text:
In language, there are grammar rules, and then there are styles. Let's consider, for example, using a series in a sentence.
English grammar says that a series ought to be parallel.
Don't write this: Laine signed the contracts, the time sheets, and wrote his name on the paychecks.
Do write this: Laine signed the contracts, the time sheets, and the paychecks.
Then style comes into play. Oxford style says a comma should come before the last item in a series.
Laine signed the contracts, the time sheets, and the paychecks.
Associated Press style says that the final comma is unnecessary.
Laine signed the contracts, the time sheets and the paychecks.
So certain rules change according to which style you are following. Easy enough, you might say. Just use the right manual.
The trouble is, however, that grammar itself doesn't have a rule for every situation. At the very least, some rules are obscure.
Consider, for example, the situation described in "My Big Fat Greek Blog Post." Never in my education as an English major did anyone ever teach that adjectives are placed in order of opinion, size, age, shape, color, origin, material, and purpose. Nor does the possessive adjective "my" fit any of those categories.
Such gaps become most evident when teaching a language to non-native speakers. One of my daughters teaches English to adults in Belgium. Recently, her students asked which of these is correct: "A friend of Mary's" or "A friend of Mary." She suggested that both are correct and mean the same thing, but the first puts a slightly greater emphasis on Mary.
Then the students changed one word. What about "A photo of Mary's" versus "A photo of Mary"? In this case, of course, the meanings are entirely different. Depending on what they wanted to say, the students would have to choose one phrase or the other.
At times like these, grammarians are forced to invent a rule to describe (or fit) the situation. In a way, such scenarios define grammar—a set of rules describing how people use language. The language comes first; the description comes second. And style trails along after that.
—Lester Smith


text:
Guideline for the optimal use of blood cultures
Ntobeko NtusiI; Lindsey AubinII; Stephen OliverIII; Andrew WhitelawIV; Marc MendelsonV
IFCP (SA). Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town
IIRN, RM, Pg Dip Educator of Adults. Clinical Skills and Training Unit, Department of Medicine, Groote Schuur Hospital and University of Cape Town
IIIMB ChB, MMed Path (Microbiol). Division of Microbiology, Clinical Laboratory Services, Groote Schuur Hospital and University of Cape Town
IVMB BCh, MSc, FCPath (Microbiol) (SA). Division of Microbiology, Clinical Laboratory Services, Groote Schuur Hospital and University of Cape Town ]]> VPhD, FRCP (UK), DTM&H. Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town
The incidence of sepsis is increasing globally, with high morbidity and mortality. Prompt, accurate detection of bacteraemia and fungaemia is imperative for improving patient care, yet health care professionals lack training in correct blood culture techniques. These guidelines discuss the clinical importance of blood cultures, the indications for their use and the correct technique for optimal yield of pathogenic micro-organisms that cause sepsis.
Detection of bacteraemia or fungaemia by blood culture is critical in managing patients with infection, and directs the appropriate selection of antimicrobials. Blood culture is a common laboratory investigation where blood is inoculated into culture medium and incubated. Media used in blood culture bottles support the growth of most medically important bacteria and fungi, including anaerobes, which grow adequately in the aerobic blood culture bottle, hence separate anaerobic bottles are infrequently used.1,2 The goal of culturing blood is to determine whether a pathogenic microorganism(s) is responsible for the patient's clinical presentation. 'False positive' results occur when a skin commensal(s) rather than a true pathogenic organism is grown. Proper cleaning of the skin is a vital component of venesection to reduce the false-positive rate, yet poor technique is common when collecting blood for culture. This lapse results in inappropriate use of antibiotics, increased antibiotic resistance and prolonged hospital stay. A further barrier to correct laboratory interpretation of blood culture results is inadequate relevant clinical details on the accompanying request form. These guidelines contextualise the place of blood cultures in the management of sepsis and detail the appropriate method for acquiring blood for culture, to reduce the false-positive rate.
Methods]]> We performed a literature review of the diagnosis and management of sepsis; identified a number of international best practice standards, including recommendations of the United Kingdom Department of Health, International Sepsis Forum, Society of Critical Care Medicine, Surgical Infection Society, American Association of Critical Care Nurses, American Association of Chest Physicians, American College of Emergency Physicians, American Thoracic Society, Australian and New Zealand Intensive Care Society, European Society of Intensive Care Medicine, Indian Society of Critical Care Medicine, European Respiratory Society, Infectious Diseases Society of America, and the Clinical and Laboratory Standards Institute; and studied consensus expert opinion documents.
Blood culture. Collection and inoculation of blood into culture medium with the aim of growing pathogenic bacteria or fungi for diagnostic purposes.
Bacteraemia. The presence of viable bacteria in the bloodstream which may be transient (e.g. following dental procedures), intermittent (e.g. undrained abscesses), or continuous (e.g. endovascular infection).
Fungaemia. The presence of viable fungi in the bloodstream.
Infection. An inflammatory response to one or more micro-organisms, or the invasion of normally sterile sites by those organisms.
Systemic inflammatory response syndrome (SIRS). A consequence of the host inflammatory response that can follow infection or other injury, defined as the clinical cluster of two or more of:
temperature >38ºC or <36ºC
heart rate >90 beats/minute]]> respiratory rate >20 breaths/minute or paCO2 <4.3 kPa (32 mmHg)
white cell count >12 000 cells/mm3, <4 000 cells/mm3, or >10% immature white blood cells (band forms).3
Sepsis. SIRS resulting from documented infection.3,4
Severe sepsis. Documented sepsis associated with organ dysfunction, hypoperfusion or hypotension. Perfusion abnormalities may manifest as, but are not limited to:
lactic acidosis
acute alteration in mental state
areas of mottled skin
capillary refilling requiring >3 seconds]]> disseminated intravascular coagulation
acute lung injury or acute respiratory distress syndrome (ARDS)
cardiac dysfunction, as defined by echocardiography or direct measurement of the cardiac index.3,5
Septic shock. The presence of severe sepsis plus one or both of the following:
systemic mean blood pressure <60 mmHg (or <80 mmHg if the patient has baseline hypertension) despite adequate fluid resuscitation
maintaining systemic mean blood pressure >60 mmHg (or >80 mmHg if the patient has baseline hypertension) requires support with inotropic/vasoactive agents.3,4
Multi-organ dysfunction/failure. Multi-organ failure is often a consequence of severe sepsis and septic shock, and refers to the presence of altered function affecting more than one organ in an acutely ill patient such that homeostasis cannot be maintained without intervention. Multiple organ dysfunction syndrome (MODS) is either primary (directly attributable to a well-defined insult) or secondary (as a consequence of the host response). MODS is characterised by, but not limited to, abnormalities in serum creatinine, platelet count, serum bilirubin, Glasgow coma score, pressure adjusted heart rate, and arterial oxygenation.3,5
Sepsis and the significance of blood culture
Some 1.8 million cases of sepsis occur worldwide each year;6 however, owing to variable definitions and reporting, this is probably an underestimate. A more accurate estimate may be as high as 18 million, an incidence of 3/1 000 population.7 Sepsis is the most common cause of death in non-coronary intensive care units worldwide.8,9 The mortality rate from sepsis is generally between 30% and 70%, and is higher in persons with a pre-existing disease.3,8 Elderly, critically ill and immunocompromised persons are particularly vulnerable.10 Population-based studies of incidence and prevalence of sepsis in South Africa have not been undertaken.]]> There are several reviews of the pathophysiology of sepsis.11-16 The direct effects of invading micro-organisms, their toxic products, or both, may contribute to pathogenesis of sepsis. Important factors include endotoxin, bacterial cell wall components (peptidoglycan, muramyl dipeptide, and lipoteichoic acid), and bacterial products such as staphylococcal enterotoxin B, toxic shock syndrome toxin-1, pseudomonas exotoxin A, and M protein of haemolytic group A streptococci.17 Cellular injury and organ dysfunction occur as a consequence of ischaemia,18 cytopathic injury19 and increased rate of apoptosis.20 Panendothelial activation in sepsis also leads to widespread tissue oedema, endothelial dysfunction, hypotension, upregulation of adhesion molecules, and impaired anticoagulant properties leading to MODS.21
Blood culture plays an integral role in the evaluation of sepsis.22 As bacteraemia is often associated with fever, clinicians are encouraged to obtain blood samples for culture from febrile patients.23 The indications for blood culture are broad and ill-defined.24 Other than pyrexia, clinical parameters alone are unhelpful in predicting bacteraemia and cannot be used in isolation to determine the timing of blood sampling for culture.25
Clinical features of sepsis
The clinical features of sepsis relate to the causative organism, the involved site, severity, and the host response to infection. Symptoms and signs of sepsis are usually superimposed on the patient's underlying illness and primary infection. Hence, their rate of development and clinical presentation varies. Common clinical features of sepsis include lethargy, fever (although hypothermia may occur) and an elevated or reduced white blood cell count.26 Sweating, rigors, tachycardia, hypotension, tachypnoea, warm peripheries, confusion, oliguria and jaundice may also occur (Table I).
Diagnosis of sepsis
Sepsis is primarily a clinical diagnosis, supported by laboratory investigation and imaging. Culture of specimens from a sterile site is the gold standard microbiological investigation and the key to successful diagnosis.27,28 Occasionally, serology may aid diagnosis. Culture is a slow process compared with rapid molecular diagnostic tests that detect genetic material and can be used at the 'point-ofcare'.29 A point-of-care test for sepsis would be an extremely useful addition to the diagnostic armory.
The indications for blood culture are shown in Table II. Although only 5 -15% of blood cultures drawn in febrile patients are positive, approximately half of all patients with severe sepsis demonstrate bacteraemia at the time of diagnosis.30 The presence or absence of a positive blood culture does not appear to influence outcome of sepsis, suggesting that prognosis is more related to severity of sepsis.31 Hospital-acquired infections (HAI) diagnosed from blood culture have a higher mortality than those acquired in the community.32
Principles of sample collection for blood culture
1. Blood cultures should be drawn when there is a clinical suspicion of bloodstream infection.33
2. Blood should not be collected from indwelling arterial or venous lines unless an infected intravenous line is suspected.34 Should blood be drawn for culture from an indwelling line, a second specimen should be obtained from a peripheral site.
3. Two or more blood specimens should be collected using sterile technique at separate sites, before administering antibiotics.35-37 Except in very unusual cases, no more than 3 sets of blood cultures should be collected in one 24-hour period. If all 4 sets are negative after 24 hours and sepsis is still suspected, more cultures may be collected.38 A larger number of cultures may have to be collected from persons already receiving antimicrobials39 although, if clinical condition allows, stopping antibiotics and re-culturing after 48 hours is preferred.
4. Ideally, a minimum of 10 ml of blood, depending on the blood culture system used, should be inoculated into a culture bottle when taking blood from adults.40 Adequate volumes of blood improve detection of pathogenic organisms and reduce time to detection. 5. Arterial blood culture provides no advantage over venous samples.41
6. Changing needles between venepuncture and inoculation into culture bottles is controversial. Discontinuing this practice owing to lack of evidence that it decreases contamination and the increased risk of sharp injuries has been recommended.42,43 However, a meta-analysis challenges this recommendation, suggesting a slight overall benefit of switching needles.44 Until more definitive studies are available, we recommend that the risk of changing needles after venepuncture does not outweigh the benefit. More important ways to decrease contamination of blood culture bottles include the use of tincture of iodine as a disinfectant,45 avoidance of drawing blood through existing intravenous lines34 and disinfecting the membrane of the blood culture bottle.46
7. It is a medico-legal requirement that the patient's notes must always document acquiring blood for culture, including indication, site, time of taking blood culture and a legible name.
Table III details recommendations for how to correctly send blood to the laboratory for culture.]]> Optimal number of blood cultures
The optimal number of blood cultures that should be obtained in a febrile patient varies according to the suspected diagnosis or clinical condition, the suspicion of underlying infection, and the urgency of the need for treatment.47
One blood culture is rarely, if ever, sufficient or advisable.21 A positive result on a single culture is difficult to interpret, unless an unequivocal pathogen is isolated.
Two blood cultures are usually adequate when continuous bacteraemia is anticipated.48
Three blood cultures are reasonable when intermittent bacteraemia is suspected.49
We believe that more than 3 blood cultures is rarely justifiable in a resource-limited setting. Furthermore, the probability of obtaining a false-positive result increases steadily as more blood cultures are performed.
Timing of blood cultures
Few systematic studies have been conducted on the timing of blood cultures and the optimal interval between successive tests.38 The ideal is to collect blood at time intervals ranging from one to several hours.50 However, it is sufficient and appropriate to obtain blood from 2 separate sites within minutes of each other from patients who are acutely ill or those in whom the likelihood of continuous bacteraemia is high.51 By contrast, in patients suspected to have intermittent bacteraemia, it is advisable to obtain multiple blood cultures 6 -36 hours apart.38,52 One study showed no difference in yield whether blood samples for cultures performed within a 24-hour period were drawn simultaneously or at spaced intervals.53 Antibiotics should not be withheld in sick patients apart from a reasonable delay to collect more than 1 culture sample.
Volume of blood to be taken for culture]]> A minimum of 10 ml (and preferably 20 ml) of blood should be obtained from adults,38,41,53,54 and 1 - 5 ml (and preferably more) from infants and children.40,55,56 The yield from blood culture depends upon the volume of blood cultured,57-59 the yield in adults increasing approximately 3% per ml of blood cultured.
Maintaining the correct ratio of blood to culture medium is important. Most blood culture bottles contain the anticoagulant sodium polyanetholsulphonate (SPS). SPS can inactivate lysozyme, some antibiotics, and parts of the complement cascade. However, SPS can also be toxic to certain fastidious organisms. Adding sufficient blood to the bottle helps negate this latter effect. A dilution of blood in broth by a ratio of 1:5 has been recommended.60,61
Type of blood culture bottle
Most blood culture systems are now automated, with some form of continuous monitoring to detect growth. The bottles contain broth supplemented with additives. Different bottles are designed either to be used in different patient groups, or to isolate different classes of pathogens. A few general principles apply:
Standard aerobic bottles are suitable for the recovery of most common bacterial pathogens, including aerobes and facultative anaerobes. These are not as suitable for supporting the growth of strict anaerobes, and therefore traditional advice has been to use a paired set of aerobic and anaerobic bottles when taking blood cultures.62 The routine use of anaerobic bottles has been questioned, as the incidence of anaerobic bacteraemia is decreasing61,63,64 and most infections involving anaerobes are clinically suspected and appropriate empiric therapy is administered before blood culture results become available.65,66 Conversely, improved yield of micro-organisms when using aerobic-anaerobic paired blood cultures has been demonstrated.67,68 Although firm evidence is unavailable, we believe that the routine use of anaerobic bottles is not warranted, particularly in resource-limited settings.
Some manufacturers produce aerobic and anaerobic bottles with additives (such as charcoal or resins) that inactivate antibiotics. These are preferable when taking blood cultures from patients already on antimicrobials, but are more expensive. There is evidence that the average time to positivity with these bottles is shorter than with normal aerobic and anaerobic bottles; however, their cost-effectiveness is unclear.61 Paediatric bottles are often supplemented with growth factors and usually have additives which will bind antibiotics, allowing improved recovery of bacteria. Together with the lower concentration of SPS, these features allow smaller volumes of blood to be inoculated.60,61
Mycobacterial blood culture bottles contain broth suitable for the isolation of mycobacteria and are valuable for the detection of disseminated mycobacterial infections, both M. tuberculosis and non-tuberculous mycobacteria. However, these bottles are often also used to enhance the recovery of yeasts from blood, although there is less evidence to justify this practice.69,70 Given the additional expense, routine blood culture bottles should be used for detection of candidaemia, and mycobacterial blood cultures should be reserved for suspected mycobacterial infections.71
Conclusion]]> Blood culture remains one of the most important microbiological tests available to the clinician. Members of the healthcare team who perform blood cultures must have a sound comprehension of the principles that underlie this important diagnostic tool. These guidelines provide practical and accessible guidance for medical students, nurses and doctors on the correct performance of blood collection for culture and should be applicable to all levels of healthcare in South Africa. Adoption of these guidelines and implementation of procedures to improve the quality of blood culture investigations will reduce the risk of blood sample contamination and improve the management and care of patients with sepsis.
These guidelines are endorsed by the South African Society for Clinical Microbiology (SASCM).
The authors acknowledge Dr Colleen Bamford and Professors Janet Seggie, Vanessa Burch and Bongani Mayosi for their constructive comments during the development of this document.
Dr Ntusi receives support from the Discovery Foundation and the Medical Research Council of South Africa. Professor Mendelson receives support from PEPFAR USAID through the ANOVA Health Institute.
1. Murray PR, Traynor P, Hopson D. Critical assessment of blood culture techniques: analysis of recovery of obligate and facultative anaerobes, strict aerobic bacteria, and fungi in aerobic and anaerobic blood culture bottles. J Clin Microbiol 1992;30:1462-1468. [ Links ]
2. Morris AJ, Wilson ML, Mirrett S, Reller LB. Rationale for selective use of anaerobic blood cultures. J Clin Microbiol 1993;31:2110-2113. [ Links ]]]>
3. American College of Chest Physicians/Society of Critical Care Medicine. Consensus Conference: Definitions for sepsis and organ failure and guidelines for use of innovative therapies in sepsis. Crit Care Med 1992;20:864-874. [ Links ]
4. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESCIM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;31:1250-1256. [ Links ]
5. Balk RA. Severe sepsis and septic shock. Definitions, epidemiology, and clinical manifestations. Crit Care Clin 2000;16:179-192. [ Links ]
6. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of sepsis in the US: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-1310. [ Links ]
7. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:1546-1554. [ Links ]]]>
8. Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 2006;34:344-353. [ Links ]
9. Padkin A, Goldfrad C, Brady AR, et al. Epidemiology of severe sepsis occurring in the first 24 hours in intensive care units in England, Wales, and Northern Ireland. Crit Care Med 2003;31:2332-2338. [ Links ]
10. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32: 858-873. [ Links ]
11. Remick DG. Pathophysiology of sepsis. Am J Pathol 2007;170:1435-1444. [ Links ]
12. Bone RC. Immunologic dissonance: A continuing evolution in our understanding of the systemic inflammatory response syndrome (SIRS) and the multiple organ dysfunction syndrome (MODS). Ann Intern Med 1996:125:680-687. 13. Bone RC. The pathogenesis of sepsis. Ann Intern Med 1991;115:457-469. [ Links ]]]>
14. Peters K, Unger RE, Brunner J, Kirkpatrick CJ. Molecular basis of endothelial dysfunction in sepsis. Cardiovasc Res 2003;60:49-57. [ Links ]
15. Rigato O, Salomao R. Impaired production of interferon-gamma and tumor necrosis factor-alpha but not of interleukin-10 in whole blood of patients with sepsis. Shock 2003;19:113-116. [ Links ]
16. Pinsky MR, Matuschak GM. Multiple organ failure: Failure of host defense homeostasis. Crit Care Clin 1989;5:199-220. [ Links ]
17. Pugin J. Recognition of bacteria and bacterial products by host immune cells in sepsis. In: Vincent JL, ed. Yearbook of Intensive Care and Emergency Medicine. Berlin: Springer-Verlag, 1996:11. [ Links ]
18. Piagnerelli M, Boudjeltia KZ, Vanhaeverbeek M, Vincent JL. Red blood cell rheology in sepsis. Intensive Care Med 2003;29:1052-1061. [ Links ]]]>
19. Crouser ED, Julian MW, Blaho DV, Pfeiffer DR. Endotoxin-induced mitochondrial damage correlates with impaired respiratory activity. Crit Care Med 2002;30:276-284. [ Links ]
20. Marshall JC, Watson RW. Apoptosis in the resolution of systemic inflammation. In: Vincent JL, ed. Yearbook of Intensive Care and Emergency Medicine. Berlin: Springer-Verlag, 1997:100. [ Links ]
21. Aird WC. The role of the endothelium in severe sepsis and multiple organ dysfunction syndrome. Blood 2003;101:3765-3777. [ Links ]
22. Shanson DC. Blood culture technique: current controversies. J Antimicrob Chemother 1990;25(Suppl C):17-29. [ Links ]
23. Aronson M, Bor D. Blood cultures. Ann Intern Med 1987;106:246-253. [ Links ]]]>
24. Chandrasekar PH, Brown WJ. Clinical issues of blood cultures. Arch Intern Med 1994;154:841-849. [ Links ]
25. Peduzzi P, Shatney C, Sheagren J, Sprung C. Predictors of bacteremia and gram-negative bacteremia in patients with sepsis. Veterans Affairs Systemic Sepsis Cooperative Study Group. Arch Intern Med 1992;152:529-535. [ Links ]
26. Harris RL, Musher DM, Bloom K, et al. Manifestations of sepsis. Arch Int Med 1987;147:1895-1906. [ Links ]
27. von Landenberg P, Shoenfeld Y. New approaches in the diagnosis of sepsis. Isr Med Ass J 2001;3:439- 442. [ Links ]
28. Cohen J. Microbiological requirements for studies of sepsis. In: Sibbald WJ, Vincent JL, eds. Clinical Trials for the Treatment of Sepsis. Berlin: Springer-Verlag, 1995:29. [ Links ]]]>
29. Cursons RT, Jeyerajah E, Sleigh JW. The use of polymerase chain reaction to detect septicemia in critically ill patients. Crit Care Med 1999;27:937-940. [ Links ]
30. Bone RC, Fisher CJ, Clemmer TP, et al. Sepsis syndrome: A valid clinical entity. Methylprednisolone Severe Sepsis Study Group. Crit Care Med 1989;17:389-393. [ Links ]
31. Brun-Buisson C, Doyon F, Carlet J, et al. Bacteremia and severe sepsis in adults: A multicenter prospective survey in ICUs and wards of 24 hospitals. French Bacteremia-Sepsis Study Group. Am J Resp Crit Care Med 1996;154:617-624. [ Links ]
32. Shorr AF, Tabak YP, Killian AD, et al. Healthcare-associated bloodstream infection: A distinct entity? Insights from a large U.S. database. Crit Care Med 2006;34:2588-2595. [ Links ]
33. Henke PK, Polk HC Jr. Efficacy of blood cultures in the critically ill surgical patient. Surgery 1996;120:752-758. [ Links ]]]>
34. Norberg A, Christopher NC, Ramundo ML, et al. Contamination rates of blood cultures obtained by dedicated phlebotomy vs. intravenous catheter. JAMA 2003;289:726-729. [ Links ]
35. Bates DW, Goldman L, Lee TH. Contamination blood cultures and resource utilization. The true consequences of false-positive results. JAMA 1991;265:365-369. [ Links ]
36. McKenzie R, Reimer LG. Effect of antimicrobials on blood cultures in endocarditis. Diagn Microbiol Infect Dis 1987;8:165-172. [ Links ]
37. Washington JA II, Ilstrup DM. Blood cultures. Issues and controversies. Rev Infect Dis 1986;8:792- 802. [ Links ]
38. Weinstein MP. Current blood culture methods and systems: Clinical concepts, technology and interpretation of results. Clin Infect Dis 1996;23:40-46. [ Links ]]]>
39. Pazin GJ, Saul S, Thompson ME. Blood culture positivity: suppression by outpatient antibiotic therapy in patients with bacterial endocarditis. Arch Intern Med 1982;142:263-268. [ Links ]
40. Connell TG, Rele M, Cowley D, et al. How reliable is a negative blood culture result? Volume of blood submitted for culture in routine practice in a children's hospital. Pediatrics 2007;119:891. [ Links ]
41. Reller LB, Murray PR, MacLowry JD. Blood Cultures II. In: Washington JA II, Cumitech IA, eds. Washington DC: American Society for Microbiology,1982. [ Links ]
42. Krumholz HM, Cummings S, York M. Blood culture phlebotomy: switching needles does not prevent contamination. Ann Intern Med 1990;113:290-292. [ Links ]
43. Leisure MK, Moore DM, Schwartzman JD, et al. Changing the needle when inoculating blood cultures: A no benefit and high risk procedure. JAMA 1990;264:2111-2112. [ Links ]]]>
44. Spitalnic SJ, Woolard RH, Mermel LA. The significance of changing needles when inoculating blood cultures: A meta-analysis. Clin Infect Dis 1995;21:1103-1106. [ Links ]
45. Little JR, Murray PR, Traynor PS, Spitznagel E. A randomized trial of povidone-iodine compared with tincture for venipuncture site disinfection: Effects on rates of blood culture contamination. Am J Med 1999;107:119-125. [ Links ]
46. Eskira S, Gilad J, Schlaeffer P, et al. Reduction of blood culture contamination rate by an educational intervention. Clin Microbiol Infect 2006;12:818-821. [ Links ]
47. Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of blood stream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007;45:3546-3548. [ Links ]
48. Weinstein MP, Reller LB, Murphy JR, Lichtenstein KA. The clinical significance of positive blood cultures: a comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Rev Infect Dis 1983;5:35-53. [ Links ]]]>
49. Washington JA II. Blood cultures: principles and techniques. Mayo Clin Proc 1975;50:91-98. [ Links ]
50. Noskin GA, Phair JP. Approach to the patient with bacteremia and sepsis. In: Kelly WN, Dupont HL, Glick JH, et al., eds. Textbook of Internal Medicine. Wickford RI, USA: Lippincott-Raven Publishers, 1997:1575-1581. [ Links ]
51. Strand CL. Blood cultures: consensus recommendations in 1988. Microbiology no. MB 88-1. American Society for Clinical Pathologists Check Sample Continuing Education Program. Chicago: American Society for Clinical Pathologists,1988. [ Links ]
52. Ilstrup DM, Washington JA II. The importance of volume of blood cultures in the detection of bacteremia and fungaemia. Diagn Microbiol Infect Dis 1983;1:107-110. [ Links ]
53. Li J, Plorde JJ, Carlson LG. Effects of volume and periodicity on blood cultures. J Clin Microbiol 1994;32:2829-2831. [ Links ]]]>
54. Mermel LA, Maki D. Detection of bacteremia in adults: Consequences of culturing an inadequate volume of blood. Ann Intern Med 1993;119:270-272. [ Links ]
55. Schelonka RL, Chai MK, Yoder BA, et al. Volume of blood required to detect common neonatal pathogens. J Pediatr 1996;129:275-278. [ Links ]
56. Brown DR, Kutler D, Rai B, et al. Bacterial concentration and blood volume required for a positive blood culture. J Perinatol 1995;15:157-159. [ Links ]
57. Isaacman DJ, Karasic RB, Reynolds EA, Kost SI. Effect of number of blood cultures and volume of blood on detection of bacteremia in children. J Pediatr 1996;128:190-195. [ Links ]
58. Plorde JJ, Tenover FC, Carlson LG. Specimen volume versus yield in the BACTEC blood culture system. J Clin Microbiol 1985;22:292-295. [ Links ]]]>
59. Tenney JH, Reller LB, Mirrett S, Wang W-LL, Weinstein MP. Controlled evaluation of the volume of blood cultured in detection of bacteremia and fungemia. J Clin Microbiol 1982;15:558-561. [ Links ]
60. O'Hara CM, Weinstein MP, Miller JM. Manual and automated systems for detection and identification of micro-organisms. In: Murray PR, Baron EJ, Jorgensen JH, Pfaller MA, Yolken RH, eds. Manual of Clinical Microbiology, 8th ed. Washington DC: ASM Press, 2003. [ Links ]
61. Reimer LG, Wilson ML, Weinstein MP. Update on detection of bacteraemia and fungaemia. Clin Microbiol Rev 1997:10:444-465. [ Links ]
62. Mylotte JM, Tayara A. Blood cultures: clinical aspects and controversies. Eur J Clin Microbiol Infect Dis 2000;10:157-163. [ Links ]
63. Lazarovitch T, Freimann S, Shapira G, Blank H. Decrease in anaerobe-related bacteraemias and increase in Bacteroides species isolation rate from 1998 to 2007: a retrospective study (in press). Anaerobe 2009; doi:10.1016/j.anaerobe.2009.09.003. [ Links ]]]>
64. Dorsher CW, Rosenblatt JE, Wilson WR, Ilstrup DM. Anaerobic bacteremia: decreasing rate over 15- year period. Rev Infect Dis 1991;3:633-636. [ Links ]
65. Iwata K, Takahashi M. Is anaerobic blood culture necessary? If so, who needs it? Am J Med Sci 2008;336:58-63. [ Links ]
66. Ciobutaro P, Lishner M, Kilan A, et al. Decreasing the use of anaerobic blood culture bottles in selected febrile patients - is it reasonable? Eur J Intern Med 2005;16:485-488. [ Links ]
67. Karunakaran R, Raja NS, Quek KF, et al. Evaluation of the routine use of the anaerobic bottle when using the BACTEC blood culture system. J Microbiol Immunol Infect 2007;40:445-449. [ Links ]
68. Riley JA, Heiter BJ, Bourbeau PP. Comparison of recovery of blood culture isolates from two BacT/ ALERT FAN aerobic blood culture bottles with recovery from one FAN aerobic bottle and one FAN anaerobic bottle. J Clin Microbiol 2003;41:213-217. [ Links ]]]>
69. Kirby JE, Delaney M, Qian Q, Gold HS. Optimal use of Myco/F Lytic and standard BACTEC blood culture bottles for detection of yeast and mycobacteria. Arch Pathol Lab Med 2009;133:93-96. [ Links ]
70. Horvath LL, George BJ, Hospenthal DR. Detecetion of fifteen species of Candida in a automated blood culture system. J Clin Microbiol 2007;45:3062-3064. [ Links ]
71. Horvath LL, Ospenthal DR, Murray CK, Dooley DP. Detection of simulated candidaemia by the Bactec 9240 system with Plus Aerobic/F and Anaerobic/F blood culture bottles. J Clin Microbiol 2003;41:4714-4717. [ Links ]
Accepted 30 June 2010.
Corresponding author: N B A Ntusi (email@example.com)]]>

subset: commoncrawl


text:
christmas card reveal
For me, one of the top ten perks of having my newborn back in 2009 was at Christmastime. I finally got to join the troops of parents who made the cute holiday cards out of their kids' photos that I'd always envied.
But the first year, I was stressed. My baby was two months old, always crying, and it really put a damper on any creative abilities I thought I'd accumulated for the Christmas card talent I was supposed to have in adulthood. I let Picture People make this card out of one of the pictures from his first photo session and called it a day.
These were the days when I thought every single photo of my newborn was amazing. Nevermind his frown and half closed eyes.
There's a small victory I soak up from this card, though. Three years later, he still sleeps with the same bear. Except he's half as fluffy.
The next year, I had a photographer do a photo shoot with us at North Carolina's Art Museum. I'd hoped to include Matt and I in this one, but I honestly didn't like any of the pictures she took. I picked my favorite one of Carter and used
Tiny Prints
to create my card design the week before Christmas. I think I paid more than $40 for last minute shipping alone.
Last year, I got really into
and was inspired by the whole
do it yourself
world. I started to think I could possibly take a professional-looking photo myself, and, at the very least, I'd be using my own creative vision instead of someone else's photography.
I had an idea of what I wanted to do, and luckily my baby was old enough to be bribed with candy for sitting still. I could never tell you how to photograph in low light, but I got lucky with this shot and started to believe that almost any photo I took with determination and vision could be better than the professional photo cards I'd had made in the past. I used
Tiny Prints
again, just to add the text and have it printed.
This year, we put our tree up extra early just so I could get the lights in the background of the card. One lazy morning, I gave Carter a crash course on the concept of Christmas cards. I showed him his old ones and some I'd saved that people sent us last year. He was in a good mood and totally compliant to every word. Probably because I told him he could have three gummy worms when we were done.
I tried a few different setups with candy canes and winter hats. I moved on to a milk and cookies idea I'd had and set them in front of him. Eyes full of thanks, he immediately reached for a cookie.
"Wait! Don't touch them yet, Carter! I have to refocus the camera."
Then this face happened. And I got my 2012 Christmas card.
(Yes, I let him eat the cookies.)
The first picture with the little smile reaching for the cookie tormented me. I was dying to use it. I felt so cynical even considering sending out a Christmas face that was anything but happy. But the frustrated, crumpled eyebrows pulled at my heart.
Clicking back and forth between the two for hours, I decided not to let myself get sucked into a world that uses Christmas cards to make our lives look perfect. In reality, he will probably make that same face on Christmas eve and a hundred other times this week. And I love that disgruntled, little furrowed brow just as much as I love his smile.
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NOTCH - India's First Entertainment & Lifestyle Magazine Releases its Third Issue
Nov 29, 2012, 02:27 ET
CHENNAI, November 29, 2012 /PRNewswire/ --
Vidya Balan to Grace the Cover of NOTCH
NOTCH is India's first interactive, digital publication that showcases contemporary India to a global audience. With a strong focus on entertainment, NOTCH showcases lifestyle through fashion, design, art, food and travel. The engaging content is delivered through state-of-the-art technology platforms.
(Logo: http://photos.prnewswire.com/prnh/20120921/204377)
NOTCH is now available to subscribers on Kindle, apart from iPad, Android tablets and a downloadable web version from the NOTCH website.
The December edition has India's Avant Garde actress Vidya Balan on the cover. The issue celebrates 25 years of Indian fashion with designers Tarun Tahiliani, Suneet Varma, Abu Jani - Sandip Khosla, Rohit Bal and Ritu Kumar.
Renowned artist Satish Gujral talks about his unstoppable spirit, while interior designer Pavitra Rajaram depicts her talent with colorful homes. Industrialist Yash Birla takes you through his new venture of Professional Fitness. Get completely flipped as German chef Olaf Niemeier shares his recipes for Indian Chutneys!
You can read e-book reviews, watch food videos, interactive style guides, yoga tutorials, enjoy stunning travel photo essays, play games and much more!
Speaking about NOTCH's third issue, Chairman & CEO Pradeep Dadha, said, "I am excited to share the third edition of NOTCH and would like to take this opportunity to thank our readers for their continuous support and appreciation. NOTCH's vision is to redefine the "magazine experience" while keeping our readers surprised and delighted and who better than Vidya Balan, an actor par excellence who has redefined Bollywood."
Features of NOTCH include:
•Interactive tools that allow readers to scroll, flip, swipe and navigate their way through content
•Embedded photo galleries allow for a limitless showcase of high-res images
•Audio files with improved clarity of sound
•Videos within the articles bring static content to life with superior audio-visual options.
NOTCH, which recently launched a Facebook page, already has over 401,000 fans in such a short period of time.
About NOTCH Media Pvt Ltd:
NOTCH Media Pvt. Ltd. established in 2011, is the media and entertainment flagship of the Pradeep Dadha Group of Companies (PDGOC). PDGOC, a global $100M+, multi-vertical e-commerce privately held corporate, acts as a holding company for a variety of sales, marketing, media and entertainment companies. Headquartered in Chennai, the group caters to consumers in more than 150 countries from centers in Malta, the UK, Singapore and the US. With a multi-vertical portfolio of wholly owned brands of jewelry and fashion, the PDGOC 'shared success' model encourages innovation and collaboration in the e-commerce space.
For more information on NOTCH, contact: Neha Lidder - [email protected]
Visit: http://www.notchmag.com/, http://www.facebook.com/notchmag, https://twitter.com/NOTCHmag, http://www.youtube.com/user/NOTCHmag
Primary Media Contact: Noor Enayat, [email protected], 91-9810790846
Secondary Media Contact: Roopak Sharma, [email protected], 91-9810338626
SOURCE Notch Media Pvt Ltd


text:
Special Procedures Seminar Report 2008
June 27, 2008 | Economic, Social and Cultural Rights | Brazil, Bulgaria, Colombia, Congo, India, Kenya, Lebanon, Mexico, Mozambique, Nigeria, Peru, Philippines, Thailand, Uganda
The active filter is illustrated below, you can exclude a filtering condition by clicking on it
Note: The search will take into account your active filter. i.e. it will be performed within Events and Kenya and 2008
The numbers on the right side shows how many new articles appeared in the last 7 days and the total number of articles. Active filters are colored in red.


text:
|Search by keyword - Browse Top 10 - Browse Recent Additions & Suggestions
|Top Index /
Diaper Product Reviews
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If you go to your listing, look in the URL in the address box of your browser for your ID number - it will look like this:
So the company ID number is 46
When you click on "Modify My Listing", there is a link there called "Forgot Your Password?".
Browse by Region:Hint: mouseover the green swirls to see how many listings and/or subregions are in each region.
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Now you can help out first-time cloth diaper buyers - share your pans and hurrahs! Have you had a good (or bad!?) experience with any diapering products or diaper companies?
DISCLAIMER: We do not censor reviews posted. This is a consumer's forum. However, these reviews should not be taken as absolute fact. They are simply personal experiences - open to bad days and difficulties beyond the company's control. Born to Love takes no responsibility for the reviews posted. They remain the personal property of the submitter.
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-ass AS80 behaviour mimicall calculations are done with 32 bits integer values and wrong rounding macro parameters are not protected with {} anymore multiple declarations with DEFB,DEFW,DEFI got reference adress of the first outputed byte. That's why with AS80, using multiple DEFB produces a different result than using DEFB with multiple values MACRO declaration directive must be used after the macro name
Hi,Now I feel dumb, I can not get the program to run. I just see the command prompt window to open in a fraction of a second, not able to read what it says, and that's it.Bill
Yes, 81 seems to be a good number. Everything stable and well here too.
org #8000call #BBBA ; GRA initializeld a,1call #BC0E ; mode 1ld a,1call #BD97 ; degld de,320ld hl,200call #BBC9 ; origin 320,200ld de,180ld hl,0call #BBC0 ; move 180,0ld b,0circle_trace push bc ld hl,angle ld de,incre call #BD7C ; angle=angle+incre ld de,angle ld hl,tmp call #BD61 ; tmp=angle call #BDAF ; tmp=cosinus(tmp) ld de,rayon call #BD85 ; tmp=tmp*rayon call #BD6A ; HL=int(tmp) call m,fixsign push hl ld de,angle ld hl,tmp call #BD61 ; tmp=angle call #BDAC ; tmp=sinus(tmp) ld de,rayon call #BD85 ; tmp=tmp*rayon call #BD6A ; HL=int(tmp) call m,fixsign pop de call #BBF6 ; LINE DE,HL pop bc djnz circle_traceretfixsign ld de,0 ex hl,de or a sbc hl,de ret rayon defr 180angle defr 0incre defr 360/256tmp defr 0
I just learned (at the Revision, from Offset) that Basic has an integer division, with the symbol \ (or ç on French keyboard). I already reported you that the "accurate" division was a bit problematic in some cases. Do you think something similar could be implemented?
a=10b=2repeat 10print a,"/",b," normal=",a/b," int()=",int(a/b)," floor()=",floor(a/b)b=b+1rend
10.00 / 2.00 normal= 5.00 int()= 5.00 floor()= 5.0010.00 / 3.00 normal= 3.33 int()= 3.00 floor()= 3.0010.00 / 4.00 normal= 2.50 int()= 3.00 floor()= 2.0010.00 / 5.00 normal= 2.00 int()= 2.00 floor()= 2.0010.00 / 6.00 normal= 1.67 int()= 2.00 floor()= 1.0010.00 / 7.00 normal= 1.43 int()= 1.00 floor()= 1.0010.00 / 8.00 normal= 1.25 int()= 1.00 floor()= 1.0010.00 / 9.00 normal= 1.11 int()= 1.00 floor()= 1.0010.00 / 10.00 normal= 1.00 int()= 1.00 floor()= 1.0010.00 / 11.00 normal= 0.91 int()= 1.00 floor()= 0.00
Bad Behavior has blocked 632 access attempts in the last 7 days.
Page created in 0.136 seconds with 100 queries.


text:
Argument preview: Court to consider liability for DA's offices on Brady violations
In 1978, the Supreme Court held in Monell v. Department of Social Services of New York that municipalities and local governmental entities can be held liable under Section 1983 if their policies or customs inflict a constitutional injury. Nine years later, in City of Canton v. Harris, the Court made clear that a governmental entity can be held liable under Section 1983 for its failure to train employees only if the plaintiff can prove "deliberate indifference" to an obvious risk that constitutional violations will directly result from the policy or custom. In so holding, the Court discussed two hypothetical scenarios that might meet this standard: (1) cases in which the policymaker has been alerted to a training problem by a series of prior violations; and (2) cases involving single incidents, in which the need for training is so glaringly obvious that constitutional violations are inevitable. On October 6, in Connick v. Thompson, the Court will consider whether a district attorney's office may be held liable for failing to train its prosecutors on Brady violations, notwithstanding the fact that the office has no history of prior violations.
In 1985, John Thompson was arrested and charged with murder in New Orleans. After seeing Thompson's picture in the newspaper, victims of a recent attempted armed robbery came forward to identify Thompson as their assailant. Anticipating that an armed robbery conviction would keep Thompson from testifying at his murder trial, the Orleans Parish District Attorney's ("DA")'s Office rescheduled the robbery trial to occur before the murder trial. Approximately one week before that trial, the DA's office tested blood from the pants of one robbery victim and learned that the robber had type B blood. However, the prosecutors failed to either disclose this information to Thompson or introduce it at trial, where Thompson was eventually convicted. Fearing impeachment with the robbery conviction, Thompson declined to testify at his murder trial; he was convicted of first-degree murder and sentenced to death.
In 1999, shortly before Thompson was scheduled to be executed, an investigator on his defense team found the buried blood report. Testing indicated that Thompson in fact had type O blood, and the investigation that followed revealed that an assistant district attorney (and, possibly, other members of the prosecution team) had deliberately withheld the blood report and several other pieces of valuable evidence. In light of these revelations, Thompson's execution was stayed, the DA's Office chose not to prosecute him again for robbery, and he was acquitted at a new murder trial.
In 2003, Thompson sued the Orleans Parish District Attorney's Office, as well as several individuals in their official capacities. At the trial on his claim under Section 1983 "" regarding the wrongful suppression of the exculpatory evidence "" the jury did not attribute the violation to an unconstitutional Brady policy in the DA's Office. However, based on its finding that District Attorney Harry Connick had failed, through deliberate indifference, to establish policies and procedures sufficient to protect defendants from Brady violations, it awarded Thompson $14 million in damages.
The Fifth Circuit affirmed, emphasizing the "especially deferential" standard of review due to jury verdicts. In the panel's view, because Brady violations are "a highly predictable consequence" of failure to train, a pattern of similar violations is not required to show the "deliberate indifference" required by Canton. Rather, the panel found that Thompson had demonstrated Connick's deliberate indifference to the obvious need to train prosecutors on Brady by proving that the prosecutors were indeed inadequately trained and that Connick knew that failure to train would result in violations. Thus, Thompson could recover damages under Section 1983
After ordering rehearing en banc, the equally divided Fifth Circuit affirmed over a detailed dissenting opinion from Judge Clement. The DA's Office filed a petition for certiorari, which was granted on March 22, 2010.
In its opening brief, the DA's Office emphasizes that it would be inappropriate to extend Canton's single-incident liability example to prosecutors. First, without a history of violations, it is impossible to consciously ignore an obvious need for Brady training because the need to train lawyers on Brady is far from obvious. All of the hypothetical examples in which liability could be imposed based on a single incident, they note, arise in the context of training police on citizens' constitutional rights. By contrast, prosecutors are trained professionals, subject to licensing and an ethical regime designed to reinforce their duties as officers of the court, and "" unlike with police officers "" a DA may rely on prosecutors' adherence to these standards. Unless there are strong indications that training is required, a DA cannot be deliberately indifferent in not implementing training. Thus, under Canton's analytical framework, a DA's office can be held liable for failure to train only when a history of violations alerts the office to a specific problem demanding a targeted solution "" a scenario that simply did not exist in Orleans Parish.
Second, even if a Section 1983 plaintiff can prove a failure to train, there must be an ironclad connection between the flawed training program and an injury. Here, the particular assistant district attorney's violation was so obviously an intentional and knowing misdeed that no amount of training would have prevented it.
Third and finally, the DA's Office warns that diluting Canton's rigorous fault standard, which requires deliberate indifference to, and injury of, the rights of citizens, will take a form of municipal liability that was intended to be rare and make it commonplace and "ruinous." Applied to a DA's office, this "ruinous" liability will extend not only to Brady, but also to prosecutors' decisions on search and seizure, Miranda, expert witnesses, sentencing, and more. Holding it liable for this single violation, the DA's Office argues, will collapse Section 1983 liability into respondeat superior, punishing offices solely for employing a tortfeasor.
In his brief on the merits, Thompson first contends that the facts of his case meet the criteria outlined in Canton for liability based on a single incident. Connick knew that many inexperienced prosecutors would come into contact with Brady material, that proper Brady decision-making would require difficult analytical judgments, and that failure to produce such evidence would result in constitutional violations. Nonetheless, he did not provide any Brady training for prosecutors, and that failure reflects deliberate indifference to the rights of Orleans Parish citizens. Moreover, the nature of the withheld evidence and the prosecutors' inability to fully explain Brady at trial indicate that the lack of training substantially caused the violation of Thompson's constitutional rights.
Second, Thompson argues that even if the District Attorney's actions do not meet the high standard required for a municipality to be held liable based on a single incident, his particular case is not limited to a single violation of constitutional rights. Instead, he emphasizes, four prosecutors were involved in the suppression of Thompson's Brady evidence, and those four individuals suppressed multiple pieces of evidence, thereby establishing a pattern of violations.
Third, Thompson emphasizes the absence of a training program at the DA's Office and the inaccuracies in what little information the Office did provide to prosecutors. In particular, he highlights testimony and evidence reflecting Connick's complete disregard for the need to safeguard the Brady rights of defendants, including Connick's testimony that he stopped "reading law books" in 1974 and evidence that the prosecutors' training manual was both vague and inaccurate on several Brady issues.
Finally, Thompson stresses that the rule espoused by the DA's Office is dangerous: it would create a blanket exemption unless the plaintiff could show a pattern of violations, thereby effectively requiring that some citizens' rights actually be violated even when deliberate indifference might somehow otherwise be proven. Nor, Thompson argues, will a ruling in his favor have the negative effects that the DA's Office predicts. Rather, Connick's deliberate indifference is exactly the type of behavior Canton sought to target, and in the twenty years since Canton there has been no flood of cases seeking to hold municipal entities liable. The facts of his case, Thompson concludes, "are""one very much hopes""unique."


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The author of the fourth gospel was singled out among the disciples as the one "whom Jesus loved." He was a special figure in Jesus' life, yet, few stop to consider why this beloved disciple used terms like the "other disciple, whom Jesus loved" to conceal his identity.
The beloved disciple stood openly at the foot of the cross, so why did this "other disciple" hide his identity when he wrote the fourth gospel?
The Disciple Whom Jesus Loved is a free eBook that shows scripture is better than the traditions of men when it comes to identifying the one who wrote the fourth gospel, and the one-of-a-kind gift from God that made this beloved disciple so unique.
This book presents the testimony of scripture for your consideration. You are the jury and the Bible is Exhibit A, as we look for answers in the mystery of the beloved disciple who wrote the fourth gospel.
In cases of The Bible vs. Tradition, how we decide what to believe will depend on our measure of truth. If we put confidence in men, then if preachers, scholars, or commentaries tell us 'John wrote the Gospel', then we will simply assume this is true.
"It is better to trust in the Lord than to put confidence in man" (Ps. 118:8), and since scripture is inspired by God, why not use it to test every idea, including the idea that John was the beloved disciple?
See how the Bible can solve the mystery of the beloved disciple, and discover why he behaved differently than all the rest.
Share the free eBook and free printable downloads of this Bible study with others. Scripture is profitable for correction, so why not welcome correction regarding the identity of the author of the fourth gospel. This study proves honoring the authority of God's word is the key to a better Bible study method.
Preview this Bible study on Amazon, click "Look Inside"
A Better Bible Study Method - Book Two
The authority of scripture
Free eBooks
The beloved disciple who wrote the fourth gospel did not label his work the Gospel of John,
Gospel According to John, Saint John's Gospel or the Book of John. Those titles were added
to this gospel author's work long after it was written. From the Transfiguration to Jesus
raising Lazarus from the dead, from the Last Supper to Jesus' prayers at Gethsemane, the
Bible facts in this free printable Bible study prove the Apostle John was not the beloved
disciple who wrote the gospel that man-made tradition later called John. Who was the disciple
whom Jesus loved? Search the scriptures!
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text:
Jefferson County Family Court is comprised of 10 divisions and 10 judges. Family Court is involved in the most intimate and complex aspects of human nature and social relations. For that reason, Family Court uses a case management process that distinguishes it from other trial courts. With the One Family, One Judge, One Court approach, cases are presented in a single court, allowing the same judge to hear all matters involving a particular family. This reduces the stress that can arise when individuals are shuttled between courts to resolve a variety of issues.
Because Family Court gives cases involving families and children the highest priority, these cases do not compete with criminal and other civil cases for judicial time. As a division of Circuit Court, which is the highest trial court in Kentucky, Family Court employs full-time judges with the same qualifications as those who serve the other divisions of Circuit Court.
Family Court jurisdiction includes the following:
Family Court DivisionOffice of Circuit Court ClerkJefferson County Judicial CenterRoom 105, First Floor700 W. Jefferson St.Louisville, KY 40202Get Directions
Phone: 502-595-3025
Monday - Friday
8:30 a.m. - 4:30 p.m.


text:
As Fernando Torres sat on the substitutes' bench and watched Chelsea haul themselves back into this tie, he may well have felt his humiliation was complete. It took the Spaniard 14 games, 732 minutes to be precise, to score his first goal for Chelsea after his £50m transfer from Liverpool in January 2011, and here was Demba Ba requiring just 61 minutes to get two on his debut for the club.
It was the sort of impact a striker can only dream of and could well provide Torres with a deepening of his Stamford Bridge nightmare. For the 28-year-old, having started 31 of Chelsea's 33 competitive games this season, may now have to get used to watching from the sidelines. Certainly he has stiff competition for the team's lone-striker berth with Ba putting in an impressive display following his £7m arrival from Newcastle on Friday, showing a level of muscular determination – something that has been sorely lacking in Torres's play over the past two years.
The first of his goals got Chelsea on level terms after they had fallen behind to Jay Rodriguez's opener while his second extended the FA Cup holders' lead to 4-1. Rafa Benítez, Chelsea's interim manager, insisted the pair could play together in attack but he is a man who prefers one up front and, on current form, Ba is undoubtedly the frontrunner for that role.
"I prefer this problem," said Benítez when asked it would be difficult for him to choose between Torres and Ba. "For some time we have only had one striker and it is important for the team to have these different options. They can compete or they can play together. We will see."
Ba's display was just one of the highlights of a hugely satisfactory afternoon for Chelsea, who well and truly banished the painful memories of Wednesday's shock 1-0 defeat to Queens Park Rangers with a display of ruthless attacking swagger, the seal on which was placed with a Frank Lampard penalty on 83 minutes that enabled the midfielder, who came on as a 65th minute substitute, to go level with Kerry Dixon as Chelsea's second all-time record scorer with 193 goals, nine behind Bobby Tambling. Little wonder those packed into the away end could be heard chanting: "Sign him up," soon after the 34-year-old had placed the ball past Artur Boruc in the Southampton goal.
"It is a great achievement for Frank and hopefully he can score more goals until the end of the season," Benítez said before he was then asked to respond to claims that Lampard's agent was in discussions with Chelsea about a contract extension despite having claimed last week that the player would definitely leave in the summer, when his deal ends. "Frank is under contract and he is doing fine," Benítez replied. "I know they have had conversations but the main thing for me is to bring the best out of him."
By the time Lampard had scored, it was hard to remember that Chelsea had at one stage looked in danger of losing this tie. The visitors had begun sluggishly against well-organised opponents and it did not come as a huge shock when Rodriguez, a surprise selection in attack over Southampton's top scorer Rickie Lambert, put his team ahead on 22 minutes with a low strike, having collected Jason Puncheon's through pass and run clean through following poor defending from César Azpilicueta and Gary Cahill.
It took going behind for Chelsea to wake up and, as has often been the case this season, Juan Mata proved to be their spark. Following a quick exchange of passes between Victor Moses and Eden Hazard, the Spaniard lifted the ball over Boruc and presented Ba with the opportunity to open his Chelsea account on 35 minutes, with the Senegal striker getting in front of Steven Davis to stab the ball into an empty net.
Ten minutes later, and after more relentless pressure from the visitors, it was 2-1, with Moses driving the ball in from inside the area. Branislav Ivanovic headed in Mata's cross to make it 3-1 before Ba got his second of the game, slotting in Hazard's cross from close range having done well initially to keep possession for Chelsea while under pressure from José Fonte. The Southampton captain injured his knee in the tussle and had to be carried off on a stretcher soon afterwards.
Lampard added to the Saints misery late on following Davis's handball. The holders march on.


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March 24, 2013
Box Score | Photo Gallery 1 | Photo Gallery 2
NOTRE DAME, Ind. – The No. 7 University of Notre Dame women's lacrosse team improved to 8-0 for the second consecutive year with a 14-2 win over BIG EAST foe Villanova Sunday afternoon at Arlotta Stadium.
The Irish defense smothered the Wildcat offense the entire day, allowing only two goals on 18 shots. The two goals allowed are tied for the fourth lowest total in school history.
Goalie Ellie Hilling continued her impressive showing between the pipes, stopping 12 of the 14 shots that were on goal. The 12 saves tied a season high for the Hilling.
"It was a special weekend for Ellie," said head coach Christine Halfpenny. "She was able to show up and execute after putting in a lot of work ahead of time in getting ready for our two BIG EAST openers. I think she showed a ton of leadership in that regard. She did extra scouting and was able to see the ball really well. We also have to give credit to the defense that is in front of Ellie. They were able to limit the looks that she had to see and to give her the looks that she likes. That aside, she was lights out all weekend."
Notre Dame jumped out to a 4-0 lead after the first 20 minutes as four different Irish players found the back of the net on Wildcat goalie Ama Hirschfeld. With the defense holding Villanova at bay, the Irish took a 4-1 lead into the break.
The Irish offense finally broke through a packed-in Wildcat defense to out-score the opposition 10-1 in the second half. Notre Dame improved its lead to 7-1 just seven minutes into the second half. A Wildcat goal cut the lead to 7-2 before the Irish ran off six goals in under seven minutes to put the game away. Included in the scoring spree were three goals in 54 seconds from 13:58 to 13:04, with the first two goals coming from sophomore Caitlin Gargan in just 18 seconds and the last coming from junior Lauren Sullivan 36 seconds later.
Gargan recorded a hat trick in the second frame to give her four for the day. She also added a pair of helpers to give herself five points in the second half and six for the game.
"Caitlin has been an incredible example of what happens when you stay focused on your process and development," said Halfpenny. "She is a player that has so much unique ability, talent and athleticism that we have told her to stick to the plan and that good things will happen when she stays focused on her basics and bringing to the table what she has the ability to bring to the table. Today she did a great job of being an on the field leader for us."
Eight different Notre Dame student-athletes found the back of the net on the day, including sophomore defender Barbara Sullivan, who recorded her first career goal after collecting a ground ball, sprinting several yards up the field and dishing to teammate Jenny Granger who passed to Kaitlyn Brosco who passed back to Sullivan for the easy fast-break goal. The Garden City, N.Y., native also added a team-high eight draw controls and two ground balls.
Granger ended the day with two goals and an assist, while Brosco finished with two goals and two assists.
Villanova's two goals came from Jackie Froccaro with 1:08 left in the first half and from Chelsey Henderson with 22:41 left in the second frame.
The Irish have now started the season at 8-0 for the second consecutive year under Halfpenny.
Notre Dame looks to continue its undefeated season after taking a break from games for the Easter holiday. The Irish hit the road to meet No. 20/20 Louisville April 5 and Cincinnati April 7 in a pair of BIG EAST contests.


text: I have tried it on one Chinese .223 and it fit perfectly without any mods at all. If an AR mag will fit in your rifle now and fit flush against the magrail, it will work for you the same way. AK's are fairly standard. Not exact, by any means, but close. Oh, BTW the receiver has to be stamped not milled, to fit without modding.


text:
So let's take a proactive approach, shall we? Spoil them for yourself before your friends have the pleasure of spoiling them for you. It'll be quick and painless – like taking off a band-aid.
Additional contributions by Henry Gilbert, Cheryll Del Rosario and Tyler Nagata
Bayonetta is the left eye. Cereza is Bayonetta. Balder is her father. Jeanne is good.
Abaddon is the Destroyer. War defeats him and summons the remaining three Horsemen to begin the Apocalypse.
Army of Two: The 40th Day
The nuclear bomb Jonah says is rigged to blow up Shanghai if he is killed is a bluff.
Dark Void
Aliens provided the Axis powers with alien weaponry during WWII. Will escapes the Void.
Mass Effect 2
The collectors are protheans that the reapers genetically modified to use as a slave race. Shepard and team storm the reaper base successfully and discover a gigantic human-reaper hybrid.
No More Heroes 2
Travis defeats Jasper.
Dante's Inferno
Above: Mildly NSFW for butt reasons
Dante sacrifices himself for Beatrice so she can ascend to heaven, which in turn bumps Dante up to purgatory for his good deed. Lucifer escapes hell in the form of a snake?
Ace Attorney Investigations: Miles Edgeworth
Shih-Na is Calisto Yew, and she's not actually Cece's sister but an undercover Interpol agent, and actually even more secretly a member of the smuggling ring, which Quercus Alba runs. She also killed Byrne Faraday, Kay Faraday's father.
SOCOM: US Navy Seals Fireteam Bravo 3
The team destroys the cache of chemical weapons and kill Gozorof and they all celebrate by going on vacation together. D'awww. Lonestar is killed by a sniper though.
Deadly Premonition
Sheriff George Woodman is the new raincoat killer. York is really named Zach. The red seeds really have supernatural power, and they come from trees grown out of a woman's stomach, specifically York/Zach's mother and Emily, who both die from the stomach trees.
Heavy Rain
The origami killer is Scott Shelby.
Last Rebellion
FromWikipedia: NIS America's president, Haru Akenaga, stated that the game was "not the kind of title we should release in the United States because of its quality", and that he felt "really sorry for our customers because we released that title."
White Knight Chronicles
Kara is the Black Knight. Setti is Grazel is the Sun King is the ultimate leader of the evil Magi. Ends on a cliffhanger with Grazel rallying like a zillion troops to war for the glory of the Yshrenian empire.
Command & Conquer 4:Tiberian Twilight
Colonel James mortally wounds Commander Parker, but in Parker's dying act he helps Kane (who is an alien, btw) activate the Scrin tower with his optical implant. Kane ascends and disappears along with all the followers of Nod. The Tiberium growth abates.
Final Fantasy XIII
Fang and Vanille turn into Ragnarok together and save both Cocoon and Pulse by creating a giant crystal pillar to prevent the worlds from crashing into each other. Everyone's l'Cie brands are removed. Sazh and Dajh are reunited and so are Snow and Serah. Happy!
Metro 2033
Artyom either destroys the Dark Ones with missiles, or he hallucinates and spares the Dark Ones, believing them to be peaceful.
Red Steel 2
The hero kills Shinjiro, breaking his katana in Shinjiro's chest. Then he throws the other half of the katana off a cliff.
Sakura Wars: So Long, My Love
The Star Division defeats Nobunaga but he manages to escape as his castle is destroyed.
Shin Megami Tensei: Strange Journey
The three endings depending on your alignment are:
-Law: Heaven takes over the world, freeing humanity of suffering but taking away free will.
-Chaos: The demon world prevails and humans retain their free will but live by only the law of brutality.
-Neutral: You complete the mission to destroy the Schwarzwelt and the world goes back to normal.
Just Cause 2
All the countries are fighting over Panau because it has the world's richest oil supply. Panay is killed – no, wait – he's still alive! Rico attaches him to a nuclear missile and aims it at the oil fields, destroying all the oil to end the conflict.
Dead to Rights: Retribution
Jack kills Redwater. Shadow survives.
The people we think are humans are actually Replicants, which were bodily shells created to save the human race from a virus 1300 years ago, but gained their own sentience. Shades are what's left of the original humans who want their bodies back. Nier and Yonah are reunited, but in a subsequent playthrough Nier sacrifices himself for Kaine to save humanity.
3D Dot Game Heroes
The hero saves the kingdom. The princess says they can be "friends."
Lost Planet 2
The Over-G is destroyed, preventing another ice age. The mercenaries save the day.


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For All KIDS
Go ahead and Gift it to yourself or Gift it to someone special
We deliver great gifts made for you. Personalized mug for any occasion!
They make the perfect way to give someone memories that lasts forever.
All prints remain permanent for years without any fading or scratching.
Bulk Orders / Enquiries:
We take BULK orders for Mugs Printing and other Corporate Gifting @ best rates.
Feel free to get in touch with us for more details and corporate/bulk orders @ 084608 93151
or email: firstname.lastname@example.com
Please Note: Once the image is printed, the order will not be cancelled or returned.
We print our mugs in very high quality and assure you full satisfaction.
Please give us your +VE Feedback, and fill detailed seller ratings, if you are satisfied.
If any issues please let us know and we will try our best to resolve the issue within stipulated time.
Donأ¢â'¬â"¢t put -ve/neutral feedback straight away, that discourages us and decrease the chances of any solution to the problem.
Handling & packing:
We duly take every care in packing, so that the item reaches the buyer safely and in undamaged condition.
Also, it is the responsibility of the buyer to ensure that the packet received by them is in a non-tempered condition.
Donأ¢â'¬â"¢t accept the packet if it is not sealed, for any doubts open packet in front of courier personnel and return the pack if the item is found to be broken or damaged.
Shipping time:
We usually ship within 3 days of order/cleared payment.
Shipment partners:
We ship mainly by trackoncourier.com.
It is possible that they may have tie-up internally to reach out interior and not accessible areas. Delivery time varies and can take between 5 to 10 business days.
- Product Code: MU01
- Availability: In Stock
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A WordPress Theme for Sports Clubs
Evergreen Sports is a WordPress theme for sports clubs and societies. The main team, players and fixtures functionality is provided via a free plugin made by the theme developer called Simnor Sports Club Manager.
The theme is designed and developed by Simon North and has been created to help support the projects that EvergreenPA (a not-for-profit company) operates, these include helping support football clubs, choirs and other community projects that help to keep young people on the path to success and away from gangs and bad influences.
Full Feature List
- Clean and fast loading design
- Responsive
- Theme Options to change the logo, site title, header social links, home slider, home announcement, fonts, colours, custom css, which sections of the site to show the sidebar and footer text.
- 5 custom widgets which include: latest news, top scorers, players, next fixture and gallery.
- Gallery custom post type which uses the default WordPress gallery manager to easily update and manage your gallery images.
- Simple homepage slider (not a fancy over-the-top slow-loading slider, just a simple fading in and out slider), click the screenshots button at the top to see the options available.
- Shortcode support through the free Simnor Shortcodes plugin.
- Non-bloated code, everything nicely organised ready for developers.
Support is provided via the comments section or via the contact form on our profile page. Documentation can be viewed online here
Note about Demo Images
Images in the demo are licensed for use only in the demo and therefore are not available in the download.
@fontface fonts are provided via Google Web Fonts
Font Awesome icon font: http://fortawesome.github.io/Font-Awesome/
Zocial icon set through the fontello icon font generator: http://fontello.com/
Images are from http://photodune.net, http://pixabay.com/ or produced by me
= 1.4 =
- single-fixture.php added ability to show text based version of date (requires plugin update)
- header.php added ability to show text based version of date on next fixture (requires plugin update)
- includes/theme-widgets.php added ability to show text based version of date on upcoming fixtures widget (requires plugin update)
- responsive.css fixed css issues on the single fixture score entry, now you can add longer scores for sports like cricket
- js/script.js fixed issue when adding multiple upcoming fixtures widgets
- archive.php, index.php, single.php fixed icon issue
- archive.php, index.php fixed issue with not showing continue reading link in some places
- includes/theme-shortcodes.php fixed issue with galleries not showing if the thumbnail is set
= 1.3 =
- includes/theme-widgets.php fixed upcoming widgets only displaying 1 fixture
= 1.2 =
- js/script.js fix fixture bar going onto two lines issue, fixed problem stopping multiple player widgets showing on one page
- header.php fixed next fixture to show by time as well as date, added option to change next fixture text in theme options
- includes/admin/theme-options.php added option to change next fixture text in theme options
- single-fixture.php fixed ordering of fixtures
- includes/theme-widgets.php Fixed upcoming fixtures widget
= 1.1 =
- sidebar.php, header.php, archive.php, index.php, page.php, search.php, single-fixture.php, single-player.php, single-sn_gallery.php Fixed sidebar issues
- includes/theme-functions.php, single-fixture.php Add ability to change dates via plugin
- includes/theme-widgets.php Bring in date format from plugin
- includes/theme-widgets.php Fixed icon issues
- style.css General CSS fixes
= 1.0 =
- First release.


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Xulia Metallic Rhinestone Top - Silver Sparkle
🔥buy 3 get 10% off!(Hurry! Until 14th December)*(Contact us through messenger if the discount doesn't work. The discount will be applied automatically.)
Stay fab with Bella Barnett!
🎁the best party dresses
customers are viewing this product
- Also available in Gold
- Split on the back
- Length: 20
- Bust: 79-90
- Machine wash
- Model wearing one size
- Colour may vary due to lighting on images
- Item runs true to size chart and is cut to suit our size chart. Please refer to our size chart for the best fit
Shipping & Returns
Delivery Time=Processing Time + Shipping Time
Processing time : 2-5 business days
- Free standard delivery over $100
- Express delivery fee: $19, 3-6 business days
- Standard delivery fee: $9, 7-15 business days
Items delivered from Bella Barnett can be returned within 30 days after delivery