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Monday, November 24, 2014
Moxifloxacin for MRSA: Why is this not standard of care?
Moxifloxacin and MRSA. Why is this interesting?
The drug company Bayer applied for a patent on yet another drug in the flouroquinolone category of antibiotics in 1989 and received approval by the Food and Drug Administration in 1999 for Avelox, the brand name they gave to moxifloxacin. A Japanese company had discovered in the 1970s that adding a flourine to relatively ineffective antibiotics in the quinolone family, such as nalidixic acid, made them dramatically more active, thus creating flouroquinolones. That discovery led to the development of norfloxacin, then ciprofloxacin and levofloxacin which have become mainstays of antibiotic therapy.
Ciprofloxacin is extremely useful for treating urinary infections and a variety of other serious infections including anthrax and traveler's diarrhea. Levofloxacin has become one of our drugs of choice for treating pneumonia and is especially useful because it achieves the same levels when given by mouth as it does by intravenous injection. Moxifloxacin hasn't really caught on to the same extent, even though it also is absorbed extremely well when taken orally and achieves particularly high levels in the lungs. It is also more effective for treating infections caused by gram positive organisms than ciprofloxacin or levofloxacin, including resistant Streptococcus pneumoniaeand Staphylococcus aureus. It is approved for treating skin, lung and abdominal infections caused by susceptible organisms and in some hospitals (like the VA, I hear) it is the least expensive flouroquinolone option due to deals with the manufacturer, so it is used more often. It just became available in a generic form in the U.S. in 2014.
Methicillin-resistant Staphylococcus aureus (MRSA) has grabbed headlines as it has become more common, both as a bug acquired in the hospital and now in the community, that is to say outside of hospitals. In some places resistant staph infections are now more common than the ones that are sensitive to the antibiotics we use most often. S. aureus is usually quite a virulent bug, spreading aggressively in infected tissue and often seeding the bloodstream and even establishing itself on heart valves. It can cause particularly severe pneumonia, especially in already ill hospitalized patients and patients from nursing homes. It has become an especially big problem among intravenous drug abusers who are some of our sickest patients anyway, with coexisting issues like HIV infection and lack of adequate medical care. We have struggled to find antibiotics which work for MRSA and have turned to older and sometimes less effective antibiotics as well as newer and absurdly expensive ones.
A few weeks ago, while treating a patient with a MRSA infected wound, a colleague who is a wound care doctor suggested using moxifloxacin to treat her infection. I thought he was maybe just a little stupid, not to know that MRSA is usually resistant to flouroquinolones. I told him as much, except the stupid part and he told me that I was wrong, that he had just heard a talk at a wound care meeting and that moxifloxacin was good for MRSA.
I checked the microbiology sensitivity sheet for my patient's MRSA to see what antibiotics it was sensitive to, and it was, indeed, resistant to levofloxacin and ciprofloxacin and our lab did not even test for moxifloxacin. I started poking around in the literature to find out what supported his claim that moxifloxacin was good for MRSA. There wasn't much, but there was an article that showed that, using MRSA from 12 patients who acquired it in the community or the hospital, moxifloxacin was more effective in killing the staph than trimethoprim sulfamethoxazole, linezolid or clindamycin. Another article showed that moxifloxacin was more effective than vancomycin, a standard treatment for MRSA, in treating MRSA in experimental biofilms, like the bacterial mats that characterize infected wounds. A third one looked at the effectiveness of vancomycin, ciprofloxacin and moxifloxacin at curing experimental heart infections (endocarditis) in rats and found that moxifloxacin was more effective than vancomycin and that ciprofloxacin didn't work at all. There were no human studies comparing moxifloxacin, head to head, with other standard antibiotics such as vancomycin for MRSA. So I guess he was right and I was wrong.
Standard of Care
The Journal of the American Medical Association featured an article entitled Clinical Management of S. aureus Bacteremia, A Review, by Thomas L. Holland MD et al. The article concluded that vancomycin and daptomycin (a moderately toxic and very expensive new antibiotic for MRSA) are the first line antibiotic choices for MRSA bacteremia , that is infection found in the blood. This was based on 81 studies, none of which looked at moxifloxacin. The antibiotics studied were pretty much all the newer, recently released, very expensive and usually intravenous antibiotics. Studies involving humans are very expensive to perform, and funding is usually from pharmaceutical companies attempting to show that their drug works, which will make back the money they spend in research if all goes as planned. To give the article credit, the final conclusion was that well-designed studies to address the management of S. aureus bacteremia are needed.
Sepsis and Pneumonia
The standard of care in the hospitals where I have practiced is to use vancomycin (along with other broad spectrum antibiotic coverage) for patient who are seriously ill, in whom MRSA is suspected. Vancomycin is a difficult antibiotic to use, requiring measurement of levels to assure it is effective but not reaching toxic levels. It can cause kidney failure and hearing loss and if it is given quickly can cause "red man syndrome" which is what it sounds like, and quite disconcerting, though not deadly. Vancomycin must be given slowly which is a bit of an issue when a person is dying of rapidly progressive infection. But that's not actually the whole problem. We tend to use vancomycin when we suspect that there may be resistant staph in the lungs, but vancomycin actually has poor lung penetration and, even at standard doses, falls to what are probably ineffective levels during treatment.
It is often difficult to exclude pneumonia as a cause of serious infection in a patient who presents with sepsis, and the usual approach is to clobber them with broad spectrum antibiotics to cover whatever they might have. We try to get the antibiotics in to the patient as soon as humanly possible, ideally within an hour of arrival. Sometimes, however, it is difficult to get an intravenous line started and so a central venous catheter is placed, which must wait for a physician to do it, usually. Then there is a chest X-ray done to make sure that the line is in the right place and there is no lung collapse complicating the procedure. Then come the antibiotics. It can be agonizingly slow to get that first dose of life-saving antibiotics into a patient. Moxifloxacin can be given orally. "Here, take this." Bloop. Done. Or it can be given intravenously, if gut function is questionable, but quickly. Moxifloxacin covers most gram negative and gram positive organisms as well as atypical lung pathogens that cause serious infection including MRSA. Moxifloxacin dose is 400mg once daily and need not be adjusted for kidney or liver function.
So what is the catch?
What is wrong with moxifloxacin and why are we not using it more commonly? Moxifloxacin does not reach adequate levels in the urinary tract to treat urinary tract infections, which can be the cause of sepsis. But we can evaluate the urine quite quickly, in minutes actually, and adequately rule out urinary tract infection. Moxifloxacin can cause liver failure and serious skin rashes, but liver failure is extremely rare and all antibiotics cause skin reactions in some patients. It can cause tendons to rupture, similar to other fluoroquinolones, though that is also pretty rare. Moxifloxacin isn't cheap, somewhere between $5 and $20 a pill. But that is compared to $8 a day plus administration costs for vancomycin and about $300 for daptomycin, plus administration costs. And moxifloxacin is now generic and produced by over 30 companies worldwide so its cost will likely become negligible. The biggest issue is that it hasn't been adequately studied in the setting of serious infection and isn't likely to be studied because it will make nobody money to do the expensive research.
If, by some chance, it were to be studied and found to be superior to our present goofy standard of care, it would make some pretty profound changes in the way we do things. If moxifloxacin could be used to treat S. aureus bacteremia then patients would not have to remain in the hospital or have outpatient intravenous antibiotics for 2 weeks, or 4-6 weeks in the case of complicated infections. It is incredibly inconvenient and dangerous to have patients on intravenous antibiotics for a prolonged amount of time. Intravenous drug abusers cannot be allowed to go home with an intravenous catheter in place because they will use it to inject drugs and the catheter will become infected. Those patients end up becoming fixtures in our hospital wards, often bored and disruptive, as they finish their prolonged treatments. When they leave against medical advice without completing their course of treatment a significant number will return, gravely ill, with a recurrence of their infection. The intravenous lines themselves, in addition to being very expensive, can cause infections and blood clots. Moxifloxacin achieves nearly identical levels when given orally as it does when given intravenously, so there would be no need for IV lines for 2-6 weeks.
In light of this information, what now?
I am not prepared to go against the standard of care at this point and use oral moxifloxacin for S. aureus bacteremia, except in patients for whom intravenous therapy is impossible or likely to cause harm. I am, however, likely to use it for sepsis, when the urinary tract is not the source, in place of vancomycin plus other empiric gram negative and atypical organism coverage. I am also likely to choose it for treatment of wounds in which S. aureus and gram negative organisms are identified or suspected. It is more than about time that adequate research was done to determine how we should use this drug for staph, especially MRSA bacteremia.
Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Labels: antibiotics, guest post, infectious disease, Janice Boughton, MRSA, Why is American health care so expensive?
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
PLoS Blog
The Public Library of Science's open access materials include a blog.
White Coat
One of the most popular anonymous blogs written by an emergency room physician.


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sweet beans: red or white beans, mongo, garbanzos etc. sweetened fruit: langka, kaong, macapuno, etc. prepared gelatin, cubed ube jam leche flan NESTLE Cornflakes shaved ice sugar, to taste CARNATION Evaporated Milk
1. Place three or more combinations of around a tablespoon each of the suggested ingredients in half buko, (complete with husk or in sherbet glasses). 2. Mix and enjoy scooping buko meat along with each spoonful. For special Halo-halo, top with a scoop of your favorite ice cream flavor.
Ripening Papaya
Papayas that are one-quarter to one-half ripe should keep for one to two weeks. Ripen papayas at room temperature and never store a papaya that is (...)
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|Property type
|Minimum Stay
|3 - 5 nights
When you book through the HomeAway checkout, your booking is backed by our Book with Confidence Guarantee™ offering comprehensive payment protection.Learn more
Saddlewood 52 - a SkyRun Breckenridge Property
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- Please keep all outdoor equipment in the garage to keep the property looking great.
What You'll Love:
- Ski-In/Ski-Out property located on Peak 8/Snowflake Run
- Outdoor private hot tub
- Has three king beds


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Debian Snapshots Provide Package History
The Debian project provides a new snapshot service to access old package versions in their repository.
With the new shapshot.debian.org archive, administrators, developers and advanced users can view and install packages and their sources from every Debian distro version at any point of time. The snapshot archive is organized by date and version number. The project sees its benefit in tracking down regressions or specific application environments. It also recommends that administrators use the new snapshots to test upgrade paths in staging before putting apps into production and in environments with stringent change control.
The snapshot archive is a "kind of time machine for Debian archives," Alexander Reichle-Schmehl of the Debian press team revealed to Linux Magazine. "You can 'rewind' the package status of the archive. Others, for example, can revert to the exact package state where they were certified. Pretty practical." The project itself uses the snapshots, for example when diagnosing a particular problem.
The snapshot archive contains all Debian packages and their source since May of 2005, including debian-main and debian-security, but excludes a few packages removed because of licensing problems. It is accessible like any normal apt repository.
For snapshot service hosting, the project decided on the Electrical and Computer Engineering department of the University of British Columbia in Vancouver, Canada, and the Welcome Trust Sanger Institute that does genetic research in the U.K. As far as a win-win situation, apparently NordicBet online casino gaming licensed by the Lotteries and Gaming Authority of Malta found that it wouldn't hurt to provide the Debian project with needed hardware.
Go Debian!Although I use SUSE, Debian was on the first distros that I have heard of when I discovered Linux back in 2004. Innovation, insight, and guidance are some of what Debian is known for.
Issue 28: GIMP Handbook 4th Ed./Special Editions
Buy this issue as a PDF
OpenSUSE Site Hacked
News site for the openSUSE community falls victim to a Wordpress exploit.
LibreOffice Goes Online with 5.3 Release
The source code is available online.
Microsoft Brings Clear Linux OS to Azure
One out of three virtual machines on Microsoft Azure Cloud run Linux.
ASUS Announces a Single-Board Computer
The form factor of the board makes it a drop-in replacement for Raspberry Pi.
Red Hat Releases RHEL 6.9 Beta
Makes it easier for customers to move workloads into container-centric applications.
SUSE Working on a New Operating System Called MicroOS
SUSE's answer to container-centric operating systems.
Biggest Kernel Release Ever
Linux 4.9 is the biggest release in terms of number of commits.
CentOS Linux 7 (1611) Released
The latest version of the official RHEL clone is here.
openSUSE Rolls Out 42.2 Leap
New release targets Linux professionals.
Cutting-Edge Fedora 25 Released
The Fedora project adds Wayland and Gnome 3.22


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[vc_row][vc_column][vc_column_text]Progressive Marxist Obama has played the blame game for his failures from the very beginning of his reign. For the two years of the beginning of his regime when the Democrats controlled both houses of Congress, the nation heard ad nauseam, in historically unpresidential fashion, how his predecessor, George W. Bush, was the cause of all societal ills.[/vc_column_text][banner300 banner="5517620b381df"][vc_column_text]Then, after running the Democrat Party off the left cliff, the Dems lost the House, and then the Senate, so the evil boogeyman became those rascals in the Republican Party trying to slow down (and doing a piss-poor job of it) Obama's tyrannical rule that has been wildly successful in bringing America down a notch in more than just its former triple-A credit rating.
And of course, those rascals in the American Tea Party movement, those peaceful, flag-waving, freedom-loving patriotic Americans who just want to follow the U.S. Constitution, have been blamed and ridiculed repeatedly by Obama for somehow causing his failures, even while he controlled the legislative branch.
Having worn out both the Bush, Tea Party, and GOP blame cards (as well as the race card which he refuses to retire), President Selfie has shifted to a new target to blame for his massive failures…HIS OWN SUPPORTERS!
That's right. Obama is literally blaming the "we" in the moronic "Yes We Can" mob-like chants from his 2008 presidential campaign.
In a fundraising speech at leftist Hollywood actor and producer Tyler Perry's Santa Monica, CA, home Thursday night, only one day after the horrific Charleston, SC, mass murders at a black church, Obama was feeling sorry for himself because of the letters he received from former worshipers who wondered why the "hope and change" he promised didn't happen.
As the Washington Examiner reported:
"I got a letter a while back from a gentleman living in Colorado, and clearly an intelligent guy, and he had taken a lot of time to write this letter. And he said, you know, I voted for you twice, but I'm feeling disillusioned,'" Obama said.
"And I get letters, people say, 'You are an idiot,' and here's what you didn't do, and here's the program that is terrible, and all kinds of stuff. But this gentleman, he said, I voted for you twice but I'm deeply disappointed. And it went on and on, chronicling all the things that hadn't gotten done," added Obama.
As the number of Americans out of the workforce hits record highs almost monthly and as the percentage of Americans on welfare is through the roof, President Alinsky didn't elaborate on the specifics of the complaints, for obvious reasons, but did launch a real hail Mary in attacking his supporters, saying he'd lived up to his end of the bargain, but they'd failed to live up to theirs.[/vc_column_text][banner300 banner="553157113d3ff"][vc_column_text]"What are you doing?" Obama asked the audience of 250, who paid as much as $33,000 per plate to attend. "It takes decades of work sometimes just to make a little bit of progress," he said after he'd earlier taken credit for saving the U.S. economy all by himself.
About the division and gridlock in Washington, DC, that one would assumed to be fixed by now considering the utopian promises made to elect the "savior" and "the One."
"When I ran in 2008, I in fact did not say I would fix it. I said we could fix it," Obama told an audience of about 2″I didn't say, 'Yes, I can.' I said, 'Yes, we can.'"
Again, it's not his fault. Nothing is. Now he's even stooped to blaming his own sycophantic supporters into guilt for his failures. He's almost out of targets to blame, but the finger will never point back at him.
It's the Alinsky way, especially for a person with serious delusional, narcissistic, sociopathic tendencies.[/vc_column_text][/vc_column][/vc_row]


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MRP Pinion Gear (21T)
This item is discontinued and no longer available for purchase. You may want to search our site for a similar item.
This is a replacement MRP 21 Tooth Pinion Gear, and is intended for use with the MRP Ripper II 1/10 scale stadium truck.
This product was added to our catalog on November 8, 2012.


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Watch Windlands trailer
Buy the digital serial or cd key for Windlands at the best price it is now possible thanks to our cd keys price comparison engine, Gocdkeys! You can preorder Windlands for Steam in any of the online stores that our platform shows in the following list, all fully reliable and valued by our user community. To activate the download from Steam you only need to enter the digital serial or cd key of Windlands into your user account. Remember that this title is under "Early Access" so it may contain errors and bugs that can hinder the gaming experience, but will be solved as the progress game development. Windlands is a first person game focused on the exploration of a vast and lively territory. We can fly over the ruins of ancient civilizations and freely explore a huge world full of secrets. Although originally it was developed to be played with virtual reality , it is possible to enjoy it without that component. As we explore the vast world, we receive rewards and skills that will help us overcome the obstacles. This title does not contain any fighting or violence, just focusing on the relaxed exploring of a colorful world that will take us to the fantastic worlds fantasies of our mind. Remember that all stores appearing in gocdkeys have been tested by our team so they are 100% reliable, even so, you are recommended to carefully read the specifications in each store at the time of shipping, ways of activation (in case they are digital) versions and methods of payment.
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by Conor McPherson
October 21 – November 20, 2016
"Something bright and beautiful pulses in the shadows of The Night Alive," wrote New York Times reviewer Ben Brantley about McPherson's most recent play, winner of the New York Drama Critics Circle Award. Brantley praised McPherson's "singular gift for making the ordinary glow with an extra dimension, like a gentle phosphorescence waiting to be coaxed into radiance." The often dark, at times violent, drama about the relationship among five highly imperfect people is also infused with black comedy as these sad souls fumble in the darkness toward the light. Directed by Jack Sbarbori and featuring Grant Cloyd, David Dubov, Chelsea Mayo, Joe Palka, and Matthew Vaky.
by John Patrick Shanley
April 7 – May 7, 2017
This Pulitzer Prize and Tony Award-winning drama, set in 1964, pits Catholic school principal Sister Aloysius against the new, charismatic priest, Father Flynn, when his relationship with the school's first African American student is perceived to be suspicious. Armed with only her moral certitude, Sister Aloysius sets off on a personal crusade to unearth the truth. Featuring Chelsea Mayo and Stephanie Mumford.
by Horton Foote
July 14 – August 13, 2017
Quotidian life assumes Biblical proportions in this devastating family drama by Pulitzer Prize and Academy Award-winning playwright/sceenwriter Horton Foote. In 1935 Harrison, Texas, Leonard Tolliver's successful life is dismantled to the point where he realizes the axioms by which he lives are false. Directed by Jack Sbarbori and featuring QTC favorites and talented newcomers.
Subscribe to our 2016-2017 Season today and see all three plays for $70 and get a free bring-a-friend ticket!
As much as $50 off regular ticket prices (single tickets $30, $25 seniors, $15 students)
QTC Subscription Benefits Include:
- One FREE Bring-a-Friend Ticket
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• Download and print your subscription form: PDF | DOCX
• Send the from along with a check or money order with payment of $70 per subscription to:
Quotidian Theatre Company
5705 Brewer House Circle, #202
North Bethesda, MD 20852.
Questions? firstname.lastname@example.com


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Elieen Elizabeth kirton
- 68 years old
- Date of birth: Aug 16, 1947
- Date of passing: Dec 31, 2015
|Let the memory of Elieen be with us forever
This memorial website was created in memory of our loved one, Elieen kirton, 68, born on August 16, 1947 and passed away on December 31, 2015. We will remember her forever.
Memorial Tributes
"Our loving mum and wife grandma daughter sister in loving memories we all shared so much together who reached us all from right to wrong through think and thin she will always remain in are hearts and never forgotten we all love and miss you so much love claire"
"forever in our hearts xx"
"Missed so much by so many miss you sis sleep in peace till we meet again xxxx"
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Carolina Roofing & Remodeling, LLC is a remodeling contractor in Charlotte, NC who specializes in providing outstanding customer service, quality construction and exceptional workmanship using the best roofing, siding installation, windows, sheet rock installation, and emergency roof repair, and gutter materials available. Since their inception Carolina Roofing & Remodeling has grown into one of the leading roofing contractors in the Charlotte region by keeping honesty and integrity at the forefront of his operation. Now we provide a variety of services, including of course roofing and general remodeling, but also carpentry contractor work, sheet rock contracting and installation, window replacement, remodeling contractor work, vinyl siding installation, gutter installation, and emergency roof coverings and emergency roof repairs.
Call (704) 334-4239 Today For A Free Consultation!!!Payment Options: Cash, Visa, Master Card, American Express, Discover, Personal Checks
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Logo Embroidery Scotland Ltd
Embroidered Clothing, custom embroidery, logo embroidery
Embroidery is the preferred method to personalise or custom brand clothing as in most cases, it is the most professional looking. Not only does it have a quality look and feel , it is also as durable as the clothing itself and will withstand repeated washing.
Print this page
Logo Embroidery Scotland are workwear suppliers specialising in branded and embroidered workwear. They provide workwear throughout Edinburgh, Scotland and the UK.
LES supply a large range of baseball caps perfect as promotional materials and specialise in golf days and corporate events.
Perfect if you are looking for high quality embroidered polo shirts.
Huge range of hoodies available for small and large embroidery on the front and back.
With several options available, call Logo Embroidery Scotland for in depth advice on the best options from your business workwear to promotional event clothing.
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This Marvelous Millennium Falcon Wedding cake was done by CakeCentral member Rachelinauk. Wouldn't it be great to have R2-D2 dressed up in a bow tie at your Star Wars themed wedding? Princess Leia looks cute holding the pink daisies. Han Solo's shirt and vest are painted on just like the LEGO figure.
Between The Pages is an Amazon affiliate


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Andrea Sisco"Dave Earley...shares the spiritual secret and the blessings that are available to all believers who want a closer relationship with God. Whatever the season of our lives, God is present and we can all enjoy a full and rich relationship with Him. That in and of itself is a gift, but to also learn to enjoy a transforming and powerful Christian life through Earley's fourteen keys is simply magnificent... Thoughtfully read Earley's book and experience God's presence in your life because whatever was missing will be found."
Armchair Interviews.com


text:
The Local · 25 May 2016, 17:41
Published: 25 May 2016 17:41 GMT+02:00
Updated: 25 May 2016 17:41 GMT+02:00
- 10 fascinating contribution we never knew about Berlin (23 May 16)
- 6 things about Munich that'll stay with we forever (20 May 16)
- IN PICTURES: Berlin's Carnival of Cultures (16 May 16)
Just a glance of a brew-guzzling during Berlin's annual drink festival. Photo: DPA.
Photo: DPA.
Photo: Robert Aehnelt/Wikimedia Commons.
Image: Wimdu.
Left: Konrad Zuse with one of his initial computers (DPA). Right: A condom vending appurtenance (Stefan Kühn/Wikimedia Commons).
For some-more news from Germany, join us on
and Twitter.
The Local (firstname.lastname@example.com)
Article source: http://www.thelocal.de/20160525/even-more-fascinating-facts-you-never-knew-about-berlin


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Sunderland AFC
Papy Djilobodji
Will Sunderland bring Papy Djilobodji straight back into the fold against Manchester City?
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Sunderland's acid test: Why April will be the defining month in the Black Cats' survival campaign
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Sunderland U23s discover semi-final opponents in Premier League International Cup
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It could be ugly! Sunderland will have rediscover their work ethic against Manchester City
Fabio Borini says Sunderland must put in the hard work and do the 'ugly bits' if they are to stun title hopefuls Manchester City this weekend
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Fabio Borini on the frustrations of life as Sunderland's utility man
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Who will referee Sunderland vs Manchester City at the Stadium of Light this weekend?
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Everton 2-0 Sunderland: Rate the Black Cats players after defeat at Goodison Park
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'I hate weekends' - Sunderland fans frustrated after Everton defeat
David Moyes' side slipped to a second successive defeat to leave them three points adrift of safety
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Adnan Januzaj: Hard work can save Sunderland from Premier League relegation
Adnan Januzaj knows the Black Cats need to be stronger at both ends, but the on-loan Manchester United man believes hard work will see them through
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Sunderland to train in London near Heathrow? Beware of flying pigs!
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Bebe Cutout Sleeve Hoodie
$71 Sold out bebe.com
Cut out - fancy! Our crystalized bebe logo sweatshirt features the sexiest accented shoulders and double front pockets. Perfect for an on-trend run when it's nice outside. 57% Rayon, 38% cotton, 5% spandex. Hand wash. Imported. Center back to hem: 22" (56 cm) Model is 5'10" and wears a US size S.
- Like it to get in stock alerts


text: How should we go about teaching our children to pray? I have thought a lot about this recently because my daughter, who is 3, has taken to praying for everything recently. We always pray before meals and at bedtime, and until fairly recently she would pretty much follow allow with her older brother, (10). Over Thanksgiving we were at my MIL's and her family tradition is to hold hands and bless the meal, after which we go around the table and tell everyone what we are thankful for and give our favorite Bible verse. Ever since Carinna has taken special care in closing her eyes bowing her head and telling God what she is thankful for. My favorite was when we were out shopping. She is finally potty trained, but is scared of the automatic flush toilets in public restrooms. Well she had to go to the bathroom. I didn't want her to touch anything so I held both of her hands. All of a sudden she says, "I almost forgot". She proceeded to make me close my eyes and then she thanked God for mommy and the toilet, and the fact that mommy wouldn't let her fall in! She concluded with a hearty "AMEN". She will do something similar periodically throughout the day. Anyway, how and when did you teach your children how to pray?


text:
keepintouch.com was registered 1 decade 7 years ago. It has a alexa rank of #5,184,954 in the world. It is a domain having .com extension. It is estimated worth of $ 240.00 and have a daily income of around $ 1.00. As no active threats were reported recently, keepintouch.com is SAFE to browse.
|Daily Unique Visitors:
|Daily Pageviews:
|Income Per Day:
|$ 1.00
|Estimated Worth:
|$ 240.00
|Google Indexed Pages:
|Not Applicable
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|Not Applicable
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|Not Applicable
|Google Backlinks:
|Not Applicable
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|Not Applicable
|Google Safe Browsing:
|No Risk Issues
|Siteadvisor Rating:
|No Risk Issues
|WOT Trustworthiness:
|Very Poor
|WOT Privacy:
|Very Poor
|WOT Child Safety:
|Very Poor
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Allie.ca may be for sale at DomainNameSales.com, the online marketplace for premium domains.
Music,Songwriters,Music Production,Movie & Video ideas,
Future of Flight Flies and Free Future Science Fiction Blog Stories.
|Domain Registrar:
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|1999-09-04 1 decade 7 years 5 months ago
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Clicks5.6kWorld's Biggest Wave Ever Surfed
This is suppose to be the Biggest Wave ever Surfed. Amazing this man is still alive. (Something different)
Write a comment …
I thought we lost him at 00:58, but he reappeared five seconds later, still standing. But I do not think he managed to stay on his feet after 01:19. It looked like he was tumbling over. I hope he knows how to swim.


text:
BPA Free Feeding
Only Organic Pouch Serving Spoons are so easy to use simply screw onto a Only Organic pouch and squeeze to dispense babyfood one mouthful at a time giving you a free hand to do all those other things you need to do at mealtimes.
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Having dealt with setting up an AdWords account and testing landing pages, it's time to perfect your creatives — those challenging three lines Google taunts you with, or the daunting 40 and 70 characters Yahoo allows you.
Writing ads for search engine advertising is almost like writing headlines. It requires an ability to distill information into attention grabbing character restricted words.
Reading headlines from any of the more sensational newspapers can get you in the mindset. Now you have to add a thesaurus-like knowledge of vocabulary aided by a deep knowledge of the industry you're advertising for.
Unlike headlines, however, the ads need to include a call to action. "Buy, learn, click, try" are all words that motivate readers to do something that involves them interacting with your site through the ad. Using this type of approach will help improve your CTRs (define).
As a starting point, look at ads that are already running for the keywords you want to use. They can tell you what elements are being used to attract clients.
Then, look at the ads of more competitive industries. What are the most competitive verticals in PPC (define)? Try real estate, ringtones, and financial services, to name a few, as good sources of inspiration.
The next thing that helps is using the actual keywords in the ad. Most engines allow for dynamic keyword insertion. Google does it by adding {keyword}, though you should add alternative text in case the keyword runs more than the 25 characters of the title line or the 35 of the two lower lines. Thus, it will end up like this: {KeyWord: Other Text Here}.
Using capitalization for each word has proven to be effective for Google ads, but you can use variations to capitalize anyway you want:
- keyword — No capitalization, all word(s) are in lower case
- Keyword — The first word is capitalized
- Key Word — Every word is capitalized
- KEY word — Every letter in first word is capitalized
- KEY Word — Every letter in the first word AND the first letter of the second is capitalized
Yahoo and Microsoft adCenter also have these options.
The key to finding the perfect ad? Testing.
When starting a campaign, write two ads for each ad group. After you've had enough impressions — anything over a few thousand is good enough to start — keep the winning ad (the one with the best conversion rates — see AdWords 101 for how to calculate that) and write a new challenger.
Keep the winner running for 75 percent of all impressions and give the rest to the challenger. How do you do this? All engines now allow you to run numerous ads.
Duplicate the winning ad three times to the challenger's one. By doing this, you're always working to improve your creatives, but not risking the bulk of your potential conversions.
Try this in combination with the information outlined in my two previous articles and you're on your way to PPC advertising success.
Beyond just improving the CTR, tie in conversion success. Sometimes an ad will have a high CTR but convert poorly. No sense paying for that non-converting traffic. Use tracking code with the ads so you can compare the cost per acquisition.
As you go forward, you're able to test and keep the ads that really sell your products and services. I'll go into analytics and conversion tracking in more detail for my next article, so keep coming back.
Join us for SES London February 19-21 and for training classes on February 22.
Related reading
How to target high-income consumers with AdWords
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Duration: 1min 43sec Views: 7 574 Submitted: 11 months ago Submitted by:
Description: Odette is a new student here at Innocent High. She is currently enrolled in Mr. Maxwells class where they are going over the Civil Rights Leaders for Black History Month. She expresses her concern that she doesnt know any of the names and tells that she didnt have any studies of this kind back where she was from. She was shocked when she learned that interracial marriage was so taboo seeing as she finds black men very sexy. She puts her hands all over Mr. Maxwell and even though he was reluctant at first, he pulls out his fat black rod and lets her suck it. He puts her on the desk and starts to eat her tiny teen pussy. He flings everything off the desk and pushes his meat inside her. He picks her up, fucks her on and off of his desk, rattling everything around him from the force.
Channel: Team Skeet
Tags: Pussy Fucking One on One Air Skirt Blonde Natural Tits skinny Student Classroom Black Cock Monster Cock
Pornstars: Odette Delacroix


text:
How is everyone going?
I've have been off the forums for a few weeks cause I was so down after my last BFN... This TTC is so hard and feels like it's been going on forever! If we haven't conceived by the new year we have decided we look at IVF. Hopefully we don't have to go there although we always knew it would be highly likely after the vasectomy reversal.
I have been very good this month and being as relaxed about TTC as possible. No monitors or anything. We are getting married in just under 6 weeks so that it enough to keep me distracted :-) Although I know I will O soon as I have heaps of watery CM at the moment (TMI - I actually feel like I have wet myself and keep running to the toilet).
sending everyone babydust


text:
Odoo Help
Odoo is the world's easiest all-in-one management software. It includes hundreds of business apps:
CRM | e-Commerce | Accounting | Inventory | PoS | Project management | MRP | etc.
How to assign value in Many2one field in odoo9
_name = "confirm.auction"
product_id = fields.Char("Product",readonly= True)
customer_auc_id = fields.Many2one("res.user","Customer", readonly = True)
date_bid = fields.Date("Bid Date", readonly = True)
amt_bid = fields.Float("Bid Amount", readonly = True)
conf_auc_id = fields.Many2one("auction","Auction")
_name = "bid"
auc_id = fields.Char("Auction Id", readonly = True)
product_id = fields.Char("Product",readonly= True)
amount_auc = fields.Float("Amount")
state= fields.Selection([('publish','Publish'), ('cancel','Cancel'), ('done','Done') ],'Status',readonly=True,copy=False,select=True,default='draft')
def bid_confirm(self):
date = time.strftime("%Y-%m-%d")
auc = self.env['auction'].search([('auction_id','=',self.auc_id)])
res = self.env['confirm.auction'].create({
and if i remove id [ 'customer_auc_id':self.write_uid.id, ] so it is assign [ _unknown ,1 ]
i want to store customer name in m2o field customer_auc_id but it's not assigning correctly.
how to solve this issue?
I think you've a typo in the res.users name "you writing it : res.user" without 's'.
So try:
customer_auc_id = fields.Many2one("res.users","Customer", readonly = True)
and use:
'customer_auc_id': self.write_uid.id
Hope this could helps
Hi Ahmad,
i also try this but problem is it's print value is [ _unknown ,1 ]
did you restarted and upgrade your module, if yes could you please paste your final code ?
_name = "confirm.auction"
customer_auc_id = fields.Many2one("res.user","Customer", readonly = True)
_name = "bid"
def bid_confirm(self):
date = time.strftime("%Y-%m-%d")
auc = self.env['auction'].search([('auction_id','=',self.auc_id)])
res = self.env['confirm.auction'].create({
It's print
[DPP] Early payment discount _unknown,1 11/25/2016 900.00
Man, You're still writing res.user it is res.users not res.user
ohk. Thanks...dear
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|Asked: 11/23/16, 4:45 AM
|Seen: 147 times
|Last updated: 11/24/16, 12:54 AM


text: [ { "catentry_id" : "360352", "Attributes" : { "Colour_Yellow":"1" }, "ItemImage" : "/wcsstore/StorefrontAssetStore/images/NoImageIcon.jpg", "ItemImage467" : "/wcsstore/StorefrontAssetStore/images/NoImageIcon.jpg", "ItemThumbnailImage" : "/wcsstore/StorefrontAssetStore/images/NoImageIcon.jpg" } ] Elements Yellow Stacking Mug £0.99 was £1.99 save £1.00 Qty (1) Qty (2) Qty (3) Qty (4) Qty (5) Qty (6) Qty (7) Qty (8) Qty (9) Qty (10) Qty (11) Qty (12) Qty (13) Qty (14) Qty (15) Qty (16) Qty (17) Qty (18) Qty (19) Qty (20) Add to basket × Your item has been added to basket Your items have been added to basket One line title Qty%(quantity)s %(price)s Continue Shopping Checkout Share Elements Yellow Stacking Mug Elements Yellow Stacking Mug is rated 5.0 out of 5 by 1. Rated 5 out of 5 by Lou from Yellow or green?! I bought 4 different coloured stacking mugs from my local store and im extremely happy with them! They brighten up my kitchen whilest stacking which is space saving in my small flat. I'm looking forward to getting matching plates and bowls to go with them. I was a bit surprised to find this was referred to as yellow as the mug I have I would say is lime! There is a ridge half way down and on the inside this seems to collect tanin from the tea but as long as I remember to run the scourer over that particular part it comes up clean every time :) Date published: 2016-06-27 y_2017, m_2, d_20, h_11 bvseo_bulk, prod_bvrr, vn_bulk_0.0 cp_1, bvpage1 co_hasreviews, tv_0, tr_1 loc_en_GB, sid_1000058155, prod, sort_[SortEntry(order=SUBMISSION_TIME, direction=DESCENDING)] clientName_dunelm


text:
The Evil That Lurks in the Work Fridge Part 2: Dudes that Eat Your Food!
It Happens at Every Office
Every office has at least one: a dude that will eat your food. You are looking forward to your delicious leftovers from the day before and when you look in the work fridge - GONE! Why does this happen? I can't pretend to understand what is going on in the thief's head, but I can give you some examples, some possible solutions, and some ideas for revenge.
Acceptable Food Theft Moments
Stealing food is never a good thing, but there are times when it is acceptable. For instance, if your company is buying lunch for everyone and there are leftovers, by all means, take some of that stuff. It is up for grabs. Also, if your job really does not pay that well, this may be your opportunity to get a free lunch and a free dinner for that night. Sometimes that is the only way to make ends meet. So dig in!
An exception to that rule is when everyone is still getting their lunch, but the food thief is taking two plates. Please remember, let everyone get their food first. After everyone is through with their lunch then you can pack a second plate. If there is a lot of food, break out the tupperware. I am telling you, free food is sometimes one of the only highlights in the workday.
That's My Name on that Food!
Keep in mind, when using the work fridge you must put your name on every item or someone may just take it. Don't just think everyone is honest, because they are not. Every office has food thieves. You could probably interview people at the white house and I'll bet there are even a few there. Also, sometimes you bring in the same products your co-workers eat, too. I am pretty sure I ended up eating other people's yogurt and they probably ate mine just because we all eat Yoplait. Those are honest mistakes.
Not so honest mistakes occur all the time and it is completely ridiculous. If I put a lunch bag in the fridge and someone opens it and eats my apple, shame on them! What is wrong with people? Also, if I order pizza and I don't invite you to have a slice, don't eat a slice as soon as my back is turned. Now I don't have lunch for tomorrow. Jerk!
Nothing is Sacred
You might think the work fridge theft is pretty bad and it can't get any worse. But it does. There are those that will take something out of your desk while you are out of the office. If I leave in a banana in the desk and it starts to rot while I'm out sick, PLEASE open the desk drawer and trash it. I thank you. If, however, I put a banana in my desk drawer and I go to a meeting, it better be there when I come back. If not, I am going to hunt you down and scream at you. What is wrong with people? That takes some nerve. We are all broke and hungry in this economy; theft is not the answer.
Work Poll
Do you have a food thief at work?See results without voting
Solutions and Revenge
As I said earlier, it helps to clearly mark your food in the fridge. That should prevent honest people from stealing from you. For the dishonest among us, I have some other ideas.
First, lock the desk drawer when you leave for an extended period of time. You should do that anyway. There are probably way more important items in that desk than just food.
Second, start posting notes on the refrigerator regarding the theft. You can also send an all staff email. Shaming this person may help the situation.
Often co-workers have a good idea who the culprit is stealing the food anyway. Sometimes if you have figured it out, you need to confront the person. Occasionally management may need to get involved. Maybe the co-worker is really starving and needs some assistance. Although I can honestly say it is usually the very person that can afford food that is taking food.
Finally, the last resort is revenge. I've heard of all types of revenge. Spitting in food is extremely childish, but so are most things that go on in offices. Even if the victim does not realize they just ate spit, it usually makes the spitter pretty happy. Planting a fake meal in the fridge with some laxatives added will usually teach the thief to stop, too. Sure it is mean, but they are stealing and a lesson needs to be taught. Another good idea is just to plant something really disgusting in food you think the thief is likely to steal. Lots of salt in a dessert is usually a good one.
Some Parting Words
I know we still don't have too many answers on why people eat all your food, but at least the list of solutions and revenge ideas should be helpful. I hope you've enjoyed this hub. If you are a food thief, stop doing it. Everyone knows it is you and you're an embarrassment. If you are a victim, sorry. I can relate.
Just remember, someone taking your food is not the worst thing that could ever happen. Sometimes your co-workers are just hungry. Furthermore, it is not always your co-workers. I've heard of cleaning crews stealing food as well. So don't just assume it is always your hungry co-worker.
Please visit the first installment of The Evil that Lurks in the Work Fridge - http://hubpages.com/hub/workfridge
Thanks for reading and see you next time!
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Comments 4 comments
This is a more common problem then most people even want to know about I think. You want to know your food is there for you, but who wants to know that the person they work with is that hungry that they must steal food. Very interesting hub for sure!
At my last job, we had a bunch of folks who would steal other people's food. Even worse, we had a guy who would heat up a bag of frozen broccoli every day at the same time - I used to stink to high heaven! I had no idea broccoli smells that bad when it is being nuked...But, I digress...
Great Hub!


text:
via Sports Logos.net
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Overall: 14-16 .467 W-L% (170th of 295)
Conference: 4-8, 5th in ECC
Coach: Kevin Bannon (14-16)
PS/G: 70.0 (241st of 295)
PA/G: 71.8 (84th of 295)
SRS: -9.29 (230th of 295)
SOS: -7.52 (257th of 295)
1990-91 Rider Season
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Phil Savage, former Browns GM, talks about building a culture with a team as well as what can turn the Chargers around.
Phil Savage: "Good news for the Chargers is t..
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Arlington has a population of 189,453 and is located in Arlington county.
The average in-state tuition for full time undergraduate students in multimedia design schools in Arlington during the 2009 - 2010 school year was $17,781.00. The average tuition was $17,781.00 for non-residents studying in Virginia.
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