text:
- PakistanRetailFunding via Kashf Foundation
FaithKenyaRetailFunding via VisionFund Kenya
Dina Auxili...NicaraguaRetailFunding via MiCredito
Roberto Etanislado
Don Roberto is known as a hard worker who fights for his children so that they lack nothing. With the loan requested from AFODENIC, he will purchase construction materials needed to install a lavatory so that his family can experience improved hygiene and better living conditions. His dream is to continue making these types of improvements for his family.
Additional Information
About AFODENICThis loan is administered by AFODENIC, La Asociación para el Fomento al Desarrollo Nicaragua, a Kiva Field Partner based in Managua, Nicaragua. Founded in 1999, AFODENIC was created to promote the socio-economic and cultural development of sectors that are excluded from commercial banking. Integrating economic and human resources, AFODENIC offers affordable and adaptable financial services aimed at strengthening the family unit of their clients, who include students, producers, and micro- and small entrepreneurs from rural and urban areas. AFODENIC is a socially responsible institution engaged in society and making a positive impact on its professional partners and communities.
Supporting a borrower through AFODENIC contributes to the pursuit of innovation in mitigating poverty in Nicaragua. Visit AFODENIC's partner page for more information.
About Housing Loans
Many poor families cannot afford housing that meets their needs. When you make a housing loan on Kiva, you give people access to flexible capital to obtain or improve their homes. Better housing means better health, sanitation, and even educational outcomes for children. A house can also be much more for entrepreneurs who run businesses out of their homes. In this way, housing and small business loans on Kiva share a common purpose: to alleviate poverty and enable families to enjoy more stable lives.
About Nicaragua
71View loans »
Success!! The loan was 100% repaid
- Repayment Term
- 14 months (Additional Information)
- Repayment Schedule
- Monthly
- Pre-Disbursed:
- Jan 20, 2010
- Listed
- Jan 20, 2010
- Currency Exchange Loss:
- Covered
- Ended:
- Feb 15, 2011


text:
Posts from Knives & Cutlery
Video: How To Dice an Onion
Video Tips from The Kitchn
Dicing onions: one of the most elemental tasks in the kitchen. Have you ever wondered whether you're doing it right? Watch our super-short video tutorial on dicing onions; it will give you a couple of pro secrets for chopping onions quickly, safely, and neatly!
The GIF Tutorial That's Helping Me Improve My Knife Skills
Kitchen Diaries: Kate in New York City
When I worked as a server after college, if I wasn't ferrying glasses of vino to guests on the floor you would likely find me back in the kitchen, leaning over the window and chatting with the cooks. Besides hearing a handful of very NSFW stories, it was here that I learned one of my greatest lessons in the kitchen — how to actually hold a knife.
10 Places To Hang a Magnetic Knife Rack
Recently a friend told me she'd bought a magnetic knife strip ages ago but had yet to hang it in her kitchen because she didn't know where to put it. Sound familiar? If you can relate, it may surprise you to know that there are plenty of ways and places to hang a knife rack around the kitchen. Here are 10 ideas for starters:
All Things Olive Wood for the Kitchen
Product Roundup
The nutty brown color and intricate wood grain make olive wood one of the prettiest woods you can have in the kitchen. I have a serving board similar to the one shown above, and it always makes for a great presentation. If you love the look of olive wood as well, there are plenty of kitchen accessories that make the most of this rich wood, including salt cellars, spoons, and even a citrus press!
Help! How Do I Clean Sticky Residue Off My Knife?
Good Questions
Q: I recently bought a beautiful Global santoku knife. I am always careful to wash it by hand and dry it immediately after. Yesterday, though, I cut up a butternut squash and let the knife sit for an hour or two. Upon washing it carefully with hot water and dish soap, there is still a residue. Help!
Win a Wüsthof & Microplane Knife & Grater Collection
Holiday Giveaway from The Kitchn
This is the season for giving and receiving, and every year we extend our thanks to you, our fabulous readers, with a set of giveaways. This year we narrowed the list of goodies down to just five of our all-time, hands-down favorites. Every cook needs a good knife (or two) so today's big gift is a collection of some of our personal favorite knives and accessories from Wüsthof and Microplane, including a stellar chef's knife and the only bread knife you'll ever need.
Can You Help Me Find a Small, Inexpensive Knife to Keep at Work?
Good Questions
Q: I often cut up apples, carrots or fresh herbs at the office. The kitchen has HORRIBLE knives and I am afraid one of these days I'll cut myself badly. Can you suggest an inexpensive knife that I could store in my desk that either wouldn't need lots of care/sharpening or is compact and secure enough to bring back and forth between my kitchen (to hone it) and work?
Sent by Shayna
Is It Bad Luck to Give a Knife as a Gift?
We always include knives in our gift guides; from the splurgy to the economical, a good knife is almost always a practical and welcome gift. But there are some people who would object to this, saying that it's bad luck to give a knife as a gift. Have you ever heard this, and are you superstitious about gifting knives? If so, there's one little custom that you should follow...
Chefs Catalog
Store Profile
Have you heard of CHEFS catalog? I'd venture that you almost certainly have, since the company has been selling upscale, high-quality cookware, bakeware, and all manner of kitchen utensils and tools since 1979 — first by mail-order only via their catalog, and now through their extensive online site and brick-and-mortar store in Colorado Springs. Their tagline pretty much says it all: "The best kitchen starts here."
Good Questions
Q: My last peeler broke, and since then, I've bought three others...and they're all awful! The serrated one barely takes anything off the vegetable (though it's fantastic at taking skin off my fingers), and the non-serrated ones are ineffectual. Last night's butternut squash was the last straw — I need help finding a strong and effective peeler!

subset: commoncrawl


text:
Usually Ships in 1-5 Days
Alluring, provocative, and enlightening, "Nothing but the Truth So Help Me God" reveals the powerful and positive aspects of female relationships. From the online social network for all women, A Band of Wives, this book brings together essays, poetry, and artwork that will change the way people look at the women in their lives.
About the Author
Christine Bronstein is the founder of A Band of Women, is a style blogger at 39nineteen, and is an essayist, editor and publisher for Nothing But the Truth. Her work has appeared in The San Francisco Chronicle and on The Huffington Post, Forbes.com, and Maria Shriver's website.


text:
Thursday is Feature-Freeze for Ubuntu 9.10
Whoever wants their favorite features integrated into Karmic Koala will have to hurry. From Thursday, the impending Ubuntu will accept no more changes.
The feature freeze primarily concerns developers and maintainers of single packages. Any large changes will have to be made in the source code by Wednesday, latest, writes Steve Langasek on the Ubuntu Announce List. Package changes after the deadline will have to be filed as bugs in Launchpad.
The last few days before the freeze have seen Ubuntu developers buzzing about the Pidgin issue. The free instant messenger has been replaced by Empathy in the new Ubuntu 9.10.- a decision that has not pleased all Ubuntu users. The latest version of Pidgin now comes with web cam support, a feature that has always given Empathy the edge over Pidgin. So, until Thursday, there is still a slim chance that Pidgin may well remain the default IM client, with Empathy waiting eagerly in the wings.
Issue 187/2016
Buy this issue as a PDF
Linux is the Largest Software Development Project in History
But if you are not using the latest Linux kernel, your system is insecure.
Linksys Says Yes to Open Source Firmware
Home routers will give room for custom firmware but still comply with FCC rules
OwnCloud Founder Resigns
Frank Karlitschek will continue to lead the open source ownCloud project
Ubuntu 16.04 LTS released
"Xenial Xerus" comes with a new packages format and several improvements for the enterprise.
MS Visual Studio Code Editor is Available for Linux
Linux users can now download and install the Windows code editor
Open Container Initiative announces Image Format Project
New initiative will address security and interoperability concerns around container technology.
Red Hat Lures Developers with Free RHEL and Container Development Kits
Developers can use RHEL as a development platform without a subscription fee.
Microsoft Brings the Linux Command Line to Windows
Windows users will soon have native access to the Bash shell.
Internet Research Group Proposes Better Email Standard
Improvements to SMTP will provide better guarantee of confidentiality
New Nvidia Driver Offers Wayland Support
Graphics vendor embraces new reality in Linux graphics


text:
Since haviny my ods my cycles have been 40 and 45 days.
This is our first month ttc and I'm currently in my (assumed) 2ww on CD 33.
I didn't track ovulation AT ALL and now I'm kicking myself for it. I'm driving myself crazy trying to guess when I o'd and when I should test.
Just wondering if any of you have long cycles similar in length to 40-45 days and on what cd you ovulated?!
I know everyone is different I'm just curious to hear!


text:
Media file downloader
** This ONLY WORKS on the normal video / audio objects (embed, object, HTML5 video / audio tags)
** This doesn't work on Youtube video
This extension grabs all video or audio files (such as wmv, asf, avi, mp4, etc) from the current web page, and provides you list of download links.
You can simply click the download link to save the files on your computer.
--- Change Log ---
Version 2.0
- Support Vimeo download!
Version 1.4
- Multiple video file supports
- Download icon will not appear if no file found
- Bug fixes for flash(.swf) files
Version 0.3
- Improved the file recognition algorithm


text: "Richard W.M. Jones" <rjones redhat com> wrote: > On Tue, May 20, 2008 at 03:51:53PM +0100, Daniel P. Berrange wrote: >> +if GLIBC_RPCGEN >> + mv $@ $ bak >> + sed -e 's/\t/ /g' $ bak > $@ >> +endif > > I guess it doesn't matter in a generated file, but is the above > correct? Probably better to use the 'expand' command, if it is > available. Thanks for bringing that up. While I don't know how portable expand is, (I've never used it in a portable build script or Makefile) it's certain to be less portable than sed. However, (to my constant chagrin) \t is not portable in sed regexps. Makes me want to use perl -pe 's/...//' FILE instead. With Perl, "\t" *does* work portably. On the other hand, maybe using perl (or expand) would be ok here, since the only time an end user runs those rules is if/when they modify a dependent .x file. Otherwise just use a literal TAB character.


text:
cutlass is a Node.js module / JavaScript library for parsing and dealing with ASS subtitles.
Installation is simple with npm:
$ npm install cutlass
cutlass exports an object with four classes: Script, Event, Style and Color. The one you usually want to deal with is Script, which represents a whole ASS script. (For more detailed info about the classes and the functions and properties they export, refer to
src/parser.ls for the time being.)
var ass = require'cutlass';var rawAss1 = "..." // pretend this is a full ASS script read from disk var rawAss2 = "..." // this too var script1 = rawAss1; // sort the script by event start time script1sort; // get the script as raw ASS var rawScript1 = script1toAss; var script2 = rawAss2; // for this script, we want to move all lines with the style "Sign" to the top. // `script.events` is a plain JS array, so we can use them our purpose here. var signs = ;var dialogue = ;for var i = 0 len = script2eventslength; i < len; ++i var line = script2eventsi; if linestyle === "Sign" signspushline; else dialoguepushline; script2events = signsconcatdialogue; // get the script as ASS var rawScript2 = script2toAss;


text:
Hello. I am using this plugin and it works well, but since I installed it my site title and tagline appear written twice. Something like this:
Cooking with my soul | retete de sufletCooking with my soul|retete de suflet
I tried replacing in header.php with <title><?php wp_title(''); ?></title> but it didn't work. Can you help me? I really like this plugin.
My site adress is http://www.retetedesuflet.ro/


text:
(Illustration for a children's book of horror stories)
Thank you all for the comments, I appreciate it
Thank you all for the comments, I appreciate it
Reminds me of Scary Stories to Tell In The Dark (which is gonna be a movie! )
This would go well on a terrorcore album cover.
I really like the style.
You know, if much imagination from my mind comes to what I think this picture looks like, I'd say that this creature looks like an Angler Fish. They have the big sharp pointy teeth, have those funny looking eyes and have a little light on them that attracts their victims to them. So the Angler Fish is just as scary looking as this in my opinion
Watch out for the Heffalumps and Woozles!!! Beware! (Awesome picture, though)
Yup, I still have the Adventures of Winnie the Pooh on VHS. The Heffalumps and Woozles nightmare did kinda creep me out
wonderful! my goodness what big teeth a Woozle has!
it looks like it is a child itself
O.O that's really scary... but great job!
~They ties themselves in horrible knots, they come in stripes and polka dots!
Hehe cool
Now that's just epic.
screamed so loud he spit
the stark white and big sharp teeth all in that huge smile, would terrify me as a child!
It's so curious
This is way too cute for something that looks like a Grue's big brother.
Perfect for a kid's book. Scary-looking, but so lovably happy they'll think it's kinda funny, too.
Perfect for a kid's book. Scary-looking, but so lovably happy they'll think it's kinda funny, too.
all the stuff you post, its so interesting and i love it all.. even though i dont really show it by favoriting it. but its all so woah and i love it all.
If that's a woozle, where's a heffalump?
Those teeth! It's been a while since I looked at your work too It looks like you improved a lot! Keep it up ^^
Sexy... lol...
Heffalumps and Woozles, I knew they exists!!! Lol XD
...something so simple....
and i'm going to now have night terrors.
What book is this from? I'd love to look it up and read it!
This is a snapshot of the inside of my head LOL!
now i really wanna read this book
now we just need hephelumps to go with the woozles.
all I can think of is tigger talking about how they steel honey from Pooh Bear
Dude, this is effin insane. Great job!
My favorite one!
This one is pretty cute! It'll help the kids get over the nightmares from the other pictures I guess ;;;
This is adorable
I love this!
Reminds me of Shel Silverstein.
That is brilliant. I used to read children's horror stories, and this would fit right in!!!
What is this children's story book you mention. I would like to know for future reference.... and nightmares.....
woah. freaky, but cool!
This looks like really interesting, very nice.
Nicely drawn.
Wow cool
Awesome front cover for a book !
That is amazing
My first impression of this was that it was for kids and I was right! Its a perfect balance for young children: Not too scary but still enough to let you imagine...
So funny and sweet! Children will love it!


text:
These remind me of the Capitals line's New York model in bi-colour.
I wouldn't even buy the real deal if they were $200, but that's another thing...
With the seller feedback they house, I would not touch them.
wow,this guy has many brand new valextra for auction
new stuart's choice 8D


text:
Should I be taking Tamiflu if I am Pregnant?
- Posted:
- 3 Nov 2009 by aquanaut
- Topics:
- tamiflu, influenza, avian influenza, pregnancy, swine influenza
Answers (1)
4 Nov 2009
During pregnancy, there is an increased risk of complications from influenza, including swine flu, especially in the last 3 months of pregnancy.
The drugs used to treat swine flu, including Tamiflu, have not been around for very long, so there is little data (as of Nov 09). According to many sources, they have been used by pregnant women, and have not been found to harm mothers or their babies.
You should always consult your doctor before taking any medications while pregnant.
More about swine flu medications here...
More about Tamiflu (oseltamivir) and pregnancy is here...
Further Information
- Tamiflu Information for Consumers
- Tamiflu Information for Healthcare Professionals (includes dosage details)
- Side Effects of Tamiflu (detailed)
Search for questions
Still looking for answers? Try searching for what you seek or ask your own question.
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I have enflueza a and took tamiflu how long should my symptoms last?
0 answers • 12 Mar 2016


text:
UMD dean announces retirement plans
Duluth, MN (NNCNOW.com) - The dean of the Swenson College of Science and Engineering is retiring after 14 years at UMD.
UMD manages to slash budget deficit in half
Duluth, MN (NNCNOW.com) - The University of Minnesota says plans to tackle a $9 million budget deficit are working faster than expected.
Saphire Brown brings anti-bullying message to Carlton through music
Carlton, MN (NNCNOW.com) - As an anti–bullying bill makes its way through the Minnesota legislature, Carlton High School dedicated this week to making their school a safer, bully–free place for their students.
Anti-bullying legislation clears first hurdle in MN Legislature
St. Paul, MN (NNCNOW.com) - The Safe and Supportive Schools Act received the green light from the Senate Education Committee after several hours of testimony and language tweaks.
Duluth snow angels aid homeless youth at UMD
There are those who believe that angels steer our lives and those who believe we become angels ourselves by helping others. Hundreds of those people dropped to the ground today to make snow angels that help the homeless. Dave Anderson puts us in touch with the young people who got the event going.
Discussion tabled to extend duluth school district school year
Duluth, MN (NNCNOW.com) --- This winter's polar vortex has caused a whole mess of problems for the Northland...especially for school districts. So far this winter the students in the Duluth school district have missed seven days of school, calling for makeup days at the end of the year. However, at a school board meeting tonight board members decided to table the discussion.
UMD discusses university's budget reduction plan
Duluth, MN (NNCNOW.com) --- University of Minnesota Duluth Chancellor Lendley Black announced Monday that the college needs to reduce its budget by $9.4 million.
MN high school graduation rates highest in a decade
St. Paul, MN (NNCNOW.com) - State and education officials say 79.5 percent of the state's high schooler's graduated in 2013.
Students celebrate reading at Piedmont Elementary School
Duluth , MN (NNCNOW.com)--- Students at Piedmont Elementary School in Duluth were hitting the books Tuesday as part of national "I Love to Read Week".
Speak Up Speak Out Curbing bullying takes a community
Duluth, MN (NNCNOW.com) - One in three students says they've been bullied during the school year. More than half don't ever report it. And in today's digital age, it doesn't always happen in our hallways. So where do we even begin to curb the problem?


text:
London - For Roman Abramovich, the painful irony is that, on the day he handed Liverpool £50 million for Fernando Torres, this was the sort of afternoon he was hoping to avoid.
The one in which Chelsea dominate, yet fail to close the deal. The one in which chance after chance slips away. The one in which the old warrior, John Terry, is forced to do the job the forwards cannot.


text:
Hardy, Har, Har this be a nice thank you card says me! The Pirate Personalized Thank You Note are 5x7 cards that feature a cute picture of a pirate and a custom message area.
Hints: Your text will automatically align in the Preview when typing, use the Enter key to create a new line.
Not yet rated. Be the first to Write a Review


text:
I Question the industry practice of placing the pipe so close to the outside and especially of doubling up the pipe in front of doors. Since the theory of heat is ;Heat travels to cold and the greater the difference between the two the faster the heat will travel. Therefore the greater the heat loss to the outside. I have had customers complain they can not afford to heat their home . One customer with in floor heat in his garage had enough heat loss that the snow melted off the pavement for a distance of about 5 ft. The only explanation I have seen is that they sell in floor heat by the fact that the floors are warm and they can not afford to have any area that may be cool .
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- Assembly Required: 15 DIY Kit Homes
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- 10 "Zero Dollar" Garden Hacks
- 10 Killproof Plants for a No-Effort Landscape
- 9 Insanely Easy 1-Hour Backyard Projects


text:
Employment Law This Week: Defend Trade Secrets Act, Final Overtime Rule, Leave for Disabled Workers, OT Exemption Case
Employment Law This Week: Trade Secrets, Banker Bonus Restrictions, Musicians Are Employees, Misclassification Violates NLRA
Employment Law This Week: $15 Minimum Wage, Dodd-Frank Whistleblower Provision, Transparency in Non-Competes, Protected Activity Under NLRA
Employment Law This Week: Equal Pay, Union Fees, Negative Publicity by Employees, "Commissions" Under FLSA, F-1 STEM OPT Program
Rachelle Dubow on Dealing With Trademark Hijackers In Cuba
Employment Law This Week: Sexual Orientation Discrimination Suits, Tip Pooling, Successor Liability, Trade Secrets, Workplace Solicitation
Employment Law This Week: EEOC on Position Statements, Hispanic Ruled as Race, NLRB on Computer Use, Big Data Privacy, Tip of the Week
FCPA Compliance and Ethics Report-Episode 239-Jonathan Armstrong on EU Privacy Shield
Medical Apps and Devices: The Convergence of FDA, FTC, and State and Federal Regulations
FCPA Compliance and Ethics Report-Episode 221, May the Podcast Be With You Part II-The Empire Strikes Back
Employment Law This Week: FLSA Lawsuits, Restrictive Covenant, PAGA Waiver Ruling, Title VII Claim
Employment Law This Week: Wellness Programs, Arbitration Agreements, Class Action Waivers, Non-Competes
Employment Law This Week – Episode 2
Making Them Pay: Winning Attorney Fees in Patent Litigation
What can I do if someone posts mean things about me online?
FCPA Compliance and Ethics Report-Episode 184-Marc Bohn on the Mead Johnson FCPA Enforcement Action
FCPA Compliance and Ethics Report-Episode 182-Kate Atkinson on the Miller Chevalier Summer 2015 FCPA Report
Polsinelli Podcast - Federal Circuit Delays Sandoz Biosimilar Launch
Talking PTAB with Bob Steinberg
Indefiniteness Before the PTAB
Earlier this year, US President Barack Obama welcomed Canadian Prime Minister Justin Trudeau and his delegation, the first official visit by a Canadian PM to the US in nearly two decades. By mid-summer of this year, the two...more
The Australian Renewable Energy Agency's (ARENA) funding priorities for new investment represent an area of opportunity for the mining industry. While investment in clean technology may, on the surface, seem at odds with the...more
A new "green" attitude is pervading Taiwan. Besides ongoing environmental efforts, Taiwan is home to multiple green technology companies. While revenue results for some Taiwanese solar cell manufacturers declined this year,...more
In This Issue:
- Trade Promotion Authority Bill Advances
- The U.S. Crude Oil Export Ban: An Outdated Relic Of The Past
- Rocky Road Ahead For FY2016 Appropriations Bills
- Banking Committee...more
In This Issue:
- Main Article:
.. Inter Partes Review and the ITC: The Benefits and Risks of Filing IPR on Patents Asserted in an ITC Investigation
- Noted With Interest:
.. Securities Act Claims...more
In This Issue:
- President Obama Presses For Advancement Of Trade Deals During State Of The Union
- U.S. Sanctions Updates
- Keystone Pipeline Debate Continues After Congress Approves Bill
News Of...more
In This Issue:
- Mexico: E&P Regulator Issues First Call for Bids under Round One
- Have the Challenges of the Energy Transition been Overcome?
- Challenges for energy security in Europe: Do European...more
Multiple projects are currently underway to demonstrate feasibility of fusion energy. The goal of the ITER multinational project in southern France (of which the United States is a participant) is to deliver ten times the...more
As you may know, the blog posts are getting longer and longer as more trade and other actions take place against China. Because of the length, I, therefore, am breaking this post into two parts. This first post covers Trade,...more
The Economist recently reported on a World Intellectual Property Organization study that the number of Chinese patents filed abroad is rising. China's patent office was the busiest in the world in 2012. Coupled with this...more
The recently released Global Cleantech Innovation Index 2014 suggests that despite its strength in innovation, Australia is at risk of being left behind as much of the rest of the world forges ahead with investment in...more
Department Of Energy Issues Final Approvals For LNG Exports To Non-FTA Countries From Two Terminals -
On September 10, 2014, the U.S. Department of Energy (DOE) issued licenses to Cameron LNG and Carib LNG to export...more
Innovation in the oil and gas industries, as measured by the number of patent filings, is increasing worldwide. As reported by Thomson Reuters, from 2012 to 2013 the number of patent applications filed worldwide increased by...more
In This Issue:
- Editorial
- About our Mining Sector
- Seismic Shift
- A Whole New Ball Game – Coal Sales in China
- OHADA – What Foreign Investors Need to Know
- Breaking the Drought – the...more
Colombia has issued its list of tax havens – an act that will negatively impact the tax effects of doing business in Colombia...more
In This Issue:
- The President's Climate Action Plan - Mixed Messages for the Energy Sector
- As Coal Exports Hit Record Highs, Interior Inspector General Questions Lease Valuations
- U.S. Supreme Court Agrees...more
In This Issue:
- Oil & Gas Litigation: New Decision May Impede Fracking on Federal Land
- Intellectual Property: Non-Practicing Entities (Patent Trolls) Target Oil and Gas...more
Just over a year ago, President Obama signed the America Invents Act (AIA), signalling one of the most significant revisions to U.S. patent law since 1952. As intellectual property in general, and patents in particular, are...more
Originally published in 9-10/2011 China IP, www.chinaipmagazine.com.
The U.S. Supreme Court's decision in Bilski ensures that the door to patenting business method inventions remains open in America. This ends...more
Find an Intellectual Property Author »
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This Animal Mix N Match by Edushape encourages your child to learn through play. Consisting of 46 pieces of colored foam shapes and animals, it encourages development of motor skills. Your child will learn to recognize colors, shapes and animals with this fun set.
Manufacturer's Suggested Age: 2 Years and Up
Educational Focus: Motor Skills, Shapes and Colors
Number of Players: 1 or More Players
Number of Pieces: 46
Dimensions: 12.000 H x 2.000 W x 12.000 L
Product Weight: 13.600
Care and Cleaning: Wipe Clean with Soap and Water
Battery: no battery used:
Assembly Details: assembly required, no tools needed
other Info.
- Online Item #: 13563474
- Store Item Number (DPCI): 204-10-1651
- Imported


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Jim Joyner, Pharm.D., C.G.P.
CMS has established very restrictive regulatory criteria for the use of Haloperidol and other psychotropic drugs for patients who reside in the SNFs. These criteria include restrictions on indications for use, duration of therapy, daily dose limits, monitoring, and more. The information is spelled out in F-329 Unnecessary Drugs (CMS Skilled Nursing Facility Regulations). The regulations are intended for nursing home patients who are NOT being treated under "end of life care" and this is clearly spelled out in F-329.
F-329 Unnecessary Drugs contains specific language that provides an exception to the specific criteria for antipsychotic drug use (including Haloperidol) for hospice patients in the SNF. Subsection 483.25 (l) in this F-tag contains an extensive table (Table 1) which lists examples of numerous medications for which CMS is concerned about, including all antipsychotic drugs. At the end of this extensive table is a section titled, simply, "Exception". Here is the exact language:
This means that when Haloperidol (or any antipsychotic drug) is being used for managing symptoms at end-of-life in the SNF, the regulatory criteria on max dosage, duration of therapy or related issues do not apply. Haloperidol is used extensively in hospice and palliative care for management of terminal delirium, severe agitation of end-stage dementia, and for management of nausea – vomiting. It is highly effective for these indications and generally well tolerated in many hospice patients, however in many cases, doses greater than 2 mg per day are required and are clinically appropriate. Haloperidol is recommended as a drug of choice for terminal delirium by several well respected palliative care experts and organizations (references available upon request if you need them).
Make sure that the patient's health record clearly indicates that the patient is under hospice for 'end of life' care.
|Thank you! We've been getting pushback from NH Facilities recently on what would normally be considered mild dosages for a hospice patient. I've passed out copies of this to all our Nurses.
-- Allen
Posted 5/20/2016 07:13:16 AM
|How does this relate to the more recent CMS initiative to decrease anti-psychotic use in LTCFs by 15%? We have facilities whose star ratings are being affected by the use of Haldol for N/V. Additionally, a patient cannot utilize the hospice benefit and the SNF benefit simultaneously so wouldn't that immediately eliminate our patient population?
-- Jess Smith
Posted 5/2/2016 12:56:58 PM
Jennifer Chen, PharmD, CGP
SGLT2 inhibitors
Last year, the FDA released a drug safety communication, which cautioned the use of SGLT2 inhibitors, due to case reports of ketoacidosis in patients who were being treated with these medications. Recently, the FDA has updated the labels for SGLT2 inhibitors to include the risks for both ketoacidosis and serious urinary tract infections. Patients in these case reports were found to start with urinary tract infection, which then progressed to potentially fatal urosepsis and pyelonephritis that required hospitalization or dialysis to treat kidney failure. Patients who continue to take these medications should be taught to recognize the symptoms of ketoacidosis, which include nausea, vomiting, abdominal pain, fatigue and difficulty breathing. Ketoacidosis can occur even if their blood glucose is not excessively high. Patients with suspected ketoacidosis should stop taking the SGLT2 inhibitor and receive treatment promptly. Clinicians are encouraged to report any side effects to the FDA MedWatch program.
SGLT2 inhibitor is a class of diabetic medication that works by stopping glucose from being reabsorbed into the blood. Medications in this class include Invokana (canagliflozin), Farxiga (dapagliflozin), and Jardiance (empagliflozin).
The FDA imposed the Risk Evaluation and Mitigation Strategy (REMS) for rosiglitazone-containing type 2 diabetic medications in 2010 due the concern of possible increased cardiovascular risk. It required healthcare providers to obtain a special certification in order to prescribe rosiglitazone and patients receiving rosiglitazone must be enrolled in the REMS program. In 2013, the FDA lifted the restrictions for the prescribing and use of rosiglitazone based on the data from RECORD (Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes) trial. The RECORD trial demonstrated no elevated cardiovascular risk. Recently, the FDA has lifted the entire REMS requirements for rosiglitazone-containing medications, which includes Avandia (rosiglitazone), Avandamet (rosiglitazone-metformin) and Avandaryl (rosiglitazone-glimepiride) on the basis of post-marketing data and the RECORD trial. However, most of these medications have either been removed from the market (Avandamet and Avandaryl) or are rarely used in patients (Avandia).
The FDA gave final approval in December 2015 to Basaglar (a copycat version of insulin glargine). Basaglar was not approved as a "biosimilar" product although it was demonstrated to be similar enough to another insulin glargine on the market (Lantus) regarding its effectiveness and safety. It is administered subcutaneously with the manufacturer's KwikPen injector once daily at any time of the day. Being as the first "follow-on" insulin glargine product, Basaglar received much attention for potentially lower costs. Basaglar has already launched in the UK under the brand name of Abasaglar and is priced 15% lower than Lantus (listed price of £35.28 for Abasaglar and £41.50 for Lantus according to UK Medicines Information). Pricing for Basaglar in the US is unknown at this time and the drug will not be available until after December this year.
1. FDA. FDA Drug Safety Communication: FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. http://www.fda.gov/Drugs/DrugSafety/ucm475463.htm Accessed on January 10, 2016.
2. FDA. Rosiglitazone-containing Diabetes Medicines: Drug Safety Communication - FDA Eliminates the Risk Evaluation and Mitigation Strategy (REMS). http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm477601.htm Accessed on December 28, 2015.
3. FDA. FDA approves Basaglar, the first "follow-on" insulin glargine product to treat diabetes. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm477734.htm Accessed on December 28, 2015.
Esther Liu, PharmD, MSIA, CGP
The Center for Medicare and Medicaid Services (CMS) released a new online dashboard that contains some interesting analyses of Medicare Part D drug utilization. The new dashboard presents drug data collected from Medicare Part B and Part D providers from 2010 to 2014. In an analysis of the top 15 drugs by total annual cost for Medicare Part D 2014, 10 out of the top 15 high cost medications are drugs that commonly show up on newly admitted hospice patients' medication profiles. The remaining 5 medications are all specialty medications used for chemotherapy, immunotherapy or hepatitis C treatment. These 5 medications are curative in nature and are not typically encountered by hospice providers.
The 10 high cost drugs identified by the analysis are Nexium, Crestor, Abilify, Advair, Spiriva, Lantus, Januvia, Duloxetine, Lyrica, and Namenda.
Outcome Resources also targets these medications for our hospice providers in patient medication reviews and monthly drug utilization reviews. Many of these can be switched to a more cost-effective alternative or safely discontinued at the end of life. Below are the common recommendations provided by Outcome Resources clinicians to manage hospice patients who are on the drugs listed above:
If you are interested to learn more about the Medicare Drug Spending Dashboard 2014, the direct link is: <https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Medicare-Drug-Spending/Drug_Spending_Dashboard.html>
Jennifer Chen, PharmD
Proton pump inhibitors (PPIs) and histamine H2 antagonists (H2 blockers) are the most common medications prescribed for the treatment of gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD). The treatment usually begins with antacids or over-the-counter H2 blockers for mild symptoms. Then steps up to PPIs or higher dose of H2 blockers for moderate to severe symptoms. Occasionally, PPI and H2 blocker may be combined to treat certain patients. This article will discuss the appropriateness of combination therapy and its associated risk.
Hospice patients are predisposed to PUD due to many risk factors including the age-related change in gastric mucosal defense, serious illness and long-term use of NSAID. The majority of patients are managed clinically with a once daily dose of a PPI. The unofficial use of twice daily dosing of PPI or the addition of a nighttime H2 blocker to the daytime PPI therapy may be required for optimal control in a subset of patients such as those with Barrett's esophagus or extra-esophageal disease (1).
PPIs and H2 blockers have overlapping mechanisms of actions, which ultimately suppress gastric acid secretion, but at different stages of production. When used together, the extensive acid suppression therapy may decrease the absorption of certain nutrients (i.e. vitamin B12, iron and calcium), which are dependent upon an acidic environment to be absorbed in the stomach. There is also a significant risk of hip fractures with long-term PPI treatment. This risk theoretically may be further increased with the combination therapy due to impaired calcium absorption. Combination therapy may also increase the risk of gastrointestinal infections. A recent meta-analysis evaluated Clostridium difficle (C.diff) infections in patients receiving PPIs and found an association between PPI use and an increased risk of C diff (2). H2 blockers have been showed to carry a lower risk for gastrointestinal infection compared to PPIs. However, when both PPIs and H2 blockers are used together, the further reduction of gastric acid may allow for bacteria to multiply in the digestive system and the risk of infection may be increased.
In general, long-term combination therapy does not offer any additional benefit for the management of GERD and may only be appropriate in a particular subset of patients (i.e. Barrett's esophagus or extra-esophageal disease). Practitioners are encouraged to re-evaluate patient's condition and consider discontinuation if patient no longer exhibits symptoms or has no indication for continued use. Since PPIs provide superior acid suppression, healing rates and symptom relief compared to H2 blockers, our recommendation is to discontinue H2 blockers over PPIs. If it is determined PPI is no longer indicated for a patient, it should be tapered to avoid rebound acid reflux. For patients who require long-term PPI therapy, the lowest effective dose should be considered.
Jennifer Chen, PharmD
Entacapone is a reversible and selective inhibitor of catechol-O-methyltransferase (COMT). By disrupting levodopa breakdown, the COMT inhibitors can potentiate the effect of levodopa for managing the motor symptoms of Parkinson's disease. Therefore, entacapone is used as adjunctive treatments in patients who are experiencing "wearing off" or other motor complications during treatment with carbidopa-levodopa.) It is available alone as Comtan® or in a fixed-dose combination with carbidopa-levodopa as Stalevo®.
In August 2010, FDA alerted patients and health care professionals about the increased risk of cardiovascular events and death with the use of Stalevo. The possible safety issue was observed in a clinical trial called Stalevo Reduction in Dyskinesia Evaluation in Parkinson's disease (STRIDE-PD) and in meta-analysis involving 15 clinical trials comparing Stalevo with carbidopa-levodopa. Since carbidopa-levodopa has been used extensively and has not been associated with cardiovascular risk, the FDA was concerned that entacapone might have been responsible for the increased risk. It was difficult to draw conclusions from these clinical trials because they were not designed to evaluate entacapone's cardiovascular safety.
Until recently, two studies were examined to understand the significance of cardiovascular risk with entacapone. One was a retrospective cohort study using data from an electronic commercial insurance database and found the risk for myocardial infarction was not significantly increased in patients 18 to 64 years old with Parkinson's disease treated with entacapone compared to the control group(1). The other study assessed the risk of myocardial infarction, stroke or death in Medicare patients at least 65 years old with Parkinson's disease and the result did not support an associate between entacapone use and increased cardiovascular risks(2).
Therefore, on October 26, 2015, the FDA announced that entacapone does not carry an increased risk of cardiovascular events based on recent studies. However, patients and health care professionals are still encouraged to report side effects with Comtan or Stalevo to the FDA.
We want to share some exciting news with you regarding Outcome Resources!
On October 30, Hospice Pharmacy Solutions merged Outcome Resources into its operation. The merger is very beneficial for our clients as we will be able to offer you additional unique and innovative solutions geared specifically to the hospice industry.
The business will be headquartered in Dallas, which is a central location, and operate as Hospice Pharmacy Solutions, LLC. In approximately six months, we will retire the Outcome Resources name.
We want to reassure you that while the name is changing, the exceptional service you have come to expect from Outcome Resources remains the same. This merger gives us the ability to enhance our programs and provide hospices valuable resources to better serve their patients.
You can find more details in this press release, including the new leadership structure.
We'd like to once again thank you for your services to patients and their families at a most vulnerable time in their lives. The work you do is honorable, and we are proud to support your mission.
Stephanie Cheng, PharmD, MPH
The FDA granted accelerated approval of Praxbind (idarucizumab) on October 16, 2015 for use as a specific reversal agent of the anticoagulant effects of Pradaxa (dabigatran etexilate) during emergency surgery/urgent procedures or in episodes of life-threatening or uncontrolled bleeding. This is the first drug to be approved for this indication. Praxbind is currently not available on the market yet; however, the manufacturer stated that it will be available from major U.S. hospital pharmacy distributors as quickly as possible.
Pradaxa (dabigatran) had been given FDA approval in 2010 as the first direct thrombin inhibitor for the indications of (1) to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation (2) for the treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients who have been treated with a parenteral anticoagulant for 5-10 days and (3) to reduce the risk of recurrence of DVT and PE in patients who have been previously treated. Unlike Coumadin (warfarin), Pradaxa does not require extensive lab monitoring and is given as 75mg BID or 150mg BID. However, there had been no antidotes to its anticoagulant affect until this point.
Praxbind (idarucizumab) is a monoclonal antibody fragment that is to be given IV only at a recommended dose of 5g, provided as two separate 2.5g/50mL vials to be given consecutively. Praxbind specifically binds to Pradaxa and does not interfere with the anticoagulant effects of other anticoagulants or the coagulation cascade.
Under the accelerated approval process, the FDA approves medications for serious conditions that fill an unmet medical need based on an intermediate clinical endpoint in a clinical trial that is reasonably likely to predict a clinical benefit to patients. This allows patients to gain earlier access to promising new medications, but the company is still required to submit additional clinical information after approval to support the clinical benefits of the drug.
Due to the accelerated approval process, Praxbind has only been studied in healthy patients (i.e. patient who do not require an anticoagulant) in 3 clinical trials of a total of 224 subjects. Therefore, the safety and risk profile for patients who do require an anticoagulant has not been assessed. Additionally, because the clinical trials were conducted under widely varying conditions, adverse reaction rates observed cannot be directly compared to other drugs and the rates may not reflect those observed in clinical practice.
Currently, there are no contraindications for Praxbind. However there are warnings and precautions in regards to (1) increased thromboembolic risks to the patient's underlying disease due to reversal of dabigatran's anticoagulant effects (2) re-elevation of coagulation markers (i.e. activated partial thromboplastin time (aPTT) or ecarin clotting time (ECT)) (3) Hypersensitivity reaction and (4) risk of serious adverse reactions in patients with hereditary fructose intolerance due to sorbitol excipient.
The role of Praxbind in the hospice setting will be limited, due to the limited use of Pradaxa and expense. Anticoagulant use in generally is not recommended in hospice patients due to the risk of bleeding, especially in the unpredictable declining status of hospice patients. Exception to this is if the patient has a high level of function, relatively longer prognosis for life and a reasonable quality of life, who is deemed to be at high-risk for thrombotic events. However, Praxbind does provide a safety net for life-threatening or uncontrolled bleeding in patients using Pradaxa in an otherwise helpless situation, as no other antidote for Pradaxa had been available up until this point.
Jim Joyner, PharmD, CGP
Rytary is the brand name for a new formulation of "extended-release" carbidopa-levodopa that has recently become available in the U.S. in capsule form. It is indicated for the treatment of mild to moderate to severe Parkinson's disease. Clinical trials with this new formulation were conducted comparing Rytary with immediate-release carbidopa-levodopa tablets. The study results indicated significant improvements in a patient's ability to move and perform activities of daily living, as well as experiencing significantly more "on" time and less "off" time without dyskinesia. There are currently no published studies comparing Rytary with the "controlled-release" carbidopa-levodopa tablet (originally Sinemet CR, although generics are now available). The Sinemet CR tablet is formulated as an erodible polymer matrix that slows the release of medication from the tablet. The Rytary capsule contains both immediate-release and extended-release beads. Clinically significant differences in patient response to these two "extended-release" products should be anticipated because of the difference in formulation.
"Controlled or "extended" release carbidopa-levodopa preparations have been formulated in attempts to achieve a steadier climb to peak plasma concentrations that are less extreme and provide greater duration of anti-Parkinson effects. Both Rytary and the older Sinemet CR tablet are formulated to achieve this objective, but use different technology to control dissolution rates. Both dosage forms have been shown to provide more "on" time, less "off" time, and less dyskinesia for Parkinson's patients than the immediate-release tablets. It remains to be seen how much of an advantage, if any, the new extended-release capsule (Rytary) has over the older extended-release tablet (Sinemet CR).
Rytary is not a generic equivalent to either the immediate release, nor the controlled release carbidopa-levodopa. The manufacturer provides a conversion table for guidance on converting from carbidopa-levodopa immediate release to Rytary.
Available combination strengths of Rytary Extended Release Capsules are as follows: 23.75mg/95mg, 36.25mg/145mg, 48.75mg/195mg, and 61.25mg/245mg.
The starting dose for Rytary in levodopa naïve patients is 23.75mg/95mg three times per day for 3 days. On day 4, the dose may be increased to 36.25mg/145mg three times daily. Further dosage increases may be employed based upon patient response, up to a maximum recommended dose of 97.5mg/390mg three times a day. Capsules should be swallowed whole and should not be chewed or crushed. For patients that cannot swallow capsules whole, Rytary capsules may be opened and the contents can be sprinkled on to a small amount of applesauce for immediate consumption.
Most common adverse effects noted with Rytary were nausea and headache (similar to immediate release carbidopa-levodopa in the comparison trial).
Rytary may offer a significant advantage in Parkinson's patients who are not able to achieve adequate periods of "on" time during the waking hours, or those who exhibit troublesome dyskinesia with carbidopa-levodopa immediate-release tablets. There is currently no data available to demonstrate any clinical advantage of Rytary over the carbidopa-levodopa CR (controlled release) tablets. From a practical standpoint, Rytary does have an advantage over the "CR tablets" for patients that cannot swallow whole pills, since the carbidopa-levodopa tablets should be swallowed whole and should not be chewed or crushed. As with most new products, Rytary is expensive with a mid-range dosage expected to cost the hospice between $300 - $400 per month.
Jennifer Chen, PharmD
DEA has announced that the 10th annual National Prescription Drug Take-Back will take place on September 26th from 10am to 2pm local time in every state except Pennsylvania and Delaware, where it will take place on September 12th. This is a great opportunity for the public to dispose unwanted and expired medications. These types of medications in the house are a leading cause of accidental poisoning. In addition, inappropriate disposable of medications may also lead to potential safety and health hazards. Check your own medicine cabinets and advise your patients, friends and families. Help get those drugs out of homes and reduce the threat of prescription drug abuse.
Click here to find a DEA collection site near you!
What should you do if you miss this event?
Another option for long-term care facilities to dispose of unwanted medications is to transfer those medicines to collectors registered with the DEA. These DEA-authorized collectors safely and securely collect and dispose of pharmaceuticals containing controlled substances and other medicines. In your community, authorized collection sites may be retail pharmacies or hospital pharmacies. These sites may also offer mail-back programs or collection receptacles (or "drop-boxes") to assist the public in safely disposing of medications. Click here to locate a DEA-authorized collector in your area.
If there is no take-back program or DEA-authorized collectors available in your area, you may also dispose of medicines in household trash or flush certain medicines down the toilet (be sure to know the law in your state before recommending medications to be flushed; for example, flushing medications down the toilet is not recommended in California). The FDA provides an updated list on the drugs recommended for disposal by flushing (last updated in February 2015). For more information on proper drug disposal, please review our previous blog posts on the topic of proper drug disposal.
Esther Liu, PharmD, MSIA, CGP
The U.S. Food and Drug Administration (FDA) approved another anti-clotting drug Savaysa (edoxaban) in January 2015 for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). This medication also has the FDA approved indication to reduce the risk of stroke and blood clots in patients with atrial fibrillation, but it is not recommended for patients with CrCl greater than 95ml/minutes due to its inferior efficacy in comparison to Coumadin (warfarin) at clinical trials.
This is the third oral factor Xa inhibitors approved by FDA as an anticoagulant to treat blood clots and prevent stroke risk in the last four years. The most common side effects for Savaysa observed in clinical trial participants were bleeding and anemia.(1) Just like the other FDA-approved anti-clotting drugs, bleeding, including life-threatening bleeding, is the most serious risk with Savaysa. There is no treatment that has been proven to reverse the anticoagulant effect of Savaysa like the antidote we have for Coumadin.
Factor Xa inhibitors, like Savaysa, are likely to be reserved as a second line therapy due to its lack of antidote to the anticoagulant effect and they are cost-prohibitive compared to Coumadin. When you encounter a patient with one of the new anticoagulants in the hospice setting, it is important to ask the following questions to ensure if the anticoagulation treatment is still suitable for your hospice patients:
1. Is the patient taking the medication for treatment or stroke prevention?
If the patient is taking the medication for stroke prevention in atrial fibrillation, the medication should be considered for discontinuation unless the patient has a high risk for clotting. Outcome Resources provides patient-directed letters to help hospice providers to communicate the rationale of discontinuing the anticoagulant at end of life care.
2. What is the risk vs. benefit of continuing the anticoagulation therapy? What is the likelihood of patient getting another blood clot? Did the patient have a recent clotting event even if the patient is using the medication for clotting prevention?
A study has suggested that anti-coagulants can reduce stroke risk by about 4% per year on average for ambulatory patients with atrial fibrillation.(2) Hospice patients are more likely to suffer from the side effects of bleeding at end of life than having a blood clot event. Therefore, the risks of anticoagulation treatment are greater than the benefits in this population and should be considered for discontinuation.
3. If the hospice patient has a high risk for clotting and has a reasonable functional level (Palliative Performance Scale >40%), why is the patient not able to take Coumadin (warfarin) versus the other anticoagulants?
Coumadin is the most cost-effective medication in the class of anticoagulants even after taking into account for the INR monitoring cost. It is the only oral medication in this class with an antidote for its anticoagulation effects, which makes it a safer option for patients with bleeding risk, especially in the hospice setting. The only drawback to using Coumadin is the requirement of routine INR monitoring on the anticoagulation effect while the newer agents do not. However, recent studies have suggested that routine INR monitoring improves patient adherence to the anticoagulant therapy, which leads to better outcomes from Coumadin in general.(3)
If you have asked these three sets of questions above and the answers still suggested that the patient is a candidate to continue on an anticoagulation therapy, then you can consider some of the newer oral agents, like the factor Xa inhibitors. They are generally more cost-effective than the injectable anti-coagulants like Lovenox.
Here is the clinical pearl of using anticoagulants in hospice setting. 1) Consider discontinuation if possible. 2) If not, Coumadin remains as the gold standard to treat/prevent blood clots before other newer anticoagulants. 3) Reserve the injectable anticoagulants as the last resort as it is both invasive and expensive.
View a Comparison Chart of Oral Anti-Coagulants
1. FDA approves anti-clotting drug Savaysa: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm429523.htm . Accessed August 27, 2015.
2. Archives of Internal Medicine 1994; 54: 1449-1457.
3. Comparing the New Oral Anticoagulants. Pharmacist's Letter. June 2014.
4. Anticoagulant Comparison Chart. North American Thrombosis Forum. www.natfonline.org. Accessed August 27, 2015
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1558 Tasting Notes
A sample from Shmiracles. This has got to be one of the nicer herbal/fruit blends I've tried in a while. It's not ref fruit, for starters, and there's no hibiscus — the difference! Dry, it smells delicious. Citrussy and slightly sharp — it makes me think of grapefruit. It's equally nice to taste — spearmint and orange are the main flavours I can pick out, with gooseberry hanging around in the background. It's a delicious combination, and very refreshing. I can only imagine how fabulous this would be iced on a hot day! This is a sample I will very much enjoy finishing, and one whose absence from my cupboard I know I'll come to lament.
A sample from Shmiracles. This is a very pleasant evening cup. It's delicately flavoured, with a medium strength base. I added milk to this, which is just about stands, but I imagine it'd be just as palatable without. The flavouring here is subtle, but all of the different elements are there. Vanilla is probably the strongest flavour, followed by cherry, and then chocolate. It's beautifully spring-like, both in flavour combination and appearance. The red and blue flowers scattered through the dry mix remind me of the foil wrapping on an easter egg. So pretty!
This is a welcome change from the more heavily flavoured teas I've been drinking recently. Sophisticated and satisfying! A positive first experience with Dammann Freres.
A sample from Shmiracles. Plain genmaicha isn't something I'd usually seek out, but it appealed to me tonight as I finally start to shake off my cold. For some reason, I was expecting this to be quite a pungent genmaicha, and I couldn't have been more wrong. It's actually beautifully delicate — mild, grassy green tea, with a touch of toastiness running over the top. It's delicious, and very easy to drink. It's one of the more well balanced genmaicha blends to look at, also, appearing to be equal parts popped rice, toasted rice, and green tea. Pretty AND tasty — a rare treat!
It's teas like this one that make me appreciate just how pleasing a plain tea can be. There'll always be a place in my cupboard for zany, outrageous tea in kooky flavours, but from time to time something like this is far more satisfying. Plain, straightforward, fabulous tasting TEA!
A sample from Shmiracles. This is an interesting one. I was expecting something thoroughly minty, but that's not this tea at all. The mint is actually the most subtle flavour, bar the green tea base. The main flavour here is a mixture of chai-like spices — drinking this actually reminds me quite strongly of 52 Teas GenmaiCHAI. My tastebuds are still a little off after my cold, but I'm pretty sure I can taste ginger, cardamon, and clove. I expected the mint to add a fresh edge to the flavour, but it actually adds a murky swampiness all its own, although probably assisted by the hojicha. This isn't what I was expecting, but it's uniquely pleasant. It's probably not something I'd want on hand all the time, but I'll enjoy finishing off this sample and trying to identify some more of the flavours. Different and intriguing!
Sipdown! Finished off the last of this one last night. It'll be sadly missed — the blueberry flavour here is pretty great, even if I don't get much in the way of chocolate from it any more. The ghost sprinkles are cute, too — fortunately, they seem to melt pretty easily, so I don't find them stuck to the bottom of my infuser. I'm pretty sure that helped it score points with me. I wouldn't mind drinking this one again, if the opportunity arose. I've got 52 Teas Blueberry Cream Cheese Danish to satisfy my blueberry cravings for now, though, so I can't be too sad.
Second sipdown of the day! I don't have much to add to my previous tasting note, except to say that I was surprised how much I liked this one. Chocolate and pumpkin don't make the most natural of combinations in my head, but this tastes soooo good. Definitely one I'd look to restock next autumn.
Sipdown! Finished off my last bag of this at work today. I didn't have any milk, so I was initially a bit reluctant, but it turned out pretty okay black. I could taste more of the spices, and they left a pleasant warmth at the back of my (very sore) throat. First day back at work made more bearable by tea.
Another strong flavour for a sad face sick with cold day. As far as I can determine, this one is just mint. I know what mint tastes like, so this is probably a safe one to go for when I'm not up to tasting anything really new. As might be expected, the mint flavour from this one is STRONG. It's remarkably smooth, though, and not too toothpaste like. There's a gentle sweetness, rather reminiscent of spearmint, and it doesn't have too much of the coldness in the aftertaste that I often associate with mint teas. In fact, as bagged mint teas go, this is definitely one of the nicer ones I've tried. I don't need plain mint tea in my life too often, but I'd not turn down a cup of this if it was offered. My dad is a mint tea fiend, and loves this one. I don't often understand why, but today I got a glimpse of the attraction mint can hold. It's pleasantly refreshing, and it doesn't need any additions to taste like itself. Another pleasant cup on a blah day.
My cold suddenly got a lot worse overnight, so this morning I went rooting desparately through my stash looking for some chai. I came up with this one first, and I've had two cups so far today. There's something about chai that I find soothing when I'm ill, especially when brewed at a latte. The spiciness is nice for a sore throat, and the milkiness makes me feel comforted, somehow.
This isn't the most outstanding chai I've tried, but it's passable. Certainly it's made me feel better today, and that's what's important right now. I got a very strong floral note from this initally, but that seemed to fade as I took more sips. The two main flavours here, surprisingly, were pepper and orange, followed closely by cinnamon. The cardamon and clove were pretty lost, although I know my taste buds aren't up to much at the moment. It was a pleasant change to taste a chai with a strong hit of fruit as one of the main flavours, though. That's not something I've come across very often before. This probably isn't one I'd stock all the time, but it'll probably flit through my cupboard occasionally. A pleasant chai blend.


text: We had snow on Christmas eve, then snow, sleet and rain on the 26th. Returned to work yesterday so I put the Nokians on and braved it in. The shoulders weren't clean, so it was slow going. I took a relatively short route of 10 miles and it took me well over an hour. I had fogotten how heavy and slow the Nokians are, so I was beat yesterday. I need to remember that winter means fewer, slower miles, but you're still getting plenty of work-out.


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Edwards Place was home to Benjamin and Helen Edwards and tells the story of social and domestic life in antebellum Springfield. A center for social activity, prominent citizens and politicians such as Abraham Lincoln and Stephen Douglas were entertained at lavish dinner parties and picnics. Your visit to Edwards Place will include a tour of this wonderful Italianate mansion and its fascinating collection of furnishings, incluidng the courting couch on which Mary and Lincoln sat while they were courting. Open for tours Tu - F: 1 pm, 2pm, 3pm; Sa: Noon, 1pm 2 pm
Things To Do
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Edwards Place


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Chargers use everyone
It takes a team to raise a trophy.
This has, essentially, been the mantra of many at Chargers Park, from the upstairs offices to the lockers located just off the practice field, as they prepare to embark on yet another try at a championship – and do it without two key players but with what they have repeatedly emphasize is a good team.
The Chargers don't speak from experience, of course, regarding the fact that teams win championships.
But they did go 13-3 in 2009, battling through injury after injury, by using their entire roster – and more.
Of the 12 teams that made the playoffs after last season, just three used more than the 60 players the Chargers did, according to a survey of teams and beat writers conducted by the Union-Tribune.
The Super Bowl champion New Orleans Saints (63), Super Bowl-losing Indianapolis Colts (65) and Green Bay Packers (62) were the only playoff teams to use more players than the Chargers did during the 2009 season. (Among the players the Saints lost prior to last season, by the way, was two-time Pro Bowl left tackle Jammal Brown.)
It is generally the teams that finish at the bottom of the standings that churn through players. See Kansas City (69), Buffalo and St. Louis (68) and Tampa Bay (66) as examples in '09.
Meanwhile, playoff teams used an average of 53.8 players and 37.5 different starters. On average, playoff teams' starters missed a total of 34.5 games due to injuries.
The Saints and Chargers each used 42 starters (to play the 22 offensive and defensive positions), second among playoff teams to Indianapolis' 43. The 55 games Chargers starters lost to injury were third-highest among playoff teams, behind the Saints (70) and Cincinnati Bengals (59).
The Chargers placed four players who could be considered starters on injured reserve, tied with Indianapolis and New Orleans as highest among playoff teams. The Chargers' total of 11 players placed on IR was second among playoffs team to the Saints' 16.
"That's a credit to Norv," Chargers President Dean Spanos said this week. "You can only as a coach play with the hand you're dealt, and he got dealt a bad hand early in the season. And it's a credit to A.J. (Smith, the general manager) to get the players we got in here."
Their past ability to find a way to win at least until the middle of January is significant in light of the Chargers' belief that they have the right mix and total package to chase that elusive NFL title – even without past Pro Bowlers Vincent Jackson and Marcus McNeill.
"There are 53 guys out there," Dean Spanos said this week as he gestured to players on the field below his office. "I like our 53 guys, and I like our chances."
Should that prove prescient, the Chargers will be able to look back on 2009 as where they got the footing for their success.
It was in that season that several young players got extensive playing time, even extensive starting stints.
Funny, in fact, how things work.
It is possible left tackle Marcus McNeill could have had more leverage had right tackle Jeromey Clary not gone down with a broken ankle in November. Certainly, the Chargers would not have been so certain that Dombrowski could play left tackle for them had he not started two games at right guard and the final seven games at right tackle last season.
"Absolutely," Norv Turner practically shouted when asked about the team's comfort with Dombrowski having to do with his extended work season. "If a guy (hasn't played), it is all speculative. Even in the preseason, you go out and play well in the preseason, someone may say, 'Oh, well I may not have been going full speed,' But you see it in (a regular-season) game, you know what to expect."


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Set includes a notepad of 200 sheets with a self adhesive magnet. Pad measures 4.25" x 5.5". Your choice of stock color and pad size. Design elements such as pencil, sun and desk will always appear. Flat printed in black ink. You select the way the character will look and the desk your teacher sits at!


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GM Bojkov keeps adding pieces to the board, but the opposite colored bishop keeps marauding. Here we see positions with multiple heavy pieces, which gives the attacking side an even greater chance to crash through. He also gives five simple rules for positions like this. Learn them and you'll be able to conduct some scary attacks! | Watch video
It's a good time of day for the USCL Game of the Week! GM Yermo brings his baritone to bear in showing how GM Charbonneau flipped the tables from week one. After being on the losing end of the Game of the Week judging, the New York Knights' top board plays a flexible double-fianchetto system. The bishops start dormant, but the second they come to life, White's tactics follow, and so do top honors in the league. Watch and see how the Applesauce were crushed - no straining required! | Watch video
After examining the early h4 thrust in his previous video, GM Dzindzi is much less circumspect about the more main lines of the Grünfeld Defense. Here he analyzes the very popular lines with 4. cxd5 Nxd5 5. e4 and shows some plans for both sides. The imbalance of the central majority versus the queenside majority is never easy judge, but it will be even more bewildering if you don't watch the grandmaster's cogent analysis. | Watch video
Higher-rated and need to play for a win as black? That's a situation GM Kramnik finds himself in often, and one of his go-to weapons is the Pirc Defense. Here IM Molner shows the former champion's treatment of the so-called "150 Attack" in which white plays an early Be3 and often follows with f3. Molner continues to advocate for the ...a6 lines, and warns not to fianchetto too early. If Kramnik can play it against a pair of 2600s, surely you can too! | Watch video
In his best game from one of his best tournaments ever, the witty GM Ben Finegold shows off a very pleasing attack on a 2700 player. "When your attack is so strong, your opponent's rating won't save him," Finegold says as he picks apart the Hedgehog formation with a series of double-exclam moves. Finegold's sacrifices work their way up the value ladder - first a pawn, then knight, then bishop, and finally a rook! He produces one of the gems of his long chess career. | Watch video
Who says romance is dead? GM Bojkov begins an exciting new series on his favorite player, the so-called "Positional Romantic of the 20th Century" - Danish GM Bent Larsen. Here the late GM denudes a world champion's queen, using all five of his long-range pieces to perfection. After passing on the opportunity to win black's queen, Larsen sacs his own to form a pretty mating net! | Watch video
GM Melik Khachiyan continues his incisive series on prophylaxis and calculation by showing one of his own recent games, and his missed opportunities, against the veteran GM Gregory Kaidanov. Don't be fooled by the simplicity of the opening - many subtle ideas arise after the first player decides to create twin half-open files. Watch and learn how GMs offer new insight to a position we probably all played in our junior days! | Watch video
IM Danny Rensch is back, and so is his British accent and 80s music references! This Live Session is a longer game, where he shows his pet system against the Morra that the late GM Igor Ivanov taught him. He never lets white get any initiative and actually does most of the attacking himself. His lack of an inner monologue means you get to hear his "bushes" of analysis, just as GM Melik Khachiyan teaches! | Watch video
Sure, you watch TMZ every night, but how often do you watch TMB? WGM Camilla Baginskaite uses her silky-smooth delivery to explain the nuances of the tongue-twisting Tartakower-Makagonov-Bondarevsky variation of the Queen's Gambit. Facing the upstart WFM Sarah Chiang, our author saddles black with hanging pawns, then decimates them with ease, giving her the better chances in the endgame. | Watch video
GM Melik Khachiyan continues to dispel the myth that top players are always calculating very far down the road. Using a trio of instructive positions from famous players, Khachiyan continues his series on "bushes" by finding the right path without ever straining to see past three moves. His point is simple - you only have to analyze enough moves to either find an unacceptable position or a comfortable one. Either way, it's time to stop and move on with the game! | Watch video
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"Returning to Tibet!" Top 5 Page for this destination Tibet by tremendopunto
Tibet Travel Guide: 1,399 reviews and 4,150 photos
For my latest trip in August 2006, I entered Tibet from Nepal to go all the 1.000km to Lhasa by Jeep. The typical route went from Kathmandu to the bordertown Kodari with getting stopped by the Maoists once - but because of the ongoing talks withe the democratic parties, the rebells just asked for a "goodwill" donation. When you reach the border, you have to walk over the Friendship bridge to the Chinese side to do the paper work while your baggage gets smoked with bug-killer. Ok, and on the road again from Zhangmu over passes above 5.000m past Tingri (where you get a glimpse on the Everest), Shigatse, Gyantse all the way to Lhasa. There are heavy roadconstructions going on at the moment - which blocked our way, let us wait for hours or take the worst detours possible, earning a flat tire and a broken axle of one jeep. But that is part of the game and makes Tibet still to an adventure. In a few month you will fly by with full speed on a fancy highway (that really deserves the name highway - compared to the path I saw;-), just like at home. Thats not my illusion of Tibet - but modernization finds its way. There are many beautiful places on the way. Take a look at the tips and share my impressions of those places. More detailed pages of the main places will follow soon.
Here is a very very short summary as a sneak preview short summary clip),
Finally finished, my complete Tibet video in 5 parts:
From Kathmandu to Tibet with Tingri and Qomolangma
Shigatse and Gyantse
Sera and Drepung
About my first trip in April 2004, I only went to the holy city of Lhasa, the seat of the Gods. Because of my short time and my extensive travel plans for China (it is always a trade-off between time, money and places to see) I chose to take the plane from Chengdu to Lhasa. This was a good opportunity to get a good look over the high peaks of the Himalayan mountain range.
Now that I can compare the different seasons, I have to recommend to visit Lhasa in off-season. Since it turns more into a Disney Land, crowded with tourists in summer. For example the debating classes of the monks in Sera Monastery were totally crowded with tourists in August - actually more tourists than monks, with "funny" people disturbing the scene by running right between two monks, who were doing their debate, and putting the camera into their faces - that even the nicest monks had to push them back....."nice" to see those "sensitive" tourists.....
Whereas in the beginning of April, I was on my own, enjoying their debates in silence!
Reviews (32)
At the Sera Monastery, on the outskirts of Lhasa, you can enjoy the daily debating classes every afternoon. A big number... more travel advice
Tingri actually consists of some 5 houses spread along the old trade route, now called Friendship Highway. Today´s... more travel advice
This is an adventurous tour of about 1.000 km through the evergreen Nepali side, over the high passes of the Himalaya... more travel advice
This is a nice Kora (or pilgrimage) around the monastery that goes up a little bit on the foot of Drölma Ri mountain.... more travel advice
Comments (31)
You made a great trip and created a fabulous page! Thanks a lot!~
Outstanding photos/detail - gave me a good glimpse of the mystery and magic of Tibet. Grazie, Carol <(•¿•)>
A country that is still on my wish list. Thanks for allowing us to see it through your eyes ;-)
Pity..ha ha. I was having my hands full with mum and sis. Blame the women in my life. Ha ha. I received 3 - 1 from UAE and 2 from Pakistan. Shd I expect more, mate?
Great tip on Tibet. Definetly on my things to do list...but will go via KKH..hopefully one day. Regards. Amir
Hey, ur tips and photos made me can't breath properly. I intended to visit tibet in Sept this year. But will see how the riot goes! How many days you spent it tibet?
Chris, Thanks for your comment on my youtube. Sorry I'm so late in replying. Yes, China including Tibet is awesome. It looks like you have been to the Mainland 4 times. I've only been 3 times. However, I've been to HK so many times that I lost count. :)
hoping to get to Tibet next year! :) love your pics!
What a tragedy in the news... would have loved to be able to visit Tibet whilst in Nepal, but funds restricted it. Hope the riots don't escalate further! Namaste!
i was in JiuZhaiGou several days ago . lots Tibetan there and the view is almost the same as you said here - prayer flags, prayer wheels and the wild dogs of Tibet. i had pics of those dogs too. you know what. they are very expensive. more than Euro1000
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""In the long run we are all dead" John Maynard Keynes"
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- Congo (Dem. Rep.)RetailFunding via Programme d'Appui aux Initiatives de Développement Economique au Kivu (PAIDEK)
Zamiri GroupCongo (Dem. Rep.)ClothingFunding via Programme d'Appui aux Initiatives de Développement Economique au Kivu (PAIDEK)
Indatwa GroupRwandaRetailFunding via VisionFund Rwanda
Went Plus Group
Mfutila started his business in 1990. He has been operating a car wash service to the east of the city of Kinshasa. He is a loyal client of IMF HOPE RDC and has already received three different loans and has repaid them properly. He intends to use the next loan to increase the stock of his business by buying some car wash products and other goods with the aim of increasing the profits. Each week, his business brings in a profit of US$180.
His ambition is to expand his business in Kinshasa.
Mfutila has nine children whose ages are between 8 and 23 years old. Seven of them go to school.
Additional Information
About HOPE DRCHOPE International has been providing small business loans and savings services to thousands of entrepreneurs in DRC since 2004. HOPE DRC targets small business owners who can use loans to increase their inventories or invest in assets that have the potential to increase their incomes. Funds from Kiva lenders play a major role in expanding access to affordable, flexible capital for micro-entrepreneurs, 80% of whom are women.
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 Congo (Dem. Rep.)
2View loans »
US Dollars
Success!! The loan was 100% repaid
- Repayment Term
- 6 months (Additional Information)
- Repayment Schedule
- Monthly
- Pre-Disbursed:
- Mar 16, 2012
- Listed
- Apr 4, 2012
- Currency Exchange Loss:
- Ended:
- Aug 15, 2012


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A pump station 240 feet below ground helps keep an undersized treatment plant from discharging raw sewage.
Program will eliminate wastewater from being discharged to ocean and boost the local economy by creating new jobs.
World Water Works, Inc. (WWW), a leading designer and manufacturer of wastewater treatment solutions, has been selected to provide its Ideal MBBR-DAF technology by Hopewell Regional Wastewater Treatment Facility (HRWTF), a 27 million gallons per day (MGD) facility.
The Pittsburgh Water & Sewer Authority Board of Directors has voted to continue its nearly three-year partnership with Veolia North America, the world's leading provider of environmental solutions.
Suffolk County, N.Y., is using the company's Smarter Cities Challenge to solve an $8 billion problem created by Hurricane Sandy: groundwater contamination. Instead of money, though, IBM donates time and expertise in a full-court press on local officials to join in.
Seattle officials are working to figure out how two different Seattle sewers became clogged with concrete.
This low-VOC epoxy protects water and wastewater pipelines with one coat instead of two.
The U.S. Environmental Protection Agency is providing up to $600,000 in training and technical assistance to help water utilities in more than 20 communities bolster their climate change resilience and readiness.
Third extension since '96 means Stephenville, Texas partnership will span 25 years.
It's another AMERICAN first, and a great addition to our existing line of Flex-Ring products."
Copyright ©
2016 Hanley Wood Media, Inc. All rights reserved.


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In the past 50 years, the number and share of European immigrants in the United States have declined significantly. A look at the population's size, geographic distribution, admission categories, and demographic and socioeconomic characteristics.
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Crime and insecurity are undermining economic and social prosperity in Mexico and Central America, eroding public trust in government institutions. This report examines current economic, social, and political costs resulting from insecurity, and future implications.
This interdisciplinary volume examines the health, well-being, school readiness, and academic achievement of children in Black immigrant families (most with parents from Africa and the Caribbean)—a population that has had little academic attention even as it represents an increasing share of the U.S. Black child population.
The growth of organized crime in Mexico and Central America has dramatically increased the risks that migrants crossing the region face. As this report outlines, migrants increasingly are forced to seek the assistance of intermediaries, and those unable to afford one are more likely to be abused along the way.
This report draws on a six-year longitudinal study of Palm Beach County, FL, examining parenting, child care enrollment, and other factors that encourage early school success. The authors find kindergarten-age children of Black immigrants have significantly higher odds of being ready for school than children of Latina immigrant or Black U.S.-born mothers.
Using a nationally representative U.S. birth-cohort study, this report examines levels of school readiness among young children by race/ethnicity and nativity. The authors identify the contextual factors — such as family circumstances, parenting practices, and enrollment in center-based child care — that encourage early school success.