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With a pandemic currently in progress, influenza has maintained a prominent place in the medical and lay news cycles. The coming season promises to be challenging for clinicians, who must sort through strategies for prevention, diagnosis, and treatment for both seasonal influenza and influenza due to the novel H1N1 strain.
The 3 main types of influenza virus are A, B, and C. Influenza A is subtyped according to its main surface glycoprotein components, hemagglutinin and neuraminidase. There are at least 15 different kinds of hemagglutinin and 9 types of neuraminidase and a multitude of possible combinations. Since 1977, the circulating influenza A strains have been primarily of the H1N1 and H3N2 subtypes.
Influenza A viruses have great capa-city for mutational change, and minor antigenic changes periodically occur in either the hemagglutinin or the neuraminidase component or both. This phenomenon, called "antigenic drift," introduces viruses that are different enough from preceding strains that previously acquired immunity is not fully effective. Thus "drift" contributes to the pattern of yearly seasonal epidemics, and is the basis for the yearly change in vaccine formulations.
More-dramatic antigenic change (a "shift") results in a virus of distinctly different antigenic character to which most or all of the population is susceptible. Generally, such shifts occur only every few decades, and are the basis for influenza pandemics. Influenza viruses also infect other species, including birds and pigs. Under circumstances not completely understood, these animal strains sometimes adapt to infect humans and spread from person to person. For example, despite the H1N1 designation, the currently circulating "novel" strain of H1N1 (also known as 2009 H1N1 or swine flu), which seems to have originated in swine, is entirely different from the H1N1 strains of recent years, and thus has triggered a pandemic (1).
Influenza B viruses also mutate periodically, but less dramatically; they drift but do not shift, and thus are associated with seasonal epidemics but not with pandemics. Influenza C viruses are of little clinical significance.
Seasonal epidemics of influenza A and B cause substantial morbidity and mortality, disproportionately affecting elderly persons, very young persons, and those with certain underlying medical conditions. The average yearly toll in the United States is 51 000 deaths and more than 500 000 hospitalizations due to influenza infection and its complications (2).
Pandemic disease may differ from seasonal influenza in some features. Unlike yearly epidemics during the cold-weather months, pandemics may begin and persist during the warmer months. Although pandemic disease is widespread by definition, morbidity and mortality vary depending on the virulence of the pandemic strain. The populations hardest hit may be atypical for seasonal disease. The 1918 pandemic was notable for rapid and devastating disease in young, healthy adults. Although the current pandemic seems to cause milder disease in general, both the frequency and severity of infection have been greatest in those younger than 24 years (3).
Current guidelines for vaccination against seasonal influenza, updated yearly by the Centers for Disease Control and Prevention (CDC) focus on providing universal immunization for children aged 6 months to 18 years and for adults aged 50 years or older. The CDC also recommends vaccinating all persons with conditions that place them at high risk for complications of influenza and their close contacts, including out-of-home caregivers and health care workers. Immunization is also encouraged for anyone who wants to prevent becoming infected with influenza or spreading it to others, as long as supplies are adequate and the person has no contraindications (4).
These recommendations are based on public health considerations and the CDC's assessment of risk and benefit, guided by existing data. Vaccine efficacy studies have examined populations of different ages and underlying health status and many end points, including serologic conversion, laboratory-confirmed influenza, influenza-like illness, and such complications as hospitalization and death. Efficacy varies with age, baseline health, and immune function and with the degree of match between vaccine strains and circulating strains. Recent systematic reviews found vaccine to be effective in redu-cing laboratory-confirmed influenza in healthy children older than 2 years and in healthy adults (5, 6).
Efficacy in elderly patients and in high-risk populations has been less clear. Few trials have focused on these populations, and selection bias may lead to healthier patients being more likely to be vaccinated. Several large cohort studies have shown a reduction in respiratory and cardiovascular complications as well as hospitalization and death in elderly persons living in the community and in other persons with chronic medical conditions (7–11).
A large study of community-dwelling elderly persons conducted during 10 influenza seasons (713 872 person-seasons) showed a 27% reduction in the risk for hospitalization for pneumonia and a 48% reduction in the risk for death among recipients of the influenza vaccine compared with those who had not been immunized against influenza (12).
In a cluster randomized, controlled trial during 2 influenza seasons in 44 nursing homes in the United Kingdom, vaccination was offered to staff in 22 facilities. In the 2003 to 2004 influenza season, acceptance by staff in these "intervention" homes was 48.2% compared with 5.9% in the 22 nursing homes in which vaccination was not offered; in the 2004 to 2005 season, the rates were 43.2% and 5.9%, respectively. During periods of influenza activity in 2003 to 2004, the decrease in mortality in intervention facilities was significant compared with control facilities (rate difference, −5.0 per 100 residents [95% CI, −7.0 to −2.0]). No differences were found in 2004 to 2005, when the national incidence of influenza was unusually low (13).
Pregnant women (and their infants) are at high risk for severe influenza and complications, and vaccination is recommended for women who are or will be pregnant during the influenza season. Live vaccine is contraindicated and inactivated vaccine is classed by the U.S. Food and Drug Administration as pregnancy category C, so data are limited. However, available evidence suggests that inactivated vaccine confers benefit to both mother and infant. Transplacental transfer of maternal antibody against influenza has been documented (14).
A prospective study of 340 pregnant women randomly assigned to influenza vaccine or pneumococcal vaccine (control) showed reduction in febrile respiratory illnesses among women vaccinated against influenza during pregnancy and among their infants, as well as a reduction in documented influenza in the infants, compared with women in the control group and their infants. Vaccine effectiveness against laboratory-confirmed influenza in the infants was 63% (CI, 5% to 85%). Reduction in febrile respiratory illness was 36% (CI, 4% to 57%) (15).
Recommendations for immunization of children have been expanded from those at highest risk (age >5 years) to all children aged 6 months to 18 years. Several studies show that vaccination of school-aged children results in fewer reports of flu-like symptoms by household members, suggesting the occurrence of "herd immunity" and potential benefit to the community at large (16, 17).
The emergence of the pandemic H1N1 strain, which is not included in the present formulation of vaccine for seasonal influenza, has complicated influenza vaccination policies. Guidelines advise that the following groups receive highest priority for immunization: pregnant women, household contacts and caregivers for children younger than 6 months, health care and emergency medical services personnel, all persons aged 6 months to 24 years, and persons aged 25 to 64 years who have conditions that put them at high risk for complications (Box) (18). Indications may expand as vaccine becomes available. The current recommendations are based on the rationale that children and young adults live under close conditions that foster transmission of the disease and on observations that the disease is more severe in young persons.
Two types of vaccines against seasonal influenza are available in the United States: the trivalent inactivated vaccine (TIV), which is injected, and the live attenuated influenza vaccine (LAIV), which is a nasal spray. Both vaccines contain 3 strains of influenza: an H3N2 virus, an H1N1 (seasonal) virus, and an influenza B virus. In any given year, both kinds of vaccine contain antigenically equivalent strains. Vaccine composition is adjusted yearly. The CDC uses data on the global pattern of prevailing strains to select which viruses to include in vaccine produced for the U. S. population. The match between vaccine strains and strains that come to be prevalent is not always perfect. However, even when the match is not exact, the vaccine strain and the circulating strain are often sufficiently similar to provide some immunity (19–21).
In October 2009, vaccine against novel H1N1 became available in the same formulations as seasonal influenza vaccine, TIV (including a thimerosal-free version) and LAIV, and the same cautions apply. The novel H1N1 vaccine is produced by the same manufacturers that produce seasonal vaccine, using the same process by which vaccine is adapted to yearly strain changes.
Live attenuated influenza vaccine is approved only for healthy nonpregnant persons aged 2 to 49 years. The inactivated vaccine is approved for use in all persons older than 6 months. Both vaccines are produced in a process that uses chicken eggs, and allergy to eggs (or any other vaccine component) is a contraindication to either vaccine. Neither vaccine should be given to anyone with history of the Guillain-Barré syndrome unless the risk for influenza or complications is high, in which case TIV may be preferable to LAIV. Neither vaccine should be given to persons with significant febrile illness; minor acute illness without significant fever is not a contraindication, although when significant nasal congestion is present and may impede delivery of LAIV, vaccine should be postponed or substituted with TIV. In addition, LAIV should not be given to anyone younger than 2 years or older than 49 years; to persons with asthma, reactive airways disease, or other chronic disorders of the pulmonary or cardiovascular systems; to persons with other underlying medical conditions, such as diabetes mellitus, renal dysfunction, hemoglobinopathies, or immune deficiency; to children or adolescents receiving long-term aspirin therapy; to pregnant women; or to persons receiving antiviral drugs active against influenza. Because of the theoretical risk for spreading live (albeit attenuated) virus to severely immunocompromised patients (for example, stem cell transplant recipients in protective isolation), health care workers caring for these patients and other close contacts should be immunized with TIV. Acquisition of LAIV by unimmunized children through viral shedding has been reported, but no serious illness is known to have been caused by unvaccinated persons through infection by LAIV due to accidental environmental exposure or shedding of LAIV by vaccinated contacts (4).
Not all TIV formulations are licensed for children. TIV is classified as pregnancy category C. However, data from the Vaccine Adverse Event Reporting System (VAERS) and other sources show no significant adverse events to pregnant women or to their fetuses attributable to influenza vaccine (4).
Among healthy nonpregnant persons aged 2 to 49 years, the CDC guideline states no preference for either LAIV or TIV (4). Few studies have been designed specifically to compare the 2 vaccines.
A randomized trial enrolled 1952 healthy adults during the 2007 to 2008 influenza season and assigned them to placebo or TIV or LAIV. Absolute efficacy was 68% [CI, 46% to 81%] for TIV and 36% [CI, 0% to 59%] for LAIV. Both vaccines prevented influenza, but LAIV was less effective than TIV (22).
LAIV may also offer a protective advantage by eliciting respiratory mucosal as well as systemic immunity. Some authors also cite more-rapid acquisition of antibody with LAIV than with TIV (2, 23). Table 1 summarizes differences in indications for TIV and LAIV.
Comparison of Inactivated TIV with LAIV
Ideally, persons living in the United States should receive vaccination in October and November, but vaccine should be offered throughout the winter, because the influenza season often does not peak until February or March. If vaccine is available in September, clinicians should offer it to high-risk patients who present for routine appointments or at the time of hospital discharge to avoid delayed or missed opportunities. Note that 2 doses separated by at least 4 weeks are recommended for children who have not received at least 1 dose previously; the first dose should be given as early as possible to achieve full effect by the onset of influenza season. Nursing home residents should not be immunized before October, because antibody levels may not last through the influenza season. These recommendations reflect the consensus of experts, based on the usual chronology of influenza in the United States and the duration of vaccine-induced antibody.
If difficulties in vaccine production or distribution result in shortages or delays, priority should be given to vaccinating persons at high risk for severe disease or complications and their close contacts, including health care workers. Under such circumstances in the past, the CDC has provided triage guidelines on their Web site (www.cdc.gov/flu/professionals).
Few studies have evaluated the efficacy of "nonpharmaceutical interventions" for the prevention of influenza. Adults may be able to spread influenza from 1 day before symptoms develop to 5 days after. Children and persons with immune deficiencies can be infectious longer. Handwashing and respiratory etiquette are easy, cheap, common-sense measures shown in a systematic review to contain infection caused by respiratory viruses (24). Based primarily on what is known about the transmission of disease, experts also recommend that infected (or potentially infected) persons wear a surgical mask when in close contact with others, and that they be isolated when hospitalized or confine themselves to home until afebrile for 24 hours. The protective value of facemasks to uninfected persons in the community is unknown. Other "social distancing" strategies, such as closing schools and prohibiting large gatherings, have been studied primarily historically, and these observations seem to indicate that such measures can contribute to controlling or slowing spread of disease (25).
To investigate whether hand hygiene and use of facemasks prevents household transmission of influenza, 407 persons presenting to outpatient clinics in Hong Kong with influenza-like illness and positive rapid tests for influenza A or B were randomly assigned by household to lifestyle education, hand hygiene, or surgical facemasks plus hand hygiene. Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of index patient symptom onset (26).
Antiviral drugs can supplement or replace vaccine if there is a shortage or if vaccination is contraindicated, and can prevent the spread of disease during outbreaks in institutions and in households. Zanamivir, oseltamivir, amantadine, and rimantadine are proven efficacious when used for prophylaxis in community or family settings in which circulating virus was sensitive to the drug. This protection extends to high-risk patients.
A systematic review of 7 trials involving 7021 participants found that neuraminidase chemoprophylaxis for >4 weeks decreased the frequency of symptomatic influenza (RR, 0.26 [CI, 0.18 to 0.37]), but not asymptomatic influenza infection (RR, 1.03 [CI, 0.81 to 1.30]). Prevention of influenza was not significantly different with zanamivir than with oseltamivir, but nausea and vomiting were associated with oseltamivir (27).
Prophylaxis for the duration of the influenza season has been effective in preventing laboratory-confirmed influenza and secondary complications in nursing home patients (28). Substantial evidence exists for the efficacy of prophylactic use of antiviral agents in controlling established outbreaks in nursing homes (29–32).
During an outbreak, unvaccinated staff members and residents should receive vaccine if it is available. Staff members vaccinated at the onset of the outbreak should receive chemoprophylaxis for 2 weeks. In nursing homes, the potential for high-intensity virus exposure and possible suboptimal immune response to vaccine by debilitated residents suggest that all residents, regardless of previous vaccination, should receive chemoprophylaxis in an outbreak. Anti-viral medications should be continued in residents for at least 2 weeks and for 1 week longer than the duration of the outbreak.
In the community, short-term prophylaxis for 10 to 14 days is appropriate for persons (and their close contacts) who are at high risk and received TIV after the seasonal epidemic has begun, until vaccination becomes effective. Postexposure prophylaxis (for example, in a household setting) should be considered for unimmunized high-risk persons in conjunction with vaccination (TIV) if possible, and for healthy household contacts of those with recently diagnosed influenza.
Prophylaxis may be provided throughout the influenza outbreak to high-risk persons and their close contacts (including health care workers) when vaccine is unavailable or contraindicated, when a major antigenic difference exists between the epidemic strain and the vaccine strains, or when severe immunosuppression makes response to the vaccine unlikely. Should pandemic disease with the novel H1N1 continue, antiviral prophylaxis may play an important role in management, particularly if vaccine production does not meet demand.
The selection of an appropriate anti-viral regimen has become increasingly complex. Various strains have developed resistance to some antiviral agents, and no clinically available tests exist to determine antiviral susceptibility patterns or even viral subtypes. Table 2 shows available agents and Table 3 summarizes currently prevailing sensitivity patterns, including those seen in the novel H1N1 strain. The CDC provides periodic updates to guide antiviral use (www.cdc.gov/flu/professionals/index.htm) as well as weekly surveillance reports that include the geographic distribution of prevailing strains (www.cdc.gov/flu/weekly). At present, zanamivir alone or a combination of oseltamivir and rimantadine are appropriate empirical regimens when the specific etiologic strain has not been identified.
Antiviral Drugs for Treatment and Prophylaxis of Influenza in Adults
Susceptibility of Prevailing Strains to Antiviral Agents*
All health care personnel should receive influenza vaccination unless vaccine is contraindicated or unavailable. In the latter case, clinicians should consider prophylaxis with antiviral medications for themselves and other health care workers. The use of standing orders, which allow trained health care professionals other than physicians to identify and vaccinate high-risk patients, improves rate of immunization of hospital patients at discharge and of nursing home residents, especially if structured in an "opt-out" format (33). Likewise, providing cost-free vaccine at convenient times and places may improve vaccine coverage among hospital and nursing home staff. During outbreaks, infection control measures, such as limiting visitors, using droplet precautions, and cohorting infected patients, should also be implemented.
Clinical Bottom Line: Prevention
Influenza vaccine is effective in preventing influenza and its complications, including hospitalization and death. Vaccine against seasonal influenza should be given to children between 6 months and 19 years old, to adults older than 50 years, and to persons with chronic medical conditions that increase risk for complications. Vaccination should be encouraged in persons, such as health care workers, who have close contact with high-risk persons. Prophylaxis with antiviral medication may serve as a substitute or an adjunct under some circumstances.
The symptoms of influenza frequently overlap those of other viral respiratory symptoms, but the presence of fever and cough help differentiate influenza from other viral infections, especially when influenza is known to be present in the community. Higher temperatures, acute symptom onset, and more severe symptoms also support the diagnosis of influenza (34). Symptoms may be more subtle in elderly persons. Table 4 summarizes the differential diagnosis for patients presenting with influenza-like symptoms.
Differential Diagnosis of Influenza
In a retrospective pooled analysis of baseline clinical trial data from 3744 mainly unvaccinated adults and adolescents who had influenza-like symptoms, cough and fever were found to be the best multivariate predictors of influenza infection in the setting of an outbreak, with a positive predictive value of 79% and a sensitivity of 64% for laboratory-documented influenza (35).
A prospective study of 100 patients with influenza-like illness showed fever and cough to be highly predictive of laboratory-confirmed influenza (86.8% positive predictive value, 39% negative predictive value, 77.6% sensitivity, 55% specificity) (36).
Although weakness, myalgia, sore throat, nausea, rhinorrhea, and headache are common in influenza, they occur with similar frequencies in other viral illnesses. In most cases, gastrointestinal symptoms suggest another diagnosis, although early reports of novel H1N1 disease indicate that diarrhea is prominent.
In addition to fever, the physical examination may reveal nasal congestion and tracheal tenderness. The presence of rales or consolidation on chest examination may suggest viral pneumonia or other diagnoses or complications, such as bacterial pneumonia or heart failure.
Other forms of influenza should be considered when a patient with typical influenza-like symptoms presents outside of the usual influenza season, particularly if they have traveled recently or have other history that suggests an unusual form of influenza (for example, close exposure to birds or pigs). Very severe disease, particularly in a young, previously healthy person may also suggest a nonseasonal strain.
Human infections due to various avian strains have been reported, and presentations range from very mild upper respiratory symptoms to overwhelming systemic disease with respiratory failure. Reported cases of H5N1 (avian influenza) from Asia in recent years have been characterized by rapid, fulminant disease and a mortality rate of 50% or more.
Disease due to the novel H1N1 pandemic strain has occurred throughout the northern hemisphere during the summer of 2009, but generally has been mild. Some cases of severe, rapidly progressive, often fatal cases have been reported in young adults with no underlying disease. These cases have been characterized by dyspnea, cyanosis, hemoptysis, chest pain, confusion, and hypotension. A published description of 18 hospitalized patients reported markedly elevated levels of serum lactate dehydrogenase in all; lymphopenia and elevated creatine kinase levels were also common (37). Factors that might predict such an explosive clinical course are as yet unidentified (38).
Testing should be performed early in a suspected outbreak to confirm the presence of influenza in the community and whenever necessary to confirm the diagnosis in atypical cases. It can also be done to investigate and monitor outbreaks in hospitals and nursing homes.
Although viral cultures on naso-pharyngeal specimens are most sensitive and specific, results may take 3 to 10 days or longer, which limits clinical usefulness. Rapid tests for seasonal influenza are widely available and can be helpful for individual patients in whom the results will contribute to treatment decisions. Diagnostic testing does not need to be done in all patients who present with a typical clinical picture of influenza when the disease is prevalent in the community. In hospitalized patients, rapid confirmation of diagnosis aids in prompt institution of appropriate infection-control measures and of antiviral therapy as well as a reduction in the use of antibacterial antibiotics.
In a published hospital record review, rapid testing led to a reduction of antibacterial antibiotic use in patients who tested positive for influenza (86% vs. 99%; P = 0.002) and to greater use of antivirals in patients who tested positive (73% vs. 8%; P < 0.001) (39).
In the face of increasing resistance to antiviral medications, testing that can differentiate influenza A from B may help to determine an appropriate regimen for treatment or prophylaxis, but none of the commercially available rapid tests distinguish between different subtypes of influenza A (seasonal H1N1 or H3N2). No rapid tests are designed specifically to detect the novel H1N1. Preliminary studies show that some of the rapid tests designed to detect seasonal influenza A also detect novel H1N1, but the sensitivity varies from 40% to 69%, and a positive result does not differentiate between seasonal and pandemic strains (40).
In general, CLIA (Clinical Laboratory Improvement Act)-waived tests for physicians' offices are more than 70% sensitive and more than 90% specific for the detection of seasonal influenza. Sensitivity is higher in children than in adults, higher with nasal samples than with throat samples, and higher during the first few days of illness. The positive predictive value is greatest during influenza season, and the negative predictive value is greatest outside of influenza season.
Commercial laboratories can confirm rapid tests if necessary during seasonal influenza. If novel H1N1 is suspected and if confirmation is required (for example, for community surveillance or in a very ill or immunocompromised patient), definitive testing may be obtained through public health authorities. In either of these cases, clinicians should initiate empirical management without awaiting results.
A list of commercially available tests and their performance characteristics can be found at www.cdc.gov/flu/professionals/diagnosis/labprocedures.htm.
Clinicians should consider possible bacterial complications in patients who remain ill, worsen, or have acute onset of high fever and malaise after initial improvement. Fever in adults with uncomplicated influenza generally lasts about 3 days, by which time most will show signs of improvement. Although it may take 10 to 14 days for complete recovery, lack of improvement or worsening symptoms suggest either a complication or an alternative diagnosis.
Acute bronchitis is the most commonly recognized complication, but others include sinusitis, pneumonia, and noninfectious sequelae (41). Patients who remain febrile for more than 3 to 5 days, or who develop fever or new symptoms, require evaluation. Symptoms and clinical findings should guide blood tests, cultures, and imaging studies. Consultation with a specialist should be considered, especially if the patient is severely ill or immunosuppressed.
Occasionally, serious systemic bacterial infections, such as pneumonia, staphylococcal bacteremia, meningococcal disease, and inhalational anthrax, can present initially with influenza-like symptoms. The differential diagnosis should be broadened in patients whose condition deteriorates rapidly, and work-up and treatment should be adjusted accordingly. Again, consultation with a specialist might be appropriate in such cases.
Clinical Bottom Line: Diagnosis
Clinical diagnosis of influenza on the basis of fever, cough, rhinorrhea, and symptom severity is usually reliable when influenza is present in the community. Viral cultures can be useful to determine the cause of an outbreak and rapid testing can guide management decisions in individual patients with an atypical presentation.
Hydration is important to replace the large insensible water losses that occur with fever. In patients with infection due to the novel H1N1 strain, diarrhea may also necessitate fluid replacement. Antipyretics, such as acetaminophen or ibuprofen, can help to reduce fever and thus prevent further insensible loss. Reduction of fever can prevent other consequences of increased metabolic rate, such as tachycardia, and may relieve such symptoms as chills and myalgia. No convincing evidence exists that anti-pyretic therapy either prolongs or shortens the course of illness. Aspirin and aspirin-containing medicines should be avoided, particularly in adolescents and children, because of their association with the Reye syndrome.
Clinicians should consider antiviral medication for people who present within 48 hours of symptom onset, for hospitalized patients, and for those at risk for severe disease. Pregnant women are particularly vulnerable, and especially in the context of the present pandemic, prompt antiviral therapy is recommended. The CDC provides periodic updates to guide antiviral therapy based on prevailing strains and susceptibility patterns of each strain. These guidance statements are available at www.cdc.gov/flu/professionals/index.htm. Additionally, weekly updates are available at www.cdc.gov/flu/weekly.
The selection of an appropriate anti-viral drug or combination is difficult due to the level of resistance that has emerged. Recently circulating H3N2 strains and the pandemic strain of H1N1 are resistant to the adamantanes (amantadine and rimantadine), which also have no inherent activity against influenza B. Recent seasonal strains of H1N1 have become resistant to oseltamivir but remain sensitive to the adamantanes. Table 3 summarizes these resistance patterns. All these strains remain sensitive to zanamivir, which is the treatment of choice for persons who can take aerosolized medication. In other cases, a combination of oseltamivir and rimantadine would be an appropriate empirical regimen. Rapid diagnostic testing (for example, to differentiate influenza A and B) and information from public health authorities about the identity of locally prevailing strains may help refine the selection.
Many studies showed that early treatment with either oseltamivir or zanamivir results in earlier resolution of symptoms and a more rapid return to normal activities (42–47).
The duration of treatment is 5 days. Table 2 summarizes dosages, benefits, and side effects.
A systematic review that examined trials of antiviral treatment for influenza concluded that amantadine and rimantadine use should be discouraged and that, because of their low effectiveness, neuraminidase inhibitors should be used only in serious epidemic or pandemic situations rather than for control of seasonal influenza (48, 49).
In a meta-analysis of 17 treatment trials and 7 prevention trials involving children younger than 12 years, healthy adults aged 12 to 65 years, and high-risk persons, zanamivir reduced the mean duration of symptoms by 1.0 day (CI, 0.5 to 1.5), 0.8 day (CI, 0.3 to 1.3), and 0.9 day (CI, 0.1 to 1.9), respectively. Oseltamivir reduced symptoms in the same groups by 0.9 day (CI, 0.3 to 1.5), 0.9 day (0.3 to 1.4), and 0.4 day (CI, −0.7 to 1.4), respectively. The authors concluded that both drugs were effective for treating influenza, although the evidence was limited for certain populations (50).
A retrospective pooled analysis of data exclusively from 321 high-risk patients with a clinical diagnosis of influenza showed that 154 of those patients treated with inhaled zanamivir experienced a reduction in the length of illness by 2.5 days compared with those given placebo (P = 0.015). Treated high-risk patients returned to normal activities 3.0 days earlier (P = 0.022) and had a 43% reduction in the number of complications requiring antibiotics (P = 0.045) (51).
Fewer studies have been done in hospitalized patients, but at least 1 has shown a reduction in mortality among hospitalized patients with laboratory-confirmed influenza who were treated with antiviral drugs (52). A retrospective cohort study showed decreased length of stay in hospitalized patients treated with oseltamivir (53).
Most studies on the use of antiviral agents are based on initiation of therapy within 48 hours. However, treatment is generally well-tolerated and, even if started late, may improve outcome in critically ill or high-risk patients. For this reason, some authorities endorse the use of antiviral therapy in hospitalized patients and other selected persons even after 48 hours of illness (54).
Although oseltamivir and zanamivir are pregnancy category C drugs, the CDC advises that pregnancy should not be considered a contraindication to treatment. If H1N1 is suspected, treatment should be given immediately because of the observed severity of disease in pregnant women. Under these circumstances, oseltamivir may be preferred to zanamivir because of its systemic absorption (55).
Hospitalization should be considered for patients who are severely ill because of influenza or its complications. Such conditions as dehydration, inability to maintain adequate intake, respiratory distress, or hypoxemia should prompt admission. Likewise, an uncertain clinical course or frail baseline health might prompt admission for close observation.
Consultation should be considered for help with diagnosis or management as needed. Diagnostic consultation might be useful in seriously ill patients in whom the diagnosis of influenza is suspected but unproven, in patients with an atypical presentation, when a complication is suspected, or when the differential diagnosis is unusually broad (for example, an immunosuppressed patient with atypical pneumonia).
Consultation for management should be sought with infectious disease specialists for guidance in the use of antiviral agents and the need for antibacterial antibiotics, and with pulmonary or critical care specialists for maintaining oxygenation and obtaining specimens for testing.
Consultation with public health authorities should be sought if avian influenza or another unusual strain is suspected. Public health authorities can expedite laboratory identification of the strain and can guide decisions on antiviral therapy on the basis of available susceptibility data. Also, they are responsible for monitoring disease outbreaks, determining the source, evaluating possible human-to-human transmission, and instituting measures to limit the spread of disease.
Clinical Bottom Line: Treatment
The mainstay of influenza treatment is supportive care with hydration and antipyretics. Initiate antiviral treatment in hospitalized patients and in those at risk for complications. Consider treatment of others who present early in the course of disease, because early treatment can reduce duration of disease. Hospitalization and subspecialty consultation should be considered for severe illness, uncertain diagnosis, or complications.
Since October 2005, the Centers for Medicare & Medicaid Services (CMS) has required participating nursing homes to offer influenza vaccine to all residents (56). The CMS also includes influenza immunization of patients 50 years and older as a performance measure in its Physician Quality Reporting Initiative (PQRI) (57). The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) requires documentation of efforts to vaccinate independent practitioners and staff against influenza (58).
The recommendations of most professional organizations agree with the CDC's Advisory Committee on Immunization Practices (ACIP) consensus. ACIP includes representatives from the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Medical Association, the American College of Physicians, the American Osteopathic Society, the Infectious Diseases Society of America, the National Foundation for Infectious Disease, the Society for Healthcare Epidemiology of America, and numerous other organizations. The Infectious Diseases Society of America has also recently published a set of clinical guidelines for prevention, diagnosis, and treatment of seasonal influenza (54). The recommendations listed in this issue of In the Clinic reflect those guidelines.
Recommendations for Vaccination Against Seasonal Influenza, 2009
All children aged 6 mo to 18 y
All persons aged ≥50 y
Women who will be pregnant during influenza season
Adults and children with chronic pulmonary (including asthma and any condition that causes difficulty handling respiratory secretions), cardiovascular (excluding hypertension), renal, hepatic, hematologic, or metabolic (including diabetes mellitus) disorders, or immunosuppression (including related to medications or HIV)
Residents of long-term care facilities
Persons aged 6 mo to 18 y receiving long-term aspirin therapy who are at risk for the Reye syndrome
Contacts of high-risk persons, including health care workers involved in direct patient care, out-of-home caregivers, and household contacts.
Household contacts and caregivers of children aged ≤5 y
Any other person who wants to reduce their risk for influenza or for transmitting it to others
Highest Priority Groups for H1N1 Vaccine
Pregnant women
Household contacts and caregivers for children aged <6 mo
Health care and emergency medical services personnel
All persons aged 6 mo to 24 y
Persons aged 25 to 64 y at high risk for flu complications
Things You Should Know About Influenza
What is influenza?
Influenza (flu) is an illness caused by infection with the influenza virus.
Flu symptoms include fever, cough, body aches, tiredness, sore throat, and runny nose.
Usually, flu is not serious and persons recover completely. However, older persons, very young children, and persons with long-term conditions can get very sick or even die of flu or its complications.
What is the difference between regular flu and novel H1N1 (swine) flu?
Novel H1N1 (referred to as "swine flu" early on) is a new influenza virus causing illness in people.
Novel H1N1 spreads from person to person worldwide, probably in much the same way that regular seasonal influenza viruses spread, but occurs outside the regular flu season.
Although regular flu is most serious in older persons, novel H1N1 seems to affect younger persons more than older persons.
Symptoms of novel H1N1 are similar to regular flu, but many patients also have diarrhea, which usually doesn't occur in regular flu.
How can you keep from getting the flu or spreading it to other people?
Get a flu shot every fall if you are aged 6 months to 18 years or 50 years or older; have diabetes, heart or lung disease, or other health problems; or live with or take care of an older person, someone with health problems, or children younger than 5 years.
Wash your hands often with soap and water and try not to touch your eyes, nose, or mouth.
Stay away from people who are sick.
If you get sick, stay home from work or school.
How will I know if I have the flu or something else?
Doctors usually can make the diagnosis without special tests, especially when symptoms occur during a local outbreak.
Your doctor may need to do tests to rule out other illnesses.
Call your doctor if you have the flu and you:
Have a high fever for more than 3 days
Are short of breath
Cannot eat or drink
What can I do for the fever, cough, and aches of the flu?
Fluids and medicines to lower fever are helpful.
Flu medicines do not cure the flu, but they may shorten the time you are sick. They are most effective when started within 1 to 2 days of the first symptoms.
Web Sites with Good Information about Influenza
Centers for Disease Control and Prevention
American Lung Association
National Institute of Allergy and Infectious Diseases
American Thoracic Society
Tool Kit
PIER Modules
Access the PIER module on influenza. PIER modules provide evidence-based, updated information on current diagnosis and treatment in an electronic format designed for rapid access at the point of care.
Patient Information
Download copies of the Patient Information sheet that appears on the following page for duplication and distribution to your patients.
Access MEDLINE Plus information about influenza for patients, including an interactive tutorial available in both English and Spanish.
Clinical Guidelines
Current information on seasonal influenza, vaccine and treatment recommendations, vaccine availability, and influenza activity. Includes information for health professionals and patients.
Current information for clinicians and patients on pandemic influenza due to the novel H1N1 strain.
Diagnostic Tests
Access information about CLIA-waived tests for rapid diagnosis of influenza.
Quality Measures
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Warner reveals new Batman: Arkham City DLC packs
Warner Interactive has revealed two new downloadable content bundles to keep Batman: Arkham City fans playing on.
The first pack brings together much of the content already released into one DLC pack at a reduced price. The Arkham Bundle includes the Nightwing Bundle Pack, the Robin Bundle Pack and the Arkham City Skins Pack all for the nice price of 1200 MS points or Xbox Live Marketplace or 11.99 GBP on PSN and Games for Windows Live.
The second pack announced is the Challenge Map Pack which features The Jokers Carnival Challenge Map, the Iceberg Lounge Challenge Map, and a brand new invisible predator challenge map, The Batcave. This will be available for 240 MS points on Xbox Live and 2.39 GBP on PSN and Games for Windows Live.
Fans will also be able to get their hands on the Batman Inc. Batsuit Skin for free upon completing the main story which can be worn in story mode and the Challenge maps.
Latest News
- Call of Duty: Black Ops III is coming to the PS3 and Xbox 360 after all
- Tomonobu Itagaki's Devil's Third gets a release date
- Adr1ft is coming to PC and consoles at the end of the summer
- EA gives the new Mirror's Edge a name – Mirror's Edge Catalyst
- ZombiU PS4 and Xbox One port reportedly in the works
- Mike Bithell's Volume to be released this August
- Gearbox's new shooter Battleborn gets a pre-E3 trailer
- Steam Controller launches in October, Steam Machines arrive in November
- Gears Of War devs Black Tusk change their name to The Coalition ahead of E3

subset: commoncrawl


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The sunflower seed and sesame seed crackers:
05-05-12 S.jpg
They're so so easy to make (as long as you have a food processor) I got the recipe from this website and if you're missing that satisfying crunch you get from crackers, tortillas or crisps then they're the perfect replacement. And very cheap too! All you need is a cup each of sunflower and sesame seeds and some water. You grind the sunflower seeds up in a blender until it resembles a kind of flour. Mix in the sesame with a bit of water (add progressively) and roll out between two pieces of parchment on a baking tray. Bake for about half an hour at 375f, 180 celcius. I topped mine with some butter, a bit of ham, some sundried tomato. But you could use lots of things. Guacomole would be nice, nut butters, anything you can dip or spread really. I'll definitely be doing these again!
Ovenbaked wild salmon fillet with sweet potato cooked in coconut oil and sprinkled with garam masala and salad, courgette and tomato. Really tasty.


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About Petrus
Chateau Petrus, from a prime vineyard on well-drained clay soil atop the Pomerol plateau, has for decades stood as the world's greatest example of Merlot. Petrus's rise to the top, however, was rather meteoric, happening all at once in the second half of the 20th century.
98(+?) Points | Stephen Tanzer's IWC - July/August 2013
Fully saturated ruby. Knockout aromas of fresh black cherry, blackcurrant, exotic herbs, coffee and menthol, plus a hint of minerality. Juicy, fruit-driven flavors of dark berries and cherry are complicated by cocoa, vanilla and graphite and given laser-like precision by vibrant, harmonious acidity. Manages to be both fleshy and acidic at the same time, demonstrating uncanny depth and complexity of flavor. This strikes me as deeper and longer than the already magnificent 2009: it may well turn out to be the wine of the vintage. These two wines from Petrus make for an outstanding, back-to-back pair of vintages.


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Say hi to Siv. Hi Siv! She's a beautiful long, cable knitted sweater and no wardrobe is complete without her. Wear her with a pair of tights and she transforms into a dress. Classic knitwear at it's finest.
colour: tanned not burned
In a size small the length is 75 cm and the chest width is 104 cm.


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6/28/09 - Beach Adventure
by Kenny on Sunday, June 28, 2009
This weather we're having in the Bay kicks so much ass! Went to the beach today with Max, Nai, Leslee, and I. I got raped so bad by mosquito's yesterday, 12 bites, 5-6 on each leg and a few on arms, gayyy! But at least they aren't bugging me too bad. Photos by Leslee.
seaweed mask
ty for the bomb viet-sandwiches
After headed to FOSTER FREEZE in Alameda, this place that is good but i never ever think of going to.
6/26/09 - repaint
by Kenny on Friday, June 26, 2009
Picked up my frame today from West Coast Powder, guy also hooked up it up with free clear coat. After went to get the decals made.
Taken today, frame is currently at S-CAR-GO (Brandon's other job, serious Porsche specialty shop) getting the drop-outs filed a bit. Not sure if i am gonna go through with this but my idea was to get a light glitter/flake cleared over the frame, we'll see.
Here is an awesome story, at work somebody from Hawaii had emailed me about gettin' some stickers, anyways they mailed in their Self addressed stamped envelope today that included this along with it!:
Thanks Kaitlin!
also check out all the drinks NOS energy hooked up for us+HOC:
by Kenny on Wednesday, June 24, 2009
Found this picture from Starfuckers Flickr. The day i met Jun, and Shinya, owner/creator of Starfuckers.
6/22/09 - shit from today...hairy
by Kenny on Tuesday, June 23, 2009
Today max let me check out his new Smart mag.
Later today went to Fremont to meet up some bad asssessss
white boi justin
azn @ heart! erik
eric hittin the switches
WHITE BOI JUSTIN on SPIKEY PINOY BOY 52's bike
6/21/09 - hello kitty and some videos
by Kenny on Sunday, June 21, 2009
Some of you guys may have seen this Scion XB all Hello Kitty'd out. I finally got to meet the girl who drives it and check out her ride lol.
Check out that exhaust!
Hello Kitty no joke!
I'd love to share these videos with you: ENJOY!!! The first two are from Kasou Taisho.
6/19.5/09 - this is what i did today
by Kenny on Saturday, June 20, 2009
This afternoon, headed over to West Coast Powder in South SF. The guy here kicks ass, he is such a down to earth type of guy, just bought a Turbo Renault, FIRST one i have ever seen ever!
This thing is bad ass!
Chosing my color, i actually chose the exact color my bike already is lol, but if u seen my shit in person, you know how faded and jacked up my paint as become.
After headed to Naan N' Curry.
My FAVORITE orange stuff, Chicken Tikka Masala.
Went over to Kinokuniya and found the new issue of DAYTONA Pedal Speed magazine, if you guys are interested there is one issue left.
surprising to see how many local articles are in this magazine, mostly SF.
6/19/08 - thnx scott
by Kenny on Friday, June 19, 2009
6/18/09 - Grubbinnnn'
by Kenny
After got off work today i met up with some homies @ the same spot as yesterday, Golden Gate Park. After chillin out in the freakin' windy ass weather, some of us headed to CORIYA HOT POT on Clement.
Yu trying to hide, hah.
As if that wasn't already enough, afterward Tim took us to this place called Kowloon Ton Dessert Cafe on 7th.
6/17/09 - photos from today, not gay
by Kenny on Thursday, June 18, 2009
pictures from hanging out today.
Frank book, bondage edition.
Tim riding thru the wilderness, GG Park.
Fonseca + son.
strokin' it
Afterwards we headed over to Tim's + Safeway 2 blocks away (around the corner) to pick up dinner (thanks!)
[ty sean]
Tim moved while blocking the violent images on the screen from Chris.


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text: Alumna profile: Alison Hodge In 'Postgraduate study' PhD research focusPostgraduate studyDoctoral researcher profilesAlumna profile Back to 'Department of African Studies and Anthropology' Alison Hodge graduated with a Masters in African Studies from the Centre for West African Studies (CWAS) in 1970. She is now a book publisher, as the owner of Alison Hodge Publishers. She said "Meeting and working with a wide range of knowledgeable and talented authors; developing ideas for books and making them a reality is the best part of my job. My time at CWAS led to my career in publishing. At the suggestion of Professor Fage, I contacted the publisher Christopher Hurst, and became his first editorial assistant." From there, Alison moved to Thomas Nelson & Sons, and spent several years in Nigeria as Senior Editor for Nelson Nigeria. "On my return, and on a whim, I bought a bookshop, and started publishing under my own imprint. I sold the bookshop and did a lot of freelance editing, later working for ODA (now DfID) in Jamaica as publishing consultant to a secondary schools textbook project in the Ministry of Education. On my return, I continued to work freelance, and to develop my own publishing imprint." Alison recalls her time at University of Birmingham fondly; she particularly remembers "being introduced to new subjects by excellent, enthusiastic and dedicated staff; learning in small groups; making new friends. "My Masters gave me a foundation in a subject area that, at the time, was a fairly unusual specialization, which helped me to get my first job in publishing"


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Not much of a crowd for the weekend a.m. report, so I'm going to leave up Saturday's and give you a couple Sunday morning links.
First-round pick Jiovanni Mier singled on his first pitch as part of a 2-for-3 debut with one walk. He helped rookie-level Greeneville to a blowout win.
Yorman Bazardo had a decent start numerically for Class AAA Round Rock.
Tigers manager Jim Leyland wasn't pleased with his young starter Saturday night in Houston.
No links, but it's just an off-day for Miguel Tejada.
Friday's main entry in the Astros a.m. report was by popular demand. Today's is by request.
I've been asked to take another inventory of the National League to determine the statistically based 32-man roster of the All-Star team with the following breakdown.
8 starting position players
8 backup position players
4 utility position players
8 starting pitchers
4 relief pitchers
This isn't opinion; I used the same method as I did in the first version of the team using data as of before Friday's games and available at Fangraphs.com (which by the way, leads with a Yorman Bazardo analysis as of early this morning.) Basically, it is runs contributed above average for hitters and runs saved for pitchers, but I encourage you to click the first link of this paragraph and read about the method.
Eventually, I finished up the roster and found that the only team needing affirmative action to give every team a player were the Chicago Cubs, who really have nobody putting together much of a season.
Ted Lilly is a candidate to replace the last starter, Santana, but we'll put in Kosuke Fukudome (for defense as much as offense) for Scott Hairston in the last utility spot because he's a little closer statistically to Hairston than Lilly is to Santana.
Here's the team, starters in bold.
Two more things. Not everyone on this roster is healthy, so there could be some changes soon in who, statistically, should make it. And defense matters more than you'd expect.
Brian McCann (ATL)
Yadier Molina (STL)
First base
Albert Pujols (STL)
Adrian Gonzalez (SD)
Second base
Chase Utley (PHL)
Brandon Phillips (CIN)
Third base
David Wright (NY)
Ryan Zimmerman (WAS)
Hanley Ramirez (FLA)
Jack Wilson (PIT)
Justin Upton (ARZ)
Raul Ibanez (PHL)
Matt Kemp (LA)
Ryan Braun (MIL)
Hunter Pence (HOU)
Carlos Beltran (NYM)
Prince Fielder (STL)
Joey Votto (CIN)
Ryan Howard (PHL)
Scott Hairston (SD)
Kosuke Fukudome (CHI)
Starting pitchers
Tim Lincecum (SFO)
Dan Haren (ARZ)
Javier Vazquez (ATL)
Josh Johnson (FLA)
Ubaldo Jimenez (COL)
Joel Pineiro (STL)
Chad Billingsley (LAD)
Johan Santana (NYM)
Relief pitchers
Jonathan Broxton (LA)
Heath Bell (SD)
Rafael Soriano (ATL)
Todd Coffey (MIL)
*Catchers using runs above replacement.
Hunter Pence makes the team comfortably with Miguel Tejada, who had a good defensive game last night, still hurt by his overall defense and lack of walks. Wandy Rodriguez, the other Astro on the last squad, has fallen off the pace.
Mini weekend edition of links
On our Astros page, you'll find the game recap, the story of Brandon Backe's demotion and a little lower, some raw audio from Jiovanni Mier's press conference.
Jose de Jesus Ortiz blogs about Backe's shock in being designated for assignment and asks what your favorite Backe memory was.
Astros fan blogger Chip Bailey wonders if the Astros will be above .500 at the All-Star break.
• Baseball America loves them some Astros prospects. They give high praise to Jordan Lyles and Bud Norris this week.
• However, Lyles won't be on next week's list after Lexington's blowout loss last night.
• Geoff Blum played the whole game, going 1-for-4 with an RBI double and a strikeout, while Bud Norris had another good start in Class AAA Round Rock's loss.
Express manager Marc Bombard is the minors' winningest active manager and naturally has higher aspirations. Is "winningest" a word?
Thought of the day
To the men out there: You can have your movie stars, your pop singers and your Russian tennis players. My celebrity crush du jour is Lauren Collins from the New Yorker. Someone in the relationship has to be a good writer, and she is fantastic. And though I've never seen her, I can't say I've met too many Laurens who weren't attractive.


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A president is shot, Cal Ripken Jr. breaks an unbreakable record, and the world mourns the passing of a princess, all on this day.
On this day: September 6UPDATED 1:00 AM CDT Sep 06, 2016
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Maverick's Mischief
Maverick is originally from Columbus, Ohio but prefers to produce his offspring up in Canton, an hour and forty minute trip by car. The trip is quicker for Maverick, as he prefers to fly. He was born in 2000 and by 2003 his first girl was born. They named her Lady Justice. By 2004, Maverick fathered four more offspring but it was 2005 through 2009 that he found his true love. Priscilla caught his attention, maybe it was her long neck, or the way her dark eyes scanned his face slowly, meaningful; we can never know for sure. But what we do know is that in their four blissful years together, they added 18 little ones to the planet. 2010 was a bad year; Priscilla and Maverick ended their relationship, possibly due to the stress of raising such a large family. Maverick went back to is wilder ways and fathered 4 chicks with and unknown female. Possibly, she was simply a rebound to Priscilla, his one true love.
Every year Maverick's mischief is celebrated by the good people of Canton, Ohio. Maverick prefers to birth his youngsters at the Chase Tower Canton Club on the corner of Market Avenue and Tuscarawas Street smack dab in the middle of downtown. He's a bit of showman, Maverick, nesting his little home on the ledge of the 14th floor. Maverick is a Peregrine Falcon, and he and his multitude of chicklets were considered an endangered species back in the 1970's. This status is what kick started all the fuss these dedicated Cantonians raise each spring when the falcon's eggs hatch. The Ohio Division of Wildlife are a sentimental bunch, so each year after the hatchlings prove their viability, they are displayed for the public in a sort of group birthday party. This year the little ones poked themselves into the world on May 1 and about 100 people watched the banding ceremony. Maverick has flown the coop, but is expected to continue to do his part to remove the Peregrine Falcon off the endangered list, bird by bird.
Yale Makes Extensive Digital Image Collection Available to the Public
Rural American Baroque by Ralph Steiner/via Yale Digital Commons
The above image comes from Yale University's Yale Digital Commons, a digital collection of images recently made available buy generic cialis for online public access and use. According to Yale's news release:
Scholars, artists and other individuals around the world will enjoy free access to online images of millions of objects housed in Yale's museums, archives, and libraries thanks to a new "Open Access" policy that the University announced today. Yale is the first Ivy League university to make its collections accessible in this fashion, and already more than 250,000 images are available through a newly developed collective catalog.
The goal of the new policy is to make high quality digital images of Yale's vast cultural heritage collections in the public domain openly and freely available.
Thank you to Yale for providing this valuable service.
This photograph was taken in 1929 by Ralph Steiner, an American photographer of Czech origin, and was donated to Yale in 1932 by one George Hopper Fitch.
What initially interests me about this image is the title: Rural American Baroque. Steiner can rightly call the image rural because it recalls the confirmed rural practice of front porch sitting.
But the addition of Baroque complicates the issue because Baroque is not something that one normally associates with rural America, nor is the chair really reflective of iconic Baroque style, which generally refers to an artistic or design style that is very ornate and highly decorated. Perhaps the photographer is referring to the the chair's decorative scroll pattern, which is something like Baroque in that it is decorative and not simply utilitarian. The addition of Baroque suggests a nice contradiction to traditional or common notions of rural as connoting simple, no-frills sort of design and lifestyle.
This photograph is visually interesting because the doppelganger shadow of the chair is more visible than the chair itself. Even though the chair itself is centered in the photograph and appears to be the subject, the shadow continually draws my attention away from the chair. It seems then that the shadow is the true subject of this photograph, especially because it is in the shadow that one can more clearly see the Baroque-like style which is referred to in the photograph's title.
-Josie Javens
Rural Destruction
1940 Flood in Cullowhee, NC. Photo courtesy of: digitalheritage.org
The photo above is a picture taken after one of many floods that occurred in the Western part of North Carolina in 1940. During this time, the Great Depression was still occurring, and many people were still struggling throughout the nation. If the economy was not bad enough already, the flood of 1940 in Cullowhee, North Carolina made it worse for the local Jackson County residents. This photo is more than just the image of pin-point chaos after a massive flood; it is a representation of what was happening all across Western North Carolina in 1940, the destruction of rurality.
The photo is taken on Old Cullowhee Road, right next to Western Carolina University. The flood was so powerful that it uprooted the bridge which allowed primary access for local residents and students alike to the surrounding areas. At the point when this picture was taken the water had subsided and was on the decline, however, the damage done is clearly evident. Despite all the technology of the time, even in this rural town, nature had its way and won this fight. This is just but one instance of the destruction that was usurping local rural towns through Western North Carolina.
The river shown in the photo is known as the Tuckasegee River, or more commonly referred to by its residents and students as the "Tuck." The Tuck runs through most of Western North Carolina and it is a favorite for local residents and tourists for white water rafting, kayaking, and tubing. Today, a newer stronger bridge is set in place on old Cullowhee Road. Many residents still live right alongside the river, hoping that it will remain calm, however, residents are always on alert to the dangers that the Tuckasegee River presents. If residents or students ever forget, they can always look to the photos from 1940 as a reminder of what nature can do. Hopefully the Tuck will remain calm, and this tranquil, peaceful, and beautiful rural town of Cullowhee, North Carolina can remain unchanged, incased in all of its rural splendor.
-John Temple
Hidden Rural Gem
Madisonville, Louisiana. Photo taken by: John Temple
Whenever I am asked where someone should go to enjoy Louisiana I immediately say New Orleans. I mention places like Jackson Square, Café Du Monde, and, of course, Bourbon Street. Rarely, however, do I ever mention my favorite place to go: Madisonville. Perhaps I never mention Madisonville to others out of sure spite, or perhaps it's because I am worried that it will become just another tourist attraction and lose its overwhelming appeal; that can only be defined as rurality.
Madisonville is traditionally named after the fourth President of the United States, James Madison. Madisonville is a quiet, peaceful, and, most of all, rural town. Undisturbed by the surrounding cities, the town has found a way to remain rural despite the ever expanding population after hurricane Katrina destroyed much of New Orleans in 2005.
The photo above, represents more than just a piece of Madisonville, it represents the essence of the city. The expansive green cypress trees shade the natural landscape keeping the old plantation-style houses hidden upon first glance. If you could see on the other side of the photo you would see a deep and dark murky river, brown from the sediments that have been tumultuously rounded up from the constant battering of storms and hurricanes.
As a boy my paw-paw would take me to the river and we would spend hours just watching the boats go by. As I grew older I found that Madisonville would become my haven to visit whenever I ventured to come home during my time in service. Whether I was gone a month, or coming back from a deployment, Madisonville was always where I went to clear my head. This rural town with its muddy banks and salty air is unforgettable. Whenever I look back on my favorite parts of life and Louisiana, Madisonville will be at the top.
-John Temple
Garden by the Foot
"Square Foot Gardening" – photo from Robert Goodwin's Flickr computer science homework help photostream
Developed in the 1970s by Mel Bartholomew, Square Foot Gardening produces the same amount of vegetables and fruit as traditional single-row gardens in a fraction of the space. These small, raised beds are popular among urban dwellers with limited space, particularly since they do not require digging–they build up rather than down–and can survive well in areas with poor soil. Furthermore, Bartholomew explains in his original text (there is now a second book) that this design "conserve[s] the amount of water, soil conditioners, and labor," making it economical in a variety of ways.
The first step in creating your own square foot garden is to obtain or create a "box," either of wood, brick, or stone.
Although wood is perhaps the most common material used in this design (they can be found in yards all around West Asheville, for instance), some gardeners are wary of rotting and prefer brick or stone for that reason (this raised bed kit made from recycled materials and sold by Sam's club is perhaps another option). The size of your garden box is, of course, dependent on location and the amount of available space; however, the default measurements for first-time square foot gardeners is 4′ x4′. It is important to be able to reach across the garden without having to step inside the box and onto the soil, so take that into consideration as well. For those with bad backs and/or pesky pets, try a table top design.
Once the box is complete, create a grid with whatever material you prefer–string, wood, metal, etc.–of 1′ x 1′ squares. There are several factors at play in determining the plants suitable for your garden, including climate and sunlight, but once those details are squared away (punny, right?) then you are ready to plan(t)! Honestly, a large amount of planning is involved in square foot gardens, but they are worth it. Be sure to allow enough depth for crops such as potatoes, provided trellises and support for tomatoes and vertically growing runners such as cucumber, and place the appropriate number of plants in each square foot (for instance, one broccoli plant per square, but up to sixteen plants for onion).
All of this information is available on the web. There are many websites, blogs, and forums dedicated to square foot gardening, and, of course, Bartholomew's books are invaluable. Although I grew up in a rural area of North Carolina, I've been an urban apartment dweller for the last five years and have been limited to container gardening. My tomato and sunflower plants grew taller than me (not a great feat, really, since I'm barely 5'1″), but it still did not feel enough like gardening to please my little rural heart. This summer, however, I move into a house in West Asheville, and my first major project involves constructing a square foot garden. I cannot contain my excitement (buh-dum-bum)!
–Britt Garrett


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Reese Witherspoon Flaunts Big Baby Bump at 'Mud' Premiere
Gabrielle Chung
| May 26, 2012 - 4:09 pm
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Sapphire 5970 Toxic Review
Dirt 2, Stalker, Crysis Warhead
Published: 5th August 2010 | Source: Sapphire | Price: around £800 |
Gaming Benchmarks
Moving away from the synthetic testing onto some gaming, we introduce a couple of extra tests to the mix. Firstly in the white corner we have a reference HD5970. In the silver corner we have a 5870 Crossfire setup, which we still think is the best quality per quid choice on the market, and when we tested the standard 5970 it absolutely spanked it.
Dirt 2
Codemasters Dirt 2, as we've often mentioned, benefits greatly from some good optimisation which means it will be playable on almost anything. It does mean that that even extraordinary amounts of power wont have huge benefits, but you can see here from our graph that the Toxic annihilates its 5970 brother and isn't greatly behind the Ares. Certainly nothing that the £400 odd price differential would justify.
S.T.A.L.K.E.R Call of Pripyat
If ever there was a strange graph, this is it. We've seen a few curious results in our time here at OC3D, but this is mind-blowing. We can only put it down to a couple of things. Either the 10.7 Catalyst update made huge changes to either the performance or image quality of STALKER, the Toxic absolutely eats it for breakfast, or Fraps isn't monitoring it correctly.
We will give it the benefit of the doubt though, because it's been alright in our other testing. In which case if you're a fan of the apocalyptic shooter then you will already be out the door.
Crysis Warhead
Cryteks old Crysis Warhead is the game that just refuses to lay down and die. Despite having proved with Quadfire that it just isn't up to the task of handling huge horsepower, nonetheless it's the game by which all single cards are judged.
The Sapphire 5970 Toxic comfortably keeps the framerate the right side of 60 and, barring a minimum frame-rate issue which is mirrored by the reference 5970 and therefore might be a architectural thing, would definitely be up there with the best. The graph actually belies the smoothness of the experience.
Most Recent Comments
Continue ReadingQuote
By the way, I see the award images have changed? (atleast for the performance award?) I like it, looks nice Quote
So the CPU will account for most of it, and the tiny extra theoretical grunt of the Ares gives us the few extra. If you look back at the Ares XF results you'll see that Crysis is pants no matter how much hardware you have. So really take it with a pinch of salt.Quote
A. Completely rip off the Arctic Accelero Xtreme
B. Use an Arctic Accelero Xtreme.
'cos from where I am sitting it has to be one or the other.Quote
If you look back at the Ares XF results you'll see that Crysis is pants no matter how much hardware you have. So really take it with a pinch of salt.
It's not just OC3D. Every website is "Crysis this, Crysis that". Seriously, the game is old hat now (and I'm not saying that at your or to you, just saying it in general).
Do the manufacturers (in this case Sapphire) suggest that you use Crysis?Quote
The cooler is an AC unit.Quote
Also I like to see bench's for Crysis as I find it very easy to compare real performance, I use it like a control of sort, to gauge GPU real world performance, much more useful than synthetic benchies!Quote
Am I reading the Crysis bench properly? How comes the Stock out performs the overclock @ Maximum for the toxic?
Also I like to see bench's for Crysis as I find it very easy to compare real performance, I use it like a control of sort, to gauge GPU real world performance, much more useful than synthetic benchies!
Sometime the results can be a bit strange, just the way it is dude, maybe crysis didnt like the overclock. Without spending hours researching every result we'll never know.
*stop making your replies bold*Quote
This is just a suggestion I noticed some of the websites and magazines dont put the maximum FPS they say it doesnt reflect the true performance of the graphic card because most important in game play is the minimum and average FPS which actually shows you if you can play the game between 30FPS and 60FPS which is considered (very playable) and also the maximum FPS behaviour is very strange when overclocking the GPU so why dont you scrap the maximum from your benchmarks to avoid these kinds of issues I know the maximum FPS shows the muscles of the GPU but its not really true performance.
*stop making your replies bold*
PS - stop bolding your replies.Quote
But the Toxic DID arrive before the Ares. You can see the date on this review is April 22nd; over 2 months before the arrival of the Ares.
*LINK REMOVED*Quote
"The biggest compliment we can pay, and it is a big one, is that if this had arrived before Ares we'd have looked at that differently"
But the Toxic DID arrive before the Ares. You can see the date on this[/url] review is April 22nd; over 2 months before the arrival of the Ares.
sorry about my ignoranceQuote
a normal 5970 is basicly 2 5870 chips underclocked to 5850 speeds
where was the ares, toxic and so on are full on 5870 chipsQuote


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Carrot-Zucchini Muffins
The yogurt keeps these delightfully moist muffins fresh for days (if you can hold on to them that long), and the nutmeg gives them extra zip. If you don't have time to deal with an abundance of zucchini in season, try running the squash through the food processor and freezing the grated result in 1-cup batches. (Old 8-ounce yogurt containers are perfect for this.) When you're ready to whip up a batch of muffins, just pull the zucchini out of the freezer, defrost, drain off the excess water, and add as directed.
Yield: 18 to 24 muffins
- 2 eggs, beaten
- 1 cup plus 2 tablespoons plain yogurt
- 1 cup canola oil
- 1 cup grated carrots
- 1 cup grated zucchini
- 4 cups all-purpose white flour
- 1 cup white sugar
- 2 tablespoons baking powder
- 1 teaspoon ground nutmeg
- 1 cup coarsely chopped pecans
InstructionsPreheat the oven to 375 degrees F. Grease 18 to 24 muffin cups or line with paper.
In a large mixing bowl, mix together the eggs, yogurt, and oil; then stir in the carrots and zucchini. Set aside. In another bowl, sift together the flour, sugar, baking powder, and nutmeg. Add the dry ingredients to the wet mixture and stir until just combined. The batter will be lumpy. Stir in the chopped pecans. Spoon the batter into the prepared muffin cups and bake for 15 to 20 minutes or until a tester inserted in the center comes out clean.


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3 Tips to Help You Sleep on a PlaneJacinda
Photo via Comfort First.
There are some people in this world that seem to fall asleep instantly on an airplane with no problem at all. There are others, however, that can't seem to catch even the slightest bit of shuteye. I used to fall asleep instantly on airplane flights. In fact, I could usually fall asleep even before we took off. As years have gone by though, I've found it to be increasingly more difficult to snooze the flight away. If you tend to have the same problem, there are some helpful tips that might make a difference …
1. Stay Hydrated
It's important to hydrate yourself before a flight. Instead of packing in all the water the first bit of the flight, drink up throughout the day or the night before. Staying hydrated can help your body to relax when you're in flight. You don't want to drink too much right before though or you'll be racing to the bathroom.
2. Wear Multiple Layers
Wear comfortable clothes on your flight and have a few layers. This allows you to easily adjust to different temperatures and avoid feeling either too hot or too cold. (If you are warm enough, you can always use that jacket as a pillow.)
3. Listen to Comforting Tunes
If you have trouble falling asleep because of anxiety, it can help to create a playlist of comforting tunes to listen to. This can help make you comfortable and also drown out the other sounds around you. One of the reasons it can be hard to sleep is because all your senses are stimulated on a plane, put on an eye mask and headphones, and you might be asleep in no time.
Jacinda Boneau is a fabric designer and founding co-editor at Pretty Prudent, the premier design and lifestyle blog providing inspiration and instruction to help anyone create beautiful things, food, and experiences for their friends and family.


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Mr. and Mrs. Robert Cillo, Montoursville, observed their 50th wedding anniversary Aug. 26, 2011.
They were married by the Rev. Henry A. Wayda at Holy Rosary Catholic Church. They are members of Our Lady of Lourdes, Montoursville.
Mrs. Cillo, the former Claire Tudor, is a native of Williamsport. She is the daughter of the late Viola Tudor and Robert Tudor. She graduated from St. Joseph High School in 1959. She retired from the Lycoming County Assessment Office and Sovereign Bank, Montoursville.
Article Photos
Mr. Cillo, a native of Williamsport, is the son of the late Anna and Livio Cillo. He graduated from St. Joseph High School in 1958 and the University of Scranton in 1962. He served in the Army from 1962 to 1964, the Army Reserves from 1964 to 1983 and retired as a lieutenant colonel.
He retired in 1997 from Montoursville Area High School, after 33 years as an English teacher.
They are the parents of a daughter, Deborah Bennett, Harrisburg. There is one grandchild.


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on July 9, 2013 - 4:37 PM
Mr. and Mrs. Gerald Balys of West Seneca celebrated their 50th wedding anniversary with a renewal of marriage vows by Deacon David Clabeaux and a reception for family and friends in The Columns, Elma. Mr. Balys and Bernadine Proszek were married June 22, 1963, in Transfiguration Catholic Church, Buffalo. He is retired from Teamsters Local 375; she is retired from Verizon. They have three children and eight grandchildren.


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wrote in message
>I have an XP laptop (dell) & a Vista laptop (Acer), both with built-in
> wireless networking.
> I can have both of them downstairs (WAP is upstairs) & the Vista
> laptop keep dropping the connection, while XP laptop has no problems.
> Any idea why?
I'd think it's a function of the sensitivity of the wireless card. I've got
several wireless devices-- laptops, Palmies, etc. and all do well near the
wireless router in my home office at the back of my house. As distance
increases toward the front of the house and even outside, some hold up well,
some poop out. FWIW, my poorest performer is an Averatec laptop and my Acer
laptop is second worst....


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A bunch of in-home bakers compete to earn bragging rights as 'Best in the state.' And one lucky woman gets to decide the winner.
The views expressed are not those of this site, this station or its affiliated companies. By posting your comments you agree to accept our terms of use.


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SHIFTING INTO GERE: Who says New Yorkers are jaded? When Richard Gere leaves his seventh-floor SoHo co-op, a neighbor phones a resident on the second floor and another "Richard Gere Drill" gets underway. Explains an insider: "They call the other people, and then anyone can go to the second floor apartment and watch him leave from the window, or they can run to the lobby." Surveillance is organized with different people in charge of monitoring different floors; some are assigned to comings, others to goings. When Gere isn't visible for a while, "we tell him he has a package, when he doesn't, and he goes to get it. He always falls for it." Despite their antics, Gere sounds like a model neighbor. When a bathmat was stolen from the laundry room, and its irate owner posted signs around the building asking for it back, a new note went up telling the person to go to Gere's apartment and "talk to my cleaning lady about money for a new bathmat." The actor was no thief, says a resident, "just tired of seeing the signs."
BOTTOMING OUT IN HOLLYWOOD: Judith Ivey, 35, who won a Tony after appearing naked on Broadway in Steaming, says she has found that her looks don't always measure up to Hollywood standards. Though she starred opposite Don Johnson in last season's miniseries The Long Hot Summer, she almost didn't get the part because she wasn't considered sexy enough. "Sexual to them is great big breasts that stand up, a teeny-tiny 14-year-old-boy's butt and a gorgeous face," Ivey griped to the Chicago Sun-Times. "The thing that's frustrating is that men get to be physically unattractive by stereotypical standards," she said, alluding to Dustin Hoffman and Al Pacino, "and yet they can still be considered sexy on film. But if you're not a 'pretty' woman, you're not allowed to have sex with anybody."
SHE'S CONSONANTLY AT RISK: It may come as a surprise to her, but game show supernova Vanna White has a fan in brainy British actor Ben (Chariots of Fire) Cross. "I watch Wheel of Fortune two times a day," says Cross, who is in Miami filming The Unholy, a thriller. "When I come away from working on the film and I listen to Pat Sajak say, 'Oh, Vanna,' and there she is in that special dress, suddenly my world is back in order. Listen, I watched the show when she hurt her finger. It's a dangerous job, and she does it with unusual aplomb."
IT MAKES PERFECT SCENTS: After describing herself at a fund raiser in Tel Aviv as "a typical Jewish mother," giggly Goldie Hawn, mom to three children, discussed the depths of her devotion to her brood. "God, I'm here only a few days, but I really, really miss my 4-month-old baby, Wyatt," said Hawn. "When I left on this trip, I took his dirty undershirt with me, and in the hotel I stuck it under my pillow to smell my baby."
YOU CAN'T ALWAYS GET WHO YOU WANT: "I was more taken aback when Mick said I would be a good mother and we should have a baby than I had been when he...told me that he loved me," declares Marsha Hunt, mother of Mick Jagger's 16-year old daughter, Karis, in a new tell-most book, Real Life. Hunt, 40, who became more famous for her 1978 paternity suit against Jagger than as a singer-actress, says that Jagger's enthusiasm for parenthood abated in mid-pregnancy. "The notion of a baby became my total reality as it became Mick's passing fancy," says Hunt, who apparently carries no grudges. "He was already forgetting that the baby was his idea. He'd phone as if nothing had ever happened." Before Jagger agreed to pay support, Hunt found herself in an L.A. public assistance office with another problem. "I couldn't get any government assistance without supplying the name of my child's father so that someone could contact him about support payments," writes Hunt. "Imagine a West L.A. Social Security employee trying to get Mick Jagger on the telephone."
updated 12/01/1986 AT 01:00 AM EST
•originally published 12/01/1986 AT 01:00 AM EST
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A commonly used technique in both film and television to shift focus from a foreground object to a background object by turning the the focal ring on a lens.
Examples of rack focus can be seen in almost any movie or tv show when the focus is shifted from one object--mostly people--to another. It is most often used dramatically.
作者 rack_focus 2006年2月22日
Trending Now
Can you define these popular missing words?
When a director forgets what he is shooting and films breasts up close.
"The movie is still in editing becuase the second scene was rack focused."
作者 AllChiggedOut 2007年3月08日
When a cinematographer turns the focal ring on his lens to shift focus from a foreground object to a background object.
A rack focus is really a cheap, metaphorical device for the unimaginative to link two objects/people in a frame.
作者 creedmoor 2004年11月20日


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Students at Mary MacKillop Primary, Penrith South, know Darren McErlain as their teacher. However this month Darren is making a name for himself in the literary world, launching his new book of poems, Totally Random Poems for Kids.
Designed to link in with units of work in the classroom, Totally Random Poems for Kids was created as a classroom resource for teachers to take students on a modern journey of poetry.
Darren said the 101 funny and serious poems in the book have been written for students aged 9 to 14 years and he hopes his book will generate global interest in reading and writing poetry.
"It was important for me to write and compile a book of my own poems that were serious or mildly funny and also appropriate for children,' said Darren. 'The poems are models for them about how poetry can be used to express emotions or make an observation from their surroundings."
Illustrating the book himself with additional sketches by his 11 year old daughter, Angelique, Darren said his teaching colleagues have welcomed Totally Random Poems for Kids as they know they pick any poem at random and use it with their students.
Local teacher launches poetry book to the world (Parramatta Catholic Education)


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DAVID Davis, the shadow home secretary widely tipped to succeed Michael Howard as the Conservatives' leader, could be deposed at the general election because a candidate with a confusingly similar name is set to challenge him.
The intervention of David Davies, the candidate for Veritas, Robert Kilroy-Silk's new party, could deal a blow to Mr Davis's ambitions and deprive the party of a high-profile personality - without Veritas even winning the seat.
It is the Liberal Democrats, running a close second to the Tories in the Humberside constituency of Haltemprice and Howden, who have the most to gain from Mr Davies standing.
Mr Davis's majority of more than 7,500 was slashed to just 1,903 at the last general election, giving him a slim 4.3 per cent margin over the Lib Dems.
With a single vowel separating the names of the two men, the Veritas candidate will have the advantage of having his name above Mr Davis's on the ballot paper, as by law candidates must be listed alphabetically.
The shadow home secretary has insisted his constituents will be savvy enough to know the difference. "We live in a democracy and any party is free to field any candidate they choose. There is, however, a certain irony in the fact that a person who was planning to stand for parliament on the basis of a subterfuge is standing for the 'truth' party."
Mr Davis's camp has accused Veritas of using dirty tricks to try to complicate the contest, but a spokesman for the Tory MP insisted he was "relaxed about it as he believes his constituents are too smart to be taken in by this".
The Veritas candidate was also playing down the similarity of the two men's names. He insisted that, although he lived 50 miles away from the constituency, he had a valid claim to know it well as his in-laws' family had lived there.
"It is a winnable seat," he said. "I don't want people to get confused with the name and vote Tory but there is an obvious connection with the name. I didn't choose my name, it was given to me at birth."
Mr Davies, a rail engineer and father of four, planned to stand against Mr Davis for the UK Independence Party at the election until Mr Kilroy-Silk split the group by forming Veritas.
Veritas has not formally selected its candidates yet but Mr Davies is "hopeful" of winning the nomination.
No-one is more enthusiastic about Mr Davies's eventual selection than the Liberal Democrat candidate, Jon Neal.
"If I am honest, it will bode well for me as the candidate in second place," Mr Neal said. "Having another candidate with a similar name to the incumbent will be an entertaining sideline and anything that takes votes away from the Conservatives could help us win."
This would be a sweet revenge for the Lib Dems, who lost out on the European Parliament seat for Devon and East Plymouth in 1994 after a challenge from the "Literal Democrats".
More than 10,000 people voted for the party's candidate, Richard Huggett, who was listed on the ballot paper above the official Lib Dem candidate, Adrian Sanders.
This delivered a shock victory to the Tories' Giles Chichester, who won the seat by 700 votes.
Mr Sanders, now the Lib Dem MP for Torbay, failed to have the election result overturned in a court battle that cost the party 100,000.
His defeat did, however, prompt the Electoral Commission to introduce the Registration of Political Parties Act 1998, which banned "lookalike" parties where a name could confuse voters.
Mr Sanders said Mr Davis, who has been in parliament since 1997, would be unlikely to lose his seat on the basis of a similarly named challenger alone. "Most people vote for the party rather than just the name of the candidate," he said.


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Introducing 462 Halsey Community Garden
462 Halsey Community Garden has gotten permission to use a lot on Halsey Street that has been vacant for over 20 years. Now they need a little financial support. Please donate to their ioby project.
462 Halsey Community Garden has gotten permission to use a lot on Halsey Street that has been vacant for over 20 years. Now they need a little financial support. Please donate to their ioby project.
An article on the Boston Society of Architects mentions us:
"Taking a guerrilla campaigning approach to urban farming, the group has tagged numerous abandoned lots with posters and contact numbers of local agencies in an effort to gain support for a local bill that would allow the city to turn the empty lots over to local residents for community farms. Although their goals may seem like a long shot to some, the idea of creating a network of microgrowing areas throughout the borough is a powerful suggestion of the potential and pragmatism that reprogramming empty lots represents."
Grist points to our collaboration with 350 for Insert ____ Here in an article about community responses to global warming in NYC.
Meanwhile, our friend Paula has been witnessing an occupation happening in Sao Paulo. We're excited to see that these worldwide protests for economic justice are also challenging our conceptions of urban space. One early response has been an interactive map for rating the publicly-owned private spaces in NYC that you work near (or plan on occupying).
At Treehugger, we're in their Maker Faire highlights:
"The project strives to make communities aware of the land resources around them and help residents to connect with the vacant lots in their lives. Much of the unused space is actually publicly owned and 596 acres helps residents by providing tools to help them negotiate interim and long term community uses for this public space. 596 Acres works to connect communities to the information they need to gain control of their environments."
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