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Flowchart of excluded patients. CAP indicates community-acquired pneumonia; ICU, intensive care unit.
Feldman RB, Rhew DC, Wong JY, Charles RA, Goetz MB. Azithromycin Monotherapy for Patients Hospitalized With Community-Acquired PneumoniaA 3½-Year Experience From a Veterans Affairs Hospital. Arch Intern Med. 2003;163(14):1718-1726. doi:10.1001/archinte.163.14.1718
© 2017
Current American Thoracic Society (ATS) community-acquired pneumonia treatment guidelines recommend azithromycin monotherapy for a limited subset of hospitalized patients. We evaluated the effectiveness of azithromycin monotherapy in a more generalized population of patients hospitalized with mild-to-moderate community-acquired pneumonia.
We reviewed medical records from a Veterans Affairs facility for patients admitted with community-acquired pneumonia between December 1, 1997, and June 30, 2001, comparing those receiving azithromycin monotherapy, other ATS-recommended antibiotics, and non–ATS-recommended antibiotics. We excluded patients with immunosuppression, metastatic cancer, or hospital-acquired pneumonia. Outcome measures included times to stability, meeting criteria for change to oral therapy, and eligibility for discharge; length of stay; intensive care unit transfer; and mortality. Outcomes were adjusted for pneumonia severity, skilled nursing facility status, and processes of care.
A total of 442 patients were eligible for the study (221 in the azithromycin monotherapy group, 129 in the ATS group, and 92 in the non-ATS group). Times to clinical stability and to fulfilling early switch criteria were not statistically significantly different among the 3 groups. Mean time to fulfilling early discharge criteria was 2.48 days for patients receiving azithromycin monotherapy vs 2.84 days for those receiving ATS antibiotics (P = .008) and 2.58 days for those receiving non-ATS antibiotics (P = .64). Overall mean length of stay was shorter in the azithromycin monotherapy group (4.35 days) vs the ATS (5.73 days) (P = .002) and non-ATS (6.21 days) (P<.001) groups. Mortality, intensive care unit transfer, and readmission rates were similar across the groups.
Azithromycin monotherapy is equally as efficacious as other ATS-recommended regimens for treating hospitalized patients with mild-to-moderate community-acquired pneumonia.
COMMUNITY-ACQUIRED pneumonia (CAP) remains a significant cause of morbidity and mortality and is the leading cause of death due to infection in the United States.1 An estimated 5½ million cases occur annually in the United States, of which 20% require admission to the hospital.2 In recent years, several organizations, including the British Thoracic Society (2001),3 the American Thoracic Society (ATS) (2001),4 the Infectious Diseases Society of America (2000),5 the Centers for Disease Control and Prevention (2000),6 and the Canadian Infectious Diseases Society in collaboration with the Canadian Thoracic Society (2000),7 have published guidelines that address the empiric choice of antibiotics for hospitalized patients with nonsevere CAP. Each of these organizations recommends a β-lactam plus a macrolide or an antipneumococcal ("respiratory") fluoroquinolone alone as an appropriate empiric antibiotic drug choice for individuals from the community admitted to the general medical ward. The ATS also recommends monotherapy with a macrolide, specifically, azithromycin, for a subset of patients requiring intravenous therapy who are admitted to the hospital ward. According to ATS guidelines, to be eligible for azithromycin monotherapy, patients should not have cardiopulmonary disease or any of the modifying risk factors outlined in Table 1.
Data from comparative (vs intravenous cefuroxime sodium with or without intravenous erythromycin lactobionate) and noncomparative phase 3 trials have demonstrated that parenteral azithromycin monotherapy is an effective treatment for hospitalized patients with CAP.8 Several patients in these trials had risk factors for complicated episodes. For example, approximately 50% were older than 65 years, a third were smokers, 20% had diabetes mellitus, and many experienced chronic obstructive airway disease. A randomized, multicenter study9 (mean patient age, 68 years; 30% of patients were from a nursing home) has shown that monotherapy with intravenous azithromycin has the same efficacy as and fewer adverse effects than the regimen of cefuroxime with or without erythromycin. These studies have also demonstrated shorter treatment durations and possible hospital stay advantages with azithromycin monotherapy compared with combination therapy. However, few data are available regarding the utility of parenteral azithromycin monotherapy for the treatment of CAP in clinical practice as opposed to the setting of a research study.10,11 Furthermore, some experts have expressed concerns that increasing rates of macrolide resistance among Streptococcus pneumoniae might decrease the clinical effectiveness of azithromycin monotherapy.5
For the past 5½ years, the VA Greater Los Angeles Healthcare System (VAGLAHS) has used guidelines that recommend the use of intravenous azithromycin monotherapy for the empiric treatment of patients hospitalized with nonsevere CAP (ie, not requiring care in the intensive care unit [ICU]). The objectives of this study are to evaluate the clinical and bacteriologic outcomes in patients treated with azithromycin monotherapy and to determine the effectiveness of this regimen in a "real-world" setting.
We performed a retrospective cohort study to assess clinical and bacteriologic outcomes in hospitalized patients with nonsevere CAP. We reviewed the medical records of patients hospitalized at the VAGLAHS between December 1, 1997 (when azithromycin monotherapy was first recommended as empiric treatment for hospitalized patients with nonsevere CAP), and June 30, 2001. This study was approved by the institutional review board at the VAGLAHS.
Patients were eligible for the study if they were 18 years or older, were admitted to the general medical ward, and had a documented International Classification of Diseases, Ninth Revision, code for CAP.12 To ensure accuracy of the CAP diagnosis, a physician trained in infectious diseases (R.B.F.) reviewed every potentially eligible patient medical record to verify the presence of (1) radiographic evidence of a new pulmonary infiltrate within 48 hours of admission not attributable to another cause and (2) clinical evidence suggestive of pneumonia (ie, the presence of ≥2 of the following: temperature >38°C, new or worsening cough, production of purulent sputum, pleuritic chest pain, dyspnea, rales/rhonchi, egophony, white blood cell count >10.0/µL, or leukocyte band forms >15%).
Patients were excluded from the study if they were known to be human immunodeficiency virus infected, neutropenic, or immunosuppressed for other reasons (eg, receiving corticosteroids, chemotherapy, or other immunosuppressive agents or the presence of metastatic malignancy, leukemia, or lymphoma) or if they had documented mycobacterial infection. Patients with presumed hospital-acquired pneumonia were also excluded; this group included patients who were admitted as inpatient transfers from an outside hospital or who were discharged from any hospital within 14 days preceding their admission. Patients who were admitted from an outside emergency department (ED) or urgent care facility were included in the study. Finally, patients who were transferred to the ICU within 24 hours of hospital admission were excluded from the primary analysis. It was assumed that the most likely reason these patients required ICU admission within 24 hours was that they were inappropriately admitted to the ward in the first place (ie, they should have been admitted to the ICU initially) as opposed to having failed their initial antibiotic drug regimen.
The VAGLAHS comprises the combined resources of the Veterans Affairs Sepulveda Ambulatory Care Center (Sepulveda, Calif), the Veterans Affairs Los Angeles Ambulatory Care Center, and the West Los Angeles Healthcare Center (West Los Angeles, Calif). In addition, the VAGLAHS includes 2 large satellite clinics (in Bakersfield and Santa Barbara, Calif). The catchment area of the VAGLAHS includes more than 750 000 veterans, and it is the largest and most complex health care facility in the Department of Veterans Affairs.
Comprehensive ambulatory services and all inpatient and tertiary care services for VAGLAHS are provided at the West Los Angeles Healthcare Center. This facility has 283 active acute care beds. Almost all surgical services (excluding transplantation), all subspecialties of internal medicine, and comprehensive neurologic and psychiatric services are offered.
In the 12 months ending September 30, 2000, the VAGLAHS provided medical care to more than 75 000 veterans. More than 26% of these patients were African American, more than 12% were Hispanic, and approximately 95% were male.
The following data were collected for all eligible patients: (1) choice of initial antibiotic agent, (2) patient demographics, (3) Pneumonia Severity Index (PSI) score,13 (4) adherence to key process-of-care indicators, (5) clinical outcomes, and (6) microbiologic data. For this study, the components of the patient's initial antibiotic regimen were defined as those antibiotic drugs that were administered consistently after the first dose. Most patients received their first dose of antibiotic(s) in the ED; however, this did not always reflect the antibiotic course received during the remainder of the hospitalization. We reasoned that by the second dose of antibiotic, the admitting physician had evaluated the patient and started therapy for CAP. Any addition to or discontinuation of this initial regimen was noted. Demographic data included age, race, sex, smoking history, and any previous history of pneumonia. Severity of illness was measured using the PSI.
Key process-of-care indicators included the timing of antibiotic drug administration relative to hospital admission,14 administration of antibiotics before drawing of blood cultures,14 and measurement of oxygenation within 24 hours of admission.15 Clinical outcomes included transfer to the ICU after 24 hours of admission, time to clinical stability (defined as systolic blood pressure >90 mm Hg, pulse rate <100 beats/min, temperature <38.3°C, respiratory rate <24 breaths/min, arterial oxygen saturation >90% or no further need for supplemental oxygen, able to eat, and no altered mental status),16 time to fulfilling early switch to oral antibiotic drug treatment criteria (improved cough, tolerating oral intake, defervescence, and normalized white blood cell count) and early discharge criteria (no need to treat comorbid conditions, no need for further diagnostic workup[s], and no social needs),17 number of days hospitalized, mortality (in the hospital and within 30 days of discharge), return to the ED within 30 days of discharge, and readmission to the hospital within 30 days of discharge. Microbiologic data consisted of identification of any organisms obtained from bacterial cultures and their corresponding antibiotic sensitivities and results of serologic testing (Mycoplasma pneumoniae and Chlamydia pneumoniae) or urine Legionella antigen testing.
Any microbiologic organism(s) with the potential for respiratory pathogenicity that was recovered from a usually sterile body site in a patient admitted to the study was presumed to be the cause of the pneumonia. Such sites included blood, pleural fluid, and bronchoalveolar lavage fluid; 10 000 colony-forming units per milliliter was used as the cutoff value to define a positive result.18 Also, organisms recovered from suitable sputum specimens (ie, containing >25 white blood cells and <10 squamous epithelial cells per high-power field)5 were considered true pathogens. Positive IgM titers or a demonstrated 4-fold rise in IgG titers to known pulmonary pathogens (Mycoplasma pneumoniae and Chlamydia pneumoniae) or a positive Legionella urinary antigen test result was also considered diagnostic for the presence of the corresponding "atypical" organism. All laboratory testing was performed at the discretion of the treating physician.
In vitro susceptibility testing was performed using agar-based Kirby-Bauer disk diffusion techniques, and minimum inhibitory concentrations (MICs) were determined for antibiotics using an antibiotic gradient strip (Etest; AB-BIODISK North America Inc, Piscataway, NJ).
Univariate analyses were performed to assess differences in patient characteristics. Differences in the means of continuous variables were evaluated using unpaired t tests, and differences in proportions were evaluated using χ2 tests. Cochran-Mantel-Haenszel statistics were used for severity-stratified analyses. Least squared means was used to severity adjust continuous variables (age).
Cox proportional hazards were used to adjust for severity of illness (PSI score), nursing home residence, and antibiotic drug therapy within 8 hours of hospital admission. Time to clinical stability was censored by inpatient death and discharge before achieving clinical stability. Time to early switch was censored by inpatient death and eligibility to switch to oral medication. Time to early discharge was censored by inpatient death and eligibility for early discharge. Length of stay was censored by inpatient death.
Logistic regression was used to adjust simultaneously for potential confounding variables such as PSI score (classes I and II, III, IV, and V), skilled nursing facility status, receiving antibiotic agents within the first 8 hours of treatment, and having blood cultures drawn within 24 hours of hospital admission. Odds ratios and 95% confidence intervals were computed.
One thousand twenty-six patients were initially identified for the study by International Classification of Diseases, Ninth Revision, coding. After reviewing the medical records, we excluded 584 patients from the analysis (Figure 1). The remaining 442 patients were divided into 3 comparison groups: (1) the azithromycin monotherapy group consisted of 221 patients receiving azithromycin alone as the initial antibiotic regimen for ward treatment of pneumonia, (2) the ATS group consisted of 129 patients receiving a 2001 ATS-recommended antibiotic regimen other than azithromycin monotherapy as the initial treatment of mild-to-moderate CAP, and (3) the non-ATS group consisted of 92 patients receiving an initial antibiotic regimen that was not part of the 2001 ATS recommendations for treatment of mild-to-moderate CAP.
The 3 groups did not differ significantly in terms of average age, racial composition, smoking history, or previous pneumonia history. A small but statistically significantly greater percentage of male patients received non–ATS-recommended antibiotic regimens than received azithromycin alone (Table 2). There were no significant differences in the individual PSI risk classes among the 3 groups. Also, there were no significant differences in the individual comorbid conditions composing the PSI among the 3 groups except for a higher percentage of cerebrovascular disease in the non-ATS group (data not shown). Patients admitted from skilled nursing facilities were more likely to receive non–ATS-recommended antibiotic agents than either azithromycin monotherapy or ATS-recommended antibiotics. We also evaluated whether the initial antibiotic regimens were changed as a potential surrogate marker for increased severity of illness. Individuals in the non-ATS antibiotic group were more likely to have their regimens completely changed or to have other antibiotics added within 48 hours of hospital admission than were patients undergoing azithromycin monotherapy.
In terms of adherence to process-of-care measures that have previously been shown to be associated with improved clinical outcomes,13 patients receiving either an ATS or a non-ATS antibiotic regimen were significantly more likely to have blood cultures drawn within 24 hours of admission than were patients receiving azithromycin monotherapy, and patients receiving ATS-recommended antibiotics had a higher probability of receiving oxygen assessment within 24 hours of hospital admission than patients receiving azithromycin monotherapy (Table 3). A higher percentage of patients in the ATS group than in the azithromycin monotherapy group received antibiotics within 8 hours of admission. There were no significant differences among the 3 groups in terms of receiving antibiotics within 4 hours of admission (data not shown) or in having blood cultures drawn within 24 hours of admission (for those patients who had blood cultures drawn). Influenza and pneumococcal vaccination (0.9% and 4.1% of all patients, respectively) were rarely administered but were more often given in the azithromycin monotherapy group (data not shown).
There were no significant differences among the 3 groups in terms of the mean number of days needed to reach clinical stability or to fulfill eligibility criteria for early switch from intravenous to oral antibiotic drug therapy (Table 4). However, patients receiving either non–ATS- or ATS-recommended antibiotic regimens required a longer time to fulfill early discharge criteria than those in the azithromycin monotherapy group. In addition, overall mean length of stay was significantly longer in the ATS and non-ATS groups than in the azithromycin monotherapy group. Except for the mean number of days to reach eligibility for early discharge in the non-ATS antibiotic group, these same relationships held true when end points were adjusted in a multivariate analysis using the following variables: PSI score, nursing home residence status, blood cultures drawn within 24 hours of admission, and receiving antibiotic drugs within 8 hours of admission (Table 5).
All 3 groups had similar rates of transfer to the ICU (after 24 hours), return to the ED within 30 days of discharge, and 30-day readmission. Individuals receiving non–ATS-recommend regimens had a higher 30-day mortality rate (P = .04) than those who received azithromycin monotherapy. Also, individuals who received ATS-recommended regimens had a higher rate of readmission to the hospital for pulmonary infections than patients who received azithromycin monotherapy. One in-hospital death occurred in the azithromycin monotherapy group (cardiac arrest on hospital day 7 in a patient with cardiomyopathy and congestive heart failure), 2 in the non-ATS antibiotic group (1 patient had bowel perforation with Escherichia coli and Bacteroides fragilis sepsis and the other had an acute cerebrovascular accident, cardiac arrest, and anoxic encephalopathy on hospital day 3), and none in the ATS group. All the patients who died were severely ill on hospital admission (ie, had PSI class IV or V). The number of deaths was not statistically significant among the 3 groups.
Presumed etiologic organisms were recovered in 112 cases. Consistent with findings from other studies,19 the most common pathogens recovered were S pneumoniae (41% of all isolates recovered), Haemophilus influenzae (20%), Staphylococcus aureus (13%), and Moraxella catarrhalis (7%).4 Other isolates included Klebsiella (5%), Pseudomonas (4%), other gram-negative rods (6%), and group B Streptococcus species (4%). Eighty-two percent of all isolates were recovered from sputum, 12% from blood, and 5% from other sites (eg, pleural fluid and bronchoalveolar lavage fluid). Eighty percent (36/45) of the S pneumoniae isolates were sensitive to erythromycin therapy. These isolates were obtained in essentially equal numbers across each year of the study (data not shown). There were no ICU transfers or deaths in any patient from whom S pneumoniae was recovered. A subset analysis demonstrated similar outcomes in patients with erythromycin-susceptible S pneumoniae isolates vs those with erythromycin-resistant isolates (Table 6).
Azithromycin monotherapy has been recommended by the ATS for empiric treatment of CAP in hospitalized (ward) patients in limited circumstances.4,5 Hesitation in broadening this recommendation may be due to the relative paucity of comparative clinical trials using azithromycin alone, concerns about increasing rates of S pneumoniae resistance to macrolides,3,7,20 and lack of published clinical experience regarding the effectiveness of parenteral azithromycin in the treatment of CAP in routine clinical practice.21 This study sought to provide a real-world comparison of azithromycin monotherapy and other treatment options for hospitalized patients with CAP and to potentially determine whether azithromycin monotherapy could safely and effectively be applied in a broader population of patients than defined by the ATS.5
In this study, azithromycin monotherapy resulted in equivalent times to fulfilling clinical stability and early switch criteria. In addition, there were no significant differences in rates of ICU transfer, death during hospitalization, or utilization of the ED. Patients receiving azithromycin monotherapy reached the criteria for early discharge sooner than those in the 2 comparison groups and had an overall shorter length of stay when adjusted for severity indicators. Also, patients receiving azithromycin monotherapy had lower 30-day mortality rates than patients receiving non–ATS-recommended regimens. No patients receiving azithromycin monotherapy were readmitted to the hospital within 30 days of discharge for new or recurrent pulmonary infection, whereas 6% and 5% of patients in the ATS and non-ATS groups, respectively, were readmitted for such conditions. We determined postdischarge outcomes from the medical record with reasonable certainty because most Veterans Affairs patients receive postdischarge follow-up in Veterans Affairs clinics, and the Department of Veterans Affairs has a computerized medical record system that is fully integrated with all of its clinics and hospitals. Furthermore, there is no a priori reason to expect bias in the rate of reporting of outpatient mortality in persons who did, or did not, receive monotherapy with azithromycin.
Reports of increasing pneumococcal macrolide resistance have led to recommendations for azithromycin monotherapy to be limited4,21 or altogether avoided.3,7,20,22,23 However, some authors have noted that these recommendations are primarily based on data from in vitro studies using standardized MICs,24 which may not have ideally reflected the in vivo activity or the effectiveness of the drug.25,26 In an attempt to address these issues, we performed a subset analysis of patients in whom S pneumoniae was isolated. The results showed that nearly 20% of S pneumoniae isolates were resistant to erythromycin, all but one of which were also resistant to penicillin. However, none of the 10 patients in our study with erythromycin-resistant pneumococci died or were transferred to the ICU, including the 6 who received azithromycin monotherapy. Furthermore, the initial choice of empiric antibiotic(s) did not have an effect on the times to reaching clinical stability or eligibility for switch from parenteral to oral antibiotics in patients infected with erythromycin-resistant pneumococci. This lack of correlation among erythromycin resistance, use of macrolides, and clinical outcomes has also been demonstrated in 2 prospective clinical trials.10,27 Although we do not test the azithromycin susceptibility of pneumococcal isolates at our facility, previous studies have shown an excellent correlation between the susceptibility of S pneumoniae isolates to erythromycin and azithromycin.21,28,29
In North America, 60% to 70% of macrolide resistance in pneumococci is due to the M-phenotype, an efflux pump associated with the mefE gene.30- 32 These organisms exhibit moderate resistance to erythromycin and azithromycin with MICs of 1 to 32 µg/mL.31 In contrast, high-level resistance with MICs greater than 64 µg/mL due to ribosomal methylation associated with the ermAM gene (MLSB phenotype) is more common in Europe.33 Other mechanisms for macrolide resistance are rare. Antibiotic susceptibility data from the 9 erythromycin-resistant S pneumoniae isolates in this study showed that 67% (6/9) of the isolates were resistant to clindamycin (data not shown), which suggested that the MLSB phenotype (as determined by the expression of macrolide and clindamycin resistance) predominated in most of our erythromycin-resistant S pneumoniae isolates. Despite our findings, recent reports of increasing erythromycin MICs among S pneumoniae isolates expressing the M-phenotype30,31 and failures of azithromycin monotherapy in the treatment of persons infected by pneumococci with erythromycin MICs in the 8- to 16-µg/mL range23 indicate the need for continued surveillance of the effectiveness of azithromycin monotherapy for CAP. Other studies34,35 suggest that serotype may play a more important role than antibiotic susceptibility in mortality due to pneumococcus.
To our knowledge, this study is the first to compare azithromycin monotherapy with other pneumonia treatments based on whether the treatment regimens were consistent with the 2001 ATS CAP treatment guidelines. This study corroborates the efficacy of azithromycin monotherapy for patients with CAP, as has been documented in other studies,9,10 but does so outside the artificial conditions of a clinical trial.
A recently published retrospective study by Lentino and Krasnicka11 compared intravenous azithromycin with other parenteral antibiotics for the treatment of Veterans Affairs patients hospitalized with CAP. However, there are some primary differences between the present study and that by Lentino and Krasnicka: (1) the present study enrolled a larger number of patients (442 vs 92) over a longer study period (3½ years vs 2½ years); (2) the present study assessed the "appropriateness" of the initial antibiotic regimen by classifying it according to the 2001 ATS CAP treatment guidelines, whereas the study by Lentino and Krasnicka compared patients receiving azithromycin with those receiving any other parenteral antibiotic(s); and (3) the present study evaluated several measures to assess efficacy of treatment, including time to clinical stability, time to fulfilling early switch criteria, various clinical outcomes, and length of stay, whereas the study by Lentino and Krasnicka evaluated length of hospital stay only.
This study has several limitations. First, it is a retrospective analysis, not a randomized controlled trial. Therefore, it is possible that the 3 groups may have had differing severity of illnesses or may have been managed in varying ways (beyond having received different initial empiric antibiotic choices). The azithromycin monotherapy group did not have as many individuals admitted from a skilled nursing facility or with a history of stroke as the non-ATS group, and they did not have additions or changes to their antibiotic regimens made as frequently as in the non-ATS group. These facts suggest that patients in the azithromycin monotherapy group may have been less ill compared with the other groups despite the fact that PSI scores were similar among the 3 groups. On the other hand, it does not seem that patients receiving azithromycin monotherapy received other clinical interventions that may have resulted in improved outcomes. For example, adherence to process-of-care measures associated with improved outcomes such as early initiation of antibiotic drug therapy and blood cultures drawn before administering antibiotics14 was not higher in the azithromycin monotherapy group than in the other groups. Furthermore, decreased adherence to some process-of-care measures, including the drawing of blood cultures and the assessment of oxygenation, may potentially have also been a surrogate marker for decreased severity of illness. In fact, the azithromycin monotherapy group had blood cultures drawn (within 24 hours of admission) less frequently than the other 2 groups and oxygen assessment less frequently than the ATS group.
Second, we excluded from analysis 22 patients who were transferred to the ICU within 24 hours of admission because we believe that it was not feasible to define the exact role (if any) that the initial empiric choice of antibiotics played in the rapid progression of illness and that these individuals were likely to have been misclassified as having mild-to-moderate pneumonia when they should have been categorized as cases of severe CAP. Using intention-to-treat analysis, these 22 patients would have been equally distributed among the 3 groups (7 in the azithromycin monotherapy group, 7 in the ATS group, and 8 in the non-ATS group) had they not been excluded owing to transfer to the ICU within 24 hours of hospital admission. Furthermore, there were no deaths in the 7 patients who would otherwise have been classified in the azithromycin monotherapy group, whereas there were 2 deaths in the 7 patients who would have been classified in the ATS group and 4 deaths in the 8 potential non-ATS group patients. However, patients in the latter groups were sicker (ATS group: mean age, 73.9 years; mean length of stay, 23.1 days; and mean PSI score, 128.3; non-ATS group: mean age, 65.5 years; mean length of stay, 9.4 days; and mean PSI score, 140.5) than those who would have been classified in the azithromycin group (mean age, 67.9 years; mean length of stay, 12.9 days; and mean PSI score, 95.4). Another large retrospective study36 that evaluated the relationship between the initial choice of antibiotics and clinical outcomes in patients hospitalized with CAP, similar to our study, classified patients who were admitted to or transferred to the ICU within 24 hours of admission as having received initial ICU care.
Third, our definition as to what encompassed the initial antibiotic regimen may have been oversimplified and may have allowed for some variability in the overall antibiotic agents a patient may have received. For example, if a patient received a dose of a non–ATS-recommended antibiotic in the ED, a dose of azithromycin on the ward, and then an ATS-recommended antibiotic for the remainder of the hospitalization, then this patient would have been classified as having initially received azithromycin monotherapy (with a change in therapy). However, most patients were either continued on the antibiotic regimen started in the ED or received one dose of antibiotics in the ED that was modified on arrival to the ward and subsequently continued on the modified regimen throughout the remainder of the hospitalization. There were 13 cases in which this did not occur (ie, patients received several antibiotic drug changes and may have been misclassified in the study). Reclassification of these patients would not have affected the death rates or the outcome measures among the 3 groups in analysis (data not shown). Nonetheless, some patients received one dose of intravenous antibiotic in the ED (or possibly an oral medication in the ambulatory setting) that was different from the antibiotic regimen on which the patient was maintained during the hospitalization, and this may have confounded our results.
Finally, our data are reflective of the VAGLAHS and other similar institutions, and this study may not be applicable to all patients with CAP as a whole. During the study, patients meeting the inclusion criteria had relatively low rates of bacteremia overall (12% in patients from whom an organism was isolated), had rates of macrolide resistance that may have been lower than those seen elsewhere,37 were infrequently admitted from skilled nursing facilities, and were mainly men. These data should be considered when exploring therapeutic options for CAP in the community.
Despite these limitations, the results of this study suggest that azithromycin monotherapy is safe and effective for patients hospitalized with mild-to-moderate CAP, including many patients who have cardiopulmonary disease and those with risk factors (eg, age >65 years, resident of a nursing home, and medical comorbidities) for infection with gram-negative rods or resistant pneumococcus. Decreasing the use of third-generation cephalosporins could also potentially help decrease the rates of vancomycin-resistant enterococcus38 and extended-spectrum β-lactamases39 in outbreak settings or prevent the emergence of these types of infections in the hospital.
In summary, these data suggest that azithromycin monotherapy is efficacious in treating patients hospitalized with mild-to-moderate CAP even in the presence of ATS modifying factors such as underlying cardiopulmonary disease and age greater than 65 years. It is possible that some of the patients with CAP who were excluded from the study may also have potentially benefited from the use of azithromycin alone (such as those with metastatic malignancy, human immunodeficiency virus, and immunosuppression). Future randomized controlled trials are needed to better define which groups of patients hospitalized with CAP are most suitable for azithromycin monotherapy.
Corresponding author and reprints: David C. Rhew, MD, Zynx Health Inc, 9100 Wilshire Blvd, Suite 655E, Beverly Hills, CA 90212 (e-mail: firstname.lastname@example.com).
Accepted for publication October 21, 2002.
This study was funded by an unrestricted grant from Pfizer, Inc, Global Outcomes Research.
We thank Kevin Knight, MD, PhD, for his assistance with data analysis for this study.


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18 Healthier Fall Baking Recipesby Toby Amidor, October 2nd, 2013
Baking can be a guilt-free pleasure, especially when the end result is a deliciously healthy goodie! Here's an array of seasonal recipes.
- Cinnamon Bread Twists
- Rapid Rolls
- Marbled Banana Bread (above)
- Leftover Oatmeal Bread
- Slimmed Gin...

subset: commoncrawl


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The resignation of Stockland managing director
CLSA downgraded the group to a sell on the departure and the second downgrade to the earnings per share for the 2012 financial year.
Analyst John Kim noted Mr Quinn's resignation was "an ominous sign of near-term prospects" and claimed the developer's performance and its controversial 3R strategy of residential, retail and retirement alienated "many investors" and caused the board to lose "faith in his leadership".
The new incumbent may "wipe the slate clean", but a shift in direction could result in "business disruption and expedited inventory writedowns", CLSA wrote.
The house, a long-term bear on Stockland, lowered its 2012-14 financial forecasts for net profit after tax by an average 5.1 per cent a year.
Morgan Stanley analysts said that throwing away the polarising 3R strategy would be no easy task, given the group had already sold its best office and industrial assets.
Another bugbear with investors is Stockland's costly foray into the FKP Group.
FKP could require another capital raising shortly. If Stockland does not participate, the move would further dilute the group's 14.9 per cent stake.
In a note to clients, Simon Scott of Moelis & Co said the group's retirement division "should be spun off into a separate vehicle".
He argued Stockland could fold the business into a "demerged FKP retirement portfolio to address the high operating cost base and allow investors who like this sub-sector to have a 'pure-play' retirement entity".
Commonwealth Bank analysts were surprised by the timing of Mr Quinn's exit. They are tipping Stockland's chief executive of commercial property, John Schroder, as the likely successor.
But as The Australian Financial Review revealed yesterday, many in the market are betting on banking names such as Paul Fegan, the former head of St George Bank.
While CBA analysts don't expect to see an overhaul of the 3R strategy, they anticipate "tinkering at the edges". The bank has retained its buy rating on the stock.
UBS also struck an optimistic note, emphasising Stockland "has re-confirmed 5000 settlements in FY12 and no further residential inventory impairments – a good result in an extremely difficult quarter".
Its team of listed property analysts, led by Grant McGasker, argued that the developer's performance will stabilise over the next two years and pointed out that, compared with its peers, a projected earnings per share yield of 9.8 per cent in the 2013 financial year "remains attractive".
UBS has retained its buy on the stock.
The Australian Financial Review


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IUPUI offers you more academic choices than any other university in the state. You can choose from more than 255 Indiana University degree programs, more than 95 Purdue University programs—or even pursue degrees from both universities.Learn more about IUPUI degree programs
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When it's time to relax, a myriad of cultural, dining, and entertainment options are yours to explore.


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Merck Consumer Care, the makers of Coppertone, and the scientists at the Coppertone Solar Research Center have developed the Coppertone Sport AccuSpray to help prevent overspray.
DSN presents a preview of some of the hottest beauty products that will appear on the show floor at NACDS Total Store Expo.
Greater consumer awareness about sun safety and the harmful effects of soaking up too many rays has helped boost the sun care segment, but experts will no doubt tell you that there remains much room for improvement.
Legislation that would speed up and streamline the Food and Drug Administration's approval process for new sunscreen ingredients passed the House on Monday, according to published reports.
Desert 2 Desert has been named the winner of the DSN-sponsored "Best New Product" award at the ECRM Sun Care, currently taking place in Tampa, Fla., for its My Cabana Boy sunscreen applicator.
Merck Consumer Care, the makers of Coppertone, has kicked off its second year of the "Making the Sunscreen Grade" program to help parents teach their children sun-smart behaviors.
Looking to change sunscreen habits for those with darker skin tones, La Roche-Posay and the Women's Dermatologic Society have teamed up to take a stand by not just raising awareness, but encouraging true behavioral change through educating on two key motivators.
Energizer Personal Care, the makers of Banana Boat sunscreen, along with actress Busy Philipps, announced on Thursday the launch of the Best Summer Ever Sweepstakes.
CōTZ Face Natural Skin Tone SPF 40 is sun protection with a special little something inside — a natural tint that is designed to be universally flattering to all complexions.
GlitterTots has introduced its new Jungle Screen, which uses all natural ingredients, including lemongrass, citronella, cedar and peppermint oils, to prevent bugs from biting, all while providing broad spectrum sun protection.
Energizer Personal Care, the makers of Banana Boat brand sunscreen, announced the availability of four new products in mass grocery and drug retailers nationwide, including a formula designed specifically for men.
Despite the growing incidence of melanoma, many women still grade themselves a "C" or lower on their sun care habits, according to a recent survey by L'Oréal Paris and the Melanoma Research Alliance.
Supergoop!, which makes multi-functional sun care formulas, has teamed up with entrepreneur and international tennis star Maria Sharapova, welcoming her to the Supergoop! team as a co-owner with founder and CEO Holly Thaggard.
Looking to expand availability of his skin and eye care products, Dr. Fischer has announced the opening of a dedicated store on Amazon.
Coola Suncare, a maker of organic sun care products, has announced a new retail partnership with Ulta Beauty.
Legislation introduced to unclog the backlog of sunscreen ingredients and streamline the review process for faster public access has garnered the accolades of the Public Access to SunScreen Coalition.
Skin care company derma e has introduced its first sun care products — Antioxidant Natural Sunscreen SPF 30 Oil-Free Face Lotion and Body Lotion.
Merck Consumer Care and the scientists at the Coppertone Solar Research Center have announced the launch of two new sunscreen innovations.
Natural personal care brand Kiss My Face has developed a new range of sun care products that use antioxidant defenders vitamin C and E, green tea, goji berry extract, olive oil, shea butter and aloe to provide a hydrating defense against the sun's damaging rays.
MelanSol, an all-natural sunscreen brand, has announced that it is working to expand the availability of its products across the United States.
Category saturation and competition from private label may be inhibiting sales growth within the sun care segment, but infusing additional skin care benefits, like antioxidants, and targeting such demographic groups as men and multicultural consumers could help brighten sales.
Even the most savvy sunscreen user can forget to reapply sunscreen when having fun in the sun. However, remembering to reapply is even easier with the licensed sunscreen bands from JADS International.
W.S. Badger Co. has announced that it is voluntarily recalling all lots of its 4-oz. SPF 30 Baby Sunscreen Lotion and one lot of its 4-oz. SPF 30 Kids Sunscreen Lotion due to microbial contamination.
Having performed more than 8,000 free skin cancer screenings all over the country, La Roche-Posay has been dedicated to raising awareness about the importance of sun safety with its annual SOS – Save Our Skin program over the past four years.
The NPD Group, which tracks prestige beauty, has reported that sales of makeup and skin care with SPF reached $1.1 billion in U.S. prestige department stores from June 2012 to May 2013, a 24% increase from three years ago.


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Papagomys armandvillei
|Scope: Global
Language: English
|Scientific Name:
|Papagomys armandvillei
|Species Authority:
|Jentink, 1892
Common Name(s):
|Taxonomic Notes:
|Recently, Papagomys theodorverhoeveni was reported to be still extant on Flores island on the basis of a single museum specimen consisting of a skull and mandibles, collected in 1974 at Ruteng, Manggarai, West Flores and was stored in the collections of the Museum Zoologicum Bogoriense (Suyanto and Watts 2002). However, based on comparison with extensive zooarchaeological material from Liang Bua, all evidence suggests that that record is not an example of P. theodorverhoeveni, but of P. armandvillei. Therefore, the identification of this specimen is refuted (Zijlstra et al. 2008).
|Red List Category & Criteria:
|Near Threatened ver 3.1
|Year Published:
|Date Assessed:
|Aplin, K., Helgen, K., Musser, G., Lunde, D., Amori, G. & Ruedas, L.
|Amori, G. (Small Nonvolant Mammal Red List Authority) & Schipper, J. (Global Mammal Assessment Team)
Listed as Near Threatened because its extent of occurrence is less than 15,000 km2, and it is directly hunted for food (possibly resulting in substantial population declines), but the species is somewhat, adaptable, it does not appear to have a fragmented habitat, and is believed to persist in disturbed forest habitats. Almost qualifies as threatened under criterion B1.
|Previously published Red List assessments:
|Range Description:
|This species is endemic to Flores island, Indonesia (Musser and Carleton 2005). It has been recorded between sea level and high elevations on Flores.
|Countries occurrence:
|Additional data:
|Range Map:
|Click here to open the map viewer and explore range.
|The abundance is not known, but it may be a common species. Populations may be declining, but this needs to be confirmed. It is known by extant specimens as well as subfossil fragments 3000-4000 years old (Musser and Carleton 2005).
|Current Population Trend:
|Additional data:
|Habitat and Ecology:
|It is believed to occur in a range of forest types, including disturbed areas and secondary growth, but is not expected to be present in heavily cleared areas.
|Major Threat(s):
|The large species is directly hunted for food, but it is unclear if this is resulting in significant population declines. It is possibly not heavily impacted by habitat loss due to the rugged nature of Flores island. Cats and dogs are considered predators on this species (Suyanto 1998).
|Conservation Actions:
|It has been recorded from the Rutong Protection Forest. Further surveys are needed into the distribution, and persistance of this species to severe hunting pressure and habitat modification.
|Aplin, K., Helgen, K., Musser, G., Lunde, D., Amori, G. & Ruedas, L. 2008. Papagomys armandvillei. The IUCN Red List of Threatened Species 2008: e.T15975A5335512. . Downloaded on 23 July 2017.
|To make use of this information, please check the <Terms of Use>.
|If you see any errors or have any questions or suggestions on what is shown on this page, please provide us with feedback so that we can correct or extend the information provided


text:
Prices, specials, features and availability subject to change.
Contact for details
Japanese cherry trees line the streets of Parkwood adding a spectacular show of color and richness to this beautifully landscaped community. Large living areas and bedrooms, deluxe appliances and quiet living are just three of the top reasons to make Parkwood Apartment Homes your new home. Every apartment in Parkwood II has a balcony or a garden patio giving you a space to enjoy the award-winning landscape and tranquil atmosphere.
Call to learn about our $99 move-in special!
*Restrictions apply.
Leases: 6, 9 and 12 months.
Cats Allowed. Dogs Allowed. Call for Policy. Call for service animal policy.
264 units
Contact Propertyor call
Location in complex is important. Units closer to Beaglin Park Drive are subject to a lot of traffic noise. No Read Moreise between apartments was bad at times because all entry doors open on to a common foyer. Noise didn't travel through the walls, but we could hear our neighbors clearly through our front door. Kitchens are wide enough; refrigerator door won't open completely because the oven door is in the way.
November 14, 2014
Location was fine, cut weather was not - ice, snow, etc. The community was provincial and this city, educati Read Moreon woman found it frustrating. The Rent.com card was great and allowed me o show my finance Baltimore.
July 12, 2014
Safe Neighborhood, and friendly and sincere staff.
Rooms are very insulated and the neighbors are very Read More friendly. Rooms have everything they need to ensure great living conditions! Glad I chose Parkwood Apartments =D.
January 22, 2014
I've been here almost 3 yrs, but won't be renewing my lease. 1st year was fantastic, then the property mgr. mo Read Moreved out of state. Since then, there have been at least 4 managers & 3 asst. managers that I know of (some only make it a few months). Quality of everything has suffered- landscaping, office organization, maintenance, cleanliness, etc. Pros: Good location, pretty clean, neighbors generally families, not college students. Cons: not enough maint. staff, no amenities, lack of communication
January 21, 2014
Maintenance Crew was fabulous, if had a problem, they came to fix it very quickly.
January 16, 2014
Monday-Friday: 9:00am-6:00pm
Saturday: 10:00am-5:00pm, by appointment
Sunday: Closed
Salisbury Apartments LLC
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P.O. Box 3463 (27402)
Greensboro, North Carolina 27408
United States
|Areas of Practice
|1) Litigation
|Law School
|Wake Forest University School of Law
|University of North Carolina (B.S., 1987)
|Most recent firm
|Nexsen Pruet LLC
|Relevant Jobs
Commercial Real Estate Attorney
COMMERCIAL REAL ESTATE ATTORNEY McCausland Keen + Buckman has an immediate opening in its Devon, PA office for an experienced commercial real estate attorney (2-5 years+) to join its sophisticated ...
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Transactional Real Estate Associate
USA-CA-San Jose
Berliner Cohen LLP, a mid-sized firm based in San Jose, has an immediate opening for a mid-level associate in its transactional real estate group. The successful candidate will have 3-6 years experien...
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Real Estate Specialist - Services
USA-FL-Boca Raton
Real Estate Specialist - Services The candidate will execute and deliver on the day-to-day Area Real Estate activities in accordance with firm objectives. Perform all revenue producing services to me...
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A. Harrison Barnes is a well-known attorney throughout the United States. As a member of the Malibu community, Harrison is committed to serving the needs of Malibu residents and businesses in legal matters.
Anthony Ciasulli is a senior counsel in Morgan Lewis's Real Estate Practice. Mr. Ciasulli represents both developers and lenders in connection with commercial, residential, industrial and resort real estate.


text:
'Hysteria' doesn't shake it up quite enough
Though its title has the ring of a horror movie, Hysteria (* * ½ out of four, rated R, opens Friday in New York and Los Angeles) is all about good vibrations.
A romantic comedy that centers on the development of the electromagnetic vibrator during the prudish Victorian era is an idea rife with humorous possibilities.
But the comic elements of this semi-factual tale are heavy-handed, and a key romance falls flat. Despite its titillating subject matter, Hysteria is only mildly stimulating. The final third of the story meanders during a tedious trial and clumsy speechifying.
The story does cleverly expose the fallacy of the medical diagnosis known as "hysteria," widely dispensed by doctors at the end of the 19th century.
Hugh Dancy plays Mortimer Granville, an idealistic, forward-thinking doctor who can't seem to hold a job as he argues against established medical practices such as leeching. The tale is loosely based on fact: In 1880, a doctor named Joseph Mortimer Granville did develop the electric vibrator, though for use with muscle aches, not as a sex device.
About the movie
* * 1/2 out of four
Stars: Maggie Gyllenhaal, Hugh Dancy, Jonathan Pryce, Felicity Jones, Rupert Everett
Director: Tanya Wexler
Distributor: Sony Pictures Classics
Rating: R for sexual content
Running time: 1 hour, 35 minutes
Opens Friday in New York and Los Angeles
When the fictional Granville applies for a position with the successful doctor Robert Dalrymple (Jonathan Pryce), who specializes in "hysterical" women, he gets the job and quickly develops an affinity for the doctor's unorthodox treatments. Essentially, Dr. Dalrymple believes that manually stimulating his respectable female patients with a "vulvar massage" is a physical necessity that will calm their frazzled nerves.
Granville goes along with the program and half-heartedly courts the doctor's traditionally minded daughter Emily (Felicity Jones). Emily's sister Charlotte (Maggie Gyllenhaal) is as feisty, independent and passionate as Emily is dutiful and mild. A feminist, she angers her father by helping the poor at a ramshackle London settlement house rather than playing the piano and studying phrenology, as Emily does.
Gyllenhaal gives the film's liveliest performance, though her dialogue is too often soapbox-stilted. Jones seems rather like she's sleepwalking. Pryce is pitch-perfect as the smarmy doctor, and Dancy's character is the most complex — both earnest and knowing.
For a film that ostensibly reveals women's desires, however, it's more gimmicky than sexy. And scenes featuring prolonged aural expressions of female sexual pleasure don't hold a candle to Meg Ryan's unforgettable scene in When Harry Meets Sally.
Granville's techniques begin to deteriorate as his hand stiffens and grows less dexterous. Luckily for him, his iconoclastic flatmate, Edmund St. John Smythe (Rupert Everett), an amateur inventor, has developed a vibrating utensil that Granville uses to soothe his aching hand. This leads to Granville's brainstorm: utilize the apparatus for his hysterical patients.
At its best, the film has a blithely charming quality. The production design, amid an authentic-looking London in 1880, gives it an arty polish. But the clashes between uptight, moralistic types and free-thinkers resort to stereotypes and clichés.
While it attempts to be a naughty period comedy in the vein of Oscar Wilde, by the time it reaches its climax, Hysteria lacks electricity.
Posted | Updated


text:
WCN:Talk (originally called "FutureForum") is a Web discussion forum written in Perl and MySQL. It has many options, including message selection and sorting on the top index page. It also has collapsible branches, a menu that toggles between 'no menu', 'simple', and 'advanced' modes, full text search capability, the ability to send email to the admin and original poster, and many other features. It includes password protection, HTML templates, file uploads, message subscription, multiple discussion sections, and a lot more.
Pipo-BBS allows you to install a BBS server and clients. You can chat via a nice interface with an unlimited number of people (as with IRC). This software is in a pre-release state; it is still very alpha, and can be difficult to even compile. It works under linux, MkLinux, SGI, HP-UX, and Solaris. The only interface for this BBS is telnet for the moment; an interface using GTK has been started. It has been translated into French, English, Spanish and German.
LysKOM is an online, text based, interactive discussion system sort of like a mix between Mail, News, IRC and a BBS system. It's modeled after the KOM system that was available to DECsystems running the TOPS-20 operating system ages ago. The web site for LysKOM is written in Swedish, but the README files on the FTP site are in English. Both the server and (some of) the client(s) can speak both Swedish, English and other languages. LysKOM is a client-server system. This project is the server software itself.
MBSE BBS is a full Fidonet-capable ANSI BBS package including a mailer (ifcico clone), tosser, ticfile processor, filefind, and other utilities. It supports fully configurable ANSI menus, multiple languages, IEMSI, standard file transfer protocols, and native Linux doors. The mailer supports the FTS-0001, YooHoo/2U2, EMSI protocols over modem, and the TCP/IP Binkp and IFC protocols, Zedzap, Zmodem, Telink, and Hydra file transfer protocols. Full FTN mail support, including automatic routing for hub and host systems, is included. A Fidonet/Internet gateway is also built-in. The internal mail format is JAM (c) messagebase, and there is full tic file support, including extended tic files.
mconv is an Internet BBS modelled after Monochrome BBS (menus rather than a command line). It includes several utilities for the conversion of BBS attributes to plain text, ANSI colour text, and HTML. It can also convert session logs and scrollback buffers to BBS format so they can be viewed in the BBS or in the included standalone file viewer.
Ncohafmuta is a text-based chat server that is designed for access from a telnet client. Its purpose is to allow users to communicate in a configurable environment in realtime. It allows users to create accounts with their own settings and optional personal information. Rooms are the basis for communication, whether private or public. Other features include internal email, email forwarding, a configure script for multiple Unices, support for cygwin under Win32, macros, games, a ranking system with access to more commands, ANSI coloring, banning, async DNS, soft/hot-rebooting, detailed, organized logging, and an internal Web server port.
panFora is a full featured, high performance Web-based collaboration tool for discussion forums and file sharing. Using standard web browsers and a multi-framed/windowed approach, it has a desktop application feel familiar to users of desktop email/newsgroup tools. A traditional single-frame web layout is also available as a user preference. Extensive admin features allow forums to be created, customized, colorized, reconfigured and maintained, completely from the web. Other unique features include hierarchical topic structure, announcements by groups, and full but safe HTML formatting support in message posts. A popular high performance open-source embedded database is built-in; no database installation is required by the user, making panFora installation fast and easy.
A decentralised packaging system.
Small Unix networking tools.


text:
The patrols at the Essex airport were stepped up after a burning car was driven into a terminal door at Glasgow.
The airport said passengers must be picked up and dropped off at car parks.
There may be significant delays in reaching the terminal using the airport shuttle buses so passengers are asked to allow extra time.
It said passengers could still reach the airport by public transport and this helped to avoid delays.
There is no disruption to services because of the extra security, but it may take longer for passengers to be checked in.
Police also said they would be making more use of stop and search under the Terrorism Act and there would be patrols by armed response vehicles around mainline train stations.
Most Popular Now | 56,514 people are reading stories on the site right now.";


text:
"Happiness is not a goal; it is a by-product."
-Eleanor Roosevelt
Alfreda James
TITLE: Assistant Director
INDUSTRY LIAISON: Public Policy, Government, Science Research
Alfreda S. James specializes in counseling graduate students about career options. She advises undergraduates pursuing careers in public policy, government, and science. Her professional experience includes an arrested landing and catapult launch on the USS Reagan, teaching a career exploration class, instruction on dining etiquette, and monitoring student progress in internships.
Personal/Professional Background:
She is a member of the Graduate Career Consortium, a network of career education professionals who advise graduate students. Dr. James is a member of the Turner Fellows Advisory Committee and the WISE Working Group. Dr. James and her family are members of the university's Host Family program helping international students adapt to American culture. She recently received an UUP Individual Development Award to review experiential education programs at other universities.
Raised in Norfolk, Virginia, Dr. James graduated from the College of William and Mary with a degree in History. She began her professional life writing for a weekly newspaper. After two years of interviewing local politicians and attending school board meetings, the career in journalism (and its low salary) lost its glamour. The next professional stop involved returning to William and Mary and joining the undergraduate admission staff. For the next five years Dr. James travelled throughout the state of Virginia convincing high school students to apply to the College. During this period, she acquired a M.Ed in Higher Education Administration.
Dr. James moved to Long Island in 1988 to join her husband, then a graduate student at SBU. Since the late 1980's she has completed a PhD in American History on the activities of free African American women in abolition societies, taught at Suffolk Community College, managed budgets, and directed an internship course.
Favorite part about working at the Career Center:
The endless variety of students
Frank Melville Jr. Memorial Library,
Ground Floor
(631) 632-6810
Walk-In Hours
Wednesday, 10 AM - 12 PM


text:
This medium size oil-rubbed bronze LED outdoor wall light merges traditional design with modern energy efficient technology. Cylinder style fixture presents an oil-rubbed bronze finish housing and clear seedy glass. A frosted glass diffuser inside eliminates glare. LEDs can last up to 50,000 hours, so changing bulbs is practically a thing of the past.
John Timberland™ creates beautiful contemporary lighting for today's modern home decor styles. Inspired by cutting-edge European designs, the artisans of John Timberland™ use superior quality materials and techniques to create some of the finest lighting products imaginable. If your home deserves the very best in contemporary lighting, then it deserves John Timberland™.
Our team has over 100 years combined experience with contemporary lighting.
Every EuroStyleLighting.com order is backed by our 100% Satisfaction Pledge.
Shipping and Delivery Information - For item EUV1685 if ordered by 1 pm Pacific Time


text:
Elijah's Cup by Joy Stember
By Joy stember
The Elijah Cup features the prophet's name in English and Hebrew impressed upon the sides of this handmade goblet. The finish denotes antiquity and the shape shows the essence of contemporary life. SIZE: 4.75" x 2.25" x 2.25".
Please allow up to 2 weeks for delivery.


text:
Date of birth: We need to confirm your date of birth in order to add this product to your basket.
You can only use PayPal to buy a subscription product
Delicious Stir It Slim meal replacement drink - just 204 calories per serving.
Stir it Slim is a convenient, great-tasting hot meal replacement drink that has been designed to support safe and healthy weight loss. The meal replacements are high in protein, contain 22 different vitamins and minerals, and contain only 204 calories per individual serving.
Substituting two daily meals of an energy-restricted diet with Stir it Slim contributes to weight loss, while substituting one daily meal of an energy-restricted diet with Stir it Slim contributes to the maintenance of weight after weight loss.
As a meal replacement, mix 1 sachet (55g) of powder with 250-300ml of hot water. It is recommended that you use recently boiled water that has been left to stand for at least 2 minutes. It is important to maintain an adequate daily fluid intake when using this product. Caution: Do not mix this product in a shaker cup. Due to the use of hot water, this product should be stirred with a spoon to avoid risk of injury.
Skimmed Milk Powder, Dextrose, Whey Protein Concentrate (Milk, Soya), Soya Protein Isolate, Fat Concentrate Powder (Soya, Milk), Minerals (Tri-Potassium Citrate Monohydrate, Tri-Sodium Citrate Dihydrate, Calcium Hydrogen Phosphate Anhydrous, Magnesium Oxide, Ferric Pyrophosphate, Zinc Sulphate Monohydrate, Copper Gluconate, Sodium Selenite, Potassium Iodide, Manganese Sulphate Monohydrate), Emulsifier (Soya Lecithin), Thickener (Sodium Carboxymethyl Cellulose), Coffee Flavouring (contains caffeine), Vitamins (Ascorbic Acid, Vitamin E, Nicotinamide, Vitamin A, Calcium D-Pantothenate, Vitamin D3, Folic Acid, Pyridoxine Hydrochloride, Riboflavin, D-Biotin, Vitamin B12, Thiamine Mononitrate), Colouring (Caramel), Sweetener (Sucralose)
Allergens in bold.
Size (3) Unit (EA) Height (1) Width (1) Depth (1)
Product code: 708714
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THANK YOU for wanting a RESCUED DOG/PUP!!!!
This is Yeolie and here's his story! He was adopted by a military family from ACS. When they moved they dropped him off at a gas station off 1604 and Marbach and left. Friends witnessed this and tried to catch the terrified dog. He eluded them, after terrific thunderstorms for a week., he was found huddled underneath a bush near one of the friends' home. They were able to get him and take him to a vet and have him scanned for a microchip. ACS tried to contact the owners but found the family had moved. Yeolie was brought in to another rescue where I fostered him. He was adopted and returned multiple times because he can jump a 6 ft fence with no warning and he takes off and explores. He does not come back.
Yeolie is crate trained, neutered, up to date on shots, microchipped and just a sweet little guy. He loves all dogs. He loves kids but does get excited and jumps. He can not EVER be let out in the back yard. He ALWAYS needs to be on a leash or a tie out. He loves to snuggle. He loves hard toys and bones to chew on. He will de-stuff animals so no plushies for him. He really needs a family to love him. He is 3 1/2 yrs old. It's just that wandering spirit that gets him into trouble. He is worth it if he is controlled when outside. Never alone! If you want to add this sweet boy to your family, please email Juli at firstname.lastname@example.com.
GOD'S DOGS Rescue, in San Antonio TX, does not have a shelter - ALL of our dogs are raised in foster homes in the San Antonio area. UPON adoption this dog/pup will be transported to you in YOUR area!!
Each dog comes spayed or neutered, up-to-date on vaccinations that are appropriate for their age, micro-chipped, heart worm tested and on current on monthly flea/tick and heart worm preventative. Medical records will come with each dog at the time of adoption.
****Please realize that breed mix and size when grown are guesstimates based on the dog/pup's characteristics and coloring, unless we have mother/father in our rescue...*****
ALL OF THIS IS INCLUDED IN THE ADOPTION FEE OF $200.00 for adoptions in TEXAS only. IF THIS IS AN OUT OF STATE ADOPTION, TRANSPORT TO YOU is included in the adoption fee of $400.00 for adult dogs and $450.00 for puppies. We transport all over the country!!
All our dogs are socialized and we try to provide you a good understanding of the dog's personality. Please visit our website for more information about what we do; http://www.yourtxrescueconnection.org/. You will also find helpful information about transport, our adoption application and pictures of our all our dogs/pups looking for homes!!
Please contact DEBBIE DAVIS at email@example.com,or JULI MARCHBANKS at email@example.com for more information and/or fill out an adoption application on our site.
Thank you for wanting to adopt a rescued dog, their LIVES depend on it!
Thank You!
Your message has been sent to God's Dogs Rescue.
You'll receive a copy, too, at to help you keep track of which pets you've inquired about, and which shelters and rescues you've emailed.
NOTE: Some shelters have physical locations you can visit; some of these shelters may only have pets for a limited time, so please do not wait for a reply—just go visit the shelter! Other organizations are rescue groups run by busy volunteers who may take a while to reply. You can find information about the shelter or rescue group caring for this pet, and their adoption procedures, on the pet's details page on Adopt-a-Pet.com.


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Positive Feedback
Notes of an Amateur: Gardiner's Bach Cantata Cycle
Bach Cantatas, Gardiner. Vols 12 and 18. Monteverdi Choir, English Baroque Soloists, John Eliot Gardiner, Director. Soli Deus Gloria. SDG 171 and 174.
Sitting down this week to listen to and write about the final two installments of John Eliot Gardiner's brilliant and life-giving Bach cantata cycle, I tried to let the experience of having done the same for the previous twenty-five volumes intrude as little as possible in hope of finding something new to say. I listened with as open and fresh a mind as I could call up; but to be honest, these two albums were recorded at the end of the year-long pilgrimage, so there's no escaping some sense of the occasion for the musicians, and for us.
What struck me most immediately (again) was the 'live' quality of these, in fact, live performances. We can feel the mikes set up not for absolute capture of intimate detail, the congregation be damned; we hear everything but in natural rather than spot-lighted balance. So we hear and feel the venue: churches. Churches, even small ones, are large venues, in which both human and instrumental voices have more time and space to move about than recording studios provide. We also feel an energy that comes from singing and playing 'live'—one time, no re-takes, for a congregation as well as a tape recorder. A 'this is it' quality that is part of the secret behind the whole series' emotional and aesthetic power of expression. It is as if it's always "it." And finally, we hear and feel the overall ease that is a dominant quality in these performances. "It" does not require intensity, it requires a sense of being wholly in the music, a sense that athletes talk about when asked impossible questions about their performances.
The soloists here, as always, are leading professionals, with names recognizable to even just partly knowing listeners like me—Joanne Lunn, Robin Tyson, James Gilchrist, Peter Harvey, Magdalena Kozena. But there is some of the amateur (in the best sense) in their singing. It as if they have been called away from their day jobs to perform on the weekend for the 'Gardiner Project.' Their professional reserve is down, their youthful amateur spirit recalled, for the pure love of singing this extraordinary music. I have heard this quality throughout the cycle. It is a version of the unaffected energy of Harnoncourt's and Leonhardt's cycle done a decade ago at the onset of the early music movement, when musicians were still just learning now to blow horns without valves and play gut strung instruments without vibrato. Gardiner's forces are far more polished and accustomed to their instruments (and he uses female rather than boy supranos!); but they have the same brio and lack of concern for the hyper-refinement and spirituality that can kill the essential humanity in this music dead.
Another observation, now drawing on the previous twenty-five volumes, is how consistent in spirit and musical point of view these two final performances feel with earlier ones, despite the considerable variety of soloists, choir singers, and instrumental musicians Gardiner has used. There have been some fairly regular participants, several of whom write valedictory notes at the end of each volume; but as a whole the EBS and MC number a great many folks. I have said before that much of the remarkable consistency of spirit has to be attributed to the power of Gardiner as conductor and leader. Gardiner, and the power of his pilgrimage itself. A full year, singing Bach every Sunday according to the dictates of the liturgical calendar, under the direction of a man who has Bach in his mind and heart.
Listening to BWV 140 in the final volume, No. 12, singled out by Gardiner has "the most famous and enduring cantata," we can hear the whole cycle: the 'live' energy of the choir, an exquisite violin solo that completes a trio with eloquent soprano and bass, all suspended in a huge sacramental space, its size emphasized by the organ continuo. And it all seems to rise from the floor of the church into its upper spaces, much as we hear from the a capela group, Stile Antico. This is men and women raising their vocal and instrumental voices to remind us where great human art comes from.
I understand that buying twenty-seven double CD albums amounts to a substantial investment, around $1000. But now that I look at that number, it makes me smile. What else could we spend $1000 on and get so much in return? I suspect nothing.
System used for this audition: Audio Note CDT3 transport, Blue Circle BC501ob dac, BC FtTH integrated amplifier. Jean Marie Reynaud Offrande Supreme, V2 loudspeakers. With Blue Circle BC6000 line conditioner. Audio Note Pallas and Sootto interconnects; Audio Note Sogon 40/40 speaker cables.
Bob Neill, in addition to being an occasional equipment and regular music reviewer for Positive- Feedback Online, is also proprietor of Amherst Audio in Amherst, Massachusetts, which sells equipment from Audio Note, Blue Circle, and JM Reynaud, among others.


text:
Brannen, Julia and Moss, Peter and Mooney, Ann (2004) Working and Caring over the Twentieth Century. Change and Continuity in Four-Generation Families. Palgrave Macmillian, Basingstoke. ISBN 140391477XFull text not available from this repository.
|Item Type:
|Controlled Keywords:
|Family Life including kinship, Work-family interface
|IOE Departments > Departments > Thomas Coram Research Unit
|Depositing User:
|IOE Repository Editor (2)
|Date Deposited:
|06 Apr 2010 15:46
|Last Modified:
|29 Jan 2015 10:09


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PBC Sheriff Ric Bradshaw: "Crime Stats Can be Deceptive"
The latest crime stats from the Florida Dept. of Law Enforcement show that overall crime was down by 5.2 percent over the first half of this year, compared with 2012.
It was down 4.9 percent in Palm Beach County, where Sheriff Ric Bradshaw is taking the numbers in stride.
"I'd like to be able to take credit for all of that, but there's so many things that go into whether a crime is up or down. It depends on the economics, how the economy is doing, how your crime prevention efforts are going."
He tells us that the crime stats are deceptive, because if the numbers of one type of crime are low, and all of a sudden you have several of those incidents happen, the numbers can tick up quickly.
Photo: PBSO


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As a medium-term visitor, I'm looking forward to your conscious effort
to decrease your comments and start doing things. This mailing list
has really hit a low in terms of usefulness this week.

Ā mike

On Wed, Dec 22, 2010 at 11:27 PM, Patrick Keys <firstname.lastname@example.com> wrote:

 This is my final comment before I make a conscious effort to seriously
 decrease my comments altogether for awhile...

 As a new visitor myself, it feels like there's a growing rift between
 new visitors versus long-time visitors. ĀI respect that the long-time
 visitors helped bring this space together, know more about the vision of
 the space, and make a conscious effort to keep noisebridge alive.

 That said, most of the long-time visitors don't actually show up that
 often. ĀAnd when they do, the vibe I personally get is one of
 entitlement as if to say "i own this and you're just a guest".

 On the other hand, some of us, like me, use this space as our personal
 office. ĀThis is normal for some other hackerspaces, like Hacker Dojo.
 Basically, people work long hours at the space, take legitimate naps
 there, do some collaborating, and get a lot done.

 The issue is when you spend all day here working and then long-time
 visitors show up and act like you're in their way. ĀI'm not talking
 about anybody in particular, that's just my general observation. ĀThe
 response from newer visitors, in turn, is animosity to the long-timers.
 ĀThe result kinda feels like "us-versus-them".

 That's just my observation. ĀI think making the space feel welcome for
 everybody, long-time and new alike, requires effort from everybody.

 Patrick
 _______________________________________________
 Noisebridge-discuss mailing list
 firstname.lastname@example.com
 https://www.noisebridge.net/mailman/listinfo/noisebridge-discuss


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Fill out the form below to join the Gray Matters Brain Buddies!
Disclaimer: The GrayMatters Foundation respects your privacy. The information you provide is used solely for the purpose of the Brain Buddies program and is intended for GrayMatters to use to stay in touch with the Brain Buddies and to connect them to others in the network. Your information is not sold or distributed in any way.


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Born Karola Ruth Siegel in Frankfurt, Germany, the woman now known as "Dr. Ruth" saw her father arrested by Nazis and said a final goodbye to her mother as she boarded a Kindertransport rescue train to Switzerland.
By 17, she was in the British mandate of Palestine on a kibbutz, and, later in Jerusalem, the diminutive teenager became a sniper for the Haganah forces. A bombing on the night of her 20th birthday left her badly wounded, but she recovered and went on to study at Paris' Sorbonne, as well as the New School and Columbia University (for a doctorate in education) in New York.
Three marriages (two brief ones, followed by the last to Manfred Westheimer for more than 30 years), two children (Miriam and Joel), and a long career later, 84-year-old widow recently found herself in a theater in western Massachusetts, watching an on-stage portrayal of her life.
"I had to pinch myself a few times to realize that I was in the audience and not on stage," Dr. Ruth Westheimer said in an interview with JNS.org.
A resilient survivor and self-made media darling, Dr. Ruth became an internationally known sex educator at an age when many consider retirement.
Her essential focus is living as fully as possible. "People have to be active, to do things," she said. "Do a new activity every single day. Take a course, go to a concert, make sure to keep a relationship with a neighbor — to schmooze a little, not just to cry on someone's shoulder. If you have to cry, go to a professional; no one wants to hear about problems."
She is a firm proponent of continuous growth and change. "Things have changed since 'Lady Chatterley's Lover' or 'Fear of Flying.' Establish a new vocabulary," she advised. "Read books; look at sexually arousing material."
Dr. Ruth recommends "50 Shades of Gray" — "all three volumes."
"If someone doesn't like it, you can close the chapter," she said. "If [she] does like it, the book proves the point that woman can get aroused."
And if you're in search of a partner, her advice is: Take the initiative.
"Be involved! Go to concerts, performances, lectures — events of interest. Women have to take the risk of being the one to start a relationship, to say to a man 'Would you like to go for a coffee?' If the answer is 'no,' go on to the next one!" she said.
If partnership is not possible, then "find a place that will be enjoyable, and give you some satisfaction," she said, "even if you don't meet a partner."
Even for those seniors lucky enough to find an emotional partner, establishing a physical relationship can sometimes be difficult. In that case, "see a sex therapist," said Dr. Ruth. "Very often, a problem is something physical. Go to your family physician or gynecologist. Use whatever physical or mechanical aide is needed. Engage in sex in the morning. Do not have expectations that he can hang from a chandelier!"
"Don't ask me about my sex life!" she added. "You will not get an answer. I don't ask intimate questions except of my patients."
What if one does remain alone and does not find a new partner?
"People have an obligation to themselves," she said. "If they feel a sexual urge and are alone, they should get used to the idea of masturbating —even to orgasm. They will be more satisfied — have a different way of walking. Of course it's not the same as with a partner, that's true. But I am someone who stands with two feet in reality: Make the best of it! No one will be helped by crying about things they cannot change."
The need to cultivate relationships, said Dr. Ruth, includes those with adult children: "Call them. Ask 'Do you have a moment?' Don't say, 'You didn't come to see me.' Say 'Whatever is conven-ient,that fits with your plans.' Be flexible. Go to a coffee shop. Let them know, 'I would like to see you … I'll take the time you can give me and be satisfied.' "
The same "children" who may have little time to spend with a parent, often have much to say about a parent's new partner. While the new partner "will never replace the father or mother, never be an intimate part of the family," said Dr. Ruth, children should be "civil and polite" and recognize that the mother or father's companion makes life easier. "One would never go on the assumption the partner will be an intimate part of the family."
While Dr. Ruth believes that companionship and romance enhance living; she is practical as well. "It's very important for an older person who finds a new partner to write a detailed arrangement about money," she said, which will address any fears (that you or your children might have) "that the inheritance from their parent will go to the partner's family. You don't need a fancy lawyer.
"Go to someone who can witness a legal agreement assuring that money will remain separate," she advised. "In today's contentious world, it is essential; an agreement is very important to calm any fear. Documentation is especially important when there is any unusual circumstance, such as when a grandparent is responsible for a minor child. Everything must be written. No one can foresee the future."
The experience of being a senior is one Dr. Ruth shares with many in her audience. Yet, she is clearly a work in progress. This summer, she will present Vin d'Amore, a California-bottled line of low alcohol wines — available in red, white, and rosé, of course — complete with her picture on the label.
"I tell people to drink a little, then have sex," Dr. Ruth said.
"But," she cautioned, "not too much — she falls asleep and he can't perform. With wine, less is more."


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What Do You Do When It's Too Hot? Shop!
Over the past few days, NYC residents were forced to deal with an overwhelming heat wave of record temperatures. City dwellers searched for any way to escape the heat, and for once, sitting in the office for a few extra hours just to take advantage of the blasting AC was actually enjoyable rather than aggravating! Of the many creative ways residents found to survive the heat wave, one surprising result of the 100+ degree heat was an actual increase in shopping and sales. Retailers found that during the heatpocalypse, businesses saw double-digit increases in sales on seasonal items — meaning consumers forgot about the recession, got confused about the season, and whipped out those credit cards to buy items for FALL! Personally, I can't imagine trying anything on in a dressing room except for mini dresses and bathing suits when I'm this hot, so I can hardly imagine even contemplating buying boots and sweaters. Are you spending more cash and shopping to escape the heat? And if so, what exactly are you buying? [WWD]


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before it's in the papers"
Immune system cells found to hunt like real predators
May 30, 2012
T cells—components of our immune systems that find and kill pathogens—move much like predatory animals as they do so, a study has found.
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T cells—components of our immune systems that find and kill pathogens—move much like predatory animals as they do so, a study has found. The insight should help scientists devise better models of immune-system function, possibly helping to fight diseases from cancer to AIDS to arthritis, said researchers at the University of Pennsylvania who conducted the research. The study, published in the latest issue of the research journal Nature, was conducted in mice infected with the parasite Toxoplasma gondii. This single-celled pathogen is a common cause of infection in humans and animals; as much as a third of the world's population has a dormant form of it in the brain, though it's harmless in most cases. The researchers used the infected mice to learn how the movement of T cells in the brain affects the body's ability to control the infection. The investigators tracked the movement patterns of T cells in tissue from T. gondii-infected mice using multi-photon imaging, a technique based on a refined, powerful microscope that can display living tissues in three dimensions in real time. Scientists haven't thought that much about T cell movement patterns, but to the extent that they have, many assumed T cells moved in a highly directed way toward their prey, the Penn researchers said. This turned out to be wrong, they claim. For a time, the actual movement patterns were perplexing, but the Penn group eventually concluded that the cells' movement was a variant of a known pattern called a Lévy walk. This "walk" characterizes the hunting patterns of many predators, and is really a type of path that features many short "steps" and occasional long "runs." Such a strategy seems particularly common among marine predators, including tuna, sharks, zooplankton, sea turtles and penguins, the scientists said, though land animals like spider monkeys and honeybees may use the same approach to find rare resources. The T-cells put their own twist on the Lévy walk by taking pauses between steps and runs, pauses that—like the movements themselves—were usually short but sometimes long. Christopher Hunter, a co-senior author of the study, likened the strategy to the way someone might find misplaced keys in the house. "How do you go about looking for them? You look in one place for a while, then move to another place and look there," he said. "What that leads to is a much more efficient way of finding things," added Andrea Liu, the other senior author. The strategy makes sense for T cells, which have to locate sparsely distributed parasites in a sea of mostly normal tissue, the scientists added. The parallel with predators makes sense, they said, because parasites act like prey: they have evolved to evade detection. "Many pathogens know how to hide, so T cells are not able to move directly to their target," Hunter said. "The T cell actually needs to go into an area and then see if there's anything there." The model is also relevant to cancer and other immune-mediated diseases, Hunter noted. "Instead of looking for a parasite, these T cells could be looking for a cancer cell," he said. By knowing what controls T cell movement, "you might be able to devise strategies to make the T cells more efficient at finding those cells."


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" Brand: Sainsbury's / Type: Cereal Bars "
Since trying these, I've become totally addicted, so I thought it only right that I should share the joy in a review! They are exclusively from Sainsbury's and are priced £1.49 for a box of six. They are found in the crackers and biscuits aisle, not in the cereal bars aisle which foiled me for a while and I panicked they'd been discontinued! They are not available singly.
They come in a simple red-coloured cardboard box which looks quite minimal and smart, just with the title of the product on and of course the 'wheel of health'. These aren't actually too bad for you, at 132 cals. This is comparable to similar products and other snacks like a bag of crisps, etc. However they do contain 7g of fat each which is a lot - enough to colour it red on the wheel, so maybe one for now and again rather than every day.
The reason I've got so hooked on these is because they are so nutty and crunchy, yet so chewy at the same time. They manage to be really yummy and sweet without being sickly, and also seem to keep me full for a long time. I've been eating them mid-morning at work, and they seem to keep my energy levels up much better than other cereal bars or snacks. Looking at the ingredients, they contain a large proportion of peanuts and hazelnuts and this is reflected in the taste. For nut-lovers like me they are perfect and really wholesome-tasting. Yet they also have a slight toffee taste, with a chewiness that compliments the nuttiness perfectly.
All in all, these are a really nice snack and although they aren't the best from a nutrition point of view, at least they don't contain lots of artifical ingredients and most of the fat comes from nuts, which makes me feel better about them!


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Let's read together network
Illiteracy an Impediment to Integration
There are hundreds of illiterate people in Finland and most of them are women.
Illiteracy creates such stumbling blocks in everyday life that most of us cannot even imagine:
How to monitor your childrens schoolwork and progress;
How to tell the doctor what is ailing you;
How to shop if you dont even know the alphabet.
Those immigrants who came to Finland when they were children or young adults, often seem to master Finnish fluently, but in many cases it is obvious that even they need support in their studies, for instance.
Lets Read Together Network supports immigrant women in integrating into Finnish Society. A network of Finnish women volunteers offer tuition in literacy and the Finnish language to immigrant women in various locations all over Finland. At the moment, there are some fifty Lets Read Together study groups in these locations.
The Finnish Federation of University Women is responsible for the Network in partnership with Zonta International District 20 and UN Women Finland.
Would YOU like to join us to help immigrant women integrate into Finnish Society? For further information, please contact: coordinator Henna-Maija Syrjälä: firstname.lastname@example.com, phone: 0451174282
See our study groups' time tables here.
EPALE's (Electronic Platform for Adult Learning in Europe) article about network.
LETS READ TOGETHER -project, Period 2007-2010, Final Report


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Daily Horoscope
by: Terens • 279
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by: Terens • 279
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webpageguy said
During install of UniqueShop (PrestaShop Theme) the theme never finishes the install process with a corresponding error "BAD CONFIGURATION FILE".
Any idea of a week-end solution.Yeah you have to unzip the folder. Once it is unzipped there is another zip file inside of that zipped file. You may have to search through a couple of folders but you will find it. The name will be the name of the template and will not have prestashop in it. When logged into your backend that is the file you will upload.