmmaker, as well as Austin, Texas native Holdridge.
In Bruges
If you're like me, when you saw the trailer for In Bruges your initial reaction was, "Damn it. Not that blasted Colin Farrell again." Lucky for me I decided to give the film and Farrell a shot, even though my Alexander-sense was tingling. What I received for my bold move was one the best films of 2008. The superb work of Brendan Gleeson is always a given, but Farrell breaks your heart as a remorseful hit man. But for some reason I didn't hear anybody I knew talking about the fantastic directorial feature debut of Martin McDonagh. Now's your chance. Get off your butt and go rent it.
I've Loved You So Long
This family drama may have done well in France, but I've yet to see indication that it is going to get the credit it deserves in the good old U.S. of A. Kristin Scott Thomas, who by now should be universally applauded as one of the finest actresses of her generation, gives an honest offering as Juliette Fontaine, a former prisoner thrown out into a world that has moved on without her, at the same time struggling to forgive herself for her past in order to live again.
The Orphanage
My pick for the best horror film of 2008, this ghost story will leave you clenching your fists in anxiety. Anybody who remembers the scene with the nanny in the street knows exactly what I am talking about.There aren't a ton of films where I find myself holding my breath during the viewing, but The Orphanage fits the bill. Juan Antonio Bayona's directing and the vulnerability of Belen Rueda's acting draws you in until the bittersweet end, and let's be honest, kids wearing flour sack masks are just creepy.
The Fall
When I saw The Cell in 2000, I was blown away by the colorful imagery, and I'm not talking about the sight of Jennifer Lopez in her panties. It wasn't a flawless film by any means, but director Tarsem Singh's colorful landscape helped an otherwise lacking film stand out. Singh returns to the world of fantasy and creates one of the most beautiful and surreal films of 2008. The chemistry between Lee Pace and newcomer Catinca Untaru is worth mentioning, and The Fall is a film worth watching multiple times, if only for respect of Singh's ambitious film regimen. The Fall was filmed in 18 different countries. Maybe it should have been titled The Bitch of a Film to Make.
Hamlet 2
Yeah, this film got exposure at the Sundance Film Festival, but how was this not the Napoleon Dynamite of 2008? Steve Coogan and Catherine Keener chew up every scene they're in, but even the Sexy Jesus Brigade at Comic-Con 2008 couldn't get people pumped about this film. Maybe it was the conservative nature of Americans, who found a play featuring a "cool Jesus" to be a bit too much. Or maybe American moviegoers generally have shit for taste, as evidenced by the fact they went to see Passion of the Christ in 2004, or Hancock this year, and not this film. Memo to religious America: take the cross out of your ass and lighten up.
Honorable Mention: The Wackness
What films do you feel flew under the radar for 2008?


text:
Finding and installing Firefox extensions
If you look around the Internet, you'll find a number of useful add-ons for Mozilla Firefox.
The Mozilla Firefox browser is designed to easily accommodate extensions, and the Firefox community has responded with a rich assortment of add-on modules. If you're interested in higher performance, or even if you just want to check the weather, you'll find a Firefox add-on to meet your needs. We took a look at some of the most useful modules for the new Firefox 1.5. Getting Started
If your Linux distribution doesn't have the latest version of Firefox, you can download it from the Firefox homepage at [1]. Once you have installed the latest version, you can open the Firefox Extension Manager (Figure 1) by selecting Tools | Extensions. The Extension Manager is a central tool for plug-in management.
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Ubuntu 16.04 LTS released
"Xenial Xerus" comes with a new packages format and several improvements for the enterprise.
Microsoft Visual Studio Code v1.0 is Available for Linux!
Linux users can now download and install the Windows code editor
Open Container Initiative announces Image Format Project
New initiative will address security and interoperability concerns around container technology.
Red Hat Lures Developers with Free RHEL and Container Development Kits
Developers can use RHEL as a development platform without a subscription fee.
Microsoft Brings the Linux Command Line to Windows
Windows users will soon have native access to the Bash shell.
Internet Research Group Proposes Better Email Standard
Improvements to SMTP will provide better guarantee of confidentiality
New Nvidia Driver Offers Wayland Support
Graphics vendor embraces new reality in Linux graphics
Inventor of Email Dies
Pioneer Ray Tomlinson bequeathed the @ sign to billions of Internet users
Microsoft Announces Linux Version of SQL Server
Redmond says its classic database tool will run without Windows
Strange New Attack Lets an Intruder Gain Access Through a Mouse Dongle
New intrusion technique affects most non-Bluetooth wireless mice


text: I'm starting on the path to getting a touring setup. I haven't done any long distance touring, so this will be my first purchase. I'm from a BMX background and I am curious about the different types of bikes used for touring. The bikes I see marketed as touring seem to be little more than roadbikes with a few additions. I also see/hear people using cyclocross bikes (with some part additions). I've pretty much decided that I want steel instead of aluminum in the frame. All of these "touring" bikes seem to be in the $800+ USD price range. A bit steep to me for what you get. The Fuji Touring is a bike I'm starting to hear a lot about for entry-level. I really like the Surly Long Haul Trucker frame, but at about ~$450+ USD for the frame, I would be looking at over $1000 USD after I had the bike completed. I want a bike that is going to be strong, can be fully loaded and if possible provide durability if I happen to wander off paved road. I've been to a few bike shops and all they seem to want to do is sell me some $1500 bike I don't need or know anything about. I wouldn't even mind picking up an older road bike off craigslist.org and adding parts I needed. In addition to touring, I would also like to make this my daily commuter (unloaded of course). So, for a first timer, what does everyone think would be fitting for a newcomer?