text:
VIEWS: 0 PAGES: 9 CATEGORY: Medicine POSTED ON: 8/25/2010 Public Domain
Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com Guidelines for the diagnosis and management of cow's milk protein allergy in infants Yvan Vandenplas, Martin Brueton, Christophe Dupont, et al. Arch Dis Child 2007 92: 902-908 doi: 10.1136/adc.2006.110999 Updated information and services can be found at: http://adc.bmj.com/content/92/10/902.full.html These include: Supplemental http://adc.bmj.com/content/suppl/2007/11/13/92.10.902.DC1.html Material References This article cites 41 articles, 5 of which can be accessed free at: http://adc.bmj.com/content/92/10/902.full.html#ref-list-1 Article cited in: http://adc.bmj.com/content/92/10/902.full.html#related-urls Open Access Email alerting Receive free email alerts when new articles cite this article. Sign up in the service box at the top right corner of the online article. Topic collections Articles on similar topics can be found in the following collections Unlocked (457 articles) Notes To order reprints of this article go to: http://adc.bmj.com/cgi/reprintform To subscribe to Archives of Disease in Childhood go to: http://adc.bmj.com/subscriptions Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com 902 REVIEW Guidelines for the diagnosis and management of cow's milk protein allergy in infants This paper is freely available online Yvan Vandenplas, Martin Brueton, Christophe Dupont, David Hill, under the BMJ Journals unlocked scheme, Erika Isolauri, Sibylle Koletzko, Arnold P Oranje, Annamaria Staiano see http://adc.bmj.com/info/unlocked.dtl ................................................................................................................................... Arch Dis Child 2007;92:902–908. doi: 10.1136/adc.2006.110999 Our aim was to develop guidance for general paediatricians early reactions usually manifest as urticaria, angio- oedema, vomiting or an acute flare of atopic and primary care physicians in diagnosing and managing dermatitis. The remaining 42% showed a later cow's milk protein allergy in infants. The guidelines were reaction, typically of atopic dermatitis or the developed by discussion based on existing national gastrointestinal tract. Infants with early reaction recommendations and standards, clinical experience and, were more likely to have a positive skin prick test (SPT; wheal size >3 mm) or test positive for whenever possible, evidence from the literature. Separate specific IgE than those with later reactions.7 The algorithms cover breast-fed and formula-fed infants. The amount of cow's milk that elicited the immediate recommendations emphasise the importance of comprehensive reactions varied from one drop to 161 ml.8 In a selected group of 100 children with CMPA history taking and careful physical examination. Patients with (mean age of 16 months), Hill et al reported that severe symptoms need to be referred to a specialist. Elimination 27% developed symptoms, mainly urticaria and of cow's milk protein from the infant's or mother's diet and angio-oedema, within 45 min after ingesting cow's challenges are the gold standard for diagnosis. This guidance is milk. This represents the IgE-associated reaction. About half the children in this cohort showed intended as a basis for local discussion, implementation and pallor and gastrointestinal symptoms (vomiting prospective evaluation. The algorithms should be regularly and diarrhoea) between 45 min and 20 h after assessed using clinical audit standards. Once validated, the ingestion.2 The final 20% developed atopic derma- titis, respiratory symptoms or diarrhoea after more diagnostic framework could provide a standardised approach than 20 h and up to several days after the in epidemiological and therapeutic studies. ingestion of cow's milk. The proportion of children ............................................................................. with early and late reactions, or positive or negative for specific IgE depends on how the patients were selected.2 B etween 5% and 15% of infants show symp- CMPA persists in only a minority of children. toms suggesting adverse reactions to cow's The prognosis (ie, the likelihood of becoming milk protein (CMP),1 while estimates of the tolerant to CMP) depends on the patient's age prevalence of cow's milk protein allergy (CMPA) and titre of specific IgE at the time of diagnosis.9 In vary from 2% to 7.5%.2 Differences in diagnostic the experience of the taskforce members, children criteria and study design contribute to the wide with proven CMPA who are radioallergosorbent range of prevalence estimates and underline the test (RAST) or SPT negative become tolerant to importance of an accurate diagnosis, which will CMP much earlier than atopic children with reduce the number of infants on inappropriate positive test results. Furthermore, patients with a elimination diets. CMPA is easily missed in history of IgE-positive CMPA are at increased risk primary care settings and needs to be considered of developing atopic diseases, such as asthma, as a cause of infant distress and diverse clinical atopic dermatitis and rhinoconjunctivitis, than symptoms.3 Accurate diagnosis and management those who were IgE-negative. Children with will reassure parents. CMPA can develop in negative tests are less likely to develop multiple exclusively and partially breast-fed infants, and food allergy.10 Therefore, it is preferable to test for when CMP is introduced into the feeding regimen. specific IgE (if not performed during the diagnos- Early diagnosis and adequate treatment decrease tic work-up) in children with CMPA proven on the risk of impaired growth.4 challenge. CMPA results from an immunological reaction There are guidelines for the use of dietary See end of article for authors' affiliations to one or more milk proteins.2 This immunological products for the prevention and treatment of ........................ basis distinguishes CMP allergy from other adverse CMPA.11 12 However, there are currently no guide- reactions to CMP such as lactose intolerance.5 lines that specifically assist primary care physicians Correspondence to: CMPA may be immunoglobulin E (IgE) or non- Professor Yvan Vandenplas, and general paediatricians in the accurate diagnosis Department of Paediatrics, IgE associated.6 In IgE-associated cases, CMPA and management of CMPA. This document aims to Vrije Universiteit Brussel, may be a manifestation of the atopic diathesis. In Laarbeeklaan 101, 170 unselected infants with a mean age of Brussels, Belgium; yvan. Abbreviations: AAF, amino acid formula; CMP, cow's milk 7 months (range 2–11 months) with CMPA diag- firstname.lastname@example.com protein; CMPA, cow's milk protein allergy; eHF, extensively nosed by means of double-blind, placebo-con- hydrolysed formula; GORD, gastro-oesophageal reflux Accepted 15 April 2007 trolled challenge, 58% showed an early reaction disease; IgE, immunoglobulin E; RAST, radioallergosorbent ........................ within 2 h after the last challenge dose. These test; SPT, skin prick test www.archdischild.com Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com Cow's milk protein allergy in infants 903 meet this need. However, these recommendations may need symptoms of CMPA.22 CMPA has also been related to infantile adaptation to reflect local situations and, because they are not colic. However, colic has numerous aetiologies which should be evidence based, need to be prospectively validated and revised in considered during the differential diagnosis. However, there is a the future. Despite these caveats, the authors believe application subgroup of about 10% of colicky formula-fed infants in whom of these recommendations will improve the diagnostic and the colic episodes are a manifestation of CMPA.23 therapeutic skills of physicians in primary care. While in some young infants there is a strong association The corresponding author recruited a task force to develop an between atopic dermatitis and CMPA, many cases of atopic algorithm for the diagnosis and treatment of CMPA. SHS/ dermatitis are not related. The strength of the association Nutricia donated a grant to enable the authors to meet and depends on the age and severity of the atopic dermatitis: the discuss the development of the algorithms. The recommenda- younger the infant and/or the more severe the atopic dermatitis, tions developed were based on existing national recommenda- the stronger the association.18 tions and standards, present in Germany,13 the Netherlands14 Reactions to other foods, especially egg and soy, but also and Finland,15 and personal experience of the authors. The wheat, fish, peanut and other foods depending on the regional manuscript is based on a consensus that was reached following dietary intake, may occur in combination with CMPA.24 a review of the literature and whenever possible evidence-based Therefore, complementary feeding and, preferentially, all data were used to strengthen the proposals. Separate algo- supplementary feeding should be avoided during the diagnostic rithms were developed for breast-fed and formula-fed infants. elimination diet. EVALUATION OF AN INFANT WITH SUSPECTED CMPA ALGORITHM FOR THE DIAGNOSIS AND A comprehensive history (including a family history of atopy) MANAGEMENT OF CMPA IN EXCLUSIVELY BREAST- and careful physical examination form the foundation of both FED INFANTS algorithms. The risk of atopy increases if a parent or sibling has Breast feeding is the gold standard for milk feeding in infant atopic disease (20–40% and 25–35%, respectively), and is higher nutrition and is recommended exclusively for the first still if both parents are atopic (40–60%).16 In comparison to 4 months of life at least.25 The incidence of CMPA is lower in cow's milk formula-fed infants, exclusive breast feeding during exclusively breast-fed infants compared to formula-fed or the first 4–6 months of life reduces the risk for CMPA and most mixed-fed infants. Indeed, only about 0.5% of exclusively severe allergic manifestations during early infancy.17 The breast-fed infants show reproducible clinical reactions to CMP distinction between breast-fed (fig 1) and formula-fed infants and most of these are mild to moderate. This might be related (fig 2) reflects the importance of ensuring an adequate duration to the fact that the level of CMP present in breast milk is of breast feeding. Management principles also differ. The 100 000 times lower than that in cow's milk.26 In addition, management of breast-fed infants depends on reducing the immunomodulators present in breast milk and differences in maternal allergen load and strict avoidance of CMP in the gut flora in breast-fed and formula-fed infants may supplementary feeding. It is recommended that exclusive or contribute to the prevalence of CMPA in breast-fed compared partial breast feeding is continued, unless alarm symptoms to formula-fed infants. The most frequent symptoms of CMPA (table 1) require a different management.18 The earlier CMPA in exclusively breast-fed babies are listed in table 2 and include develops, the greater the risk of growth retardation.19 general dermatological and gastrointestinal manifestations. Unfortunately, there is not one symptom that is pathogno- Severe forms of CMPA (table 1) are very rare in exclusively monic for CMPA. The most frequent symptoms of CMPA are breast-fed infants. The occasional cases that occur are usually listed in table 2. The timing and pattern of these symptoms aid severe atopic dermatitis with protein losses and failure to the differential diagnosis. Symptoms of CMPA occur often, but thrive. Other rare conditions suggesting severe CMPA include not always, within the first weeks after the introduction of anaemia due to colitis with rectal bleeding and protein-losing CMP. Many children with CMPA develop symptoms in at least enteropathy. In these cases, introducing CMP into the infant's two of the following organ systems: gastrointestinal (50–60%), diet (eg, supplementary feeding) may exacerbate the symp- skin (50–60%) and respiratory tract (20–30%).1 The symptoms toms. Cases with alarm symptoms should be referred to a associated with CMPA can range from mild to moderate to paediatric specialist for further diagnostic work-up and severe, although this stratification is by its nature subjective. In management. In these infants, diagnoses other than CMPA this guidance, symptoms that put the child at an immediate are much more likely, and identifying the correct diagnosis life-threatening risk (such as anaphylaxis or laryngeal oedema) should not be delayed. or may interfere with the child's normal development (such as Breast feeding should be promoted for the primary preven- ''failure to thrive'' or ''growth faltering'') differentiate severe tion of allergy, but breast-fed infants with proven CMPA should from mild-to-moderate CMPA. be treated by allergen avoidance.18 There is evidence that food Differential diagnoses include, among others: metabolic proteins from milk, egg, peanut and wheat are excreted in disorders, anatomical abnormalities, coeliac disease and other breast milk and may cause adverse reactions during exclusive (rare) enteropathies, pancreatic insufficiency (such as in cystic breast feeding in sensitised infants. Due to the many benefits of fibrosis), non-immunological adverse reactions to food (such as breast feeding to the infant and the mother, clinicians should fructose malabsorption or secondary lactose intolerance, mostly advise mothers to continue breast feeding but avoid the causal with an onset in older children), allergic reactions to other food foods in their own diet. Egg avoidance studies indicate the allergens (such as hen's eggs, soy, wheat, etc) or other foetus may be exposed to maternally-derived egg antigens substances (such as animal dander, moulds, dust), malignancy, despite maternal dietary avoidance measures.27 In infants with and infections (particularly gastrointestinal and urinary tract atopic dermatitis, the risk of being sensitised to milk was four infections) and sepsis. A role for allergy in recurrent otitis times higher, and to egg eight times higher, than in infants media has been heavily discussed in some of the literature.20 21 without atopic dermatitis.28 Age at first introduction of solid The clinician should also assess whether the child suffers food and diversity of solid food showed no effect on atopic from concurrent conditions. For example, 15–21% of children dermatitis incidence.28 However, there are no data on additional with suggested or proven gastro-oesophageal reflux disease systematic elimination of hen's egg in symptomatic infants. (GORD) or CMPA suffer from both conditions. Furthermore, Therefore, as fig 1 shows, if the infant develops symptoms of 16–42% of children with a history of GORD show signs or allergy, a maternal exclusion diet avoiding food containing www.archdischild.com Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com 904 Vandenplas, Brueton, Dupont, et al Figure 1 Algorithm for the diagnosis and management of cow's milk protein allergy (CMPA) in exclusively breast-fed infants. eHF, extensively hydrolysed formula. CMP and hen's eggs is advised by the task force although the mother and may increase the mother's risk of consuming an evidence for CMP is more exhaustive than for hen's egg. In a unbalanced diet. Therefore, the relative risk associated with an subgroup of children with severe atopic dermatitis, peanut extensive, first-line exclusion diet may be greater than the could as well be eliminated from the mother's diet since peanut potential benefit. In a secondary approach, the additional allergy is more likely in children with atopic dermatitis. When elimination of wheat and fish will require the advice of an deciding which foods with a high allergenic potential to suggest experienced dietician in order to ensure that an adequate avoiding (hen's eggs rather than, for example, wheat and fish), nutritional intake is maintained. If the mother has a certain the taskforce considered evidence that in most geographical suspicion that another food elicits the symptoms in her child, the regions egg proteins are the most common cause of allergy after elimination diet should be adapted accordingly. In some very rare CMPA in infants and young children. The evidence that peanut cases, such as in infants with severe atopic dermatitis with allergy can cause severe symptoms has been well established, impaired growth, breast feeding should be stopped.18 However, but not in exclusively breast-fed infants. In contrast to milk and the authors strongly propose that these infants should be referred egg, peanut consumption is common in only parts of the world to a specialist before breast feeding is discontinued. such as the USA, UK and some other European countries. In The elimination diet should be continued for a minimum of primary prevention, which is not the topic of this manuscript, it at least 2 weeks, and up to 4 weeks in cases of atopic dermatitis has been shown that peanut is secreted into breast milk or allergic colitis. The mother will require calcium supplements following maternal ingestion.29 Since peanuts are not an (1000 mg per day divided into several doses) during the essential nutritional part of a normal diversified diet, they are elimination diet. If the elimination diet fails to improve the easy to avoid, and since infant sensitisation through breast symptoms, the mother should resume her normal diet and a feeding has been suggested, the task force suggests eliminating referral to a specialist should be considered, depending on the peanut as well from the mother's diet (although the evidence type and severity of the infant's symptoms. for peanut is much weaker than for cow's milk and egg). The If symptoms improve substantially or disappear during the task force recognised the difficulties in implementing such elimination diet, one food per week can be reintroduced to the widespread dietary recommendations. Further studies are mother's diet. If symptoms do not re-appear on reintroduction required to test the feasibility of such programmes and whether of a particular food to the mother's diet, the elimination of that they are effective if implemented on a large scale. specific food can be discontinued. Furthermore, a diet that also excludes fish, wheat and other If symptoms re-appear, the food responsible should be gluten-containing grain products is very demanding for the eliminated from the mother's diet as long as she is breast www.archdischild.com Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com Cow's milk protein allergy in infants 905 Figure 2 Algorithm for the diagnosis and management of cow's milk protein allergy (CMPA) in formula-fed infants. feeding. If solid foods are introduced into the infant's diet, care likelihood of a positive food challenge but not the severity of should be taken to ensure solids are free from the food proteins the reaction. In the study from Celik-Bilgili and coworkers, 60% that the infant is allergic to. If CMP is the responsible allergen, of the patients with a RAST class 1, 50% in class 2, 30% in class the mother should continue to receive calcium supplementation 3 and even 20% in class 4 had a negative food challenge.30 during the elimination diet. If the mother is on a CMP- elimination diet for a long period, appropriate nutritional DIAGNOSTIC WORK-UP IN SYMPTOMATIC INFANTS counselling is required. When the mother wants to wean her WITH NO ALARM SYMPTOMS (MILD-TO-MODERATE infant, the child should receive an extensively hydrolysed MANIFESTATIONS) formula (eHF) with demonstrated clinical efficacy. In a case of suspected mild-to-moderate CMPA, CMP elimination should start with a therapeutic formula for CMPA. The guidelines ALGORITHM FOR THE DIAGNOSIS AND define a therapeutic formula as one that is tolerated by at least MANAGEMENT OF CMPA IN FORMULA-FED INFANTS 90% (with 95% confidence) of CMPA infants.31 These criteria are Patients with life-threatening, particularly respiratory symp- met by some eHFs based on whey, casein or another protein toms or anaphylaxis, conditions need to be referred immedi- source, and by amino acid-based formulae (AAF). Preferentially, ately to an emergency department experienced in the treatment all supplementary food should be stopped during the diagnostic of this condition. In all the other situations, the initial step in elimination diet. If this is not possible in infants beyond the diagnostic work-up for CMPA is clinical assessment 6 months, only a few supplementary foods should be allowed accompanied by history taking, including establishing whether with dietary counselling. Nevertheless, the diet should not there is a family history of atopic disease (fig 2). contain CMP or hen's eggs, soy protein or peanut. Referral to a The algorithm differs according to the severity of symptoms paediatric specialist and dietary counselling may be needed for (fig 2). If the infant does not present alarm symptoms (as listed patients who do not improve. In such cases, further elimination in table 1), the case is considered as mild-to-moderate of other allergenic proteins such as fish and wheat may be suspected CMPA, and a diagnostic elimination diet should be appropriate. In most cases, the therapeutic elimination diet initiated. Infants presenting with symptoms such as angio- should be given for at least 2 weeks, although this may need to be oedema of lips and/or eyes, urticaria and immediate vomiting increased to up to 4 weeks in gastrointestinal manifestations and are likely to have IgE-mediated allergy. In the case of IgE- atopic dermatitis before deciding that the intervention has failed. mediated allergy, improvement (and normalisation) offers a eHFs that meet the definition of a therapeutic formula are safety net before challenge. A positive SPT increases the the first choice. An AAF is indicated: if the child refuses to www.archdischild.com Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com 906 Vandenplas, Brueton, Dupont, et al Table 1 Alarm symptoms and findings (can be found elimination diets and challenge procedures remain the gold alone or in combination with items listed in table 2), standard for the diagnosis of mild-to-moderate CMPA in indicating severe CMPA as the possible cause formula-fed infants. Clinicians can consider performing SPT (with fresh cow's milk or whole CMP extracts33) or determining Organ involvement Symptoms and findings specific IgE against whole milk or single individual CMPs. SPTs Gastrointestinal tract Failure to thrive due to chronic diarrhoea with fresh cow's milk resulted in larger wheal diameters than and/or refusal to feed and/or vomiting with commercial extracts, although the difference was not Iron deficiency anaemia due to occult or significant.33 Conversely, wheal diameters were significantly macroscopic blood loss larger with fresh foods for the other food allergens.33 The overall Hypoalbuminaemia concordance between a positive prick test and positive Endoscopic/histologically confirmed enteropathy or severe colitis challenge was 58.8% with commercial extracts and 91.7% with Skin Exudative or severe atopic dermatitis with fresh foods.33 These results indicate that fresh foods may be hypoalbuminaemia or failure to thrive or more effective for detecting sensitivity to food allergens. Fresh iron deficiency anaemia foods should be used for primary testing for egg, peanut and Respiratory tract Acute laryngoedema or bronchial (unrelated to infection) obstruction with difficulty breathing cow's milk sensitivity.33 General Anaphylaxis The results of these tests may guide optimal management: SPTs and RAST are especially helpful in predicting the prognosis and the time interval until the next challenge. Infants with negative RAST and/or SPT at time of diagnosis become tolerant to the offending protein at a much younger age than those with drink the eHF, but accepts the AAF (eHF has a more bitter taste positive reactions. In addition, a negative SPT and RAST result than AAF), if the symptoms do not improve on the eHF after 2– reduces the risk of a severe acute reaction during challenge. On 4 weeks, or if the cost–benefit ratio favours the AAF over the the other hand, infants presenting with early-onset symptoms eHF. The cost–benefit ratio of AAF versus eHF is difficult to such as angio-oedema or swelling of the lips and/or eyelids, elaborate in this global overview since health care cost differs urticaria and immediate vomiting are likely to have IgE-mediated substantially from country to country, as does the cost of the allergy. If these infants have a SPT with a reaction with a large eHF and the AAF, which in some countries is (partially) diameter (.7 mm) or very high titres in the RAST test, the reimbursed by national or private health insurance. The risk of likelihood is over 90% that the child will have a positive food failure of eHF is up to 10% of children with CMPA.4 In the latter challenge.30 In these highly atopic infants, the confirmatory CMP case, clinicians should refer to a specialist for further diagnostic challenge can be postponed until the child shows a reduced work-up. reaction in the tests for CMP-specific IgE. However, an open Children may react to residual allergens in eHF, which may be challenge under medical supervision can be performed after one reason for the failure. The residual allergens in eHFs seem to taking a complete history in infants with mild-to-moderate be more likely to produce gastrointestinal and other non-IgE- reactions without any prior blood sampling or SPTs. associated manifestations compared to AAFs.4 6 32 However, IgE- Patch testing in the investigation of CMPA is still a subject of related reactions have also been reported with eHF.6 In such on-going research and can aid the diagnosis of non-IgE- cases, clinicians should consider an AAF which has been proven associated reactions. Patch tests may contribute to the diagnosis to be safe and nutritionally adequate to promote weight gain and of food allergy, even when SPT and RAST were negative.34 growth.4 6 In some situations, the infant may be initially switched However, the patch test method needs to be standardised. to an AAF, especially if they experience multiple food allergies, specific gastrointestinal manifestations or both. In these Diagnostic challenge procedures instances, the potential benefits of an AAF may outweigh its If the symptoms substantially improve or disappear after 2– higher cost. If symptoms do not disappear on the AAF, another 4 weeks on an elimination diet, an open challenge with a diagnosis should be considered. formula based on whole CMP should be performed. While the challenge needs to be performed under medical supervision, the The role of in vitro and in vivo testing for CMPA test can be done, in most cases, in non-hospital settings.35 None of the available diagnostic tests prove or disprove that the Primary care physicians should be aware that the severity of a child suffers from CMPA.8 Because of these limitations, allergen past reaction might not predict the severity of a challenge reaction, particularly after a period of dietary exclusion.36 37 Previous mild reactions may be followed by anaphylactic Table 2 Most frequent symptoms of CMPA* reactions in some infants with CMPA. For this reason, open Organ involvement Symptoms challenges should preferentially be performed in a setting where safety facilities (eg, resuscitation) are available. Mild-to- Gastrointestinal tract Frequent regurgitation Vomiting moderate reactions clearly exclude infants with severe reactions Diarrhoea in their medical history, such as systemic anaphylactic Constipation (with/without perianal rash) symptoms, respiratory symptoms with breathing problems, Blood in stool and severe enteropathy with failure to thrive. In these cases of Iron deficiency anaemia Skin Atopic dermatitis severe manifestations, the challenge should be performed Swelling of lips or eye lids (angio-oedema) according to the protocol of the hospital, with or without an Urticaria unrelated to acute infections, drug intravenous line, in a setting that offers experience of intake or other causes immediate adequate treatment. Infants with severe manifesta- Respiratory tract Runny nose (otitis media)20 21 tions can be followed with SPT or specific IgE measurements, (unrelated to infection) Chronic cough Wheezing and if these are supportive of the diagnosis, a strict exclusion General Persistent distress or colic (wailing/irritable diet should be maintained until a resolution or improvement of for >3 h per day) at least 3 days/week the allergy tests occurs. In a case of previous anaphylaxis, a over a period of .3 weeks challenge is contraindicated unless SPTs and/or specific IgE *Infants with CMPA in general show one or more of the listed symptoms. measurement show improvement. In these cases, the challenge should always be performed in a hospital setting. www.archdischild.com Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com Cow's milk protein allergy in infants 907 During oral provocation the dose of formula should be breast-fed infants. CMA in these patients is less common than titrated as follows. After a physical examination of the previously believed, and an association with viruses can be undressed infant, with inspection of the skin, a drop of the observed in some patients. CM challenge is thus essential in formula is put on the lips. If no reaction occurs after 15 min, infants who become symptom-free during a CMP-free diet to the formula is given orally and the dose is increased stepwise reduce the number of false-positive diagnoses of CMPA.38 In (0.5, 1.0, 3.0, 10, 30, 50 to 100 ml) every 30 min. Thereafter, the cases with recurrence of symptoms after reintroduction of dairy infant is observed for 2 h and examined for cutaneous and products in the mother's diet, the algorithm recommends eHF if respiratory reactions before going home. If no reaction occurs, the mother wants to start weaning the infant and if the child is the child should receive at least 250 ml of cow's milk-based younger than 9–12 months. However, one could speculate that formula each day for the next week and the parents told to since the infant reacted to the (very) small amounts of proteins observe the child for late reactions. present in its mother's milk, it might be preferable to recommend AAF. Unfortunately, no data are available on this Positive challenge: CMPA confirmed topic. Patients with severe symptoms need to be referred to a If symptoms of CMPA re-appear, the suspected diagnosis of specialist experienced in managing childhood allergies. CMPA is confirmed and the infant should be maintained on an In formula-fed infants, clinicians should consider whether elimination diet using eHF or AAF until the child is between 9 SPTs, patch tests and determination of specific IgE would aid and 12 months of age, but for at least 6 months, whichever the diagnostic work-up and guide management. However, occurs first. The challenge is then repeated. If it is possible to elimination diets and challenges are the gold standard for follow the infant with IgE-mediated allergy with SPTs and/or diagnosing CMPA in formula-fed infants.35 For simplicity and specific IgE determination, normalisation or improvement of for socio-economic reasons, an open challenge is recommended these tests would help in choosing the time point of challenge. by the taskforce. In the case of a doubtful outcome, a double- Supplementary feeding should be introduced carefully to avoid blind placebo-control challenge is helpful. If a reduction in the accidental intake of CMP. Nutritional counselling must ensure cost of diagnostic testing is important, RAST, SPT or both can a sufficient intake of the therapeutic formula (eHF or AAF) to be limited to those infants responding to an elimination diet to guarantee adequate calcium intake. guide the challenge or after a positive challenge to predict the Negative challenge: no CMPA prognosis more accurately. Children who do not develop symptoms on the cow's milk Infants with mild-to-moderate symptoms should receive eHFs, formula during challenge and up to 1 week after follow-up can or AAF if the infant refuses to drink eHF or if the cost–benefit resume their normal diet, although they should be monitored. ratio favours AAF, for at least 2–4 weeks. Children who show a Clinicians should advise parents to be attentive for delayed substantial improvement or disappearance of symptoms should reactions, which may evolve over several days following the undergo a challenge under medical supervision. If symptoms of challenge.2 CMPA emerge upon food challenge, the child should be maintained on eHF or AAF for at least 6 months or until 9– DIAGNOSTIC WORK-UP IN INFANTS WITH SEVERE 12 months of age. If symptoms do not improve on eHF, primary MANIFESTATIONS care physicians and general paediatricians should consider an Formula-fed infants suspected of suffering from severe CMPA elimination diet with AAF, other differential diagnoses or both for should be referred to a paediatric specialist. In the meantime, the symptoms and/or refer the patient to a paediatric specialist. an elimination diet should be started and the child should If the clinician suspects severe CMPA in a formula-fed infant, preferably receive an AAF. AAF is recommended because the patient should receive AAF and be referred to a paediatric infants in this group fail to thrive, suffer from macronutrient specialist experienced in managing infant allergies. Food deficiencies or have pain. In these cases, AAF minimises the challenges in infants with severe symptoms should be performed risk of failure on an eHF and further weight loss. Many of these only in a setting with personnel experienced in treating children may need further diagnostic work-up to rule out other anaphylaxis.35 The clinician should be aware that severe reactions diagnoses. However, the recommendation to use AAF as a first may also occur in patients with previously mild-to-moderate choice is based on clinical experience, not on evidence. This reactions after a period of dietary elimination.37 approach should be prospectively validated. The use of unmodified mammalian milk protein, including The decision concerning allergen challenge in cases with unmodified cow's, sheep, buffalo, horse or goats' milk, or severe CMPA should always be made by a specialist and unmodified soy or rice milk, is not recommended for infants. performed in a hospital setting. In cases with a history of a life- These milks are not adequately nutritious to provide the sole threatening reaction, a food challenge may be contraindicated. food source for infants. Furthermore, the risk of possible allergenic cross-reactivity means that these milks or formulas DISCUSSION based on other mammalian milk protein are not recommended These recommendations have been developed as guidance for for infants with suspected or proven CMPA.38–40 general paediatricians and primary care physicians to assist Soy protein, for example, is not hypo-allergenic. The incidence with the diagnosis and management of CMPA in breast-fed and of soy allergy in soy formula-fed infants is comparable to that of formula-fed infants. They emphasise the importance of breast CMPA in cow's milk formula-fed babies.41 Adverse reactions to feeding, which is the preferred method of feeding healthy soy have been reported in 10–35% of infants with CMPA, infants. The recommendations also underscore the importance regardless of whether or not they were positive or negative for of a comprehensive history taking (including a family history of specific IgE antibodies for CMP.7 In particularly, infants with atopy) and a careful physical examination to exclude other multiple food allergies and eosinophilic enterocolitis syndrome causes, identify any concurrent conditions and classify the react to formulas which include soy protein.42 condition as mild-to-moderate or severe CMPA. The algorithms Although soy formulations are significantly cheaper and have a differ according to the method of feeding (breast-fed or better acceptance than eHF and AAF, the risk that the child will formula-fed infants) and according to the severity of symp- develop soy allergy in addition to CMPA, particularly in infants toms. Blood-stained stool in an infant is alarming for the below 6 months of age, was considered by the authors to be too mother, although recent evidence suggests this is a benign and high for it to be recommended as the first choice. Soy may be self-limiting phenomenon, mostly occurring in exclusively considered in infants refusing to drink eHF and/or AAF, especially www.archdischild.com Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com 908 Vandenplas, Brueton, Dupont, et al beyond the age of 6 months.41 Moreover, soy formulations contain prospective, randomized study with a follow-up to the age of 2 years. J Pediatr 2002;140:219–24. high concentration of phytate, aluminium and phyto-oestrogens 8 Vanto T, Juntunen-Backman K, Kalimo K, et al. The patch test, skin prick test, and (isoflavones), which may have undesired effects.18 41 serum milk-specific IgE as diagnostic tools in cows' milk allergy in infants. Allergy These recommendations are intended as a basis for local 1999;54:837–42. discussion, implementation and prospective evaluation. 9 Shek LP, Soderstrom L, Ahlstedt S, et al. Determination of food specific IgE levels over time can predict the development of tolerance in cows' milk and hen's egg National or regional organisations should ensure that education allergy. J Allergy Clin Immunol 2004;114:387–91. is provided for families regarding a milk avoidance diet. Health 10 Saarinen KM, Pelkonen AS, Makela MJ, et al. Clinical course and prognosis of care providers should be instructed about rescue medications cows' milk allergy are dependent on milk-specific IgE status. J Allergy Clin Immunol 2005;116:869–75. such as antihistamine use and adrenaline in case of accidental 11 Host A, Koletzko B, Dreborg S, et al. Dietary products used in infants for exposure to the offending antigen(s), especially in infants with treatment and prevention of food allergy. Arch Dis Child 1999;81:80–4. IgE-mediated allergy. The algorithms are based as much as 12 American Academy of Pediatrics Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000;106:346–9. possible on existing evidence, but should be assessed using 13 Niggemann B, Friedrichs F, Koletzko B, et al. Positionspapier. Das Vorgehen bei clinical audit standards, such as the number of children with ¨ ¨ Sauglingen mit Verdacht auf Kuhmilchproteinallergie. Padiatrische Allergologie symptoms, growth and developmental milestones, and percen- 2005;4:14–18. tiles for height and weight. Any local versions of this guidance 14 Kneepkens CMF, Van Drongelen KI, Aarsen C. Landelijke standaard voedselallergie bij zuigelingen [National standard for food allergy in infants]. 5th should be regularly re-audited to ensure that best practice is ed. Den Haag: Voedingscentrum, 2005:80. followed. Once validated, we hope the diagnostic framework 15 Finnish Paediatric Society. Food allergy in children. Duodecim could provide a standardised approach in prospective epide- 2004;120:1524–38. 16 Bjorksten B. Genetic and environmental risk factors for the development of food ¨ miological and therapeutic studies. allergy. Curr Opin Allergy Clin Immunol 2005;5:249–53. 17 Saarinen UM, Kajosaari M. Breastfeeding as prophylaxis against atopic disease: ....................... prospective follow-up study until 17 years old. Lancet 1995;346(8982):1065–9. Authors' affiliations 18 Isolauri E, Tahvanainen A, Peltola T, et al. Breast-feeding of allergic infants. Yvan Vandenplas, Department of Paediatrics, Universitair Ziekenhuis J Pediatr 1999;134:27–32. Brussel Kinderen, Vrije Universiteit Brussel, Brussels, Belgium 19 Isolauri E, Sutas Y, Salo MK, et al. Elimination diet in cows' milk allergy: risk for impaired growth in young children. J Pediatr 1998;132:1004–9. Martin Brueton, Chelsea and Westminster Hospital, London and Child 20 Juntti H, Tikkanen S, Kokkonen J, et al. Cow's milk allergy is associated with Health at Imperial College Faculty of Medicine, University of London, recurrent otitis media during childhood. Acta Otolaryngol 1999;119:867–73. London, UK 21 Doner F, Yariktas M, Demirci M. The role of allergy in recurrent otitis media with Christophe Dupont, Neonatology and Nutrition Department, Universite ´ effusions. J Investig Allergol Clin Immunol 2004;14:514–18. ´ Rene Descartes Paris V, Hospital Cochin Saint Vincent de Paul, Paris, 22 Vandenplas Y, Salvatore S, Hauser B. Symptoms, diagnosis and management of France colicky infants with regurgitations. Int Semin Paediatr Gastroenterol Nutr 2002;11:1–7. David Hill, Murdoch Children's Research Institute, Royal Children's 23 Jakobsson I, Lindberg T. Cow's milk proteins cause infantile colic in breast-fed Hospital, Melbourne, Victoria, Australia infants: a double-blind crossover study. Pediatrics 1983;71:268–71. Erika Isolauri, University of Turku, Turku, Finland 24 Wood RA. The natural history of food allergy. Pediatrics Sibylle Koletzko, Dr. v. Haunersches Kinderspital, Ludwig Maximillians- 2003;111(Suppl):1631–7. ¨ Universitat, Munich, Germany 25 Friedman NJ, Zeiger RS. The role of breast-feeding in the development of Arnold Oranje, Department of Dermatology and Venereology, Erasmus allergies and asthma. J Allergy Clin Immunol 2005;115:1238–48. MC, University Medical Centre (Sophia Children's Hospital) Rotterdam, 26 Host A, Husby S, Hansen LG, et al. Bovine beta-lactoglobulin in human milk from atopic and non-atopic mothers. Relationship to maternal intake of homogenized Rotterdam, The Netherlands and unhomogenized milk. Clin Exp Allergy 1990;20:383–7. Annamaria Staiano, University Federico II of Naples, Naples, Italy 27 Vance GH, Lewis SA, Grimshaw KE, et al. Exposure of the fetus and infant to Funding: The consensus panel, the literature search and the drafting of the hens' egg ovalbumin via the placenta and breast milk in relation to maternal intake of dietary egg. Clin Exp Allergy 2005;35:1318–26. manuscript were funded by a grant from SHS/Nutricia. The paper was 28 Schoetzau A, Filipiak-Pittroff B, Franke K, et al. German Infant Nutritional drafted by Mark Greener, a medical writer. SHS International Ltd and Intervention Study Group. Effect of exclusive breast-feeding and early solid food Nutricia did not have any editorial control over the final manuscript, which avoidance on the incidence of atopic dermatitis in high-risk infants at 1 year of remains entirely the responsibility of the authors. age. Pediatr Allergy Immunol 2002;13:234–42. 29 Warner JO. Food allergy in fully breast-fed infants. Clin Allergy 1980;10:133–6. Competing interests: DH, CD, MB, SK and YV declare they have received 30 Celik-Bilgili S, Mehl A, Verstege A, et al. The predictive value of specific support for clinical research projects from SHS/Nutricia and the same immunoglobulin E levels in serum for the outcome of oral food challenges. Clin authors and MB declare they have presented lectures at SHS/Nutricia- Exp Allergy 2005;35:268–73. sponsored meetings. Also, SK has presented lectures at sponsored 31 Giampietro PG, Kjellman NIM, Oldaeus G, et al. Hypoallergenicity of an meetings and received support for scientific work from Mead Johnson extensively hydrolyzed whey formula. Pediatr Allergy Immunol 2001;12:83–6. and Nestle. YV has received support from Janssen Pharmaceuticals, Astra, 32 Vanderhoof JA, Murray ND, Kaufman SS, et al. Intolerance to protein Wyeth, Biocodex and Nestle. None of the other authors made any hydrolysate infant formulas: an underrecognized cause of gastrointestinal symptoms in infants. J Pediatr 1997;131:658–60. declarations relevant to the preparation of this manuscript. The authors 33 Rance F, Juchet A, Bremont F, et al. Comparison between skin prick tests with declare the absence of competing interests and confirm their independence commercial extracts and fresh foods, specific IgE and food challenges. Allergy regarding the content of this manuscript. 1997;52:1031–5. Yvan Vandenplas and Sibylle Koletzko are joint lead authors. 34 Turjanmaa K. ''Atopy patch tests'' in the diagnosis of delayed food hypersensitivity. Allerg Immunol 2002;34:95–7. 35 Bock SA, Sampson HA, Atkins FM, et al. Double-blind, placebo-controlled food challenge (DBPCFC) as an office procedure: a manual. J Allergy Clin Immunol REFERENCES 1988;82:986–97. 1 Host A. Frequency of cow's milk allergy in childhood. Ann Allergy Immunol 36 Barbi E, Gerarduzzi T, Longo G, et al. Fatal allergy as a possible consequence of 2002;89(Suppl 1):33–7. long-term elimination diet. Allergy 2004;59:668–9. 2 Hill DJ, Firer MA, Shelton MJ, et al. Manifestations of milk allergy in infancy: 37 Flinterman AE, Knulst AC, Meijer Y, et al. Acute allergic reactions in children with clinical and immunologic findings. J Pediatr 1986;109:270–6. AEDS after prolonged cows' milk elimination diets. Allergy 2006;61:370–4. 3 Ewing WM, Allen PJ. The diagnosis and management of cow milk protein 38 Restani P, Gaiaschi A, Plebani A, et al. Cross-reactivity between milk proteins intolerance in the primary care setting. Pediatr Nurs 2005;31:486–93. from different animal species. Clin Exp Allergy 1999;29:997–1004. 4 de Boissieu D, Dupont C. Allergy to extensively hydrolysed cows' milk proteins in 39 Restani P, Beretta B, Fiocchi A, et al. Cross-reactivity between mammalian infants: safety and duration of amino acid-based formula. J Pediatr proteins. Ann Allergy Asthma Immunol 2002;89(Suppl 1):11–15. 2002;141:271–3. 40 Spuergin P, Walter M, Schiltz E, et al. Allergenicity of alpha-caseins from cow, 5 Bahna SL. Cows' milk allergy versus cow milk intolerance. Ann Allergy Asthma sheep, and goat. Allergy 1997;52:293–8. Immunol 2002;89(Suppl 1):56–60. 41 Agostoni C, Axelsson I, Goulet O, et al. Soy protein infant formulae and follow- 6 Sicherer SH, Noone SA, Koerner CB, et al. Hypoallergenicity and efficacy of an on formulae: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr amino acid-based formula in children with cows' milk and multiple food Gastroenterol Nutr 2006;42:352–61. hypersensitivities. J Pediatr 2001;138:688–93. 42 Nowak-Wegrzyn A, Sampson HA, Wood RA, et al. Food protein-induced 7 Klemola T, Vanto T, Juntunen-Backman K, et al. Allergy to soy formula and to enterocolitis syndrome caused by solid food proteins. Pediatrics extensively hydrolyzed whey formula in infants with cows' milk allergy: a 2003;111:829–35. www.archdischild.com Downloaded from adc.bmj.com on August 24, 2010 - Published by group.bmj.com PostScript neurophysiology''. They emphasise that ''neu- diseases, trauma, and metabolic, toxic and Corrections rophysiologic studies provide an important degenerative diseases. doi:10.1136/adc.2007.116608 extension to the clinical evaluation and are The chapter on EEG in the evaluation of predicated on a careful history and examina- children for epilepsy surgery is very brief at a E Fitzpatrick, B Bourke, B Drumm, et al. tion'', rather than being tests to interpret in mere seven pages. However, epilepsy surgery Outcome for children with cyclical vomiting isolation. They asked the contributors ''to is an immense area and, on balance, I think syndrome (Arch Dis Child 2007;92:1001–4). In provide succinct descriptions of clinical dis- that the editorial decision to substantially table 2 of this paper row ''Medication pre- orders where neurophysiologic testing is a restrict this section is reasonable. scribed''/column ''Resolved'' should read 8/25 useful adjunct''. This pragmatic marriage of The third part of the book again takes a (32%) (not 16/8/25 (32%)). In addition, row technical and clinical considerations shines usefully clinically oriented approach, with ''Trigger factor identified''/ column ''Resolved'' through much of the text, and I feel that the chapters on the floppy infant, facial and should read 16/25 (64%) (not 25 (64%)). editors have succeeded in their aims. bulbar weakness, disorders of the anterior The 46 contributors are predominantly horn cell, plexopathies and radiculopathies, from North America, but there are four from and focal neuropathies. There are substan- Europe and two from Australasia. For the tial chapters on autonomic testing in various doi:10.1136/adc.2006.110999corr1 most part, the information is generic and, conditions, including Guillain-Barre syn-´ the chapter on the diagnosis of brain death, drome, chronic autonomic neuropathies, Vandenplas Y, Brueton M, Dupont C, et al. for example, has an orientation towards diabetes mellitus and neuromuscular trans- Guidelines for the diagnosis and management legal and practical issues pertaining to North mission defects. A whole chapter is devoted of cow's milk protein allergy in infants. Arch America. to the relationship between DNA analysis Dis Child 2007;92:902–8. The order of the The book covers electroencephalography and neurophysiological aspects of neuro- authors in this paper were published incor- (EEG), evoked potentials (somatosensory, muscular disorders. Given the relative fre- rectly; the correct order is: Y Vandenplas, S brainstem auditory and visual) and the quency of exposure to neurophysiological Koletzko, E Isolauri, D Hill, A P Oranje, M clinical neurophysiology of the motor unit examinations in these age groups, the book Brueton, A Staiano, C Dupont. (electromyography and nerve conduction is weighted heavily towards discussion of In figure 2 of this article the arrow pointing to studies). It is divided into four sections: basic neuromuscular disorders, but then this is a the right from the box ''Open challenge; Cow's principles and maturational change; disorders broad field with a large number of rare milk formula under clinical observation'' of cerebral function; neuromuscular disorders; diseases that merit some coverage. should actually point to the box ''CMPA and other neurophysiological techniques. Unsurprisingly, it is possible to find minor symptoms; Maintain CMP elimination diet This last section is relatively brief but covers points of imperfection that might be until 9–12 months of age, and for at least 6 magnetoencephalography (MEG), transcra- addressed in a second edition, for example months'' and not to the box ''No CMPA nial magnetic stimulation (TMS) and the inconsistent headings within a table on symptoms; Resume CMP in diet and monitor'' assessment of sphincter dysfunction. classification and a figure on scalp electrode as published. The first part of the book contains positions that is poorly reproduced. In addition, in figure 2 the box ''Elimination chapters describing the normal features of The book is well produced to a standard diet'' should have included the additional text: EEG in the neonatal and paediatric age typical of Elsevier products. The text and Therapeutic Extensive Hydrolysed Formula groups. Separate chapters, divided into age pictures are generally black and white, (eHF) for 2 to 4 weeks (*). periods, outline an approach to the visual although there are five colour plates. The analysis of EEG with clear and didactic index is large and comprehensive but is not suggestions about extracting essential fea- divided into separate author and subject indices, and omits, for example, some impor- doi:10.1136/adc.2007.115493 tures. This works well. The second part of the book is devoted to tant scoring systems mentioned in the text. The book is competitively priced but, M A Thomson, H R Jenkins, W M Bisset, et the investigation of disorders of cerebral because of its specialist nature, it is unlikely al. Polyethylene glycol 3350 plus electrolytes function. Having read chapters 2 and 3, to reside high on the wish list of any but the for chronic constipation in children: a which cover the features of the normal double blind, placebo controlled, crossover neonatal EEG and suggest an ordered most enthusiastic general paediatrician. However, it is an excellent text for paedia- study (Arch Dis Child 2007;92:996–1000). approach to its visual analysis, one is faced The first word of the third paragraph with chapter 13, which describes the abnor- tric neurologists and neurophysiologists, particularly those in training. The orienta- "Movico" should be "Movicol". mal features of the neonatal EEG. This presents information in a logical, progressive tion towards young people and the coverage, and user-friendly manner, with clear reviews in one volume, of EEG, peripheral neuro- of normality and age-dependent changes physiological and other techniques makes it doi:10.1136/adc.2005.080721 that are separated from details of abnormal an efficient and very useful learning and conditions and findings. It also includes reference text. It is an essential element of S Friedman, S Reif, A Assia, et al. Clinical the clinical neurophysiology departmental information on abnormalities in the various and laboratory characteristics of non e. coli library in any centre that performs these forms of evoked potentials, and a chapter on urinary tract infections (Arch Dis Child investigations in young people. their use in intra-operative monitoring. 2006;91:845–6). The fourth author of this There are excellent chapters on childhood paper, Ram Mishaal, was inadvertently sleep-wake disorders, drug effects, infectious Andrew L Lux omitted. We apologise for this error. Arch Dis Child January 2008 Vol 93 No 1 93
Pages to are hidden for
"Guidelines for the diagnosis and management of cow's milk"Please download to view full document


text:
Buy properties in Common Road, Walton Highway, Wisbech PE14
Lynn Road, Walton Highway, Wisbech PE14Detached house for sale - 4 bedrooms
Renovation opportunity! This property has had significant water damage and so needs full and extensive renovation and repair. It is situated in a sought after area within walking distance to the highly regarded Marshland High School. More details
Note: Distances are straight line measurements
- Watlington (7.6 miles)
- Downham Market (9.2 miles)
Marketed by William H Brown, PE13. Call 01945 479011£325,000
St Pauls Road North, Walton Highway PE14Detached house for sale - 4 bedrooms
Optima are pleased to offer for sale this spacious detached family home. The property boasts many features to include formal sitting room and dining room, large kitchen/dining area, 4 double bedrooms, double garage, sun room, utility room, en-suite to mas More details
Note: Distances are straight line measurements
- Watlington (7.4 miles)
- Downham Market (9.0 miles)
Marketed by Optima Property Marketing & Management, PE13. Call 01945 479043

subset: commoncrawl


text:
Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in Clinical PracticeHardback
List price $76.40
You save $17.00 22% off
Free delivery worldwide
Dispatched in 2 business days
When will my order arrive?
- Publisher: Guilford Publications
- Format: Hardback | 407 pages
- Dimensions: 160mm x 234mm x 33mm | 703g
- Publication date: 17 April 2012
- Publication City/Country: New York
- Edition: 1
- Edition statement: New.
- Sales rank: 153,475
Product description
Bringing together leading scholars, scientists, and clinicians, this compelling volume explores how therapists can cultivate wisdom and compassion in themselves and their clients. Chapters describe how combining insights from ancient contemplative practices and modern research can enhance the treatment of anxiety, depression, trauma, substance abuse, suicidal behavior, couple conflict, and parenting stress. Seamlessly edited, the book features numerous practical exercises and rich clinical examples. It examines whether wisdom and compassion can be measured objectively, what they look like in the therapy relationship, their role in therapeutic change, and how to integrate them into treatment planning and goal setting. The book includes a foreword by His Holiness the Dalai Lama.
Add item to wishlist
Other people who viewed this bought:
Mindfulness and Psychotherapy
USD$42.78 - Save $7.11 14% off - RRP $49.89
The Mindful Path to Self-compass...
USD$12.99 - Save $5.71 30% off - RRP $18.70
The Bodhisattva Vow
USD$22.94 - Save $8.23 26% off - RRP $31.17
Living with an Open Heart
USD$11.34 - Save $4.24 27% off - RRP $15.58
Buddha's Brain
USD$13.77 - Save $9.61 41% off - RRP $23.38
Man's Search for Meaning
USD$6.91 - Save $2.43 26% off - RRP $9.34
Other books in this category
Man's Search for Meaning
USD$6.91 - Save $2.43 26% off - RRP $9.34
The Boy Who Was Raised as a Dog
USD$10.60 - Save $4.98 31% off - RRP $15.58
Sitting Still Like a Frog
USD$10.56 - Save $9.71 47% off - RRP $20.27
Act Made Simple
USD$26.75 - Save $27.83 50% off - RRP $54.58
Mind Over Mood
USD$18.98 - Save $9.08 32% off - RRP $28.06
Raising an Emotionally Intellige...
USD$10.45 - Save $4.55 30% off - RRP $15.00
Author information
Edited by Christopher K. Germer, PhD, and Ronald D. Siegel, PsyD; both at the Department of Psychiatry, Harvard Medical School, Massachusetts, USA
Review quote
"I am very happy to see that ancient teachings and practices from the Buddhist tradition can be of benefit today when they are employed by Western scientists and therapists. In today's world, many people turn to psychotherapy to understand what is making them unhappy, and to discover how to live a more meaningful life. I believe that as they come to understand compassion and wisdom more deeply, psychotherapists will be better able to help their patients and so contribute to greater peace and happiness in the world." - From the Foreword by His Holiness the Dalai Lama "The deep message of the movement toward acceptance- and mindfulness-based methods is that the world without and the world within are interlinked. We need to begin to treat ourselves as we would want others to treat us: with kindness, patience, and wise attention. This book explores profound issues and describes powerful new methods for clinical practice that will carry far beyond the doors of our consulting rooms." - Steven C. Hayes, University of Nevada, USA "The essential message of this book is one of hope. Ably guided by the contributors to this important volume, therapists are invited to peer beyond therapeutic tools and techniques and glimpse the vast potential that compassion and wisdom hold for healing and self-transformation." - Zindel V. Segal, PhD, Departments of Psychology and Psychiatry, University of Toronto, Canada
Flap copy
Although wisdom and compassion are seldom discussed in the mental health literature, few would disagree that these qualities are important elements of all good treatment. But what exactly is wisdom? What is compassion? What is their relationship to psychological well-being, suffering, and psychotherapeutic change? Bringing together leading scholars, scientists, and clinicians, this volume integrates insights from ancient contemplative practices and modern research. It presents powerful methods that therapists can use to cultivate wisdom and compassion in themselves and their clients. Seamlessly edited, the book features numerous practical exercises and rich case examples. It illuminates the nature of wisdom and compassion both for therapists new to this area and those already familiar with mindfulness- and acceptance-based practices. Chapters examine whether these qualities can be measured objectively, what they look like in the therapy relationship, and how to integrate them into treatment planning and goal setting. Emphasis is given to how wisdom and compassion allow us to overcome experiential avoidance--to tolerate, accept, and even grow from suffering. Effective strategies are provided for addressing specific clinical challenges including anxiety, depression, trauma, substance abuse, suicidal behavior, couple conflict, and parenting stress. Innovative clinical techniques are described and the theory and research that supports them is summarized. The book also probes the neurobiological foundations of wisdom and compassion, including compelling findings on the effects of mindfulness meditation on the brain. Engaging, accessible, and inspiring, this volume is essential reading for clinical psychologists, psychiatrists, clinical social workers, family therapists, and counselors. Its strong research base and practical, real-world focus also make it a useful text for graduate-level psychotherapy courses.
Table of contents
His Holiness the Dalai Lama, Foreword. Germer, Siegel, Introduction. Part I: What are Wisdom and Compassion? Why Should We Care? Siegel, Germer, Wisdom and Compassion: Two Wings of a Bird. Brach, Mindful Presence: A Foundation for Compassion and Wisdom. Fredrickson, Building Lives of Compassion and Wisdom. Part II: The Meaning of Compassion. Makransky, Compassion in Buddhist Psychology. Ely, The Compassionate Therapist. Neff, The Science of Self-Compassion. Germer, Cultivating Compassion in Psychotherapy. Davidson, The Neurobiology of Compassion. Part III: The Meaning of Wisdom. Olendzki, Wisdom in Buddhist Psychology. Siegel, The Wise Psychotherapist. Sternberg, The Science of Wisdom: Implications for Psychotherapy. Surrey, Jordan, The Wisdom of Connection. Engler, Fulton, Self and No-self in Psychotherapy. Meeks, Cahn, Jeste, Neurobiological Foundations of Wisdom. Part IV: Clinical Applications. Linehan, Lungu, Suicidal Patients with Complex Disorders. Marlatt, Bowen, Lustyk, Substance Abuse and Relapse Prevention. Roemer, Orsillo, Anxiety Disorders: Acceptance, Compassion, and Wisdom. Gilbert, Depression: Suffering in the Flow of Life. Briere, Working with Trauma: Mindfulness and Compassion. R. Borofsky, A. K. Borofsky, The Heart of Couple Therapy. Part V: In and Around the Consultation Room. Goodman, Kaiser Greenland, Siegel, Mindful Parenting as a Path to Wisdom and Compassion. Pargament, Faigin, Drawing on the Wisdom of Religious Traditions in Psychotherapy. Morgan, Compassion and Wisdom: Growing through Ethics.


text:
Goodbye may seem forever by HubedihubbeWatch
©2012-2015 Hubedihubbe
Goodbye may seem forever
Farewell is like the end
But in my heart's a memory
And there you'll always be
Feels for these two~ Feels everywhere~~
Programs: SAI and Photoshop
APH © Hidekaz Himaruya
Art © Hubedihubbe
Farewell is like the end
But in my heart's a memory
And there you'll always be
Feels for these two~ Feels everywhere~~
Programs: SAI and Photoshop
APH © Hidekaz Himaruya
Art © Hubedihubbe
Mon dieu! This is so amazing and melancholy!
The feelings have hit me so hard that I can't even close the tab QQ
I just had a huge freakout moment. My mom look at me and ask if I was ok
I just spend 5 minutes screaming at my screen
Aaagghh...right in the feels T^T
you literally just made me cry
poor fritz
Aww I feel so bad for Prussia I know he's immortal but watching people grow old and die especially ones he was close to must really hurt...
The picture is beautiful, i know that it's Prusia, but who is the man lying there? ;A;
its frederick the 2nd
It what episode did Fritz appear in?
I dont think he ever appered in one. He may be in a comic or something (i havent read them yet) I was watching an music vidio on youtube about prussia and it had a diary ebtry and it had frederick the 2nd in it so he said he would call him Fritz or old man fritz
ahhhhhh .-.
When I was reading the lyrics of Mein Gott, the last things he said was "Please watch over me, Father Fritz". So sad! TT_TT
This is so awesome! And sad...TT ^ TT
Commenting because I like this; not faving because it's so sad...
But I'm faving it anyway! D8 T_T
But I'm faving it anyway! D8 T_T
love it
Poor gil.. Losing old man fritz...
WOW beautiful picture btw who's the guy who's dead is that fredrick the great of prussia?
duuude !!!
i like it SOOOO much !!!!
i like it SOOOO much !!!!
Right in the feels. Right. In. The. Feels.
I just died from explosion of feels.
I just want to hug Prussia (;_; )
This is beautifully done <3
This is beautifully done <3
That explosion was my feels.
Me: *sees this* AaHh HORRY CRAP! MAH FEELS.
Realization: when you're a Nation, if someone you love dies, it's a looooong time if ever before you get to see them again.
Gil...so sad and austere... how could you leave him, Fritz?!
is this from hetaquest?
No. Fritz was a real guy.
Garg!!! I've visited Sans Souci (Fritz residence) this year and had seen King Friedrichs Death Mask. As far as I know he died in his favourite chair. Damn, I could imagine Prussia crying like a lost child for him. You did a great job. The feeling is so intense here. ><
Though I don't pair them, the story is indeed well written and sad! I hope that Prussia is now with Fritz and Germania. ><
Thanks for the link.
Thanks for the link.
I hope so too, but then you have all the sad fangirls. ;^;


text:
The SAAQ and lg2 shine in Cannes
The SAAQ and the lg2 agency won two Lions at the Cannes Lions International Festival of Creativity.
Partial Road Safety Statistics 2015
The SAAQ is publishing statistics on road accident victims, for part of 2015. (French only)
2015 Seat Belts Campaign
The SAAQ has partnered with Québec police forces for Operation Seat Belt, running from June 15 to 21. The SAAQ has launched an awareness campaign encouraging drivers and passengers to always buckle up.
SAAQ and lg2 honoured at the Marketing Awards
The SAAQ and the lg2 advertising agency received six Marketing Awards for their Texting, Alcohol and Seat Belt campaigns during the awards gala that took place on June 4, 2015 in Toronto. The Marketing Awards recognize the best creative advertising work in Canada.
Protect those who protect you!
Did you know that you have to obey the Move Over law? When an emergency vehicle is stopped and its yellow arrow or rotating or flashing lights are activated, you have to slow down and provide a buffer lane.
ERRATA - Operating a Motorcycle guide
Errors were inadvertently introduced in the new edition of the Operating a Motorcycle guide. Please take note of the corrections
In an accident, seatbelts increase your chances of survival on average by 40%, 50% or 60%?
Answer: 50%
This statistic takes into account all types of collisions; the effectiveness of seatbelts varies based on the type of collisions, speed, etc.
More: Seat Belts


text:
Coming up in the next {{countdown}} {{countdownlbl}}
Coming up next:
Skip to this video now
Now Playing:
Related Videos
Now Playing: {{itm.title}}
Play Video
This transcript has been automatically generated and may not be 100% accurate.
Valentine's Day 2013: How to Analyze Date Night
Modern-day matchmakers setup a real-life date and ABC News' Lana Zak has the results.
Valentine's Day 2013: Men's Fashion Tips
ABC News' Molly Hunter gets expert fashion advice on how your special man can dress to impress.
Valentine's Day 2013: Looking for the Perfect Romantic Spot
ABC News' Rob Nelson checks out cuisine and the romantic ambiance of La Silhouette.
An Attorney Is Giving Free Divorce Advice on Valentine's Day
If you can come up with the best breakup story, then a Michigan attorney will help for free.
Now Playing: Valentine's Day 2013: How to Analyze Date Night
Now Playing: Valentine's Day 2013: Men's Fashion Tips
Now Playing: Valentine's Day 2013: Looking for the Perfect Romantic Spot
Now Playing: An Attorney Is Giving Free Divorce Advice on Valentine's Day
Now Playing: Chris Brown Case Costs Police Chief His Job
Now Playing: Katy Perry Eyes a New Home
Now Playing: New Details in Prison Escape Investigation
Now Playing: National Soul Food Month
Now Playing: Second Escaped Prisoner Captured
Now Playing: Regular Mike
Now Playing: The BET Awards
Now Playing: A Victory for Obamacare
Now Playing: SCOTUS On The Affordable Care Act
Now Playing: Deep Fried Big Mac on a Stick
Now Playing: Bristol Palin Announces Her Pregnancy
Now Playing: Insomniac Theater 'Ted 2' and 'Max' Hit Theaters
Now Playing: Brandon Cohen in High Heels For An Entire Day
Now Playing: James Taylor's Album Hits No. 1
Now Playing: National Catfish Day


text:
Think Geek's Vilcus Plug Dactyloadapter has some great product pictures and even better copy. Designed by Art Lebedev, the developer of the Optimus Maximus keyboard, it's being marketed by Think Geek as a tool — inspired by various Soviet-era KGBA "persuasion" devices — that lets any one quickly and easily test the functionality of any electrical socket. Lebedev himself is being less coy: "Vilcus dactyloadapter was developed specially for people who enjoy closing electrical circuits with their own fingers." For example, a sensuous duo of Castro Street electricians. I think it's a great gag product, especially for $12.99, but what I find more interesting about the Vilcus is the fact that it must be safe... or at least, safe enough that Think Geek isn't terribly worried about selling it, their bolded humorous legal patter aside. Fantastic bullet point features include "Exclusive Russian Design" and "Become more alert through free electroshock therapy." Vilcus Plug Dactyloadapter [Think Geek via book of joe]
Don't lick your fingers: the Vilcus Plug Dactyloadapter
• Discuss this post in our forums
7 Responses to "Don't lick your fingers: the Vilcus Plug Dactyloadapter"
Wow! I would've loved this as a kid — and, since it closes the circuit entire with one hand, undoubtedly safer than my practice in those days of sticking a screwdriver into an outlet.
In retrospect, it explains a lot, really…
Uh… yeah…
This was originally posted by Think Geek as an April fools joke.
It's an April Fools product. You can tell by /41/ in the URL and the nonintegral number of 'Geek Points'.
Did you try to add it to the cart? It is a leftover from April Fools Day.
This is actually an April Fools joke. Click the "Add to cart" button to spoil the fun. It's a shame too, I want one! They just need to make a tongue adapter.
Gah. I hate April's Fools. "Ha ha! We got you! We just lied!" It's all fun and games on April 1st, but then some poor, innocent blogger discovers it on December 8th three years later, and the comments are immediately filled with people calling him an idiot for not checking the date.
Hey, I live in the USA, and it's perfectly reasonable to test 120 VAC circuits with your fingers. You folks that live in civilized, non-torturing countries with your fancy-pants 240 VAC 50 Hz systems get teh bejeezus shocked out of you if you try that kind of thing, but over here in the colonies I've been testing wires for current by touching them for decades. Suckers!


text:
12 Musical Moments We're Thankful for in 2012
There's a lot for us to be grateful for in 2012 — food, family, Barack Obama's re-election, the Knicks' 8-1 record. But some of the things that made us smile most this year were in the world of music. It's been 10 months of inspiration, hilarity, and above all, great music. Read on to see the 12 musical moments that we're most thankful in 2012. —Alex Gale
(Photos: Lisa Peardon, Alberto E. Rodriguez/Getty Images and Kevin Mazur/WireImage)
Instagram Photos of the Week: Independence Day Edition07/05/2015
#Freedom: A Social Media Playlist07/04/2015
Out and About Wireless Festival 201507/03/2015
Tweets Of The Week: President Obama Keeps OutKast Rocking07/03/2015
4th of July Turn-Up Mix07/02/2015
Rihanna Proves She Can Be Deadly in 'BBHMM' Video07/02/2015
O Canada!: Canadian Born Singers07/01/2015
Creative Ice Cream Flavor Day07/01/2015
Family Reunion Hip Hop Tours06/30/2015
R & Beef06/30/2015
Album Covers Shot by Photographer Jonathan Mannion06/29/2015
The Rundown: Meek Mill, Dreams Worth More Than Money06/29/2015
Athletes Who Have Turned to Music06/28/2015
Out and About: Meek Mill's TIDAL X Event06/27/2015
J. Cole's Greatest Give-Back Moments With Fans06/26/2015
Instagram Photos of the Week: #Omeeka Up Close and Personal06/26/2015
Tweets of the Week: Joey Bada$$ Squashes His Tensions With06/26/2015
Picture Me Rollin': West Coast MCs From LA to the Bay06/26/2015
50 Cent: The Trollfather06/25/2015
Don't Label Me: Artists Beefin' With Their Record Labels06/25/2015
25 Things Music Lost Since Michael Jackson Died06/25/2015
The Rundown: Tyga, The Gold Album: 18th Dynasty06/24/2015
Who's Watching: MCs Who've Invaded Your TV Screen06/24/2015
Tidal Waves06/23/2015
Minister Farrakhan and Hip Hop06/23/2015
Class Warfare: When XXL Freshmen Clash06/23/2015
Gentlemen's Club: When Rappers Cover GQ Magazine06/22/2015
Kanye, Future and More Rock Birthday Bash 2006/22/2015
10 Things You Should Know About Rotimi06/22/2015
Your Essential Father's Day 2015 Playlist06/21/2015
Hip Hop Pops and Their Kids06/20/2015
Use of the Confederate Flag in Hip Hop06/20/2015
Tweets of the Week: Meek Mill Revokes Rachel Dolezal's Pass06/19/2015
Music Stars With Success at Different Labels06/18/2015
Rapper Sneaker Endorsements06/18/2015
Side Hustle: Actors Who Turned to Music06/18/2015


text:
Dr. Scott Hovis is a vascular surgeon in Spartanburg, SC. He treats conditions affecting the circulatory system including veins, arteries & blood vessels.
Learn More
We invite you to write a review about your experience with Dr. Hovis.
Find potential causes and treatment options with the MD.com Symptom Checker.
See our Privacy Policy and Terms of Use.


text:
Read Me Stories - Children's books
By 8Interactive Limited
Open iTunes to buy and download apps.
A new book EVERY DAY develops your child's love for books and a daily reading habit. Wow!!!
- Over 4 Million readers worldwide
- Phenomenal feedback from parents
- Top reading app for kids in the education category
- Full support - we answer every email
- Best value for money
- Free sample books
- Text highlights as read
- Touch the characters to explore further story lines
Product Details:
Your child can practice reading - anywhere, anytime - while you're driving, shopping in the grocery store, or having a quick coffee at your favorite cafe. And you can spend quality time with your child while teaching the core skills of reading and speaking that are so necessary for every child in today's modern world.
Imagine your child reading a new book every day, and developing a love for books and the habit of reading.
Spend less time searching for apps because there are great new books in Read Me Stories, already there, right in the app.
The library also includes the lovely series Tuffy's First Adventure. This series of stories takes Tuffy the pony on a grand adventure, where he learns how to meet new friends, and do good deeds. The illustrations are gorgeous. The stories are captivating. The voices are a hoot. These new stories also highlight the text as the story is read. Touching the characters on screen expands the storyline.
Here is what our customers are telling us:
"My granddaughters looooove stories and this is a wonderful app for them to enjoy!" "I love this app! Please make more books!!! :)"
"Keep them coming this grandma shares with grand-babies and I'm grandma gadget. And they look forward to the stories and the 6 year old loves to try to read the words so one had my iPod touch while the other one uses the iPad good thing I only have two grand children to see at one time. Good job. Love this app."
"My children love these books!!! We read them every night and they forward to the new books they get. Thank you for a wonderful app, I hope there are many more book to come. We love reading and plan on keeping this for a very long time!!!!
"Just so you know my kids can not wait for the next book they ask if it is ready all the time thank you for making this app."
Go ahead and get Read Me Stories right now... just click the 'Free App' button.
More Features:
- We actually want to hear from you. So, we have put a feedback page into the app. We promise to respond promptly and personally.
- Spend less time searching for apps because there are great new books in Read Me Stories, already there, right in the app.
- Some books are available for purchase and delivery to your door by Amazon.com – just a finger press away. It's a great way to get birthday and Christmas gifts for your child, and it's a nice way to help friends and family get great gifts for them too.
- Read Me Stories keeps track of your child's favorite books, so you can read them again and again.
What's New in Version 3.0.20
- Bug fixes
Customer Reviews
Gets my kid reading!
My son doesn't usually want to read but once I found these books loves to read and interact with them. It usually is difficult to get him to read for 15 minutes. With these books he has read up to an hour at a time! Has made our book reading challenges so much easier!
First reading app that my son looks forward to using!
Much like other reviewers, this app gets my son interested in reading. He looks forward to unlocking the book each day and has his favorites that he goes back to regularly. It's a great reading tool!
One free book a day? Huh?
My son loves this, however Im not sure where the one free book a day comes in? I have been buying books and never do get free books! This does not seem obvious either on how to redeem your books when you use the app! how does one get their free books? i can see the que and the rolodex of books, but they all want me to purchase em, never do i see a free book!
Customers Also Bought
- Free
- Category: Education
- Updated: Oct 23, 2014
- Version: 3.0.20
- Size: 98.2 MB
- Language: English
- Seller: 8interactive
- © 8Interactive Limited
Compatibility: Requires iOS 7.0 or later. Compatible with iPhone, iPad, and iPod touch. This app is optimized for iPhone 5.
Top In-App Purchases
- 'Snafoo's Library - Tales of Adventure' (23 books)$1.99
- 'Tuffy's First Adventure' (5 books)$1.99
- 'Snafoo's Library - Animals I' (14 books)$1.99
- 'Snafoo's Library - Tales of Life' (29 books)$1.99
- 'Snafoo's Library - Animals II' (13 books)$1.99
- 'Tuffy's Second Adventure' (4 books)$1.99
- 'Snafoo's Library - Songs' (5 books)$1.99
- 'Snafoo's Library - Animals I' (14 books)$0.99
- Frogathon Games (4 books)$1.99
- 'Snafoo's Library - Tales of Life' (29 books)$0.99


text:
The Leading eBooks Store Online
for Kindle Fire, Apple, Android, Nook, Kobo, PC, Mac, BlackBerry...
New to eBooks.com?Learn more
- Bestsellers - This Week
- Foreign Language Study
- Pets
- Bestsellers - Last 6 months
- Games
- Philosophy
- Archaeology
- Gardening
- Photography
- Architecture
- Graphic Books
- Poetry
- Art
- Health & Fitness
- Political Science
- Biography & Autobiography
- History
- Psychology & Psychiatry
- Body Mind & Spirit
- House & Home
- Reference
- Business & Economics
- Humor
- Religion
- Children's & Young Adult Fiction
- Juvenile Nonfiction
- Romance
- Computers
- Language Arts & Disciplines
- Science
- Crafts & Hobbies
- Law
- Science Fiction
- Current Events
- Literary Collections
- Self-Help
- Drama
- Literary Criticism
- Sex
- Education
- Literary Fiction
- Social Science
- The Environment
- Mathematics
- Sports & Recreation
- Family & Relationships
- Media
- Study Aids
- Fantasy
- Medical
- Technology
- Fiction
- Music
- Transportation
- Folklore & Mythology
- Nature
- Travel
- Food and Wine
- Performing Arts
- True Crime
- Foreign Language Books
Most popular at the top
Modern ChineseCambridge University Press 1999; US$ 36.00
This book describes the development of Modern Chinese from the late nineteenth century to the 1990s. more...
Chinese Phrases For DummiesWiley 2005; US$ 7.99
Hundreds of useful phrases at your fingertips Speak Chinese - instantly! Traveling to China but don't know Chinese? Taking Chinese at school but need to kick up your conversation skills? Don't worry! This handy little phrasebook will have you speaking Chinese in no time. Discover how to Get directions, shop, and eat out Talk numbers, dates, time,... more...
Enriched Composition and Inference in the Argument Structure of ChineseTaylor and Francis 2005; US$ 48.95
As with many other languages, Mandarin Chinese exhibits a rich variety of ways in expressing the arguments of the predicator in a sentence. Unlike other languages, such variation is typically devoid of any formal marking. Previous attempts in explaining such phenomena usually focus on the syntax as an explanatory tool. This book argues that a large... more...
Chinese: An Essential GrammarTaylor and Francis 2006; US$ 43.95
First published in 2006. Routledge is an imprint of Taylor & Francis, an informa company. more...
Colloquial ChineseTaylor and Francis 2009; US$ 35.95
COLLOQUIAL CHINESE is easy to use and completely up to date! Specially written by experienced teachers for self-study or class use, the course offers a step-by-step approach to written and spoken Chinese. No prior knowledge of the language is required. What makes COLLOQUIAL CHINESE your best choice in personal language learning? Interactive... more...
The Chinese HEART in a Cognitive PerspectiveDe Gruyter 2009; US$ 196.00
This book is a cognitive semantic study of the Chinese conceptualization of the heart, traditionally seen as the central faculty of cognition. The concept of HEART, encoded in the word xin , lies at the core of Chinese thought and medicine, and its importance to Chinese culture is extensively manifested in the Chinese language. The study... more...
Niubi!Penguin Publishing Group 2009; US$ 14.00
How to talk dirty and influence people?in Chinese! You can study Chinese for years, but do you really know how to talk like a native speaker? The next book in Plume?s foreign language slang series, Niubi! will make sure you learn all the colorful vernacular words and phrases used by Chinese people of all ages in a variety of situations, including... more...
Get Talking ChineseDK Publishing 2007; US$ 14.99
Ready...set...talk! Get Talking Chinese is a concise guide that provides a fun and easy way to get a handle on all aspects of Mandarin Chinese - reading, writing, speaking, and listening - as well as a look at the fantastic culture of China. Culture pages reveal amazing facts about modern China. Get Talking Chinese also includes 200 characters... more...
Colloquial CantoneseTaylor and Francis 2010; US$ 35.95
COLLOQUIAL CANTONESE is easy to use and completely up to date! Specially written by experienced teachers for self-study or class use, the course offers a step-by-step approach to written and spoken Cantonese. No prior knowledge of the language is required. What makes COLLOQUIAL CANTONESE your best choice in personal language learning?... more...
Using Chinese SynonymsCambridge University Press 2010; US$ 40.00
This essential reference book assists in the development of fluent, spontaneous and skilful use of Chinese synonyms. more...


text:
Minneapolis, MNUSA 55404
August 16, 2013
Boating, bonfires, hiking, golf - fresh air.
Fun, love the outdoors, jazz, travel anywhere and the water at anytime!
Meetup members, Log in
By clicking "Sign up" or "Sign up using Facebook", you confirm that you accept our Terms of Service & Privacy Policy


text:
Full version
The 17th Annual Summer Festival of the Arts will be held July 11 and 12, 2015. Artist applications for the 2015 Summer Festival of the Arts are now closed. Please check back in January, 2016 for the new application.
Click here to download the 2015 performance schedule.
Attention Volunteers! Click here for a printable application!Have craft items you would like to recycle? Click here for more information on how to donate craft supplies.
July 11-12, 2015
Saturday: 10am - 6pm Sunday: 11am - 5pm
at and around Youngstown State University
Click here to see the 2015 year's Artists' Market Place accepted artists!
© 2011 - Youngstown State University • One University Plaza • Youngstown, Ohio 44555Admissions: 330.941.2000 • Graduate Admissions: 330.941.3091 • General Information: 330.941.3000
ADA ComplianceAllofE Solutions


text:
START to Present at the Addiction Health Services Research Conference
Meet Our Patients
These are the faces of bravery, conviction and recovery. Learn more about our organization and the patients we serve and support.LEARN MORE
Combat Heroin Campaign
Governor Cuomo Announces Addition of Text Messaging Feature to NYS HOPElineLEARN MORE
I'm really appreciative of this program and my friends - we all need each other. There are a lot of places we could have been today, but we are here.


text:
EAN-codes: 4046443012794
Listed since: 16.12.2008, 18:08
68 of 76 visitors recommend this product (89.47%).
Rating: (86%) (33 user reviews - read all | Rate product)
HGST Deskstar 7K1000.B 1TB, SATA 3Gb/s (HDT721010SLA360) saved
Using the "offers from" options you can filter merchants from regions which are most common in our database: the UK, Germany, Austria and Poland.
If a checkbox near a flag is selected, offers from merchants from that particular region will be displayed, otherwise they will not be visible.
If you select offers from "all regions", all offers from all merchants will be displayed. These incude offers from merchants in countries not listed here.


text:
Click to expand
What do you think? Give us your opinion. Anonymous comments allowed.
Reply-6#62 to #56 - GrammarOne (01/02/2010) [-]
Capitalization, punctuation, and you spelled "where" as "were" please consider a spell check.
Sincerely, Grammar One.
Sincerely, Grammar One.
Reply+2#66 to #62 - DarkNemeisis **User deleted account** (01/03/2010) [-]


text:
To Let
Let My Roof Ltd has a variety of properties to let; below is the range which are available. Please note, not all properties would be featured here, as they may be under offer before we get a chance to advertise them.
To be proactive, we would suggest that you register your interest with us, and we can send you details before we begin to market the properties. If there is nothing in the current listing which meets your requirements, please register with us and we will carry out a free property search in order to find the right home for you.
|4 bedroom furnished property situated a few minutes walk from Wimbledon Park District Line. Maisonette style property with a practical living.
Enfield EN2
3 Bedroom House
Available: 17/08/15
|3 bedroom property situated within a secure gated area in Enfield Chase just off Windmill Hill (A110); minutes walking distance to Enfield Chase Railway Station, over looking Chase Green and close to all other local amenities.
More Details...
Wimbledon SW19
4 Hedroom House


text:
Ridge Hotels
Longpoint Cottage
1 Wynne Rd, Ridge, MD 20680
Ridge Restaurants
Boatman's Restaurant and Sports Bar: Mom and Pop's Pizza & Subs
This restaurant used to be called the Old Ridge Inn. Before that it was the Southridge, because it was south of Ridge. They opened a branch called the Northridge in Lexington Park. The Northridge has changed hands several times. This restaurant looks about the same to me as when it was the Southridge. It has a bar (smoking section) with a huge TV and billard or pool tables, and a large non-smoking side.
In 2004, we went down to put the bimini curtains down on the boat because it was supposed to rain, and we were afraid to try any of the waterfront restaurants where we usually eat for fear that they would not have recovered from the hurricane yet.
We were going to be down there again in June 2008 to put some stuff on the boat and then we wanted to go out to dinner. We decided to come back here. However this restaurant is now mostly a pizza take-out or delivery place with very little dinner type food on the menu.
Favorite Dish: In 2004, we were the only ones in the non-smoking side when we went, but two other couples came before we left.
Bob had the Pub Prime Rib (8 oz.) cole slaw and baked potato. I had the Tavern Prim Rib (12 oz), tossed salad and baked potato. We drank iced tea. The prime rib's were very good.
I wanted to get the creme brule cheesecake for dessert, but they were out of that, so I had an ordinary apple pie instead. The bill was $37.15 including tip.
In 2008, they had paper menus which offered pizza, calzone, spaghetti, hamburgers, appetizers, salads and fried seafood baskets. The prices were quite moderate, and they had delivery available. There were coupons on the menu for the family special (1 large 1 topping pizza, 12 wings and 2 liters of soda) for $19.99 or a large slab of baby back ribs for $17.99.
Hamburgers with fries and a drink were $5.59 to $6.99.
Chicken tender salad was $5.99 and Spaghetti was $7.49.
Subs ranged from $4.99 to $6.99
Bob had the fried shrimp basket for $7.99 and I had the beer battered rock fish $6.99. It was good and very hot, but also quite salty. I drank root beer which was included.Related to:
- Road Trip
- Family Travel
- Budget Travel
Courtney's: A southern Maryland gem!
I've been fishing with friends out of Scheibles in Ridge, MD for years, and we always go to Courtney's for our seafood feast afterwards.
Ther restaurant is casual with a relaxed atmosphere and featuring the typical nautical/seafood themes. Folks seem to be relaxed and conversation lively whenever we are there.
There is a partial view of St Mary's creek from a large picture window on one side of the dining room.
We like Courtney's for the crabs. When other restaurants seem to only have smaller, lightweight crabs, hers tend to be larger and heavier. The room is conducive to picking - old wooden floors, large wooden tables, and plenty of room between so that er, energetic crab picking doesn't allow crab parts to reach other diners :)
We've sampled her other seafood offerings, particularly any 'catch of the day' fish entrees available. These tend to be very fresh and well prepared, light on the batter for fried foods, and reasonably priced. Sea trout there has been particularly well prepared.
There is an extensive salad bar, but the highlight is the home made Maryland crab soup. Dense and and spicy, thick with crabmeat, and rich in it's vegetable based broth, this is one of those culinary gems that you delight to find in funky, out of the way places.
Then please don't leave without trying one of Courtney's fruit cobblers. Usually, apple, peach, or blackberry, these are served ala mode, in a tall sundae glass with the vanilla ice cream melting over the warm cobbler. Outstanding!
See you there.
Favorite Dish: The crabs tend to be larger and heavier than average.
Fish is well prepared, light when fried and not over broiled.
The crab soup is a culinary gem, and the cobbler deserts are the perfect finishRelated to:
- Fishing
- Family Travel
Ridge Hotels1 Hotels in Ridge
Ridge Favorites
Intersection of MD 5 and 235
Favorite thing: Ridge is not a tourist destination. There's a BIG volunteer fire department, a marine store, a general store, a restaurant which does pizza delivery and a couple of cemeteries.
Fondest memory: Opposite the Fire Department is the First Friendship United Methodist church which has a historical beautiful natural wood interior. Simple and homey. It is a family of friends. Mostly retired people and some grand children. Relaxing organ playing, songs and prayer.Related to:
- Sailing and Boating
- Family Travel
- Budget Travel
Instant Answers: Ridge
Get an instant answer from local experts and frequent travelers


text:
Wooster Jobs
Looking for jobs in Wooster? Snagajob has great opportunities with the area's leading companies. And applying for Wooster jobs has never been easier. Look at the job listings below, click on a job title that interests you and hit the "apply now" button. Part-time jobs, teen jobs, student jobs and summer jobs are now just a click away. Start your job search now.
Wooster, OH Job Openings
Dick's Sporting GoodsWooster, OH
Wooster, OH
ALDI2249 Akron Rd
Wooster, OH
Petco3790 BURBANK ROAD
Wooster, OH
Red Lobster3805 Burbank Road.
Wooster, OH
Applebee's Neighborhood Grill & Bar3989 Burbank Road
Wooster, OH
UPSWooster, OH
Wooster, OH
Cities within 20 miles of Wooster, OH
- Ashland, OH (54 jobs)
- Burbank, OH (22 jobs)
- Millersburg, OH (14 jobs)
- Lodi, OH (13 jobs)
- Medina, OH (12 jobs)
- Orrville, OH (11 jobs)
- Seville, OH (11 jobs)
- Rittman, OH (9 jobs)
- LOUDONVILLE, OH (8 jobs)
- Wadsworth, OH (4 jobs)


text:
Looking for a positive and supportive work environment that will inspire you to reach your full potential? Perfect. At Pardee Homes, we strive to help each of our team members shine. Perhaps that's why our employees put us in the top half of the Best Companies to Work For.
Search for open positions
Review employment benefits
Have questions? We've got answers. Send us an email!
Looking for some star spangled ideas for your 4th of July party? Check out: http://t.co/U9pW3OS7fL #4thofJuly http://t.co/U9pW3OS7fL
Moving to Another State?Check Out Our Affiliated Builders
PRIVACY POLICY – Your Privacy Rights | Important Legal Declaration | EHO Legal Disclaimer© 1998 – 2015 Pardee Homes (New Homes and Real Estate from an Award Winning Home Builder)
Pardee Homes, a member of the TRI Pointe Group.
2015 builder of the year and 2014 developer of the year.


text:
The All Ways after 'America's Got Talent': At home and unplugged in New City
Rockland County rock band The All Ways made it to the quarterfinals on the seventh season of NBC's "America's Got Talent." They sat down with Newsday Westchester to talk about their experiences on the show and their next chapter. Videojournalist: Elizabeth Daza (Feb. 26, 2013)
After 5-year hiatus, July 4th Fireworks at Jones Beach Historic shift underway for disabled workers Tall Ships arrive for festival in Greenport Summertime is here Working on the atomic bomb Religious communities feast together at Westbury interfaith iftar Boy sees woman rescued from LIRR gap Suffolk cops demonstrate dangers of illegal fireworks Fire Island resort fire Extraordinary Seniors: Yaakov Kaminetsky Opening of emergency center in Long Beach delayed New York welcomes tall ships


text:
St John's Morning Show | Dec 19, 2012 | 5:56
Nurses Union turkey drive help
There's still time to help us with our annual Turkey Drive, and the Newfoundland & Labrador Nurses' union is doing its part. Debbie Forward, president of the NLNU, drops by to tell Anthony what her members are doing to help out this year. As well, Anthony talks with Debbie Forward about their public pension plan and contract negotiations.


text:
Climate: A Very Short IntroductionPaperback Very Short Introductions
List price $12.46
You save $1.89 15% off
Free delivery worldwide
Dispatched in 2 business days
When will my order arrive?
- Publisher: Oxford University Press
- Format: Paperback | 176 pages
- Dimensions: 112mm x 172mm x 10mm | 140g
- Publication date: 24 July 2013
- Publication City/Country: Oxford
- Illustrations note: 10 black and white line drawings
- Sales rank: 226,885
Product description
In this wide-ranging Very Short Introduction to climate, Mark Maslin considers all aspects of the global climate system, exploring and explaining the different components that control climate on Earth. He considers the processes that allow energy to reach the Earth and how it is redistributed around the planet by the ocean-atmosphere system; the relationship and differences between climate and the weather; how climate has affected life on Earth and human settlements; and the cyclic and quasi-cyclic features of climate such as the Milankovitch cycles and El Nino. He concludes by touching on the issue of climate change, and outlines some of the approaches that are now being taken to tackle it. ABOUT THE SERIES: The Very Short Introductions series from Oxford University Press contains hundreds of titles in almost every subject area. These pocket-sized books are the perfect way to get ahead in a new subject quickly. Our expert authors combine facts, analysis, perspective, new ideas, and enthusiasm to make interesting and challenging topics highly readable.
Add item to wishlist
Other people who viewed this bought:
Symmetry: A Very Short Introduct...
USD$10.42 - Save $2.04 16% off - RRP $12.46
Coral Reefs
USD$9.37 - Save $3.09 24% off - RRP $12.46
Fractals: A Very Short Introduct...
USD$10.17 - Save $2.29 18% off - RRP $12.46
Revolutions: A Very Short Introd...
USD$10.42 - Save $2.04 16% off - RRP $12.46
Psychology: A Very Short Introdu...
USD$10.42 - Save $2.04 16% off - RRP $12.46
Climate Change: A Very Short Int...
USD$10.25 - Save $2.21 17% off - RRP $12.46
Other books in this category
USD$12.79 - Save $2.21 14% off - RRP $15.00
The Cloudspotter's Guide
USD$11.70 - Save $5.44 31% off - RRP $17.14
The Cloud Book
The Cloudspotter's Guide
USD$12.34 - Save $4.61 27% off - RRP $16.95
The Hockey Stick Illusion
Heaven and Earth
USD$19.46 - Save $3.85 16% off - RRP $23.31
- Categories:
Author information
Mark Maslin, Professor of Geography at UCL and Director of the Environment Institute. He is also the author of Global Warming: A Very Short Introduction.
Table of contents
1. What is climate? ; 2. Climate, atmosphere, and oceans ; 3. Weather versus climate ; 4. Origins of the modern climate system ; 5. Climate and life ; 6. Climate cooling ; 7. Climate and civilization ; 8. Future climate change ; 9. Fixing climate