text:
Synovus focuses on its position in high-growth Southeastern markets and commitment to being a great place to work to ensure the delivery of unparalleled customer experiences.
- D. Copeland, Chief Banking Officer
Synovus is a financial services company with approximately $29 billion in assets based in Columbus, Georgia. Synovus' bank divisions provide commercial and retail banking, investment and mortgage services to customers in Georgia, Alabama, South Carolina, Florida and Tennessee.
Synovus Bank
is one of the largest community banks in the Southeast, providing powerful solutions you may not expect from a community bank. We operate under 28 different trade names that reflect our deep ties to the communities we serve. While the names are different, each division shares a commitment to building long-term relationships and providing responsive, caring service. Divisions of Synovus Bank are not separately FDIC-insured banks. The FDIC coverage extended to deposit customers is that of one insured bank. Learn More
Contact Us
(706) 644-0528
P.O. Box 120
Columbus,GA 31902
Synovus Mortgage Corp
is a subsidiary of Synovus Bank, a Georgia-chartered FDIC-insured Bank, that began in 1994 as individual, affiliate bank mortgage departments offering full-service mortgage banking. In 2000, SMC brought each department under the one company. SMC offers loans from conventional to FHA and VA as well as other affordable housing products. Learn More
Contact Us
Find a location
(877) 656-2675
2204 Lakeshore Drive,
Suite 325
Birmingham, AL 35209
Synovus Securities, Inc.
J. Barton Singleton
Executive Vice President
is the registered broker-dealer offering retail brokerage, capital markets, investment banking and financial advisory services for Synovus, who entered the securities business in 1985 with the acquisition of Calumet. In 1989, Synovus renamed the company Synovus Securities, Inc. Learn More
Contact Us
Find a location
(800) 332-3403
1137 1st Avenue
Columbus, GA 31901
Synovus Trust Company, N.A.
George G. Flowers
is an affiliate of Synovus Bank that began as the trust department of Columbus Bank and Trust (CB&T inception 1930) and expanded into Synovus Trust in 1995. The company acquired a national charter in 2002. Synovus Trust provides personal trust and estate services, corporate trust services including retirement plan services and foundation and endowment services, and multi generational family office services through its Family Asset ManagementSM division. Learn More
Contact Us
Find a location
(800) 942-9764
1148 Broadway, 3rd Floor
Columbus, GA 31901
Creative Financial Group Division
Robert W. Law
is a division of Synovus Securities, Inc ("SSI"). Prior to January 1, 2011, Creative was a separate registered investment adviser affiliate of SSI. Creative provides comprehensive financial planning, asset management and tax services to corporate executives, professionals, small business owners, retired persons and others. Learn More
Contact Us
(770) 913-9704
company directory
1000 Abernathy Rd.
Northpark 400, Suite 1500
Atlanta, GA 30328
GLOBALT Investments Division
William H. Roach
is a separately identifiable division of Synovus Trust Company N.A.. GLOBALT is an SEC-registered investment since 1991, providing professional money management to both institutional and individual investors through equity, fixed income, and ETF asset allocation strategies. Effective July 2013, GLOBALT remains a registered investment adviser through a separately identifiable division of Synovus Trust Company N.A., a nationally chartered trust company. Learn More
Contact Us
(877) 428-6956
(404) 364-2188
3280 Peachtree Road NE, Suite 500
Atlanta, GA 30305


text:
Dembe Development Association Group
Julius is a market vendor mainly dealing in the sale of shoes in the Nakulabye market. He started this job in 2003 since it was the easiest business to start with the little capital he had. Julius's major challenge is reduction in his capital base, because he has to divert most of his profits to the treatment of his child who is suffering from tuberculosis. This has greatly affected his business. Julius's major customers are people who visit the market from where he operates. He will stock new shoes to sell to students who are going back to school using the funds from the loan.
Julius is very hardworking, social and honest. He has dreams of expanding his business with the loan that will be given to him and looking after his children by providing for them all their basic needs. He is confident that the relationship between him and UGAFODE Micro finance will flourish.
Additional Information
This is a Group Loan
In a group loan, each member of the group receives an individual loan but is part of a larger group of individuals. The group is there to provide support to the members and to provide a system of peer pressure, but groups may or may not be formally bound by a group guarantee. In cases where there is a group guarantee, members of the group are responsible for paying back the loans of their fellow group members in the case of delinquency or default.
Kiva's Field Partners typically feature one borrower from a group. The loan description, sector, and other attributes for a group loan profile are determined by the featured borrower's loan. The other members of the group are not required to use their loans for the same purpose.
About Uganda
152View loans »
Success!! The loan was 100% repaid
- Repayment Term
- 6 months (Additional Information)
- Repayment Schedule
- Monthly
- Pre-Disbursed:
- Jan 17, 2013
- Listed
- Feb 2, 2013
- Currency Exchange Loss:
- Possible
- Ended:
- Jan 17, 2014

subset: commoncrawl


text:
As intraday or short-term traders, we often get caught up in our particular futures contracts, ETFs, or favored indexes and we can easily miss the bigger picture in related or similar indexes, especially on the larger frame.
That's the case currently for those of us (I'm guilty too) who focus most of our attention on the Dow Jones or S&P 500 indexes.
Did you know that the NASDAQ and Russell 2000 indexes paint a dramatically different picture on the monthly frame?
Let's take a look at the standard S&P 500 and Dow Jones indexes – particualrly the key levels on which everyone seems to be focusing at the moment (the 2007 highs) – and see a different picture in the Russell and NASDAQ.
[Related -Automating Ourselves To Unemployment]
Dow Jones Industrial Index:
We'll group these two similar markets together for the moment.
The key focal point in the S&P 500 is of course the October 2007 high of 1,575 with the index roughly 50 points beneath this easy-reference level.
Those watching the Dow Jones – and even the television media – have been breathlessly focusing on 14,000 ("Look! It closed above it!") and then the all-time high of 14,198 (roughly 14,200) also formed in October 2007.
[Related -Fed: Waiting For June… Or Godot?]
While we in the short-term trading world ponder the probabilities of a near-term continuation to or even above these levels, we may missing something very obvious to those traders who focus on either the NASDAQ (technology-based) or Russell 2000 (small-cap) indexes.
Let's see these indexes and why the picture is very different than the S&P 500 or Dow Jones:
Russell 2000:
Do you see the difference?
Both the NASDAQ and Russell 2000 have long since broken above their respective October 2007 high.
The Russell 2000 completed this feat first in April/May 2011 (yes, 2011!) while the NASDAQ broke its respective October 2007 high also in April/May 2011.
Though both indexes turned back (reversed) from this interim high, both indexes have since broken their 2011 highs.
The NASDAQ completed the feat first in February 2012 while the Russell has struggled under the key resistance level (870) until recently with the January 2013 breakout.
To repeat – while the S&P 500 and Dow Jones Indexes have not yet broken above their respective 2007 highs and traders are formulating probabilities of these indexes continuing up to break to new highs – the NASDAQ and Russell 2000 indexes yawn at the excitement.
Of course, Russell and NASDAQ-focused traders are well-aware of these accomplishments, those of us who focus our attention on the Dow and S&P 500 may not be aware that the oft-mentioned October 2007 peak has been scaled by the tech-heavy and small-cap based equity indexes.
By the way, the NASDAQ – while at new recovery highs – still is no where near scaling its all-time high near 5,000 achieved in March, 2000.
We do best to be aware of broader related markets and not get caught up in the endless exciting details of our own favorite indexes/markets.
In this current era of central planning, malincentives abound. We raced to frack as fast we could for the read on...
The Federal Reserve left interest rates unchanged yesterday, as widely expected. But the possibility of a read on...
It was never supposed to be this daunting. At least that's what we were read on...
The Federal Reserve is widely expected to leave interest rates unchanged today. But perhaps standing pat read on...


text:
With his two-run double in the top of the first inning this afternoon at Fresno, Sky Sox outfielder Matt Murton extended his hitting-streak to a new Sky Sox franchise record 29 games. His deep drive to centerfield off righty Billy Sadler plated Chris Frey and Matt Miller to give the Sox an early 2-0 lead. Murton passes former Sky Sox great, and member of the Sky Sox Hall of Fame, Trinidad Hubbard who had a 28-game hitting streak for Colorado Springs in 1995.
Murton's streak started on April 15th in Colorado Springs when he went 2-for-3 with an RBI against Reno and has spanned more than two months. His streak was actually interrupted for a while when he was called up to the Colorado Rockies on April 28th leaving behind a 13-game streak. He played for the Rockies until June 6th when he was optioned back down to the Sky Sox and picked up right where he left off.
Including the double in his first at-bat today, Murton has hit .432 (48-for-111) during his streak with eight home runs, 11 doubles, 34 RBIs and 28 runs scored. His streak has included 15 multi-hit games and breaks down as 10 home games and 19 road games.
KKTV firmly believes in freedom of speech for all and we are happy to provide this forum for the community to share opinions and facts. We ask that commenters keep it clean, keep it truthful, stay on topic and be responsible. Comments left here do not necessarily represent the viewpoint of KKTV 11 News.
If you believe that any of the comments on our site are inappropriate or offensive, please tell us by clicking "Report Abuse" and answering the questions that follow. We will review any reported comments promptly.powered by Disqus


text:
Anonymously Scrape Web Sites at Warp Speed
- Send up to 600 Queries Per Minute to your target websites - without being detected or blocked
- Each GET Request sent on randomly rotating IP addresses, C Classes and locations from across the United States
- Every request is completely anonymous
- Compatible with most Software
Perform mass Web Scraping and Data Extraction, while completely hiding your identity and not tipping off your target sites that they're even being scraped. Every one of your Internet requests is randomly distributed across our Proxy Server network of thousands of Private Proxy Servers designed for this purpose.
You can connect your software to Trusted Proxies' Proxy Server Cloud service, and send your queries at up to 600QPM. So not only can you extract the business intelligence data you need without getting blocked, you can do it really fast too!
It's easy to connect your custom software via our API, or for smaller businesses on our SmallBiz plans, it is compatible with virtually all desktop scraping software.
Control Your IP Distribution
Choose from 3 types of Cloud Services depending on your software's scraping requirements:
- Classic Cloud: Random new IP address assigned automatically for every GET request
- Uber Cloud: IP-on-Demand service: Your software requests a new IP on demand. Typically used to enable a multi-step transaction to complete on the same IP address, before requesting a new random IP address for the next transaction
- Continuum Cloud: Time-based IP Service. Session's IP address changes automatically every X minutes
Get started now by Requesting a Free Trial Account, or
View Proxy Server Cloud Pricing Plans
How do I get my software to use it?
If you're a SaaS company, or are using your own custom software, our Tech Services department will show you how to connect via our API which can be called from PHP, Python, Java and C# among others, If you're using a third party desktop scraping package, you configure your software to use a Proxy Server, and enter the settings we send you in your Welcome Email. If your software doesn't have these settings, you set it in Internet Explorer instead, and MS Windows then tells your software to use the Proxy Server Cloud that way.
How fast can I really send my queries?
The Proxy Server Cloud is designed to accept 600QPM. However you may not necessarily always be able to achieve these speeds due to limitations of your software or computer or network. Depending on your target site(s), in coordination with our Tech Services department, you may be able to query faster.
How does the pricing work?
Pricing works on a Pay As You Go "metered" principle, buying packages of 5 million GETs at a time. On our SmallBiz Plans, with the help of our Tech Services department, you estimate the number of GET Requests you're likely to do in a month and sign up for the appropriate fixed monthly fee plan. Unused GET Requests are NOT carried over to the next month.
What constitutes a "GET Request"?
* POST and CONNECTION Requests count toward your GET Request limit as they are still Requests that must be anonymized by our service.
How do I know how much I'm using during the month?
You will receive a daily report by email with your usage. You can also check your usage anytime by logging into your Customer Portal account.
Does the Proxy Server Cloud work with Google and other Search Engines?
No. Instead we recommend the Big-G Stealth Extractor which is optimized for Google and Bing and works very effectively using our own proprietary technology.
Why do you charge different rates for GETs to Search Engines?
Many web pages contain internal links to scripts on Google, Bing, Yahoo or other search engine domains. So even if you're not scraping search engines directly, your routine scraping will likely result in GETs to search engine domains. As major search engines like Google, Bing and Yahoo limit the number and speed of requests you can send from an IP address, the cost of servicing these requests is much higher.
Which countries is the Proxy Server Cloud available in?
At the moment, our main Proxy Server Clouds are available in the United States only. We have a smaller UK Proxy Server Cloud available on a custom quote, depending on your needs.
Can I have a Free Trial?
Yes, and indeed it is mandatory that new customers must first perform a successful free trial before a paid account can be activated. Request your Free Trial now.


text:
My baby girl was diagnosed with a left cdh a couple weeks ago and since then I have had several tests and ultrasounds. The doctors at CHOP have given her a 70-73% chance of survival with an LHR of 0.90. Her stomach, bowel, and very small portion of liver (7%) is up. I know we have a long road yet to see how she grows but I was just wondering if anyone has/had a similar story to our's. Thank you for sharing. =)
my cdh baby
Sorry so late in getting back, just wanted to update that Caden got to come home April 8th. We DO have follow ups with the liver specialists as the TPN he was on in NICU apparently sometimes has effects on the liver. His numbers are going back to "normal" (whatever that is lol) and we should only have one more follow up. The follow up with the surgeon went well, he was pleased and now what we've learned is the biggest side effect that could occur is hearing loss. They aren't sure why, but we won't be in the clear til he's 5. So far hearing is good. :-)
I had a baby that was diagnosed with a cdh, a severe case and we had to terminate thfe pregnancy and we want to start trying again but i am so nervous that it will happen again. I did not know if you had a input to help me stay at ease with trying for another one. I am soo sorry for what you had to go through my heart goes out to you and all mothers out there going throught the same or other related issues. thank you!
My doctor told me my baby will be having cdh (left side) at my 37th week ultrasound. I had no knowledge about cdh, and was shocked when I heard this. I did few ultrasounds before that and everything looks good. my baby will be due in a week, I am afraid of whats coming up, but i need to stay strong. I hope everything will be fine and my baby is able to come home asap.
My son was diagnosed with CDH when he was 20 weeks. His heart was pushed over to the left side of his chest and his stomach and a few other organs were up in his chest cavity. One of his lungs was fine the other appeared to be squashed. It was such a hard time for my husband and I. The waiting was excrutiating. They kept saying that they couldn't tell us anything until he was born. So we just kept positive for 20 more weeks knowing our son had a 50/50 shot at survival. Well I am happy to say that he will be 1 this March and shows absolutely no signs that he ever had CDH or holes in his heart!! He was only in the NICU for 2 weeks and barely needed oxygen when he was born. He has been an absolute superstar! CDH is scary and varies in severity but you MUST STAY POSITIVE as there is no way to know whats coming until they are born. Just take one day at a time and do not focus on the negative, it will only bring you down. When its time to worry - worry then! They are safe while they are inside you! I am just pregnant with my second one now - and I am terrified about what is possible - I'd never known how lucky you are to have a perfect healthy baby. Its a blessing! I will have my first ultrasound in a few weeks. I am scared but I will hope for the best! Good luck to all of you.
All my love!
Hi there a few weeks ago my baby girl was diagnosed with left side CDH, I'm expecting twins and the other twin (boy) is fine. I'm going crazy and really trying not to worry. I have a fetal echo tomorrow and they say she is in the 75% for survival which is good odds so I'm just hoping and praying she will be ok. All the positive posts are very encouraging.


text:
Long time since I visited. I include a photo of our new baby. It is a Kinesis 7005 aluminium framed bike with Shimano Deore. We installed a Marzocchi ZI Wedge front fork. Can you get stifffer springs for these forks??? Still have to install M's suspension seat post.
We also installed a Cordless FD SC6501 Flight Deck cycle computer on our new MTB Tandem. We live in Mozambique and with the bad roads, potholes, gravel with some stretches of tar as well as fog in the eaarly mornings we installed cateye safety blinking light fore and aft. I eagerly installed the FD but it would not work. I "imported" batteries form South Africa but nothing. It would only show the time and the gear indicator bubbles worked. One morning while cycling I switched the front Cateye off and lo and behold the FD started working!!!!! I then experimented and if I turned the Cateye upright (it can swivel to be vertical or horizontal) and turned the light on steay (ie not blinking) the FD operated perfectly.
Has anybody experienced the same problem???? I find this very strange and will drop an email to Cateye and Shimano.
Keep those wheels spinning!!!!!
Big H


text:
What's going on with you guys this week?
Weekly Chat: 12/2 - 12/8
Lauren :)
SAHM of 2 with one lil pumpkin on the way.
Saturday, my big kids spent the night at my parents' house so DH and I could go and get some Christmas shopping done. When we picked them up yesterday, I got the surprise of my mother cutting DD's hair without asking me first, like 6 inches. That's a huge vent that I could go on and on about, but I won't.
Other than that, we're just getting ready for Christmas this week. I'm getting ready to take the baby and go shopping and the bigs are helping DH decorate outside. Tomorrow we have family pictures at noon and I'm nervous about that for two reasons. 1. Lately Mason likes to be awake from 12 am - 5 am - I'm going to look like a zombie in our pictures. 2. It takes us forever to get ready now and we haven't been on time for a single thing since the baby has been born. 3 kids is harder than I imagined. Kudos to anyone who has more - I'm a mess!
Lauren :)
SAHM of 2 with one lil pumpkin on the way.
Mathis - This is my fave time of the year too (aside from fall). I have to say I'm really slacking on the decorating though. Sleep deprivation has sort of made me not care very much.
Lauren :)
SAHM of 2 with one lil pumpkin on the way.
My friend who has a photography degree came over and did newborn portraits yesterday. She got some cute ones! Ezra had a doctor's appt this morning - he is 8lb 2oz and 20.5." Still needing the same amount of oxygen, which was kind of disappointing but not unexpected.
We are not doing a Christmas tree this year - DH insists on real trees and neither of us want to deal with one right now. I am still finding needles from last year's! Plus our tiny apartment is too full of baby stuff for a tree to fit. I might dig out our nativities though.
Mama to Ezra (9/16/12, 31+0, 66 days in NICU) & Asher (3/20/15, 39+6 via VBAC!)
Christmas trees- we didn't do one till my boys were much older. This year we have MIL's fake tree so far odd is being good with it.
Lauren - I think I'd go crazy if my mom cut dd's hair without asking.
Adjusting to normal life - I've had a few mini segments when DH left me with all the kids. They went well but I'm dreading tomorrow when DH officially goes back to work. Breakfast takes forever to get to (poor kids have been eating an hour late some days) and dinner time is always insane.
Verity had her 12 day appt. she's up 5 oz from her birth weight now!! That's huge for me as I normally have low supply... I think I'm ok so far cause I'm eating a ton. Bad for weight loss good for BF.
Brittany: mommy to Logan 06/06, Ransom 07/07, Everly 11/10, Verity 11/12 & Laine 5/3/15
Christmas time!!! Decorations are in boxes in the living room. I'm determined yo have it done by Sunday night!
MIL comes over tomorrow for several hours so I can get stuff done. Wednesday my great aunt and uncle come to meet Brendan.
Saturday my mom is babysitting so dh and I can go to dinner!!!!!! I'm so excited. Reminds me I have to pump this week so I am ready to leave him. I should only miss one feeding if that, but want a safety net.
This week should be more bonding and getting to know my baby boy.
Saturday is DH's Christmas party with the national guard. It's formal so I get to get all dressed up and fancy. My mom is coming to town on Friday and she'll be watching Everett, so it should be fun. But it will be the first night out so I'll be sure to worry.
Baby E born 2012
Bronze Mama
Molli is 4 weeks today and a month on Wednesday. Makes me sad how fast time is going by. Not that I want her to be a nb for forever, but this is our last baby so it's the last time for everything baby related. :(
Ep'ing bronze (o)(o)
Oh I was soooo mad about the hair issue. Overall, my parents generally don't really care about my opinion when it comes to MY children. It wasn't just the hair, but my mother was going on and on about me giving Mason some kind of cereal because 'he's big = he needs more to eat than just BM'. We delayed solids to between 6 - 7 months with DD and it drove them NUTS. Honestly, my mother probably gave her baby food behind my back. But seriously, he's not even a month old and even if I did decide to give him food (which I'm not) grains are the last thing I would give him. THEN, my parents know I don't usually let my kids have juice unless it's 100% juice and even then it's limited. Well, they went to Sam's Club and bought a couple of huge packs of Capri Suns and said one was for us to take home. I said no thank you, we have some juice at home and mostly we like them to have water, and as we left, my Dad gave DS the Capri Sun pack.
Sorry for the vent. It just gets super frustrating! We are constantly going back and forth between trying to be one big happy family and us not spending much time there because of stuff like that. Most times though I feel like one big happy family = DH and I get steamrolled when it comes to our wishes.
ST - I feel the same way about the growing too fast. Good luck w/ the pictures. Mason wasn't happy, but we got 3 or 4 where he wasn't crying or with 1 eye open. LOL. However, getting 3 kids (and let's face it, DH) ready takes FOREVER. My hair was not looking great in our family picture for Christmas cards. It was barely even dry when we left the house , at the very last minute - of course.
The bigs are still working with DH on decorating outside. My living room is piled with storage containers full of inside decorations that I really need to get done. Our house is also experiencing seasonal confusion as there are fall/ Halloween decorations mixed with Christmas decorations. Lol. One day I'll get there!
Lauren :)
SAHM of 2 with one lil pumpkin on the way.


text:
Number: 0285
Aetna considers plasmapheresis (PP), plasma exchange (PE), or therapeutic apheresis medically necessary for any of the following indications:
Aetna considers PP/PE or therapeutic apheresis experimental and investigational for all other indications, including the following conditions (not an all-inclusive list) because the medical literature does not support the value of PP/PE for these indications:
Aetna considers high density lipoprotein (HDL) delipidation and plasma re-infusion for acute coronary syndrome and all other indications experimental and investigational becasue its efectiveness has not been established.
See also CPB 0241 - Extracorporeal Photochemotherapy (Photopheresis) and CPB 0355 - Extracorporeal Immunoadsorption (Prosorba Column).Background
The terms plasmapheresis (PP) and plasma exchange (PE) are often used interchangeably, but when properly used, denote different procedures. Plasmapheresis refers to a procedure in which the plasma is separated from the blood either by centrifugation or membrane filtration. Once separated the plasma can be manipulated in a variety of ways. Plasma exchange refers to discarding the plasma totally and substituting a replacement fluid. In this assessment PP/PE will be used to describe the combined procedure.
Randomized trials have shown that PP/PE is a safe and effective treatment of Guillain Barre syndrome (GBS), particularly if instituted early in the course of disease. Hughes et al (2007) reported on a systematic evidence review of immunotherapy for GBS. In 4 trials with altogether 585 severely affected adult participants, those treated with PP/PE improved significantly more on this scale 4 weeks after randomization than those who did not, weighted mean difference (WMD) -0.89 (95 % confidence interval (CI): -1.14 to -0.63). In 5 trials with altogether 582 participants, the improvement on the disability grade scale with intravenous immunoglobulin (IVIG) was very similar to that with PP/PE, WMD -0.02 (95 % CI: -0.25 to 0.20). There was also no significant difference between IVIG and PP/PE for any of the other outcome measures. In 1 trial with 148 participants, following PP/PE with IVIG did not produce significant extra benefit.
Less conclusive information is available regarding PP/PE as a treatment of chronic inflammatory demyelinating polyneuropathy (CIDP); however, this therapy is widely accepted by the medical community. In a Cochrane systematic evidence review, Mehndiratta et al (2004) identified evidence from 2 small trials showing that PP/PE provides significant short-term benefit in about 2/3 of patients with CIDP but rapid deterioration may occur afterwards. The authors reported that adverse events related to difficulty with venous access, use of citrate and hemodynamic changes are not uncommon. The authors noted that a separate Cochrane evidence review found no significant difference in the benefit from PP/PE and IVIG.
Although PP/PE is an accepted treatment of GBS and CIDP, its mechanism of action is still poorly understood. It is presumed that the symptomatology of these diseases is immune mediated and that PP/PE will remove the pathogenic immune circulating factors. However, the specific immune factors responsible for the disease have not been identified. Thus PP/PE is a non selective approach, eliminating the entire plasma. It should be noted that both these therapies are primarily symptomatic; they do not directly address the production of the pathogenic factors. Guillain Barre syndrome is an acute self-limited disease; therefore therapy is needed only for a limited period of time. On the other hand, CIDP is a chronic disease, and PP/PE or IVIG is often needed on a chronic basis. Physicians titrate the frequency of therapies to the recurrence of symptomatology.
Controlled clinical trials have failed to validate the effectiveness of PP/PE as a treatment of systemic lupus erythematosus (SLE), polymyositis/dermatomyositis and rheumatoid arthritis. Early small case series of PP/PE as a treatment of rheumatoid vasculitis have not been followed-up with larger controlled studies and no conclusions can be reached as to its effectiveness. There is minimal information on other autoimmune rheumatic diseases.
There was early enthusiasm for PP/PE as a treatment of chronic rheumatic diseases. The rationale was based on the fact that humoral factors, such as immunoglobulins or circulating immune complexes, can accumulate in the plasma in rheumatic diseases. It was hypothesized that the removal of these factors by PP/PE would correct the clinical abnormality. While PP/PE can indeed lower the serologic level of various disease markers such as circulating immune complexes, anti-DNA antibodies, cryoglobulins or rheumatoid factor, a positive clinical effect on symptomatology has not been demonstrated in clinical trials. The discrepancy may be related to the fact that PP/PE is essentially a symptomatic treatment. Although PP/PE may remove circulating immunoglobulins and immune complexes, their local production may persist unabated.
In a systematic review of randomized controlled trials of PP/PE, Shehata et al (2002) identified 8 studies (n = 192), 6 of rheumatoid arthritis and 2 studies of progressive systemic sclerosis (scleroderma). Plasmapheresis/plasma exchange was not as effective as adjunctive therapy in patients with rheumatoid arthritis. In addition, there were no benefits for the use of PP/PE in patients with progressive systemic sclerosis. In 2 studies (n = 140) the addition of PP/PE was not shown to benefit disease activity, the relapse rate, or the number of deaths in patients with polyarteritis nodosa and Churg-Strauss syndrome. In 7 studies (n = 268), therapeutic PP/PE has not been found to have an additive benefit in SLE patients with active disease or renal disease.
Choy et al (2005) reported on a systematic evidence review of immunotherapy for dermatomyositis and polymyositis. The investigators reported that 2 randomized placebo-controlled trials assessing PE, leukapheresis and azathioprine produced negative results. The authors concluded that this systematic review highlights the lack of high quality randomized controlled trials that assess the efficacy and toxicity of immunosuppressants in inflammatory myositis.
Franc et al (2005) reviewed the evidence from randomized controlled clinical trials for treatments for lupus nephritis. The investigators found, based upon a review of clinical trials, that the current use of cyclophosphamide combined with steroids remains the best option to preserve renal function in proliferative lupus nephritis. The authors found no benefit with addition of PE to cyclophosphamide or azathioprine plus steroids for mortality (risk ratio [RR] 0.71, 95 % CI: 0.50 to 1.02), doubling of serum creatinine (RR 0.17, 95 % CI: 0.02 to 1.26) or end-stage renal failure (RR 1.24, 95 % CI: 0.60 to 2.57).
Fisher syndrome is one of the regional variants of GBS, characterized by impairment of eye movements (ophthalmoplegia), incoordination (ataxia) and loss of tendon reflexes (areflexia). It can occur in more limited forms, and may overlap with GBS. A Cochrane systematic evidence review found no randomized or non-randomized prospective controlled trials of immunotherapy in Fisher Syndrome or related disorders (Overell et al, 2007). In the largest study of PP/PE for Miller Fischer syndrome reported to date, Mori et al (2002) reported on a retrospective analysis of 50 patients with Miller Fisher syndrome to determine its effect on speed of recovery. The investigators found no effect of PP/PE on measures of speed of recovery.
There are no proven effective therapies for neuromyelitis optica. Based on experimental and pathological evidence, it is thought that immunoglobulins and complement deposition are likely to play a role in the pathogenesis of neuromyelitis optica. Glucocorticoids are typically used to treat cases acutely and may be beneficial. Azathioprine has been used for subsequent attacks. Information from the National Institute of Neurological Disorders and Stroke (2007) states that PE may be tried in patients who do not respond to glucocorticoids. In an uncontrolled case series, 6 of 10 patients with neuromyelitis optica treated with PE showed moderate or marked improvement (Keegan et al, 2002). A double-blind cross-over study of PP versus sham exchanges found that PP (7 exchanges of approximately 55 ml/kg administered every other day) was beneficial treating exacerbations of demyelinating disease (including neuromyelitis optica) that are not responsive to methylprednisolone (Weinshenker et al, 1999).
Lehmann et al (2008) examined the clinical value of therapeutic PE in the treatment of multi-focal motor neuropathy (MMN). This study was a retrospective analysis of 7 patients with MMN, who underwent 4 to 18 sessions of PE. Clinical response, electrophysiological parameter and anti-ganglioside antibody titers were reviewed. Two patients, who had anti-ganglioside antibodies, exhibited transient clinical responses to PE, manifested by improved neurological function. Whereas electrophysiological parameters continued to worsen in all patients, anti-ganglioside antibody titers declined during PE, but increased after PE. The authors concluded that PE is of limited therapeutic value in patients with MMN, who do not respond to established treatment options. It may only be useful as an adjunctive treatment in a subset of patients. The transient decrease of anti-ganglioside-antibodies titers suggested that pathogenic humoral factors in MMN are only temporarily reduced. Further, PE treatment alone is insufficient to prevent axons from continuing degeneration, which may explain the failure of PE to substantially influence the disease course of patients with MMN.
In a Cochrane review, Micheal et al (2009) evaluated the benefits and harms of different interventions for hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) separately in patients of all ages. The authors concluded that PE with fresh frozen plasma is still the most effective treatment available for TTP. For patients with HUS, supportive therapy including dialysis is still the most effective treatment. All studies in HUS have been conducted in the diarrheal form of the disease. There were no randomized controlled trials evaluating the effectiveness of any interventions on patients with atypical HUS who have a more chronic and relapsing course.
The Multiple Sklerose Therapie Konsensus Gruppe (2006) stated that the monoclonal antibodies provide considerable improvement of treatment for multiple sclerosis (MS), but their use in basic therapy is restricted by their side effect profile. Thus, natalizumab is only approved for monotherapy after basic treatment has failed or for rapidly progressive relapsing-remitting MS. In contrast, long-term data on recombinant beta-interferons and glatiramer acetate (Copaxone) show that even after several years no unexpected side effects occur and that a prolonged therapeutic effect can be assumed which correlates with the dose or frequency of treatment. Recently IFN-beta1b (Betaferon) was approved for prophylactic treatment after the first attack (clinically isolated syndrome, CIS). During treatment with beta-interferons, neutralizing antibodies can emerge with possible loss of effectivity. In contrast, antibodies play no role in treatment with glatiramer acetate. During or after therapy with mitoxantrone, serious side effects (cardiomyopathy, acute myeloid leukemia) appeared in 0.2 to 0.4 % of cases. Plasmapheresis is limited to individual curative attempts in escalating therapy of a severe attack. According to the revised McDonald criteria, the diagnosis of MS can be made as early as the occurrence of the first attack.
Tackenberg et al (2007) stated that the natural course of MS is probably more favorable than previously assumed years ago. Since the introduction of interferons in Germany, the establishment and further development of new diagnostic criteria (McDonald criteria), the causal and symptomatic treatment possibilities and initiation of therapy early in the course of the disease have led to a considerable change in the treatment of MS. Attacks of MS are usually treated with the intravenous administration of high-dosed steroids. When the attack symptoms do not sufficiently subside, PP can be considered. For long-term treatment of MS, beta interferon, glatirameracetate and natalizumab are available as basic causal therapy and natalizumab and mitoxantrone are available for escalation therapy. Frequently occurring spasticity, chronic fatigue syndrome, depression, cognitive disturbances, incontinence, pain, ataxia and sexual disorders must be treated symptomatically. Overall, the outpatient treatment of MS is complex and should be carried out with close co-operation between the family doctor, neurological practices and outpatient departments specialized in treating MS.
Oh et al (2008) noted that B-cells and humoral immunity have been implicated in the pathogenesis of MS. The most common pattern of demyelinating pathology in MS is associated with the deposition of antibodies and the activation of complement, as well as T-cells and macrophages. Plasmapheresis has been found to be an efficient therapeutic approach in patients with this type of pathological lesion.
Matsui (2008) noted that Japanese patients with relapsing-remitting multiple sclerosis (RRMS) consists of 2 groups. One is opticospinal form (OSMS), in which major neurological symptoms derive from optic neuritis and myelitis, and the other is conventional form (CMS) that shares similar genetical and clinical features with western type of MS. Patients with OSMS tend to experience disease relapses more frequently with the resultant severer neurological deficit than CMS ones. Both OSMS and CMS patients are treated with intravenous high-dose methylprednisolone in acute exacerbations, and PP may be considered for those who do not respond to repeated intravenous steroids. For prevention of disease relapse, interferon-beta is effective; however, patients with long spinal cord lesion extending over 3 vertebral segments should be followed-up with caution, as this finding indicates a risk of treatment failure.
Ohji and Nomura (2008) discussed steroid pulse therapy and apheresis therapy indicated for the treatment of MS. In the basic treatment course for MS, steroid pulse therapy is a 1st-line treatment for RR-MS in the course of the exacerbation, and apheresis therapy is performed in refractory cases. Treatment strategies for chronic progressive MS are not to be established. Steroid pulse therapy has been established as a treatment for MS in the active phase through randomized controlled trials (RCT). Apheresis therapy includes PP and cytapheresis, and PP includes PE and immunoadsorption plasmapheresis (IAPP). Plasma exchange and IAPP are performed for MS treatment. The former has been established as a useful treatment for active phase MS. The efficacy of IAPP has been frequently reported, but no reports have been based on RCT.
Schroder et al (2009) stated that apheresis is a general term that describes removal of abnormal blood constituents by extracorporeal blood purification methods. To date, therapeutic PE is the most common apheresis procedure. Here, plasma is separated from corpuscular blood constituents and replaced with a substitution fluid. In contrast to immunoadsorption, PE is a non-specific treatment modality with elimination of the entire plasma. The therapeutic effect is based on the removal of circulating, pathogenic immune factors including autoantibodies. Currently, PE is used for treatment of several immune-mediated neurological disorders. While first experiences relate to acute life-threatening conditions, such as treatment of GBS or myasthenic crisis, therapeutic success was also shown in chronic diseases where immunosuppressive therapy is often required for long-term management. Plasma exchange has been applied successfully in CIDP, paraproteinemic polyneuropathy, stiff person syndrome, and may also be tried in several diseases of paraneoplastic origin. In recent years, PE was also established as an escalation therapy for steroid-unresponsive relapses of MS, and thus has gained more widespread attention.
Olek (2009) stated that PE may be beneficial in patients with acute central nervous system (CNS) inflammatory demyelinating disease who do not respond to glucocorticoid therapy. In the only formally reported clinical trial, 22 patients with CNS demyelinating disease (12 with MS) were randomly assigned to either active PE or sham treatment, with a total of 7 treatments, given every 2 days over 14 days. Moderate or greater improvement in neurologic disability occurred during 8 of 19 (42 %) courses of active treatment compared with 1 of 17 (6 %) courses of sham treatment. Improvement occurred early in the course of treatment and was sustained on follow-up. However, 4 of the patients who responded to the active treatment experienced new attacks of demyelination during 6 months of follow-up. Given these data, the author suggested treatment with PE for patients with acute, severe neurologic deficits caused by MS who have a poor response to treatment with high-dose glucocorticoids.
Ruprecht and colleagues (2004) reviewed a series of 10 consecutive patients treated with PE for acute, severe optic neuritis (ON) largely unresponsive to previous high-dose intravenous glucocorticosteroids. Plasma exchange was associated with an improvement of visual acuity according to the study criteria in 7 of 10 patients. On follow-up, 3 of these patients continued to improve, 2 remained stable, and 2 had worsened again. The authors noted that PE may be beneficial as an escalating treatment in a subset of patients with severe ON; but a controlled trial is needed. Furthermore, in a review on ON, Osborne and Volpe (2009) stated that data on the use of PE in the treatment of patients with ON are too scarce to make any recommendations.
Boada-Rovira (2010) noted that results from a pilot study and its 2-year extension performed on patients with mild or moderate Alzheimer's disease (AD) revealed a tendency towards clinical stabilization after a PP program with PE with therapeutic albumin Human albumin Grifols 5 %. Plasma levels of alphabeta(40) and alphabeta(42) presented a saw-tooth pattern associated to PE. These findings encouraged a new randomized, controlled, parallel, blind study to confirm the previous working hypotheses, i.e., that alphabeta(40) and alphabeta(42) concentrations in plasma were modified pre- and post-PP with human albumin Grifols 5 % and, in the clinical area, that the cognitive capabilities of patients could be stabilized or even improved. Other aims of the study were focused on neuroimaging evaluation of structural and functional changes in the brain the by means of magnetic resonance and single-photon emission computerized tomography. Preliminary results from the randomized study performed after a follow-up of 1 year of the first 29 patients (80 % of the recruited) show a clear difference between the treated and the control groups with regard to the levels of alphabeta(40), both in plasma and in cerebrospinal fluid, that are associated with the PE. This pattern is not so evident for alphabeta(42). Regarding cognitive performance, the treated group scored better than the control group after the period study, according to the evaluation performed by using the Mini-Mental State Examination (MMSE) and AD Assessment Scale-Cognitive (ADAS-Cog) tests. The authors concluded that these preliminary results suggested that PP with PE with human albumin Grifols 5 % may have a promising future as a treatment of mild-moderate AD.
In a Cochrane review, Kirtschig et al (2010) evaluated treatments for bullous pemphigoid (BP); RCTs of treatments for subjects with immunofluorescence-confirmed BP were included in this analysis. At least 2 authors evaluated the studies for the inclusion criteria, and extracted data independently. A ttoal of 10 RCTs (with a total of 1,049 participants) of moderate-to-high risk of bias were selected. All studies involved different comparisons, none had a placebo group. In 1 trial PE plus prednisone gave significantly better disease control at 1 month (0.3 mg/kg: RR 18.78, 95 % CI: 1.20 to 293.70) than prednisone alone (1.0 mg/kg: RR 1.79, 95 % CI: 1.11 to 2.90), while another trial showed no difference in disease control at 6 months.No differences in disease control were seen for different doses or formulations of prednisolone (1 trial each), for azathioprine plus prednisone compared with prednisone alone (1 trial), for prednisolone plus azathioprine compared with prednisolone plus PE (1 trial), for prednisolone plus mycophenolate mofetil or plus azathioprine (1 trial), for tetracycline plus nicotinamide compared with prednisolone (1 trial). Chinese traditional medicine plus prednisone was not effective in 1 trial. There were no significant differences in healing in a comparison of a standard regimen of topical steroids (clobetasol) with a milder regimen (RR 1.00, 95 % CI: 0.97 to 1.03) in 1 trial. In another trial, clobetasol showed significantly more disease control than oral prednisolone in people with extensive and moderate disease (RR 1.09, 95 % CI: 1.02 to 1.17), with significantly reduced mortality and adverse events (RR 1.06, 95 % CI: 1.00 to 1.12). The authors concluded that very potent topical steroids are effective and safe treatments for BP, but their use in extensive disease may be limited by side-effects and practical factors. Milder regimens (using lower doses of steroids) are safe and effective in moderate BP. Starting doses of prednisolone greater than 0.75 mg/kg/day do not give additional benefit, lower doses may be adequate to control disease and reduce the incidence and severity of adverse reactions. The effectiveness of adding PE, azathioprine or mycophenolate mofetil to corticosteroids, and combination treatment with tetracycline and nicotinamide needs further investigation.
In January 2011, the American Academy of Neurology (AAN) published a new guideline on PP in neurologic disorders (Cortese et al, 2011). It states that PP/PE can be used as 2nd-line treatment of steroid-resistant exacerbations in relapsing forms of MS. Moreover, PP is established as ineffective and should not be offered for chronic or secondary progressive MS. The guideline also stated that PP is probably not effective and should not be considered for neuropathy associated with immunoglobulin M gammopathy.
The AAN (Scott et al, 2011) evaluated the evidence for diagnostic tests and therapies for transverse myelitis (TM) and made evidence-based recommendations. A review of the published literature from 1966 to March 2009 was performed, with evidence-based classification of relevant articles. Level B recommendations: Neuromyelitis optica (NMO)-immunoglobulin G (IgG) antibodies should be considered useful to determine TM cause in patients presenting with clinical acute complete transverse myelitis (ACTM) features. The presence of NMO-IgG antibodies (aquaporin-4-specific antibodies) should be considered useful in determining increased TM recurrence risk. Level C recommendations: In suspected TM, distinction between ACTM or acute partial transverse myelitis may be considered useful to determine TM etiology and risk for relapse (more common with APTM). Age and gender may be considered useful to determine etiology in patients presenting with TM syndrome, with spinal infarcts seen more often in older patients and more female than male patients having TM due to MS. Brain MRI characteristics consistent with those of MS may be considered useful to predict conversion to MS after a first partial TM episode. Longer spinal lesions extending over more than 3 vertebral segments may be considered useful in determining NMO versus MS. Cerebrospinal fluid examination for cells and oligoclonal bands may be considered useful to determine the cause of the TM syndrome. Plasma exchange may be considered in patients with TM who fail to improve after corticosteroid treatment. Rituximab may be considered in patients with TM due to NMO to decrease the number of relapses. Level U recommendations: There is insufficient evidence to support or refute the efficacy of other TM therapies or the usefulness of ethnicity to determine the cause of a subacute myelopathy.
An UpToDate review on "Clinical manifestations, diagnosis, treatment, and prevention of babesiosis" (Gelfand and Vannier, 2012) states that "Partial or complete red cell exchange transfusion is appropriate for patients with high-grade parasitemia (≥10 percent), severe anemia (hemoglobin ≤10 g/dL), or pulmonary, renal, or hepatic compromise …. Exchange transfusion is intended to clear the systemic compartment of infected red blood cells, to remove inflammatory mediators and toxic by-products of cell lysis, and to correct anemia. Management of exchange transfusion should be handled in close consultation with experts in hematology and pheresis. A single red cell exchange may be adequate, but multiple exchanges may be needed. A 90 percent reduction in parasitemia has been proposed as the desired target of red blood cell exchange in babesiosis. The volume of allogeneic red cells required to achieve such reduction in parasitemia is predicted to be 2.5 times the estimated volume of recipient's red blood cells".
In a Cochrane review, Carless et al (2011) examined the evidence for the efficacy of platelet-rich plasmapheresis (PRP) in reducing peri-operative allogeneic red blood cell (RBC) transfusion, and the evidence for any effect on clinical outcomes such as mortality and re-operation rates. These investigators identified studies by searching MEDLINE (1950 to 2009), EMBASE (1980 to 2009), the Cochrane Library (Issue 1, 2009), the Internet (to March 2009) and the reference lists of published articles, reports, and reviews. Controlled parallel group trials in which adult patients, scheduled for non-urgent surgery, were randomized to PRP, or to a control group that did not receive the intervention were selected for analysis. Primary outcomes measured were: the number of patients exposed to allogeneic RBC transfusion, and the amount of RBC transfused. Other outcomes measured were: the number of patients exposed to allogeneic platelet transfusions, fresh frozen plasma, and cryoprecipitate, blood loss, re-operation for bleeding, post-operative complications (thrombosis), mortality, and length of hospital stay. Treatment effects were pooled using a random-effects model. A total of 22 trials of PRP were identified that reported data for the number of patients exposed to allogeneic RBC transfusion. These trials evaluated a total of 1,589 patients. The relative risk (RR) of exposure to allogeneic blood transfusion in those patients randomized to PRP was 0.73 (95 % CI: 0.59 to 0.90), equating to a relative risk reduction (RRR) of 27 % and a risk difference (RD) of 19 % (95 % CI: 10 % to 29 %). However, significant heterogeneity of treatment effect was observed (p < 0.00001; I² = 79 %). When the 4 trials by Boldt were excluded, the RR is 0.76 (95 % CI: 0.62 to 0.93). On average, PRP did not significantly reduce the total volume of RBC transfused (weighted mean difference [WMD] -0.69, 95 %CI: -1.93 to 0.56 units). Trials provided inadequate data regarding the impact of PRP on morbidity, mortality, and hospital length of stay. Trials were generally small and of poor methodological quality. The authors concluded that although the results suggested that PRP is effective in reducing allogeneic RBC transfusion in adult patients undergoing elective surgery, there was considerable heterogeneity of treatment effects and the trials were of poor methodological quality. They stated that the available studies provided inadequate data for firm conclusions to be drawn regarding the impact of PRP on clinically important endpoints.
The American Academy of Child and Adolescent Psychiatry's practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder (AACAP, 2012) stated that "Therapeutic plasma exchange and intravenous immunoglobulin remain experimental interventions with substantial risk and potential morbidity".
Hanna and Wong (2013) stated that sepsis remains an important challenge in pediatric critical care medicine. These investigators provided an appraisal of adjunctive therapies for sepsis and high-lighted opportunities for meeting selected challenges in the field. The authors stated that future clinical studies should address long-term and functional outcomes as well as acute outcomes. Potential adjunctive therapies such as corticosteroids, hemo-filtration, hemo-adsorption, and PP may have important roles, but still require formal and more rigorous testing by way of clinical trials.
Low high-density lipoprotein (HDL) is associated with increased risk of cardiovascular disease. Plasma selective delipidation converts alphaHDL to prebeta-like HDL, the most effective form of HDL for lipid removal from arterial plaques.
Tardif et al (2007) investigated the effects of reconstituted HDL on plaque burden as assessed by intra-vascular ultrasound (IVUS). Between July 2005 and October 2006, a total of 183 patients had a baseline IVUS examination and of those, 145 had evaluable serial IVUS examinations after 6 weeks. A total of 60 patients were randomly assigned to receive 4 weekly infusions of placebo (saline); 111 to receive 40 mg/kg of reconstituted HDL (CSL-111); and 12 to receive 80 mg/kg of CSL-111. The primary efficacy parameter was the percentage change in atheroma volume. Nominal changes in plaque volume and plaque characterization index on IVUS and coronary score on quantitative coronary angiography were also pre-specified end-points. The higher-dosage CSL-111 treatment group was discontinued early because of liver function test abnormalities. The percentage change in atheroma volume was -3.4 % with CSL-111 and -1.6 % for placebo (p = 0.48 between groups, p < 0.001 versus baseline for CSL-111). The nominal change in plaque volume was -5.3 mm3 with CSL-111 and -2.3 mm3 with placebo (p = 0.39 between groups, p < 0.001 versus baseline for CSL-111). The mean changes in plaque characterization index on IVUS (-0.0097 for CSL-111 and 0.0128 with placebo) and mean changes in coronary score (-0.039 mm for CSL-111 and -0.071 mm with placebo) on quantitative coronary angiography were significantly different between groups (p = 0.01 and p = 0.03, respectively). Administration of CSL-111 40 mg/kg was associated with mild, self-limiting transaminase elevation but was clinically well-tolerated. The authors concluded that short-term infusions of reconstituted HDL resulted in no significant reductions in percentage change in atheroma volume or nominal change in plaque volume compared with placebo, but did result in statistically significant improvement in the plaque characterization index and coronary score on quantitative coronary angiography. They stated that elevation of HDL remains a valid target in vascular disease and further studies of HDL infusions including trials with clinical end-points are needed.
Waksman et al (2010) examined if serial autologous infusions of selective HDL delipidated plasma are feasible and well-tolerated in patients with acute coronary syndrome (ACS). Patients with ACS undergoing cardiac catheterization with greater than or equal to 1 non-obstructive native coronary artery atheroma were randomized to either 7 weekly HDL selective delipidated or control plasma apheresis/reinfusions. Patients underwent IVUS evaluation of the target vessel during the catheterization for ACS and up to 14 days following the final apheresis/reinfusion session. Two-dimensional gel electrophoresis of delipidated plasmas established successful conversion of alphaHDL to prebeta-like HDL. The trial was complete with 28 patients randomized. All reinfusion sessions were tolerated well by all patients. The levels of prebeta-like HDL and alphaHDL in the delipidated plasma converted from 5.6 % to 79.1 % and 92.8 % to 20.9 %, respectively. The IVUS data demonstrated a numeric trend toward regression in the total atheroma volume of -12.18 +/- 36.75 mm(3) in the delipidated group versus an increase of total atheroma volume of 2.80 +/- 21.25 mm(3) in the control group (p = 0.268). The authors concluded that in ACS patients, serial autologous infusions of selective HDL delipidated plasma are clinically feasible and well-tolerated. They stated that this therapy may offer a novel adjunct treatment for patients presenting with ACS. Moreover, they stated that further investigation is needed to determine its ability to reduce clinical cardiovascular events.
An UpToDate review on "HDL metabolism and approach to the patient with abnormal HDL-cholesterol levels" (Rosenson and Durrington, 2013) cited the study by Tardif et al (2007) and listed infusion of reconstituted HDL as an investigational therapy. Moreover, the review does not mention HDL delipidation and plasma re-infusion as a therapeutic option.
Guidelines from the National Comprehensive Cancer Network (NCCN, 2014) on Waldenstrom's Macroglobulinemia/Lymphoplasmacytic Lymphoma state that plasmapheresis should be performed for patients with symptomatic hyperviscosity, and before treatment with rituximab or ofatumumab containing regimen in patients with patients with IgM greater than or equal to 5000 mg/dL on ritxumab-containing therapy to avoid aggravation of serum viscosity on the basis of rituximab-containing IgM flare. The guidelines state that rituximab or ofatumumab may also be held in patients with elevated serum IgM levels for initial treatment cycles.
Current guidelines recommend plasmapheresis for acute hemoral rejection of renal transplants. Kidney Disease: Improving Global Outcomes (KDIGO) clinical guidelines suggest treating antibody-mediated acute rejection with one or more of the following alternatives, with or without corticosteroids (2C recommendation): plasma exchange; intravenous immunoglobulin; anti-CD20 antibody; or lymphocyte-depleting antibody (Kasiske, et al., 2009). European Association of Urology guidelines on renal transplantation (Kälble, et al., 2009) state that treatment of acute humoral rejection of a renal transplant may include steroid bolus therapy, conversion to tacrolimus, antibody elimination and intravenous immunoglobulin (Grade B recommendation). Guidelines from the Renal Association (Baker, et al., 2011) suggest that antibody mediated rejection should be treated with one or more of the following modalities: steroids; plasma exchange; intravenous immunoglobulin; anti-CD20 antibody; or lymphocyte-depleting antibody (2C recommendation).
Brouet et al (1990) stated that monoclonal IgM from patients with peripheral neuropathy react in nearly 80 % of the cases with some components of myelin. The main target is myelin associated glycoprotein (50 % of the cases); several types of glycolipids or gangliosides have been identified as the reactive antigen in the other cases. Anti-MAG IgM shared little cross reactive idiotopes. Only primate anti-sera identified a combining site related public idiotope. In fact, these IgM used various light and heavy chains belonging to different variability subgroups. The authors concluded that the preliminary results of an ongoing trial aimed to establish the benefit of plasmapheresis in these patients.
Rimmer et al (2014) evaluated the safety and effectiveness of PE in patients with sepsis. These investigators searched MEDLINE, EMBASE, CENTRAL, Scopus, reference lists of relevant articles, and grey literature for relevant citations. They included RCTs comparing PE or plasma filtration with usual care in critically ill patients with sepsis or septic shock. Two reviewers independently identified trials, extracted trial-level data and performed risk of bias assessments using the Cochrane Risk of Bias tool. The primary outcome was all-cause mortality reported at longest follow-up. Meta-analysis was performed using a random-effects model. Of 1,957 records identified, these researchers included 4 unique trials enrolling a total of 194 patients (1 enrolling adults only, 2 enrolling children only, 1 trial enrolling adults and children). The mean age of adult patients ranged from 38 to 53 years (n = 128) and the mean age of children ranged from 0.9 to 18 years (n = 66). All trials were at unclear to high risk of bias. The use of PE was not associated with a significant reduction in all-cause mortality (RR 0.83, 95 % CI: 0.45 to 1.52, I2 60 %). In adults, PE was associated with reduced mortality (RR 0.63, 95 % CI: 0.42 to 0.96; I2 0 %), but was not in children (RR 0.96, 95 % CI: 0.28 to 3.38; I2 60 %). None of the trials reported ICU or hospital lengths of stay. Only 1 trial reported adverse events associated with PE including 6 episodes of hypotension and 1 allergic reaction to fresh frozen plasma. The authors concluded that insufficient evidence exists to recommend PE as an adjunctive therapy for patients with sepsis or septic shock. They stated that rigorous RCTs evaluating clinically relevant patient-centered outcomes are needed to evaluate the impact of PE in this condition.
Hildebrand et al (2014) stated that therapeutic PE (TPE) has been used as adjunctive therapy for various kidney diseases dating back to the 1970s. In many cases, support for TPE was on mechanistic grounds given the potential to remove unwanted large molecular-weight substances such as autoantibodies, immune complexes, myeloma light chains, and cryoglobulins. More recently, growing evidence from RCTs, meta-analyses, and prospective studies has provided insights into more rational use of this therapy. These investigators described the role of TPE for the 6 most common kidney indications in the 2013 Canadian Apheresis Group (CAG) registry and the evidence that under-pined current recommendations and practice. These kidney indications include (i) thrombotic microangiopathy, (ii) antiglomerular basement membrane disease, (iii) anti-neutrophil cytoplasmic antibody-associated vasculitis, (iv) cryoglobulinemia, (v) recurrence of focal and segmental glomerulosclerosis in the kidney allograft, and (vi) kidney transplantation.
The Society of Obstetricians and Gynecologists of Canada's guideline on "Treatment of the hypertensive disorders of pregnancy" (Magee et al, 2014) states that "The following interventions were considered but not recommended or there was insufficient evidence to make a recommendation: plasma exchange or plasmapheresis for HELLP syndrome …. The guideline developers recommend against plasma exchange or plasmapheresis for hemolysis, elevated liver enzymes, low platelets syndrome, particularly within the first 4 days postpartum". SOGC guidelines note insufficient evidence for plasma exchange or plasmapheresis, noting that observational studies have suggested improved hematological and biochemical indicators, but small RCTs have found no maternal or perinatal outcome improvement.
Also, an UpToDate review on "HELLP syndrome" (Sibai, 2014) does not mention plasmapheresis, plasma exchange, or therapeutic apheresis as therapeutic options.
By contrast, guidelines from the American Society of Hematology (Rajasekhar, et al., 2013) recommend the use of plasma exchange in HELLP syndrome if thrombocytopenia, hemolysis, or renal failure continues to worsen 48 to 72 hours postpartum.
A review by Gernsheimer, et al. (2013) recommends plasma exchange if thrombocytopenia, hemolysis, or renal failure continues to worsen 48-72 hours postpartum and differentiating between preeclampsia/HELLP/AFLP and thrombotic thrombocytopenic purpura (TTP)/atypical hemolytic uremic syndrome that can follow a normal pregnancy becomes difficult, if not impossible. The authors noted that several case series suggest that the use of plasma exchange treatment may improve the outcome of both severe HELLP and AFLP.
Pagano et al (2014) noted that the effectiveness of TPE in stiff-person syndrome (SPS) is unclear. These researchers performed a retrospective analysis of patients diagnosed with SPS who underwent TPE and a systematic literature review. A total of 9 patients with the presumptive diagnosis of SPS who underwent TPE were identified. The mean age was 55 years (range of 34 to 72 years) and 78 % (n = 7) were female. Anti-GAD65 was present in 89 % (n = 8) of the patients (range of 1.9 to 40,000 U/ml), and 33 % (n = 3) had a history of diabetes; 44 % (n = 4) of patients had previously received immunosuppressive medication and 67 % (n = 6) received IVIG. The main indication for TPE was worsening of symptoms despite treatment with first-line therapy; 78 % of the patients (n = 7) had 5 TPE procedures; 78 % (n = 7) of patients demonstrated at least minimal clinical improvement and 56 % (n = 5) had a significant response. Most of the patients who demonstrated a significant response to treatment improved and their symptoms stabilized. Two patients (22 %) developed adverse events, including catheter-associated infection and transient hypotension. A total of 18 publications were found from the literature review, which resulted in a total of 26 patients diagnosed with SPS; 42 % (n = 11) of patients had a significant symptomatic improvement after TPE treatment, and 2 patients (8 %) developed adverse events. The authors concluded that TPE may benefit patients with SPS who are not responsive to first-line therapy, and it is well-tolerated. These preliminary findings need to be validated by well-designed studies.
|CPT Codes / HCPCS Codes / ICD-10 Codes
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":
|ICD-10 codes will become effective as of October 1, 2015 :
|Plasmapheresis (PP) or plasma exchange (PE) :
|CPT codes covered if selection criteria are met:
|Therapeutic apheresis: for plasma pheresis
|with extracorporeal immunoadsorption and plasma reinfusion
|Other CPT codes related to the CPB:
|Therapeutic apheresis: with extracorporeal selective adsorption or selective filtration and plasma reinfusion [extracorporeal immunoadsorption (ECI) or Prosorba column]
|93015 - 93018
|Cardiovascular stress test
|Other HCPCS codes related to the CPB:
|Azathioprine, oral, 50 mg
|Azathioprine, parenteral, 100 mg
|Cyclosporine, oral, 100 mg
|Cyclosporine, oral, 25 mg
|Cyclosporine, parenteral, 250 mg
|ICD-10 codes covered if selection criteria are met:
|Babesiosis [if member has high-grade parasitemia greater than or equal to 10%]
|Waldenström macroglobulinemia
|Multiple myeloma
|Essential (hemorrhagic) thrombocythemia
|Autoimmune hemolytic anemias
|Other non-autoimmune hemolytic anemias [microangiopathic]
|Secondary polycythemia
|Autoimmune thyroiditis
|Pure hypercholesterolemia [in persons refractory to diet and maximum drug therapy see criteria1-17]
|Acute disseminated encephalitis and encephalomyelitis (ADEM) [where conventional treatment has failed]
|Other encephalitis and encephalomyelitis [Noninfectious acute disseminated encephalomyelitis (noninfectious ADEM)]
|Other myelitis (transverse)[ who fail to improve after corticosteroid treatment]
|Multiple sclerosis [acute, severe neurological deficits with poor response to treatment with high-dose glucocorticoids] [not covered for chronic or secondary progressive multiple sclerosis (maintenance therapy)]
|Neuromyelitis optica [Devic]
|Acute transverse myelitis in demyelinating disease of central nervous system [who fail to improve after corticosteroid treatment]
|Refsum's disease
|Guillian-Barre syndrome [covered for severe, grades 3-5 Guillain-Barre syndrome - not covered for Miller Fisher syndrome]
|Chronic inflammatory demyelinating polyneuritis [CIDP with severe or life threatening symptoms , in persons who have failed to respond ]
|Myasthenia gravis [acute with sudden worsening of symptoms][needs rapid improvement of strength before surgery or irradiation] [intermittent treatment for failure to respond to all other treatments] [neuropathy associated with immunoglobulin M gammopathy]
|Toxic liver disease with cholestasis
|Chronic passive congestion of liver [pruritis from cholestatic liver disease]
|Other specified diseases of liver [pruritis from cholestatic liver disease]
|Obstruction of bile duct
|Pemphigus vulgaris [resistant to standard therapy]
|Pruritus [from cholestatic liver disease]
|Felty's syndrome
|Rheumatoid arthritis [moderate to severe active in adults with longstanding who have failed or are intolerant of diseases-modifying anti-rheumatic drugs (DMARDs)]
|Polyarteritis nodosa
|Polyarteritis with lung involvement [Churg-Strauss]
|Hypersensitivity angiitis [Goodpasture's syndrome]
|Thrombotic microangiopathy
|Wegener's granulomatosis with or without renal involvement
|Systemic lupus erythematosus [life threatening, last resort when conventional therapy has failed]
|Polymyositis [in persons unresponsive to conventional therapy]
|Systemic sclerosis [in persons unresponsive to conventional therapy]
|Acute glomerulonephritis, nephrotic syndrome, chronic glomerulonephritis, and nephritis and nephropathy, not specified as acute or chronic [associated with antiglomerular basement membrane antibodies and advancing renal failure or pulmonary hemorrhage]
|Chronic kidney disease (CKD) and unspecified renal failure
|Severe pre-eclampsia and HELLP syndrome [in persons not getting better within 5 days of delivery]
|Other complication of kidney transplant [recurrent focal segmental glomerulosclerosis after renal transplantation]
|ICD-10 codes not covered for indications listed in the CPB:
|Streptococcal and other sepsis
|Multiple myeloma
|Immune thrombocytopenic purpura
|Obsessive-compulsive disorder
|Amyotrophic lateral sclerosis
|Parkinson's disease
|Stiff-man syndrome
|Alzheimer's disease
|Other demyelinating diseases of central nervous system [anti-MAG neuropathy]
|Nerve disorders, nerve root and plexus disorders, mononeuritis, neuropathy, and myoneural disorders (except Refsum's disease, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuritis, and myasthenia gravis) [neuropathy associated with immunoglobulin M gammopathy] [idiopathic progressive polyneuropathy] [anti-MAG neuropathy]
|Myopathy, unspecified [idiopathic]
|Optic neuritis
|Sudden idiopathic hearing loss
|Rheumatic chorea without heart involvement [Sydenham's chorea]
|Unstable angina [intermediate coronary syndrome]
|Raynaud's syndrome
|Alveolar proteinosis
|Crohns' disease [regional enteritis]
|Acute pancreatitis [related to hyperlipidemia]
|Bullous pemphigoid
|Other urticaria [chronic urticaria]
|Chronic nephritic syndrome with diffuse mesangial proliferative glomerulonephritis [in kidney allograft]
|Tachycardia, unspecified [postural orthostatic tachycardia syndrome]
|Chronic fatigue, unspecified
|Leukapheresis :
|CPT code covered if selection criteria are met:
|Therapeutic apheresis: for white blood cells [for acute debulking only]
|ICD-10 codes covered if selection criteria are met:
|Plasma cell leukemia
|Lymphoid, myeloid, monocytic, other specified, and unspecified leukemias
|Therapeutic cytopheresis:
|CPT code covered if selection criteria are met:
|Therapeutic apheresis: for red blood cells
|ICD-10 codes covered if selection criteria are met:
|Sickle-cell disorders


text:
I Wish I Lived in a Land of Lipton …
What makes Southern sweet tea so special?
Offering up a glass of sweet tea on a hot day in the South is as welcoming a gesture as passing the doobie at a Phish show. It's so ingrained in the Southern DNA—Marion Cabell Tyree included the recipe in a cookbook called Housekeeping in Old Virginia as early as 1879—that people now post videos online of their infants sampling the stuff. It's a frequent menu item for the condemned, as well as a centerpiece at church suppers. As an April Fools' Day prank in 2003, Georgia State Rep. John Noel introduced a bill that would have made it a misdemeanor for a restaurant owner not to include sweet tea on the menu. Most Southerners can easily tell the difference between fresh sweet tea and the stuff from concentrate—and unless their sugar jones is too strong that day, chances are they'll send the latter back.
It's a refreshing combination of sweet and cold, sure, but how does something that's simply tasty become the unofficial beverage for an entire region? Well, there's this: The South reveres its traditions, and sweet tea is one of them. Dixie has had some embarrassments in its time: There's that whole Civil War thing, the whole Judge Roy Moore thing, that whole Naples, Fla., Swamp Buggy Queen thing, to name a few. Getting your nose rubbed in your own traditions too many times makes you cling to those that aren't, well, illegal. And you revere them as much because they have proven resistant to change as you do for their particular qualities.
For me, personally—and I suspect I'm not alone—sweet tea is a primal link to my own Southern past. I grew up a Jewish kid in Atlanta, with a mom from Brooklyn, N.Y., and a dad from Cleveland. To assimilate with my classmates, I quickly learned to say y'all, talk about Herschel Walker, put honey on my biscuits, and enjoy sweet tea. While my parents made us drink an unsweetened mint tea blend at home, I strong-armed them into stopping by Po Folks on the way home from baseball practice. A middling Southern-style chain (we didn't know enough to eat at Mary Mac's), known for horrible phonetic misspellings, heavily larded chicken, and, most importantly, sweet tea served in Mason Jars, it was practically the only place I could get hooked up properly—at least, that is, until I began raiding the always-full homemade pitchers in my friends' refrigerators.
I may live in Massachusetts now, but I still consider myself Southern at heart. In the fall, I ask the bartender to let me watch the Bulldogs game. In the spring, I feel a potentially suicidal need to stop wearing a coat. And in the summer, I still look for sweet tea. Even on the rare occasion I can find someplace that has it on the menu, it's often slightly off. Maybe it isn't sweet enough. Maybe it's the lack of free refills. Whatever it is, it chills me.


text:
On June 6th, police say 46-year-old Daniel Saunders hurled himself through the front window of a Rainier Valley church. Saunders, a Hepatitis C-positive ex-con with
On June 6th, police say 46-year-old Daniel Saunders hurled himself through the front window of a Rainier Valley church. Saunders, a Hepatitis C-positive ex-con with multiple appearances in Mental Health Court, then allegedly vandalized the church, tearing photos from the walls, messing with the display case and smearing enough blood so as to require a HazMat clean-up.
Four days later, a clerical error accidentally sprung Saunders from jail. But according to an article in the Seattle Times, Saunders decided he should probably come back to the evidence unit and pick up his stuff. Because he's a guy who willingly jumped into a plate-glass window, we'll call this his version of common sense.
As you can see in the video above, Saunders opens the door for three officers and then there's an almost immediate struggle. Saunders ends up on the ground, flailing his legs, not looking exactly like he's cooperating, while the cops hit him multiple times with their fists, a baton, a flashlight and, according to their report, "four or five" times with a Taser.
Saunders now has a lawyer. He says his client was being a "good samaritan" by opening the door for officers and might sue the department.
The King County prosecutor's office says that while the video isn't pretty, it actually exonerates the officers, who reported that Saunders was trying to stab them with a screwdriver.
An internal investigation was opened on October 26th, five months after the arrest and only after the Times requested the video. But without audio or a decent camera angle, look for this case to come down to the officer's word versus the crook's.


text:
User talk:Miley Spears/Men in Black
From Uncyclopedia, the content-free encyclopedia
< User talk:Miley Spears
Revision as of 19:26, January 28, 2010 by Why do I need to provide this? (talk | contribs)
Brilliant ~~Shan~~
Named a Good Article
Just in case anyone ever sees this, [1]. WHY???PuppyOnTheRadio 19:26, January 28, 2010 (UTC)


text:
"Uyuni and Details for 4WD Tours North and South" Top 5 Page for this destination Uyuni by AlbuqRay
Uyuni Travel Guide: 303 reviews and 919 photos
Uyuni is the jumping off point for the 4WD tours of southern Bolivia. There is a standard 4-day loop to the far south and a less traveled 2-day loop to the northern part of the Salar. Both loop tours do the Salar de Uyuni, i.e., Colchani (salt processing village), the old salt hotel west of Colchani (there is a new, big salt hotel being built north of Colchani), and Incahuasi (an island with cacti in the Salar mistakingly called Fish Island by some). The southern loop leaves Incahuasi and goes to places on the way to Laguna Colorado and the most southern part of Bolivia. However, if you have less time (2 days), you may do the first three stops and then spend the night near Volcan Thunupa in the northern Salar before returning to Uyuni.
My detailed southern loop itinerary was Colchani, mounds of salt, salt hotel, Incahuasi, Chuvica (first night), Paso de Leon, Laguna Canapa, Laguna Hedionida, red rocks with viscachas, Arbol de Piedra, Laguna Colorado (second night), Sol de Manana geysers, Laguna Polques hot springs, Dali rocks, Laguna Verde, bus stop to San Pedro at Laguna Blanca, upper end of Laguna Colorado, village of Culpino, Rio Grande crossing, and back to Uyuni. It was supposed to be a 4-day tour but my guide had an emergency in La Paz and had to get back. We drove all the way back to Uyuni on the third day. Normally the tour would have a third night in a rough shelter and end at the train cemetery near Uyuni. I have done Things to Do tips below (with multiple pics and in chronological order) for most of these places. Be sure to scroll down; there are three pages. Endure a few inconveniences and don't miss this 4WD tour if you get a chance. It will be one of the all time highlights of your travels.
It is Jan 08. I was looking for information on the Salar de Uyuni during the rainy season, when I happened upon this amazing journey by a young family with two kids that cycled from Canada to Chile. What an adventure! 4WD vehicles have a hard time going across some of the places they went.
The northern part of the Salar de Uyuni is empty and untouched. There are also many wonderful places to visit in this area. My detailed northern loop itinerary was Colchani, mounds of salt, salt hotel, Incahuasi, north shore of the Salar, Coquesa (spent the night), Volcan Thunupa, the mummy caves, Pukara, Jirira and the "eyes of salt," before returning to Uyuni via Colchani. The Coquesa tips and travelogues include Volcan Thunupa, the mummy caves, Pukara and Jirira.
Not much to do in Uyuni itself besides the train cemetery outside of town. Uyuni is on the railroad from Oruro to Chile and Argentina. It also has numerous 4WD tour companies. I used Colque Tours to do the southern loop and Thunupa Tours to do the northern loop. I had good experiences with both. Although I would rate the Colque driver, Nicholas, as just okay. He was a no show the next morning to take me to the bus station and that was after I gave him a good tip the day before. Guess I should have waited to tip him. The Thunupa driver, Ramiro, and cook, Janet, were excellent.
- Pros:Can get a 4WD tour to spectacular places
- Cons:Limited selection of hotels
- In a nutshell:Transit point but not a place to stay
Reviews (32)
As for when to go, I have been in October and April. Both were good. The rainy season is November to March. If the water... more travel advice
I have taken the bus from La Paz to Oruro and the train from Oruro to Uyuni twice (2003 and 2006). The first time Fremen... more travel advice
I have been trying to decide how to answer the question about how to choose a Salar de Uyuni tour company (there are... more travel advice
There is now (Nov 08) another alternative to staying in Uyuni. Lonely Planet in Apr 04 said that the two old salt hotels... more travel advice
Comments (8)
Absolutely fascinating! Beautiful photos as well.
Like all tips should be - informative with good pictures! Looks like they pinched some of roos judging by the viscachas. Cheers.
Never thought of doing a 4wd tour but you have convinced me ;-)
All your photos are wonderful !!! Great and informative pages as always, Mr Bolivia ;-)
Amazing! Great info, j
Very good pages and photos Gracias
visit a salt mine? not my idea of fun. they do make for a good picture though. :) did you buy any fruit?
I love all the photos ! :)
AlbuqRay's Related Pages
Uyuni Travel Guide
Member Travel Pages
- "Uyuni Tour(3.650 m to 4.300m)"
- "Under the table in the Salar de Uyuni"
- "Uyuni and Details for 4WD Tours North and South"
- "The Great Salar and Lagunas Tour"
- "Uyuni and surrunding areas"
- "where tourists rules"
- See All...
- Things to Do in Uyuni
- Hotels in Uyuni
- Transportation in Uyuni
- Nightlife in Uyuni
- Restaurants in Uyuni
- Shopping in Uyuni
- Warnings and Dangers in Uyuni
- See All...
"Karma with free will: we earn our destiny by choosing among countably infinite eigenstates"
- Member Rank:
- 0 0 1 9 1
- Forum Rank:
- 0 0 2 0 6
- 1,795 Reviews
- 7,662 Photos
- Add Friend
- Follow
- Send Message
Badges & Stats in Uyuni
- 32 Reviews
- 124 Photos
- 35 Forum posts
- 8 Comments
- 4,643PageViews
- See All Stats
- See All Badges (69)
Have you been to Uyuni?Share Your Travels
Latest Activity in Uyuni
- Posted in Travel La Paz Forum "Re: Private guide"
- updated a Uyuni Travel Page "Uyuni and Details for 4WD Tours North and South"
- Uploaded a Photo to "When to Go to Salar de Uyuni"
- Wrote a Review When to Go to Salar de Uyuni in Uyuni Favorites
- Commented on one of annieruel's Uyuni travel pages
Photos in UyuniSee All Photos (124)
Top 10 Pages
- Top 5 Page for this destination Alice Springs Intro, 111 reviews, 574 photos, 7 travelogues
- Top 5 Page for this destination Northern Territory Intro, 64 reviews, 334 photos, 6 travelogues
- Top 5 Page for this destination State of Sarawak Intro, 57 reviews, 298 photos, 5 travelogues
- Top 5 Page for this destination Darwin Intro, 50 reviews, 286 photos, 7 travelogues
- Top 5 Page for this destination Albuquerque Intro, 72 reviews, 236 photos, 5 travelogues
- Macdonnell Ranges Intro, 41 reviews, 260 photos, 10 travelogues
- Uluru National Park (Ayers Rock) Intro, 45 reviews, 219 photos, 2 travelogues
- Top 5 Page for this destination Gettysburg Intro, 44 reviews, 213 photos, 3 travelogues
- Top 5 Page for this destination New Mexico Intro, 50 reviews, 199 photos, 1 travelogue
- Top 5 Page for this destination Mataranka Intro, 27 reviews, 215 photos, 11 travelogues


text:
In addition to credit cards, we also accept Paypal.
This item has been discontinued and is no longer available
Ordering for a Team?
Let our Team Division Help!
Item has a Minimum Qty
The Speedo Float Coach helps assist children float on their backs with comfortable flotation support.
Confusing Picture
From the picture, it looks a lot bigger than what it looked like in person. Also it isn't very adjustable. Had to give it to a friend, because it didn't even come close to fitting my daughter.
Lori P.
Greensburg, PA
Report abuse
Your comment has been posted.
Safe & good freedom of movement
First: great product! Our daughter loves it for jumping into the water and swimming around. It gives the arms the freedom to be moved freely and she is able to wipe water out if her face by herself.When putting it on, make sure the vest sits as high as possible. Ifthe vest sits too low, the kid will not float right and tend to switch over. This could stop the fun.Negative: the side connections under the arms are tight and cannot be loosened much. Safety reasons I guess. But this makes it hard and uncomfortable for the little one to get it put on or taken off.
Columbus, GA
Franklin Lakes, NJ
Very happy
Very happy with this product id recommend it to anyone that is looking for a great float:-)
Matthew O.
New York
Too small
They look nice, but are too small and we need to return them. We bought them for our 3-5 year old swim class. They look like they would fit a 2 year old but not older than that. Frustrating when things are not described correctly.
Brooklyn, NY
Not good
Very small!!
Jennifer S.
Pittsburgh, PA
Get an alert when we add new styles of Speedo! Simply sign up and we'll notify you.
The world's leading swimwear brand, Speedo is passionate about life in and around the water. The brand's heritage of innovation derives from its leadership in competitive swimming, where more Olympic Gold Medals have been won in Speedo than any other brand. Using the pioneering technology created for the planet's top swimmers, Speedo brings performance, comfort and style to all who enter the water, whether racing for a record finish, swimming laps for better health or making memories at the beach.
Our Performance Collection includes the competition and training suits that remain the number one choice of the world's fastest swimmers; our Fitness and Active Recreation Collections feature men's and women's swimwear, men's water shorts, and kids swimwear in fashion-forward styles that are designed to perform. And with Speedo's expanded range of Footwear, Packs, Aquatic Fitness and Swim Training Equipment, our Accessories Collection is unmatched in performance, fit and feel. No matter why you dive in – training, fitness or fun – those moments in the water are always better with Speedo.
On YourFirst Purchase


text:
President Obama "in the spirit of 2015 retiree David Letterman" releases a top 10 list for 2015. Did your issue make the list? Continue Reading →
Health Care
Recent Posts
Obamacare "Is Here To Stay" – Reaction To Supreme Court Ruling
"Five years in, this is no longer about a law. This is not about the Affordable Care Act as legislation, or Obamacare as a political football. This is health care in America." – President Obama Continue Reading →
Filed under: DC, Health Care, affordable care act, Barack Obama, obamacare, U.S. Supreme Court
GOP Leader Bends Truth In Claim About MNsure
Minnesota Senate Minority Leader David Hann stretched the truth a bit Monday as Republicans prepared to fly around the state to rev up their campaign to win back the House from the Democrats (DFL). Continue Reading →
Filed under: Health Care, Minnesota, Bill Walsh, David Hann, Minnesota, Minnesota Legislature, mnleg, MNsure
Fighting For Health Care that Doesn't Leave You Broke & Naked… An UpTake Profile: Elizabeth Frost
If Minnesota ever adopts a single-payer heath care system, the work of Dr. Elizabeth Frost will be remembered as one of the key reasons for its passage. Continue Reading →
Filed under: Health Care, Minnesota, UpTake Leadership Profile, Ann Settgast, david bly, elizabeth frost, health care, Jacob Wheeler
Cleaning Workers Ask Target, Other Firms to "Unlock" Future, Raise Pay, Benefits
Non-unionized retail cleaning workers walked off the job for a one-day strike Tuesday to protest what they say are cuts to pay and poor benefits. Continue Reading →
Filed under: Economy/Jobs, Health Care, Immigration, Issues, Labor/Unions, Minnesota, CTUL, Kmart
Half Native, Half Asian: All Service to the People…An UpTake Profile: DANIEL YANG
Daniel Yang is part of a new cohort of young leaders in the Native American community in South Minneapolis, a half-Native, half-Asian grassroots activist with a passion for public service and a special compassion for refugees. The experience of being lost, exiled and afraid is one his family knows well: Yang's father was a Hmong refugee who, along with his Ojibwe mother, instilled a commitment to social justice and community service in his son. Continue Reading →
Filed under: Economy/Jobs, Health Care, Indian Affairs, Minnesota, UpTake Leadership Profile, american indian movement, Bill Means, Brother Ali
2012 Homeless Memorial: Remembering Minnesotans Who Died on the Street
Every year, a silent march and vigil is held to honor those who died while living on the streets of Minnesota. More than 250 names were read at the Simpson United Methodist Church in Minneapolis during the memorial's 28th year in existence. Continue Reading →
Filed under: Economy/Jobs, Health Care, Minnesota, homeless, Homeless Memorial and VIgil, Homelessness in Minnesota, National Coalition for the Homeless, Simpson Housing Services
Quist Blames Workplace Killings On "Deterioration Of The Family"
Republican candidate for Congress Allen Quist blames the "deterioration of the family in the United States" for the mass killings committed by a mentally ill man last month at Accent Signage in Minneapolis. Continue Reading →
Filed under: CD1, Health Care, Minnesota, Accent Signage, Allen Quist, CD1, Debate Minnesota, Minnesota
Fear Of $100 Hospital Bill Delayed Life Saving Care
Minnesotans describe personal benefits of Affordable Health Care Act, now affirmed by the US Supreme Court. Continue Reading →
Filed under: Health Care, Minnesota, ACA, acha, health care, Minnesota, pre existing conditions, TakeAction MN
Immigrant Rights Committee Morns Loss of Walker Church Home
Brad Sigal, MIRAC (Minnesota Immigrant Rights Action Committee), describes his reactions to the fire that destroyed historic Walker Church in a May 27 fire. Continue Reading →
Filed under: Health Care, Immigration
Walker Church Tenants Say Fire Investigation Botched
Did someone intentionally torch the headquarters of several Minneapolis political and social action groups on Memorial Day? Tenants of the building are not satisfied with the city's apparent non-investigation into possible arson. Continue Reading →
Filed under: FBI Actions, Health Care, Immigration, Minnesota, Church Fire, immigrant rights, Minneapolis, police brutality
Fairview Hospital Workers: "Patients First Not Bottom Line"
Workers at Fairview hospital see there's a link between Fairview, a hospital that is being investigated for aggressive debt collection, and Wells Fargo, a bank that aggressively forecloses on people's homes. Continue Reading →
Filed under: Health Care, Labor/Unions, Fairview Hospital, health care, Minnesota, SEIU, Wells Fargo
Boisterous Protests At Local Banks Stay Non-Violent
Occupy coalesced activists from many neighborhood and civic groups to protest bank actions: Home foreclosures, refusing Somali funds transfer, voter photo ID, anti-immigrant actions. Continue Reading →
Filed under: Economy/Jobs, Health Care, Immigration, Minnesota, Occupy Movement, Voter Suppression, Bank, foreclosures
Minnesota Somali Women And Men Discuss Infertility Issues
Somali women and men gather to discuss the many aspects of female infertility with medical and social experts. Continue Reading →
Filed under: Health Care, Minnesota, Somalia, Infertility, Insuroon, jeff hayden, Minnesota Somali, Somali
MN Welfare Bill Improved After Citizen Pressure
Most punitive and draconian welfare provisions removed from final bill after citizen pressure. Continue Reading →
Filed under: Economy/Jobs, Health Care, Minnesota, Deb Konechne, Mary Franson, Minnesota Legislature, Welfare, Welfare Rights Committee
A Life Saved By MN's Emergency Medical Assistance
Governor Dayton restored money to Emergency Medical Assistance, which helps some of Minnesota's sickest regardless of their immigration status. Minneapolis resident Luis Fuentes is a testament to that. Continue Reading →
Filed under: Health Care, Minnesota, Emergency Medical Assistance, Mark Dayton
MN Temporarily Restores Some Medical Care For Non-Citizens
Minnesota's Governor signs legislation that restores some funding for some emergency, life-saving services for the sickest Minnesotans, regardless of their citizenship status. However, the law still restricts the program from helping undocumented immigrants pay for some life-saving care. Continue Reading →
Filed under: Health Care, Immigration, Minnesota, Emergency Medical Assistance, immigration, Mark Dayton
MN GOP Healthcare Plan "Not Vetted" Says DFL
Minnesota House Democrats complain not only about the content, but also about the how a Republican health care plan was brought to a floor vote during a rare Saturday session. Continue Reading →
Filed under: Health Care, MN House, MN House Live, health care, joe atkins, Minnesota, mnleg, obamacare
MN GOP Denies it Copied Health Care Bill From ALEC
House DFLers offered evidence that Republicans have "cut and pasted" model legislation from the American Legislative Exchange Council (ALEC). ALEC has come under fire the past month as several large corporations have pulled out of it. Continue Reading →
Filed under: Health Care, MN House, ALEC, American Legislative Exchange Council, health care, Minnesota, mnleg, Steve Gottwalt
'Don't' Mess With My Momma's Medicare'
A bill that would ask Congress to let Minnesota keep the health care dollars it sends to the federal government passed the MN state house 70 to 59. Opponents argued it would "mess with" Medicare. Continue Reading →
Filed under: Health Care, MN House, ALEC, American Legislative Exchange Council, health care, Minnesota, mnleg, Steve Gottwalt
Abortion Bill Sparks Passionate Debate in MN House
A bill requiring a doctor to be present when a woman takes an abortion pill such as RU-486 won approval in the Republican-controled Minnesota State House after a passionate debate. Continue Reading →
Filed under: Health Care, MN House, abortion, anti-choice, Pro-Life, ru-486
How Did MN Cut Off Immigrants From Life Saving Health Care?
Representative Karen Clark traces the history and deadly consequences of the severe cuts made in Emergency Medical Assistance in the wee hours of the last legislative session. Effect did not come to light until late 2011. Continue Reading →
Filed under: Health Care, Minnesota, chemotherapy, Dialysis, EMA, Emergency Medical Assistance, Immigrants, Karen Clark
At Least One Death From Legislative Cuts To Emergency Medical Services
The drastic cuts in Emergency Medical Assistance by the 2011 special session of the Minnesota Legislature has resulted in at least one death. Continue Reading →
Filed under: Health Care, Minnesota, EMA, Emergency Medical Assistance, Kaen Clark, Minnesota, Minnesota Legislature
Peace At Planned Parenthood On Good Friday
Planned Parenthood supporters and pro-life demonstrators meet at the new St. Paul office of Planned Parenthood for the annual Good Friday demonstrations. Continue Reading →
Filed under: Health Care, Minnesota, anti-abortion, Planned Parenthood, Pro-Choice, Pro-Life, St. Paul MN, Woman' Right to Choice
EBT Card: Fraud or Confusion?
Rules for issuance and use of EBT (Electronic Benefits Transfer) Cards explained and comments on the final Welfare Bill. Continue Reading →


text:
Real news. Real funny.
Real news. Real funny.
If you can read this, either the style sheet didn't load or you have an older browser that doesn't support style sheets. Try clearing your browser cache and refreshing the page.
NO headlines found matching 'Margaux Tocci'
NEW To Fark? Find Out HOW TO FARKX
Displayed 0 of about 947 links -- join TotalFark to see them all
Submit a Link »
In Other Media
Stories from our partner sites:
Man Rescued After 2 Months At Sea Ate...
Think You're Having A Bad Day? Watch...
Boaty McBoatface Loses Out On Ship Na...
Internet Agrees That 'Hottest Cop' Is...
More news at HuffPostWeirdNews »
London Poised to Get First Muslim Mayor
Jamie Lee Curtis: I, Too, Was Addicte...
Internet Goes Crazy for Timberlake's...
The Top 10 Baby Names Revealed
More news at Newser »


text:
I am planning to throw a party for LO's first birthday and I can't even decide who to invite. I take LO to various different playgroups (library, meetup, etc.) and met a few moms/babies that I would consider inviting. However, I am not sure if I should because 1. our place is small so we can't accommate too many people (but I can probably find another place if need be), 2. since the moms/babies are from different groups, it's not like they would know each other, so they might be uncomfortable? 3. I am not sure how to deal with mixed groups (moms/babies, families, friends, including single ones).
I keep hearing that the 1st birthday is really for the adults because babies don't know birthdays... Who are you inviting? Is it odd to invite playgroup mom/babies? Should I just stick with families and friends only?
I am running out of time! Yikes!


text:
Robert Driscoll Garrett
Position: QB
Height: 6-1 Weight: 198 lbs.
Born: August 16, 1932 in Los Angeles, CA
Died: December 5, 1987 in Westminster, CA
High School: South Pasadena
College: Stanford (school history)
Drafted by the Cleveland Browns in the 1st round (1st overall) of the 1954 NFL Draft.
Weighted Career AV (100-95-...): 0 (15060th overall since 1950)
Promote your website or business by sponsoring this page for $5 on Pro-Football-Reference.com. Your message will replace this ad.